外科创伤患者的护理.ppt

Nursing Care of Client Experiencing Trauma,创伤病人的护理,Definition of Trauma Trauma morbidity（发病率） and mortality（死亡率） constitute a major health care challenge. 创伤的发病率和死亡率构成了健康的最大挑战。 Although significant strides have been made in combating heart disease and selected cancers, traumatic injury continues to be the number-one killer of the young.,Section 1 Overview,Trauma,traumatic injury,heart disease,cancer,The number-one killer of the young,It is estimated that traumatic injury causes about 140,000 deaths per year. An additional 57 million people suffer nonfatal (不致命的）injuries each year.,当肯尼迪乘坐敞蓬轿车驶过德克萨斯州达拉斯的迪利广场（Dealey Plaza）时，遭到枪击身亡 。约翰·肯尼迪是美国历史上第四位遇刺身亡的总统，也是第八位在任期内去世的总统。 assassination 遇刺，暗杀,John Fitzgerald Kennedy,肯尼迪诅咒 curse,11941年，约瑟夫的残疾女儿死于失败的脑叶切除手术； 21944年，约瑟夫长子小约瑟夫·肯尼迪战时死于飞机失事； 31948年，约瑟夫二女儿凯瑟琳死于飞机失事； 41963年，肯尼迪总统的第三个儿子出生两天后夭折； 51963年，约瑟夫二子肯尼迪总统遇刺身亡； 61968年，约瑟夫三子罗伯特遇刺身亡； 71983年，罗伯特之子博比因吸毒被判刑； 81984年，罗伯特之子戴维因过量吸服海洛因死亡； 91997年，罗伯特之子迈克尔死于滑雪事故； 101999年，约翰之子小约翰·肯尼迪死于飞机失事； 112009年，约瑟夫四子爱德华死于脑癌；,Traumatic injury usually occurs suddenly, leaving both the client and family with little time to prepare for its consequences. 创伤发生得太突然，没有任何时间留给病人和家庭来准备承受后果。 Nurse provide a vital link in both the physical （生理的）and psychosocial（心理社会） care for the injured client and family. 护士要提供给护士伤员及家庭一个关健的护理不仅是生理上的还包括心理社会的。,traffic accident,In caring for the client who has experienced trauma, nurses must consider not only the initial physical injury ,but also its long-term consequences, including rehabilitation and the clients return to his or her previous way of life. 护士护理创伤人员时，不仅必须考虑最原先的生理创伤，而且也要考虑长期的后序治疗，包括康复和伤员能回归原来的生活轨道。,Types of Trauma 创伤类型,Severity 严重程度分类 Whether intentional or accidental, trauma causes injury to one or more parts of the body.,1 Minor trauma,2 Major or multiple trauma,1 Minor trauma 轻伤,Minor trauma causes injury to a single part or system of the body and is usually treated in the hospital or emergency department . 轻伤导致身体一个部分或一个系统的损伤，通通都会在医院或急诊科被治疗。 A fracture of the collarbone, a small second-degree burn ,and a cut requiring stitches are all considered minor trauma. 锁骨的骨折，二度烧伤和一个需要缝合的伤口都被认为是轻伤。,2 Major or multiple trauma 重伤及多发伤,Major or multiple trauma involves serious single-system injury(such as the traumatic amputation of a leg) or multiple-system injuries. Multiple trauma requires immediate intervention （立即干预）that is specifically focused on ensuring the survival of the client. 多发伤需要立即干预，尤其重心是保证病人的生命。,Clients who suffer multiple trauma receive immediate emergency care and often require long periods of intensive nursing care. 多发创需要立即接受急救治疗，并且经常需要常长时间的护理。,Types of Trauma,Skin Integrality 按皮肤的完整性来分 1 Blunt trauma 闭合性损伤 Blunt trauma occurs when there is no communication from the damaged tissues to the outside environment. 2 Penetrating trauma 开放性损伤 Penetrating trauma occurs as the result of foreign objects set in motion. Penetration of tissues causes damage to body structures, most commonly the intestines（肠道）, liver（肝脏）, spleen（脾脏）, and vascular system（血管系统）.,Types of Trauma,Organ and location 创伤器官和部位分 trauma of abdomen 腹部创伤 trauma of bladder 膀胱损伤;膀胱外伤 trauma of limbs 四肢损伤 Trauma of chest 胸部损伤 trauma of breast 乳腺外伤 trauma of gastrointestinal tract 胃肠道创伤 trauma of nose 鼻外伤 trauma of brain 脑外伤 trauma of spinal cord 脊髓外伤,Effects of Traumatic Injury 创伤的影响,Causes and Initial Management 创伤原因和处理 Airway obstruction 气道阻塞 Tension pneumothorax 张力性气胸 Hemorrhage 出血 Integumentary effects 皮肤损伤 Hypovolemic shock 低血容量性休克 Neurologic effect 对神经系统的影响 Effect on the family 对家庭的影响,1 Causes and Initial Management 创伤原因和处理,(1)Natural Disasters Earthquake 地震 Mudslide；mudflow 泥石流 volcano 火山vl'keinu lahar 火山泥流'l:h: avalanche 雪崩'æv,lænt Blizzard 暴风雪 'blzd Hurricane 飓风 Typhoon taifu:n台风 Flood 洪水 ice storm 冰雹,1 Causes and Initial Management 创伤原因和处理,Man-made disasters Derail 火车出轨 Traffic crash; traffic accident 交通事故 Plane crash 飞机失事 attack; slaughter ; fight 袭击；屠杀；打架 terrorist attack 恐怖袭击 Shooting 枪击 War；battle 战争；战斗 Sport activity,Initial Management,A mentioned as the opening of this chapter, death is a common result of serious traumatic injury. Death from trauma may be immediate ,early, or late. 创伤引起的死亡可以是立即的，早期的或是晚期的。 Immediate death is death is death at the scene from such injuries as a torn thoracic aorta（主动脉撕裂伤）. Early death is death occurring within several hours of the injury from ,for example, shock （休克）or lack of treatment for unrecognized injuries （无法诊断的损伤）.,Late death generally occurs one or more days after the injury and results from multiple organ failure（器官衰竭）. Because of the serious consequences of a traumatic injury , it is important to identify rapidly and take interventions appropriately. 因为创伤的严重后果，对于迅速确定并且适当地采取措施非常重要。,EP 10 mins 急救白金十分钟,platinum'plætnm,CRASH PLAN检查顺序,C cardic 心脏 R respiratory 呼吸 A abdomen 腹部 S spine 脊柱 H head 头颅 P Pelvic 骨盆 L 1imb 四肢 A artery 血管 N nerve 神经,2 Airway obstruction 气道阻塞,The trauma clients airway may become obstructed by the presence of blood ,teeth ,the tongue, and vomitus（呕吐）. Airway interventions may include: 1 Clearing the airway by suctioning（吸引）。 2 Use of airway adjuncts, such as an oropharyngeal（口咽的） airway 3 Intubation with an oral endotracheal airway（气管插管）. 4 Needle or surgical circothyroidotomy. （气管切开）This procedure is performed only after other methods are ineffective in opening and maintaining an open airway.,开放气道 Airway,Clearing the airway by suctioning,an oropharyngeal airway,口咽管,Intubation with an oral endotracheal airway,circothyroidotomy,3 Tension pneumothorax 张力性气胸,A pneumothorax results from air in the pleural space from blunt and penetrating injuries to the chest. When a one way valve（阀门） is created so that air can enter the pleural space but not exit, a tension pneumothorax may develop.,4 Hemorrhage 出血,1 External Hemorrhage （外出血） When the client has suffered an injury that causes external hemorrhage, such as severing of an artery ,the bleeding must be controlled immediately methods to achieve this include: (1)Applying direct pressure over the wound (2)Applying pressure over arterial pressure points 压迫伤口上方动脉 (3) Elevating the injured limb 抬高 (4)Clamping the bleeding vessel. （固定，夹紧） (5)Applying a tourniquet. (止血带),压迫止血Applying direct pressure over the wound,包扎止血Clamping the bleeding vessel,Applying pressure over arterial pressure points 压迫伤口上方动脉,4 Hemorrhage 出血,2 Internal Hemorrhage 内出血 Internal hemorrhage may result from either blunt or penetrating traumatic injury. Discovering the cause of ，location of ,and extent of blood loss related to the injury is the most important concerns. Methods to discover the presence and location of internal hemorrhage include: Diagnostic peritoneal lavage (诊断性腹腔清洗 ) CT scans of the head, chest, and abdomen,Diagnostic peritoneal lavage,The body has several potential spaces that can accommodate（容纳） large amount of blood that may accumulate （集聚）follow injury. 在身体中有几个潜在的腔隙可以容纳大量的血液。 Fox example, bleeding into the pleural space （胸膜腔）may occur with chest trauma, and bleeding into the abdominal cavity（腹腔） may occur with abdominal trauma. Pelvic fracture（骨盆骨折） may cause massive hemorrhage in the retroperitoneal(腹膜后) region.,Once the source of internal hemorrhage has been recognized, interventions are initiated ,including: Operative control of bleeding 手术控制出血 Continual assessment of the client, including physical assessment, vital signs, and serial laboratory work. 评估患者通过身体检查，生命体征和一系列的辅助检查,5 Hypovolemic shock 低血容量性休克,A serious and potentially lethal complication of external or internal hemorrhage is hypovolemic shock. The most common cause of hypovolemic shock is trauma injury. The client who has suffered multiple injuries may develop shock from a combination of multiple source of blood and fluid loss.Care of the client who is experiencing hypovolemic shock may include rapid identification of the source bleeding ; fluid replacement; blood transfusion; and operative intervention to control bleeding.,6 Integumentary effects 皮肤损伤,Four specific injuries to the integument include contusions（挫伤） , abrasions（擦伤）, puncture wounds（刺伤）, lacerations（裂伤）.,bullet wound,Stabbing wound,contusions,puncture wounds,abrasions,lacerations,Injuries to the integument （表皮）are at risk for contamination（污染）from dirt, debris, or foreign objects. Intervention for injuries to the integument include: 1 Controlling any active bleeding 2 Immobilizing the affected area. （固定） 3 Stabilizing any penetrating objects. (固定) 4.Cleaning the wound.,5.Applying the appropriate dressing 6.Administering tetanus （破伤风）immunization as indicated 7.Providing information about home wound care when the client is discharged.,7 Neurologic effect 神经系统影响,Head injuries are one of the most common types of injury sustained（承受） as the result of trauma. Injury to the spinal cord resulting in loss of neurologic function is one of the most devastating outcomes.(破坏性后果) The majority of head and spinal cord injuries result from blunt trauma and sustained in motor vehicle crash（车祸）, Fall（摔倒）, sport injuries（运动损伤）, and assault（斗殴）are some of the other sources of neurologic injury.,8 Effect on the family 对家庭的影响,Traumatic injury usually occurs suddenly and with little warning. It may result in death or cause injury serious enough to alter dramatically both the clients and the family lives. Signs and symptoms of psychologic crisis include the following: 1 shock 2 Fear 3 Numbness 4 Anxiety 5 Guilt 6 Hostility（敌对的） 7 Anger,8 Effect on the family 对家庭的影响,Immediate interventions include: 1 Establishing communication with the family as quickly as possible. 2 Providing information about client, the incident, and the care. 3 Accompanying the family to see the client.,Section 2 Nursing care of client with trauma,Nursing Diagnoses and Collaborative Problems Nursing care of the client who has been injured begins with a primary assessment and the initiation of collaborative interventions for any life-threatening injuries, Nursing care is directed toward the clients specific responses trauma. Nursing diagnoses for the client with trauma may include:,Nursing Diagnoses and Collaborative Problems,1 Impaired airway Clearance related to the block of airway caused by trauma. 2 Risk for infection related to trauma 3 Impaired physical mobility related to the pain caused by trauma 4 Spiritual distress 5 Post-trauma response 6 Risk for trauma,Nursing Intervention,The client who has suffered multiple is at great risk for developing airway obstruction and apnea（窒息）. Facial injuries, loose teeth, blood, and vomitus （呕吐物）increase the risk for aspiration（误吸) and obstruction. Neurologic injuries and cerebral edema(脑水肿) alter the clients respiratory drive and ability to keep the airway clear.,Nurses should observe whether the clients airway is patent（张开的）, maintainable（可维持的）.Assess the client for signs and symptoms of airway obstruction： 1 Facial trauma 2 Debris（异物） in the airway, such as teeth ,blood, or vomitus 3 Stridor（喘鸣） 4 Tachypnea （呼吸急促） 5 Bradypnea （呼吸缓慢） 6 Cough （咳嗽） 7 Cyanosis （紫绀） 8 shortness of breath. 9 Decreased or absent breath sounds.,Nurses also need to monitor oxygen saturation. Oxygen flow is adjusted to maintain the clients oxygen saturation from 94%100%.,Risk for infection,Traumatic injuries are considered dirty wounds. The trauma often occurs in a dirty environment. Nursing intervention with rationales（基本理论） are as follows: 1 Use careful hand washing practices. Hand washing remains the single most important factor in preventing the spread of infection. 2 Use strict universal precautions. （全面防护）The use of universal precautions is essential in protecting the client and the nurse from injection.,3 When applying or changing dressings（敷料）use strict aseptic technique. 4 Take and record vital signs 5 Provide adequate fluids and nutrition. 6 Use strict aseptic technique when inserting catheters, suctioning ,administering parenteral（肠外的） medications，or performing any other invasive procedure.,Impaired physical mobility,The client with traumatic injuries is often unable to change positions independently and is at risk for complication of the integumentrary(表皮), cardiovascular(心血管）, gastrointestinal（胃肠道）, respiratory（呼吸）, musculoskeletal（肌肉骨骼） ,and renal systems（泌尿系统）.,Nursing intervention with rationales are as followed 1 Provide active or passive exercises at least once every 8 hours. 2 Turn, cough, and deep breath at least every 2 hours. 3 Monitor the lower extremities each day for manifestation of deep vein thrombosis.,Spiritual distress,Trauma generally strikes with little or warning and carries potentially devastating（破坏） consequences ranging from severe alterations in the lives of the victim and family, to death. The traumatic death of a loved one may be the most difficult event a family may ever experience. Providing the family with resources that may be used in the future may help prevent future crises and dysfunction.,Post-trauma response,Post-trauma response is an intense, sustained emotional, response to a disastrous event. This response is characterized by emotions that range from anger to fear and by flashbacks or psychic numbing（反应麻木）. In the initial stage, the client may be calm or may express feeling of anger（生气）, disbelief（不信任）, terror（恐怖）, and shock（惊吓）. In the long-term phase, the client often experiences flashbacks （闪回）and nightmares（恶梦）of the traumatic event.,The client may call on ineffective coping mechanisms, such as the use of alcohol or drugs ,and withdraw from relationship with others. 患者也许会求助于不积极的妥协机制就像运用酒精和药物或者避开人群。,Post-traumatic stress disorder 创伤后应激障碍,美国911恐怖袭击，虽然它已经过去了10年，但那些曾经亲生经历或亲眼目睹这一悲剧的人们，似乎还未能从中走出来。有一部分人躲过了911那一场劫难，现在却在承受着身体和心理上的另一场煎熬。有研究报告显示，当初参与911救援的消防人员罹患癌症的几率比常人高，一部分民众一直受到创伤后应激障碍（PTSD）的困扰。,Nursing intervention with rationales are as follows: 1 Assess the clients emotional responses while providing physical care. Observe for crying, suspiciousness, and fear during the initial phase of treatment. 当提供护理的时候评估患者的情况反应，并且在治疗阶段的时候观察是否有哭泣、怀疑和恐惧。,2 Be available if the client wishes to talk about the trauma ,and encourage the client to express his or her feeling when the client seems ready to do so. 如果患者愿意讨论创伤是被允许的，并且鼓励患者愿意表达他或她的感觉当如患者看起来已经做好了准备。 The client may initially deny negative feeling; this denial is a coping mechanism in the initial phase of recovery. 患者刚开始也许会否认消极的感觉：这种否定是一种恢复起始阶段的合作机制。,3 Teach relaxation techniques, such as deep breathing , progressive muscle relaxation, or imagery. 教给放松技术，就如深呼吸，渐渐的肌肉放松和想象。,4 Refer the client and family members for counseling（咨询）, psychotherapy, or support groups as appropriate. Continued therapy may be necessary in allowing the client and family to resolve the acute and long-term effects of trauma. 患者和家庭成员的咨询，心理治疗或者群组支持是适当的。连续的治疗可能是必要的，允许患者或家庭解决短期或长期的创伤影响,If the client is unconscious ,encourage family members and friends to express their feeling. These assessments provide valuable information about the clients ability