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1、vDefinition of Trauma vTrauma 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。 vAlthough 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
2、 1 Overview Trauma traumatic injury heart disease cancer The number-one killer of the young vIt is estimated that traumatic injury causes about 140,000 deaths per year. vAn 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
3、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 v 11941年,约瑟夫的残疾女儿死于失败的脑叶切除手术; v 21944年,约瑟夫长子小约瑟夫肯尼迪战时死于飞机失事; v 31948年,约瑟夫二女儿凯瑟琳死于飞机失事; v 41963年,肯尼迪总统的第三个儿子出生两天后夭折; v 51963年,约瑟夫二子肯尼迪总统遇刺身亡; v 61968年,约瑟夫三子罗伯特遇刺身亡; v 71983年,罗伯特之子博比因吸毒被判刑; v 81984年,罗伯特之子戴维因过量吸服海洛因
4、死亡; v 91997年,罗伯特之子迈克尔死于滑雪事故; v 101999年,约翰之子小约翰肯尼迪死于飞机失事; v 112009年,约瑟夫四子爱德华死于脑癌; vTraumatic injury usually occurs suddenly, leaving both the client and family with little time to prepare for its consequences. v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。 vNurse provide a vital link in both the physical (生理的)and
5、psychosocial(心理社会) care for the injured client and family. v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 vIn 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 cl
6、ients return to his or her previous way of life. v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 vWhether 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 vM
7、inor trauma causes injury to a single part or system of the body and is usually treated in the hospital or emergency department . v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。 vA fracture of the collarbone, a small second- degree burn ,and a cut requiring stitches are all considered minor trauma. v锁骨的骨折,二度烧伤
8、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 vMajor or multiple trauma involves serious single-system injury(such as the traumatic amputation of a leg) or multiple-system injuries. vMultiple trauma requires immediate intervention (立即干预)that is specifically focused on ensuring the survival o
9、f the client. v多发伤需要立即干预,尤其重心是保证病人的 生命。 vClients who suffer multiple trauma receive immediate emergency care and often require long periods of intensive nursing care. v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 v1 Blunt trauma 闭合性损伤 Blunt trauma occurs when there is no
10、communication from the damaged tissues to the outside environment. v2 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 sys
11、tem(血管系统). Types of Trauma Organ and location 创伤器官和部位分 vtrauma of abdomen 腹部创伤 vtrauma of bladder 膀胱损伤;膀胱外伤 vtrauma of limbs 四肢损伤 vTrauma of chest 胸部损伤 vtrauma of breast 乳腺外伤 vtrauma of gastrointestinal tract 胃肠道创伤 vtrauma of nose 鼻外伤 vtrauma of brain 脑外伤 vtrauma of spinal cord 脊髓外伤 Effects of Traum
12、atic Injury 创伤的影响 v Causes and Initial Management 创伤原因和处理 vAirway obstruction 气道阻塞 vTension pneumothorax 张力性气胸 v Hemorrhage 出血 v Integumentary effects 皮肤损伤 v Hypovolemic shock 低血容量性休克 v Neurologic effect 对神经系统的影响 v Effect on the family 对家庭的影响 1 Causes and Initial Management 创伤原因 和处理 (1)Natural Disas
13、ters v Earthquake 地震 v Mudslide;mudflow 泥石流 v volcano 火山vlkeinu v lahar 火山泥流l:h: v avalanche 雪崩v,lnt v Blizzard 暴风雪 blzd v Hurricane 飓风 v Typhoon taifu:n台风 v Flood 洪水 v 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 cra
14、sh 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 vA mentioned as the opening of this chapter, death is a common result of serious traumatic injury. vDeath 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
15、晚期的。 vImmediate death is death is death at the scene from such injuries as a torn thoracic aorta(主动 脉撕裂伤). vEarly 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). vLate death generally occurs one or mo
16、re days after the injury and results from multiple organ failure(器官衰竭). vBecause of the serious consequences of a traumatic injury , it is important to identify rapidly and take interventions appropriately. v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 emergency platinum 10 mins 10 platinumplt
17、nm CRASH PLAN检查顺序 vC cardic 心脏 vR respiratory 呼吸 vA abdomen 腹部 vS spine 脊柱 vH head 头颅 vP Pelvic 骨盆 vL 1imb 四肢 vA artery 血管 vN nerve 神经 2 Airway obstruction 气道阻塞 vThe trauma clients airway may become obstructed by the presence of blood ,teeth ,the tongue, and vomitus(呕吐). Airway interventions may inc
18、lude: v1 Clearing the airway by suctioning(吸引)。 v2 Use of airway adjuncts, such as an oropharyngeal(口咽的) airway v3 Intubation with an oral endotracheal airway (气管插管). v4 Needle or surgical circothyroidotomy. (气管 切开)This procedure is performed only after other methods are ineffective in opening and m
19、aintaining an open airway. 开放气道 Airway Clearing the airway by suctioning an oropharyngeal airway v口咽管 Intubation with an oral endotracheal airway circothyroidotomy 3 Tension pneumothorax 张力性气胸 vA pneumothorax results from air in the pleural space from blunt and penetrating injuries to the chest. vWh
20、en 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 v1 External Hemorrhage (外出血) vWhen the client has suffered an injury that causes external hemorrhage, such as severing of an artery ,the bleeding must be contr
21、olled immediately methods to achieve this include: v(1)Applying direct pressure over the wound v(2)Applying pressure over arterial pressure points 压迫伤口上方动脉 v(3) Elevating the injured limb 抬高 v(4)Clamping the bleeding vessel. (固定,夹紧 ) v(5)Applying a tourniquet. (止血带) 压迫止血Applying direct pressure over
22、 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 v2 Internal Hemorrhage 内出血 vInternal hemorrhage may result from either blunt or penetrating traumatic injury. Discovering the cause of ,location of ,and extent of blood loss related t
23、o the injury is the most important concerns. Methods to discover the presence and location of internal hemorrhage include: vDiagnostic peritoneal lavage (诊断性腹腔清洗 ) vCT scans of the head, chest, and abdomen Diagnostic peritoneal lavage v The body has several potential spaces that can accommodate(容纳)
24、large amount of blood that may accumulate (集聚)follow injury. v在身体中有几个潜在的腔隙可以容纳大量的血 液。 vFox 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. vPelvic fracture(骨盆骨折) may cause massive hemorrhage in the
25、 retroperitoneal(腹 膜后) region. vOnce the source of internal hemorrhage has been recognized, interventions are initiated ,including: vOperative control of bleeding 手术控制出血 vContinual assessment of the client, including physical assessment, vital signs, and serial laboratory work. v评估患者通过身体检查,生命体征和一系列的
26、 辅助检查 5 Hypovolemic shock 低血容量性休克 vA serious and potentially lethal complication of external or internal hemorrhage is hypovolemic shock. The most common cause of hypovolemic shock is trauma injury. vThe client who has suffered multiple injuries may develop shock from a combination of multiple sourc
27、e 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 vFour specific injuries to the integument in
28、clude v contusions(挫伤) , vabrasions(擦伤), vpuncture wounds(刺伤), vlacerations(裂伤). bullet wound Stabbing wound contusions puncture woundsabrasions lacerations vInjuries to the integument (表皮)are at risk for contamination(污染)from dirt, debris, or foreign objects. Intervention for injuries to the integu
29、ment include: v1 Controlling any active bleeding v2 Immobilizing the affected area. (固定) v3 Stabilizing any penetrating objects. (固定) v4.Cleaning the wound. v5.Applying the appropriate dressing v6.Administering tetanus (破伤风) immunization as indicated v7.Providing information about home wound care wh
30、en the client is discharged. 7 Neurologic effect 神经系统影响 vHead 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) vThe majority of head and spinal
31、 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 vTraumatic injury usually occurs suddenly and with little warning. It may result in deat
32、h or cause injury serious enough to alter dramatically both the clients and the family lives. Signs and symptoms of psychologic crisis include the following: v1 shock v2 Fear v3 Numbness v4 Anxiety v5 Guilt v6 Hostility(敌对的) v7 Anger 8 Effect on the family 对家庭的影响 vImmediate interventions include: v1
33、 Establishing communication with the family as quickly as possible. v2 Providing information about client, the incident, and the care. v3 Accompanying the family to see the client. Section 2 Nursing care of client with trauma vNursing Diagnoses and Collaborative Problems vNursing care of the client
34、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 Collaborat
35、ive Problems v1 Impaired airway Clearance related to the block of airway caused by trauma. v2 Risk for infection related to trauma v3 Impaired physical mobility related to the pain caused by trauma v4 Spiritual distress v5 Post-trauma response v6 Risk for trauma Nursing Intervention vThe client who
36、has suffered multiple is at great risk for developing airway obstruction and apnea(窒息). v Facial injuries, loose teeth, blood, and vomitus (呕吐物)increase the risk for aspiration(误 吸) and obstruction. vNeurologic injuries and cerebral edema(脑水 肿) alter the clients respiratory drive and ability to keep
37、 the airway clear. v 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: v 1 Facial trauma v 2 Debris(异物) in the airway, such as teeth ,blood, or vomitus v 3 Stridor(喘鸣) v 4 Tachypnea (呼吸急促) v 5 Bradypnea
38、 (呼吸缓慢) v 6 Cough (咳嗽) v 7 Cyanosis (紫绀) v 8 shortness of breath. v 9 Decreased or absent breath sounds. vNurses also need to monitor oxygen saturation. Oxygen flow is adjusted to maintain the clients oxygen saturation from 94%100%. Risk for infection v Traumatic injuries are considered dirty wounds
39、. The trauma often occurs in a dirty environment. Nursing intervention with rationales(基本理论) are as follows: v 1 Use careful hand washing practices. Hand washing remains the single most important factor in preventing the spread of infection. v 2 Use strict universal precautions. (全面防护)The use of uni
40、versal precautions is essential in protecting the client and the nurse from injection. v3 When applying or changing dressings(敷料 )use strict aseptic technique. v4 Take and record vital signs v5 Provide adequate fluids and nutrition. v 6 Use strict aseptic technique when inserting catheters, suctioni
41、ng ,administering parenteral (肠外的) medications,or performing any other invasive procedure. Impaired physical mobility vThe 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
42、(胃肠 道), respiratory(呼吸), musculoskeletal(肌 肉骨骼) ,and renal systems(泌尿系统). vNursing intervention with rationales are as followed v1 Provide active or passive exercises at least once every 8 hours. v2 Turn, cough, and deep breath at least every 2 hours. v3 Monitor the lower extremities each day for ma
43、nifestation of deep vein thrombosis. Spiritual distress vTrauma 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. vThe traumatic death of a loved one may be the most difficult
44、 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 vPost-trauma response is an intense, sustained emotional, response to a disastrous event. This response is characterized by emo
45、tions that range from anger to fear and by flashbacks or psychic numbing(反应麻木). vIn 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
46、 traumatic event. vThe client may call on ineffective coping mechanisms, such as the use of alcohol or drugs ,and withdraw from relationship with others. v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。 vPost-traumatic stress disorder v创伤后应激障碍 v 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
47、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。 vNursing intervention with rationales are as follows: v1 Assess the clients emotional responses while providing physical care. Observe for crying, suspiciousness, and fear during the initial phase of trea
48、tment. 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。 v2 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。 vThe client may initially deny negative fe
49、eling; this denial is a coping mechanism in the initial phase of recovery. v 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。 v3 Teach relaxation techniques, such as deep breathing , progressive muscle relaxation, or imagery. v教给放松技术,就如深呼吸,渐渐的肌肉放松 和想象。 v4 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 ef
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