创伤病人护理优秀课件.ppt

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1、创伤病人护理第1页，本讲稿共80页【概述】v 创伤创伤(trauma)有广义和狭义之分，广义的是指机械、物理、化学或生物等因素造成的气伤；狭义的是指机械性致伤因素作用于机体所造成的组织结构完整性破坏或功能障碍。v 临床多见的是机械性致伤因素作用于机体所致的损伤，如工伤事故、交通事故等导致的却软组织破损、出血、脏器破裂、骨折、关节脱位等。第2页，本讲稿共80页v In the past,the term trauma has been associated with the word accident.vAccident means that the injury ocurred without

2、 intent,just a result of random chance.We now know that considerable number of injuries are preventable and not of random chance.Intentional and nonintentional trauma encompasses a variety of injuries resulting from motor vehicle crashes,pedestrian injuries,gunshot wounds,falls,voilence towards othe

3、rs,or self-inflicted violence.vThe injuries,disabilities,and deaths resulting from these acts constitute a major healthcare challenge.第3页，本讲稿共80页Role of Nurses vTrauma usually occurs suddenly,leaving the patient and family with little time to prepare for its consequences.vTrauma may alter the patien

4、ts previous way of life,potentially effecting independence,mobility,cognitive thinking,and appearance.vNurses provide a vital link in both the physical and psychosocial care for the injured patient and family.v In caring for the patient who has experienced trauma,nurses must consider not only the in

5、itial physical injury,but also its long-term consequences,including rehabilitation.第4页，本讲稿共80页v由于创伤往往是突然发生的，患者和家属没有足够时间来应对创伤带来的各种不良后果。而护士对于患者及家属身体的、心理社会的安抚照料发挥着重大作用。护士在护理创伤患者过程中不仅要考虑其最初的身体伤害，还要拟定后期康复等长远护理计划，因为创伤对于患者的影响可能不单涉及到生活方式的改变，还可能潜在地影响其独立性，生活活动能力，认知能力以及外表形象。第5页，本讲稿共80页Types of Trauma vGenerall

6、y,trauma can be classified as:minor trauma major trauma第6页，本讲稿共80页vMinor traumacauses injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department.veg.a fracture of the clavicle,a small second-degree burn,and a laceration（撕裂伤）req

7、uiring sutures(缝合)第7页，本讲稿共80页vMajor or Multiple traumainvolves serious single-system injury(such as the traumatic amputation截肢 of a leg)or multiple-system injuries.第8页，本讲稿共80页vSpecifically,trauma is further classified as either blunt or penetrating第9页，本讲稿共80页Blunt traumavBlunt traumaoccurs when ther

8、e is no communication between the damaged tissues and the outside environment.vBlunt forces often cause multiple injuries that may affect the head,spinal cord,bones,thorax(胸腔)，and abdomen.Blunt trauma is frequently caused by motor vehicle crashes,falls,assaults,and sports activities.第10页，本讲稿共80页Blun

9、t traumavIt includes:contusion(挫伤)sprain（扭伤）crush injury（挤压伤）concussion（震荡伤）luxation and semiluxation（关节脱位和半脱位）closed fracture（闭合性骨折）closed internal injury（闭合性内脏损伤）第11页，本讲稿共80页Penetrating traumav Penetrating traumaoccurs when a foreign object enters the body,causing damage to body structures.vStruct

10、ures commonly affected include the brain,lungs,heart,liver,spleen,the intestines,and the vascular system.v Examples of penetrating trauma are gunshot or stab wounds(刺伤),impalement（穿刺）,and incised injury(切割伤).第12页，本讲稿共80页Other typesvOther types：inhalation injuries from gases,smoke,steam,burn or freez

11、ing injuries blast injuries from explosions第13页，本讲稿共80页 Classes of Trauma vOutcome studies show a correlation between survival rates of multiple trauma victims and rapid respose times by pre-hospital providers,coupled with appropriate decision making with regards to transporting victims.大量有关创伤的结局研究显

12、示，多发伤患者的存活率与院前急救者的快速反应及采取正确急救措施相关。第14页，本讲稿共80页Classes of Traumav Trauma patients are classified as Class 1,2 or 3 based on factors,including：mechanism of injuries,vehicle speed,height of falls,location of penetrating injuries.第15页，本讲稿共80页vClass 3 trauma the least severe,without loss of consciousness

13、 or significant injury.vClass 1 trauma the most severe,involves life-threatening injuries likely to require medical specialists or immediate surgical intervention.So what is Class 2 trauma?第16页，本讲稿共80页vAny hospital emergency department should be capable of caring for Class 3 trauma patients,patients

14、 meeting Class 1 or 2 should be transported to a designated trauma center when possible.第17页，本讲稿共80页【病理生理】v（一）局部反应 损伤后，局部血管通透性增加、血浆成分外渗，白细胞等趋化因子迅速集聚于伤处以吞噬和清除致病菌或异物，出现疼痛、发热表现，其病理过程与一般炎症相同，一般35日后逐渐消退。v（二）全身反应 损伤可引起神经内分泌活动增强，组织功能和代谢发生应激性改变。1、发热：损伤释放炎性介质和细胞因子作用于下丘脑体温调节中枢引起机体发热。第18页，本讲稿共80页【病理生理】v 2、神经内分

15、泌系统反应：疼痛、血容量不足，下丘脑-垂体-肾上腺皮质轴、交感神经肾上腺髓质轴分泌大量儿茶酚胺，以及肾素-血管紧张素醛固酮系统被激活，代偿性保证回心血量。v 3、代谢反应：基础代谢率增高，分解代谢增强导致负氮平衡；表现体重下降，疲乏无力、反应迟钝。水电解质代谢紊乱，可致水钠潴留。v 4、机体免疫力下降：严重损伤可致机体免疫防御能力下降（中性粒细胞、单核-巨噬细胞吞噬和杀菌能力减弱，淋巴细胞数量减少、功能降低等），易发生感染。第19页，本讲稿共80页【病理生理】（三）损伤的修复v、修复的基本方式：完全修复：即缺损组织完全由原来性质的组织细胞修。（愈后结构功能与原组织相同）不完全修复：是由成纤维细

16、胞增生替代代替原来的组织，而形成瘢痕愈合。第20页，本讲稿共80页v、损伤的修复过程（三阶段）：（1）炎性反应阶段：约35天。主要为血管和细胞反应、免疫应答、血液凝固和纤维蛋白溶解，伤口由血凝块充填；而后，血浆纤维蛋白沉积构成网架，封闭创口，为组织再生和修复奠定基础。（2）肉芽形成阶段：成纤维细胞、内皮细胞等经增殖、分化、迁移，形成肉芽组织充填伤口，形成瘢痕愈合。（3）组织塑形阶段：胶原纤维交联和强度的增加，多余的胶原纤维被降解和吸收，过度丰富的毛细血管网逐步消退，伤口黏蛋白和水分减少，伤部外观和功能得到改善。第21页，本讲稿共80页v、损伤的愈合类型 （1）一期愈合：又称原发愈合。伤口修复以

17、原来的细胞为主，仅含少量纤维组织，伤口边缘整齐、严密、呈线状，组织结构和功能修复良好。见于创伤轻、范围小、无感染的伤口。（2）二期愈合：又称瘢痕愈合。伤口修复以纤维组织为主，需周围上皮逐渐覆盖或植皮后才能愈合。局部结构和功能有不同程度的影响，多见于组织缺损较大、感染或异物存留的伤口。第22页，本讲稿共80页v4、影响损伤愈合的因素v （1）局部因素：细菌感染；创口内异物；血运障碍；特殊部位（如关节处）v （2）全身性因素：年龄（老年人）；慢性疾病：如糖尿病、结核、肿瘤等；营养状况：营养不良或肥胖；药物：抑制细胞增生药(如皮质类固醇)；免疫功能低下。第23页，本讲稿共80页Clinical Ma

18、nifestationvSymptom:pain fever Systemic Inflammatory Response Syndrome (SIRS)第24页，本讲稿共80页【临床表现】v（一）症状：1、疼痛：2、发热：3、全身炎症反应综合征(SIRS)：表现：体温38OC或90次分钟；呼吸20次分钟或过度通气，PaC0212X109L或0.1。4、其他：可伴有食欲减退、倦怠和失眠等第25页，本讲稿共80页Clinical ManifestationvSigns:P、R、BP wound and hemorrhage tenderness(压痛)and swell dysfunction

19、第26页，本讲稿共80页【临床表现】v（二）体征v 1、生命体征改变(P、R、BP）v 2、创口和出血v 3、压痛和肿胀v 4、活动或功能障碍 第27页，本讲稿共80页【辅助检查】v（一）实验室检查 1、血常规和红细胞比容（失血、感染）。2、尿常规、尿淀粉酶检查（泌尿系和胰腺的损伤）。3、血生化检查：肾功能检查肾损伤；淀粉酶检查胰腺损伤；血电解质检测和血气分析。第28页，本讲稿共80页【辅助检查】v（二）影像学检查 1、X线透视或摄片：可证实有无骨折、脱位、金属异物存留和胸、腹腔内游离气体。2、CT和MRI：主要用于颅脑损伤的检查。MRI对脊髓、颅底、骨盆底部等处损伤的诊断具优越性。3、B超检

20、查：实质性器官损伤和腔内积液。第29页，本讲稿共80页【辅助检查】v（三）诊断性穿刺：内脏器官破裂、出血。v（四）置管灌洗检查：诊断性穿刺不能明确诊断，可穿刺后置导管灌洗，抽取灌洗液作检查（如腹腔灌洗）。v（五）监测中心静脉压 可判断血容量和心功能。第30页，本讲稿共80页Effects of Traumatic Injury 创伤后效应和结果创伤后效应和结果第31页，本讲稿共80页vDeath is a common result of serious traumatic injury,and may be immediate,early,or late.Immediate.v Becaus

21、e of the serious consequences of trauma,it is important to rapidly identify the patients injuries and institute appropriate interventions quickly.第32页，本讲稿共80页vHead and Neck EffectsvThoracic Effects vHemorrhage vAbdominal EffectsvNeurologic Effects v Multiple Organ Dysfunction Syndromes(MODS)第33页，本讲稿

22、共80页Head and Neck Effects第34页，本讲稿共80页Head and Neck Effects vAirway Obstruction Maintenance of the airway and cervical spine（颈椎）（颈椎）are the highest priority in the trauma patient.Head and Neck Effects 第35页，本讲稿共80页Assessment vAssessment includes：determining airway patency.reassess the effectiveness of

23、 the intervention.assess the effectiveness of breathing.Head and Neck Effects 第36页，本讲稿共80页Determining airway patencyvIf the patient is unresponsive,manual opening of the airway using a jaw thrust maneuver（托下颌法托下颌法)is necessary vThe jaw thrust maneuver is recommended in patients with actual and poten

24、tial C-spine injury.Head and Neck Effects 第37页，本讲稿共80页Determining airway patencyvOnce the airway is opened,the practitioner must identify any potential obstruction from the tongue,loose teeth,foreign bodies,bleeding,secretions,vomitus,or edema.If the patient is responsive and can vocalize,that is a

25、good indication that the airway is clear.Head and Neck Effects 第38页，本讲稿共80页Reassess the effectiveness of the interventionvFor example,if you suction(吸，抽吸)the airway to remove vomitus,you would reassess the airway after suctioning to determine if that intervention was successful or if you have to re-

26、suction the airway a second time.Head and Neck Effects 第39页，本讲稿共80页Reassess the effectiveness of the interventionvIn addition to suctioning,other airway adjuncts available include oral or nasal pharyngeal(鼻咽部)airways,laryngeal（喉部）airway and endotracheal intubation(气管内插管气管内插管).Intubation is the prefe

27、rred method of airway management.第40页，本讲稿共80页Assess the effectiveness of breathing vAssessment should include if the patient has spontaneous breathing（自主呼吸）,good rise and fall of the chest,determination of skin color,general rate and depth of respirations,abdominal or accessory muscle use,position o

28、f the trachea（气管）,observation of chest wall（胸壁）integrity，presence of jugular vein distension(颈静脉怒张)as well as the presence of any surface trauma.第41页，本讲稿共80页 Trauma patients may exhibit several aspects of airway management that are unique and require special preparation and precautions.Head and Neck

29、 Effects 第42页，本讲稿共80页Closed head injury vChanges in hemodynamics,oxygenation,and ventilation should be minimized in order to maintain adequate cerebral perfusion pressure(脑灌注压).vThe goal is to maintain a PaCO2 of 30-35mmHg.Head and Neck Effects 第43页，本讲稿共80页Closed head injuryvBut intubation can cause

30、 a marked increase in intracranial pressure(ICP,颅内压颅内压),and also lidocaine administered 3-5minutes prior to intubation can blunt（使减弱）an increase in ICP that is secondary to laryngeal stimulation（喉部刺激）.vBeta blockers（普萘洛尔、阿替洛尔普萘洛尔、阿替洛尔）can be given 2-3 minutes prior to intubation to attenuate the sym

31、pathetic(交感神经的交感神经的)response in a normotensive patient.Head and Neck Effects 第44页，本讲稿共80页Maxillofacial trauma颌面部创伤颌面部创伤 vSignificant distortion of normal anatomy in facial trauma and respiratory compromise(呼吸道损害)is not uncommon.vA surgical airway may be the only alternative.Head and Neck Effects 第45

32、页，本讲稿共80页Direct airway trauma vPenetrating trauma to the neck is associated with a high degree of morbidity and mortality.v Airway involvement includes dyspnea,cyanosis,subcutaneous emphysema,hoarseness.Head and Neck Effects dyspnea dispni:呼吸困难，cyanosis,sainusis发绀，emphysema,emfisi:m皮下气肿，hoarseness嘶哑

33、第46页，本讲稿共80页Direct airway traumavOrotracheal intubation is the technique of choice.vThe key is early identification of the need for intubation before the patient has no airway at all.Head and Neck Effects Orotrachealr trt i:l intubation 口腔气管插管第47页，本讲稿共80页Cervical spine injury vApproximately 3%-6%of

34、major trauma victims have clinically significant C-spine injuries.vOral intubation with manual in-line axial head and neck stabilization(MIAS，头颈，头颈部的轴向固定部的轴向固定)is a safe method.Head and Neck Effects Cervical spine 颈椎，axial axial ksl轴向的 第48页，本讲稿共80页Burns vBurn patients with airway compromise require

35、aggressive management(紧急处理紧急处理).vUpper airway edema associated with inhalation can progress during the post burn phase.So securing an airway sooner than later is the goal.Head and Neck Effects 吸入性烧伤患者需要紧急处理。烧伤后期上呼吸道水肿导致呼吸不畅会越来越重，因此应尽早采取措施保护气道。第49页，本讲稿共80页Thoracic Effects Thoracic rsk 胸的第50页，本讲稿共80页T

36、ension pneumothorax vA pneumothorax results when air enters the potential space between the parietal and visceral pleura.vAir present in the pleural space will eventually collapse the lungs.vA tension pneumothorax is life-threatening and requires immediate intervention.Thoracic Effects pneumothorax,

37、nju:m:rks高压性气胸，张力性气胸，parietal praiitl腔壁的，visceral visrl内脏的，pleura plur胸膜，thorax rks 胸廓，胸膛第51页，本讲稿共80页Tension pneumothoraxvOn inspiration air enters the pleural space（胸膜腔）（胸膜腔）,does not escape on expiration,and increases the intrapleural(胸膜内的)pressure.vThis pressure collapses the injured lung,shifts

38、the mediastinal contents，compressing the heart,great vessels,trachea and eventually the uninjured lung.vIn turn,this causes the following signs and symptoms:Severe respiratory distress;Hypotension;Jugular vein distension;Tracheal deviation(气管偏移气管偏移)toward the uninjured side;Cyanosis.Thoracic Effects

39、 mediastinal,mi:distinl 纵隔的,trachea(气管),Cyanosis,sainusis(发绀).第52页，本讲稿共80页Tension pneumothoraxvThe immediate short-term life-saving intervention is a needle thoracostomy:inserting a large bore over the needle catheter into the second intercostal space（第二肋间）（第二肋间）at the mid-clavicular（锁骨的)line(MCL,锁骨

40、中线).Thoracic Effects needle thoracostomy,:rkstmi,u-(胸腔穿刺造口术)，intercostal(肋间的)第53页，本讲稿共80页Flail chest连枷胸连枷胸 vFlail chest is the fracture of tow or more ribs in two or more separate locations,leading to an unstable thoracic wall（胸壁）segment.vParadoxical movement（反常运动）（反常运动）of the chest wall is seen wit

41、h the area sinking into the chest cavity(胸腔)with inspiration and protrusion（突出）with expiration.vThe area must be supported quickly to re-establish the thoracic bellows effect.（塌陷区域需要修复以重建胸廓的呼吸运动）Thoracic Effects protrusionprtrun 突出第54页，本讲稿共80页Hemorrhage Hemorrhage hemrd 出血 第55页，本讲稿共80页Hemorrhage vWh

42、en the patient has suffered an injury that causes external hemorrhage,such as severing(切割，分离切割，分离)of an artery,the bleeding must be controlled immediately.vThis may be done by applying direct pressure over the wound and applying pressure over arterial pressure points.vOnce the source of internal hem

43、orrhage has been recognized,interventions are initiated,including operative control of bleeding and continual assessment of the patient.Hemorrhage may result in hypovolemic shock(低血容量性休克).Hemorrhage 第56页，本讲稿共80页HemorrhagevInternal hemorrhage may result from either blunt or penetrating traumatic inju

44、ry.vDiscovering the cause and location of the injury,as well as the extent of related blood loss,are the most important concerns.Hemorrhage 第57页，本讲稿共80页HemorrhagevSeveral potential spaces in the body can accommodate large amounts of blood that may accumulate(called third spacing)following injury.v F

45、or example,bleeding into the pleural space may occur with chest trauma(hemothorax,血胸)，and bleeding into the abdominal cavity may occur with abdominal trauma.A pelvic fracture may cause massive hemorrhage in the retroperitoneal region.Hemorrhage pelvic pelvik骨盆的，retroperitoneal retru,peritni:l腹膜后的第58

46、页，本讲稿共80页Abdominal Effects 第59页，本讲稿共80页Abdominal EffectsvThe abdomen contains both solid organs(liver,spleen,and pancreas)and hollow organs(stomach and intestines):Direct trauma to the abdomen can lacerate(撕撕碎碎)and compress the solid organs and cause burst injuries to the hollow organs.Blood vessels

47、 may be torn and organs may be displaced from their blood supply,producing life-threatening hemorrhage.Abdominal Effects 第60页，本讲稿共80页Abdominal EffectsDamage to the mesenteric vessels(肠系膜血肠系膜血管管)supplying the bowel can result in bowel ischemia and infarction(梗塞).Injury to the stomach,pancreas,and sma

48、ll bowel may allow digestive enzymes to leak out into the abdominal cavity.Rupture of the large bowel results in escape of feces,which causes peritonitis.Abdominal Effects mesenteric,mesnterik肠系膜，infarction inf:kn梗塞，enzymes enzaims 酶abdominal cavity 腹腔，Rupture 破裂，使破裂，peritonitis,peritnaitis腹膜炎第61页，本

49、讲稿共80页Neurologic Effects第62页，本讲稿共80页Neurologic EffectsvInjuries to the spinal cord(脊髓)，resulting in loss of neurologic function,are devastating outcomes of trauma,but they are much less common than head injuries.v Care of the patient with a neurologic injury is discussed in later unit.Abdominal Effe

50、cts 第63页，本讲稿共80页Multiple Organ Dysfunction Syndromes(MODS)第64页，本讲稿共80页MODSvMultiple organ dysfunction syndrome(MODS)is a common complication of severe injury and a frequent cause of death in intensive units.vIt is a progressive impairment of two or more organ systems.Multiple Organ Dysfunction Syndr