硬膜下血腫語教學(xué)查房ppt課件

1、護(hù)理護(hù)理教學(xué)教學(xué)查房查房teaching wardteaching wardround of nursinground of nursingsubdural hematoma硬膜下血腫硬膜下血腫 目錄目錄 contents查房目的 purpose1病例匯報 case presentation23護(hù)理措施 nursing intervention6 65出院指導(dǎo) health ducation 護(hù)理診斷 nursing diagnosis專科知識 specialist knowledge4教學(xué)目標(biāo)教學(xué)目標(biāo) teaching objectivesteaching objectives*1 1、un

2、derstand the understand the related knowledge related knowledge about the subdural about the subdural hematomahematoma*2 2、master nursing master nursing diagnosis and diagnosis and nurnur- - inging measures about measures about the subdural the subdural hemathemat- - omaoma*1 1、理解硬膜下血腫、理解硬膜下血腫的相關(guān)知識的

3、相關(guān)知識*2 2、掌握硬膜下血腫掌握硬膜下血腫的護(hù)理診斷和護(hù)理措的護(hù)理診斷和護(hù)理措施施教學(xué)目標(biāo)教學(xué)目標(biāo) teaching objectivesteaching objectives3 3、掌握硬膜下引流掌握硬膜下引流的相關(guān)的相關(guān)知識知識3 3、getting to know the getting to know the related knowledge ab- related knowledge ab- out sout subdural drainageubdural drainage病例匯報病例匯報 case reportcase report體格體格檢查檢查 physical exa

4、minationphysical examination*t p beats/min r t p beats/min r times / min bp mmhg times / min bp mmhg *g general:normaleneral:normal development development good nutrition good nutrition*consciousnessconsciousness：consciousconscious*p pupilupil：both sides pupil both sides pupil equal and round, 3mm e

5、qual and round, 3mm diameterdiameter，light reflex light reflex sensitivitysensitivity * physical examinationphysical examination：left side - autonomic left side - autonomic activity, normal muscle activity, normal muscle tonetone *right side autonomic right side autonomic activity, normal muscle act

6、ivity, normal muscle tonetone *體溫 脈搏次/分 呼吸次/分 血壓mmhg*一般情況：發(fā)育正常，營養(yǎng)良好*意識清醒*瞳孔：雙側(cè)瞳孔等大等圓,直徑3mm,對光反射靈敏*四肢查體:左側(cè)-自主活動,肌張力正常*右側(cè)自主活動,肌張力正常 一一、定義、定義 definitiondefinitionsubdural hematoma refers to the bleeding in the subdural space between the endocranium and the arachnoid) and it is one o f t h e c o m m o n

7、 intracranial hematomas. it is divided into three types, i.e., acute, subacute and chronic subdural hematomas.硬膜下血腫是指出血集聚在硬膜下隙（硬腦膜與蛛網(wǎng)膜之間）的出血，是常見的顱內(nèi)血腫之一。分急性，亞急性和慢性三種。 輔助檢查 auxiliary examination *ct checkct檢查extradural hematomaextradural hematomasubdural hematomasubdural hematomaintracerebral hematoma

8、intracerebral hematoma 三、三、 病因病因 cause cause of diseaseof diseaseviolence or indirect violent factors暴力或間接暴力因素四、四、 臨床表現(xiàn)臨床表現(xiàn) clinical clinical manifestationmanifestation1,acute and subacute subdural 1,acute and subacute subdural hematomas: disturbance of hematomas: disturbance of consciousness occurs

9、 from the consciousness occurs from the period of a few hours after period of a few hours after injury to 1-2 days; often, injury to 1-2 days; often, increased intracranial increased intracranial pressure and cerebral hernia pressure and cerebral hernia symptoms (headache, nausea, symptoms (headache

10、, nausea, h y p e r e m e s i s ) a r e h y p e r e m e s i s ) a r e progressively aggravated in progressively aggravated in 1-3 days.1-3 days.2, chronic subdural hematoma: 2, chronic subdural hematoma: symptoms of chronic increased symptoms of chronic increased intracranial pressure: intracranial

11、pressure: headache, nausea, vomiting headache, nausea, vomiting and optic disc edema.and optic disc edema.1、急性和亞急性硬膜下血腫：傷后數(shù)小時至1-2日意識障礙，顱內(nèi)壓增高及腦疝的征象（頭痛、惡心、嘔吐劇烈）多在1-3日內(nèi)進(jìn)行性加重。2、慢性硬膜下血腫：慢性顱內(nèi)壓增高表現(xiàn)：頭痛，惡心，嘔吐，視神經(jīng)盤水腫。五、意識狀態(tài)的評估五、意識狀態(tài)的評估 assessment of the state of consciousnessgcs評分包括哪幾部分內(nèi)容？五五、意識、意識狀態(tài)的評估狀態(tài)的評估 a

12、ssessment of the state of consciousnessglasgow rating:最高分為最高分為1515分，表示意識清楚；分，表示意識清楚；12121414分為分為輕度；輕度；9 91111分為中度；分為中度；8 8分以下為昏迷；最低分以下為昏迷；最低3 3分，分?jǐn)?shù)越分，分?jǐn)?shù)越低則意識障礙越重低則意識障礙越重。六、治療要點(diǎn)六、治療要點(diǎn) major treatmentmajor treatment處理原則：一經(jīng)確診，通常以手術(shù)清除血腫。treatment principlestreatment principles： once confirmed，usuallyrem

13、ove the hematoma by operation.治療要點(diǎn)therapy highlights常用藥物：甘露醇、速尿、甘油果糖、地米、白蛋白應(yīng)用止血和抗凝藥物 防止再出血prevent rebleeding凝血障礙疾病所致必須應(yīng)用進(jìn)行降壓處理常用的藥物尼莫地平、硝普鈉、速尿急性期血壓驟降提示病情危重常用的脫水利尿劑藥物：甘露醇、甘油果糖、速尿。 控制血壓control blood pressure 控制腦水腫 control edema降低顱內(nèi)壓 reduce icp1 , b r a i n p e r f u s i o n abnormalities： related to h

14、igh intracranial pressure2,pain : related to operation3,self-care deficiencies： related to consciousness disorder and operation4, hyperthermia： related to absorption of hematoma1、腦組織灌注異常：與顱內(nèi)壓升高有關(guān)；2、疼痛: 與手術(shù)有關(guān)3、自理能力缺陷：與意識障礙及手術(shù)有關(guān)4、體溫過高 與血腫吸收有關(guān)6, potential complications：brain hernia, constipation, cathe

15、ter shedding, epilepsy, pressure sores, and so on6、潛在并發(fā)癥：腦疝，便秘，導(dǎo)管脫落，癲癇，壓瘡等急性期絕對臥床休息，避免不必要的搬動。 lying in bed避免情緒波動。 emotional stability保持病房安靜、光線柔和，減少探視. quiet抬高床頭1530，促進(jìn)腦部血液回流，減輕腦水腫，保持術(shù)區(qū)引流通暢。 smooth drainage密切觀察患者意識、瞳孔、生命體征的變化。consciousness 、vital signs 監(jiān)測血壓，保持血壓平穩(wěn)。 blood pressure stablebrain perfusio

16、n abnormalities2、疼痛的護(hù)理措施pain（1）鼓勵病人說出疼痛的感覺，給予心理安慰 encoursge console（2）各種護(hù)理工作應(yīng)準(zhǔn)確輕柔，減少不必要痛苦 soft work（3）教會病人分散注意力，如聽輕音樂、聊天、緩慢深呼吸等。distraction（4）密切觀察疼痛程度，必要時遵醫(yī)囑使用止痛劑（如氨基比林咖啡因片等）amidopyrine caffeine tablets3、自理能力缺陷的護(hù)理 self-care deficiencies吸氧：持續(xù)吸氧，可提高血氧含量。 oxygen基礎(chǔ)護(hù)理：晨、晚間護(hù)理每日一次。 life care皮膚護(hù)理：定時翻身，按摩受壓部

17、位皮膚。 skin care保持肢體功能位，避免受壓，維持關(guān)節(jié)韌帶的活動度，防止肌肉萎縮。 orthostatic保持二便通常：鼻飼新鮮的蔬菜和水果。按摩腹部，促進(jìn)腸蠕動，注意做好肛周護(hù)理。 toilet4、體溫過高的護(hù)理 降低體溫：患者住院期間體溫最高為38.3，可采用物理降溫，如溫水擦浴。 lower the temperature加強(qiáng)監(jiān)護(hù)：觀察生命體征，定時測體溫. monitor monitor補(bǔ)償營養(yǎng)和水分：鼻飼充足的溫開水，予高熱量、高蛋白、高維生素、易消化的流質(zhì)或半流質(zhì)飲食。 nutrition促進(jìn)患者舒適：囑患者多休息。 comfort5、預(yù)防再出血的護(hù)理預(yù)防再出血的護(hù)理 pr

18、evention of further hemorrhage嚴(yán)密控制血壓，避免血壓過高； control bp密切觀察生命體征、意識、瞳孔的變化，如有異常立即報告醫(yī)生。 monitor避免搬動：病情危重者發(fā)病初24-48小時內(nèi)避免搬動，12小時內(nèi)大幅度翻身。 avoid moving保持大便通暢，避免屏氣用力，劇烈咳嗽、打噴嚏等。avoid hard觀察有無劇烈頭痛：伴惡心、嘔吐。 headache觀察瞳孔變化：兩側(cè)瞳孔是否等大等圓，對光反射的靈敏度。 pupil觀察意識狀態(tài)：通過交流、疼痛刺激及肢體活動情況來判斷意識障礙程度。 consciousness觀察生命體征：血壓升高、脈搏變慢、呼吸

19、深慢，是顱內(nèi)壓增高的早期癥狀。 vital signs保持呼吸道通暢，按需吸痰，及時清除口鼻分泌物和嘔吐物，持續(xù)吸氧。 airway7、硬膜下引流管的護(hù)理（1）、嚴(yán)格無菌操作，妥善固定引流管并保持通暢，每日更換引流袋。（2）、引流高度1015cm，并根據(jù)引流液的顏色、速度遵醫(yī)囑調(diào)節(jié)高度。每日引流量應(yīng)小于300ml。觀察并記錄引流液的性狀和量7、subdural drainage tube（1）,strict aseptic operation,properly fixed drainage tube and maintain patency, daily change drainage bag

20、（2）, drainage height 10 15 cm, and according to the color, drainage of liquid, speed adjustable height in accordance with the doctors advice. the daily traffic should be less than 300 ml. observe and write down the quantity and the volume on the properties of liquid7、subdural drainage tube care（3）, drainage time, 3 4 days after craniotomy, 5 7 days after surgery（4） after extubation watch consciousness, pupil, blood pressure . dressing clean and dry。7、硬膜下引流管的護(hù)理（3）、引流時間，開顱術(shù)后