院區(qū)-燒傷科二十病區(qū)

常州市第二NURSINGWARDROUNDOFABURNPATIENT一例燒 的護理查TheHospital-WideEnglishNursingWardRoundTHEDEPT.OF德技雙 至Teammembers團隊成Liu Dept.of Zhou FuZhenYuTangQi

Dept.ofCardiologyDept.ofTraumaticBengbuMedicalCollege蚌埠醫(yī)學(xué)德技雙 至MainContents主要內(nèi)BASICKNOWLEDGEOF疾病基本知MEDICAL病NURSINGDIAGNOSISESAND護理診斷及措DISCHARGE出院指德技雙 至MainContents主要內(nèi)請周微為我們介紹疾病相關(guān)知德技雙 至MainContents主要內(nèi)BASICKNOWLEDGEOF疾病基本知MEDICAL病NURSINGDIAGNOSISESAND護理診斷及措DISCHARGE出院指德技雙 至BasicKnowledge基本知Burn:Itgenerallyrefersthatthe(includinghotliquid, ,hotgas,fire,electricity,chemicalsandradiation,hotmetalliquidorsolid...)leadstotissuedamage.Itmainlyreferstothedamageoftheskinorthemucousmembrane,forseriousinjuryandotherorganizationsaswell.Theburnscausedbyhotliquidaretermedasthethermaldamageof

德技雙 至BasicBurnarea：theChineseRuleof燒傷面積 中國新九分德技雙 至335657131313

Basic (doublehandsdoubleforearmdoubleupperarm) doublefeet (frontbodybackbody Adultfemale'ship,doublefeetbothare雙手雙前臂雙上臂臀部雙足小腿大腿前軀干后軀干部 至BasicFirst-degreeburnisthelightest.Itusuallydamagetheskinstratumcor transparentlayer,granularlayer. 德技雙 至BasicSuperficialseconddegreeburnincludetheentireepidermis,untilthegerminallayer,ordamagethedermalpapillalayer.德技雙 至BasicDeepseconddegreeburnincludethepapillarydermisfollowingtheinjury,butthereisstillapartofthedermis. 德技雙 至BasicThirddegreeburnincludefull-thicknessskindamage,epidermis,dermisanditsaccessoriesallhavebeendestroyed.德技雙 至BasicFourthdegreeburndamagemuscleandevenbone,internalorgans,etc.德技雙 至BasicDeterminationofburn 表皮真肌肉、肌腱、筋膜德技雙 至Gradingofburn燒傷分Gradingofburndegreein1970NationalBurnMildburnThetotalarealessthan10%ofⅡdegreeModerateburnThetotalareaof11%-30%ordegreeburnareaunder輕度總面積10中度總面積11%-30%或Ⅲ度燒傷面積9德技雙 至BasicGradingofburndegreein1970NationalBurnSevereburnThetotalareain31%-50%orⅢdegreeburnarea10%-19%orburnarealessthan31%，Butthereisoneofthefollowingsituations:(1)Wholebodyorseverecaseshaveshock(2)compoundinjury(severetrauma,defense,radiationinjury,chemicalpoisoning,etc.)(3)modera ysevererespiratorytractburn(respiratoryspreadbelowthethroat)重度總面積在31%-50%或Ⅲ度燒傷面積10%-19%或燒傷面積 呼吸道燒傷（呼吸道波及喉以下者德技雙 至BasicGradingofburndegreein1970NationalBurnExtremelysevereThetotalareaof50%ormore,orⅢdegreeburnareaof20%andabove,orwithserious

44.特重?zé)齻录茧p 至BasicBurnsfirstaid Mildburn:wash--takeoff--immerse--cover-- Severeburn:quicklyoutofheat,savelives,preventshock,protectsurfaceofburn,rapid

德技雙 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSISESANDDISCHARGE德技雙 至GeneralInformationBednumberAdmissionNumber

德技雙 至GeneralDateofAdmission:2015-08-11Chiefcomplaint:multiplebodyhotoilburnswithpainforhalfanhourbodyhotoilburns,Ⅱ-Ⅲdegree,60%burnarea

度60%德技雙 至General德技雙 至DiseaseHistory疾病Presenthistory:InAugust11,around09:00,thepatientwasburnedbyhotoilonthebody,limbsandhips,feelingwoundpainwithagreatnumberofblistersformed,partialepidermalshedding.Aftertreatedwithcoldwaterwashing,thepatientwassenttoourhospitalimmedia Pasthistory:healthstatewas

現(xiàn)病史：患者8月既往史德技雙 至一般情況一般情況TPRBPTPRBP德技雙 至PhysicalSpecialistThebody,limbs,andhipswereburnedwithwoundswelling.Burnedskinhasdifferentdimensionalblisters,partialexfoliation,itwasredandwhiteinbasal,exudating.

肢和燙傷，創(chuàng)面德技雙 至Laboratory 檢Positive Tip:irritablyimpairedliverfunction,nootherabnormalcondition

γ-谷氨酰轉(zhuǎn)移 乳酸脫氫 德技雙馨 至TreatmentPlan治療計系統(tǒng)的治療包括：抗休克，抗 Systemictreatmentincludinganti-shock,anti-infection,improvingmicrocirculation，improvingthecellmetabolism，protectingthekidney，preventingtheoccurrenceofstressulcerandblood德技雙 至TreatmentPlan重癥監(jiān)護、心24小時進出量，監(jiān)測中心靜脈壓，患肢抬高，注意末intensecare,electrocardiogrammonitoring,bloodoxygensaturationmonitoring,recordingurinevolumeofperhourand24hours’intakeandouttakevolume,raisingtheaffectedlimbs,observingpatients’peripheralblood德技雙 至TreatmentProcedure治療08- 08- 09-Gothroughtheshock

Rotatingbed

翻身床治 出院指德技雙 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSESAND護理診斷及措DISCHARGE德技雙 至2015-08-12,TangGuirongwentthroughfirst24hinourburnsdepartment.Thepatientisinacuteshockstageatthistime，atthisstage,generalnursingdiagnosesandmeasuresasfollows:年月日，唐桂榮入我科第一個24小時，患者此德技雙馨至Nursing Fluidvolumedeficitrelatedtolargeamountsofwoundexudate

護理診體液不足與大量液體滲出有 relatedtoskindamage,dressingchangeAnxietyrelatedtosuddentrauma

焦

與皮膚受損與突 有 Self-caredeficitrelatedtobeingconfinedtobed,

自理缺陷與臥床 有德技雙 至目標(biāo):患者生措施

Goal：thepatientwithstablevitalToevaluatepatient’sburnareaanddepth,toestimatevolumeofthewoundexudate,tocalculatetheamountofrehydrationcorrectlyWithin72hoursafterinjury,toobservetheurineoutputperhour,color,proportionofurineandrecordcarefully,accordingtotheamountofurine,toadjusttherehydrationrate德技雙 至護理措施輸入晶體、膠體,保水電解質(zhì)平衡

NursingObservethepatient'sconsciousnessandtheexpression,skin,mucousmembrane,peripheralbloodcirculation.Observepatient'svitalsignsandcentralvenouspressureandrecordInputcrystal,colloidreasonably,keepthebalanceofwaterandelectrolyteinaccordancewithdoctor’s準(zhǔn)確記錄24小時 1.6Record24hours’intakeandouttake 德技雙 至觀察、評估、記

Goal：thepatientcantoleratethe2.1Observe，estimate，andrecordthenatureanddegreeof疼痛性質(zhì)、程度、時間pain, 伴隨

護理2.2Conductnursing避免不良的

carefullyandavoidbad gesicdrugsinaccordancewiththedoctor‘sadviceandobserveitsclinicaleffect德技雙 至

Adjustcomfortablepostures,avoidlocalcompression

Explainthecauseofthepaintothepatient,withsymptomsandpreventivemeasuresCarryoutpsychologicalguidance,eliminatepsychologicalfactors德技雙 至措施充分調(diào)動的積極性，對的焦慮

Goal：Thepatient'sanxietylightensEvaluate degree warmandcomfortablehospitalenvironmentFullyarousepatients’enthusiasm,understandpatients’anxiety德技雙 至3.4向患者及家屬

Introducethepatientandfamilywithmethodsofburntreatment,howtotakecareandprognosis,andemphasizetheimportanceoffacingtherealityandclosecooperationwithdoctorsandnursesIntroducesuccessful

confidence ethe德技雙 至措施

Goal：NecessaryneedscanbemetduringlyinginbedEvaluatepatients’self-care協(xié)助生活護理，4.2Assistdailylife,provide腔清潔

helpin4.3Oralcaretwotimesaday,keepmouthclean，avoidcomplications發(fā)癥的發(fā) 德技雙 至EnglishNursingWardRoundFirstActNursesondutyareconductingnursingwardroundforthefirsttime......德技雙 至EnglishNursingWardRoundFirstAct德技雙 至Situational P:HiNb:HowdoyoufeelP:Iamwellnow,butalwaysthirstyand德技雙 至SituationalNa:Ok!Letmehavealook…oh,yoururinevolumeperhour,bloodpressureareallfine,butyourwoundissohuge,exudateisverymuch,youcouldalsobeinimbalanceofwaterandelectrolyte.Don’tworry,wehavetakensomemeasurestorecoverthebalance.德技雙 至Situationalhavingacheck?Nb:Now,IwillshowNb:Now,Iwillshowyouadrawing，itcanhelptotesthowmuchyouare德技雙馨至

SituationalNb:Lookhere.Thereisalinefromzerototen.zeromeansnopain,tenrepresentsextremepain.AndyoucanlocateP:Ididnotsleepwelllastnight.IthinkmypainscoreisNa:Didyoutrytoconvertyourattention?Forexample,listeningtomusic,medicating.

德技雙 至SituationalP:Ihave,butitdidnotNa:Youcanoftenchangeyourslee positioninordertoavoidpressingthewound.Nb:Youcanalsoraiseyourburnedlegsuptothelevelofyourheartinordertorelieveswelling.Ifyoustillcannotstandthepain, lus,wewillgiveyoursomepainkillersaccordingtodoctor'sadvice.P:Thank

德技雙 至Atthesametime,nursescheckthetightnessofwounddressing,volumeandcolorofthewoundexudateandperipheralbloodcirculationoflowerlimbs,checkwhetherpipesareunobstructedandfastened,theyalsomakehealtheducation.德技雙 至Afterdiscussion,theylistnursingInviewoftheabovenursingdiagnoses,weputforwardssometargetednursingmeasures,andthepatientwentthroughtheshockstagesmoothly德技雙 至白細(xì)胞計 血紅蛋血小 血 白蛋白 氯化EnglishNursingWardRoundSecondAct2015-08-15,threedaysafteradmission,thepatientwentthroughshockstagesmoothly,begantolieonrotatingbed……德技雙 至EnglishNursingWardRoundSecondActInthisperiod,Infectionisthemostdistinguishingfeaturesothisperiodisalsocalledinfectivestage.此 是最顯著的特點，所以也稱之 期德技雙 至體溫變化曲線圖入院第四

期溫開始啦 時日9時

德技雙 至EnglishNursingWardRoundSecondActThefollowingismainnursingdiagnosesandmeasuresattheinfectivestage。以下 期主要的護理診斷及措德技雙 至護理診斷體溫過高與創(chuàng)面等有營養(yǎng)缺乏

NursingHightemperaturerelatedtowoundinfectionNutritiondeficiencyrelatedtohighmetabolicHavethepotentialoftraumarelatedtolyingonrotatingbed德技雙 至措施

temperatureisclosetothenormalrangehours,ifbodytemperaturerisesdrastically,reportto treatment,increasethefrequencyofmonitoringUseantibioticsaccordingtothedo advice德技雙馨 保持室28-使用保

AssistdoctorstodealwiththewoundproperlyKeeproomtemperaturein28-32℃2.5.Followthedoctor'stohelppatientscool2.6Useprotectiveframe,roastlamp,keepthewounddry，avoidcompressingthewound.德技雙 至向患者介營養(yǎng)治療對于提供高

Goal：PatientscantakeinenoughIntroducetheimportancenutritionaltherapytopatientsitcanhelprepairwoundProvidehighcalorie,highprotein,richvitamin,digestive德技雙 至

Encouragepatientstoeatfoodthroughthemouth;KeepthemouthNutritionsupporttreatmentinaccordancewiththedoctor'sadvice德技雙 至

Goal：ThepatientdidnothaveatraumaticinjuryAssessthepatient'sriskfalling,completethemission,andmakerecordIntroducesignificanceandnotesofrotatingbedtreatmenttoCheckallofpartsofrotatingbedcarefullyanditssafety德技雙 至3.4翻身前做好 時發(fā)現(xiàn)意外征

3.4EnoughpreparationbeforerotatingWhennecessary,usingprotectiveconstraintstrapsPatrolward,findsignsofaccidentsintime，eliminatesuddentroubles德技雙 至Rotatingbed:Atpresent,therearetwokindsofrotatingbed,includingmanualandelectric.ItconsistsofProne,supinebedsheet,boardslimbs,operationbox德技雙 至OperationprocedureNursesspreadmattress,placesmallspongepillowunderpatients’shoulders,doublesacroiliacjointFoldthetwobedsheetstightly,fixthemwiththreebracers德技雙 至OperationMovedripstandfromonesidetotheotherside,twonursesstandateachsideofthebed,then,putdownsupportingfeet,nextstartingpower

德技雙 至OperationprocedureChoosedirection,turnleftorright,liftsupportingfeetupinstantly,releasethethreebracers,unloadupperbedsheetassoonaspossible,placeallkindsofpipesproperlyandhelppatientstotaketheproperposition德技雙 至SituationalNow,afternursingwardround,nursesarediscussinghowtopreventthepatientfromfallingdownfromtherotatingbedinthedemonstrationroom. 德技雙 至Situational德技雙 至SituationalNa:Firstofall,weshouldsatisfythebasicneedsofthepatient,forinstanceeating,drinking...Nb:Inmyview,weshouldobservehisconsciousness.Ifthepatientmovesrestlessly,wemustuserestraintstrapstokeepthepatientsafe. 德技雙 至Situational前無前無需使用約束護士a：事實上concerned,currently,wedonotneedtouserestraintstraps.德技雙 至SituationalNb:Wealsopaymoreattentiontopatient’spsychologicstatus,afterall,hisfamiliescan’t panywithhimeveryday,andheisplacedinasingleroom.Na:Right！Wealsoshouldaccessthestatementofpatientbeforeoperatingandmakesurethatthepressurebetweenthetwobedsheetsshouldbe

德技雙 至Situational措施相應(yīng)措施

Nursestookcorrespondingnursingmeasures,andthepatientdidnotfalldownfromtherotatingbedduringthis德技雙 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSISESANDDISCHARGE出院德技雙 至EnglishNursingWardRoundThirdActAfteronemonthoftreatment,thepatient’shealbasically,vitalsignsarestableandheisgoingtodischargetomorrow,nursesareguidingthepatienthowtotakecareofhisnewskin. 德技雙 至EnglishNursingWardRoundThirdAct德技雙 至Discharge患者：太好了！Tang,accordingtodoctor'sadvice,youaregoingtodischargetomorrow.Na:NowIamgoingtogiveyousomeadvicesabouthowtolookafteryourhealedwoundbecauseyournewskinisstillvulnerable.德技雙 至DischargeP:HowshouldINa:Firstly,youshouldcontinuetostrengthennutritioninordertoincreaseyourbody’s.Then,youhavetoreducesunlight exposuretopreventpigmentation.P:Okay！Iwill患者

德技雙 至DischargeNa:Andyournewskinisthin,nottootough,lackingofelasticity,andeasytoha