外科創(chuàng)傷患者的護理

1、Nursing Care of Client Experiencing Trauma,創(chuàng)傷病人的護理,Definition of Trauma Trauma morbidity（發(fā)病率） and mortality（死亡率） constitute a major health care challenge. 創(chuàng)傷的發(fā)病率和死亡率構成了健康的最大挑戰(zhàn)。 Although significant strides have been made in combating heart disease and selected cancers, traumatic injury continues to

2、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,當肯尼迪乘坐敞蓬轎車駛過德克

3、薩斯州達拉斯的迪利廣場（Dealey Plaza）時，遭到槍擊身亡 。約翰肯尼迪是美國歷史上第四位遇刺身亡的總統(tǒng)，也是第八位在任期內去世的總統(tǒng)。 assassination 遇刺，暗殺,John Fitzgerald Kennedy,肯尼迪詛咒 curse,11941年，約瑟夫的殘疾女兒死于失敗的腦葉切除手術； 21944年，約瑟夫長子小約瑟夫肯尼迪戰(zhàn)時死于飛機失事； 31948年，約瑟夫二女兒凱瑟琳死于飛機失事； 41963年，肯尼迪總統(tǒng)的第三個兒子出生兩天后夭折； 51963年，約瑟夫二子肯尼迪總統(tǒng)遇刺身亡； 61968年，約瑟夫三子羅伯特遇刺身亡； 71983年，羅伯特之子博比因吸毒被判

4、刑； 81984年，羅伯特之子戴維因過量吸服海洛因死亡； 91997年，羅伯特之子邁克爾死于滑雪事故； 101999年，約翰之子小約翰肯尼迪死于飛機失事； 112009年，約瑟夫四子愛德華死于腦癌,Traumatic injury usually occurs suddenly, leaving both the client and family with little time to prepare for its consequences. 創(chuàng)傷發(fā)生得太突然，沒有任何時間留給病人和家庭來準備承受后果。 Nurse provide a vital link in both the phys

5、ical （生理的）and psychosocial（心理社會） care for the injured client and family. 護士要提供給護士傷員及家庭一個關健的護理不僅是生理上的還包括心理社會的,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

6、and the clients return to his or her previous way of life. 護士護理創(chuàng)傷人員時，不僅必須考慮最原先的生理創(chuàng)傷，而且也要考慮長期的后序治療，包括康復和傷員能回歸原來的生活軌道,Types of Trauma 創(chuàng)傷類型,Severity 嚴重程度分類 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 輕

7、傷,Minor trauma causes injury to a single part or system of the body and is usually treated in the hospital or emergency department . 輕傷導致身體一個部分或一個系統(tǒng)的損傷，通通都會在醫(yī)院或急診科被治療。 A fracture of the collarbone, a small second-degree burn ,and a cut requiring stitches are all considered minor trauma. 鎖骨的骨折，二度燒傷和一

8、個需要縫合的傷口都被認為是輕傷,2 Major or multiple trauma 重傷及多發(fā)傷,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 （立即干預）that is specifically focused on ensuring the survival of the

9、client. 多發(fā)傷需要立即干預，尤其重心是保證病人的生命,Clients who suffer multiple trauma receive immediate emergency care and often require long periods of intensive nursing care. 多發(fā)創(chuàng)需要立即接受急救治療，并且經常需要常長時間的護理,Types of Trauma,Skin Integrality 按皮膚的完整性來分 1 Blunt trauma 閉合性損傷 Blunt trauma occurs when there is no communication

10、from the damaged tissues to the outside environment. 2 Penetrating trauma 開放性損傷 Penetrating trauma occurs as the result of foreign objects set in motion. Penetration of tissues causes damage to body structures, most commonly the intestines（腸道）, liver（肝臟）, spleen（脾臟）, and vascular system（血管系統(tǒng),Types o

11、f Trauma,Organ and location 創(chuàng)傷器官和部位分 trauma of abdomen 腹部創(chuàng)傷 trauma of bladder 膀胱損傷;膀胱外傷 trauma of limbs 四肢損傷 Trauma of chest 胸部損傷 trauma of breast 乳腺外傷 trauma of gastrointestinal tract 胃腸道創(chuàng)傷 trauma of nose 鼻外傷 trauma of brain 腦外傷 trauma of spinal cord 脊髓外傷,Effects of Traumatic Injury 創(chuàng)傷的影響,Causes an

12、d Initial Management 創(chuàng)傷原因和處理 Airway obstruction 氣道阻塞 Tension pneumothorax 張力性氣胸 Hemorrhage 出血 Integumentary effects 皮膚損傷 Hypovolemic shock 低血容量性休克 Neurologic effect 對神經系統(tǒng)的影響 Effect on the family 對家庭的影響,1 Causes and Initial Management 創(chuàng)傷原因和處理,1)Natural Disasters Earthquake 地震 Mudslide；mudflow 泥石流 vol

13、cano 火山vlkeinu lahar 火山泥流l:h: avalanche 雪崩v,lnt Blizzard 暴風雪 blzd Hurricane 颶風 Typhoon taifu:n臺風 Flood 洪水 ice storm 冰雹,1 Causes and Initial Management 創(chuàng)傷原因和處理,Man-made disasters Derail 火車出軌 Traffic crash; traffic accident 交通事故 Plane crash 飛機失事 attack; slaughter ; fight 襲擊；屠殺；打架 terrorist attack 恐怖襲擊

14、 Shooting 槍擊 War；battle 戰(zhàn)爭；戰(zhàn)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. 創(chuàng)傷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 injur

15、ies as a torn thoracic aorta（主動脈撕裂傷）. Early death is death occurring within several hours of the injury from ,for example, shock （休克）or lack of treatment for unrecognized injuries （無法診斷的損傷,Late death generally occurs one or more days after the injury and results from multiple organ failure（器官衰竭）. Be

16、cause of the serious consequences of a traumatic injury , it is important to identify rapidly and take interventions appropriately. 因為創(chuàng)傷的嚴重后果，對于迅速確定并且適當?shù)夭扇〈胧┓浅Ｖ匾?EP 10 mins 急救白金十分鐘,platinumpltnm,CRASH PLAN檢查順序,C cardic 心臟 R respiratory 呼吸 A abdomen 腹部 S spine 脊柱 H head 頭顱 P Pelvic 骨盆 L 1imb 四肢 A art

17、ery 血管 N nerve 神經,2 Airway obstruction 氣道阻塞,The trauma clients airway may become obstructed by the presence of blood ,teeth ,the tongue, and vomitus（嘔吐）. 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 Intuba

18、tion with an oral endotracheal airway（氣管插管）. 4 Needle or surgical circothyroidotomy. （氣管切開）This procedure is performed only after other methods are ineffective in opening and maintaining an open airway,開放氣道 Airway,Clearing the airway by suctioning,an oropharyngeal airway,口咽管,Intubation with an oral

19、endotracheal airway,circothyroidotomy,3 Tension pneumothorax 張力性氣胸,A pneumothorax results from air in the pleural space from blunt and penetrating injuries to the chest. When a one way valve（閥門） is created so that air can enter the pleural space but not exit, a tension pneumothorax may develop,4 Hem

20、orrhage 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 pre

21、ssure points 壓迫傷口上方動脈 (3) Elevating the injured limb 抬高 (4)Clamping the bleeding vessel. （固定，夾緊） (5)Applying a tourniquet. (止血帶,壓迫止血Applying direct pressure over the wound,包扎止血Clamping the bleeding vessel,Applying pressure over arterial pressure points 壓迫傷口上方動脈,4 Hemorrhage 出血,2 Internal Hemorrhage

22、內出血 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 periton

23、eal lavage (診斷性腹腔清洗 ) CT scans of the head, chest, and abdomen,Diagnostic peritoneal lavage,The body has several potential spaces that can accommodate（容納） large amount of blood that may accumulate （集聚）follow injury. 在身體中有幾個潛在的腔隙可以容納大量的血液。 Fox example, bleeding into the pleural space （胸膜腔）may occur w

24、ith 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

25、 bleeding 手術控制出血 Continual assessment of the client, including physical assessment, vital signs, and serial laboratory work. 評估患者通過身體檢查，生命體征和一系列的輔助檢查,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 cau

26、se 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

27、; blood transfusion; and operative intervention to control bleeding,6 Integumentary effects 皮膚損傷,Four specific injuries to the integument include contusions（挫傷） , abrasions（擦傷）, puncture wounds（刺傷）, lacerations（裂傷,bullet wound,Stabbing wound,contusions,puncture wounds,abrasions,lacerations,Injuries

28、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

29、appropriate dressing 6.Administering tetanus （破傷風）immunization as indicated 7.Providing information about home wound care when the client is discharged,7 Neurologic effect 神經系統(tǒng)影響,Head injuries are one of the most common types of injury sustained（承受） as the result of trauma. Injury to the spinal cord

30、 resulting in loss of neurologic function is one of the most devastating outcomes.(破壞性后果) The majority of head and spinal cord injuries result from blunt trauma and sustained in motor vehicle crash（車禍）, Fall（摔倒）, sport injuries（運動損傷）, and assault（斗毆）are some of the other sources of neurologic injury

31、,8 Effect on the family 對家庭的影響,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 Numbnes

32、s 4 Anxiety 5 Guilt 6 Hostility（敵對的） 7 Anger,8 Effect on the family 對家庭的影響,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 Nur

33、sing 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 resp

34、onses 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

35、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 （嘔吐物）increase the risk for aspiration（誤吸) and obstruction. Neurolog

36、ic injuries and cerebral edema(腦水腫) alter the clients respiratory drive and ability to keep the airway clear,Nurses should observe whether the clients airway is patent（張開的）, maintainable（可維持的）.Assess the client for signs and symptoms of airway obstruction： 1 Facial trauma 2 Debris（異物） in the airway,

37、 such as teeth ,blood, or vomitus 3 Stridor（喘鳴） 4 Tachypnea （呼吸急促） 5 Bradypnea （呼吸緩慢） 6 Cough （咳嗽） 7 Cyanosis （紫紺） 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,R

38、isk for infection,Traumatic injuries are considered dirty wounds. The trauma often occurs in a dirty environment. Nursing intervention with rationales（基本理論） are as follows: 1 Use careful hand washing practices. Hand washing remains the single most important factor in preventing the spread of infecti

39、on. 2 Use strict universal precautions. （全面防護）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

40、 aseptic technique when inserting catheters, suctioning ,administering parenteral（腸外的） 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 integum

41、entrary(表皮), cardiovascular(心血管）, gastrointestinal（胃腸道）, respiratory（呼吸）, musculoskeletal（肌肉骨骼） ,and renal systems（泌尿系統(tǒng),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 Mon

42、itor the lower extremities each day for manifestation of deep vein thrombosis,Spiritual distress,Trauma generally strikes with little or warning and carries potentially devastating（破壞） consequences ranging from severe alterations in the lives of the victim and family, to death. The traumatic death o

43、f 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.

44、This response is characterized by emotions that range from anger to fear and by flashbacks or psychic numbing（反應麻木）. In the initial stage, the client may be calm or may express feeling of anger（生氣）, disbelief（不信任）, terror（恐怖）, and shock（驚嚇）. In the long-term phase, the client often experiences flashbacks （閃回）and nightmares（惡夢）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. 患者也許會