PICC初級(jí)培訓(xùn)1-6課件

1、PICC 培訓(xùn)吳麗芬2003 Becton, Dickinson and Company PICC證書(shū)Historical Perspective 歷史回顧Prior19401990- 今天 1980 -1990 1960 1940 -1960Wren 注射鴉片及酒; 第一次在人體上輸血醫(yī)生參與作為急診使用鋼針的使用Ada Plumer 建立了每一個(gè)IV小組Meng et al 報(bào)道CVC在狗身上進(jìn)行試驗(yàn)Dudrick建立 TPN理論第一個(gè)PICC應(yīng)用在新生兒護(hù)士開(kāi)始植入 PICC第一個(gè)中等長(zhǎng)度導(dǎo)管被應(yīng)用PICC及中等長(zhǎng)度導(dǎo)管被應(yīng)用:NICU家庭護(hù)理成人護(hù)士開(kāi)始植入CVC導(dǎo)管超聲診斷血管通路專(zhuān)

2、家 1970-1980 1940 -19701940之前PICC的特征穿刺部位Antecubital veins肘部靜脈Basilic貴要V, Cephalic頭V, Median cubitals正中靜脈Dwell time留置時(shí)間Not established (INS recommends up to 1 year)目前尚無(wú)具體留置時(shí)間（INS建議為1年）Appropriate infusates 輸注液體的要求Any solutionInsertion technique 植入技術(shù)Maximum sterile barrier precautions最大程度上的無(wú)菌操作X-ray Ti

3、p verification required 導(dǎo)管尖端位置需要用X光確認(rèn)PICC的優(yōu)點(diǎn)相對(duì)外周留置針:減少治療中斷保護(hù)靜脈系統(tǒng)提供可依賴(lài)的通路Compared to other Central Venous Catheters, PICCs provide:相比中心靜脈導(dǎo)管減少CVC置管并發(fā)癥降低費(fèi)用減少病人外傷的發(fā)生減少導(dǎo)管相關(guān)性感染增加病人滿(mǎn)意度Therapy Considerations治療評(píng)估pHpH reflects the Hydrogen ion concentration of a solutionPH反映溶液H離子濃度Acidity 酸性 = pHAlkalinity 堿性

4、= pHRisk風(fēng)險(xiǎn)pH 8 may result in severe histological changes in the venous endothelium pH 8將嚴(yán)重破壞組織細(xì)胞Therapy ConsiderationsPatient Considerations病人評(píng)估拒絕PICC治療同意書(shū)病人有權(quán)力接受或拒絕治療拒絕PICC治療同意書(shū)的內(nèi)容：拒絕治療后的不益之處病人需了解所有相關(guān)文件可以通過(guò)文字或口頭的形式患者教育患者教育不是可供選擇額外的事情應(yīng)人施教主要內(nèi)容：基本信息特殊導(dǎo)管信息更換敷料指導(dǎo)沖管指導(dǎo)注射器規(guī)格指導(dǎo)原則處理解決并發(fā)癥家庭護(hù)理Site Assessment &

5、 Evaluation穿刺部位的評(píng)估OverviewThe Skin皮膚Associated Structures相關(guān)組織Veins Anatomy Upper Extremities and Thorax 上臂及胸腔的血管解剖Site Selection血管部位的選擇Venous Assessment血管評(píng)估Measuring for Location血管部位的測(cè)量2003 Becton, Dickinson and Company Associated Structures Nerves 神經(jīng)4 major nerves pass through the antecubital fossa

6、 肘窩處4個(gè)主要神經(jīng)Medial cutaneous正中皮神經(jīng)Median正中神經(jīng)Radial橈神經(jīng)Ulnar尺神經(jīng)Site Assessment & EvaluationMeasuring for Tip Placement導(dǎo)管頭端的測(cè)量Measure from the proposed insertion site, along the track of the vein to the desired tip position從需穿刺的點(diǎn)量起，沿著血管到預(yù)定的頭端位置PICC measure with arm abducted 90 from the insertion site to t

7、he head of the right clavicle and down to the third intercostal space手臂向外伸展90度，從穿刺點(diǎn)至右側(cè)鎖骨然后至第三肋間Midline 中等長(zhǎng)度導(dǎo)管 measure with arm abducted at 45 from the proposed insertion site to the level of the axillary fold測(cè)量時(shí)手臂伸展45度角，從預(yù)定置入位置折到腋下Site Assessment & EvaluationOverview總論Criteria for Choosing a Vascula

8、r Access Device (VAD)選擇血管通路工具（VAD）的條件Types of VAD VAD的類(lèi)型Advantages and Disadvantages of PICCs and MidlinesPICC和中等長(zhǎng)度導(dǎo)管的優(yōu)勢(shì)和劣勢(shì)Introducer Options穿刺鞘的選擇Selecting Catheter Size選擇導(dǎo)管的規(guī)格Physical Characteristics of VADs VAD的物理特性Trimming Considerations 切割器的選擇Stylet Considerations導(dǎo)引鋼絲的考慮2003 Becton, Dickinson a

9、nd Company Types of VADs 血管通路工具的種類(lèi)Midline Catheter中等長(zhǎng)度導(dǎo)管No established dwell time尚無(wú)固定的留置時(shí)間 2-4 weeks most common dwell time 最常見(jiàn)的留置時(shí)間為2-4周PICCNo established dwell time尚未確定留置時(shí)間INS recommendation up to 1 year INS推薦為1年CDC 2002美國(guó)疾控中心2002PICCs may be the preferred CVC for short, intermediate and long-term

10、 therapies PICC是首選的中心靜脈導(dǎo)管，適用于短，中及長(zhǎng)期的治療AHRQ 2002 美國(guó)衛(wèi)生研究及質(zhì)量機(jī)構(gòu)2002PICCs reduce the incidence of complications associated with other CVCs PICC相比其他中心靜脈導(dǎo)管而言，能明顯降低相關(guān)并發(fā)癥Device SelectionSelecting Catheter Size選擇導(dǎo)管的規(guī)格Size of vein at insertion site根據(jù)置管部位的血管大小，導(dǎo)管選擇最小原則Characteristics of the vein血管的特性Beyond the

11、point of insertion穿刺點(diǎn)外的狀況Tip placement尖端位置Therapy and fluid requirements治療及輸液的要求Device Selection防針刺傷可撕裂導(dǎo)入鞘革新的防針刺傷技術(shù)經(jīng)臨床實(shí)踐證明，該技術(shù)降低95%靜脈輸液相關(guān)的針刺傷。輕按保護(hù)按鈕，穿刺針自動(dòng)回縮，易于醫(yī)護(hù)人員快速掌握減少感染因素，保護(hù)醫(yī)生患者的安全防針刺傷可撕裂導(dǎo)入鞘卓越的套管尖端技術(shù)高質(zhì)量套管尖端處理技術(shù)，將穿刺針和鞘間萊距離最為優(yōu)化提高首次穿刺成功率，減少病人痛苦防針刺傷可撕裂導(dǎo)入鞘人性化的遞送技術(shù)其未端新增“漏斗型”導(dǎo)管遞送孔方便醫(yī)護(hù)人員遞送PICC導(dǎo)管，縮短整體操作時(shí)間

12、，降低感染的發(fā)生Clinician Considerations醫(yī)護(hù)人員的評(píng)估2003 Becton, Dickinson and Company Overview總論P(yáng)rofessional Issues專(zhuān)業(yè)要求Competency and Credentialing能力及資格Policies and Procedures規(guī)章及程序Outcomes Monitoring結(jié)果監(jiān)測(cè)2003 Becton, Dickinson and Company 結(jié)果監(jiān)測(cè)保證患者安全性及積極的患者最終利益前后一致的監(jiān)測(cè)導(dǎo)管的完整性全整跟蹤：植入-維護(hù)-取管Site Preparation穿刺部位的準(zhǔn)備2003

13、 Becton, Dickinson and Company Infection Control Measures感控的評(píng)估Principles of Infection Control感控的原則Skin Preparation皮膚準(zhǔn)備Universal and Standard Precautions通用及標(biāo)準(zhǔn)的預(yù)防Maximum Sterile Barrier Precautions最大程度的消毒Overview總論2003 Becton, Dickinson and Company 感染的四大因素宿主（感染源）傳播方式寄主因素器材特點(diǎn)Handwashing洗手The primary infection control measureSite PreparationInfection Control Measures感控評(píng)估Principles of Infection Control感控的基本要求院內(nèi)