1000題 生命體征觀察護(hù)理

1/11000題生命體征觀察護(hù)理1000題生命體征觀察護(hù)理Vitalsignsobservationnursing(146-193questions)146thekeypointsofattentioninmeasuringbodytemperature,pulseandheartrate(TPR)werediscussed.Answer:lmentalabnormalities,coma,infantsandyoungchildren,oraldiseases,oralandnasalsurgery,breathingdifficulties,cannotbeuncooperative,cannotuseoralthermometer:2aftereating,smokingandcoldandhotcompressonthecheeks,theintervalshouldbe30min,andthethermometercanbemeasuredbytheoralthermometer.3rectaldiseaseorsurgery,diarrhea,myocardialinfarctionpatientsnotfromtherectaltemperature,hotwaterbath,afterenemaissubjectto30minbehindthefeasiblerectaltemperature.4,infants,mentalpatients,agitatedpatientsrectaltemperaturemeasurement,thenursemusthandanustable,inordertopreventtheanustablebrokenorintotherectum,causingaccidents,5usetheaxillarytable,firstwipeyourarmpitsweat,andputitinyourarmpit.Axillarytrauma,surgery,inflammation,sweating,shoulderjointinjuriesorexcessiveweightloss,patientsavoidaxillarytables,patientsafterashowertobemeasuredforamoment6,anustableandmouthtable,axillarytablecleaning,disinfection7don’tthumbpulse,weakpulsewithastethoscopetolistentotheheartrate1minpulsenumber8poorpulse,2peopleweremeasuredatthesametime,respectively,listeningtoheartrateandthenumberofpulsecount,1min9severeactivity,emotionalstress,askpatientstorestafter20minpulserate10,whenbreathing,cannottalktopatients,irregularbreathofpatientsandinfants1min1477.5mmHg=1kPa148howdoesapulsecomeabout?Definition,characteristicsandmeasuringmethodsofclumsyveinsAstheheartcontracts,thepressureinthearterialductincreases,thewallexpands,andthewallretractsduringdiastole.Thisrhythmiccontractionofthelargearterialwallspreadsoutwardintotheperipheralvesselsandproducesapulse.Thepulserateislessthantheheartrateperunittime.Itiscalledclumsypulse.Thecharacteristicistherhythmoftheheartcompletelyirregular,theheartrateisfast,notoneheartsoundintensityisunequal.Themethodofmeasurementconsistedoftwopeoplesimultaneouslymeasuring1min,oneperson’sheartrate,oneperson’spulserate,andthencomparingthem149pulsefullpulsegap?Commoninthosediseases?Interstitialvein:anormal,uniformpulsewithanearlierandweakerpulse,followedbyamoreextendedcompensatoryinterval,referredtoas.HeartdiseaseanddigitalisintoxicationarecommonFullpulse:anincreaseincardiacoutput,peripheralarterialresistancesmallarteryfillingdegreeandpulsepressureislarge,andstrongpulse,called.Morecommoninhighfeverhyperthyroidism150,themainfactorsaffectingbloodpressurewere5outputvolume,heartrate,peripheralresistance,elasticcirculation,bloodvolumeandvesselvolumeofaortaandlargevesselwall151whatarethephysiologicalchangesinbloodpressure?1ageandsex:middleagedwomenarelowerthanmen2,dayandnightandsleep:theeveningishigherthanthemorning,overworkedandsleeppoor,highbloodpressure3environmentalimpact:elevatedbloodpressureincoldenvironment,lowbloodpressureinhightemperatureenvironment4theinfluenceofposture:thelowestinsystolicandlyingposition,thehighestinsittingposition,andthereversediastolicpressure5Effectsofeating:increasedsystolicbloodpressureaftereatingandrecoveryat16,theinfluenceofdifferentparts:25%oftherightupperlimbbloodpressureishigherthantheleftupperlimb,mostpeoplelowerbloodpressurethantheupperlimb7theinfluenceofmentalstate:tension,fear,fear,excitementandothermentalstatechangescancauseincreasedsystolicpressure152whatarethekeystomeasuringbloodpressure?1forpatientswhoneedtoobservethebloodpressureforalongtime,thetime,location,positionandsphygmomanometermustbedetermined.2,inflationcannotbetoofierce,toohigh,topreventmercuryspills;gascannotbetoofast,soastoavoidreadingerror,3,whenthebloodpressureisnotclearorabnormalsoundcalled,hempanalysisexcludeexternalfactors;repeatedmeasurementsshouldbecarriedoutwithinthepumpinggasdrive,themercurydroppedto0points,waitamomentafterthemeasurement.4hemiplegiclimbs.5adiastolicbloodpressureanddisappearanceofsounddifferenceislarger,shouldberecordedatthesametimetwovalues.153whatkindsofabnormalbloodpressuredoyouhave?Answer:highbloodpressure,criticalhypertension,hypotension,pulsepressurechanges.154describethephysiologicalchangesofthepupil.Answer:normalpupilisrelatedtoage,refraction,physiologicalstate,externalenvironmentandsoon.ChildrenunderLyearsofagehavetheleastpupil,andchildrenandadolescentshavelargerpupils,whichgraduallybecomesmaller.Thepupiloftheeyeislargerthanthehyperopia,andwhenthesympatheticnerveisexciting(suchaspanic,pain,etc.),thepupilexpands;whentheparasympatheticnerveisexcited(suchasdeepbreathing,bowelmovement,labor,sleep,etc.),thepupilshrinks155,thestandardofnormalpupiljudgmentis1round,withflatedges,innaturallight,2.5-4mm.2indiameter,bilaterallysymmetrical,andsolarge,3responsivetolight156,trytoobservethesignificanceofthepupilandthemainpointsofobservation.Answer:avarietyofdiseases,especiallyintracranialdiseases,drugpoisoninganddiseasechangescancausepupilchanges,sotheobservationofthepupilofthediseasediagnosis,treatmentandrescueareofgreatvalue.Themainpointofpupilobservationisthetwoaspectsoflightresponseandsize.157whatarethecommonsymptomsofabnormalpupils?Answer:1pupildilationpupildiameter5mm.commonglaucoma,belladonnadrugspoisoningpeoplemydriaticagentssuchasatropine,scopolamine,ephedrineandotherEastgrate.2pupilconstriction:pupildiameterlessthan2mm,commoninorganophosphoruspoisoning,morphineandchlorpromazinepoisoning,pontinehemorrhage,whenthepupilisneedlelike,withdiagnosticvalue.3,thesizeofbothsidesofthepupilisdifferent:intracraniallesions,braintumors,intracranialhemorrhage,cerebralhernia,etc..4,thepupilchangesthelightresponse:withaflashlight,thechangeisverysmall,afterremovingthelightsource,thepupilisonlyslightlyincreased,calledslowresponsetolight.Whenthepupilhasnochangeinlightstimulation,itiscalledthedisappearanceofthelightresponse,mostofwhichisarapidchangeintheconditionoradeathbedmanifestation.158whatisdelirium?Howaboutit?Answer:deliriumreferstotheincreasedexcitabilityofhighernervousactivitymainlymanifestedasacutedisorder,consciousnessfilmpaste,disorientation,paresthesia,restlessgibberish159whatisvertigo?Answer:vertigoisakindofmotionillusionofspatialorientation,whichisthemainsymptomoflabyrinthinesyndrome,anditisalsoacommonsymptominclinic.Lightthingsconsciouslyleaptandswayorsway;orfeelthemselvesoraroundtheobjectrotationandoutofbalance,withasenseofdumping,darenotopenwitheyes,turnintensified,butconscious.160howisthedifferencebetweensyncopeandvertigo?Answerlsyncopeisduetoneurogenicorheartdisease,whichcausessuddendropinbloodpressureanddecreasesincardiacoutput,resultingintransientbraininsufficiencyandsuddenlossofconsciousnessinthepatient.Theclinicalmanifestationsweresuddenblurredvision,weaknessoflimbs,fainting,andlastedforseveralsecondsorminutes.Thesymptomsdisappearedafterhalfsupine,mostlywithoutconvulsions,tonguebitingandurinaryincontinence.2vertigoisasymptomofsubjectivefeeling,Nopatientswithdisturbanceofconsciousness,consciousnessisalwaysclear,onlyfeelthesurroundingscenerytorotateinacertaindirection,oftenaccompaniedbyimbalance,top-heavy,standinginstability,nystagmus,vomitingandpallor.161whatarethecommoncausesofvertigo?Answer1vestibularorganpathologicalchanges:internaleardrum,labyrinth,seeper,causeinflammation2vertebrobasilarischemia.,3cervicallesions.4intracraniallesions.162.trytodiscusstheinfluenceofvertigoonthebody.Answer:1,easytocausetrauma.2haveanimpactonhearing:suchastinnitus,hearingimpairmentandsoon.3easilycausevomiting.4psychologicalimpact:tension,irritability,fear163depthcoma,howtodistinguish?Coma:mostofthelossofconsciousness,involuntarymovement,noresponsetothesurroundingthingsandsoundandlightstimulation,strongstimulationmayappearpainfulexpression,pupillightreflex,cornealreflexandavarietyofdefensivereflectionexistsDeepcoma:lossofconsciousness,noresponsetoanyexternalstimuli,disappearanceofvariousreflexes164Glasscomaindexclinicalsignificance:itwillbetraumaticbrainstimulationafterthepatient’seyeopeningresponse,languagebehavior,response,motorresponselistrecords,todeterminetheseverityofthetotalscore.15pointsbelownormal8pointscoma,inthefirsttestscores,basedonthedifferenceof2points,suggestingthatpatientswithneuropsychiatricsymptomschangeevery3points,suggestingintracranialhypertensionorintracranialhematomaformationpossibility165regulatingfunctionofnormalbreathingmovement?Respirationisregulatedbytherespiratorycenter.Therespiratorycenteristhenervecellgroupwhichproducesandregulatestherespiratorymovementinthecentralnervoussystem.Theyaredistributedinthespinalcordofbulbopontinediencephaloncerebralcortexnerve.Themedullaoblongataandponsproducebasicallynormalrhythmicbreathing.Thecerebralcortexcancontrolbreathingatrandom,suchasholdingone’sbreathandspeedingupbreathing166externalrespiration:referstotheexternalenvironmentandbloodinthelungsofthegasexchange,includingpulmonaryventilationandlungventilationtwoprocesses.Pulmonaryventilationistheexchangeofgasesbetweenthelungsandtheenvironment.Pulmonaryventilationistheexchangeofgasesbetweenthealveoliandthepulmonarycapillaries.Themodeofexchangeisspreadfromhightolowthroughthepartialpressuredifferenceofgas167pulmonarystretchreflex:reflexrespiratorychangescausedbydilatationandcontractionofthelungs.Alsoknownasblackandwhitereflex.Physiologicalsignificance:maketheinhalationnottoolong,toodeep,makeinspiratory,turntoexhale.Inconjunctionwiththepontinerespiratorycenter,regulatethefrequencyanddepthofrespiration168whatisthereflexregulationofrespiratorymovement?1pulmonarystretchreflex2respiratorymuscleproprioceptivereflex3defensivebreathingreflex169chemicalregulationofrespiratorymovement?EffectsofchangesinPao2,PaCO2andhydrogenionconcentrationonrespiration.Intheblood,PaCO2risesandthehydrogenionincreases.WhenPaO2decreases,itstimulatesthechemoreceptortoactontherespiratorycenterandleadstothedeepeningofrespiratorymovement,acceleratingthemaintenanceoftherelativestabilityofPaO2,PaCO2andhydrogenionsintheblood.PaCO2playsanimportantroleintheregulationofrespiratorymovement170oxygentherapy:throughtoimprovetheoxygenPaO2andSaO2,increasearterialoxygencontent,hypoxiacausedbycorrectingavarietyofreasons,acommonlyusedtreatmentmethodtopromotetheorganizationtomaintainthelifeactivitiesofthehumanbodyThenewsupersedestheold.171hypoxiaisdividedinto4broadcategoriesofcommondiseases1hypoxiadecreasedPaO2inCOPGhearttissueoxygendeficiencyofmountainsickness2,bloodhypoxia,HBdecline,resultingindecreasedbloodorhemoglobinbindingoxygenisnoteasytorelease,foundinanemia,carbonmonoxidepoisoning3circulatinghypoxiaiscausedbyreducedbloodflowtotissues,resultingindecreasedoxygensupplytotheheart,asseeninshockandheartfailure4tissuehypoxiaiscausedbyabnormalutilizationofoxygenbytissuesandcells,andisfoundincyanidepoisoning172,underwhatcircumstancesoxygentreatmentpronetoadversereactions?Concentrationabove60%,durationofmorethan24h,oxygentreatmentadversereactions.Therefore,bloodgasanalysisshouldbeperformedfrequentlyduringhighconcentrationoxygentherapy,andthetherapeuticeffectofoxygentherapyshouldbeobserveddynamicallyClinicalmanifestationsof173deepandabnormalbreathingDeepbreath:alsoknownasKussmaulbreathing,isalargeanddeepbreathingrules,inthegenerationofacidpoisoning,suchasdiabeticketoacidosisSuperficialbreathing:asmall,irregular,irregularbreathing,sometimessighing,moreoftenseenindyingpatients174whatarethemainpointsofclinicalobservationofrespiratoryfunction?1payattentiontorespiratoryrhythm,frequencyrange,chestorabdominalbreathing,degreeofdifficultyandnature,andtheinfluenceofposturalchangeonrespiration,anddeterminewhetherthereisanyairwayobstructionorrespiratorydepression2,payattentiontothechangesofconsciousness,restlessness,unconsciousness,andtheretentionofcarbondioxide3toobservethesurroundingcirculationofskincolorwithoutcyanosis175.Themechanismoftidalbreathing?Becausetherespiratorycenterexcitabilityisweakenedorhighlyanoxic,thenormalconcentrationofcarbondioxideinthebloodcannotarousetherespiratorycenterthroughthechemoreceptor,sothattherespirationisreducedtothepause.Asaresultoftheapnea,thepartialpressureofcarbondioxideinthebloodincreasestoacertainextent,andtherespiratorycenterisstimulatedbythechemoreceptorofthecarotidsinusandtheaorticarchtoinducerespiration.Asthebreathingproceeds,carbondioxideisremoved,causingpartialpressureofcarbondioxidetodecrease,andrespirationslowsdownagainsothatitissuspended.Thusformingperiodicrespirationcalledtidalrespiration176clinicalmanifestationsofinspiratorydyspnea?Thesuctionwasdifficult,inspiratorytimeprolonged,thethreeobviousdisease(concaveinhalesuprasternalfossasupraclavicularfossaintercostalspacedepression)duetoupperrespiratorytractobstruction,aircansmoothlyenterlung,respiratorymusclecontractioninhale,extremelynegativepressurecausedbytheincreaseoflung177typesofdyspneaAspiration:trachealobstruction,tracheaforeignbody,laryngealedema,expiratory:bronchialasthma,emphysemaMixedtype:severepneumonia,pleuraleffusion,extensivepulmonaryfibrosis,largeatelectasis178pneumothorax?Classification?Anycauseofperforationofthelungorchestwall,whichdestroysthetightnessofthepleuralcavity,causesthegastoenterthepleuralcavityandformpneumothorax.Itisdividedintoclosedpneumothorax,openpneumothorax,highpressurepneumothorax179howmanykindsofcommonoxygentherapyarethere?Whatismeantbyfourprevention?Nasalcathetermethod,nasalobstructionmethod,funnelmethod,maskmethod,oxygenpillowmethod,oxygenaccountmethod.Fourprevention:fireprotection,oilprotection,thermalshockresistance180forwhichpatientsoxygentherapyindications:1respiratorydiseaseaffectingasthmabronchialpneumonia2thoracicbreathingcapacitycardiopulmonarydysfunctiontopulmonarycongestionanddifficultybreathing3oxygenintoxicationdyspneacausedbyhypoxiacannotpenetratetissuecapillaries,barbitalpoisoning4comasuchascerebrovascularaccident,headinjury5,somepatientswithseverebleedingbeforeandaftersomesurgicalprocedures,shock,delivery,orfetalheartfailure181evaluationoftheeffectofoxygentherapybyrestlessbreathingchangingrisingruddyskincyanosisdisappearedhypoxiasymptomsimprovedheartrateslowbloodpressure.Laboratoryindicatorsasanobjectiveindicatorofoxygentherapy.PaO2(normalvalue95-100mmhg),PaCO2(35-45mmhg)andSaO2(95%)wereobservedafteroxygentherapy182adversereactionsofoxygentherapy:1oxygenpoisoning:substernaldiscomfortandpainfulburningbreathinghabitsagitated2atelectasis:Breathingheartratebloodpressurerespiratorysecretionscyanosiscoma3dry:noteasytoproduce4stickysecretionsblindnessin5respiratorydepression:typetwodyspneacausedbyrespiratorydepression183oxygentherapynote:1strictlyabidebytherules,dothefouroilshockin2firecontinuednursing2bilateralnasalcatheteroxygenintubation3alternatenostriltoregulatetheflowofoxygen,oxygenisstopped,unplugtheductswitch4toobservethepatientswithhypoxia5cylinderoxygennotexhausted,tomarklesskeep0.5MPa,6runoutofoxygencylinderisempty,thetimelyreplacementof184howtousethebloodgasanalysistodeterminethedegreeofhypoxia?Mildhypoxia:PaO26.7-9.3kpa(50-70mmhg)moderate4-6.7(30-50),severe4(30)below185howtocalculatetheoxygenconcentration?=21+4*oxygenflowrate(L/min)186whyisdeepandslowbreathingfasterthanshallowandfastbreathing?Respiratoryfrequencyandtidalvolumearethedirectfactorssuchasalveolarventilation,andrapidshallowbreathing,onceinhaledgasissmall,thenremovetheinvalidstayinthegaschamber,theactualgasintothealveolarvolumeissmall,evenbreathingfaster,everytimedoesnotincreaseintothealveolargas.Slowanddeepbreathing,alargeinhalation,intothealveolargasvolumeisalsolarge,althoughtherespiratoryrateisnotfast,butthealveolarventilationvolumeincreasedduetoinhalation187useartificialventilatorattention1,familiarwiththeperformance,control,useandmaintenancemethods2payattentiontowhetherthepatient’sbreathingisintuneandtheventilationvolumeisinsufficient,whichsuggeststhatthereareseriousphlegmobstructionorseriouspulmonarycomplications3givethepatienttimetoturnoverthesputum,wetthesputum,andpromotethedischargeofsputum,observethesymmetryofthetwosidesofthechest,checktheintensityofthebreathsound,findtheunusualandreportittothedoctorintime.4observethebreathingrateandtheoperationofthemachineregularly5observethevitalsignsandpaycloseattentiontothecomplicationssuchasarrhythmia6preventendotrachealintubationortracheotomytubeandaccidentaldisengagementofventilator7wetbottlesarecleaned,disinfectedandreplacedeveryday188heatingprocessandmainmanifestation?Temperaturerise:paleskindryskinchills,chillsHighfeverduration:rapidheartrate,flushingoftheskin,burninglips,dryskin,deepbreathing,headache,lossofappetite,generalmalaiseAntipyreticperiod:moistskin,profusesweating189,commonheattypeandcharacteristicsEneciatemperaturecontinuedat39to40DEGCorhigher,uptoafewdaysorweeks,24hat1DEGC.Thistypeoffevercanbeseeninlobarpneumonia,typhoidfeverandsoon.Remittentfeverlastsmorethanatemperatureof39DEGC,24htemperaturedifferenceintemperatureisabove1,buttheminimumtemperatureisstillhigherthannormal.Thiskindofheatismorecommoninpurulentinfection,septicemia,rheumaticfeverandsoon.Intermittentthermalhighandnonthermalcyclesoccuralternately.Highfever,thebodytemperatureofupto39degreesormore,afterseveralhours,thebodytemperaturedroppedtonormalorbelownormal,afteragap,andrepeatedattacks.Thatis,hightemperatureandnoheatperiodalternate.Typicaldiseasesaremalaria,acutepyelonephritisandsoon.Irregularheatisacommontypeoffever.Thebodytemperaturevariesirregularlyandthehighfeverisuncertain.Thistypeoffevercanbeseenintheepidemicofcancerfever190,whichwaydoesthebodyheatou