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 医学全在线 > 精品课程 > 护理学 > 南华大学 > 正文
护理学基础教案-理论课教案:第十六章
来源:南华大学资源网 更新:2013/9/10 字体:
 <第十六章 病情观察及危重病人的抢救和护理> 
 ※<第十六章 病情观察及危重病人的抢救和护理>

南华大学护理学院

教案

  课程名称:《护理学基础》  第  12 周   第  1   次课  2004年 11  月 18  日

教师姓名

段功香

职称

副高

教研室

基护教研室

教学时数

6

授课题目

病情观察及危重病人的抢救和护理

教学对象

2001级护理本科01、02 班

授课地点

2-101

教学方式

讲授、讨论、示教

本课的重点、难点:

1.病情观察的方法

2.病情观察的内容

3.心肺复苏术

4.人工呼吸机的使用

5.多功能心电监护仪

6.危重病人的护理

 

教学目标:

1.复述病情观察的内容。

2.列出心跳、呼吸停止的判断标准及原因。

3.复述心肺复苏的基本步骤。

4.描述胸外心脏按压及人工呼吸的有效指标。

5.描述洗胃的适应症、禁忌症。

6.根据病人具体情况正确选择洗胃方式和洗胃溶液。

7.复述人工呼吸机的使用方法。

8.为危重病人制定护理计划。

9. 按操作规程进行心肺复苏与洗胃。

 

本次课应用的教具:

1、自制多媒体课件

2、电脑、投影仪、等。

3、红外线笔

主要教学内容:

Chapter 1  Observing the Patients’ Condition

Methods of Observing Patient’s Condition

Direct observation  

Direct observation is the solution that the patient is observed through sensory organs.

Inspecting  It is the essential method that the nurse should master. Lighting should be adequate during examination. Inspecting should include the appearance, behavior and consciousness of the patient and the systems’ variation of physiology and pathology.

Auscultation  Sounds caused by different positions of the patient can be differentiated with ears or stethoscope. It should be carried out with no disturbance.

Palpation  We can know the temperature, humidity, elasticity, and glossiness of skin and outward appearance, rigidity, movement of organs with tactile sensation.

Percussion  It is applied to assess the condition of chest and abdomen. We use percussion or slap to examine the special part of body. According to the vibration and sounds, we can know the shape, position and density of organs, e.g., lower boundary of lung, boundary of heart.

Smelling  Smelling can be used to distinguish all kinds of the patient’s odor in order to definite the patient’s health condition.

●  The Respiratory system  There is the absence or presence of abnormal odor, for example, fetid odor, rotte执业医师n or fruity.

●  The Digestive system  Is halitosis present or not? Can you find out special odor of stool?

●  The Urinary and reproductive system  There is the absence or presence of unusual odor, for example, fetid, sweet, musty. Has discharge of genitalia abnormal odor?

●  Skin  Has discharge of skin fetid odor?

Contents of Observing the Patient’s Condition

Patient’s general condition

Development and bodily form  Development is judged by age, height, weight, intelligence. Anthropometric measurements are used to determine body dimensions. They can give indirect measurements of body protein and fat stores. Height and Weight are the most common anthropometric measurements.

Diet and nutrition  Rational diet is important in the course of treating illness. The nurse should pay attention to observing the patient and gather information concerning appetite, food intake, reaction after dinner, custom and some addition.

Facial features expression  Normal expression is natural and relaxed. Some characteristic faces and expression will appear when the diseases are developing constantly. 

Commonly special faces are as follows:

●  Acute facies 

●  Chronic facies 

● Critical facies  

●  Mitral facies 

●  Anaemic facies (hippocrates facies) 

Position  The patient’s position is intimately related to diseases.

Posture and gait  Rocking when walking is called wadding gait, which could result from congenital dislocation of the hip, rickets, hypoalimentation and so on.

Sleep  The nurse should interview the client to obtain a sleep history.

Skin and mucosa  Skin and mucosa can reflect some diseases. The nurse should observe the color, temperature, humidity, elasticity and absence or presence of hemorrhage, edema, rashes (skin eraption), cysts, subcucmeous nodules and so on. Lips, nail beds and conjunctive of anaemic patients are pallor. Cyanosis is blueness of the skin due to a lack of oxygen in the blood. It often occurs in the conditions of cor pulmonale (pulmonary heart disease) and heart failure. Jaundice is another change in the color of the patient’s skin. Edema (swelling) is the result of an abnormal amount of water in the tissue.

Vomitus  Emesis (vomiting) is a phenomenon that material in the stomach is spat out through esophagus and oral cavity. Emesis has many causes. It follows mental or emotional disturbance and has no physical cause. It may be due to the disturbance or obstruction of the alimentary tract; the vomited material may tell much about this.

States of consciousness

Disturbance of consciousness is the state of lacking normal response to the surroundings. It can be classified:

Somnolence  It is the slightest disturbance of consciousness. The patient keeps on the state of sleeping, but can be wakened by words or slight stimuli, and answer questions correctly and simply. Besides, the patient is slow in thought and reaction.

Confusion  The patient has partially or completely wrong orientation to time, place and person, slow in thought and reaction and use of simple, nontechnical words.

Stupor  The patient sleeps deeply and is difficult to be wakened. Strong stimulation can waken him and he will answer the question vaguely and even give an irrelevant answer. The patient will fall asleep at once after stropping stimulation.

Coma  It is the heaviest disturbance of consciousness. It can be classified:

Observation of pupils

Pupils always change because of brain diseases, poisoning, coma and so on. So a nurse should observe the change of pupils in order to find out the change of the patient’s condition. Normal pupils are round, equal diameter of two pupils and have sensitive light reflex.

Chapter 2  Cardiopulmonary Resuscitation

Relating to Concepts

Basic life support:  Basic life support includes a rapid entry into the emergency medical service (EMS) system, use of techniques to clear an obstructed airway, and performance of CPR.

Cardiopulmonary resuscitation (CPR):  Cardiopulmonary resuscitation is a technique that externally supports the circulation and ventilation (breathing) in a victim of cardiopulmonary arrest. It helps to provide oxygen to the brain, heart, lungs, and other organs, until advanced life support can be given.

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary resuscitation must be performed immediately after cardiac and respiratory arrest. Studies indicate that hospital discharge rates are highest when CPR is started within 4 minutes from the time of the cardiopulmonary arrest and in patients who also receive advanced life support within 8 minutes of the arrest.

Assess lack of pulse and breathlessness

●  Unresponsiveness or unconsciousness

●  Breathlessness

●  Lack of pulse, especially carotid pulse

●  Pupils are larger than 5 mm.

● Skin is pale or in cyanosis

●  Cardiac sound is disappear

●  Wound is never bleeding

ABC of CPR

The nurse can assess patients in any emergency situation in an orderly manner by using the following memory help:

  A = Airway

  B = Breathing

  C = Circulation

A:  Airway

Assess responsiveness  The person must establish unresponsiveness, shake the person’s shoulder, cleawww.med126.com/yaoshi/r his pupils, and shout, “Are you okay?”

Call for help  Call out for someone to help you. You may need (1) to turn to the person or (2) to call the emergency medical system (EMS).

Position the person  The person must be in a supine (back-lying) position, a hard surface, if you are to perform CPR.

Finger-sweep to remove foreign matter  Any foreign matter, vomitus, or liquids should be removed from the airway before resuscitation begins. If a foreign body can be seen in the mouth, it should be removed with the fingers. Do not finger-sweep a child’s mouth!

The tongue is the most common cause of obstructed airway in an unconscious victim. In many cases all that is needed is to open the patient’s airway to restore breathing. If dentures can be taken out, remove them.  

Open the airway  If a neck injury is not suspected, you can: open the patient’s airway by placing your hand close to the patient’s head on the patient’s forehead, pressing back and down; and placing the fingers of your other hand under the bony part of the patient’s chin and lifting it up.

If the nurse has a reason to believe that there may be a neck injury, the jaw-thrust method should be used to open the airway. This is done by positioning the hands at the angle of the patient’s jaw. The jaw is displaced forward while tilting the head backward.

B:  Breathing

Determine if the person is breathing  To assess the absence or presence of breathing, the nurse’s ear should be placed near the person’s nose and mouth while holding the person’s airway in an open position. Several ways are used to determine if the person is breathing, such as: (1) look at the chest, to see if it rises and falls; (2) listen for sounds of breathing; (3) feel for any air exchange against your cheek. If the nurse determines that the patient is not breathing, rescue breathing must be performed.

Perform rescue breathing  With the head positioned to keep the airway open, grasp the nose with the fingers of your hand on the person’s forehead. The nurse should take a breath and create an airtight seal with his or her lips around the person’s mouth. Breathe into the patient’s mouth twice. The nurse takes a new breath before each rescue breath. The patient is allowed to exhale passively between breaths. Ventilate the adult patient 14 to16 times a minute. The child should be ventilated 18 to 20 times a minute. This is called mouth-to-mouth ventilation.

C:  Circulation

Check the pulse  The nurse should gently palpate the pulse for 5 to 10 seconds, being careful not to compress the artery, and avoid reaching across the patient to palpate the carotid pulse. Take the pulse of only one carotid artery at a time.

Resuscitation if the patient’s heart is beating  If a pulse is present, keep on ventilating the patient. Continue to monitor the pulse, because it may stop.

Resuscitation if the patient’s heart is not beating  If there is no pulse, external chest compressions must be applied.

●  Single-rescue CPR 

The adult chest is compressed from 3 to 5 cm, at the rate of 60 to 100 times a minute, with a ratio of 15 compressions to 2 breaths. This is continued for approximately 1 minute. After 1 minute the pulse is checked for 5 seconds. If a pulse is not found, CPR is continued for 4 to 5 minutes before the pulse is again checked. If no pulse is found, resume CPR. Recheck the pulse every few minutes.

Standard for evaluating

●  Respiration is resuming and heart is beating again.

●  Pulse can be touched.

●  The color of face, lips, nails and skin turns red.

●  Sounds of breath can be heard during exhalation.

●  Dilating pupils reduces.

●  Consciousness resumes.

●  Urine appears.

●  ECG waveform alters.

Chapter 3  Gastric  Lavage

Gastric lavage is the way that the stomach is washed down with some washing, via nasogastric cavity taken from oral cavity or nasal cavity to the stomach. The procedure, which is usually done within 6 hours, is most frequently carried out in case of poisoning. Otherwise, the stomach contents are removed that can relieve edema of gastric mucosa to the patient who has pyloric obstruction and prepare for some operations or examinations. The procedure is the same as nasogastric gavage. In an emergency or when the physician’s order is given, the nurse is responsible for carrying it out.

病情观察是临床护理工作中的一项重要内容,及时、准确的观察病情可为诊断、治疗、护理和预防并发症提供依据。本章中主要介绍了一些急救技术,如心肺复苏、洗胃、止血、包扎、心电监护仪等;并讲述了病情观察的内容。同学们在学习中,要培养良好的职业道德和高度的责任心;准确运用基础生命支持、洗胃等常用抢救技术,熟悉相应的抢救程序,同时又要全面、细致的做好危重病人的身心护理。

1.举例说明病情观察的内容。

2.复述心跳、呼吸停止的判断标准及原因,心肺复苏的基本步骤及基本步骤。

3.描述洗胃的适应症、禁忌症及基本步骤。

4.根据病例制定危重病人的护理计划。

5.按操作规程进行心肺复苏与洗胃。

1.濒死及死亡的定义

2.临终关怀

3.临终病人生理反应和护理

4.临终病人的心理变化和护理

5.尸体护理

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