氣道異物梗阻護(hù)理查房

1、問題,,,,2003年12月9日柯受良（臺灣知名影視藝 人，首創(chuàng)駕車飛越黃河） 有知情人士透露，柯受良 當(dāng)晚是因飲酒過量，發(fā)生嘔吐，因嘔吐物阻塞氣管導(dǎo)致窒息，凌晨猝死于上海一賓館里，時(shí)年50歲。,,,小若寧 2005.3.15消費(fèi)者權(quán)益保護(hù)日這天，一場悲劇降臨到可愛的小若寧身上，年僅1歲零7個(gè)月、因吸食果凍窒息死亡。男, 4歲,2005.2江蘇南京一名4歲男孩不慎被果凍窒息死亡,主要內(nèi)容（Main Cont

2、ents）,護(hù)理程序,健康指導(dǎo),病史回顧,Disease knowledge introduction,The history review,Nursing process,Health guidance,Discussion,1,1,患者床號：21床 姓 名：劉明性 別：男 年 齡：76歲入院時(shí)間：2014年11月10日19時(shí)10分主 訴:進(jìn)食中突發(fā)哽噎，出現(xiàn)意識不 清10

3、分鐘。,,1,1,簡要病史：患者1年前患腦埂塞，經(jīng)住院治療好轉(zhuǎn)出院（具體診治不祥）。出院后因右側(cè)肢體活動不靈長期臥床，進(jìn)食、喝水易發(fā)生嗆咳。于今日下午晚飯進(jìn)食間突發(fā)哽噎，繼而呼吸困難、意識障礙，后急呼“120”送入我科。入院查體：患者意識喪失，呼之不應(yīng)，表情痛苦，面唇紫紺，呼吸停止。雙側(cè)瞳孔等大等圓，直徑4.5：4.5mm，對光反射減弱；頸軟，無抵抗。脈搏微弱不可及。氣管居中，呼吸音消失，心音消失。腹平、軟。四肢軟癱。測P：50次/分，

4、BP：100/64mmHg。搶救：立即予以臥位腹部沖擊法取出氣道梗阻異物，行CPR，準(zhǔn)備搶救用物，遵醫(yī)囑予以吸氧、監(jiān)護(hù)、開通靜脈、運(yùn)用呼吸興奮劑等，經(jīng)上述搶救后患者心跳及自主呼吸恢復(fù)，面色變紅潤，但意識障礙情況仍然存在。,,1,1,臨床診斷：1、窒息； 2、腦功能損傷。Clinical diagnosis:1.Asphyxia 2.Brain damage,,,,,,,,病因,年

5、齡因素,酗酒,飲食不慎,老年人因咳嗽吞咽功能差,全麻或昏迷者,,醫(yī)源性異物,定義：窒息是指氣流進(jìn)入肺臟受阻或吸入氣缺氧導(dǎo)致的呼吸停止或衰竭。,,臨床表現(xiàn),表現(xiàn)為吸氣性呼吸困難，出現(xiàn)“四凹征”（胸骨上窩、鎖骨上窩、肋間隙及劍突下軟組織）。氣道阻塞可分為兩類：（1）氣道不完全阻塞：患者張口瞪目，有咳嗽、喘氣或咳嗽微弱無力，呼吸困難煩躁不安。皮膚、黏膜、甲床、面色青紫、發(fā)紺。（2）氣道完全阻塞：面色灰暗青紫，不能說話及呼吸，很快失去知覺，

6、陷入呼吸停止?fàn)顟B(tài)。,v”形手勢顏面青紫不能發(fā)聲肢體抽搐,,,特殊體征,救治原則(Treatment doctrine),保持氣道通暢是關(guān)鍵， 其次是采取病因治療。To keep airway unobstructed is the key, the second is to adopt etiological treatment.,,1、身體評估（護(hù)理體檢）Body evaluation care (m

7、edical)2、實(shí)驗(yàn)室及其它檢查 Lab and other inspection,護(hù)理評估 Nursing Assessment,護(hù)理診斷,,,,,患者呼吸 平穩(wěn)、氣道保持通暢。Patients breathe smoothly and keep unobstructed airway.,護(hù)理目標(biāo) Nursing Goals,①迅速解除窒息因素，保持呼吸道通暢；②給與高流量吸氧；③保證靜脈通路通暢，遵醫(yī)囑給予藥

8、物治療；④監(jiān)測生命體征；⑤備好搶救物品。(1) rapidly relieve suffocation factors, keep respiratory tract unobstructed; (2) provide high flow oxygen; (3) ensure venous channel unobstructed, prescribed for drug treatment; (4) monitoring vit

9、al signs; 5. Save items ready.,護(hù)理措施 Nursing management,,患者意識障礙程度無加重。Patients with disturbance of consciousness degree aggravating.,護(hù)理目標(biāo) Nursing Goals,①休息與安全：保持病房環(huán)境安靜、安全，限制探視，運(yùn)用保護(hù)性床欄；②生活護(hù)理：給予高蛋白、高維生素清淡飲食，遵醫(yī)囑予以胃管鼻飼。每2小時(shí)協(xié)

10、助變換體位，預(yù)防壓瘡的發(fā)生，做好口腔護(hù)理和大小便的護(hù)理；③密切監(jiān)測意識和瞳孔并詳細(xì)記錄，使用脫水降顱壓藥物時(shí)注意監(jiān)測尿量與水、電解質(zhì)的變化。,,護(hù)理措施 Nursing management,患者生命體征平穩(wěn)，無肺部感染的發(fā)生。In patients with stable vital signs, without the occurrence of lung infection.,護(hù)理目標(biāo) Nursing Goals,①密切監(jiān)測體

11、溫情況；②定時(shí)協(xié)助患者翻身拍背,促進(jìn)痰液的排出；③嚴(yán)格執(zhí)行無菌操作,及時(shí)予以吸痰；(1)close monitoring of temperature; (2) to assist patients turn back regularly, to promote the excretion of sputum; (3) strict aseptic operation, be in sputum suction.,護(hù)理措施 N

12、ursing management,,1、患者呼吸通暢,未出現(xiàn)呼吸困難征象；2、患者意識障礙程度減輕；3、患者未出現(xiàn)發(fā)熱等肺部感染的征象。1, the patient breathe unobstructed, does not appear dyspnea signs; 2 disturbance of consciousness, patients with ease; 3, does not appear in patien

13、ts with fever and other signs of lung infection,評價(jià) Evaluation,健康指導(dǎo),2．疾病知識指導(dǎo) 向患者家屬講解窒息發(fā)生的原因、發(fā)展與治療及其預(yù)后，教會家屬及身邊的人當(dāng)氣道異物梗阻時(shí)，如何應(yīng)用Heimlich手法自救。,1．疾病預(yù)防指導(dǎo)①選擇合適的食物, 對老年患者特別腦梗后容易發(fā)生嗆咳和吞咽困難者，食物以半流質(zhì)為宜，如粥、蛋羹、菜泥、面糊等。避免容易引起嗆咳的湯、水食物及容易引

14、起吞咽困難的干食，避免進(jìn)食黏性較大的年糕等食物，水分的攝入應(yīng)盡量混在半流汁的食物中給予，以減少誤吸的可能。②采取科學(xué)的進(jìn)食體位 一般采取坐位或半臥位，臥床的病人應(yīng)抬高床頭30°～ 40°，以利于吞咽動作，減少誤吸機(jī)會。,,討 論Discussion,總結(jié)Summary,謝謝,1,1,Bed no：21 Name：LiuMingSex：male Age：76Admission

15、time ： On November 10, 2014 at 19:00.The main description: Eating in a sudden, a lot of unconsciousness for 10 minutes.,,1,1,A brief history: Patients suffering from brain insuperior to plug a year ago, were hospitalize

16、d with improved (specific diagnosis and ominous). After discharge because of the right limbs activity is ineffective in bed for a long time, eat, drink water prone to choke to cough. This afternoon eating dinner between

17、breaking a lot, and difficulty breathing, disturbance of consciousness, nasty shout after "120" into our department. Hospital physical examination: patients with loss of consciousness, should not be, look, lip

18、purple purple, breathing stops. Bilateral pupil etc. Large such as round, diameter 4.5:4.5 mm, light reflex; Neck soft, without resistance. Pulse is weak. Tracheal middle and breath sounds disappeared, heart sounds. The

19、abdomen flat, soft. Limb palsy. P: 50 times/min, BP: 100/64 mmHg.,,1,1,Define and cause,Definition: asphyxia is refers to the air into the lungs caused by blocked or inhaled air oxygen breathing stops or failure.Pathoge

20、nsis: Age、Excessive drinking、 Careless diet、 Impaired swallowing and so on.,,1,1,Of inspiratory dyspnea, appear "four concave" (sternal elevation nest, supraclavicular fossa, rib gap and xiphoid process under t

21、he soft tissue). Airway obstruction can be divided into two categories: (1) incomplete airway obstruction: patients with open mouth stare, cough, weakness of breath or cough, dyspnea fidgety. Skin, mucous membrane, nail

22、bed, was blue, cyanosis (2) the airway obstruction: completely complexion dark purple, unable to speak and breathing, loss of consciousness, quickly fall into a state to stop breathing,Clinical Manifestation,,1,1,,Nursin

23、g diagnosis,1、Impaired gas exchange:Associated with airway foreign body causing difficulty in breathing, suffocation.2、Acute confusion：Related to brain tissue hypoxia, impaired brain function.3、Risk for infection:Relat

24、ed to long-term lie in bed, lung sputum not easy eduction.,,1,護(hù)理措施 Nursing management,Rest and security: (1) keep the ward environment quiet, safe, limiting visits, use protective bed bar; (2) life care: give high protei

25、n, high vitamin bland diet, be stomach nasogastric tube in accordance with the doctor's advice. Every 2 hours to help transform position, prevent the occurrence of pressure ulcers, do a good job in oral nursing care

26、and urine; (3) close monitoring of consciousness and the pupil and detailed records, pay attention to when using dehydration of intracraninal pressure drug monitoring and the change of the water, electrolyte of urine.,1,

27、1,Health guidance,1. Disease prevention guide (1) choose the right foods, particularly after cerebral infarction was prone to choke to elderly patients with cough and swallowing difficulty, food with semifluid advisable,

28、 such as porridge, custard, puree, batter, etc. Avoid easily cause choking cough soup, water, food and is easy to cause dysphagia dry food, avoid eating viscosity larger food such as rice cake, water intake should be mix

29、ed in half flow juice food give, in order to reduce the possibility of aspiration. (2) to adopt scientific feeding position Generally take seat or half supine position, bedridden patients should raise the head of a bed 3

30、0 ° ~ 40 °, can swallow, reduce aspiration.,2. The disease knowledge instruction The patients' families on choking causes, development and treatment and prognosis, family members of the church and the peopl