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1、急性有机磷农药中毒的护理查房Acute organophosphate pesticide poisoning (AOPP)care rounds2011/8/181病例介绍病例介绍伍南臻伍南臻v患者,周桂云,女性,46岁v入院时间:2011-08-07v主诉:呕吐、口吐白沫、神志不清、大小便失禁4小时vPatients, guiyun Zhou, female , 46years old vAdmission time:2011-08-07vChief Complaint: vomiting, foaming at the mouth, confusion, incontinence 4 h
2、ours基本资料12病例介绍病例介绍现病史:患者于4小时前因争吵后自服农药(半硫磷)约100ML,服用后出现神志改变。History of present illness,For four hours after an argument with his family before, She take the pesticide about 100Milliliters, Pesticides considered for the half sulphur phosphoric. After take appear mind change. 3病例介绍病例介绍家人行紧急救治后送入当地医院行洗胃
3、治疗,于家人行紧急救治后送入当地医院行洗胃治疗,于2011-08-0712:20急诊平车转入我院肾病内科急诊平车转入我院肾病内科Patientsaftermedicationwithvomiting,aftertheemergencysalvage,shewassendtothelocalhospitalforgastriclavageforherfamliy.Inaugust7,201112:20,Shewastransferredtoourhospitalnephropathyinternalmedicinewithemergencyflatcar.4病例介绍病例介绍转运途中出现呕吐,大小
4、便失禁症状。门诊以转运途中出现呕吐,大小便失禁症状。门诊以“急性有机磷农药中毒急性有机磷农药中毒”收治。起病以来,精神差,收治。起病以来,精神差,体重无明显变化。体重无明显变化。Intransit,PatientshadrepeatedvomitingandEliminationofurineandfecesarenotcontrolledbyherself,ClinicdiagnosisisAOPP,Afterthepatientisadmittedtohospital,herSpiritwassobadandweightdidnothavesignificantlychange.5病例介绍
5、病例介绍既往有肺脓肿病史,已行部分肺叶切除术,既往有肺脓肿病史,已行部分肺叶切除术,术中有输血,有青霉素过敏史术中有输血,有青霉素过敏史。shehadlungabscessbefore,andwasdoneapartiallobectomy,inthatoperation,Shehadabloodtransfusion.ThemostimportantisshehadthePenicillinallergy.6病例介绍病例介绍全凤春全凤春体格检查:体格检查:T35.8P126次次/分分R20次次/分分BP109/69mmHgvPhysicalexamination:vTemperature:3
6、5.8,Pulse:126BeatPerMinute,respiration:20BeatPerMinute,BloodPress109/69mmHg7病例介绍病例介绍神志浅昏迷,双侧瞳孔等大等圆神志浅昏迷,双侧瞳孔等大等圆3mm,对光反射迟钝,口唇发绀,对光反射迟钝,口唇发绀,皮肤湿冷,双肺呼吸音粗,可闻及大量湿性啰音。皮肤湿冷,双肺呼吸音粗,可闻及大量湿性啰音。Comaconsciousness,Pupilsareequalroundnessandsamesizewith3mm,reactiontolightshowsdelay,whilethelipsiscyanotic,Breaths
7、oundshowsCoarsewhileitCanbeheardandalotofwetrales.8病例介绍病例介绍心率心率126次次/分,肠鸣音活跃,四肢肌张力稍高,无自主活分,肠鸣音活跃,四肢肌张力稍高,无自主活动,病理反射未引出。动,病理反射未引出。Heartrateis126BeatPerMinute,borhorygmusshowsincreased,Limbmuscletoneisslightlyhigher,thereisnoindependentactivity,Pathologicalreflexisnotelicited.9病例介绍病例介绍刘伟明刘伟明v入院诊断入院诊断:
8、1、急性重症农药中毒(半硫磷)、急性重症农药中毒(半硫磷)2、中毒性心肌炎、中毒性心肌炎3、吸入性肺炎、吸入性肺炎vAdmissiondiagnosis:1、severeacutepesticidepoisoning(halfsulphurphosphorous)2、toxicmyocarditis3、aspirationpneumonia10主要病情变化主要病情变化马志群马志群v8-801:40T39.1摄氏度,予温水擦浴摄氏度,予温水擦浴05:20患者开始出现躁动,予丙泊酚患者开始出现躁动,予丙泊酚5毫升毫升IV效果不明显效果不明显,予地西泮镇静,予地西泮镇静vOnefortyonaugu
9、st8th,thepatientsbodytemperaturerisestothirty-onepointonedegreescelsius,wegivehimawarmwaterbath.vFivetwenty,thepatientbegintoappearrestless,propofulfivemilliliterintravenensinjection,theeffectisnotobvious,tothediazepamsedation.11病例介绍病例介绍v12:30患者躁动不安,血氧饱和度波动在患者躁动不安,血氧饱和度波动在70%-80%请请麻醉科及麻醉科及ICU会诊后考虑气管
10、插管脱出予重新插管会诊后考虑气管插管脱出予重新插管v14:50患者转入患者转入ICUvTwelvethirty,thepatientisrestless,fluctuationsofoxygensatturationinseventypercenttoeightypercent.thenpleaseanesthesiaandintensivecareunitconsulation,consideringtheendotrachealtobeextrusion,toreintubationforhim.vFourteenfifty,thepatientistransforredtotheinte
11、nsivecareunit12病例介绍病例介绍贺贺舒舒v转入转入ICU时情况:体温时情况:体温37.3,脉搏,脉搏140次次/分,呼吸分,呼吸35次次/分,血压分,血压116/87mmHg,血氧饱和度,血氧饱和度95%vWhentransferredtoICUconditions:temperature37.3,pulse140beats/min,breathing35times/min,bloodpressure116/87mmHg,oxygensaturation95%.13病例介绍病例介绍v神志镇静中,躁动不安,两侧瞳孔等大等圆神志镇静中,躁动不安,两侧瞳孔等大等圆4mm4mm,对光反射
12、,对光反射迟钝,气管插管,呼吸机辅迟钝,气管插管,呼吸机辅 助呼吸,气道内少量痰液,皮助呼吸,气道内少量痰液,皮肤干燥肤干燥 。vconscioussedation,irritability,Pupilsareequalroundnessandsamesizewith4mm,reactiontolightshowsdelay,endotrachealintubation,mechanicalventilation,Withinafewairwaysputum,dryskin.14病例介绍病例介绍v双肺可闻及中等量湿性啰音,腹部叩诊呈鼓音,双肺可闻及中等量湿性啰音,腹部叩诊呈鼓音,诊断为:诊断为
13、:1.急性有机磷农药中毒;急性有机磷农药中毒;2.吸入性肺炎、吸入性肺炎、1型呼吸衰竭;型呼吸衰竭;3.中毒性心肌炎中毒性心肌炎。vdouble-lungcanbeheardandmoderatemoistrales,ThedrumsoundabdominalsoundThediagnosisis:1:acuteorganophosphoruspesticidepoisoning;2:aspirationpneumonia,type1respiratoryfailure;3:toxicmyocarditis.15病例介绍病例介绍予以呼吸机辅助呼吸,留置胃管,胃肠减压,留置深静脉导管,予以呼吸机
14、辅助呼吸,留置胃管,胃肠减压,留置深静脉导管,遵医嘱予抗感染、护胃、护心、解毒、导泻等对症支持治疗。遵医嘱予抗感染、护胃、护心、解毒、导泻等对症支持治疗。Tomechanicalventilation,indwellingstomachtube,decompression,indwellingvenouscatheters,prescribedtofightinfection,protectstomachmucosa,protectionofheartfunction,detoxification,catharsis,symptomaticandsupportivetreatment.16病例
15、介绍病例介绍苏敏苏敏现患者的情况:神志模糊,躁动不安,双侧瞳孔等大瞪圆现患者的情况:神志模糊,躁动不安,双侧瞳孔等大瞪圆3mm,对光反射迟钝,皮肤干燥对光反射迟钝,皮肤干燥。Thecurrentsituationofpatients:mindfuzzy,restless,Pupilsareequalroundnessandsamesizewith4mm,reactiontolightshowsdelay,theskinisdry.17病例介绍病例介绍有发热,最高体温有发热,最高体温39,予物理降温。血压稳定,仍给予阿托,予物理降温。血压稳定,仍给予阿托品间断静推品间断静推。withfever,
16、themaximumtemperatureabout39,tothephysicalcooling.Bloodpressurestability,intermittentintravenousinjectionofatropine,18病例介绍病例介绍气道内有少量的黄色痰液,双肺未闻及湿啰音,四肢有自主活动。气道内有少量的黄色痰液,双肺未闻及湿啰音,四肢有自主活动。therewereafewoftheairwayyellowsputum,doublelungnotsmellandwetgosound,limbshaveindependentactivities.19病例介绍病例介绍主要的实验室
17、检查v8-7WBC27.3*109/L,CHE23KU/L,v8-8尿常规尿常规RBC2-4/HP,K+3.38mmol/L,钙离子钙离子1.73mmol/L,CHE10KU/L,心肌酶、肝功能基本正常心肌酶、肝功能基本正常vThemainlaboratorytestsvOn8-7ThepatientsWBCis27.3*109/LandCHEis23KU/L.vOn8-8FormtheRoutineExaminationofUrineonhighpowerlenswecansee2to4redbloodcells,ThepatientsPotassiumis3.38mmol/L,calciu
18、mis1.73mmol/LandCardiacenzymeandliverfunctionarenormal.CHE10.0KU/L20病例介绍病例介绍v8-9CHE8.0KU/L,。胸片提示:肺部感染及双侧。胸片提示:肺部感染及双侧胸膜炎。胸膜炎。v8-12血常规正常,血常规正常,CHE32KU/LvOn8-9,CHE8.0KU/L;ChestXraytip:lunginfectionandbilateralpleurisy.vOn8-12Bloodroutineisnormal,andCHEis32KU/L21病因与发病机制病因与发病机制谢妹娜谢妹娜病因病因v生产及使用过程的不当:如生产设
19、备密封不严导致化学毒物生产及使用过程的不当:如生产设备密封不严导致化学毒物泄漏;喷洒杀虫药过程中经皮肤和呼吸道吸收泄漏;喷洒杀虫药过程中经皮肤和呼吸道吸收EtiologyvImproperproductionanduse:Forexample,productionequipmentsealedpoorlyresultinleakageofchemicaltoxicant;intheprocessofsprayingpesticide,absorbedthroughskinandairway.22病因与发病机制病因与发病机制生活性中毒:主要由于自服、误服或摄入被生活性中毒:主要由于自服、误服或摄
20、入被污染的水源和实物水果等。污染的水源和实物水果等。Livingpoisoning:Mainlyduetodrinkingoreatingcontaminatedwaterandfruitvoluntarilyorbymistakeetc.23病因与发病机制病因与发病机制有机磷农药中毒机制主要是抑制体内胆碱酯酶的活性。正常有机磷农药中毒机制主要是抑制体内胆碱酯酶的活性。正常情况下,胆碱能神经兴奋所释放的递质情况下,胆碱能神经兴奋所释放的递质乙酰胆碱被胆碱乙酰胆碱被胆碱酯酶水解为乙酸及胆碱而失去活性。酯酶水解为乙酸及胆碱而失去活性。vMechanismofpoisoningvThePrimary
21、mechanismoforganophosphatepesticidepoisoningisinhibitionoftheactionofcholinesteraseinbody.Ingeneral,excitementofcholinergicnervereleasesneurotransmitter-acetylcholinewhichcanbehydrolyzedtocholineandaceticacidbycholinesteraseandloseitsactivity.24病因与发病机制病因与发病机制有机磷农药进入人体后与体内胆碱酯酶迅速结合形成有机磷农药进入人体后与体内胆碱酯酶迅
22、速结合形成磷酰化胆碱酯酶,使胆碱酯酶失去水解乙酰胆碱磷酰化胆碱酯酶,使胆碱酯酶失去水解乙酰胆碱的能力的能力。vOnceorganophosphatepesticidesenterintobody,itwillbindrapidlytocholinesteraseandformphosphorylatedcholinesterase,thusmakecholinesteraselosetheabilitytohydrolyzeacetylcholine.25病因与发病机制病因与发病机制导致组织中的乙酰胆碱过量蓄积,产生胆碱导致组织中的乙酰胆碱过量蓄积,产生胆碱能神经功能紊乱,先表现为兴奋,然后出
23、能神经功能紊乱,先表现为兴奋,然后出现抑制。现抑制。vbringoutexcessiveaccumulationofacetycholineintissue,WhichresultindisfunctionofCholinergicNerve.Itmanifestatesexcitementatfirstandtheninhibition.26护理评估护理评估Nursingassessment袁清红v临床表现临床表现v胆胆碱碱能能危危象象急急性性有有机机磷磷农农药药中中毒毒的的典典型型表表现现vClinicalSituationvCholinergiccrisisTypicalperforma
24、nceofAOPP.27护理评估护理评估Nursingassessmentv毒蕈碱样症状毒蕈碱样症状v主要是副交感神经兴奋所致主要是副交感神经兴奋所致,临床表现有恶心临床表现有恶心,呕吐呕吐,腹痛腹痛,多汗多汗,流涎流涎,瞳孔瞳孔缩小缩小,支气管痉挛支气管痉挛,分泌物增多分泌物增多,心率减慢心率减慢,气急气急,严重者严重者出现肺水肿出现肺水肿vMuscarinicsymptomsvMainlycausedbytheparasympatheticnervousexcitement,Clinicalmanifestationshavenausea,vomiting,abdominalpain,sw
25、eating,salivation,miosis,bronchospasmandIncreasedsecretionsheartratedecreased,dyspnea,theseriouscasesappearpulmonaryedema.28护理评估护理评估Nursingassessment v烟碱样症状烟碱样症状v患者常有肌束颤动患者常有肌束颤动,肌肉强直性痉挛肌肉强直性痉挛,心率加快心率加快,甚至全身抽搐甚至全身抽搐,最后出现肌麻痹最后出现肌麻痹,呼吸肌麻痹引呼吸肌麻痹引起周围性呼吸衰竭起周围性呼吸衰竭vNicotine-likesymptomsvPatientsoftenhavem
26、usclebundleoftrembling,tetanicspasm,heartrateincreased,Eventhewholebodytwitching,finally,myoplegiahappen,breathmyoparalysiscauseperipheralrespiratoryfailure29护理评估护理评估Nursingassessment v中枢神经系统症状中枢神经系统症状v表现为头晕表现为头晕,头痛头痛,疲乏无力疲乏无力,共济失调共济失调,烦躁不安烦躁不安,意识模糊意识模糊,抽搐抽搐及昏迷及昏迷vCentralnervoussystemsymptomsvManife
27、stedasdizziness,headache,fatigue,ataxia,irritability,confusion,convulsionsandcoma30护理评估护理评估Nursingassessment 莫思慧v急性有机磷中毒分为轻、中、重三级:急性有机磷中毒分为轻、中、重三级:v轻度中毒:头晕、头痛、恶心、呕吐、多汗、轻度中毒:头晕、头痛、恶心、呕吐、多汗、流涎、视力模糊、瞳孔缩小、全血胆碱脂酶流涎、视力模糊、瞳孔缩小、全血胆碱脂酶活力一般在活力一般在7050。vAOPPcanbedividedinto3grades:mild,moderate,severevMildpoiso
28、ning:dizziness,headache,nausea,vomiting,sweating,salivation,blurredvision,miosis,andthewholebloodcholinesteraseactivitywasinthe5070%31护理评估护理评估Nursingassessment v中度中毒:除上述症状外,还出现肌纤维颤动、瞳孔明显缩小、中度中毒:除上述症状外,还出现肌纤维颤动、瞳孔明显缩小、轻度呼吸困难、大汗、腹痛、腹泻、意识清楚或轻度障碍、步轻度呼吸困难、大汗、腹痛、腹泻、意识清楚或轻度障碍、步态蹒跚。全血胆碱脂酶活力降至态蹒跚。全血胆碱脂酶活力降至5
29、030。vModeratepoisoning:Inadditiontotheseabove,symptomsalsoincludemuscularfibrillation,milddyspnea,sweat,abdominalpain,diarrhea,clearormilddisordersofconsciousness,andstaggeringgait.Wholebloodcholinesteraseactivitydeclinedto50%-30%.32护理评估护理评估Nursingassessment v重度中毒:除上述症状外,发生肺水肿、惊厥、昏迷重度中毒:除上述症状外,发生肺水肿
30、、惊厥、昏迷及呼吸麻痹。全血胆碱脂酶活力降至及呼吸麻痹。全血胆碱脂酶活力降至30以下。以下。vSeverepoisoning:Inadditiontotheseabove,symptomsalsoincludepulmonaryedema,convulsions,comaandrespiratoryparalysis.Wholebloodcholinesteraseactivitydeclinedtobelow30%.33护理评估护理评估Nursingassessment 王丽炜v有机磷农药中毒后,经急救临床症状好转,可在数日有机磷农药中毒后,经急救临床症状好转,可在数日到一周内突然再次发生昏
31、迷,甚至发生肺水肿或突然到一周内突然再次发生昏迷,甚至发生肺水肿或突然死亡,此为中毒后反跳现象。死亡,此为中毒后反跳现象。vOrganophosphoruspesticidepoisoningwerethefirstaidclinicalsymptom,canbeinafewdaystogetbetterwithinaweek,evenhappenagainsuddenlyapulmonaryedemaorsuddendeath,saysbouncephenomenon.34护理评估护理评估Nursingassessment v这与残留在皮肤、毛发和胃肠道的有机磷农药重吸收或解毒药这与残留在皮
32、肤、毛发和胃肠道的有机磷农药重吸收或解毒药停用过早或减量过快等原因有关。停用过早或减量过快等原因有关。vThisandremainintheskin,hairandthegastrointestinaltractisabsorbedbyheavyorantidotetocreditdoseorreasonssuchastooearlyon.35护理评估护理评估Nursingassessment v在急性中毒症状缓解后迟发性神经病变发病前,一般在中毒后在急性中毒症状缓解后迟发性神经病变发病前,一般在中毒后2496小时突然发生以呼吸肌麻痹为主的症状群,称小时突然发生以呼吸肌麻痹为主的症状群,称“中
33、间型中间型综合征综合征”。vInpatientswithacutepoisoningsymptomsafterthelate-occurredneuropathy,generallyinthepoisoningbefore24to96hoursafterhappensuddenlybyrespiratorymuscularparalysisprimarilythesymptoms,saysmiddletypesyndrome.36护理评估护理评估Nursingassessment v发病机制可能与胆碱酯酶长期受到抑制,影发病机制可能与胆碱酯酶长期受到抑制,影响神经肌肉接头突触后功能有关。响神经
34、肌肉接头突触后功能有关。vThemechanismmayandcholinesteraselong-termeffectisrestrained,neuromuscularpostsynapticfunctioning.37治疗原则治疗原则严超严超v治疗原则治疗原则v我们都知道,中毒后,我们要迅速清除毒我们都知道,中毒后,我们要迅速清除毒物,一般来说越快洗胃效果越好物,一般来说越快洗胃效果越好vTreatmentprinciplevAsweknow,themostimportantofallisremovingtoxicasquicklyaswecanwhensomeonepoisoned.G
35、enerallyspeaking,thefasterlavagethebettereffectweget.38治疗原则治疗原则v幸运的是,这个病人中毒后幸运的是,这个病人中毒后4小时就在当地医小时就在当地医院洗胃。另外,导泻也是一个好办法。院洗胃。另外,导泻也是一个好办法。vFortunately,thatpatientlavagedinlocalhospitalafterdrinkingtoxic4hours.Inaddition,guidingdiarrheaisaneffectivemeasure.39治疗原则治疗原则v第二,促进毒物进一步排除也十分重要,在此,第二,促进毒物进一步排除也
36、十分重要,在此,我们应用的是血流灌注。我们应用的是血流灌注。vSecondly,promotingdischargepoisonisnecessary,weusedbloodperfusionforher.40治疗原则治疗原则v第三,特殊解毒剂的应用,如阿托品、碘解磷第三,特殊解毒剂的应用,如阿托品、碘解磷定定,这取得不错的效果。,这取得不错的效果。vThirdly, the application of the special effects antidotesuchasatropineandpralidoximeiodide.Thus,thedoctorsachievedgoodresul
37、tsintheprocessofthattreatmeat.41治疗原则治疗原则v最后也是非常重要的一点,对症支持治疗最后也是非常重要的一点,对症支持治疗。v抗感染,促进炎症消散抗感染,促进炎症消散;v护胃,保护胃黏膜护胃,保护胃黏膜;v护心,治疗中毒性心肌炎护心,治疗中毒性心肌炎;vThe last but not least , Symptomatic support treatmentincludingFightinginfectiontopromoteinflammation dissolve ; Protecting stomach to caregastricmucosa;Hear
38、tcare,itispositivefortoxicmyocarditis.42治疗原则治疗原则v升压、降温,维持生命体征平稳很重要升压、降温,维持生命体征平稳很重要v镇静,细心照顾他,安慰情绪镇静,细心照顾他,安慰情绪v尽快纠酸和纠正电解质紊乱,以稳定内环境尽快纠酸和纠正电解质紊乱,以稳定内环境vElevatingbloodpressureanddecreasingtemperatureareofimportancetomaintainvitalsignssmoothly;weshouldbettercalmdownheremotionandtakecareoftenderly.Asquic
39、klyaspossible to correct acidosis and electrolytes disturbancetostableinnercondition.43护理诊断护理诊断 Nursing diagnosis 彭瑜v气体交换受损气体交换受损与肺水肿有关与肺水肿有关v清理呼吸道无效清理呼吸道无效与呼吸道炎症、气道分泌物增多有关与呼吸道炎症、气道分泌物增多有关v急性神志改变急性神志改变与胆碱能神经功能紊乱有关与胆碱能神经功能紊乱有关vImpairedgasexchangeRelatingtopulmonaryedemavAcuteconsciousnesschangingRela
40、tingtocholinergicdisturbancesvIneffectiveairwayclearanceRelatingtoairwaysinflammationandairwaysecretionsincreasing.44护理诊断护理诊断 Nursing diagnosisv有效血容量不足有效血容量不足与大量呕吐、感染等有关与大量呕吐、感染等有关v体温过高体温过高与肺部感染、应用阿托品等有关与肺部感染、应用阿托品等有关v有受伤的危险有受伤的危险与躁动不安有关与躁动不安有关v有猝死的危险有猝死的危险与毒物的重吸收和阿托品使用不当有关与毒物的重吸收和阿托品使用不当有关vRiskforS
41、uddenDeathRelatingtopoisonabsorbingandthewronglyusingofatropinevHyperthermiaRelatingtoLungInfectionandapplicationatropineetcvRiskforinjuryRelatingtorestlessnessvInsufficientofblooddecreaseRelatingtoprofusevomiting,infectionandsoon.45护理措施护理措施 刘 萍v迅速清除毒物迅速清除毒物v清除胃内毒物清除胃内毒物v催吐:神志清楚、能合作的服毒者,可行催吐。让患者饮温水催
42、吐:神志清楚、能合作的服毒者,可行催吐。让患者饮温水300500毫升,然后用压舌板或患者手指刺激咽后壁或舌根毫升,然后用压舌板或患者手指刺激咽后壁或舌根部引起呕吐。部引起呕吐。vQuicklyremovetoxicvremovaloftheundigestedpoisonsvEmetic:Thisonlyappliestothepationswhocancooperatewith,Letthepatientdrinkwarmwater300to500ml,andthenwithaspatulaorfingerstimulatepatients,posteriorpharyngealwallor
43、thebaseofthetonguecausedvomiting,46护理措施护理措施 v洗胃:一般在服药后洗胃:一般在服药后6小时内洗胃有效,但如果超过小时内洗胃有效,但如果超过6小时,仍小时,仍有洗胃的必要。有洗胃的必要。v导泻:洗胃后灌入泻药以清除进入肠道的毒物,常用硫酸钠或导泻:洗胃后灌入泻药以清除进入肠道的毒物,常用硫酸钠或硫酸镁。硫酸镁。v清除皮肤上的毒物清除皮肤上的毒物脱去污染的衣服,用肥皂水或大量清水冲洗脱去污染的衣服,用肥皂水或大量清水冲洗皮肤和毛发皮肤和毛发。vGastriclavage:generallywithin6hours.ifmorethan6hours,itis
44、alsonecessaryforgastriclavage.vCatharsis:aftergastriclavagewecanfilllaxativestocleartheintestinalpoison,commonlyusedsodiumsulfateormagnesiumsulfate.vCleartheskin.Removecontaminatedclothing,washtheskinandhairwithsoapwater.47护理措施护理措施 v 促进已吸收毒物排出促进已吸收毒物排出 v利尿利尿 绝大多数毒物由肾脏排泄绝大多数毒物由肾脏排泄v人工透析人工透析vPromotion
45、hasbeenabsorbingpoisonoutvDiuresis:Thevastmajorityofpoisonexcretedbythekidneys,vArtificialdialysis48护理措施护理措施 龙丽娟v应用阿托品的观察与护理应用阿托品的观察与护理v抢救治疗中使用阿托品的原则:早期,足量,快速,抢救治疗中使用阿托品的原则:早期,足量,快速,反复给药,直到阿托品化后再逐渐减量或延长间隔时反复给药,直到阿托品化后再逐渐减量或延长间隔时间。间。vApplicationofatropineobservationandnursingvTherescueoftheprincipleo
46、ftreatmentusingatropine:early,enough,fast,repeateddose,untiltheatropineagainafterreducinggraduallyorextendthetimeinterval.49护理措施护理措施 v阿托品化和阿托品中毒的剂量接近,后者可引起抽搐、阿托品化和阿托品中毒的剂量接近,后者可引起抽搐、昏迷等。因此使用过程中应严密观察病情变化,注意昏迷等。因此使用过程中应严密观察病情变化,注意区别区别“阿托品化阿托品化”与阿托品中毒。与阿托品中毒。vThecauseatropineandatropinetoxicdosageisclo
47、se,thelattercancauseconvulsions,coma,etc.Thereforewhenusingatropineweshouldmonitortheconditionchanges,andpayattentiontothedistinctionbetweentheatropineandatropinepoisoning.50护理措施护理措施 v阿托品化的表现包括:阿托品化的表现包括:v意识清楚或模糊意识清楚或模糊v颜面潮红、干燥颜面潮红、干燥v瞳孔由小扩大后不再缩小瞳孔由小扩大后不再缩小v体温正常或轻度升高体温正常或轻度升高v心率心率120次分,脉搏快而有力。次分,脉搏快
48、而有力。vTheperformanceofatropineinclude:v(1)clearconsciousnessorfuzzyv(2)redanddryfacev(3)thepupilbecomebigandnotsmallanymorev(4)andthetemperatureisnormalorlittleraisev(5)theheartrateismorethan120timeseveryminute,andthepulsefastandpowerful51护理措施护理措施 v阿托品化的表现包括:阿托品化的表现包括:v意识清楚或模糊意识清楚或模糊v颜面潮红、干燥颜面潮红、干燥v瞳
49、孔由小扩大后不再缩小瞳孔由小扩大后不再缩小v体温正常或轻度升高体温正常或轻度升高v心率心率120次分,脉搏快而有力。次分,脉搏快而有力。vTheperformanceofatropineinclude:v(1)clearconsciousnessorfuzzyv(2)redanddryfacev(3)thepupilbecomebigandnotsmallanymorev(4)andthetemperatureisnormalorlittleraisev(5)theheartrateismorethan120timeseveryminute,andthepulsefastandpowerful
50、52护理措施护理措施 v阿托品中毒的表现包括:阿托品中毒的表现包括:v谵妄、躁动、幻觉、双手抓空、抽搐、昏迷谵妄、躁动、幻觉、双手抓空、抽搐、昏迷v皮肤紫红、干燥皮肤紫红、干燥v瞳孔极度散大瞳孔极度散大v高热,高热,T40v心动过速,甚至有室颤发生心动过速,甚至有室颤发生vAtropinepoisoningperformanceincluding:v(1)thedelirium,agitated,illusion,convulsions,comav(2)amaranthineanddryskinv(3)thepupilsextremelyenlargev(4)highfever,thetemp
51、erature40centigradev(5)tachycardiaandevenaventricularfibrillationhappen.53护理措施护理措施 王洁v应用胆碱酯酶复能药的观察和护理应用胆碱酯酶复能药的观察和护理v首先首先,你必须尽早用药。你必须尽早用药。v第二第二,轻度中毒轻度中毒,你可以单独使用这个药物你可以单独使用这个药物,但是中度以上中毒但是中度以上中毒,你你必须和阿托品一起使用。必须和阿托品一起使用。vTheclinicalobservationandnursingoftheapplicationofacetylcholinesterase:vFirst,youm
52、ustusethemedicineearly.vSecond,lightpoisoningyoucanusethemedicine,butifbadpoisoning,youcanusetheatropinetogether.54护理措施护理措施 v第三第三,很高的浓度或快速注射能引起中毒,所很高的浓度或快速注射能引起中毒,所以你必须稀释后使用,注意给药速度。以你必须稀释后使用,注意给药速度。v第四第四,不可皮下注射,确定针头在血管内方可不可皮下注射,确定针头在血管内方可用药。用药。vThird,Muchhighconcentrationorfastinjectioncancausepoiso
53、ning.soyoumustdilutethemedicine.Payattentiontothemedicinespeed.vFourth,youcannotuseanintramuscularinjection.Whenyouwanttoinjectit,youmustdefinethepininthevein.55护理措施护理措施丁广湘丁广湘 v气管插管和呼吸机的护理气管插管和呼吸机的护理v体位:患者卧床休息,予抬高床头体位:患者卧床休息,予抬高床头3040v固定:导管固定要牢靠,确定导管已准确插入气管后,用长胶固定:导管固定要牢靠,确定导管已准确插入气管后,用长胶布将导管和牙垫一起捆扎
54、固定;布将导管和牙垫一起捆扎固定;vTrachealintubationandbreathingmachinecare.vBodyPosition:bedrestforthepatientwithbedraising3040vFix:Thecathetershouldbefirmlyfixedtomakesurethatitisinsertedintotracheaandbetiedtogetherwithteethcushionthroughadhesiveplaster;56护理措施护理措施 v气道护理气道护理v气道的湿化气道的湿化v保持气道通畅保持气道通畅吸痰吸痰vPeriodicall
55、ycheckthedepthoftracheaandcatheter,auscultationbreathsoundsfromlungs.Bereadyforbedsideshift.AirfluecarevAirwayhumidificationvMaintainairwayunobstructedSuctionphlegm.57护理措施护理措施 v密切观察生命体征、密切观察生命体征、spo2、神志、皮肤面色、出入、神志、皮肤面色、出入量、观察人机是否同步,并做好记录量、观察人机是否同步,并做好记录。v心理护理心理护理。vCloseobservationofvitalsigns、spo2、c
56、onsciousnessandskincomplexion.Observewhethermanandmachinearesynchronization.vPsychologicalCare.58护理措施护理措施 刘 斌v患者机械通气病程长,机体抵抗力低下患者机械通气病程长,机体抵抗力低下,口腔自净作口腔自净作用和黏膜抵抗力减弱,使大量细菌在口腔里繁殖,容用和黏膜抵抗力减弱,使大量细菌在口腔里繁殖,容易造成口腔感染易造成口腔感染。vOralcavitynurse.vTheprocesswithmachineryventilationofpatientislong,herorganismresis
57、tibilityislow,oralcavitysautomaticdepurationfunctionandthemucousmembraneresistibilityareweaken,somassivebacteriareproduceinsidetheoralcavityanditiseasytobeinfected.59护理措施护理措施 v有有机机磷磷农农药药中中毒毒的的病病人人的的口口中中会会有有大大蒜蒜样样臭臭味味,并并且且口口腔腔黏黏膜膜干干燥燥、唾唾液液分分泌泌减减少少,因因此此应应做做好好口口腔腔护护理理、保保持持口口腔腔的的清清洁洁和和湿湿润润,每每日日高高质质量量的的口
58、口腔腔护护理理是是预预防防口口腔腔并并发发症和肺部感染的重要方法之一症和肺部感染的重要方法之一.vThe patient who is poisoning by AOPP will have thegarlicstink,theiroralcavitymucousmembranedryandsaliva reduces at the same time, therefore they shouldcompleteoralcavitynursing,maintainoralcavitycleanand the moistness, every day high grade oral cavity
59、nursing is one of the important methods in preventingoralcavitycomplicationandlungsinfection.60护理措施护理措施 v中毒后肌肉震颤导致产热增加,大量阿托品应用后出中毒后肌肉震颤导致产热增加,大量阿托品应用后出现散热障碍,均可致体温上升。现散热障碍,均可致体温上升。vAfterthepoisoning,themuscletremblescausestoproduceincreaseshotlyandheatdissipationbarrierwillappearaftermassiveatropinea
60、pplication,bothofthemmayleadtobodytemperaturerising.61护理措施护理措施 v一般低度或中度发热不需处理,如出现高热,可以采一般低度或中度发热不需处理,如出现高热,可以采取物理降温,同时可以给病人补充液体以达到降温,取物理降温,同时可以给病人补充液体以达到降温,一般不用药物降温。一般不用药物降温。vNormallyormoderatefeverheatneednttodealwith.Butifitpresentsthehighfever,wemayadoptthephysicalcooling.Simultaneouslywemaysuppl
61、ementtheliquidforpatienttodecreasethebodytemperature,generallywedontneedthemedicineforcooling.62护理措施护理措施 罗富群v饮食饮食v重度中毒一般需禁食重度中毒一般需禁食3-5天,待病情稳定,意识清醒天,待病情稳定,意识清醒后可以口服蛋清以保护胃粘膜,禁食刺激性及含油脂后可以口服蛋清以保护胃粘膜,禁食刺激性及含油脂多的食物。多的食物。vDietvSeverepoisoning,whichnormallytakes1-3daysoffasting,beinstablecondition,consciou
62、sandaliveafteroraltemperatureofliquideggwhitetoprotectthegastricmucosa,Prohibittheconsumptionofirritatingandgreasyfastfoodandmore.63护理措施护理措施 v昏迷昏迷3-5天患者鼻饲饮食,注意补充维生素和无机盐,天患者鼻饲饮食,注意补充维生素和无机盐,供给足够的优质蛋白。供给足够的优质蛋白。vComainpatientswithnasalfeedingdietfor3-5days,payattentiontovitaminandmineral,thesupplyofad
63、equatequalityprotein.64护理措施护理措施 何蓉v安全护理安全护理v患者昏迷,躁动不安,应派专人护理,防止意外发生。必要时患者昏迷,躁动不安,应派专人护理,防止意外发生。必要时对其用约束带限制其四肢活动,但应防止约束过紧,定时放松,对其用约束带限制其四肢活动,但应防止约束过紧,定时放松,以免造成局部末梢循环障碍和皮肤损伤以免造成局部末梢循环障碍和皮肤损伤。必要时使用镇静药。必要时使用镇静药。vSafevComapatientswithrestless,shouldsendsomeonetocare,topreventaccidents.Whenitisnecessaryto
64、useconstraintstolimittheirlimbswithactivities,butshouldpreventbindingtight,timetorelax,toavoidlocalperipheralcirculationdisordersandskinlesions.Usesedativewhennecessary.65护理措施护理措施 刘芳v心理护理心理护理v待患者病情稳定后转入单间病房,保持室内清洁安静。防止围观,注意待患者病情稳定后转入单间病房,保持室内清洁安静。防止围观,注意保护隐私。保护隐私。v建立良好的护患关系,予以心理支持;良好的护患关系可使患者产生信建立良好
65、的护患关系,予以心理支持;良好的护患关系可使患者产生信任感和安全感。用心理解患者苦恼,允许患者发泄,鼓励其哭诉,让不任感和安全感。用心理解患者苦恼,允许患者发泄,鼓励其哭诉,让不良情绪充分释放出来。良情绪充分释放出来。vPsychologicalNursingvTobetransferredtoasinglepatientinstableconditionafterward,tokeeptheroomcleanquiet.Preventonlookers,toprotectprivacy.vEstablishagoodnurse-patientrelationship,toheartsuppo
66、rt;goodnurse-patientrelationshipallowspatientsasenseoftrustandsecurity.Hardtounderstanddistressinpatients,allowingpatientstovent,toencouragetheirtears,sofullofnegativeemotionsreleased.66护理措施护理措施 医医护护人人员员及及家家属属尽尽量量不不在在患患者者面面前前谈谈论论病病情情和和预预后后,及及时时将将良良性性信信息息反反馈馈给给患患者者,并并尽尽快快取取得得患患者者家家属属的的配配合合,帮帮助助患患者者寻寻
67、求求有有效效支支持持;实实施施心心里里护护理理除除了了直直接接面面对对患患者者外外,同同时时还还需需给给予予患患者者家家属属心心里里疏疏导导。使使其其更体恤患者处境,主动深入患者的内心世界,为患者赢得跟多的支持。更体恤患者处境,主动深入患者的内心世界,为患者赢得跟多的支持。vHealthcareworkersandtheirfamiliesbeforethepatientisnotasmuchaspossibleabouttheconditionandprognosis,andtimelypositivefeedbacktopatients,andpatientsassoonaspossibl
68、ewiththefamilies,relativesandfriendstotemporarilytakecareoffamilyresponsibilities,torelievethepatientsworries,assoonaspossiblesothatpatientsunderstandingoftheirattendingdoctorsandnurses.67护理措施护理措施 找找到到有有效效的的支支持持,以以帮帮助助病病人人;实实施施心心理理护护理理除除了了直直接接面面对对病病人人,家家庭庭成成员员也也很很重重要要,让让它它们们更更加加同同情情病病人人的的现现状状,积积极极深深
69、入病人内在的世界。入病人内在的世界。vTohelppatientsfindeffectivesupport;implementationofheartcareinadditiontodirectlyfacethepatient,thefamilymembersofpatientsalsoneedtogivemyheartease.Makeitmoresympathetictothesituationofpatients,activein-depthpatientsinnerworld.68相关知识相关知识 Hemoperfusionisamedicalprocedurewhichisusedt
70、ocleansethebloodoftoxins.Duringthisprocessthebloodispassedthroughanadsorbentmaterialwhichattractstoxicsubstances.血血液液灌灌流流是是指指将将血血液液通通过过体体外外循循环环经经过过具具有有广广谱谱解解毒毒作作用用的的吸吸附附装装置置,以以清清除除血血中中外外源源性性或或内内源源性性毒毒物物,从从而而达达到到血血液液净净化化的的一一种种医医疗疗治疗方法。治疗方法。vWhatIsHemoperfusion?v什么是血液灌流什么是血液灌流?69护理措施护理措施 血血液液灌灌流流的的实实质
71、质是是血血液液吸吸附附,即即溶溶解解在在血血中中的的物物质质被被吸吸附附到到具具有有较较大大表表面面积积的的固固形形物物质质上上去去,从从而而清清除除血血中中有有毒毒物物质质。目目前前常常用用的的吸吸附附剂剂有有两两种:一类是活性炭,一类是合成树脂。种:一类是活性炭,一类是合成树脂。vTheadsorbentmaterialisusuallycharcoaloractivatedcarbonfixedtoasolidsurfaceinsideacolumn.Duringtreatment,thepatientsbloodispassedthroughthecolumnandtoxinsbind
72、totheadsorbentmaterial,allowingcleansedbloodtoflowoutofthecolumn.Thisprocesscontinuesuntilasmuchtoxicmaterialaspossiblehasbeenremovedfromtheblood.70护理措施护理措施 Hemoperfusion isusually carried outfor Severalreasons.进行血液灌洗通常有几种原因。进行血液灌洗通常有几种原因。vwhenitisused?v适应症适应症71护理措施护理措施 首首先先,血血液液灌灌流流主主要要用用于于急急性性药药物物
73、或或毒毒物物中中毒毒,特特别别是是胎胎溶溶性性毒毒物物或或与与蛋蛋白白结结合合的的毒毒物物。血血液液灌灌洗洗等等能能成成功地排除毒素和代谢废物功地排除毒素和代谢废物.vFirst,theprocedureisusedasanemergencymedicaltreatmentincaseswhereapatienthasingestedalargeamountofasubstancewhichistoxictothekidneys。Hemoperfusioncansuccessfullyremovetoxinsorwasteproductswhicharepresentinapatientsbl
74、ood.72护理措施护理措施 其其次次,血血液液灌灌流流对对于于那那些些接接受受脏脏器器移移植植(如如肝肝脏脏,肾肾脏脏移移植植)是是一一种种辅辅助助治治疗疗,移移植植患患者者在在此此之之前前和和之之后后接受血液灌流,这样受体脏器就不会负担过重。接受血液灌流,这样受体脏器就不会负担过重。vSecond.,thisprocessisusedasasupportivetreatmentforpeoplewhoareundergoingalivertransplant,Beforeandafterthetransplantitself,patientsundergobloodcleansingsot
75、hatthenewly-transplantedliverisnotoverburdened.73护理措施护理措施 最最后后,血血液液灌灌洗洗等等也也是是一一种种辅辅助助治治疗疗患患者者肾肾功功能能衰衰竭竭的透析治疗方法。的透析治疗方法。vFinally.Hemoperfusionisalsoatypeofdialysis,itisusedasasupportivetreatmentforpeoplewithkidneyfailure.74护理措施护理措施 最最后后,血血液液灌灌洗洗等等也也是是一一种种辅辅助助治治疗疗患患者者肾肾功功能能衰衰竭竭的透析治疗方法。的透析治疗方法。vFinally
76、.Hemoperfusionisalsoatypeofdialysis,itisusedasasupportivetreatmentforpeoplewithkidneyfailure.75护理措施护理措施 v洗胃时间洗胃时间v一般认为,洗胃的时间应该在一般认为,洗胃的时间应该在6小时内。超过小时内。超过6小时就没有洗胃小时就没有洗胃的必要。但事实证明:有些患者服毒超过的必要。但事实证明:有些患者服毒超过6小时,其胃液和呕吐小时,其胃液和呕吐物仍有蒜臭味,表明毒物存在。因此,首次洗胃后,应该保留胃物仍有蒜臭味,表明毒物存在。因此,首次洗胃后,应该保留胃管管24小时,每隔小时,每隔4小时重复洗胃
77、一次,直到症状好转。小时重复洗胃一次,直到症状好转。vGastriclavagetimevGenerallythought,Thegastriclavagetimeshouldin6hours.Itsunnecessarywhenthetimelongerthan6hours.Somesuffererscommitbypoisonlongerthan6hours,itsstomachliquidandvomitsathingtostillhavegarlicbadsmell,expresspoisonexistence.Therefore,fortheveryfirsttimeafterwas
78、hingstomach,shouldreservestomachandtakecareoffor24hours,againwashstomachevery4houronce,untilsymptomamendment.76护理措施护理措施 v胃管长度胃管长度v有研究证明:将胃管长度由有研究证明:将胃管长度由4555cm延长到延长到5570cm,使,使胃管侧孔全部在胃内,可使患者不论取何种体位,均达到洗胃液胃管侧孔全部在胃内,可使患者不论取何种体位,均达到洗胃液流出快、通畅,洗胃时间短,洗胃彻底的目的,为抢救赢得了宝流出快、通畅,洗胃时间短,洗胃彻底的目的,为抢救赢得了宝贵的时间贵的时间。vGa
79、strictubelengthvResearchproves:willthetubelengthby45-55cmextendto55-70cm,makegastrictubesideholesinthestomach,allwithincanmakepatientstakenomatterwhatposition,achieveswashoutfast,unobstructed,gastriclavagetimeisshort,lavagecompletely,forthepurposeoftherescuetowintheprecioustime.77护理措施护理措施 v导泻导泻v有研究认
80、为:在早期充分洗胃的基础上给予有效导泻处置,可充有研究认为:在早期充分洗胃的基础上给予有效导泻处置,可充分地清除已进入患者体内但尚未吸收人血的有机磷成分,减轻中分地清除已进入患者体内但尚未吸收人血的有机磷成分,减轻中毒症状。即使中毒已超过毒症状。即使中毒已超过6小时,小时,3天内未予导泻处理者,仍应天内未予导泻处理者,仍应给予有效的导泻。给予有效的导泻。vCatharsisvAstudyfoundthatintheearlydaysonthebasisoffullylavageprovideeffectiveguide,anditcanfullydiarrheadisposaltoremove
81、hasenteredintothepatientsbodiesbutnotyetabsorbbloodcomposition.Evenmorethansixhourspoisoninghaswithinthreedays,stillshouldgiveeffectivecatharsis.78护理措施护理措施 v阿托品化阿托品化v有学者认为,在有学者认为,在AOPP患者中有患者中有30始终不出现瞳孔散大,心始终不出现瞳孔散大,心率增快的速度变慢。这是因为他们对抗胆碱剂的耐受性增加。为率增快的速度变慢。这是因为他们对抗胆碱剂的耐受性增加。为此,提出把心率维持在此,提出把心率维持在80100次分,
82、口腔、皮肤干燥,是次分,口腔、皮肤干燥,是判断阿托品化较为可靠,而且是相对稳定的指标,称为判断阿托品化较为可靠,而且是相对稳定的指标,称为“简化阿简化阿托品化托品化”。vAtropinizationvSomescholarsthink,AOPPin30%ofpatientsnotalwaysappearinallpupil,heartrateincreasespeedslowbecausetheyfightchorineagentstoleranceincreases,Forthis,putforwardtheheartratein80-100,oralcavity,dryskin,isthe
83、morereliablejudgmentatropinization,andarerelativelystableindicators,calledsimplifiedatropinechange.79护理措施护理措施 简简化化阿阿托托品品化化与与快快速速胆胆碱碱酯酯酶酶活活力力动动态态同同步步观观察察。避避免免了了抗抗胆胆碱碱剂剂的的不不足足、过过量量和和中中毒毒现现象象的的发发生生,与与传传统阿托品化指标相比。指标数量少,便于掌握及观察。统阿托品化指标相比。指标数量少,便于掌握及观察。vThesimplifiedatropinewithfastcholinesteraseenergydyn
84、amicsynchronousobservation.Avoidanticholinergicagentisinsufficient,excessiveandpoisoninghappens,andtraditionalatropinecomparedtheindex.Indexnumberlessconvenientmasterandobserve.80护理措施护理措施 v新型抗胆碱药新型抗胆碱药长托宁长托宁v特点:特点:起效快,起效快,M样症状与中枢神经系统症状消失时间明显缩样症状与中枢神经系统症状消失时间明显缩短;短;用药总量小,用药次数少,用药间隔时间长,减轻了医护用药总量小,用药次数
85、少,用药间隔时间长,减轻了医护人员的工作强度;人员的工作强度;不良反应轻,毒性低,安全可靠;不良反应轻,毒性低,安全可靠;提高抢提高抢救成功率。救成功率。vNewanticholinergicactivity-penehyelidinehydrochloridevFeatures:(1)theeffecttofast,Mkindsymptomsandcentralnervoussystemsymptomsdisappeartimesignificantlyshortened;v(2)thesmallamountofdruguse,druguse,druguselesstimeintervallong,v(3)theadversereactionlight,lowtoxicity,safeandreliable;v(4)improvethesuccessrateoftherescue.812024/8/1282