《濒死的病人生理学的变化症状的处理》由会员分享，可在线阅读，更多相关《濒死的病人生理学的变化症状的处理（35页珍藏版）》请在金锄头文库上搜索。
1、目目 的的Objectivesl识别、评估、并估、并处理理濒死病人的病学理生理学死病人的病学理生理学变化化lRecognize, assess, and manage the pathophysiologic changes of dying家庭成家庭成员的引的引证Family Members Quote“过过去数年的个人去数年的个人去数年的个人去数年的个人经历经历使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的记忆记忆中留下永久中留下永久中留下永久中留下永久的烙印。失去所的烙印。失去所的烙印。失去所的烙印
2、。失去所带带来的痛苦依然是很来的痛苦依然是很来的痛苦依然是很来的痛苦依然是很强强烈的，但是当感受到所有可以做的都做烈的，但是当感受到所有可以做的都做烈的，但是当感受到所有可以做的都做烈的，但是当感受到所有可以做的都做了，而且所有的了，而且所有的了，而且所有的了，而且所有的职业职业照照照照护护者都以者都以者都以者都以专业专业知知知知识识、职业职业道德、奉献精神和道德、奉献精神和道德、奉献精神和道德、奉献精神和爱爱心心心心对对病人病人病人病人给给予了姑息关予了姑息关予了姑息关予了姑息关怀怀，让让患者能患者能患者能患者能够够在他在他在他在他们们所深所深所深所深爱爱的人的关的人的关的人的关的人的关怀怀
3、下没有痛苦地和舒服地下没有痛苦地和舒服地下没有痛苦地和舒服地下没有痛苦地和舒服地死亡，我死亡，我死亡，我死亡，我们们心中就充心中就充心中就充心中就充满满了无限的感激和了无限的感激和了无限的感激和了无限的感激和对这对这一医学一医学一医学一医学领领域的敬畏。域的敬畏。域的敬畏。域的敬畏。”“ “My personal experience of the past few years has taught me that those last My personal experience of the past few years has taught me that those last few
4、days color ones memories permanently. The pain of loss is still immense, few days color ones memories permanently. The pain of loss is still immense, but to feel that everything that could have been done was done, that those who but to feel that everything that could have been done was done, that th
5、ose who cared did so with knowledge, professionalism, devotion, and even love, and cared did so with knowledge, professionalism, devotion, and even love, and that the person died without pain, comfortably, with those they loved around that the person died without pain, comfortably, with those they l
6、oved around them, is to feel immense gratitude and a curious humility.”them, is to feel immense gratitude and a curious humility.”诊断断“濒死死”的障碍的障碍Barriers to Diagnose “DYING”l对病人可能会好病人可能会好转的期待的期待l不能明确地不能明确地诊断断l对病人状况的分歧病人状况的分歧l不能不能识别关关键的症状和体征的症状和体征l不知怎不知怎样对濒死病人用死病人用药lHope that the patient may get bette
7、rlNo definite diagnosislDisagreement about the patients conditionlFailure to recognize key symptoms and signslFailure to know how to prescribe for the dying patientl不能很好地与病人及其家属交流不能很好地与病人及其家属交流l维持持还是撤除治是撤除治疗的考的考虑l对生存期生存期缩短的恐惧短的恐惧l文化和宗教的障碍文化和宗教的障碍l医学医学- -法律的思考法律的思考lPoor ability to communicate with th
8、e family and patientlConcerns about withholding or withdrawing treatmentslFear of foreshortening lifelCultural and spiritual barrierslMedico-legal concernsEllershaw, Ward. BMJ; 1/4/03如果不如果不对“濒死死”进行行诊断断 If Diagnosis of “DYING” is Not Made . . .l病人及其家属不能意病人及其家属不能意识到死亡的到死亡的逼近逼近l病人及其家属病人及其家属对内科医生和内科医生和护
9、士士失去信任失去信任l由于无法控制的症状由于无法控制的症状,病人在痛病人在痛苦和无尊苦和无尊严的状况下死亡的状况下死亡lPatient and family not aware that death is imminentlPatient and family loses trust in the physician and nurseslPatient dies with uncontrolled symptoms leading to a distressing and undignified deathl病人及其家属感病人及其家属感觉不不满意意l死亡死亡时心肺功能状心肺功能状态尚可尚可l
10、不能不能满足文化和宗教的需求足文化和宗教的需求lPatient and family feel dissatisfiedlCardiopulmonary resuscitation may be initiated at deathlCultural and spiritual needs not met濒死死过程的生理学程的生理学变化化Physiologic changes during the dying processl进行性增加的无力和疲乏行性增加的无力和疲乏Increasing weakness, fatiguel进行性减少的食欲行性减少的食欲/水水摄入入Decreasing app
11、etite / fluid intakel进行性降低的血液灌注行性降低的血液灌注Decreasing blood perfusionl闭眼功能的眼功能的丧失失Loss of ability to close eyesl神神经性功能障碍性功能障碍Neurologic dysfunctionl疼痛疼痛Pain无力无力/ /疲乏疲乏Weakness / fatiguel运运动能力减弱能力减弱Decreased ability to movel关关节部位乏力部位乏力Joint position fatiguel褥褥疮的危的危险性增加性增加Increased risk of pressure ulcer
12、sl姑息关姑息关怀的需求增加的需求增加Increased need for carel日常生活的行日常生活的行为activities of daily livingl翻身，运翻身，运动，按摩，按摩turning, movement, massage进行性减少的食欲行性减少的食欲/食物食物摄入入Decreasing appetite / food intakel恐惧：恐惧：“屈服屈服”与与饥饿 Fears: “giving in” and starvationl提示提示Reminders食物可致呕吐食物可致呕吐 food may be nauseating厌食可起保食可起保护作用作用 anore
13、xia may be protective吸入的危吸入的危险 risk of aspiration锉牙以表达食欲与控制牙以表达食欲与控制 clenched teeth express desires,ontroll帮助家属找出照帮助家属找出照护的替代方法的替代方法 Help family find alternative ways to care进行性减少的液体行性减少的液体摄入入 Decreasing fluid intake . . .l口服口服补充液体充液体l恐惧：脱水，口渴恐惧：脱水，口渴=痛苦痛苦l提醒家属及照提醒家属及照护者者脱水不会引起痛苦脱水不会引起痛苦脱水可能是一种保脱水可能
14、是一种保护口渴可以通口渴可以通过良好的口腔良好的口腔护理得以治理得以治疗lOral rehydrating fluidslFears: dehydration, thirst = sufferinglRemind families, caregiversdehydration does not cause distressdehydration may be protectiveThirst can be treated by good mouth care进行性减少的液体行性减少的液体摄入入Decreasing fluid intakel胃胃肠外外补液可能是有害的液可能是有害的液体液体负荷荷
15、过大，呼吸困大，呼吸困难，咳嗽，分泌增加，咳嗽，分泌增加全身性水全身性水肿l粘膜粘膜/结膜的膜的护理理lParenteral fluids may be harmfulfluid overload, breathlessness, cough, secretionsanasarcalMucosa / conjunctiva care进行性减少的血液灌注行性减少的血液灌注Decreasing blood perfusionl心心动过速，低血速，低血压l外周厥冷，外周厥冷，发绀l皮肤斑点状阴影皮肤斑点状阴影l尿量减少尿量减少l胃胃肠外的液体不回流外的液体不回流lTachycardia, hypot
16、ensionlPeripheral cooling, cyanosislMottling of skinlDiminished urine outputlParenteral fluids will not reverse神神经功能障碍功能障碍Neurologic dysfunctionl意意识进行性的降低行性的降低l与无意与无意识的病人的交流的病人的交流l终末期末期谵妄妄l呼吸的呼吸的变化化l吞咽能力吞咽能力丧失，括失，括约肌失控肌失控lDecreasing level of consciousnesslCommunication with the unconscious patientlT
17、erminal deliriumlChanges in respirationlLoss of ability to swallow, sphincter control死亡的两条途径死亡的两条途径2 roads to death烦烦躁不安躁不安躁不安躁不安RestlessRestless精神精神精神精神错错乱乱乱乱ConfuseConfused d幻幻幻幻觉觉HallucinationsHallucinations麻木性麻木性麻木性麻木性谵谵妄妄妄妄Mumbling DeliriumMumbling Delirium肌肌肌肌阵挛阵挛Myoclonic JerksMyoclonic Jerks
18、倦睡倦睡倦睡倦睡SleepySleepy疲乏疲乏疲乏疲乏LethargicLethargic反反反反应迟钝应迟钝ObtundedObtunded半昏迷状半昏迷状半昏迷状半昏迷状态态SemicomatoseSemicomatose昏迷状昏迷状昏迷状昏迷状态态ComatoseComatose 抽搐抽搐抽搐抽搐SeizuresSeizures通常的途径通常的途径THE USUAL ROAD痛苦的途径痛苦的途径THE DIFFICULT ROAD正常正常Normal死亡死亡Dead震震震震颤颤TremulousTremulous进行性减弱的意行性减弱的意识Decreasing level of con
19、sciousnessl“死亡的通常途径死亡的通常途径” “The usual road to death”l死亡死亡进展展 Progressionl睫毛反射睫毛反射 Eyelash reflex与无意与无意识的病人交流的病人交流 Communication with the unconscious patient . . .l对亲属造成痛苦属造成痛苦l意意识能力反能力反应能力能力l假定病人能假定病人能够听懂每一句听懂每一句话lDistressing to familylAwareness ability to respondlAssume patient hears everything与无意
20、与无意识的病人交流的病人交流 Communication with the unconscious patientl创造熟悉的造熟悉的环境境l在交流中在交流中应包含包含确保有人在确保有人在场与安全与安全l允允许死亡死亡l接触接触lCreate familiar environmentlInclude in conversationsassure of presence, safetylGive permission to dielTouch 终末期末期谵妄妄Terminal deliriuml“死亡的痛苦之路死亡的痛苦之路” “The difficult road to death”l临床床处
21、理理Medical management停止刺激停止刺激剂discontinue offending agents适当地适当地进行水化作用？行水化作用？gentle hydration?苯二氮卓苯二氮卓类benzodiazepines劳拉西泮拉西泮, 咪达咪达唑仑lorazepam, midazolam 神神经安定安定药物物neuroleptics氟氟哌啶醇，醇，氯丙丙嗪haloperidol, chlorpromazinel抽搐（抽搐（癫痫发作）作）Seizuresl家属需要支持与教育家属需要支持与教育Family needs support, education呼吸的呼吸的变化化 Chan
22、ges in respiration . . .l呼吸模式的改呼吸模式的改变进行性减少的潮气量行性减少的潮气量呼吸呼吸暂停停切尼切尼斯斯铎克斯氏呼吸克斯氏呼吸应用用辅助肌助肌末期反射性呼吸末期反射性呼吸lAltered breathing patternsdiminishing tidal volumeapneaCheyne-Stokes respirationsaccessory muscle uselast reflex breaths呼吸的呼吸的变化化Changes in respiration l恐惧恐惧窒息窒息l处理理亲属支持属支持氧气可延氧气可延长濒死死过程程呼吸困呼吸困难lFea
23、rssuffocationlManagementfamily supportoxygen may prolong dying processbreathlessness吞咽能力的吞咽能力的丧失失Loss of ability to swallowl呕吐反射的呕吐反射的丧失失l唾液与分泌液的蓄唾液与分泌液的蓄积使用使用东莨菪碱以减少分泌液莨菪碱以减少分泌液 体位引流体位引流特殊体位特殊体位吸痰吸痰lLoss of gag reflexlBuildup of saliva, secretionsscopolamine to dry secretionspostural drainagepositi
24、oningsuctioning括括约肌失控肌失控Loss of sphincter controll大小便失禁大小便失禁l家属需要知家属需要知识与支持与支持l清清洁与皮肤与皮肤护理理l安置尿管安置尿管l吸收吸收垫，表面清，表面清洁lIncontinence of urine, stoollFamily needs knowledge, supportlCleaning, skin carelUrinary catheterslAbsorbent pads, surfaces疼痛疼痛 Pain . . .l对增加疼痛的恐惧增加疼痛的恐惧l对无意无意识病人的病人的评估估持持续性与短性与短暂性的表性
25、的表现痛苦面容或者体征痛苦面容或者体征突突发性疼痛与静止性疼痛性疼痛与静止性疼痛区区别于于终末期末期谵妄妄lFear of increased painlAssessment of the unconscious patientpersistent vs fleeting expressiongrimace or physiologic signsincident vs rest paindistinction from terminal delirium疼疼 痛痛Painl对无尿的无尿的处理理停止停止吗啡的按啡的按时剂量和量和输注注必要必要时给予突破性予突破性剂量量(prn)最少侵最少侵袭性
26、的性的给药途径途径lManagement when no urine outputstop routine dosing, infusions of morphinebreakthrough dosing as needed (prn)least invasive route of administration闭眼功能眼功能丧失失Loss of ability to close eyesl眶后脂眶后脂垫丧失失l眼眼睑长度不足度不足l结膜裸露膜裸露干燥和疼痛的危干燥和疼痛的危险增加增加保持湿保持湿润lLoss of retro-orbital fat padlInsufficient eyeli
27、d lengthlConjunctival exposureincreased risk of dryness, painmaintain moisture药物治物治疗Medicationsl仅限于基本限于基本药物物l选择侵侵袭性性较少的少的给药途径途径首先考首先考虑颊粘膜或口服粘膜或口服给药，其次考，其次考虑直直肠极少极少进行皮下和静脉行皮下和静脉输注注给药几乎不几乎不进行肌内注射行肌内注射lLimit to essential medicationslChoose less invasive route of administrationbuccal mucosal or oral fir
28、st, then consider rectalsubcutaneous, intravenous rarelyintramuscular almost never最大限度的舒服措施最大限度的舒服措施药物学的物学的Full Comfort Measures . . . Pharmacologicl药物治物治疗Medicationsl疼痛疼痛Pain焦焦虑或或烦躁不安躁不安Anxiety or restlessness充血充血/分泌增加分泌增加Congestion / secretionsl给药途径途径Route of administrationl皮下皮下/静脉静脉输注注Subcutaneou
29、s/IVl舌下舌下Sublingual直直肠Rectal最大限度的舒服措施最大限度的舒服措施药物学的物学的Full Comfort Measures . . . Pharmacologicl镇痛痛药物物Analgesicsl吗啡，啡，氢吗啡啡酮Morphine, hydromorphone地塞米松，地塞米松，酮咯酸咯酸Dexamethasone, ketorolac焦焦虑/末期末期烦躁不安躁不安Anxiety / terminal restlessnessl氯羟安定，氟安定，氟哌啶醇，苯巴比妥醇，苯巴比妥Lorazepam, haloperidol, phenobarbital氯丙丙嗪（静脉注
30、射或直（静脉注射或直肠给予）予） Chlopromazine (IV or PR)最大限度的舒服措施最大限度的舒服措施药物学的物学的Full Comfort Measures . . . Pharmacologicl上呼吸道充血上呼吸道充血胃胃长宁，阿托品宁，阿托品 皮下注射皮下注射 或静脉注射或静脉注射莨菪碱（舌下），莨菪碱（舌下），东莨菪碱透皮莨菪碱透皮剂l由于呼吸由于呼吸频率减慢，血率减慢，血压过低，或由于低，或由于过度度镇静，不要静，不要给予予镇静静剂或阿或阿片片类制制剂给药l继续给抗惊厥抗惊厥药lUpper airway congestionGlycopyrrolate, atrop
31、ine SC or IVHyoscyamine (SL), scopolamine patchlDo not hold sedative medications or opioids because of low respiratory rate, low blood pressure or sedationlContinue anti-convulsant最大限度的舒服措施最大限度的舒服措施非非药物学的物学的Full Comfort Measures . . . Non-pharmacologicl停止常停止常规医嘱医嘱l考考虑停止鼻胃管停止鼻胃管/corpakl对呼吸困呼吸困难者吹者吹风扇
32、扇l最喜最喜爱的音的音乐或保持安静或保持安静l定定时翻身翻身l对精神精神错乱者反复定向乱者反复定向l必要必要时每两个小每两个小时口腔口腔/眼部眼部护理理lDC routine orderslConsider DC NGT/corpaklFan on face for dyspnealFavorite music or quietlFrequent repositioninglFrequent re-orientation for confusionlMouth/eye care every 2 hours as neededl每日床上沐浴和清洗每日床上沐浴和清洗l放松技放松技术l适当的限制探适
33、当的限制探访者者l柔和的光柔和的光线照明照明l轻轻接触接触l甚至当病人昏迷甚至当病人昏迷时也也对病人病人轻言言细语地交地交谈l搬走室内不必要的家具搬走室内不必要的家具lDaily bed bath and lotionlRelaxation techniqueslRestrict visitors as appropriatelSoft lightinglSoft touch lSpeak softly to patient even when comatoselRemove unnecessary equipment from the room提提问Askl我我们是否需要是否需要Do we
34、need to _?每日四次地每日四次地检查血糖血糖? Check blood glucose QID?每班都每班都检查生命体征生命体征? Check vitals q shift?每天上午都做每天上午都做实验室室检查?Get labs q AM?对病人病人进行行X光光检查? Send the patient down for x-rays?建立另一个静脉通道建立另一个静脉通道? Put in another IV?肌内注射肌内注射给药? Give medications IM?控制病人控制病人饮食食? Restrict his/her diet?l我我们是否可以皮下注射是否可以皮下注射给药?
35、 Can we give this medication subcutaneously?皮下皮下输注注Subcutaneous Infusionl吞咽困吞咽困难 Trouble swallowingl需多次注射需多次注射给药 Need for multiple injections and medicinesl在英国，常在英国，常应用注射用注射驱动器（微器（微泵） In UK, a syringe driver is commonly usedl在美国，在美国，应用用计算机控制的微算机控制的微泵 In USA, computerized pump is used微微泵用用药物物Syringe
36、Driver Medicines常用常用常用常用CommonCommon偶尔偶尔偶尔偶尔OccasionalOccasional不用不用不用不用NeverNever吗啡吗啡 Morphine酮咯酸酮咯酸 Ketoralac丙氯拉嗪丙氯拉嗪Prochlorperazine东莨菪碱东莨菪碱 Hyoscine芬太尼芬太尼 Fentanyl地西泮地西泮 Diazepam咪达唑仑咪达唑仑 Midazolam氯硝安定氯硝安定 Clonazepam度冷丁度冷丁/ /哌替啶哌替啶Demerol/Pethidine塞克利嗪塞克利嗪 Cyclizine甲氧异丁嗪甲氧异丁嗪Methotrimeparazine氯丙嗪
37、氯丙嗪 Largactil氢化吗啡酮氢化吗啡酮Hydromorphone苯巴比妥苯巴比妥 Phenobarbital胃长宁胃长宁Glycopyrolate地塞米松地塞米松 Dexamethasone氟哌啶醇氟哌啶醇 Haloparadol氯胺酮氯胺酮 Ketamine灭吐灵灭吐灵 Metoclopramide奥曲肽奥曲肽 OctreotideOctMidMetoMethKetHBrHaldGlycMorpDexCyclHBBrIncompatibleSometimes incompatibleCompatibleNo data available急症急症Emergenciesl状况状况Situ
38、ations颈动脉破裂或大出血脉破裂或大出血Ruptured carotid or massive hemorrhage严重呼吸困重呼吸困难Severe respiratory distressl药物治物治疗Medications吗啡啡 10mg，静脉注射，静脉注射/ Morphine 10mg IV/SQ劳拉西泮拉西泮 2mg，静脉注射，静脉注射/ Lorazepam 2mg IV/SQ如果不是阿片如果不是阿片类药物初用者，物初用者，则需要需要给予高予高剂量量药物物Higher doses needed if not opioid-nave家属引家属引证Family Members Quot
39、e“ “我在我在我在我在过过去几年中的个人去几年中的个人去几年中的个人去几年中的个人经历经历使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的使我明白了一个人的最后几天会在人的记忆记忆中留下永久的烙印。中留下永久的烙印。中留下永久的烙印。中留下永久的烙印。丧丧失失失失亲亲人的痛苦依然是很人的痛苦依然是很人的痛苦依然是很人的痛苦依然是很强强烈的，但是当感烈的，但是当感烈的，但是当感烈的，但是当感受到一切可以做的都做了，所有关受到一切可以做的都做了，所有关受到一切可以做的都做了，所有关受到一切可以做的都做了，所有关怀怀病人的人都以病人的人都以病人
40、的人都以病人的人都以专业专业知知知知识识，专业专业技技技技能，奉献精神，和能，奉献精神，和能，奉献精神，和能，奉献精神，和爱爱心心心心对对病人病人病人病人给给予了关予了关予了关予了关怀怀，并且病人能，并且病人能，并且病人能，并且病人能够够在他在他在他在他们们所深所深所深所深爱爱的人的关注下毫无疼痛地安的人的关注下毫无疼痛地安的人的关注下毫无疼痛地安的人的关注下毫无疼痛地安乐乐地去世，我地去世，我地去世，我地去世，我们们心中就充心中就充心中就充心中就充满满了无尽的感了无尽的感了无尽的感了无尽的感激和激和激和激和对这对这一医学一医学一医学一医学领领域的敬畏。域的敬畏。域的敬畏。域的敬畏。” ”“
41、“My personal experience of the past few years has taught me that those My personal experience of the past few years has taught me that those last few days color ones memories permanently. The pain of loss is still last few days color ones memories permanently. The pain of loss is still immense, but
42、to feel that everything that could have been done was immense, but to feel that everything that could have been done was done, that those who cared did so with knowledge, professionalism, done, that those who cared did so with knowledge, professionalism, devotion, and even love, and that the person died without pain, devotion, and even love, and that the person died without pain, comfortably, with those they loved around them, is to feel immense comfortably, with those they loved around them, is to feel immense gratitude and a curious humility.”gratitude and a curious humility.”
