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1、Nursing Care of Client Experiencing Trauma创伤病人的护理创伤病人的护理vDefinition of TraumavTrauma morbidity（发病率）（发病率） and mortality（死亡率）（死亡率） constitute a major health care challenge. 创伤的发病率和死亡率构成了健康的最大挑战。创伤的发病率和死亡率构成了健康的最大挑战。vAlthough significant strides have been made in combating heart disease and selected ca
2、ncers, traumatic injury continues to be the number-one killer of the young. Section 1 OverviewTraumatraumatic injuryheart diseasecancerThe number-one killer of the youngvIt is estimated that traumatic injury causes about 140,000 deaths per year. vAn additional 57 million people suffer nonfatal (不致命的
3、）不致命的）injuries each year. 当肯尼迪乘坐敞蓬轿车驶过德克萨斯州达拉斯的迪利广场（当肯尼迪乘坐敞蓬轿车驶过德克萨斯州达拉斯的迪利广场（Dealey Plaza）时，遭到枪击身亡）时，遭到枪击身亡。约翰约翰肯尼迪肯尼迪是美国历史上第四位遇刺身亡的总统，也是第八位在是美国历史上第四位遇刺身亡的总统，也是第八位在任期内去世的总统。任期内去世的总统。 assassination 遇刺，暗杀遇刺，暗杀John Fitzgerald Kennedy 肯尼迪诅咒肯尼迪诅咒 curse v1 119411941年，约瑟夫的残疾女儿死于失败的脑叶切除手术；年，约瑟夫的残疾女儿死于失败的脑叶
4、切除手术；v2 219441944年，约瑟夫长子小约瑟夫年，约瑟夫长子小约瑟夫肯尼迪战时死于飞机失事；肯尼迪战时死于飞机失事； v3 319481948年，约瑟夫二女儿凯瑟琳死于飞机失事；年，约瑟夫二女儿凯瑟琳死于飞机失事； v4 419631963年，肯尼迪总统的第三个儿子出生两天后夭折；年，肯尼迪总统的第三个儿子出生两天后夭折； v5 519631963年，约瑟夫二子肯尼迪总统遇刺身亡；年，约瑟夫二子肯尼迪总统遇刺身亡； v6 619681968年，约瑟夫三子罗伯特遇刺身亡；年，约瑟夫三子罗伯特遇刺身亡； v7 719831983年，罗伯特之子博比因吸毒被判刑；年，罗伯特之子博比因吸毒被判
5、刑； v8 819841984年，罗伯特之子戴维因过量吸服海洛因死亡；年，罗伯特之子戴维因过量吸服海洛因死亡； v9 919971997年，罗伯特之子迈克尔死于滑雪事故；年，罗伯特之子迈克尔死于滑雪事故； v101019991999年，约翰之子小约翰年，约翰之子小约翰肯尼迪死于飞机失事；肯尼迪死于飞机失事； v111120092009年，约瑟夫四子爱德华死于脑癌；年，约瑟夫四子爱德华死于脑癌； vTraumatic injury usually occurs suddenly, leaving both the client and family with little time to pre
6、pare for its consequences. v创伤发生得太突然，没有任何时间留给病人和创伤发生得太突然，没有任何时间留给病人和家庭来准备承受后果。家庭来准备承受后果。vNurse provide a vital link in both the physical （生理的）（生理的）and psychosocial（心理社会）（心理社会） care for the injured client and family. v护士要提供给护士伤员及家庭一个关健的护理护士要提供给护士伤员及家庭一个关健的护理不仅是生理上的还包括心理社会的。不仅是生理上的还包括心理社会的。traffic acc
7、identvIn caring for the client who has experienced trauma, nurses must consider not only the initial physical injury ,but also its long-term consequences, including rehabilitation and the clients return to his or her previous way of life.v护士护理创伤人员时，不仅必须考虑最原先的护士护理创伤人员时，不仅必须考虑最原先的生理创伤，而且也要考虑长期的后序治疗，包生
8、理创伤，而且也要考虑长期的后序治疗，包括康复和伤员能回归原来的生活轨道。括康复和伤员能回归原来的生活轨道。Types of Trauma 创伤类型创伤类型Severity 严重程度分类严重程度分类vWhether intentional or accidental, trauma causes injury to one or more parts of the body.1 Minor trauma2 Major or multiple trauma1 Minor trauma 轻伤轻伤vMinor trauma causes injury to a single part or syste
9、m of the body and is usually treated in the hospital or emergency department .v轻伤导致身体一个部分或一个系统的损伤，通轻伤导致身体一个部分或一个系统的损伤，通通都会在医院或急诊科被治疗。通都会在医院或急诊科被治疗。vA fracture of the collarbone, a small second-degree burn ,and a cut requiring stitches are all considered minor trauma.v锁骨的骨折，二度烧伤和一个需要缝合的伤口锁骨的骨折，二度烧伤和一
10、个需要缝合的伤口都被认为是轻伤。都被认为是轻伤。2 Major or multiple trauma 重伤及多发伤重伤及多发伤vMajor or multiple trauma involves serious single-system injury(such as the traumatic amputation of a leg) or multiple-system injuries. vMultiple trauma requires immediate intervention （立即干预）（立即干预）that is specifically focused on ensuring
11、 the survival of the client. v多发伤需要立即干预，尤其重心是保证病人的多发伤需要立即干预，尤其重心是保证病人的生命。生命。vClients who suffer multiple trauma receive immediate emergency care and often require long periods of intensive nursing care.v多发创需要立即接受急救治疗，并且经常需要多发创需要立即接受急救治疗，并且经常需要常长时间的护理。常长时间的护理。Types of TraumaSkin Integrality 按皮肤的完整性来分
12、按皮肤的完整性来分v1 Blunt trauma 闭合性损伤闭合性损伤 Blunt trauma occurs when there is no communication from the damaged tissues to the outside environment. v2 Penetrating trauma 开放性损伤开放性损伤 Penetrating trauma occurs as the result of foreign objects set in motion. Penetration of tissues causes damage to body structur
13、es, most commonly the intestines（肠道）（肠道）, liver（肝脏）（肝脏）, spleen（脾脏）（脾脏）, and vascular system（血管系（血管系统）统）.Types of TraumaOrgan and location 创伤器官和部位分创伤器官和部位分vtrauma of abdomen 腹部创伤腹部创伤vtrauma of bladder 膀胱损伤膀胱损伤;膀胱外伤膀胱外伤vtrauma of limbs 四肢损伤四肢损伤vTrauma of chest 胸部损伤胸部损伤vtrauma of breast 乳腺外伤乳腺外伤vtraum
14、a of gastrointestinal tract 胃肠道创伤胃肠道创伤vtrauma of nose 鼻外伤鼻外伤vtrauma of brain 脑外伤脑外伤vtrauma of spinal cord 脊髓外伤脊髓外伤Effects of Traumatic Injury 创伤的影响创伤的影响v Causes and Initial Management 创伤原因和处理创伤原因和处理vAirway obstruction 气道阻塞气道阻塞vTension pneumothorax 张力性气胸张力性气胸v Hemorrhage 出血出血v Integumentary effects 皮
15、肤损伤皮肤损伤v Hypovolemic shock 低血容量性休克低血容量性休克v Neurologic effect 对神经系统的影响对神经系统的影响v Effect on the family 对家庭的影响对家庭的影响1 Causes and Initial Management 创伤原因创伤原因和处理和处理(1)Natural DisastersvEarthquake 地震地震vMudslide；mudflow 泥石流泥石流vvolcano 火山火山vlkeinuv lahar 火山泥流火山泥流l:h:vavalanche 雪崩雪崩v,lntvBlizzard 暴风雪暴风雪 blzdv
16、Hurricane 飓风飓风vTyphoon taifu:n台风台风vFlood 洪水洪水v ice storm 冰雹冰雹1 Causes and Initial Management 创伤原因创伤原因和处理和处理Man-made disastersDerail 火车出轨火车出轨Traffic crash; traffic accident 交通事故交通事故Plane crash 飞机失事飞机失事attack; slaughter ; fight 袭击；屠杀；打架袭击；屠杀；打架terrorist attack 恐怖袭击恐怖袭击Shooting 枪击枪击War；battle 战争；战斗战争；战
17、斗Sport activityInitial ManagementvA mentioned as the opening of this chapter, death is a common result of serious traumatic injury. vDeath from trauma may be immediate ,early, or late. 创伤引起的死亡可以是立即的，早期的或创伤引起的死亡可以是立即的，早期的或是晚期的。是晚期的。vImmediate death is death is death at the scene from such injuries as
18、 a torn thoracic aorta（主动（主动脉撕裂伤）脉撕裂伤）.vEarly death is death occurring within several hours of the injury from ,for example, shock （休（休克）克）or lack of treatment for unrecognized injuries （无法诊断的损伤）（无法诊断的损伤）. vLate death generally occurs one or more days after the injury and results from multiple organ
19、 failure（器官衰竭）（器官衰竭）.vBecause of the serious consequences of a traumatic injury , it is important to identify rapidly and take interventions appropriately.v因为创伤的严重后果，对于迅速确定并且适当因为创伤的严重后果，对于迅速确定并且适当地采取措施非常重要。地采取措施非常重要。EP 10 mins 急救白金十分钟急救白金十分钟emergency platinum 10 mins10platinumpltnmCRASH PLAN检查顺序检查顺序
20、vC cardic 心脏心脏vR respiratory 呼吸呼吸vA abdomen 腹部腹部vS spine 脊柱脊柱vH head 头颅头颅vP Pelvic 骨盆骨盆vL 1imb 四肢四肢 vA artery 血管血管vN nerve 神经神经2 Airway obstruction 气道阻塞气道阻塞vThe trauma clients airway may become obstructed by the presence of blood ,teeth ,the tongue, and vomitus（呕吐）（呕吐）. Airway interventions may incl
21、ude:v1 Clearing the airway by suctioning（吸引）。（吸引）。v2 Use of airway adjuncts, such as an oropharyngeal（口咽的）（口咽的） airwayv3 Intubation with an oral endotracheal airway（气管插管）（气管插管）. v4 Needle or surgical circothyroidotomy. （气管（气管切开）切开）This procedure is performed only after other methods are ineffective
22、in opening and maintaining an open airway.开放气道开放气道 AirwayClearing the airway by suctioningan oropharyngeal airwayv口咽管口咽管Intubation with an oral endotracheal airwaycircothyroidotomy3 Tension pneumothorax 张力性气胸张力性气胸vA pneumothorax results from air in the pleural space from blunt and penetrating injuri
23、es to the chest. vWhen a one way valve（阀门）（阀门） is created so that air can enter the pleural space but not exit, a tension pneumothorax may develop.4 Hemorrhage 出血出血v1 External Hemorrhage （外出血）（外出血）vWhen the client has suffered an injury that causes external hemorrhage, such as severing of an artery
24、,the bleeding must be controlled immediately methods to achieve this include:v(1)Applying direct pressure over the woundv(2)Applying pressure over arterial pressure points 压迫伤口上方动脉压迫伤口上方动脉 v(3) Elevating the injured limb 抬高抬高v(4)Clamping the bleeding vessel. （固定，夹紧）（固定，夹紧）v(5)Applying a tourniquet.
25、(止血带止血带)压迫止血压迫止血Applying direct pressure over the wound包扎止血包扎止血Clamping the bleeding vesselApplying pressure over arterial pressure points 压迫伤口上方动脉压迫伤口上方动脉 4 Hemorrhage 出血出血v2 Internal Hemorrhage 内出血内出血vInternal hemorrhage may result from either blunt or penetrating traumatic injury. Discovering the
26、 cause of ，location of ,and extent of blood loss related to the injury is the most important concerns. Methods to discover the presence and location of internal hemorrhage include:vDiagnostic peritoneal lavage (诊断性腹腔清洗诊断性腹腔清洗 )vCT scans of the head, chest, and abdomenDiagnostic peritoneal lavagev Th
27、e body has several potential spaces that can accommodate（容纳）（容纳） large amount of blood that may accumulate （集聚）（集聚）follow injury. v在身体中有几个潜在的腔隙可以容纳大量的血在身体中有几个潜在的腔隙可以容纳大量的血液。液。vFox example, bleeding into the pleural space （胸膜腔）（胸膜腔）may occur with chest trauma, and bleeding into the abdominal cavity（腹
28、腔）（腹腔） may occur with abdominal trauma. vPelvic fracture（骨盆骨折）（骨盆骨折） may cause massive hemorrhage in the retroperitoneal(腹腹膜后膜后) region.vOnce the source of internal hemorrhage has been recognized, interventions are initiated ,including:vOperative control of bleeding 手术控制出血手术控制出血vContinual assessment
29、 of the client, including physical assessment, vital signs, and serial laboratory work.v评估患者通过身体检查，生命体征和一系列的评估患者通过身体检查，生命体征和一系列的辅助检查辅助检查5 Hypovolemic shock 低血容量性休克低血容量性休克vA serious and potentially lethal complication of external or internal hemorrhage is hypovolemic shock. The most common cause of h
30、ypovolemic shock is trauma injury.vThe client who has suffered multiple injuries may develop shock from a combination of multiple source of blood and fluid loss.Care of the client who is experiencing hypovolemic shock may include rapid identification of the source bleeding ; fluid replacement; blood
31、 transfusion; and operative intervention to control bleeding.6 Integumentary effects 皮肤损伤皮肤损伤vFour specific injuries to the integument includev contusions（挫伤）（挫伤） ,vabrasions（擦伤）（擦伤）, vpuncture wounds（刺伤）（刺伤）, vlacerations（裂伤）（裂伤）.bullet woundStabbing wound contusionspuncture woundsabrasionslacerati
32、onsvInjuries to the integument （表皮）（表皮）are at risk for contamination（污染）（污染）from dirt, debris, or foreign objects. Intervention for injuries to the integument include:v1 Controlling any active bleedingv2 Immobilizing the affected area. （固定）（固定）v3 Stabilizing any penetrating objects. (固定固定)v4.Cleanin
33、g the wound.v5.Applying the appropriate dressingv6.Administering tetanus （破伤风）（破伤风）immunization as indicatedv7.Providing information about home wound care when the client is discharged.7 Neurologic effect 神经系统影响神经系统影响vHead injuries are one of the most common types of injury sustained（承受）（承受） as the
34、result of trauma. Injury to the spinal cord resulting in loss of neurologic function is one of the most devastating outcomes.(破坏性后果破坏性后果) vThe majority of head and spinal cord injuries result from blunt trauma and sustained in motor vehicle crash（车祸）（车祸）, Fall（摔倒）（摔倒）, sport injuries（运动损伤）（运动损伤）, an
35、d assault（斗殴）（斗殴）are some of the other sources of neurologic injury.8 Effect on the family 对家庭的影响对家庭的影响vTraumatic injury usually occurs suddenly and with little warning. It may result in death or cause injury serious enough to alter dramatically both the clients and the family lives. Signs and sympt
36、oms of psychologic crisis include the following:v1 shockv2 Fearv3 Numbness v4 Anxietyv5 Guiltv6 Hostility（敌对的）（敌对的）v7 Anger8 Effect on the family 对家庭的影响对家庭的影响vImmediate interventions include:v1 Establishing communication with the family as quickly as possible. v2 Providing information about client,
37、the incident, and the care.v3 Accompanying the family to see the client.Section 2 Nursing care of client with traumavNursing Diagnoses and Collaborative ProblemsvNursing care of the client who has been injured begins with a primary assessment and the initiation of collaborative interventions for any
38、 life-threatening injuries, Nursing care is directed toward the clients specific responses trauma. Nursing diagnoses for the client with trauma may include:Nursing Diagnoses and Collaborative Problemsv1 Impaired airway Clearance related to the block of airway caused by trauma.v2 Risk for infection r
39、elated to traumav3 Impaired physical mobility related to the pain caused by traumav4 Spiritual distressv5 Post-trauma responsev6 Risk for traumaNursing InterventionvThe client who has suffered multiple is at great risk for developing airway obstruction and apnea（窒息）（窒息）. v Facial injuries, loose tee
40、th, blood, and vomitus （呕吐物）（呕吐物）increase the risk for aspiration（误（误吸吸) and obstruction. vNeurologic injuries and cerebral edema(脑水肿脑水肿) alter the clients respiratory drive and ability to keep the airway clear. vNurses should observe whether the clients airway is patent（张开的）（张开的）, maintainable（可维持的
41、）（可维持的）.Assess the client for signs and symptoms of airway obstruction：v1 Facial traumav2 Debris（异物）（异物） in the airway, such as teeth ,blood, or vomitusv3 Stridor（喘鸣）（喘鸣）v4 Tachypnea （呼吸急促）（呼吸急促）v5 Bradypnea （呼吸缓慢）（呼吸缓慢）v6 Cough （咳嗽）（咳嗽）v7 Cyanosis （紫绀）（紫绀）v8 shortness of breath.v9 Decreased or abse
42、nt breath sounds.vNurses also need to monitor oxygen saturation. Oxygen flow is adjusted to maintain the clients oxygen saturation from 94%100%.Risk for infectionvTraumatic injuries are considered dirty wounds. The trauma often occurs in a dirty environment. Nursing intervention with rationales（基本理论
43、）（基本理论） are as follows:v1 Use careful hand washing practices. Hand washing remains the single most important factor in preventing the spread of infection.v2 Use strict universal precautions. （全面防护）（全面防护）The use of universal precautions is essential in protecting the client and the nurse from injecti
44、on.v3 When applying or changing dressings（敷料）（敷料）use strict aseptic technique.v4 Take and record vital signs v5 Provide adequate fluids and nutrition.v 6 Use strict aseptic technique when inserting catheters, suctioning ,administering parenteral（肠外的）（肠外的） medications，or performing any other invasive
45、 procedure.Impaired physical mobilityvThe client with traumatic injuries is often unable to change positions independently and is at risk for complication of the integumentrary(表皮表皮), cardiovascular(心血管）心血管）, gastrointestinal（胃肠（胃肠道）道）, respiratory（呼吸）（呼吸）, musculoskeletal（肌（肌肉骨骼）肉骨骼） ,and renal sys
46、tems（泌尿系统）（泌尿系统）. vNursing intervention with rationales are as followedv1 Provide active or passive exercises at least once every 8 hours.v2 Turn, cough, and deep breath at least every 2 hours.v3 Monitor the lower extremities each day for manifestation of deep vein thrombosis.Spiritual distressvTrau
47、ma generally strikes with little or warning and carries potentially devastating（破坏）（破坏） consequences ranging from severe alterations in the lives of the victim and family, to death.vThe traumatic death of a loved one may be the most difficult event a family may ever experience. Providing the family
48、with resources that may be used in the future may help prevent future crises and dysfunction.Post-trauma responsevPost-trauma response is an intense, sustained emotional, response to a disastrous event. This response is characterized by emotions that range from anger to fear and by flashbacks or psy
49、chic numbing（反应麻木）（反应麻木）.vIn the initial stage, the client may be calm or may express feeling of anger（生气）（生气）, disbelief（不信任）（不信任）, terror（恐怖）（恐怖）, and shock（惊吓）（惊吓）. In the long-term phase, the client often experiences flashbacks （闪回）（闪回）and nightmares（恶梦）（恶梦）of the traumatic event. vThe client ma
50、y call on ineffective coping mechanisms, such as the use of alcohol or drugs ,and withdraw from relationship with others.v患者也许会求助于不积极的妥协机制就像运用患者也许会求助于不积极的妥协机制就像运用酒精和药物或者避开人群。酒精和药物或者避开人群。vPost-traumatic stress disorder v创伤后应激障碍创伤后应激障碍v美国美国911恐怖袭击，虽然它已恐怖袭击，虽然它已经过去了经过去了10年，但那些曾经年，但那些曾经亲生经历或亲眼目睹这一悲亲生经历或
51、亲眼目睹这一悲剧的人们，似乎还未能从中剧的人们，似乎还未能从中走出来。有一部分人躲过了走出来。有一部分人躲过了911那一场劫难，现在却在承那一场劫难，现在却在承受着身体和心理上的另一场受着身体和心理上的另一场煎熬。有研究报告显示，当煎熬。有研究报告显示，当初参与初参与911救援的消防人员罹救援的消防人员罹患癌症的几率比常人高，一患癌症的几率比常人高，一部分民众一直受到创伤后应部分民众一直受到创伤后应激障碍（激障碍（PTSD）的困扰。）的困扰。vNursing intervention with rationales are as follows:v1 Assess the clients em
52、otional responses while providing physical care. Observe for crying, suspiciousness, and fear during the initial phase of treatment. 当提供护理的时候评估患者的情况当提供护理的时候评估患者的情况反应，并且在治疗阶段的时候观察是否有哭泣、反应，并且在治疗阶段的时候观察是否有哭泣、怀疑和恐惧。怀疑和恐惧。v2 Be available if the client wishes to talk about the trauma ,and encourage the cl
53、ient to express his or her feeling when the client seems ready to do so. 如果患者愿意讨论创伤是被允许的，并且鼓如果患者愿意讨论创伤是被允许的，并且鼓励患者愿意表达他或她的感觉当如患者看起来已经做励患者愿意表达他或她的感觉当如患者看起来已经做好了准备。好了准备。vThe client may initially deny negative feeling; this denial is a coping mechanism in the initial phase of recovery.v患者刚开始也许会否认消极的感觉：
54、这种否定是一种患者刚开始也许会否认消极的感觉：这种否定是一种恢复起始阶段的合作机制。恢复起始阶段的合作机制。v3 Teach relaxation techniques, such as deep breathing , progressive muscle relaxation, or imagery. v教给放松技术，就如深呼吸，渐渐的肌肉放松教给放松技术，就如深呼吸，渐渐的肌肉放松和想象。和想象。v4 Refer the client and family members for counseling（咨询）（咨询）, psychotherapy, or support groups a
55、s appropriate. Continued therapy may be necessary in allowing the client and family to resolve the acute and long-term effects of trauma.v患者和家庭成员的咨询，心理治疗或者群组支患者和家庭成员的咨询，心理治疗或者群组支持是适当的。连续的治疗可能是必要的，允许持是适当的。连续的治疗可能是必要的，允许患者或家庭解决短期或长期的创伤影响患者或家庭解决短期或长期的创伤影响vIf the client is unconscious ,encourage family members and friends to express their feeling. These assessments provide valuable information about the clients ability to cope with the trauma.v如果患者是不清醒的，鼓励家庭成员和朋友让如果患者是不清醒的，鼓励家庭成员和朋友让他们表达感情，这些评估会提供关于患者处理他们表达感情，这些评估会提供关于患者处理创伤的能力的有价值的信息。创伤的能力的有价值的信息。
