急性有机磷农药中毒的护理查房课件

急性有机磷农药中毒的护理查房 Acute organophosphate pesticide poisoning （AOPP）care rounds 2011/8/18 病例介绍 伍南臻 v 患者，周桂云，女性，46岁 v 入院时间：2011-08-07 v 主诉：呕吐、口吐白沫、神志不清、大小便失禁4小 时 v Patients, guiyun Zhou, female , 46years old v Admission time：2011-08-07 v Chief Complaint: vomiting, foaming at the mouth, confusion, incontinence 4 hours 基本资料1 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. 病例介绍 家人行紧急救治后送入当地医院行洗胃治疗，于2011- 08-07 12:20急诊平车转入我院肾病内科 Patients after medication with vomiting, after the emergency salvage , she was send to the local hospital for gastric lavage for her famliy.In august 7, 2011 12:20, She was transferred to our hospital nephropathy internal medicine with emergency flatcar. 病例介绍 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”收治。起病以来，精神差，体 重无明显变化。 In transit, Patients had repeated vomiting and Elimination of urine and feces are not controlled by herself, Clinic diagnosis is AOPP,After the patient is admitted to hospital, her Spirit was so bad and weight did not have significantly change. 病例介绍 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。 she had lung abscess before,and was done a partial lobectomy,in that operation,She had a blood transfusion. The most important is she had the Penicillin allergy. 病例介绍 全凤春 体格检查： T35.8 P126次/分 R20次/分 BP109/69mmHg v Physical examination: v Temperature：35.8 ,Pulse :126 Beat Per Minute, respiration:20 Beat Per Minute, Blood Press 109/69mmHg 病例介绍 神志浅昏迷，双侧瞳孔等大等圆3mm,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。 Coma consciousness ,Pupils are equal roundness and same size with 3mm,reaction to light shows delay, while the lips is cyanotic ,Breath sound shows Coarse while it Can be heard and a lot of wet rales . 病例介绍 心率 126次/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。 Heart rate is 126Beat Per Minute,borhorygmus shows increased,Limb muscle tone is slightly higher,there is no independent activity,Pathological reflex is not elicited . 病例介绍 刘伟明 v 入院诊断: 1 、急性重症农药中毒（半硫磷） 2、中毒性心肌炎 3、吸入性肺炎 v Admission diagnosis: 1、 severe acute pesticide poisoning (half sulphur phosphorous) 2、 toxic myocarditis 3、 aspiration pneumonia 主要病情变化 马志群 v 8-8 01:40T39.1摄氏度，予温水擦浴 05：20 患者开始出现躁动，予丙泊酚5毫升IV 效果不明显 ，予地西泮镇静 v One forty on august 8th,the patients body temperature rises to thirty-one point one degrees celsius,we give him a warm water bath. v Five twenty,the patient begin to appear restless,propoful five milliliter intravenens injection,the effect is not obvious,to the diazepam sedation. 病例介绍 v 12:30 患者躁动不安，血氧饱和度波动在70%-80% 请 麻醉科及ICU会诊后考虑气管插管脱出予重新插管 v 14：50 患者转入ICU v Twelve thirty ,the patient is restless,fluctuations of oxygen satturation in seventy percent to eighty percent .then please anesthesia and intensive care unit consulation,considering the endotracheal to be extrusion,to reintubation for him . v Fourteen fifty,the patient is transforred to the intensive care unit 病例介绍 贺 舒 v 转入ICU时情况：体温37.3，脉搏140次/分，呼吸35 次/分，血压116/87mmHg，血氧饱和度95% v When transferred to ICU conditions: temperature 37.3, pulse 140 beats / min, breathing 35 times / min, blood pressure 116/87mmHg, oxygen saturation 95% . 病例介绍 v 神志镇静中，躁动不安，两侧瞳孔等大等圆4mm，对光反射 迟钝，气管插管，呼吸机辅 助呼吸，气道内少量痰液，皮 肤干燥 。 v conscious sedation, irritability, Pupils are equal roundness and same size with 4mm,reaction to light shows delay, endotracheal intubation, mechanical ventilation, Within a few airway sputum ,dry skin. 病例介绍 v 双肺可闻及中等量湿性啰音，腹部叩诊呈鼓音， 诊断为：1.急性有机磷农药中毒；2.吸入性肺炎 、1型呼吸衰竭；3.中毒性心肌炎 。 v double- lung can be heard and moderate moist rales, The drum sound abdominal sound The diagnosis is: 1: acute organophosphorus pesticide poisoning; 2: aspiration pneumonia, type 1 respiratory failure; 3 :toxic myocarditis . 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， 遵医嘱予抗感染、护胃、护心、解毒、导泻等对症支持治疗。 To mechanical ventilation, indwelling stomach tube, decompression, indwelling venous catheters, prescribed to fight infection, protect stomach mucosa, protection of heart function, detoxification, catharsis,symptomatic and supportive treatment. 病例介绍 苏敏 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 。 The current situation of patients: mind fuzzy, restless, Pupils are equal roundness and same size with 4mm,reaction to light shows delay, the skin is dry . 病例介绍 有发热，最高体温39，予物理降温。血压稳定，仍给予阿托 品间断静推 。 with fever, the maximum temperature about 39, to the physical cooling. Blood pressure stability, intermittent intravenous injection of atropine, 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 。 there were a few of the airway yellow sputum, double lung not smell and wet go sound, limbs have independent activities. 病例介绍 主要的实验室检查 v 8-7 WBC 27.3*109/L， CHE 23KU/L, v 8-8尿常规RBC2-4/HP,K+3.38 mmol/L ,钙离子1.73 mmol/L ，CHE 10KU/L，心肌酶、肝功能基本正常 v The main laboratory tests v On 8-7 The patient s WBC is 27.3*109/L and CHE is 23 KU/L. v On 8-8 Form the Routine Examination of Urine on high power lens we can see 2 to 4 red blood cells, The patient s Potassium is 3.38 mmol/L,calcium is 1.73 mmol/L and Cardiac enzyme and liver function are normal. CHE 10.0KU/L 病例介绍 v 8-9 CHE 8.0 KU/L,。胸片提示：肺部感染及双侧 胸膜炎。 v 8-12血常规正常，CHE32 KU/L v On 8-9, CHE 8.0KU/L ;Chest X ray tip： lung infection and bilateral pleurisy. v On 8-12 Blood routine is normal，and CHE is 32KU/L 病因与发病机制 谢妹娜 病因 v 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 Etiology v Improper production and use: For example, production equipment sealed poorly result in leakage of chemical toxicant; in the process of spraying pesticide , absorbed through skin and airway . 病因与发病机制 生活性中毒：主要由于自服、误服或摄入被 污染的水源和实物水果等。 Living poisoning: Mainly due to drinking or eating contaminated water and fruit voluntarily or by mistake etc. 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 情况下，胆碱能神经兴奋所释放的递质乙酰胆碱被胆碱 酯酶水解为乙酸及胆碱而失去活性。 v Mechanism of poisoning v The Primary mechanism of organophosphate pesticide poisoning is inhibition of the action of cholinesterase in body. In general, excitement of cholinergic nerve releases neurotransmitter - acetylcholine which can be hydrolyzed to choline and acetic acid by cholinesterase and lose its activity. 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 磷酰化胆碱酯酶，使胆碱酯酶失去水解乙酰胆碱 的能力 。 v Once organophosphate pesticides enter into body, it will bind rapidly to cholinesterase and form phosphorylated cholinesterase, thus make cholinesterase lose the ability to hydrolyze acetylcholine. 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 能神经功能紊乱，先表现为兴奋，然后出 现抑制。 v bring out excessive accumulation of acetycholine in tissue,Which result in disfunction of Cholinergic Nerve. It manifestates excitement at first and then inhibition . 护理评估 Nursing assessment 袁清红 v临床表现 v胆碱能危象 急性有机磷农药中毒的典型表现 v Clinical Situation v Cholinergic crisis Typical performance of AOPP . 护理评估 Nursing assessment v毒蕈碱样症状 v主要是副交感神经兴奋所致, 临床表现有恶心,呕吐,腹痛,多汗, 流涎,瞳孔 缩小,支气管痉挛,分泌物增多,心率减慢,气急,严重者 出现肺水肿 v Muscarinic symptoms v Mainly causedby the parasympathetic nervous excite ment, Clinical manifestations have nausea,vomiting, ab dominal pain, sweating,salivation, miosis, bronchospas m and Increased secretions heart rate decreased, dyspnea, the serious cases appear pulmonary edema. 护理评估 Nursing assessment v 烟碱样症状 v 患者常有肌束颤动,肌肉强直性痉挛,心率加快 ,甚至全身抽搐,最后出现肌麻痹,呼吸肌麻痹 引起周围性呼吸衰竭 v Nicotine-like symptoms v Patients often have muscle bundle of trembling, tetanic spasm ,heart rate increased , Even the whole body twitching, finally, myoplegia happen,breath myoparalysis cause peripheral respiratory failure 护理评估 Nursing assessment v中枢神经系统症状 v表现为头晕,头痛,疲乏无力,共济失调,烦躁不安,意识模糊,抽搐 及昏迷 v Central nervous system symptoms v Manifested as dizziness, headache, fatigue, ataxia, irri tability, confusion, convulsions and coma 护理评估 Nursing assessment 莫思慧 v 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 、流涎、视力模糊、瞳孔缩小、全血胆碱脂 酶活力一般在7050。 v AOPP can be divided into 3 grades: mild, moderate, severe v Mild poisoning：dizziness, headache, nausea,vomiting, sweating, salivation, blurred vision, miosis, and the whole blood cholinesterase activity was in the 50 70% 护理评估 Nursing assessment 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 、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5030 。 v Moderate poisoning：In addition to these above, symptoms also include muscular fibrillation, mild dyspnea, sweat, abdominal pain, diarrhea, clear or mild disorders of consciousness, and staggering gait. Whole blood cholinesterase activity declined to 50% - 30%. 护理评估 Nursing assessment v重度中毒：除上述症状外，发生肺水肿、惊厥、昏迷 及呼吸麻痹。全血胆碱脂酶活力降至30以下。 v Severe poisoning：In addition to these above, symptoms also include pulmonary edema, convulsions, coma and respiratory paralysis. Whole blood cholinesterase activity declined to below 30% . 护理评估 Nursing assessment 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 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。 v Organophosphorus pesticide poisoning were the first aid clinical symptom, can be in a few days to get better within a week, even happen again suddenly a pulmonary edema or sudden death, says “bounce“ phenomenon . 护理评估 Nursing assessment 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 停用过早或减量过快等原因有关。 v This and remain in the skin, hair and the gastrointestinal tract is absorbed by heavy or antidote to credit dose or reasons such as too early on. 护理评估 Nursing assessment 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 2496小时突然发生以呼吸肌麻痹为主的症状群，称“中间型 综合征”。 v In patients with acute poisoning symptoms after the late-occurred neuropathy, generally in the poisoning before 24 to 96 hours after happen suddenly by respiratory muscular paralysis primarily the symptoms, says “middle type syndrome“. 护理评估 Nursing assessment v 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。 v The mechanism may and cholinesterase long-term effect is restrained, neuromuscular postsynaptic functioning. 治疗原则 严超 v治疗原则 v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 v Treatment principle v As we know, the most important of all is removing toxic as quickly as we can when someone poisoned. Generally speaking, the faster lavage the better effect we get. 治疗原则 v幸运的是，这个病人中毒后4小时就在当地医 院洗胃。另外，导泻也是一个好办法。 v Fortunately, that patient lavaged in local hospital after drinking toxic 4 hours. In addition, guiding diarrhea is an effective measure. 治疗原则 v第二，促进毒物进一步排除也十分重要，在此 ，我们应用的是血流灌注。 v Secondly, promoting discharge poison is necessary, we used blood perfusion for her. 治疗原则 v第三，特殊解毒剂的应用，如阿托品、碘解磷 定 ，这取得不错的效果。 v Thirdly, the application of the special effects antidote such as atropine and pralidoxime iodide. Thus, the doctors achieved good results in the process of that treatmeat. 治疗原则 v 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； v 护胃，保护胃黏膜； v 护心，治疗中毒性心肌炎； v The last but not least , Symptomatic support treatment including Fighting infection to promote inflammation dissolve ; Protecting stomach to care gastric mucosa ；Heart care ,it is positive for toxic myocarditis. 治疗原则 v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 v尽快纠酸和纠正电解质紊乱，以稳定内环境 v Elevating blood pressure and decreasing temperature are of importance to maintain vital signs smoothly ; we should better calm down her emotion and take care of tenderly . As quickly as possible to correct acidosis and electrolytes disturbance to stable inner condition . 护理诊断 Nursing diagnosis 彭瑜 v气体交换受损 与肺水肿有关 v清理呼吸道无效 与呼吸道炎症、气道分泌物增多有关 v急性神志改变 与胆碱能神经功能紊乱有关 v Impaired gas exchange Relating to pulmonaryedema v Acute consciousness changing Relating to cholinergic disturbances v Ineffective airway clearance Relating to airways inflammation and airway secretions increasing. 护理诊断 Nursing diagnosis v有效血容量不足 与大量呕吐、感染等有关 v体温过高 与肺部感染、应用阿托品等有关 v有受伤的危险 与躁动不安有关 v有猝死的危险 与毒物的重吸收和阿托品使用不当有关 v Risk for Sudden Death Relating to poison absorbing and the wrongly using of atropine v Hyperthermia Relating to Lung Infection and application atropine etc v Risk for injury Relating to restlessness v Insufficient of blood decrease Relating to profuse vomiting,infection and so on. 护理措施 刘 萍 v迅速清除毒物 v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 300500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。 v Quickly remove toxic v removal of the undigested poisons v Emetic: This only applies to the pations who can cooperate with, Let the patient drink warm water 300 to 500 ml, and then with a spatula or finger stimulate patients, posterior pharyngeal wall or the base of the tongue caused vomiting, 护理措施 v洗胃：一般在服药后6小时内洗胃有效，但如果超过6小时，仍 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 硫酸镁。 v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 皮肤和毛发 。 v Gastric lavage: generally within 6 hours .if more than 6 hours, it is also necessary for gastric lavage. v Catharsis:after gastric lavage we can fill laxatives to clear the intestinal poison, commonly used sodium sulfate or magnesium sulfate. v Clear the skin. Remove contaminated clothing, wash the skin and hair with soap water . 护理措施 v 促进已吸收毒物排出 v利尿 绝大多数毒物由肾脏排泄 v人工透析 v Promotion has been absorbing poison out v Diuresis: The vast majority of poison excreted by the kidneys, v Artificial dialysis 护理措施 龙丽娟 v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， 反复给药，直到阿托品化后再逐渐减量或延长间隔时 间。 v Application of atropine observation and nursing v The rescue of the principle of treatment using atropine: early, enough, fast, repeated dose, until the atropine again after reducing gradually or extend the time interval . 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 、昏迷等。因此使用过程中应严密观察病情变化，注 意区别“阿托品化”与阿托品中毒。 v The cause atropine and atropine toxic dosage is close, the latter can cause convulsions, coma, etc. Therefore when using atropine we should monitor the condition changes, and pay attention to the distinction between the atropine and atropine poisoning. 护理措施 v阿托品化的表现包括： v意识清楚或模糊 v颜面潮红、干燥 v瞳孔由小扩大后不再缩小 v体温正常或轻度升高 v心率120次分，脉搏快而有力。 v The performance of atropine include: v (1) clear consciousness or fuzzy v (2) red and dry face v (3)the pupil become big and not small any more v (4) and the temperature is normal or little raise v (5) the heart rate is more than 120 times every minute, and the pulse fast and powerful 护理措施 v阿托品化的表现包括： v意识清楚或模糊 v颜面潮红、干燥 v瞳孔由小扩大后不再缩小 v体温正常或轻度升高 v心率120次分，脉搏快而有力。 v The performance of atropine include: v (1) clear consciousness or fuzzy v (2) red and dry face v (3)the pupil become big and not small any more v (4) and the temperature is normal or little raise v (5) the heart rate is more than 120 times every minute, and the pulse fast and powerful 护理措施 v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 v皮肤紫红、干燥 v瞳孔极度散大 v高热，T40 v心动过速，甚至有室颤发生 v Atropine poisoning performance including: v (1) the delirium, agitated, illusion, convulsions, coma v (2) amaranthine and dry skin v (3)the pupils extremely enlarge v (4)high fever, the temperature 40 centigrade v (5) tachycardia and even a ventricular fibrillation happen . 护理措施 王洁 v应用胆碱酯酶复能药的观察和护理 v首先,你必须尽早用药。 v第二,轻度中毒,你可以单独使用这个药物,但是中度以上中毒,你 必须和阿托品一起使用。 v The clinical observation and nursing of the application of acetyl cholinesterase： v First，you must use the medicine early. v Second, light poisoning you can use the medicine, but if bad poisoning , you can use the atropine together. 护理措施 v 第三,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。 v 第四, 不可皮下注射，确定针头在血管内方可 用药。 v Third , Much high concentration or fast injection can cause poisoning. so you must dilute the medicine. Pay attention to the medicine speed . v Fourth , you can not use an intramuscular injection. When you want to inject it, you must define the pin in the vein. 护理措施 丁广湘 v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3040 v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固定； v Tracheal intubation and breathing machine care . v Body Position: bed rest for the patient with bed raising 3040 v Fix: The catheter should be firmly fixed to make sure that it is inserted into trachea and be tied together with teeth cushion through adhesive plaster; 护理措施 v气道护理 v 气道的湿化 v 保持气道通畅吸痰 v Periodically check the depth of trachea and catheter ,auscultation breath sounds from lungs .Be ready for bedside shift . Air flue care v Airway humidification v Maintain airway unobstructed Suction phlegm. 护理措施 v密切观察生命体征、spo2 、神志、皮肤面色、出入 量、观察人机是否同步，并做好记录 。 v心理护理 。 v Close observation of vital signs 、 spo2、consciousness and skin complexion .Observe whether man and machine are synchronization . v Psychological Care. 护理措施 刘 斌 v患者机械通气病程长，机体抵抗力低下,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 易造成口腔感染 。 v Oral cavity nurse. v The process with machinery ventilation of patient is long, her organism resistibility is low, oral cavitys automatic depuration function and the mucous membrane resistibility are weaken, so massive bacteria reproduce inside the oral cavity and it is easy to be infected. 护理措施 v有机磷农药中毒的病人的口中会有大蒜样臭味,并且口腔 黏膜干燥、唾液分泌减少，因此应做好口腔护理、保持口 腔的清洁和湿润,每日高质量的口腔护理是预防口腔并发 症和肺部感染的重要方法之一. v The patient who is poisoning by AOPP will have the garlic stink, their oral cavity mucous membrane dry and saliva reduces at the same time, therefore they should complete oral cavity nursing, maintain oral cavity clean and the moistness, every day high grade oral cavity nursing is one of the important methods in preventing oral cavity complication and lungs infection. 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 现散热障碍，均可致体温上升。 v After the poisoning, the muscle trembles causes to produce increases hotly and heat dissipation barrier will appear after massive atropine application, both of them may lead to body temperature rising. 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 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。 v Normally or moderate fever heat neednt to deal with. But if it presents the high fever, we may adopt the physical cooling. Simultaneously we may supplement the liquid for patient to decrease the body temperature, generally we dont need the medicine for cooling. 护理措施 罗富群 v饮食 v重度中毒一般需禁食3-5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 多的食物。 v Diet v Severe poisoning, which normally takes 1-3 days of fasting, be in stable condition, conscious and alive after oral temperature of liquid egg white to protect the gastric mucosa, Prohibit the consumption of irritating and greasy fast food and more. 护理措施 v昏迷3-5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。 v Coma in patients with nasal feeding diet for 3-5 days, pay attention to vitamin and min