copd教学查房演练课件

慢性阻塞性肺疾病 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 主讲：昆医主讲：昆医主讲：昆医主讲：昆医2008200820082008级级级级 护理实习组护理实习组护理实习组护理实习组 目录 一、定义 三、流行病学 二、病案介绍 四、病因与发病机制 五、临床表现 六、实验室检查 七、诊断要点 八、治疗要点 九、护理诊断及措施 十、健康教育 CONTENTS 1. Definition 3. Epidemiology 2. Clinical Case 4.Etiology & Pathogenesis 5. Clinical Manifestation 6. Laboratory Tests 7. Diagnosis 8. Treatment 9. Nursing Diagnosis & Implementations 10. Health Education 关键词 (Key Words) 咳嗽 cough 咳痰 sputum production 呼吸困难 dyspnea 桶状胸 “barrel-shaped” chest 气流受限 airflow limitation 急性加重期 acute exacerbations 气体交换受损 impaired gas exchange 清理呼吸道无效 ineffective airway clearance AE COPD 、什么是慢性阻塞性肺疾病(COPD)？ 、哪些人群更容易患COPD？ 、作为医护人员，我们应该如何诊断、治疗？ 、作为21世纪的新护士，我们应该如何提供护理？ 思考 ? 一、COPD定义 慢性阻塞性肺疾病简称慢阻肺，是一种以 气流受限为特征的可以预防和治疗的疾病，气 流受限不完全可逆、呈进行性发展。 Chronic obstructive pulmonary disease: “COPD“, is a preventable and treatable disease. It is characterized by airflow limitation. The airflow limitation is not fully reversible and usually progressive. Definition 二、COPD病案介绍 姓名：郭其文 性别：男 年龄：83岁 简要病史： 患者二十余年来反复出现咳嗽、咳痰，无咯血 及胸痛，无低热、盗汗。两天前受凉后咳嗽、咳痰 加重，痰量多，为黄色粘痰，畏寒，感咽痛声嘶。 查体：T：36.4，P：80次/分，R：19次/分，BP ：126/72mmHg（卧位）,可见桶状胸，横膈下移， 肢端发绀。X线：双肺纹理增多、肋间隙增宽增粗 ，确诊为“慢性阻塞性肺疾病”，为进一步诊治于 2011年8月14日收住我院。 Clinical Case Name: Qiwen Guo Gender: male Age: 83 Case history： The patient complained of cough and sputum production over 20 years. In the past two days, he has been having a cold, an exacerbated cough productive of yellow mucous sputum. PE: T: 36.4, P: 80/min, R: 19/min, BP: 126/72mmHg (supine).“Barrel-shaped” chest, downward displacement of diaphragm, acrocyanosis are existed. Chest fluoroscopy: increased bilateral lungs markings, widened intercostal spaces. He was diagnosed as COPD and admitted on August 14th, 2011. 体格检查 三、流行病学 03-04年，我国通过对七个地区的40 岁以上人群抽样调查发现，COPD总 患病率为8.2%，患病率存在性别、地 区等差异。 1. 吸烟 ； Smoking 2. 职业性粉尘及化学物质； Occupational dusts and chemicals 3. 空气污染； Air pollution 4. 呼吸道感染； Respiratory tract infection 5. 其他 Others 四、病因与发病机制 四、病因与发病机制 有害颗粒或气体 COPD病理学改变 蛋白酶氧化应激 抗氧化 物 抗蛋白 酶 粘 液 分 泌 增 加 肺 实 质 破 坏 肺 血 管 壁 增 厚 气 道 壁 结 构 重 塑 气流受限 炎症反应 五、临床表现：症状 1. 慢性咳嗽 晨间明显，白天较轻，睡眠时有阵咳或排痰。 Chronic cough It is obvious in the morning and relieved in the daytime. There is a paroxysmal cough or sputum production when sleeping. 2. 咳痰 为白色粘液或浆液性泡沫痰，偶可带血丝。急 性发作伴细菌感染时，痰量增多，可有脓性痰。 Sputum production There is a white mucus or serous frothy sputum, with blood occasionally. The sputum would be too much and purulent with bacterial infection. 五、临床表现：症状 3. 气短或呼吸困难 仅在体力劳动或上楼等活动时出现，病情重时 日常活动也能感到气促，是的标志症状。 Shortness of breath or dyspnea It only appears when laboring, going upstairs or doing other activities. Patient may feel unwell even in daily activities when it is worse, which is the signal symptoms of COPD. 五、临床表现：症状 4. 喘息和胸闷 重度病人或急性加重时出现喘息和胸闷. Asthma and chest distress Critically serious patients may show asthma and chest distress in acute exacerbations. 五、临床表现：症状 五、临床表现：症状 5. 其他 晚期病人有体重下降，食欲减退等全身症状。 Others Terminally ill patients have systemic symptoms such as weight loss, loss of appetite. 视诊 桶状胸，呼吸浅快，严重者 可有缩唇呼吸。 Inspection Barrel-shaped chest, rapid and shallow breathing, severe cases may have pursed-lip breathing. 五、临床表现：体征 触诊 触觉语颤减弱或消失。 Palpation Tactile fremitus is weakened or disappeared. 五、临床表现：体征 叩诊 呈过清音，心浊音界缩小， 肺下界和肝浊音界下降。 Percussion It sounds too voiceless, the border of cardiac dullness narrows, inferior boundary of lung and the border of hepatic dullness go down. 五、临床表现：体征 听诊 两肺呼吸音减弱，呼气延长 ，部分病人可闻及干性啰音和（或） 湿性啰音。 Auscultation Breath sounds reduces, expiratory sound extends, some patients can be heard wheezes or moist crackles. 五、临床表现：体征 I 级：轻度 级：中度 级：重度 IV级：极重度 COPD严重程度分级 FEV1/FVC15 h/d). Nursing Implementations 5. 呼吸功能锻炼 （1）缩唇呼吸 方法： 闭嘴经鼻吸气，缩唇缓 慢呼气，同时收缩腹部。 （二）护理措施 (1) Pursed-lip breathing Method : Close your mouth and use your nose to breathe in. Then purse lip and exhale slowly. At this time, you must contract the abdominal muscles. 5. Respiratory function exercise Nursing Implementations （2）腹式呼吸 方法： 用鼻缓慢吸气，膈肌最 大限度下降，腹肌松弛。呼 气时用口呼出，腹肌收缩， 膈肌松弛。 如图所示: （二）护理措施 (2) Abdominal respiration Breathe in with your nose, in order to put down your diaphragm muscles furthest and relax your abdominal muscles. Breathe out with your mouth, to contract your abdominal muscles and relax your diaphragm muscles. Method: Nursing Implementations 患者呼吸困难减轻、呼吸频率减慢、发绀减轻、 心率减慢、活动耐力增加、呼吸功能得到改善。 The symptoms of dyspnea and cyanosis was lightened, breath rate and heart rate slowed down, activities endurance increased and respiratory function improved. （三）护理评价 九、 护理诊断、 措施及依据 清理呼吸道无效 Ineffective Airway Clearance B 相关因素 Related factors 1.分泌物多而黏稠 Sticky mucus 2.气道湿度减低 The low humidity of windpipe 3.无效咳嗽 Ineffective coughing （一）护理依据 1. 病情观察 密切观察咳嗽咳痰情况，包括 痰液的颜色、量及性状，以及咳痰 是否顺畅。 Patients condition observation: Observe closely about the state of coughing, including the sputum color, nature, odour and quantity. （二）护理措施 2. 用药护理 注意观察药物疗效和不良反应。 （1）止咳药 （2）祛痰药 （二）护理措施 Medication nursing: Especially observe the therapeutic effects and the side effects. (1) Antitussive (2) Expectorant 3. 对症护理 患者胸痛时，常随呼吸、咳嗽而加重，可采取 侧卧位。 Symptomatic nursing: When the patient is suffering the chest pain, the pain usually increases following breathing and coughing. Lateral position can be adopted. （二）护理措施 1. 患者能有效地将痰咳出，保持呼吸道畅通。 The patient is able to expectorate the sputum effectively and keep the respiratory tract open. 2. 患者掌握了有效的排痰技巧。 The patient masters effective skills of expectoration. （三）护理评价 九、 护理诊断、 措施及依据 焦虑 Anxiety C 相关因素 Related factors 1.健康状况的改变 Health condition changed 2.病情危重 Severity 3.经济负担 Economic burden （一）护理依据 1.了解患者的心理状态及其原因 TO understand the patients psychological state and reasons. （二）护理措施 2.与家属和患者进行沟通 Communicate with family members and the patients 3.制定康复计划和协助康复活动 Make rehabilitation programs and help rehabilitation activities. 4. 教给患者缓解焦虑的方法 Teach patients the ways to relieve anxiety. （二）护理措施 患者焦虑情绪缓解，积极 配合治疗与康复活动。 The patient relieves anxiety, and cooperate with treatment and rehabilitation activities . （三）护理评价 十、COPD健康教育 饮食指导 1 2 有效排痰指导 3 用药指导 4 长期家庭氧疗指导 5 疾病知识指导 1. Food Nutrition Guidance 2. Long- term Domiciliary Oxygen Therapy 3. Effective Expectoration Guidance 4. Medication Guidance 5. Disease Knowledge Guidance Health Education 1. 进食高热量、高蛋白、高 维生素的食物； Keep in the high-protein, high-calorie, multi-vitamins digestible diet. 2. 避免进食产气和引起便秘 的食物； Avoid the foods which can cause gas and constipation . （一）饮食指导 Food Guidance Limit the salt intake less than 3. 限制食盐的摄入：每日食盐量小于6克。 6 grams every day. （一）饮食指导 Food Guidance Eat smaller, more frequent meals and avoid the recumbent position which is helpful to your digestion. 4. 少量多餐，餐后避免 平 卧，利于消化； （一）饮食指导 Food Guidance 可稳定或阻断肺动脉高压的发展,增加动脉血氧饱 和度,改善缺氧症状，提高生活质量和生存率。 （二）长期家庭氧疗 Long- term Domiciliary Oxygen Therapy 1. 家庭氧疗注意事项: 供氧装置“四防”：防火、防震、防热、防油 To use oxygen apparatus safely, we should do as the following tips:fireproofing,shockproofing, heatproofing， greaseproofing. （二）长期家庭氧疗 Long- term Domiciliary Oxygen Therapy 2. 定期清洁、消毒供氧装置，预防感染。 In order to prevent the infection, we shoud clean and disinfect the oxygen apparatus regularly. （二）长期家庭氧疗 Long- term Domiciliary Oxygen Therapy 鼓励病人有效咳嗽，清除呼吸道分泌物。对痰 液粘稠不易咳出者和年老体弱者，可给予翻身、拍 背、雾化吸入、祛痰剂等协助排痰。 （三）有效排痰指导 Effective Expectoration Guidance Encourage the patients to cough effectively which can help to clear the respiratory secretions. For the people who are difficult to expectorate due to viscosity and the elderly, some measures can be given such as turning over, clapping back, aerosol inhalation,expectorant,etc.to assist the expectoration. （三）有效排痰指导 Effective Expectoration Guidance （三）有效排痰指导 Effective Expectoration Guidance COPD患者在疾病稳定期, 应遵医嘱使用支气管舒张药,如 2受体激动剂和抗胆碱药，教 会病人正确的吸入方法和注意 事项，嘱患者切勿自行停药、 减药，指导患者在用药过程中 注意观察药物疗效和不良反应 ，定期复诊，如有不适，及时 就诊。 （四）用药指导 Medication Guidance Instruct the patients to use drugs with doctors advice and tell them the proper inhalation way