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慢性阻塞性肺疾病,Chronic Obstructive Pulmonary Disease,主讲：昆医2008级,护理实习生,目录 Contents,Contents,7.Diagnostic Highlights,8.Treatment Points,9.Nursing Diagnosis and Measures,10.Health Education,6.Laboratory Exam,一、什么是慢性阻塞性肺疾病（）？ 哪种人群更容易患？ 作为医护人员，我们应该如何诊断、治疗？ 作为新时代的护士，我们应该如何提供护理？,？,一、定义,简称慢阻肺，是一种具有气流受限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，与肺部对香烟烟雾等有害气体或有害颗粒的异常炎症反应有关。,慢性阻塞性肺疾病（）,Chronic obstructive pulmonary disease: “COPD“, is a kind of very limited characteristics of airflow prevention and treatment of disease can be limited, air is not completely reversible, a progressive development, and lung to cigarette smoke and other harmful gases or harmful particles inflammation of the abnormal.,二、病案介绍,姓名：郭其文 Name: Qiwen Guo,性别：男,Gender: Male,年龄：,Age:,入院诊断：慢性阻塞性肺疾病 Admitting Diagnosis：,现病史,患者二十余年来反复出现咳嗽、咯痰，无咯血及胸痛，无低热、盗汗。两天前受凉后再发咳嗽、咯痰，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）,横隔下移，双肺纹理增多、肋间隙增宽增粗，肢端发绀，可见桶状胸，确诊为“慢性阻塞性肺病”，2011年8月14日为进一步诊治收住院。,History of Present Illness:,、Cough, cough up phlegm，No hemoptysis，Sputum volume of yellow sputum, stick 、No low heat, night sweats，Chills, feeling sore throat screamed 、Every move down the double lung texture, increased, rib widened the gap thick, acromegaly cyanosis, visible barrel shaped the chest,三、病因,至今尚未完全阐明，多认为其发生是多种因素共同作用的结果。引起慢支的各种因素均可引起阻塞性肺气肿，如吸烟、感染、大气污染、职业性粉尘和有害气体的长期吸入、过敏等，其中吸烟尤为重要，故慢性阻塞性肺气肿实际上属于慢性支气管炎的并发症。,A.,B.,D.,Has not yet been fully elucidated, many believe that its occurrence is the result of many factors. Cause a variety of factors can cause chro-nic bronchitis emphysema, such as infection, smoking, air pollution, occupational dust and harmful gases long-term inhalation, allergies, etc., of which smoking is particularly important, it actually belongs to bronchitis.chronic obstructive pulmonary emphysema complications of chronic, Etiology,四、发病机制,1.吸烟 Smoking 2.弹性蛋白酶及其抑制因子的失衡 Elastase proteas and inhibitor imbalance 3.肺组织弹性减退 Decreased lung tissue elasticity 4.小气管的不完全阻塞 Small airway obstruction is not completely,5.职业性粉尘和化学物质 6.空气污染 Air pollution 7.感染 Infection 8.其他 Other, Pathogenesis,Professional dust andchemical substance,五、临床表现：症状,慢性咳嗽： 晨间明显，白天较轻，睡眠时有阵咳或排痰,Chronic cough: The morning light, and the days are obvious, a cough or sleep in row sputum.,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: It is white mucus or serous Frothy sputum, with blood occasionly. Acute attack with bacterial infections and sputum volume increased.It can have a purulent sputum.,临床表现：症状,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 breathing difficulties: Only in the physical labor or go upstairs and other activities when the illness weight daily activities, when also can feel shortness of breath which is the sign of COPD symptoms.,临床表现：症状,喘息和胸闷：重度病人或急性加重时出现喘息 Breathing and chest tightness: serious patients or acute exacerbation when the breathing hard.,其他：晚期病人有体重下降，食欲减退等全身症状 Other: Late patients have weight loss, systemic symptom such as anorexia.,临床表现：症状,What are the signs of COPD? The signs of COPD include:,六、体征 Signs,、疾病中后期随疾病可出现： the disease can occur in the late with the disease: 视诊 桶状胸，呼吸浅快，严重者可有缩唇呼吸。 visual examination: barrel chest, rapid shallow breathing, severe cases may have reduced lip breathing,触诊： 触觉语颤减弱或消失。 Palpation: Tactile fremitus weakened or disappeared,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: diminished breath sounds lungs, breath longer, some patients can be heard and dry La tone (or) moist rales.,体征,叩诊: 呈过清音，心浊音界缩小，肺下界和肝浊界下降。 Percussion: was too voiceless, voiced sector reduced heart, lung and liver cloud sector lower bound down.,体征,COPD严重程度分级,分级,0级：高危,级(中度),级(重度),IV(极重度),Grading,Zore:High-risk, level (moderate), grade (severe),IV (very severe),七、实验室检查,1、肺功能检查： （）FEV1下降（正常83%） （）FEV1/FVC下降（60）最敏感 （） RV升高 （）RV/TLC升高（40%）最有诊断价值,1、 Pulmonary function tests:,（） FEV1decreased ( normal 83%),（） FEV1 / FVC decreased ( 60 %) is the most sensitive,（）RV elevation,（） RV / TLC elevated ( 40% ) have the most diagnostic value,2、 X线检查 X line check,慢阻肺早期X线胸片可无明显变化，以后出现肺纹理增多、紊乱等非特征性改变；,COPD early chest radiograph may be no obvious change, later increased lung markings, disorder and other non-characteristic changes;,实验室检查,3 、动脉血气分析,血气异常首先表现为轻、中度低氧血症。随疾病进展，低氧血症逐渐加重，并出现高碳酸血症，呼吸衰竭的血气诊断标准为静息状态下海平面吸空气时动脉血氧分压（PaO2）60mm Hg伴或不伴动脉血二氧化碳分压（PaCO2）增高50mm Hg。,实验室检查,espiratory failure blood diagnostic criteria for resting state sea level suction air arterial partial pressure of oxygen ( PaO2 ) 50mm Hg.,arterial blood gas analysis：,COPD laboratory tests,4 、其他,并发感染时痰涂片可见大量中性粒细胞，痰培养可检出各种病原菌，常见者为肺炎链球菌、流感嗜血杆菌、卡他莫拉菌、肺炎克雷伯杆菌等。,实验室检查,The other： Complicated infection sputum smear revealed numerous neutrophils, sputum culture can be found in various pathogens, common for Streptococcus pneumoniae, Haemophilus influenzae, Moraxella, pneumonia bacteria Mora Cray s bacillus,COPD laboratory tests,七、诊断要点,临床表现+体征+实验室检查,八、COPD的防治,戒烟是最有效、最经济的手段； 临床劝诫、宣教支持、治疗外的社会支持； 针对香烟依赖治疗的药物； 防控职业因素，改善环境卫生。,早期干预,急性加重期治疗,稳定期治疗,Prevention & Treatment,1、Smoking cessation is the most effective means 2、Clinical exhorts, education, social support 3、Nicotine replacement therapy 4、Occupational health.,Early Intervention,Treatment of Acute Exacerbations of COPD,Treatment of Stable COPD,COPD的防治,早期干预,急性加重期治疗,稳定期治疗,Prevention & Treatment of COPD,应根据急性加重程度，结合患者COPD的严重程度、合 并症情况。 和以往加重频度与严重程度，对病人进行针对性治疗. 应以控制感染和祛痰、镇咳为主； 伴发喘息时，加用解痉平喘药物。,早期干预,急性加重期治疗,稳定期治疗,COPD的防治,1、Oxygen therapy; 5、Aminophylline; 2、Bronchodilators; 6、Respiratory stimulants; 3、Corticosteroids; 7、Non-invasive ventilation; 4、Antibiotics; 8、General hospital care,Prevention & Treatment,九.常用护理诊断、措施、依据,护理诊断 (Nursing Diagnosis),（一）气体交换受损 Impaired gas exchange,Common nursing diagnosis, measures and basis,相关因素 Related factors,1.气道阻塞 （airway obstruction ） 2.通气不足 （hypoventilation ) 3.呼吸肌疲劳 (respiratory muscle fatigue ) 4.分泌物过多 (secretions too much ) 5.肺泡呼吸面积减少 (superficial area of alveolar abatement),护理依据,Nursing basis,护理措施 (nursing intervention),1.休息与活动 体位（Position） (Rest and movement ) 活动量（Activity amount） 环境（Environment ） 2.病情观察 观察症状（Observed (Observing state symptoms) of an illness ) 监测体征 (Monitoring physical signs ),护理措施 (nursing intervention),3.用药护理 应用(application ) (Administration nursing ) 效果(effectiveness ) 反应 (reaction) 4.氧疗护理 (Oxygen therapy nursing ) 用氧方法(oxygen uptake methods )、 观察症状(observed symptoms) (1)鼻导管吸氧，氧流量12L/min (By nasal catheter intaking air, flow is 1 2L/min ),(2)长期家庭氧疗（Long-term Domiciliary Oxygen Therapy, LTOT ) 持续低流量吸氧，每日15h，对COPD慢性呼吸衰竭者可提高生活质量和生存率。 Continually torpid oxygen intake, 15 hours daily, long-term domiciliary oxygen therapy can improve quality of life and survival rate to chronic respiratory failure of patients who acquired COPD.,护理措施 (Nursing Intervention),5.呼吸功能锻炼,Taking some exercise about breathing function 1）缩唇呼吸Pursed lip breathing： 方法：闭嘴经鼻吸气，缩唇缓慢呼气，同时收缩腹部 Method :closing your month and using your nose to breathe in, pursed lip and exhaled slowly, at this time ,you must contract the abdominal muscles.,如图所示：,护理措施 (Nursing Intervention,（2）膈式或腹式呼吸 diaphragmatic respiration or abdominal respiration 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。 method: taking a inspiration with your nose ,try your best to put down your diaphragm muscle and relax your abdominal muscle. Expiring with your mouth, contracte your abdominal muscle and relax your diaphragm muscle.,如图所示:,护理措施 (nursing intervention,护理评价 Nursing evaluation,病人呼吸困难减轻、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 symptom of breath hard and cyanosis will be release, breath rate and heart rate slows down, Activities endurance Increase and respiratory function develops.,（二）清理呼吸道无效 Ineffective airway clearance,护理诊断 Nurses Diagnosis,相关因素 related factors 1.分泌物多而黏稠 The secretion is quantity and sticky 2.气道湿度减低 the low humidity of windpipe 3.无效咳嗽 It is fail when to cough,护理依据 Nursing basis,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 , cluding the sputum color, nature, odour and quantity,护理措施 (nursing intervention),2.用药护理：注意观察药物疗效和不良反应。 Admimingstrition nursing: Especially observe the therapeutic effect and adverse reaction of the drug. （1）止咳药 intitussive （2）祛痰药 expectorant,护理措施 (nursing intervention),3.排痰措施 : 鼓励病人有效咳嗽，清除呼吸道分泌物。痰液粘稠不易咳出、年老体弱者，可给予翻身、拍背、雾化吸入、祛痰剂等协助排痰。,护理措施 (nursing intervention),Encourage the patient to effectively cough and clear the respiratory secretions. For the people who are difficult to expectorate the sputum due to viscosity and the elderly, some measures will be given such as turning over, clapping back, aerosol inhalation,expectorant,etc., to assist the expectoration,Expectoration measures :,4.对症护理: 病人胸痛时，常随呼吸、咳嗽而加重，可采取侧卧位。,nursing: When the patient is suffering the chest pain, the pain usually increases with breathing and coughing. Lateral position can be adopted.,护理措施 (nursing intervention),护理评价 Nursing evaluation,1. 病人能否有效地将痰咳出，保持呼吸道畅通。 If the patient is able to effectively expectorate the sputum and keep the respiratory tract open 2. 病人是否掌握了有效的排痰技巧。 If the patient masters the effective skills of expectoration,护理诊断 (nurses diagnosis),（三）焦虑 Anxiety,护理依据 Nursing basis,相关因素 Related factors 1.健康状况的改变 Healthcondition change 2.病情危重 sb, critical 3.经济负担 economic burden,1.了解病人的心理状态及其原因 Understanding the patients psychological state and the reasons 2.与家属和病人进行沟通 To communicate with family members and patients 3.制定康复计划和协助康复活动 To make Rehabilitation programs and help rehabilitation,护理措施 (nursing intervention),4. 教给病人缓解焦虑的方法 To teach patients ways to ease anxiety.,护理措施 (nursing intervention),护理评价 Nursing evaluation,病人焦虑情绪缓解，积极配合治疗与康复活动。 Ease patient anxiety, and actively cooperate with treatment and rehabilitation activities.,护理诊断 Nursing diagnosis,（四）营养失调: 低于机体需要量 Malnutrition: less than body requirements,相关因素 Related factors,1.食欲降低 loss of appetite 2.摄入减少 reduced intake 3.腹胀 abdominal distention 4.呼吸困难 dyspnea 5.痰液增多 Increased sputum,护理依据 Nursing basis,护理措施 (nursing intervention),1. 给予高热量、高蛋白、高维生素的饮食，避免食用产气多的食物，少吃多餐。 Given high-calorie, high protein, high vitamin diet, avoid eating more food gas, frequent meals.,护理措施 (nursing intervention),2. 便秘者，多饮水，多食含纤维素多的食物和水果。 Constipation, drink more water, eat more fiber-containing food and fruit.,护理措施 (nursing intervention),3.良好的进餐环境，进食时半卧位，餐前、餐后漱口，促进食欲。必要时口腔护理。 Good dining environment, eating semi-supine, fasting and postprandial mouth, and appetite. Oral care when necessary.,护理措施 (nursing intervention),4.必要时静脉输液补充营养。 Intravenous nutritional supplements when necessary.,护理评价 Nursing evaluation,能建立合理的饮食方式和结构，营养指标在正常范围内。 Can establish a reasonable diet and structure, nutritional indicators within the normal range.,五. 活动无耐力 Activity intolerance,护理诊断 (nurses diagnosis),(a) 多食含纤维素高的食物,相关因素 : (Related factors) (1 )疲劳 ( fatigue) (2)呼吸困难 (difficulty breathing) (3)氧供与氧耗失衡 (imbalance between oxygen supply and oxygen consumption),护理依据 Nursing basis,护理措施 (nursing intervention),（1）评估活动耐力 Assess activity tolerance 了解病人过去和现在的活动类型、强度、持续时 间和耐受力 Understanding the patientspast and present types of activities ，intensity, duration and tolerance,护理措施 (nursing intervention),（2）协助做好一般护理 To help make the general care 休息与活动: （Rest and activity) 舒适体位: (Comfortable position),护理措施 (nursing intervention),（3）减少体力消耗 Reduce physical exertion 指导病人采取有利于气体交换又能减少能量消 耗的姿势 Guiding the patient to take that help of gas exchange and can reduce energy consumption,护理措施 (nursing intervention),（4）协助和指导病人生活自理: Patient self-care assistance and guidance 在病人活动耐力可及的范围内，鼓励病人尽可能自理 in the range form patients endurance encourage patients to take care of themselves as much as possible,护理措施 (nursing intervention),（5）病情观察 Condition observed 观察有无右心衰竭的表现：如心悸、胸闷腹胀、量减少、下肢水肿等 Observe whether the performance of right heart failure：such as palpitations, chest tightnessabdominal distension, decreased urine output, lower extremity edema,（5）病情观察 Condition observed 观察有无肺性脑病的表现：如头痛、烦躁不安、神智改变等 Observe whether the performance of pulmonary encephalopathy :such as headache, irritability, and changes in mentally,护理措施 (nursing intervention),护理评价 Nursing evaluation,能根据自身耐受能力，完成活动计划，活动时无明显不适且心率、血压正常。 Be tolerated, according to their ability to finish plan of action, without obvious discomfort and the heart rate and blood pressure is normal.,十、健康教育 Health Education,长期家庭氧疗指导,康复锻炼指导,Health Education,1、Disease Knowledge Guidance,2、Food Nutrition Guidance,3、Long- term Domiciliary Oxygen Therapy,4、Effective Expectoration Guidance,5、Medication Guidance,6、Respiratory Function Exercise,7、Psychological Counseling,（一）疾病知识指导,1、使病人了解COPD相关知识，识别使病情 恶化的因素； Tell the revelant konwledge about COPD to the patients and let them know how to distinguish the dangerous factors.,2、劝导病人戒烟； Try to persuade the patients to quit smoking.,Disease Knowledge Guidance,（一）疾病知识指导,3、避免粉尘和刺激性气体的吸入； Avoid dust and stimulating gas sucked in. 4、预防感染； Prevent infections. 5、注意保暖，避免受凉。 Be sure to keep warm to avoid catching cold.,（二）饮食指导 Food Guidance,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 cause gas and constipation .,（二）饮食指导,Eat smaller, more frequent meals and avoid the recumbent position which is helpful to your digestion.,3、少量多餐，餐后避免平卧，利于消化；,（三）长期家庭氧疗,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