涉外护理英语unit6AssessingaPostoperativePatient.ppt

涉外 护理英语,Unit 6 Assessing a Postoperative Patient,对外经济贸易大学出版社,Giving a postoperative handover Checking a postoperative patient Explaining postoperative pain management Dealing with aggressive behaviour Using pain assessment tools Giving an oral report of the case,Assessing a Postoperative Patient,患者术后评估,进行术后交接班 检查术后患者 解释术后疼痛控制 处理攻击性行为 运用疼痛评估工具 口头汇报病人病情,Description,Postoperative patient aseessment is to assess the patient and record the data including level of consciousness, temperature, pulse, respiration, and blood pressure, surgical area for bleeding. Assessment continues from the PACU (postanesthesia care unit) to the intensive care or medical-surgical nursing unit.,翻译,单元描述,患者术后评估是指评估并记录患者的意识状态、体温、脉搏、呼吸、血压、切口有无出血及渗血范围等病情变化。术后评估从患者术后进入麻醉恢复室开始持续到患者转入重症监护室或内、外科护理病房。,Work Description,In the PACU, the anesthesiologist or the nurse anesthetist reports on the patients condition, type of surgery performed, type of anesthesia given, estimated blood loss, and total input of fluids and output of urine during surgery. The PACU nurse should also be made aware of any complications during surgery, including variations in hemodynamic (blood circulation) stability. Assessment of the patients airway patency (openness of the airway), vital signs, and level of consciousness is the first priority upon admission to the PACU. After the hospitalized patient was transferrted to the PACU, the nurse taking over his/her care should assess the patient again. The anesthesiologist or nurse anesthetist should discuss the possibility of an episode of awareness under anesthesia with the patient. Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two,翻译,hours for at least the first eight hours. Body temperature must be monitored, since patients are often hypothermic after surgery, and may need a warming blanket or warmed IV fluids. Respiratory status should be assessed frequently, including assessment of lung sounds (auscultation) and chest excursion, and presence of an adequate cough. Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate. The physician should be notified if the patient has not urinated six to eight hours after surgery. If the patient had a vascular or neurological procedure performed, circulatory status or neurological status should be assessed as ordered by the surgeon, usually every one to two hours. The patient may require medication for nausea or vomiting, as well as pain. Patients with a patient-controlled analgesia pump may need to be reminded how to use it by the nurse. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication. The patient should be asked to rate his/her pain level on a pain scale in order to,determine his/her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bedsit up, and, eventually, walk. After the initial 24 hours, vital signs can be monitored every four to eight hours if the patient is stable. The incision and dressing should be monitored for the amount of drainage and signs of infection. The surgeon may order a dressing change during the first postoperative day which should be done by using sterile technique. The hospitalized patient should be sitting up in a chair at the bedside and ambulating with assistance by this time. Respiratory exercises are still performed every two hours, and incentive spirometry values should improve. Bowel sounds are monitored, and the patients diet gradually increased as tolerated, depending on the type of surgery and the physicians orders. The patient should be monitored for any evidence of potential complications, such as leg edema, redness, and pain (deep vein thrombosis), shortness of breath, dehiscence of the incision, or ileus. The surgeon should be notified immediately if any of these occur. If dehiscence occurs, sterile saline-soaked dressing packs should be placed on the wound.,单元工作任务描述,在麻醉恢复室，麻醉师或麻醉护师报告患者术中的身体状况、手术方式、所用麻醉剂种类、估计失血量和术中液体输入总量及尿量。麻醉恢复室护士还应警惕患者术中有无出现并发症，包括循环血流动力学的变化。患者进入麻醉恢复室后，护士应即刻评估患者气道是否开放、意识状态和生命体征。 住院患者被转入麻醉恢复室后，接管护士应该重新评估患者。麻醉师或麻醉护师应该考虑患者在麻醉状态下短暂的意识清醒的可能性。至少在术后第一个8小时内，应每隔12小时监测一次生命体征、呼吸状态、疼痛状况、切口与引流管状况。必须监测患者体温，因为术后常有低体温状况，需要使用保温毯或静脉输入温暖的液体。应经常评估患者呼吸状况，包括听诊呼吸音、观察胸廓起伏以及评估咳嗽是否有效。每12小时应观察记录摄入液量和排尿量，如果患者没有置导尿管，应该评估膀胱充盈度，并检查患者能否自行排尿。如果患者术后68小时仍没有排尿，应该通知医生。如果患者接受的是血管或神经手术，要遵医嘱每隔12小时评估患者的循环状况和神经功能。术后患者常需要使用镇痛剂和止吐药或者是抑制恶心的药物。 护士需指导患者如何使用自控镇痛泵。如果患者术后立即昏昏入睡，护士可按按钮以给予患者镇痛药。为确定患者对疼痛的耐受性，可请患者借助疼痛评分量表估计疼痛程度。疼痛控制至关重要，这样患者才得以有效咳嗽、进行深呼吸锻炼、床上翻身、坐起，最终得以下床行走等。 术后第一个24小时后，如果患者病情稳定，可以每48小时监测生命体征。需观察切口和敷料，查看引流量及是否有感染征象。术后第一天，外科医生会开出更换敷料的医嘱。更换敷料须运用无菌技术。在此期间，住院患者应该坐在床旁椅上，并在协助之下移动身体。患者每2小时仍须做呼吸锻炼，这样诱发性肺量测定值会有改善。根据患者手术方式的不同和医生的医嘱，要注意患者肠鸣音的变化，并在患者能耐受的情况下逐渐增加饮食。 应该警惕患者有无潜在并发症的迹象，如下肢水肿、发红、疼痛（深静脉血栓）、气促、切口裂开或肠梗阻。如有异常，应该立即通知外科医生。如果切口裂开，须用无菌生理盐水浸泡的敷料覆盖伤口。,Description,When patients return to the ward after an operation, a handover on the patients status is given to the ward staff. The Recovery Room nurse will check through the details of the operation which has just been performed, inform ward staff of any complications encountered during the recovery stage and review postoperative instructions. Postoperative instructions outline any special observations needed, for example circulation and neurological observations, wound management instructions, instructions about the removal of drains, pain management and the presence of a urinary catheter.,Task 1 Giving a postoperative handover,翻译,任务描述,当患者术后回到病房时，患者的病情状况会交接给病房工作人员。恢复室护士将会核查手术中的详细情况，告知病房工作人员患者恢复期出现的并发症，并复核术后指导。术后指导列出了重点观察的项目，如循环方面和神经功能的观察，还有伤口护理指导、怎样倾倒引流液、疼痛控制留置导尿管等相关事宜。,Related Information,FOCUSED ASSESSMENT of the Client on Arrival at the Medical-Surgical Unit after Discharge from the Post Anesthesia Care Unit Airway Is it patent? Is the neck in proper alignment? Breathing What is the quality and pattern of the breathing? What is the respiratory rate and depth? Is the client receiving oxygen? At what setting? What is the pulse oximetry result? Mental Status Is the client awake, able to be aroused, oriented, and aware? Does the client respond to verbal stimuli? Surgical Incision Site How is it dressed?,翻译,Mark the amout of drainage on the dressing immediately. Is there any bleeding or drainage under the client? Are there any drains present? Are the drains set properly? How much drainage is present in the drainage container? Temperature, Pulse, and Blood Pressure Are these values within the clients baseline range? Are these values significantly different from when the client was in the Post-anesthesia Care Unit (PACU)? Intravenous Fluids What type of solution is infusing and with what additives? How much solution was remaining on arrival? How much solution was infused in the transport time from PACU? What is the infusion rate supposed to be set at? Is it? Other Tubes Is there a nasogastric or other intestinal tube? What is the color, consistency, and amount of drainage? Is it set on suction if it is supposed to be? Is it on the right amount of suction?,相关信息,气道 它是开放的吗？ 颈部安置是否妥当？ 呼吸 呼吸质量和模式怎么样？ 呼吸频率和深度怎么样？ 患者在吸氧吗？用的什么装置？脉搏血氧仪的结果怎样？ 精神状态 患者是清醒的吗？能被唤醒吗？有定向力吗？有意识吗？ 患者对言语刺激有反应吗？ 手术切口部位 敷料覆盖得怎么样？ 立即记录敷料渗血或渗液量。 患者身下有流血或引流液吗？,当前有引流液吗？ 引流装置是否正确？ 引流容器里当前有多少引流液？ 体温、脉搏、血压 这些值在患者基准范围内吗？ 这些值与患者在麻醉恢复室时有显著不同吗？ 静脉输入液体 输入的是何种液体？加入了何种药物？ 患者返回病房时尚余多少输入液体？ 患者从麻醉恢复室返回病房的途中输入了多少液体？ 设定的输液速度是多少？是这个速度吗？ 其他插管 有无鼻胃管或其他肠道置管？ 引流液的颜色、粘度和量是多少？ 是否按要求设定为负压吸引？吸引力是否合适？ 有气囊导尿管吗？ 气囊导尿管引流是否通畅？ 尿液的颜色、透明度和量怎么样？,An example of postoperative handover checklist,Postoperative handover is one of the most critical phases in the care of a patient undergoing surgery. However, handovers are largely informal and variable. A thorough understanding of the problem is necessary before safety solutions can be considered. Postoperative Handover Assessment Tool (POHAT) was developed through task analysis, semi-structured interviews, literature review, and learned society guidelines. The following chart is an example of it.,翻译,术后交接核对单,术后交接是护理手术患者的一个重要环节。然而，交接大多是非正式的，而且变化很大。在想到安全的解决方案前，有必要全面了解存在的问题。术后交接评估工具（POHAT）建立在任务分析、半结构式访谈、文献回顾和包罗万象的社会指南基础上。下表是手术交接核对单的例子。,翻译,续表,Discussion of the nursing topic,1. What information and documentation needs to be passed on to the ward nurse during the postoperative handover? Name of operation performed, any complications, analgesia given in Recovery, any complications in Recovery, drains and dressings in situ, new Prescription Charts (IV Infusion Orders), medication orders and follow-up instructions. All pre-op charts also need to be handed back, with new orders on new charts, and the Operation Report. 2. What sort of things does the ward nurse crosscheck when a patient comes back from an operation? The Ward Nurse crosschecks the Operation Report, Prescription Chart, Obs. Chart, the patients wound, drains and IV.,3. How is a postoperative handover different from a change-of-shift handover? All previous orders (Prescription Charts, medication and dressings) have changed.,Common questions when giving a postoperative handover,1. Are you taking over her care? 2. OK, Brian, Ill just go through the operation report with you. 3. Shes still half asleep, isnt she? 4. His GCS was thirteen out of fifteen. She opens her eyes to command. 5. Can you just breathe normally for me? 6. Are you feeling warmer now？,Practice of the task,（Rose Smith, a 30-year-old who has surgery following a heavy traffic accident, comes back to the ward. Haley, the recovery nurse, hands Rose over to Brian, the ward nurse. Brian performs an initial return-to-ward check and starts Rose on postoperative observations.） Haley: Hello, Ive brought Rose Smith back from Theatres. Are you taking over her care? Brian: Right, thats me. Hello, Rose, youre back on the ward now from Recovery. Can you hear me? Rose: Mmmmm. Brian: Ill just get a quick handover, and then Ill help you a bit so as to feel better. OK? Rose: Mmmm. Haley: OK, Brian, Ill just go through the operation report with you. Urn, Rose Smith came in after a heavy traffic accident, er, she had the truck accident this morning.,翻译,Brian: Ah huh. Haley: Shes had a splenectomy today at 10:30 am. The operation was run very well. No post-op complications, except a bit of delayed awakening. Brian: Mm. Shes still half asleep, isnt she? Haley: Yes, thats right. I put her on neuro obs. to keep an eye on it. Ive put the chart in her notes. Her GCS was nine out of fifteen at first. She was opening his eyes to pain, making incomprehensible sounds and obeying commands for movement. When she left Recovery, her GCS was twelve out of fifteen. She opens her eyes to command. Rose, can you open your eyes for me? Haley: Thats it. Can you tell me where you are, Rose? Rose: Urn, hospital. Brian: Thats it. Youre back on the ward. Haley: Right, her obs. are stable, temp thirty-six, pulse seventy-three, BP one thirteen over sixty-eight; oxygen sats are ninety-eight percent on three liters of oxygen.,Brian: Ill just switch over to our oxygen. Rose, Im changing the oxygen tubing over to our wall unit. Can you just breathe normally for me? Rose: Mm, yeah. OK. Haley: Thats it. OK, fluids. Shes got a litre of five percent dextrose running. Brian: Right. Ill just transfer the bag to our IV stand now. There we are. Haley: That litre is due in an hour or so, and there are more fluids recorded on the Prescription Chart. Er, Rose had a few episodes of vomiting post-op, so you might like to keep the IV going for a while. She was given an anti-emetic and she has a prn order in case she has any nausea later on. Brian: Great. Er, what about drains? Haley: Shes got one redivac in situ. Rose, can I have a check at your drain for a minute?,Rose: OK. Haley: Here it is. Its patent. Lets just have a check. Look, its working well. And its draining small amounts. Its supposed to be removed when it drains less than twenty mils a day. Brian: OK. OK. Haley: Rose, can I check the wound now? Ill just take the blanket off for a minute. There it is. The wound was closed with clips, as you can see. There are just five clips. The wounds been covered with a non-adhesive dressing. Leave it intact until review by the surgeon tomorrow, please. Brian: OK. Er, what about analgesia? Haley: Shes been ordered pethidine seventy-six mg IM four hourly for three days, then oral analgesia. She was given pethidine seventy-six mg just before leaving Recovery at, er, 12:20 pm. I gave her an extra blanket, too, as she was a bit hypothermic. Brian: Right. Thanks. Are you feeling warmer now, Rose? Rose: Um, yeah, Im OK now. Just feel sleepy. Brian: All right, Ill just put your notes back, and then Ill come and take a few obs. And make you feel more comfortable.,任务案例,（罗斯史密斯，30岁，在遭遇了一场严重的车祸后接受了外科手术治疗，术后回到病房。恢复室护士哈利将罗斯交给病房护士布莱恩。布莱恩完成了患者回到病房后的首次检查，然后开始了对罗斯术后的观察。） 哈利： 你好，我将罗斯史密斯从手术室带回来了，是你接管她的护理工作吗？ 布莱恩： 是的，是我。您好，罗斯，您现在已从恢复室回到了病房。您能听得见吗？ 罗斯： 呣呣呣呣。 布莱恩： 我将快点完成交接，然后采取措施让您感觉好些，行吗？ 罗斯： 呣呣呣呣。 哈利： 好的，布莱恩，我和你一起回顾这份手术报告单吧。呃，罗斯史密斯因为一场严重的车祸入院，呃，她今天早上出了卡车事故。,布莱恩： 嗯。 哈利： 今天上午10:30，她做了脾切除术，手术进行得非常顺利，没有术后并发症，除了术后清醒略有延迟。 布莱恩： 嗯，她仍处于半睡半醒状态吗？是吗？ 哈利： 是的，起初，她的格拉斯哥昏迷指数是9，总分为15。她在疼痛时有睁眼反应，发出不可思议的声音，并能遵从移动指令。当她离开恢复室时，她的格拉斯哥昏迷指数是12，总分为15，她能遵从指令睁开双眼。罗斯，您能睁开双眼给我看看吗？ 罗斯： 呃。 哈利： 很好，您能告诉我您在哪里吗？罗斯。 罗斯： 呃，医院。 布莱恩： 真棒，你回到病房了。 哈利： 行，她的生命体征是稳定的，体温36，脉搏73，血压113/68，给氧3 L/min时血氧饱和度稳定在98%。,布莱恩： 我即将换到病房的供氧装置上。罗斯，我正将给氧管接到病房墙头设备带上，您能正常呼吸给我看吗？ 罗斯： 嗯，好的。 哈利： 对，好的，液体，再说说液体，她有1升5%葡萄糖溶液仍在输注。 布莱恩： 对的，我现在将这袋液体挂到我们的输液架上，在那里。 哈利： 差不多一小时这升液体就会输完，在医嘱单上还开出了更多要输的液体。呃，罗斯术后发生过几次呕吐，所以输液要持续一段时间，给她服用了止吐药，还给她开了长期备用医嘱以备不时之需。 布莱恩： 太好了，呃，引流情况怎么样？ 哈利： 给她放了一根雷氏抽吸引流管。罗斯，我能检查一下您的引流情况吗？ 罗斯： 好的。 哈利： 这就是，是开放的，让我们检查一下，看，引流通畅，已经引流出少量液体了，当每天的引流液少于20 ml时，就考虑拔管。,罗斯： 好的。 哈利： 这就是，是开放的，让我们检查一下，看，引流通畅，已经引流出少量液体了，当每天的引流液少于20 ml时，就考虑拔管。 布莱恩： 好的，好的。 哈利： 罗斯，我现在能看看您的伤口吗？我要将毯子移开一下，这里，正如你看到的，伤口由回形针缝合着，有5枚回形针，伤口由无胶棉敷料覆盖，请保持它的完整度直到医生明天看了之后再由医生定夺。 布莱恩： 好的，呃，镇痛怎么样？ 哈利： 医生已经给她开出哌替啶75 mg，肌内注射，每4小时1次，共计3天，然后口服止疼药。离开恢复室前，呃，中午12:20前已经注射过一次哌替啶。因为她体温过低，我给她加盖了一条毛毯。 布莱恩： 好的，谢谢，您现在感觉暖和点了吗？罗斯。 罗斯： 嗯，嗯，我现在很好，就是感觉有点困。 布莱恩： 好的，我将您的记录放回去，然后返回来给您测量生命体征，让您感觉舒服一点儿。,A. Read the following conversation first and then answer the questions followed.,1. What operation has Rose just been given? Shes had a splenectomy. 2. Why did the recovery nurses keep an eye on Rose carefully after her operation? Because she was slow to wake up after her operation. 3. Why will Rose continue to receive IV fluids on the ward? Because she had some post-op nausea and vomiting. 4. How is Roses redivac draining? It is patent and working well. And its draining small amounts,5. How was Roses wound treated by the surgeon? The wound was closed with clips. 6. What instructions are given about wound dressing this evening? It is to be left intact for the surgeon to review the next day. 7. What pain management is given to relieve Roses pain after operation? Shes been ordered pethidine seventy-six mg IM four hourly for three days, then oral analgesia. She was given pethidine seventy-six mg just before leaving Recovery at, er, 12:20 p.m.,B. Fill in the missing information on Rose Smiths Operation Report according to the conversation above.,C. Fill in the blanks, using the abbreviations in the box,is a Glasgow Coma Scale and records the conscious state of a patient. （ GCS ） 2、 is the measure of the amount of oxygen which is loaded or saturated into the red blood cells as the pass through the lungs. （ oxygen sats / SaO2 ） is from the Latin pro re nata: take whenever required. （ pm） is observations which assess neurological function and include a GCS assessment. （neuro obs） is Non-Adhesive Dressing. （ NAD ）,D. Work in pairs. Practice handing over a postoperative patient according to the following information you might use.,Venda Smith, a 47-year-old woman who had abdominal surgery to remove gallstones yesterday. There are no significant health problems other than gallstones. Postoperative Orders: Nasogastric tube to low Continuous Gomco suction Postoperative medications include cefazolin, intermittent IV, Morphine via PCA, acetaminophen PO, and metoclopramide IV; IV fluids include D50.45 NS at 80 ml/hr. Physical Exams: VS: T 100 degree F, p 88, R 12, BP 125/80,Alert: Breath sounds diminished at bases Unable to cough deeply Feet and legs warm and pink Pedal pulses palpable No bowel sounds auscultated Abdominal dressing has bloody drainage over incision with Penrose drain Has T-tube to straight drainage Has voided 350 ml clear yellow urine since midnight States pain 7-8 out of 10 States she has no nausea,Task 2 Checking a postoperative patient,Description,After receiving a postoperative patient on the ward, the nurse will commence postoperative observations of vital signs. Postoperative patients have their vital signs checked hourly for the first four hours and then four hourly if vital signs are satisfactory. Its important to check for excessive blood loss, pain level, dehydration, nausea and vomiting, and loss of consciousness.,翻译,任务描述,接收了术后患者后，护士就要开始检查术后生命体征。在最初的4小时内，要每小时检查一次术后患者的生命体征，如果生命体征令人满意，就改为4小时一次。检查失血过多、疼痛水平、脱水、恶心和呕吐和意识丧失十分重要。,Related Information,Vital Signs Assess blood pressure, pulse, and heart sounds on admission to the PACU and then at least every 15 minutes until the clients condition is stable. Automated blood pressure cuffs and cardiac monitoring assist in continuous assessReview vital signs after surgery for upward or downward trends and compare them to those taken before surgery. Report blood pressure changes of more or less than 25% of values obtained before surgery (15-to 20-point difference, systolic or diastolic) to the anesthesia provider or the surgeon. Decreased blood pressure, pulse pressure, and heart sounds indicate possible cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drugs. Bradycardia could ind