有机磷中毒查房

Welcome for attending our English clinical round !,organophosphorus pesticide intoxication,June, 2009Emergency Department,the First Affiliated Hospital of Wenzhou medical College,Step by step,CONTENTS,Learning key words together,Introduction of case history,Questions and answers,Nursing diagnosis and interventions,Dynamic condition change,Key words related to Organophosphate Poisoning,organophosphorus pesticide poisoning有机磷农药中毒,Poisoning 中毒Acute 急性cholinergic crisis 胆碱能危象muscarinic signs and symptoms 毒蕈碱样症状 nicotinic signs and symptoms 烟碱样症状symptoms of central nervous system 中枢神经症状,Key words related to Organophosphate Poisoning,alliaceous 大蒜味blushing 颜面潮红decreased heart rate 心率减慢pupil as needle tip 针尖样瞳孔muscular spasms 肌肉抽搐secrete of glandular organ 腺体分泌saliva 流涎,Key words related to Organophosphate Poisoning,acetylcholine 乙酰胆碱 cholinesterase 胆碱酯酶cholinesterase reactivator 胆碱酯酶复能剂pralidoxime 解磷定pyraldoxime methylchloride 氯磷定pilocarpine 毛果云香碱blood purification 血液净化,Key words related to Organophosphate Poisoning,rebound 反跳 intermediate syndrome 中间综合征 atropinization 阿托品化atropine poisoning 阿托品中毒dilatation of pupil 瞳孔扩大dry mouth 口干,Key words related to Organophosphate Poisoning,ECG Monitoringsuction; aspirationoxygen inhale turn the body over tap the backchest Physical treatmenturethral catheterization nasogastric tube insertion,心电监护吸痰 氧气吸入 翻身 拍背 胸部物理疗法 导尿 留置胃管,Key words related to nursing intervention,Key words related to nursing intervention,tracheal intubation extubationgastrointestinal decompressiongastric lavage emetic purgationdiuresismechanical ventilation,气管插管 拔管 胃肠减压 洗胃 催吐 导泻 利尿 机械通气,Key words related to nursing intervention,blood gas analysismental nursingphlebotomize skin testblood transfusion intramuscular injectionhypodermal injection,血气分析 心理护理 静脉采血皮试 输血 肌肉注射 皮下注射,Key words related to nursing intervention,intravenous infusion.skin carenasal feedingphysical method coolingsemi-reclining position temperature controller,静脉輸液 皮肤护理 鼻饲物理降温 半卧位 控温仪,mind 神志drowsiness 嗜睡coma 昏迷Delirium 谵妄pupil 瞳孔agitated 烦躁self-care ability 自理能力,Key words related to Symptom of nervous system,cough 咳嗽rattle 罗音wheezing rale 哮鸣音pulmonary edema 肺水肿breathing sound 呼吸音expectoration 咳痰respiratory paralysis 呼吸麻痹,Key words related to Symptom of respiratory system,abdominal pain 腹痛diarrhea 腹泻abdominal distension 腹胀constipation 便秘copracrasia 大便失禁nausea 恶心vomit 呕吐gastric juice 胃液appetite 食欲,Key words related to Symptom of digestive system,Key words related to Symptom of circulation system,Blood pressure 血压hypertension 高血压Hypotensive drug 降压药arhythmia 心律失常headache 头痛systolic pressure 收缩压Diastolic pressure 舒张压pulse 脉搏,Blood urine 血尿proteinuria 蛋白尿Urethral catheterization 留置导尿oliguria 少尿anuria 无尿urorrhagia 多尿aconuresis 小便失禁,Key words related to Symptom of urinary system,past history 既往史present history 现病史smoking 吸烟drinking 饮酒surgical history 手术史family history 家族史fall score 跌倒评分education 学历,Key words related to Social assessment,Name: ZhengsuijieAge:19 years oldSex: femaleBirthplace : YueqingOccupation: studentAdmission Date: May，19th，2009Discharge Date：June，3rd，2009,General information,Chief complaint,Suffering dyspnea for 3 days after take two kinds of organophosphate orally DiagnosisAcute Organophosphate PoisoningIntermediate Syndrome,Present illness 1,Three days ago , she drank 100 ml of two kinds of organophosphate .an hour later ,her parents found her unconscious, lip cyanosis and spittle outflow. She was rushed to the local hospital for emergency department. She became conscious after gastric lavage , establishing mechanical ventilation and using atropine and pralidoxime chloride.,Present illness 2,Two days ago ,she became unconscious again, following by a fever with the temperature of 39, spittle outflow and lower limbs tic. This morning ,she became coma and was sent to our hospital, admitting in EICU department.,一般情况及现病史,郑碎洁,女,19岁,EICU 7床,住院号 542293主诉：口服敌敌畏和马拉硫磷后呼吸困难3天现病史：患者3天前口服敌敌畏和马拉硫磷混合农药100ml。1小时后被家人发现口吐白沫，神志模糊，口唇发绀，即送当地医院行气管插管，洗胃，并予阿托品，氯解磷定，呼吸机辅助通气等治疗后神志转清。2天前出现发热，体温39，神志模糊，大量口水，下肢抽动。今上午出现神志不清，呼之不应，为求进一步诊治，转我院。于2009-5-19收住EICU。,诊 断,急性重度有机磷中毒中间期肌无力综合症,Physical examinations on admission,Physical examinationsPsychiatric system and Social assessment,入院体检,生理评估心理和社会系统评估,Physical examinations and assessment,T: 36.6, P: 82 bpm, R: 12 bpm, BP:100/70 mmHg,生命体征,体温36.6，脉搏82次/分,呼吸12次/分,血压100/70mmHg,Nervous system,She was conscious but weary. The pupils were about 1.0 mm in diameter and light reflect was a little bit slow,神经系统,入院时,患者神志清，精神软，两瞳孔等大等圆，大小1.0mm ， 对光反射迟钝,Respiratory system,She had endo-tracheal intubation and mechanical ventilation. The breathing sound was thickening with sputum sound. Offer aspiration of sputum, the sputum was yellow and glutinous. X-ray film was normal.,呼吸系统,经口气管插管接呼吸机辅助通气两肺呼吸音粗，闻及痰鸣音。辅助吸痰，为少量黄色粘痰胸片检查未见明显异常,Circulatory system,She was health without Heart trouble, high blood pressure, heart murmurs, or chest pain. Heart rate was 82 bpm. Electrocardiogram was normal,心血管循环系统,无诉胸痛，心律齐，未及杂音心率82次/分心电图显示正常窦性心律,Digestive system,When we pushed our fingers deeply and steadily into her abdomen, then quickly released the pressure, we could not elicit pain and rebound tenderness. She had bad appetite and was given liquid diet through gastric tube. She took formed stool every 2-3 days. The type-B ultrasonic of the abdomen was normal.,消化系统,腹软，无压痛及反跳痛，肝脾肋下未及胃纳欠佳，予鼻饲流质患者2-3天解大便一次，为少量黄色软便，成形腹部B超未见明显异常,Urinary system,She was suffered catheterization, the urine was yellow and limpid.,泌尿系统,患者留置导尿，尿色黄，质清,Endocrine system,She was health without thyroid trouble or diabetes mellitus.,内分泌系统,患者无糖尿病，甲亢等基础疾病血生化示血糖在正常范围,Musculoskeletal system,The muscle power of the upper limbs was band 4 and the lower ones was band 3. The muscle tone was normal.,运动系统,双上肢肌力4级，双下肢肌力3级。双下肢腓肠肌未见肌束颤动肌张力正常,Hematologic system,Blood-RT showed WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012. She had no blood transfusions before.,血液系统,入院时血常规示WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012 。既往无输血史,Skin,Her skin was warm and dry .She had some skin eruption on her face, which was caused by the transfusion pre-hospital.,皮肤,全身皮肤温暖干燥脸面部可见少许皮疹，家属诉是由外院输液后引起的,Psychiatric system and Social assessment,She was in storm since her admission and didnt cooperate well with the treat. She was diffidence and liked watching Korean teleplay. It was the third year in senior high school for her, which pressed her a lot. She was a league member. She had two sisters.,Her parents worried a lot about her admission. They had no financial problem on this admission. She didnt understand her own condition very well and accepted the lie that she had fallen down from the 4th floor, which was told by her mother.,Psychiatric system and Social assessment,入院后，患者一直情绪较激动，不愿配合治疗。患者平时相对比较内向，喜欢看韩剧。患者是高三学生，学习压力较大。无宗教信仰，是团员。患者有一姐一妹，平时在家比较叛逆。入院后，家属比较担心预后，住院没有经济负担压力。患者对住院原因不是很清楚，相信父母的从四楼掉下来的谎言。,心理社会评估,Lab examinations,Cholinesterase Was 234 U/L on her admissionUrine-RT : normalStool-RT : normalBlood-RT: WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012 albumin 28.3g/L,实验室检查,入院时胆碱酯酶234U/L大小便常规正常血常规示WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012 白蛋白28.3 g/L,other examinations,X-ray film: normalElectrocardiogram : normal,辅助检查,X片:未见明显异常心电图:窦性心律,Therapy process,EICU special nursing Liquid diet through gastric tube anti-inflammatory and fluid infusionUsing atropine and pralidoxime chloride Had endo-tracheal intubation and mechanical ventilation She was in storm since her admission and didnt cooperate well with the treat.On May 26th, we removed the trachea tube ,the gastric tube and the indwelling Catheter.On May 27th ,she was transferred to Ward 25.,诊疗经过,入院后医嘱予EICU特护，鼻饲流质，补液、抗感染，阿托品、长托宁、氯解磷定等解毒药对症支持治疗。经口气管插管处予接呼吸机辅助通气，并于完善各项辅助治疗。入院后，患者一直情绪教激动，不愿配合治疗。5-26予以拔除经口气管插管 ，胃管和导尿管。5-27 患者转25病区继续治疗,Therapy process,EICU special nursing Liquid diet through gastric tube anti-inflammatory and fluid infusionUsing atropine and pralidoxime chloride Had endo-tracheal intubation and mechanical ventilation She was in storm since her admission and didnt cooperate well with the treat.On May 26th, we removed the trachea tube ,the gastric tube and the indwelling Catheter.On May 27th ,she was transferred to Ward 25.,main nursing diagnosis,1. Inability to Sustain Spontaneous Ventilation2. Ineffective Airway Clearance3. impaired Verbal Communication4. Risk for Selfinflicted injury5. Activity Intolerance6. Risk for Infection7. Risk for ImPaired Skin Integrity8. Altered Nutrition:less Than Body Requirements9. Altered Urinary Elimination,主要的护理问题,1.不能维持自主呼吸2.清理呼吸道无效3.语言沟通障碍4. 有受伤的危险5. 活动无耐力6. 有感染的危险7.有皮肤完整性受损的危险8. 营养失调：低于机体需要量9. 排尿异常,Nursing intervention,Inability to Sustain Spontaneous Ventilation)/(Ineffective Airway Clearance) 1) observe vital signs, assess the symptom and physical sign of the respiratory system and record it.if it is abnormal ,report to the doctor in time.2) do physiotherapy of chest, keep the airway open, inhaust sputum and observe the color , quantity ,quality of the sputum .,Nursing intervention,3) fix the tracheal intubation well, mechanical ventilation, monitor the pressure of the aerocyst timely, observe blood gas analysis to adjust the parameter in time.4)use aminophylline to relieve cramp of the respiratory tract and Inflammatory reaction. 5) when she was annoyed and mental nursing was ineffective; gave her sedatives to calm down under supervision of a physician.6) take sputum culture to help the doctor choose suitable antibiotics.7) try our best to prevent Ventilator-associated Pneumonia.,护理措施,不能维持自主呼吸 清理呼吸道无效1)监测生命体征，准确评估呼吸系统的症状体征并做好记录，发现异常及时报告医生. 2)做好胸部物理疗法，保持呼吸道通畅，按需吸痰，观察痰液的量、色、性质，必要时按医嘱给予雾化，做好气道护理。3)妥善固定气管插管，经口气管插管接呼吸机辅助通气，定时监测气囊压力，做好呼吸机相关护理，及时根据血气分析结果调整呼吸机参数。,4)遵医嘱使用氨茶碱等药物减轻气道痉挛及炎症反应. 5) 病人烦躁、心理护理无效时遵医嘱给予镇静药物保证患者休息，减轻人机对抗。6)按医嘱及时留取痰培养，协助医生选择合适的抗生素.7)尽量预防呼吸机相关性肺炎的发生.,护理措施,Nursing intervention,impaired Verbal Communicationeliminate her scruple, tell her that anepia is transient due to the assisted ventilation .communicate by writing board; gesture , booklet ,so as to satisfy her needs.3) encourage her to communicate in different ways.,Drink,Turn over,Write,Urine,stool,语言沟通障碍1)消除患者顾虑，解释由人工气道造成的语言交流障碍是暂时的 .2)使用写字板，手势、图册等及时与患者沟通满足其需要 .3)鼓励患者使用多种方式沟通 .,护理措施,Nursing intervention,Risk for Selfinflicted injury 1) observe the change of her feeling and report to every shift if it was abnormal. use mental nursing to get her partner treatment .2) get the message about the aim of her suicide,do mental nursing to aim directly at cause of her suicide to get rid of pessimistic emotion.3) encourage family member to do mental nursing,her mother keep her company more time .,Nursing intervention,4) medical staff listen to her chief complaint patiently,know her need ,to satisfy her need as far as possible if it is not violated to the therapeutic principle.5) when Dysphoria was happened,make sure she was safe ,use sedatives or stop atropine to make her calm down.6) fix all the tubes especially the tracheal intubation well to prevent unexpected extubation.7) use restraint strap when it is needed,observe blood circulation of the acra.,有受伤的危险1)观察患者情绪变化，发现异常做好交接班，加强心理疏导使其配合治疗与护理 .2)仔细了解病人自服农药的动机，针对患者自杀原因做好心理护理，使其摆脱悲观消极情绪.3)争取家属配合一起做好心理护理,母亲陪伴的时间较多。4) 医务人员耐心听取患者主诉，及时了解她的需求，在不违反治疗原则的基础上尽量给予满足.5)病人烦躁不安时做好安全护理防止坠床等，必要时尊医嘱使用镇静药物或停止阿托品治疗。6)妥善固定各管道尤其是气管插管，防止意外拔管.7)必要时使用肢体约束带，注意观察肢端血运。,护理措施,Nursing intervention,Activity Intolerance 1) assess the recovery of myodynamia.2) help her move in bed ,help her do myodynamia of both lower extremities exercise.3) observe duration of amyostasia.4) observe cholinesterase under supervision of a physician.,活动无耐力 1)评估患者肌力恢复情况.2)协助患者翻身床上活动，指导患者做好双下肢功能锻炼. 3) 观察肌震颤持续时间. 4)按医嘱监测胆碱酯酶.,护理措施,Nursing intervention,Risk for Infection 1) emphasis the hand hygiene and Sterilization and insulation of the ward .2) aseptic processing when inhaust sputum and transfusion.3) oral cavity and perineum nursing. 4）observe the change of body temperatur and hemogram.5) give antibiotics under supervision of a physician and observe the effect.,有感染的危险1)加强操作前后洗手，做好病室消毒隔离工作.2)吸痰、输液等严格无菌操作.3)做好口腔及会阴护理. 4)监测体温及血象变化.5)遵医嘱使用抗生素，观察药物疗效.,护理措施,Nursing intervention,Risk for ImPaired Skin Integrity)1) look for the origin of skin rash, observe its distribution and quality .2) tell her not to scratch.3) Emphasis basic nursing keep the skin clean .4) turn over timely,keep the bed tidy.5) use the topica as calamine lotion under supervision of a physician).,有皮肤完整性受损的危险1)协助医生查找皮疹的原因，观察皮疹的分布范围、性质等 .2)指导患者勿搔抓皮肤.3)加强基础护理，做好全身皮肤的清洁.4)定时翻身，保持床单清洁平整 .5) 遵医嘱正确使用炉甘石洗剂等外用药物 .,护理措施,Nursing intervention,Altered Nutrition： less Than Body Requirements assess gastric retention, bowel sound, whether there is stomachache or abdominal distention or not, observe defecation ,nasol feeding under supervision of a physician.,营养失调：低于机体需要量 评估胃潴留、肠鸣音情况，注意患者有无腹痛、腹胀的主诉，观察排便情况，按医嘱给予鼻饲流质，保证能量供应。,护理措施,Nursing intervention,Altered Urinary Elimination 1) fix the urethral catheter to femoribus internus .2) perinaeum nursing twice every day .3) observe urine volume,colore,and quality,if it was abnormal ,report the doctor to handle with timely. 4)do urine culture under supervision of a physician.,排尿异常1)妥善固定导尿管于大腿内侧.2)每日2次会阴护理.3)观察尿量，色，性质，发现异常及时报告医生处理.4)按医嘱做好尿培养.,护理措施,Dynamic condition changeMay 19th,she was hospitalized into 7 bed in EICU at 18:12. Special care was ordered, gastric tube and nasol feeding was given. She was assisted by mechanical ventilator through oral trachea cannula. Respiratory frequency was set to 12bpm. It was required to record the volume of input and output during the 24h.,Dynamic condition changeMay 19th,We used Tazocin for anti-infection. 1 milligram Prolonged action atropine were used every 12 hours as nitramuscular injection. 2.5 milligram pyraloxime chloride were intervenous drop infused every 6 hours. 2.5 aminofilina were kept in 5 milliliter every hour by Micropump. The patient was agitated all the time. So we had to restrain her limbs. At 22 oclock there was a little sweaty on her chest. Sweating decreased after 1 milligram atropin given.,Dynamic condition changeMay 20th,The ultrasound of abdomen showed normal, so did X-ray of chest.The liver function results showed that the total protein 51.8g / L , albumin 28.3 g / L ; the rash on the face of the patient increased, and the calamine lotion was used for external using. At about 6 oclock ,it was sweaty on the forehead of the patient, after being given 1mg of atropine, the patient became very irritable.,At 9 oclock,the doctor ordered to stop using the Penehyclidine,but the patient still kept agitated all the night,she pulled out the gastric tube herself at about 1 oclock,and the oral trachea cannula was pulled out by herself at 6 oclock.With the help of hypnotic ,we intubated again as soon as possible.,Dynamic condition changeMay 20th,Dynamic condition change May 21th,The patient was relative quiet, she can go with our treatment, and the hypnotic medication was stopped,but she was still very weak and sleepy. Some rash appeared on the arm besides the face. The Routine blood test showed WBC 12.9, RBC3.7 , Hb 109g / L, plt 382.,Dynamic condition change May 22th,The blood cholinesterase was 1153U / L. 2.5 milligram pyraloxime chloride were changed to every 8 hours by intervenous drop infusion.The rash spread to the back,we still gave her the external medication.But it was no use.,Dynamic condition change May 23th,The Dermatologist was invited.The doctor advised that we should stop using Tazocin. So Fortum took place for anti-infection.Blood gas analysis showed PH 7.421, PO2 128.7mmHg, PCO2 38.2mmHg, Respiratory frequency was adjust to 10bpm.,Dynamic condition change May 24th,The red rash was resolving.she can partner our treatment and communicate with us well through the writing board. Blood gas analysis showed PH 7.40, PO2 137.8mmHg, PCO2 33.6mmHg, Respiratory frequency was adjust to 8bpm,Dynamic condition change May 25th,The blood cholinesterase was 2080 U / L. Blood gas analysis showed PH 7.37 ,PO2 159.3mmHg, PCO2 36.3mmHg, Respiratory frequency was adjust to 6bpm. 2.5 milligram pyraloxime chloride were changed to every 12 hours by intervenous drop infusion. Aminofilina were stopped.We planned to pull out the oral trachea cannula the same day, but the muscle strength of the patient were lower,so we decided to delay the plan of extubation. The patient was a bit emotional again. She refused our treatment and the effect of the psychological nursing was poor, we had to restrain her limbs.,Dynamic condition change May 26th,Blood gas analysis showed PH 7.415, PO2 157.4mmHg, PCO2 38mmHg, routine blood test showed WBC 15.2 X 109, RBC3.9 X 1012, Hb 109g / L, plt 352 X 1012.The doctor orderd to remove the oral tracheal cannula,and 10L/min oxygen through the mask was intaken, the breath was stable.After remove the gastric tube, she can take semi-flow diet by herself without bucking. She can urinate herself without the catheter. The rash all over the body disappeared. Her feeling was stable, she wished to stay with her family member and feel sorry for her bad beh