一氧化碳中毒双语教学查房

,石 莹 左瑞芬 马丽娟 周海华陈晓芳 胡 珊 冷文娇 毛秭钰郭倩雯 张 敏 张思敏 朱 丽,护理双语教学查房,一 氧 化 碳 中 毒CARBON MONOXIDE POISONING,重点、难点：,重点 一氧化碳中毒的急救处置和护理难点 一氧化碳中毒的毒理作用,关键词 Key Words,一 氧 化 碳 中 毒 carbon monoxide poisoning一氧化碳血红蛋白 carbon monoxide hemoglobin樱 桃 红 cherry pink,一、病 案,The History,杜昌秀女，42岁，已婚,昏迷不醒口吐白沫,T：37P:93次/分R:20次/分BP:95/65mmhg,煤罐及煤气热水器呈开放状态,心肌酶 碳氧血红蛋白,初步诊断：煤气中毒,Du Changjun, male, 42 years old, married. The family members found that the patient is coma and can not talk when his coal bottle inside the room and open coal gas water heater at 11:15 October 5,2011. Then his family call 120 and send him to our department.,The body temperature is 37 degrees, pulse is 93 times per minute, respiration is 20 times per minute, blood pressure is 95 to 65mmhg. The clients skull has no abnormal, the neck is soft, lips are cyanosis ,the pupils reflex to light are sensitive. His double lung respiratory sound rough, audible and moist rales, heart rate tidy, each valve has no murmur.The abdomen is soft.,2、实验室检查：,1.ECG manifestation:The heart rate is slowly. 2.Cardiamyocardial enzymes: 3.The carbon oxygen hemoglobin is,The initial diagnosis: Carbon monoxide poisoning,3、病史评估,既往史Past history,个人史Personal history,家族史Household history,婚育史The married history,过敏史Allergic history,体 格 检 查,Physical Examination,一氧化碳中毒是含碳物质燃烧不完全时的产物经呼吸道吸入引起中毒。中毒机制是CO极易与血液中的血红蛋白结合，从而使血红蛋白不能与氧气结合，造成生物体内缺氧，严重时候会危及性命。,二、概念 Concept,Carbon monoxide poisoning is contain carbon material burnable incompletely causes through the breath way inhalation poisoned.The poisoned mechanism is carbon monoxide combine with the hemoglobin in the blood.It cant make the hemoglobin combine with oxygen.The patient express anoxia, if the poison is severe the patient will die.,三、一氧化碳的中毒过程,How is the carbon monoxide to influence your body?,四、中毒常见原因The cause of carbon monoxide poisoning,The usage coal stove keeps warm to cook a meal in the closeness living room.,Use a gas water heater, poor ventilation, take a bath for long time.,In winter the people sleep inside the car.,The industrial production, furnace doorclosed lax or pipe leakage and coal gas explosion.,五、 中毒机制 O2 Hb CO 氧离曲线左移 COHb O2Hb HbO2中的O2和Hb更紧密 组织缺氧 中枢系统 脑血管麻痹、扩张 脑内三磷腺苷耗尽 脑血管病变 钠离子蓄积于细胞内 少数：迟发型脑病 严重者：脑水肿,六、中毒程度分级和临床表现Classification and Clinical Manifestations,1、中毒程度分级,(1)轻度中毒The light degree 血液中一氧化碳血红蛋白浓度为10%20%。 Carbon monoxide in the blood hemoglobin concentration of 10% to 20%. (2)中度中毒Mild poison 血液中一氧化碳血红蛋白浓度为30%40%。 Carbon monoxide in the blood hemoglobin concentration of 30% to 40%.,1、中毒程度分级,(3)重度中毒Severe poison 血液中一氧化碳血红蛋白浓度为50%. Severe poisoning: Carbon monoxide in the blood hemoglobin concentration of 50%.,2、中毒的临床表现,(1) 轻度中毒： 病人表现为头痛、头晕、乏力、恶心、呕吐，心悸、四肢无力，甚至短暂晕厥等。 The patient expresses for the headache, dizziness, fatigue, nausea, vomiting, the heart palpitations weakness, or even a short syncope.,(2)中度中毒 病人除具有轻度中毒的上述症状以外，可出现皮肤粘膜呈樱桃红色，神志不清、呼吸困难、烦躁、谵妄、昏迷，对疼痛刺激可有反应，瞳孔对光反射、角膜反射可迟钝，腱反射减弱，脉搏增快，多汗全身瘫痪无力等症状，并逐渐进入虚脱昏迷。病人经积极治疗可恢复正常，且无明显并发症。 In addition to mild symptoms of poisoning, can appear a skin and mucous present cherry pink, confusion, dyspnea, irritability, delirium, coma, can have reaction to the ache incitement, eye pupil to light reflex, cornea reflex can be dull, tendon reflexes , faster pulse, sweating and so on. The patient can recover normally after active treatment, and have no significant complications.,(3)重度中毒病人出现深度昏迷， ，病人可睁眼，但无意识，不语、不动、不主动进食或大小便，呼之不应、推之不动， 大小便失禁，瞳孔散大，皮肤由樱桃红变为灰白或者紫色，并有肌张力增强。出现心肌损害和脑、肺水肿等严重症状与体征，引起急性肾小管坏死和肾功能衰竭。病人死亡率高，抢救能存活者多有不同程度的后遗症。,The patient will be placed in deeply coma, various reflex disappear, can present to the state of the cerebral cortex. Patients can open eyes, but unconscious, can not talk with orthers, can not move, do not take a meal or urine, and can not push of immobility, also the muscle tension strengthen. Cerebral edema can also occur with convulsions, respiratory depression, shock, arrhythmias, upper gastrointestinal bleeding Parts of patients appear the oppression muscle dead,dead muscle release of the muscle globulin can cause an impatient kidney and kidney function failure.Patient death rate increased,the survival have the different residual.,七、辅助检查 Laboratory Examinations,1、血液一氧化碳血红蛋白的测定： Determination of carbon monoxide hemoglobin in blood（1）加减法 Addition and Subtraction（2）煮沸法 Boiling（3）分光镜检验法 Spectroscopic test2、脑电图检查 electroencephalogram (EEG) examination3、头部CT检查 Head CT examination,八、急救原则,1、现场急救迅速打开门窗进行通风换气，断绝煤气来源。将病人移至空气清新的地方。,Emergency principle,1. The First AidQuickly open doors and windows to change air to rupture coal gas source. Move patient to the place of fresh air.,2、治疗 Teatment,(1)迅速纠正缺氧 Rectify Hypoxic Rapidly 氧疗是一氧化碳中毒最有效的治疗方法。应采用高浓度面罩给氧，或鼻导管吸氧（流量8-10L/分)有条件者应该积极采用高压氧治疗高压氧治疗可以清除机体内有害气体，防治肺水肿，降低病死率。,(1) Rectify Hypoxic Rapidly Oxygen treatment is the most valid treatments of Carbon monoxide poisoning .Hyperbaric oxygen therapy can prevent and cure pulmonary edema with the clearance machine harmful air inside the body and lower an ill rate.,(2)防治脑水肿，改善脑代谢 Prevent Cerebral Edema and Improve the Cerebral Circulation,严重中毒后2-4小时，即可出现脑水肿,快速静滴20%的甘露醇250ml,以防治脑水肿，用低分子右旋糖酐.能量合剂，如辅酶A、ATP、细胞色素,改善脑代谢。 The severity is poisoned behind 2-4 hour, can immediately appear brain edema. The quickly drop is 20% mannitol 250 ml, in order to prevent cure brain edema ,improvement brain metabolism.,(3)对症治疗 Cure to the Disease,昏迷者应保持呼吸道通畅 。深昏迷者可予苏醒剂，可用纳洛酮。高热抽搐者，可采用头部降温亚低温疗法及止痉药物。呼吸障碍者应用呼吸兴奋剂。 The coma should keep airway open. When the patients have high fever and muscular spasms, we can adopt head to reduce the heat, low temperature treatment and antispasmodic drugs. Breathing disorder can apply breathing stimulant.,九、一氧化碳中毒病人的护理诊断,The Nursing Diagnosis of Carbon Monoxide poisoning,1、意识障碍 与急性中毒引起中枢神经损关 Disorder of consciousness Related to acute poisoning cause central nerve damage.2、体液失衡 与急性中毒有关 The imbalance of body fluid Related to the acute poison3、低效性呼吸型态 与一氧化碳中毒有关 Tissue hypoxia Related to carbon monoxide poisoning,4、恐惧，焦虑 Fear, anxiety5、有皮肤完整性受损的危险 The dangerous of skins integrity damaged6、潜在并发症 肺部感染、迟发性脑病、呼吸衰竭、上消化道出血 The complications of carbon monoxide poisoning,十、一氧化碳中毒病人的护理目标及措施和评价,The Nursing Target，Cares and evaluation of Carbon Monoxide Poisoning,（1）护理目标病人意识障碍无进一步加重或逐渐好转 The patient disorder of consciousness have not improve.（2）护理措施,入院评估患者的昏迷程度，给予高流量的面罩吸氧，及时纠正脑缺氧，去枕平卧，头偏向一侧，注意保持呼吸道通畅。 Making the patients consciousness have no aggravate that we must do hospitalize valuation. We can give the patient high flow of the oxygen mask, rectify cerebral anoxia in time. Keep the respiratory tract open. the head is partial to one side.Make the patient recovers consciousness, the anoxia gets an improvement.（3）评价病人意识逐渐恢复，缺氧得到改善。 The patient gradually recovers consciousness and the lack of oxygen to be improved.,1、意识障碍,2、体液失衡,（1）护理目标脑水肿减轻或颅内压恢复正常。 Brain edema reduced or intracranial pressure is normal.（2）护理措施由于脑部缺氧引起脑水肿，颅内压增高，给予的体位是头部抬高15-30度，遵医嘱用脱水利尿药物20%甘露醇快速静滴，联合应用醒脑药物和促进脑细胞代谢的药物，要注意水，电解质平衡，准确记录24小时出入量。 Because the brain anoxia causes brain edema and increase intracranial pressure, we keep the head raise up 15-30 degrees. Use dehydration diuretic drugs, such as 20% Mannitol, and brain medicine to help the brain cell. Monitor water and electrolyte balance. Record 24 hours amounts. Make the patient have no brain.（3）评价病人无脑水肿危险。 The patient intracranial pressure are normal.,3、低效性呼吸型态,（1）护理目标患者呼吸平稳，能有效排痰 The patients respiration is stable.（2）护理措施为保持呼吸道通畅，要使患者呼吸新鲜空气；保温；吸氧；呼吸微弱或停止呼吸的患者，必须立即进行人工呼吸；必要时，可用冬眠疗法，已达到呼吸通畅。病人呼吸保持平稳。能有效地排痰。动脉血气分析值正常。 Breathing fresh air. Heat preservation, oxygen.The breath is weak or stop breath of patient, have to immediately carry on artificial respiration. Can use to hibernate therapy when its necessary.Patients breath keeps steady,can effectively discharge sputum.Arterial blood gas analysis are normal. （3）评价患者呼吸平稳，有效排痰 The patients respiration is stable.,4、恐惧、焦虑,（1）护理目标帮助病人尽早消除恐惧，焦虑，使其早日恢复健康 Help a patient remove to fear and anxiety as early as possible, make them recover soon.（2）护理措施患者清醒后对环境陌生和突发患病的恐惧。我们予介绍病区情况，说明病情。一氧化碳中毒昏迷者清后精神尚处于不平衡状态，我们应该多安慰和鼓励病人，可适当安排家属探视。告知病人治疗的必要性和重要性，积极配合治疗。 We explain the circumstance and disease knowledge. We should encourage patient,arrange family members visiting.Tell the patient that the necessity and importance of the treatment in order to cooperate treatment.（3）评价恐惧，焦虑消除，能积极配合治疗。 The patient can cooperate the treatment.,（1）护理目标病人皮肤完整，无褥疮发生。 The nursing target is make a patients skin integrity and have no bedsore.（2）护理措施给予鼻饲营养，鼻饲营养应该进高热量，高维生素饮食，同时还要做好口腔护理，皮肤护理，定时翻身拍背以防褥疮和肺部感染。 Give the nasogastric nutrition to the patient.The nasogastric nutrition should enter high quantity, high vitamin food, still need to take care of the month well. About the skin cares, the nurse can told the patient turn over in order to prevent bedsore and lung infection. （3）评价营养符合机体需要，口腔清洁，皮肤完整，无褥疮发生。 The satisfied nutrition requirements, the clean mouth, skin integrity, have no bedsore.,5、有皮肤完整性受损的危险,（1）肺部感染 The lung infection（2）迟发性脑病 部分急性一氧化碳中毒病人在急性期意识障碍消失后，经260天“假愈期”，又出现一系列神经精神症状，称为迟发性脑病表现为迟钝、精神错乱、痴呆、大小便失禁等。The patient appears a series of the nerval symptom.（3）呼吸衰竭 Respirato