MODS护理查房

MODS护理查房,蚌埠医学院第一附属医院 重症医学科,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,患者胡某某，女，22岁，于2014.2.27顺产一活婴，2.28出现皮肤巩膜黄染、阴道持续流血（当地医院治疗，具体不详）。3.1阴道流血未改善，并出现尿少。于3.2 06:30入住我科,“产后出血并发MODS”,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,体格检查,神志清楚、贫血貌、口唇苍白 皮肤巩膜黄染、有多处瘀点瘀斑 双侧瞳孔等大等圆，对光反射灵敏 腹膨隆、腹水征阳性、肠鸣音2次/分 阴道血性恶露、量较多 四肢水肿明显,T：36，HR：132次/分，R：24次/分，BP：133/88mmHg,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,实验室检查,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,实验室检查,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,什么是MODS,表现如何,如何治疗,如何护理,诊断标准,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,多器官功能障碍综合征MODS,多器官功能障碍综合征（multiple organ dysfunction syndrome，MODS） 指机体遭受严重创伤、休克、感染及大手术等急性损害24小时后，同时或相继出现两个或两个以上器官系统的功能障碍以致机体内环境稳定必须靠临床干预才能维持的综合征,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,原发致病因素是急性而继发受损器官可在远隔原发伤部位，不能将慢性疾病、组织器官退化、机体失代偿时归属其中。呈序贯性器官受累，致病因素与发生MODS必须24h。发生MODS前，机体器官功能基本正常，功能损害呈可逆性，一旦发病机制阻断、及时救治，器官功能有望恢复。,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,病死率,病死率,累及器官数（个）,1,2,3,4,100,30,73,55,MODS病死率很高，并随衰竭器官的数目增加而增高,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,病因,严重创伤,休克,严重感染,医源性原因,心跳骤停,1,2,3,4,5,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,机制,主流的看法是失控的全身炎症反应综合征（SIRS） 1）缺血再灌注损伤假说 2）炎症失控假说 3）肠道细菌、毒素移位假说 4）两次打击和双项预激假说 5）应激基因假说,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,诊断标准,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现循环,临床特征性表现：急性肺循环淤血和供 血不足 呼吸困难、咳嗽和咯血,急性心功能不全,心源性休克,心搏骤停,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现呼吸,临床特征表现为：发绀和呼吸困难 血气分析检查常呈现为低氧血症 ARDS或急性呼吸功能不全,吸氧,机械通气,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现肾脏,临床特征性表现：氮质血症、少尿、无 尿和水、电解质及酸碱平衡紊乱,氮质血症,CRRT,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现肝脏,临床特征性表现：细胞性黄疸，巩膜、 皮肤黄染，尿色加深呈豆油样 血清生化：总胆红素升高、肝脏酶学水 平升高,肝功能不全,肝性脑病,肝衰竭,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现胃肠,临床特征性表现：消化道出血及肠鸣音 减弱,消化道出血,胃肠道蠕动减弱,胃肠麻痹,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现凝血,临床特征性表现：黏膜、皮肤形成花斑，皮下出血，注射部位或手术切口、创面自发性弥散性渗血，内脏器官及脑部的出血,DIC 化验检查：血小板计数呈进行性减少、凝血酶原时间延长,皮肤黏膜出血,内脏出血,大脑出血,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,临床表现中枢神经系统,临床特征性表现：意识障碍 瞳孔变化、神经系统的病理反射,清醒,嗜睡,昏睡,浅昏迷,深昏迷,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,治疗原则,消除引起MODS的病因和诱因，治疗原发疾病 改善和维持组织充分氧合 保护肝、肾功能 营养支持及代谢调理 合理应用抗生素,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,病史,3.2(第一天）12:50 意识清醒、紧急经鼻气管插管3.2(第一天）15:20 腹腔穿刺,引流出大量黄色液体3.3(第二天）08:00 意识昏睡、24h尿量50ml3.3(第二天）09:20 CRRT治疗3.4(第三天） 24h尿量220ml3.5(第四天） 24h尿量2620ml3.6(第五天）08:00 瞳孔不等大，昏迷状态，急查CT双侧大脑枕叶大面积脑梗塞伴出血,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,病史,3.7(第六天)患者瞳孔等大，意识昏迷、皮肤巩膜黄染3.8(第七天)皮肤巩膜黄染明显，有多处瘀点、瘀斑3.9(第八天)考虑颅内静脉窦血栓形成(需磁共振确诊)3.10(第九天)拟进行“人工肝”治疗（血浆准备）3.10(第九天)23:30 出现心率血压的下降，升压药物处理，心率血压恢复，SPO2无改善，而后家属放弃治疗，自动出院,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,实验室检查,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,实验室检查,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,CT检查,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,出血,低氧血症,肝肾功能不全,胃肠功能紊乱,心脏功能不全,脑组织病变,MODS,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,护理,观察,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,呼吸功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,呼吸道护理,人工气道的管理,VAP预防,循环功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,病情观察,痰液的性状、量,出入量的控制,血流动力学的监测、护理,肾功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,尿量的变化,肾功能化验结果,CRRT护理,肝功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,意识变化,皮肤巩膜黄染程度,肝功能化验结果,中枢神经系统功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,意识的改变,瞳孔的变化,镇静、镇痛,胃肠功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,胃液观察,大便观察,肠内营养护理,凝血功能障碍护理,The First Affiliated Hospital of Bengbu Medical College in intensive medicine,皮肤黏膜的观察,凝血功能化验结果,预防内脏及大脑的出血,细节护理,The First Af