气道异物梗阻护理查房

问题,2003年12月9日柯受良（台湾知名影视艺 人，首创驾车飞越黄河） 有知情人士透露，柯受良 当晚是因饮酒过量，发生呕吐，因呕吐物阻塞气管导致窒息，凌晨猝死于上海一宾馆里，时年50岁。,小若宁 2005.3.15消费者权益保护日这天，一场悲剧降临到可爱的小若宁身上，年仅1岁零7个月、因吸食果冻窒息死亡。男, 4岁,2005.2江苏南京一名4岁男孩不慎被果冻窒息死亡,主要内容（Main Contents）,护理程序,健康指导,病史回顾,Disease knowledge introduction,The history review,Nursing process,Health guidance,Discussion,1,1,患者床号：21床 姓 名：刘明性 别：男 年 龄：76岁入院时间：2014年11月10日19时10分主 诉:进食中突发哽噎，出现意识不 清10分钟。,1,1,简要病史：患者1年前患脑埂塞，经住院治疗好转出院（具体诊治不祥）。出院后因右侧肢体活动不灵长期卧床，进食、喝水易发生呛咳。于今日下午晚饭进食间突发哽噎，继而呼吸困难、意识障碍，后急呼“120”送入我科。入院查体：患者意识丧失，呼之不应，表情痛苦，面唇紫绀，呼吸停止。双侧瞳孔等大等圆，直径4.5：4.5mm，对光反射减弱；颈软，无抵抗。脉搏微弱不可及。气管居中，呼吸音消失，心音消失。腹平、软。四肢软瘫。测P：50次/分，BP：100/64mmHg。抢救：立即予以卧位腹部冲击法取出气道梗阻异物，行CPR，准备抢救用物，遵医嘱予以吸氧、监护、开通静脉、运用呼吸兴奋剂等，经上述抢救后患者心跳及自主呼吸恢复，面色变红润，但意识障碍情况仍然存在。,1,1,临床诊断：1、窒息； 2、脑功能损伤。Clinical diagnosis:1.Asphyxia 2.Brain damage,病因,年龄因素,酗酒,饮食不慎,老年人因咳嗽吞咽功能差,全麻或昏迷者,医源性异物,定义：窒息是指气流进入肺脏受阻或吸入气缺氧导致的呼吸停止或衰竭。,临床表现,表现为吸气性呼吸困难，出现“四凹征”（胸骨上窝、锁骨上窝、肋间隙及剑突下软组织）。气道阻塞可分为两类：（1）气道不完全阻塞：患者张口瞪目，有咳嗽、喘气或咳嗽微弱无力，呼吸困难烦躁不安。皮肤、黏膜、甲床、面色青紫、发绀。（2）气道完全阻塞：面色灰暗青紫，不能说话及呼吸，很快失去知觉，陷入呼吸停止状态。,v”形手势颜面青紫不能发声肢体抽搐,特殊体征,救治原则(Treatment doctrine),保持气道通畅是关键， 其次是采取病因治疗。To keep airway unobstructed is the key, the second is to adopt etiological treatment.,1、身体评估（护理体检）Body evaluation care (medical)2、实验室及其它检查Lab and other inspection,护理评估 Nursing Assessment,护理诊断,患者呼吸 平稳、气道保持通畅。Patients breathe smoothly and keep unobstructed airway.,护理目标 Nursing Goals,迅速解除窒息因素，保持呼吸道通畅；给与高流量吸氧；保证静脉通路通畅，遵医嘱给予药物治疗；监测生命体征；备好抢救物品。(1) rapidly relieve suffocation factors, keep respiratory tract unobstructed; (2) provide high flow oxygen; (3) ensure venous channel unobstructed, prescribed for drug treatment; (4) monitoring vital signs; 5. Save items ready.,护理措施 Nursing management,患者意识障碍程度无加重。Patients with disturbance of consciousness degree aggravating.,护理目标 Nursing Goals,休息与安全：保持病房环境安静、安全，限制探视，运用保护性床栏；生活护理：给予高蛋白、高维生素清淡饮食，遵医嘱予以胃管鼻饲。每2小时协助变换体位，预防压疮的发生，做好口腔护理和大小便的护理；密切监测意识和瞳孔并详细记录，使用脱水降颅压药物时注意监测尿量与水、电解质的变化。,护理措施 Nursing management,患者生命体征平稳，无肺部感染的发生。In patients with stable vital signs, without the occurrence of lung infection.,护理目标 Nursing Goals,密切监测体温情况；定时协助患者翻身拍背,促进痰液的排出；严格执行无菌操作,及时予以吸痰；(1)close monitoring of temperature; (2) to assist patients turn back regularly, to promote the excretion of sputum; (3) strict aseptic operation, be in sputum suction.,护理措施 Nursing management,1、患者呼吸通畅,未出现呼吸困难征象；2、患者意识障碍程度减轻；3、患者未出现发热等肺部感染的征象。1, the patient breathe unobstructed, does not appear dyspnea signs; 2 disturbance of consciousness, patients with ease; 3, does not appear in patients with fever and other signs of lung infection,评价 Evaluation,健康指导,2疾病知识指导 向患者家属讲解窒息发生的原因、发展与治疗及其预后，教会家属及身边的人当气道异物梗阻时，如何应用Heimlich手法自救。,1疾病预防指导选择合适的食物, 对老年患者特别脑梗后容易发生呛咳和吞咽困难者，食物以半流质为宜，如粥、蛋羹、菜泥、面糊等。避免容易引起呛咳的汤、水食物及容易引起吞咽困难的干食，避免进食黏性较大的年糕等食物，水分的摄入应尽量混在半流汁的食物中给予，以减少误吸的可能。采取科学的进食体位 一般采取坐位或半卧位，卧床的病人应抬高床头30 40，以利于吞咽动作，减少误吸机会。,讨 论Discussion,总结Summary,谢谢,1,1,Bed no：21 Name：LiuMingSex：male Age：76Admission time ： On November 10, 2014 at 19:00.The main description: Eating in a sudden, a lot of unconsciousness for 10 minutes.,1,1,A brief history: Patients suffering from brain insuperior to plug a year ago, were hospitalized with improved (specific diagnosis and ominous). After discharge because of the right limbs activity is ineffective in bed for a long time, eat, drink water prone to choke to cough. This afternoon eating dinner between breaking a lot, and difficulty breathing, disturbance of consciousness, nasty shout after 120 into our department. Hospital physical examination: patients with loss of consciousness, should not be, look, lip purple purple, breathing stops. Bilateral pupil etc. Large such as round, diameter 4.5:4.5 mm, light reflex; Neck soft, without resistance. Pulse is weak. Tracheal middle and breath sounds disappeared, heart sounds. The abdomen flat, soft. Limb palsy. P: 50 times/min, BP: 100/64 mmHg.,1,1,Define and cause,Definition: asphyxia is refers to the air into the lungs caused by blocked or inhaled air oxygen breathing stops or failure.Pathogensis: Age、Excessive drinking、 Careless diet、 Impaired swallowing and so on.,1,1,Of inspiratory dyspnea, appear four concave (sternal elevation nest, supraclavicular fossa, rib gap and xiphoid process under the soft tissue). Airway obstruction can be divided into two categories: (1) incomplete airway obstruction: patients with open mouth stare, cough, weakness of breath or cough, dyspnea fidgety. Skin, mucous membrane, nail bed, was blue, cyanosis (2) the airway obstruction: completely complexion dark purple, unable to speak and breathing, loss of consciousness, quickly fall into a state to stop breathing,Clinical Manifestation,1,1,Nursing diagnosis,1、Impaired gas exchange:Associated with airway foreign body causing difficulty in breathing, suffocation.2、Acute confusion：Related to brain tissue hypoxia, impaired brain function.3、Risk for infection:Related to long-term lie in bed, lung sputum not easy eduction.,1,护理措施 Nursing management,Rest and security: (1) keep the ward environment quiet, safe, limiting visits, use protective bed bar; (2) life care: give high protein, high vitamin bland diet, be stomach nasogastric tube in accordance with the doctors advice. Every 2 hours to help transform position, prevent the occurrence of pressure ulcers, do a good job in oral nursing care and urine; (3) close monitoring of consciousness and the pupil and detailed records, pay attention to when using dehydration of intracraninal pressure drug monitoring and the change of the water, electrolyte of urine.,1,1,Health guidance,1. Disease prevention guide (1) choose the right foods, particularly after cerebral infarction was prone to choke to elderly patients with cough and swallowing difficulty, food with semifluid advisable, such as porridge, custard, puree, batter, etc. Avoid easily cause choking cough soup, water,