ICU护理上海护理学会

临床重症监护新进展,徐丽华上海交通大学护理学院世界健康基金会（ProjectHOPE）,TheDevelopmentofCriticalCareNursing重症监护发展,1950年照顾脊髓灰白质炎病人1960年开始麻醉恢复室1960开始JohnsHopkinsHospital3-bed神经外科手术后重症护理床开始，而后有CCU及在芝加哥建立早产儿单位1970年发展共性重症监护室,适当的ICU环境能促进病人安全,NICUProgressin90s(3),Surfactanttherapy肺表面张力素治疗AntenatalSteroids产前激素治疗FolatetopreventNTDs叶酸预防神经管道缺损Improvedsurvivalofmicropremies微小早产儿提升存活率NitricOxidetherapy一氧化氮治疗FetalTherapy胎儿治疗“BacktoSleep”reducedSIDS“平躺”预防婴儿悴死症发生byDr.AvroyFanaroff,2001,AACNDefinesRoleofCriticalCareNurses定义重症护理角色,重症护理是一个专业，处理人们面临危及生命的问题及反应工作范畴包括病危者、家属、重症护理同事、及重症护理工作环境目标：确保有效的互动及最佳的患者照顾结果,TheDevelopmentofCriticalCareNursing重症护理发展,认可护理人员在重症护理贡献及角色，促进与医师间的合作医疗技术与仪器发展促进特别的重症护理单位建立,ContemporaryCriticalCare现代的重症护理,多医疗梯队的照顾：physicianintensives,specialtyphysicians,nurse,advancedpracticenurses,andothernurseclinicians,pharmacists,RT,PT,OT,socialworkers,clergy,childlifespecialist照顾的连续性Continuumofcarefromonesettingtoanother（连接医院到家庭、社区),ICU相关人员,ICU病人,微生物学家,临床心理治疗师,深切治疗专家,专科医师,职业治疗师,物理治疗师,医学社工,营养师,院感护士,伤口护士,ICU护士,ICUPatientandFamily,引导重症护理发展的理念,SynergyModel(Villaire,1996):叙述护士与病人间的相互关系病人的特质促使护理能力的发展，以便能提供整体的、修复的照顾，促使病人达到最佳的护理结果,SynergyModel:护理胜任能力,Clinicaljudgment临床判断Advocacy建言Caringpractices关怀的实践Collaboration协和性Systemsthinking系统思维Responsetodiversity多元性的反应Clinicalinquiry临床的质疑Facilitationofpatientandfamilylearning是病人及家属学习的促进者,SynergyModel:环境Environment,Value价值官Respect尊重Knowledge知识Ethical道德Collaboration协作Diversity多元化,Leadership领导Life-longlearning终身学习Optimizedtalentandresources扩展能力及资源Innovationandcreativity创新及创造,Nursescreateahealing,humane,andcaringenvironment,AACN重症护理专业标准,QualityofCare照顾品质IndividualPracticeEvaluation个别实践评价Education教育Collegiality同事间合作Ethics道德Collaboration共同合作Research科研ResourceUtilization资源应用,ICU护理重视议题,重症医疗与护理趋势,重症病人复杂性增加老年病人有慢性疾病及多器官问题、留院时间长、费用增加、增加重症护理的负荷。重症医疗费用昂贵，占据大部分的医疗预算重症护理护理人力不足，病人住院时间缩短、评价护理成效与结果,重症医疗与护理趋势-(2),重视病人安全、临床护理指引、以循证为基础医疗梯队合作适应高科技的发展与应用，及高科技所带来的道德冲突临终关怀与护理远距医疗与护理,重症护理中所重视的护理议题,降低ICU院内感染发生率（管道、呼吸机、抗生素降低自身免疫力)ICU陪客与家属看护问题ICU护理成效及指标入住ICU指标及病情严重度评价ICU管理：财务、仪器、费用平衡、新技术与材料可及性ICU病人出院后的随访与康复，如何降低ICU出院病人的再入院或急诊再使用率？,重症疾病照顾与家属压力,重症单位家属需求：1。需要离重病家属近（Keske，1992），病室要有足够空间容纳家属2。家属需要舒适感：情绪与生理舒适，等候室空间、医疗进程报告护理人员工作在重症单位的压力（符合、单位设计、休息时间与场所，环境舒适感）,重症单位病人的经验,沟通困难疼痛口渴吞咽困难焦虑失去控制忧郁害怕缺少朋友及家属,被约束觉得被拖累无法活动舒适睡眠困难寂寞思想死亡或有滨死感觉,Concernptcomfort,ICU环境与患者问题,Sensoryoverload感官刺激过渡Sensorydeprivation感官刺激不足Sleepdeprivation睡眠不足Lackofprivacy缺乏隐私Technologydependent仰赖科技Separationfromfamiliarsettingandpeople与家属分离UncomfortablesensationassociatedwithTreatment与治疗相关的不舒适,ICU精神心理健康,ICU病人曾经历焦虑、烦躁、及幻觉1964年发现ICU病人的心理问题：ICUPsychosis,Intensivecaredelirium,.许多ICU的疾病进展也可能导致病人产生幻觉ICU病人需要实际的讯息护理目标：确保病人的安全，使病人有安全感、降低环境刺激、提供环境定向感建立、促进病人休息,影响ICU病人心理健康因素,年龄发展阶段过去疾病经验家庭关系及社会支持个人对生命与死亡看法文化因素（不同种族对空间与接触的看法不同）,重症病人家属,一个重症病人可以影响全家人精神心理压力及医疗财务压力照顾家属照顾病人，协助家庭（病人与家属）度过危机压力期,ICU的睡眠问题,patientsincriticalcareunitsmayspend40%to50%oftheirsleeptimeawake（清醒）,andoftheremainingsleeptimeonly3%to4%inREMsleep（快速动眼期）notbeingabletosleepwasrankedasthesecondmostimportantstressor,secondonlytopain.无法入睡是ICU病人最大的压力,ICU病人的睡眠混乱问题,镇静剂催眠影响:在幼儿中睡眠混乱导致儿童日间行为减少,因睡眠不佳而累积的疲惫增加,依赖,耐受,快速动眼期受抑止或反弹.,ICU病人的睡眠问题,正常睡眠降低心血管系统的生理负荷如睡眠不足可导致生理与精神的消耗与延迟恢复精神心理情况改变，重症监护相关的精神病及强化疼痛,重症监护室的噪音,监护室噪音应低于35to40dB以利有效休息，在白天低于180mmHg(orincreaseof20%ormore)ordiastolicBP100mmHgHeartrate120beats/minute(orincreaseof20%ormore),Respiratoryrate30breaths/minute(orchanging50%ormore)SpO290%Signsofincreasedworkofbreathing-dyspnea,accessorymusclesuseDiaphoresisFatigueorpain,Hemodynamicmonitoring,BP:6070/40-50mmHgLA12-14mmHgRA15-18mmHgMaintainHCTabove35%，,Hemodynamicmonitoring,动脉导管:Transducerposition不能有空气淡肝素持续绝对无菌,Hemodynamicmonitoring,DrugsUsedtoImproveCOandBP多巴安5-10ug/kg/minMilrione米力农0.5ug/kg/min,Hemodynamicmonitoring,小剂量及单位剂量IV给药Labelmeds.Settherate,。,动脉导管波形,代表在QRS后收缩压的锋值:cardiacsystolicpressurewavetoreachtheperipheralcatheterandsensor双锋代表动脉瓣的关闭Dichoticnotchindicatestheclosureoftheaorticvalve,CardiacOutput,心输出量主要与心跳及心排（strokevolume)有关，心跳增加时，心输出量可能增加。但心跳过速影响心室灌注，并减少心输出量导致系统的循环失常。因此心跳过慢或心跳过速（180200/min)均应仔细评估。Cardiacoutput=HRXStrokeVolume,Preload,Afterload,Contractility,ThePulmonaryArterycatheter(PAC),Thepurposeofthiscatheteristo:Indirectlymeasuretheleftventricularend-diastolicpressure.Evaluatethehemodynamictreatmentsandmeasurethepatientshemodynamicstatus.Drawmixedvenousbloodsamples.Obtaincentralvascularpressuresmeasurements.Measurecardiacoutput.,PACatheterIndicator,Conditionsofshocksuchassepticandhypovolemicshock.Evaluationoffluidvolumestatus.Evaluationofcardiacoutputincomplexmedicalsituations.Prophylacticinsertionforhigh-risksurgeries.,ParameterNormalValue,BloodPressureSystolic(SBP)90-140mmHgDiastolic(DBP)60-90mmHgMeanArterialPressure(MAP)70-100mmHgCardiacIndex(CI)2.5-4L/min/m2CardiacOutput(CO)4-8L/minCentralVenousPressure(CVP)(alsoknownasRightAtrialPressure(RA)2-6mmHg,ParameterNormalValue,PulmonaryArteryPressure(PA)Systolic20-30mmHg(PAS)，Diastolic8-12mmHg(PAD)Mean25mmHg(PAM)PulmonaryCapillaryWedgePressure(PWCP)4-12mmHgPulmonaryVascularResistance(PVR)37-250dynes/sec/cm5RightVentricularPressure(RV)Systolic-20-30mmHg，Diastolic0-5mmHgStrokeIndex(SI)25-45ml/m2StrokeVolume(SV)50-100mlSystemicVascularResistance(SVR)800-1200dynes/sec/cm5,心脏指标计算方式,BodySurfaceArea(BSA)=(Height(cm)xWeight(kg)/3600)1/2CardiacIndex(CI)=CardiacOutput(CO)/BodySurfaceArea(BSA)MeanArterialPressure(MAP)=(2xDBP)+SBP/3PulmonaryVasularResistance(PVR)=PAM-PCWP/COX80StrokeIndex(SI)=StrokeVolume(SV)/BodySurfaceArea(BSA),心脏指标计算方式,StrokeVolume(SV)=istheamountofbloodejectedbytheleftventricleintothevasculatureinoneheartbeat.SystemicVascularResistance(SVR)=(MAP-CVP)/COX80,系统重症患者的监护,休克症状评估原理-1,焦炉，混乱，失去方向感乃因早期休克交感神经反应及缺氧及休克晚期脑部灌注不良所导致深而快的呼吸：因循环氧量减少，乳酸及二氧化碳聚集所导致,Sao295%,Pao25sec)尿量降低每小时少于30西西(UO10mmHgwithin30minutes,tolerancedependsonptcondition)促使分泌物及压力的放松,PositionandVAP,Semi-recumbenthead-of-bedpositioning(45degree)todecreaseVAP抬高床头ICUpt抬高头部减少胃液反流及细菌游走到呼吸道(Helmanet.al.,2003),PreventionofVAP呼吸机相关性肺炎预防,1.好的口腔护理.2.在ICU执行口腔卫生评估3.适当的处理与呼吸道接触的医疗用物4.Eliminatingtheroutinechangingofdisposableequipment.减少不必要的更换5.Useasterilesingle-usecatheterwitheachprocedure使用一次性的抽吸管,VAPandHandwashing肺炎与洗手,ImportanceofHandHygientforallpatientcareactivity强调洗手重要性TheCDCrecommendsusingalcohol-basedhandrubstoincreasehandhygienecomplianceanddecreasetheincidenceofhand-transmittedinfections使用含酒精的免洗手液,预防吸入及呼吸机相关性肺炎,Removeendotrachealandtracheostomytubesassoonaspossible早拔管AvoidReintubation避免重复插管Elevatetheheadofthebedforallpatientswithenteralfeedingstoanangleof30to45degrees.喂食时抬高床头3040度,预防吸入与呼吸机相关性肺炎(con.),regulationofenteralfeedingrateandvolumetopreventgastricregurgitation挑整肠胃喂食率与量以预防胃反流Practicedeepbreathing,coughing,andfrequentturning.促进肺扩张运动及体位Encouragetoincreasepatientmobilitybyambulatingorplacingthepatientuprightinachair鼓励病人活动及坐起,AACN“VentilatorBundle”,Elevationoftheheadofthebedto30-45degreeifnocontraindicationContinuousremovalsubglotticsecretionsChangeofventilatorcircuitnomoreoftenthanevery48hoursWashingofhandsbeforeandaftercontactwitheachpatientTolentino-DelosReyes,2007,重症护理基本概念,NutritionalSupport营养支持Mechanicalventilation机械通气Homodynamicmonitoring血液动力监测Sedatingandpaincontrol镇静与疼痛控制Alternationsinconsciousness意识改变Woundandskincare伤口与皮肤护理Prolongedimmobility长期卧床PsychosocialSupportptandfamily心理支持Ethicalconsiderationincriticalcarepractice道德观,ICU护士的职业疲惫（burnout）及哀伤失落,疲惫感及无力感是ICU护士离职的主因护理人员应检视自己对死亡的看法及观念，了解自己如何因应死亡及哀伤，及所需要的回馈与支持。,影响病危期医疗品质因素,医护人员著重在治疗疾病,治愈病童病危期的舒适及支持往往在急着救治生命时被忽略家属们认为选择临终治疗就等于放弃治疗,不愿意做此决定医护人员对个案病情及放弃治疗的矛盾反应,ICU的高科技挑战与管理,呼吸机：种类与模式输液泵监视器除颤仪心内、心外起搏器腹透,FromtheManufacturers,SmartBreathDeliveryInteractiveModeConfigurableSafetyUpgradability,HKQMH黎自强,FromtheUsers,ManagingthePatient/Ventilatorsystemislessdifficultwithanunderstandingofthefundamentalsofoperation,alarms,andcapabilities.,HKQMH黎自强,MechanicalVentilators,NegativepressureventilatorPositivepressureventilatorPressureventilatorHigh-frequencyventilator,WheretoStart?从何开始？,IPPV,SIMV,MMV,BIPAP,CPAP,SPONT,PCV,VCV,APRV,PLV,PS,ASB,ILV,PRVC,VAPS,PAV,HKQMH黎自强,Methods-InhaledNitricOxideTherapy一氧化氮吸入治疗,Concentration:(5-40)ppmMonitorNO2、MetHBIndications:-reactivePH/PHC-hypoxemiaafterGlennorFontanprocedure,PulseOximetry,ReflectsthearterialoxygensaturationofhemoglobinSaturationsof93%to99%arenormal,ArterialBloodGases,pH:7.357.45PaO2:80100mmHgPaCO2:3545mmHgHCO3:2226mmHgSaO2:9399%,OtherDiagnosticTests,ChestX-rayVentilation-perfusionscanPulmonaryangiogramPulmonaryfunctiontest(PFT)BronchoscopyThoracentesisSputumculture,ArtificialAirways,Nasopharyngeal/OropharyngealSizebyplacingdevicefromearlobetocornerofmouthEndotrachealtubeUncuffedtubesforchildrenyoungerthan10yearsofageLaryngomaskairway(LMA)Sizes1,2,3,4,and5Sizes3and4formostofthepopulationTracheostomies,气管插管发展以减少呼吸机相关肺炎为目的，减少会咽处分泌物聚集,ChestPTforIntubatedInfants插管婴儿胸部理疗,IssuesinVentilationmanagementforchildren儿童呼吸管理议题,ExtracorporealMembraneOxygenationECMO:TherapeuticeffectveryControversial,casedecreasingfrom1200in1990to700peryearin2000.体外膜肺使用ApplyMultimodetherapytotreatadultsandchildrenwithAcutehypoxiaresp.针对呼吸衰竭者使用多重呼吸模式,Bohn,2001Ped.ClinicN.Am,P.565,ECMOSupportinthePediatricCardiacPatient,降温处理减少耗氧Cooling,CoolingblanketCoretemperature:3436Preventshivering(mechanicalventilation,sedatives,musclerelaxants,nitroprusside)Indications:-tachycardia(SVT,JET)-mild-to-moderatehypotension,PacemakerTreatmentforAVBlock,Single-chamberLeadintheventricleDualchamberLeadintheatriumLeadintheventricle,ICDLead,ProximalCoil,DistalCoil,CRT/CHFdevicetoday,CRTICDFullyprogrammableCHFmonitoring,ChronicCareandRehabilitation(SOP)心脏ICU后康复I,Long-termFollow-upGeneralcardiaccare一般护理Patient/FamilyEducationCHFpatients心衰病人AdjustmentofdecongestivemedsMonitoringweight/NYHAclass/VO2AssessforcardiactransplantationDevicetherapy介入治疗护理EvaluationofdeviceAssessinterventionwithdevicetherapyPsychosocialsupport,ChronicCareandRehabilitation(SOP)心脏病人康复II,CardiacRehabilitation心脏康复Earlymobilizationofpatientafteracuteevent早期下床PsychosocialManagement-depression/anxiety缓解焦虑忧郁Pharmacotherapy药物辅助LipidloweringBPcontrolAntiplatelettherapyBeta-blockersAngiotensin-convertingenzymeinhibitors,KolbsExperientialLearningCycle,Experience,Reflection,Conceptualization,Experimentation,SimulationScenarios,Infectioncontrol:linesanddressingsAirwaymanagementArrhythmiainterpretationandmanagementHemodynamics/CardiacOutputNeuromonitoringIntubationPost-opAdmissionRolesinacodeandemergencyequipmentMegaCode,心脏重症病人康复与随访III,Monitorlong-termoutcomes测量长期效果MaintenanceofsmokingcessationLipidprofilesBodyMassIndex,Hemodialysis,Removesurea,creatinine,anduricacidRemovesexcesswaterRestoresthebodybuffersystemMaintainsappropriatelevelsofelectrolytes,重症护理发展关键(1),1.Prevention,detectionandtreatmetnofinfection:Avoidnosocomialinfectionfromvariouscathetersorventilator,gutdecontaminationandpreventionoforalpharyngealcolonization预防院内感染,重症护理发展关键(2),Newapproach“Inflammationcontrol”:byusing“immunotherapyorantibodytherapy”tolessenthedevelopmentofSIRS使用免疫治疗及抗体治疗处理炎症反应,重症护理发展关键(3),2.MaintenanceoftissueoxygenationtoavoidHypoperfusionandorganhypoxemia促进组织关注Lactate（乳酸值）levelindicatetheseverityofimpairedperfusionandlacticacidosisDecreaseoxygendemands:bysedation,paincontrol,mechanicalventilation,temp.control,andrest减少病人耗氧情况,重症护理发展关键(4),3.Nutritional/metabolicsupport营养及代谢上的支持:hypermetabolismresultsprofoundweightloss,andlossoforganfunction高代谢引发严重体重下降，丧失器官功能Enteralfeedingsmaylimitbacterialtranslocation肠道进食避免细菌移位,重症护理质量指标,管道及IV静脉护理皮肤护理、褥疮以家庭为中心的护理（家属与护理人员间的认知差距）意外拔ET管率、失败撤机率、气管切开率跌倒与使用约束带限制病人家属参与率、病人满意率（睡眠、协助、满足需求、环境）ICU院内感染率ICU再入室率（出ICU后2448小时）与住院天数,ICU的核心指标测量,呼吸机相关性肺炎病人体位头抬高30度/呼吸机上机天数呼吸机与胃压力性溃疡预防：预防天数/呼吸机使用天数深部静脉栓塞预防与呼吸机上机天数中央静脉血源感染种类/CVP种类天数ICU病人住院天数医院病人曾入院ICU死亡率JCAHO，2003,InterdisciplinaryPlanningforCare医疗梯队间计划照顾,采取统筹的过程以支持及协调病人整个、连续性的健康照顾。以病人为中心、连续性导向、以结果为目的的团队方式,ICUCaseManagementTool重症个案管理工具,ClinicalPathway临床路径Algorithm临床指引Practiceguideline实践指导Protocol方案Orderset医嘱群,ICUOutcomes-HOTSPUD,Headofbedelevated30degreeOralcareevery2hoursTurnptfromsidetobackandtosideevery2hoursSedationvacation-allowpttoawakeatleastonceper24h