体格检查头部检查课件

汇报人：xxx20xx-03-15体格检查头部检查ppt课件目录头部检查概述头皮与颅骨检查面部器官检查颈部检查脑部神经检查头部常见疾病与体征01头部检查概述Part评估头部形态、结构以及功能状况，发现潜在疾病或异常情况。目的头部检查是体格检查的重要组成部分，对于诊断颅内疾病、神经系统疾病等具有重要意义。意义头部检查目的与意义询问病史→观察头颅形态→检查头皮及颅骨→检查眼、耳、鼻、口等器官→进行神经系统检查。流程包括视诊、触诊、叩诊、听诊等，必要时需借助辅助检查设备如CT、MRI等。方法头部检查流程与方法以下附赠各项管理制度英文版（不需要可删）急救药品、器材管理制度:1.Rescuedrugsandequipmentshouldbe"fivefixed"(fixedquantityandvariety,designatedplacement,designatedpersonstorage,regulardisinfectionandsterilization,regularinspectionandmaintenance)and"twotimely"(timelyinspectionandmaintenance,timelyreceiptandsupplementation).Theitemisclearlymarkedandcannotbeusedarbitrarily.2.Thenecessaryrescueequipmentiscomplete,ingoodperformance,andinstandbycondition.3.Therescuedrugsarecomplete,withcleardruglabelsandnodiscoloration,deterioration,expiration,ordamage.Theyshouldbeplacedandusedintheorderofdrugexpirationdates(fromrighttoleft).4.Emergencydrugsanditemsforeachdepartment'srescuevehicleshallbeuniformlyequippedaccordingtorequirements.Specializedemergencydrugsanditemsmustbereviewedandapprovedbythedepartmentdirectortodeterminethetype,quantity,specifications,anddosagetobeequipped.Rescuevehiclesmustbeplacedindesignatedlocationsandmanagedbydesignatedpersonneltoensuresafetyandeaseofuse.5.Afterusingrescuedrugsandequipment,theyshouldbefullyreplenishedwithin24hours.Iftheycannotbereplenishedduetospecialreasons,theyshouldbenotedonthehandoverregistrationformandreportedtotheheadnurseforcoordinationandresolutiontoensuretimelyuseduringpatientrescue.6.Thereisaregistrationbookfortheprovisionofdrugsandequipment.Ensureconsistencybetweenaccountsandmaterials,andhandoverbetweenshifts.7.Managementofsealedrescuevehicles:Beforesealing,theheadnurse(ornurseincharge)andanothernurseshallcountthedrugsandequipmentaccordingtotheregistrationbookofdrugandequipmentequipment,verifytheiraccuracy,andsealthemwithaseal.Twopeopleshallsignandfillinthesealingtime.Nurseschecktheconditionofthesealsoncepershiftandcompletethehandover.Theresponsiblenursescheckonceaweek,andtheheadnurseandresponsiblenursesopenthesealsandinspectthedrugsandequipmentintheambulanceonceamonth,withrecordskept.8.Nonsealedrescuevehiclemanagement:Eachshiftshallcountthedrugsandequipmentaccordingtotheregistrationbookandcompletethehandover.Theresponsiblenurseshallinspectonceaweek,andtheheadnurseshallinspectonceeverytwoweeksandkeeprecords,ensuringthattheaccountsmatchthematerials.护理文书书写制度:

1.Nursingstaffstrictlyfollowthelatestrequirementswhenwritingnursingmedicalrecords.2.Thecontentofnursingrecordsshouldbeobjective,truthful,accurate,timely,complete,andstandardized.3.Allnursingdocumentsshouldbewrittenwithablueblackorcarboninkpen.4.AllnursingdocumentsshouldbewritteninArabicnumeralsfordateandtime,withdatesinyears,months,anddays,usinga24-hoursystem,specifictominutes.5.WritingshoulduseChinese,medicalterminology,andcommonlyusedforeignlanguageabbreviations;Completerecorditems;Thetextisneat,thehandwritingisclear,andthelayoutisclean;Accurateexpression,fluentsentences,simpleandconcise:correctformatandpunctuation,notypos.6.Whenerrorsoccurduringthewritingprocess,doublelinethemonthewrongwords,keeptheoriginalrecordclearanddistinguishable,signthemodifier,indicatethemodificationtime,continuetowritethecorrectcontent,anddonotusescraping,sticking,paintingorothermethodstocoveruporremovetheoriginalhandwriting.Eachpageshouldbemodifiednomorethantwotimes,otherwisetheoriginalrecorderwillpromptlycopyagain(exceptformodificationsmadebysuperiors).7.Nursingrecordswrittenbyinternnurses,probationarynurses,orunregisterednursesshouldbereviewedandsignedbynurseswithlegalprofessionalqualificationsinthismedicalinstitution.8.Furthertrainingnursescanonlywritenursingdocumentsafterbeingrecognizedbythemedicalinstitutionreceivingthetrainingfortheirworkability.9.Superiornursingstaffhavetheresponsibilitytoreviewandmodifythewrittenrecordsofsubordinatenursingstaff.Whenmakingmodifications,reddoublelinesshouldbeusedtomarkerrors,writethemodifiedcontent,signandindicatethemodificationtime.10.Temperaturerecords,medicalorders,patientcarerecords,andsurgicalinventoryrecordsshouldbearchivedontime.头部检查注意事项环境安静、光线适宜确保检查环境安静，光线适宜，有利于准确观察头部情况。与患者保持良好沟通在检查过程中与患者保持良好沟通，解释检查目的和方法，消除患者紧张情绪。尊重患者隐私在检查过程中，应尊重患者隐私，保护患者个人信息。注意检查顺序按照一定顺序进行检查，避免遗漏重要部位或器官。02头皮与颅骨检查Part观察头皮颜色、有无肿胀、瘢痕、肿物或异常分泌物等。检查头皮的质地、压痛、包块等，注意有无波动感或颅骨缺损。头皮外观与触诊触诊头皮外观颅骨形态观察颅骨的轮廓、大小、形状及对称性，判断有无颅骨畸形。压痛检查用适当的力量按压颅骨各部位，询问患者有无疼痛感，以判断颅骨及颅内病变的可能性。颅骨形态与压痛检查颅缝检查触摸颅缝的闭合情况，判断有无颅缝早闭或异常增宽。囟门检查对于婴幼儿，观察前囟和后囟的闭合情况、大小、张力等，以评估颅内压及脑发育状况。颅缝与囟门检查03面部器官检查Part1423眼部检查眼睑观察眼睑有无水肿、下垂，结膜有无充血、水肿。眼球检查眼球运动是否自如，有无凸出或凹陷，巩膜有无黄染。瞳孔观察瞳孔大小、形态，对光反射是否灵敏。视力检查视力是否正常，有无近视、远视等屈光不正。耳部检查耳廓观察耳廓有无畸形、红肿、结节。外耳道检查外耳道有无分泌物、异物，鼓膜是否完整。听力通过对话或音叉试验初步判断听力是否正常。STEP01STEP02STEP03鼻部检查鼻外观观察呼吸时鼻翼是否煽动，判断呼吸频率和深度。鼻翼煽动鼻腔检查鼻腔是否通畅，有无分泌物、异物或出血。观察鼻部皮肤颜色、有无肿胀、畸形。口唇观察口唇颜色、有无干裂、疱疹。牙齿检查牙齿排列是否整齐，有无龋齿、残根、缺牙。牙龈观察牙龈颜色、有无肿胀、出血。口腔黏膜检查口腔黏膜是否完整，有无溃疡、白斑等异常表现。舌观察舌体大小、形态，舌苔颜色、厚薄，舌质颜色，伸舌是否居中，有无震颤。咽喉检查咽喉部有无充血、水肿、分泌物，扁桃体大小、形态、有无化脓等。口腔检查04颈部检查Part颈部外观与触诊颈部外观观察颈部是否对称，有无肿块、瘢痕、瘘管等异常表现。颈部触诊通过触摸检查颈部肌肉、淋巴结、甲状腺等结构是否正常，有无压痛、结节等异常体征。评估颈部前屈、后伸、侧屈及旋转等活动范围是否正常。活动范围观察颈部活动时是否平稳、协调，有无疼痛、僵硬等异常表现。活动质量颈部活动度检查VS通过触诊和听诊检查颈部动脉、静脉等血管是否正常，有无异常搏动、杂音等体征。神经检查评估颈部神经支配区域的感觉、运动功能是否正常，有无麻木、疼痛、肌力减退等异常表现。血管检查颈部血管与神经检查05脑部神经检查Part按功能可分为感觉神经、运动神经和混合神经三类。常见损伤原因包括外伤、肿瘤、炎症等，损伤后可出现相应神经功能障碍。脑神经共有12对，左右成对发出，主要分布于头面部，其中迷走神经还分布到胸腹腔内脏器官。12对脑神经概述注意事项避免使用刺激性较强的溶液，如醋、酒精等。检查方法让患者闭目并用手指堵住一侧鼻孔，然后用有气味但无刺激性的溶液（如松节油、香水等）置于患者另一侧鼻孔下，让其说出所闻到的气味。异常表现嗅神经受损时，患者可出现嗅觉减退或丧失。嗅神经检查观察患者眼球运动及瞳孔变化，检查视力及视野范围。检查方法注意事项异常表现在检查视力时，应让患者遮挡一侧眼睛，用另一侧眼睛注视目标。视神经受损时，患者可出现视力下降、视野缺损等；视交叉受损时，可出现双眼视野颞侧偏盲。030201视神经与视交叉检查动眼神经、滑车神经、展神经检查位听神经检查舌咽神经、迷走神经检查副