有机磷中毒查房

1、Welcome for attending our English clinical round !,organophosphorus pesticide intoxication,June, 2009 Emergency Department, the First Affiliated Hospital of Wenzhou medical College,Step by step,CONTENTS,Learning key words together,Introduction of case history,Questions and answers,Nursing diagnosis

2、and interventions,Dynamic condition change,Key words related to Organophosphate Poisoning,organophosphorus pesticide poisoning 有机磷农药中毒,Poisoning 中毒 Acute 急性 cholinergic crisis 胆碱能危象 muscarinic signs and symptoms 毒蕈碱样症状 nicotinic signs and symptoms 烟碱样症状 symptoms of central nervous system 中枢神经症状,Key

3、words related to Organophosphate Poisoning,alliaceous 大蒜味 blushing 颜面潮红 decreased heart rate 心率减慢 pupil as needle tip 针尖样瞳孔 muscular spasms 肌肉抽搐 secrete of glandular organ 腺体分泌 saliva 流涎,Key words related to Organophosphate Poisoning,acetylcholine 乙酰胆碱 cholinesterase 胆碱酯酶 cholinesterase reactivator

4、胆碱酯酶复能剂 pralidoxime 解磷定 pyraldoxime methylchloride 氯磷定 pilocarpine 毛果云香碱 blood purification 血液净化,Key words related to Organophosphate Poisoning,rebound 反跳 intermediate syndrome 中间综合征 atropinization 阿托品化 atropine poisoning 阿托品中毒 dilatation of pupil 瞳孔扩大 dry mouth 口干,Key words related to Organophospha

5、te Poisoning,ECG Monitoring suction; aspiration oxygen inhale turn the body over tap the back chest Physical treatment urethral catheterization nasogastric tube insertion,心电监护 吸痰 氧气吸入 翻身 拍背 胸部物理疗法 导尿 留置胃管,Key words related to nursing intervention,Key words related to nursing intervention,tracheal in

6、tubation extubation gastrointestinal decompression gastric lavage emetic purgation diuresis mechanical ventilation,气管插管 拔管 胃肠减压 洗胃 催吐 导泻 利尿 机械通气,Key words related to nursing intervention,blood gas analysis mental nursing phlebotomize skin test blood transfusion intramuscular injection hypodermal inj

7、ection,血气分析 心理护理 静脉采血 皮试 输血 肌肉注射 皮下注射,Key words related to nursing intervention,intravenous infusion. skin care nasal feeding physical method cooling semi-reclining position temperature controller,静脉輸液 皮肤护理 鼻饲 物理降温 半卧位 控温仪,mind 神志 drowsiness 嗜睡 coma 昏迷 Delirium 谵妄 pupil 瞳孔 agitated 烦躁 self-care abil

8、ity 自理能力,Key words related to Symptom of nervous system,cough 咳嗽 rattle 罗音 wheezing rale 哮鸣音 pulmonary edema 肺水肿 breathing sound 呼吸音 expectoration 咳痰 respiratory paralysis 呼吸麻痹,Key words related to Symptom of respiratory system,abdominal pain 腹痛 diarrhea 腹泻 abdominal distension 腹胀 constipation 便秘 co

9、pracrasia 大便失禁 nausea 恶心 vomit 呕吐 gastric juice 胃液 appetite 食欲,Key words related to Symptom of digestive system,Key words related to Symptom of circulation system,Blood pressure 血压 hypertension 高血压 Hypotensive drug 降压药 arhythmia 心律失常 headache 头痛 systolic pressure 收缩压 Diastolic pressure 舒张压 pulse 脉搏,

10、Blood urine 血尿 proteinuria 蛋白尿 Urethral catheterization 留置导尿 oliguria 少尿 anuria 无尿 urorrhagia 多尿 aconuresis 小便失禁,Key words related to Symptom of urinary system,past history 既往史 present history 现病史 smoking 吸烟 drinking 饮酒 surgical history 手术史 family history 家族史 fall score 跌倒评分 education 学历,Key words r

11、elated to Social assessment,Name: Zhengsuijie Age:19 years old Sex: female Birthplace : Yueqing Occupation: student Admission Date: May，19th，2009 Discharge Date：June，3rd，2009,General information,Chief complaint,Suffering dyspnea for 3 days after take two kinds of organophosphate orally Diagnosis Acu

12、te Organophosphate Poisoning Intermediate Syndrome,Present illness 1,Three days ago , she drank 100 ml of two kinds of organophosphate . an hour later ,her parents found her unconscious, lip cyanosis and spittle outflow. She was rushed to the local hospital for emergency department. She became consc

13、ious after gastric lavage , establishing mechanical ventilation and using atropine and pralidoxime chloride.,Present illness 2,Two days ago ,she became unconscious again, following by a fever with the temperature of 39, spittle outflow and lower limbs tic. This morning ,she became coma and was sent

14、to our hospital, admitting in EICU department.,一般情况及现病史,郑碎洁,女,19岁,EICU 7床,住院号 542293 主诉：口服敌敌畏和马拉硫磷后呼吸困难3天 现病史：患者3天前口服敌敌畏和马拉硫磷混合农药100ml。1小时后被家人发现口吐白沫，神志模糊，口唇发绀，即送当地医院行气管插管，洗胃，并予阿托品，氯解磷定，呼吸机辅助通气等治疗后神志转清。2天前出现发热，体温39，神志模糊，大量口水，下肢抽动。今上午出现神志不清，呼之不应，为求进一步诊治，转我院。于2009-5-19收住EICU。,诊 断,急性重度有机磷中毒 中间期肌无力综合症,Ph

15、ysical examinations on admission,Physical examinations Psychiatric system and Social assessment,入院体检,生理评估 心理和社会系统评估,Physical examinations and assessment,T: 36.6, P: 82 bpm, R: 12 bpm, BP:100/70 mmHg,生命体征,体温36.6， 脉搏82次/分, 呼吸12次/分, 血压100/70mmHg,Nervous system,She was conscious but weary. The pupils we

16、re about 1.0 mm in diameter and light reflect was a little bit slow,神经系统,入院时,患者神志清，精神软，两瞳孔等大等圆，大小1.0mm ， 对光反射迟钝,Respiratory system,She had endo-tracheal intubation and mechanical ventilation. The breathing sound was thickening with sputum sound. Offer aspiration of sputum, the sputum was yellow and

17、glutinous. X-ray film was normal.,呼吸系统,经口气管插管接呼吸机辅助通气 两肺呼吸音粗，闻及痰鸣音。辅助吸痰，为少量黄色粘痰 胸片检查未见明显异常,Circulatory system,She was health without Heart trouble, high blood pressure, heart murmurs, or chest pain. Heart rate was 82 bpm. Electrocardiogram was normal,心血管循环系统,无诉胸痛，心律齐，未及杂音 心率82次/分 心电图显示正常窦性心律,Digesti

18、ve system,When we pushed our fingers deeply and steadily into her abdomen, then quickly released the pressure, we could not elicit pain and rebound tenderness. She had bad appetite and was given liquid diet through gastric tube. She took formed stool every 2-3 days. The type-B ultrasonic of the abdo

19、men was normal.,消化系统,腹软，无压痛及反跳痛，肝脾肋下未及 胃纳欠佳，予鼻饲流质 患者2-3天解大便一次，为少量黄色软便，成形 腹部B超未见明显异常,Urinary system,She was suffered catheterization, the urine was yellow and limpid.,泌尿系统,患者留置导尿，尿色黄，质清,Endocrine system,She was health without thyroid trouble or diabetes mellitus.,内分泌系统,患者无糖尿病，甲亢等基础疾病 血生化示血糖在正常范围,Musc

20、uloskeletal system,The muscle power of the upper limbs was band 4 and the lower ones was band 3. The muscle tone was normal.,运动系统,双上肢肌力4级，双下肢肌力3级。双下肢腓肠肌未见肌束颤动 肌张力正常,Hematologic system,Blood-RT showed WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012. She had no blood transfusions before.,血液系统,入院

21、时血常规示WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012 。 既往无输血史,Skin,Her skin was warm and dry . She had some skin eruption on her face, which was caused by the transfusion pre-hospital.,皮肤,全身皮肤温暖干燥 脸面部可见少许皮疹，家属诉是由外院输液后引起的,Psychiatric system and Social assessment,She was in storm since her admis

22、sion and didnt cooperate well with the treat. She was diffidence and liked watching Korean teleplay. It was the third year in senior high school for her, which pressed her a lot. She was a league member. She had two sisters.,Her parents worried a lot about her admission. They had no financial proble

23、m on this admission. She didnt understand her own condition very well and accepted the lie that she had fallen down from the 4th floor, which was told by her mother.,Psychiatric system and Social assessment,入院后，患者一直情绪较激动，不愿配合治疗。患者平时相对比较内向，喜欢看韩剧。患者是高三学生，学习压力较大。无宗教信仰，是团员。患者有一姐一妹，平时在家比较叛逆。入院后，家属比较担心预后，

24、住院没有经济负担压力。患者对住院原因不是很清楚，相信父母的从四楼掉下来的谎言。,心理社会评估,Lab examinations,Cholinesterase Was 234 U/L on her admission Urine-RT : normal Stool-RT : normal Blood-RT: WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt 304*1012 albumin 28.3g/L,实验室检查,入院时胆碱酯酶234U/L 大小便常规正常 血常规示WBC 12.3*109 , RBC4.2*1012 , Hb 112g/L , plt

25、 304*1012 白蛋白28.3 g/L,other examinations,X-ray film: normal Electrocardiogram : normal,辅助检查,X片:未见明显异常 心电图:窦性心律,Therapy process,EICU special nursing Liquid diet through gastric tube anti-inflammatory and fluid infusion Using atropine and pralidoxime chloride Had endo-tracheal intubation and mechanica

26、l ventilation She was in storm since her admission and didnt cooperate well with the treat. On May 26th, we removed the trachea tube ,the gastric tube and the indwelling Catheter. On May 27th ,she was transferred to Ward 25.,诊疗经过,入院后医嘱予EICU特护，鼻饲流质，补液、抗感染，阿托品、长托宁、氯解磷定等解毒药对症支持治疗。经口气管插管处予接呼吸机辅助通气，并于完善各

27、项辅助治疗。入院后，患者一直情绪教激动，不愿配合治疗。5-26予以拔除经口气管插管 ，胃管和导尿管。5-27 患者转25病区继续治疗,Therapy process,EICU special nursing Liquid diet through gastric tube anti-inflammatory and fluid infusion Using atropine and pralidoxime chloride Had endo-tracheal intubation and mechanical ventilation She was in storm since her adm

28、ission and didnt cooperate well with the treat. On May 26th, we removed the trachea tube ,the gastric tube and the indwelling Catheter. On May 27th ,she was transferred to Ward 25.,main nursing diagnosis,1. Inability to Sustain Spontaneous Ventilation 2. Ineffective Airway Clearance 3. impaired Verb

29、al Communication 4. Risk for Selfinflicted injury 5. Activity Intolerance 6. Risk for Infection 7. Risk for ImPaired Skin Integrity 8. Altered Nutrition:less Than Body Requirements 9. Altered Urinary Elimination,主要的护理问题,1.不能维持自主呼吸 2.清理呼吸道无效 3.语言沟通障碍 4. 有受伤的危险 5. 活动无耐力 6. 有感染的危险 7.有皮肤完整性受损的危险 8. 营养失调

30、：低于机体需要量 9. 排尿异常,Nursing intervention,Inability to Sustain Spontaneous Ventilation)/(Ineffective Airway Clearance) 1) observe vital signs, assess the symptom and physical sign of the respiratory system and record it.if it is abnormal ,report to the doctor in time. 2) do physiotherapy of chest, keep

31、the airway open, inhaust sputum and observe the color , quantity ,quality of the sputum .,Nursing intervention,3) fix the tracheal intubation well, mechanical ventilation, monitor the pressure of the aerocyst timely, observe blood gas analysis to adjust the parameter in time. 4)use aminophylline to

32、relieve cramp of the respiratory tract and Inflammatory reaction. 5) when she was annoyed and mental nursing was ineffective; gave her sedatives to calm down under supervision of a physician. 6) take sputum culture to help the doctor choose suitable antibiotics. 7) try our best to prevent Ventilator

33、-associated Pneumonia.,护理措施,不能维持自主呼吸 清理呼吸道无效 1)监测生命体征，准确评估呼吸系统的症状体征并做好记录，发现异常及时报告医生. 2)做好胸部物理疗法，保持呼吸道通畅，按需吸痰，观察痰液的量、色、性质，必要时按医嘱给予雾化，做好气道护理。 3)妥善固定气管插管，经口气管插管接呼吸机辅助通气，定时监测气囊压力，做好呼吸机相关护理，及时根据血气分析结果调整呼吸机参数。,4)遵医嘱使用氨茶碱等药物减轻气道痉挛及炎症反应. 5) 病人烦躁、心理护理无效时遵医嘱给予镇静药物保证患者休息，减轻人机对抗。 6)按医嘱及时留取痰培养，协助医生选择合适的抗生素. 7)尽量

34、预防呼吸机相关性肺炎的发生.,护理措施,Nursing intervention,impaired Verbal Communication eliminate her scruple, tell her that anepia is transient due to the assisted ventilation . communicate by writing board; gesture , booklet ,so as to satisfy her needs. 3) encourage her to communicate in different ways.,Drink,Turn

35、 over,Write,Urine,stool,语言沟通障碍 1)消除患者顾虑，解释由人工气道造成的语言交流障碍是暂时的 . 2)使用写字板，手势、图册等及时与患者沟通满足其需要 . 3)鼓励患者使用多种方式沟通 .,护理措施,Nursing intervention,Risk for Selfinflicted injury 1) observe the change of her feeling and report to every shift if it was abnormal. use mental nursing to get her partner treatment . 2)

36、 get the message about the aim of her suicide,do mental nursing to aim directly at cause of her suicide to get rid of pessimistic emotion. 3) encourage family member to do mental nursing,her mother keep her company more time .,Nursing intervention,4) medical staff listen to her chief complaint patie

37、ntly,know her need ,to satisfy her need as far as possible if it is not violated to the therapeutic principle. 5) when Dysphoria was happened,make sure she was safe ,use sedatives or stop atropine to make her calm down. 6) fix all the tubes especially the tracheal intubation well to prevent unexpect

38、ed extubation. 7) use restraint strap when it is needed,observe blood circulation of the acra.,有受伤的危险 1)观察患者情绪变化，发现异常做好交接班，加强心理疏导使其配合治疗与护理 . 2)仔细了解病人自服农药的动机，针对患者自杀原因做好心理护理，使其摆脱悲观消极情绪. 3)争取家属配合一起做好心理护理,母亲陪伴的时间较多。 4) 医务人员耐心听取患者主诉，及时了解她的需求，在不违反治疗原则的基础上尽量给予满足. 5)病人烦躁不安时做好安全护理防止坠床等，必要时尊医嘱使用镇静药物或停止阿托品治疗。

39、6)妥善固定各管道尤其是气管插管，防止意外拔管. 7)必要时使用肢体约束带，注意观察肢端血运。,护理措施,Nursing intervention,Activity Intolerance 1) assess the recovery of myodynamia. 2) help her move in bed ,help her do myodynamia of both lower extremities exercise. 3) observe duration of amyostasia. 4) observe cholinesterase under supervision of a

40、 physician.,活动无耐力 1)评估患者肌力恢复情况. 2)协助患者翻身床上活动，指导患者做好双下肢功能锻炼. 3) 观察肌震颤持续时间. 4)按医嘱监测胆碱酯酶.,护理措施,Nursing intervention,Risk for Infection 1) emphasis the hand hygiene and Sterilization and insulation of the ward . 2) aseptic processing when inhaust sputum and transfusion. 3) oral cavity and perineum nursi

41、ng. 4）observe the change of body temperatur and hemogram. 5) give antibiotics under supervision of a physician and observe the effect.,有感染的危险 1)加强操作前后洗手，做好病室消毒隔离工作. 2)吸痰、输液等严格无菌操作. 3)做好口腔及会阴护理. 4)监测体温及血象变化. 5)遵医嘱使用抗生素，观察药物疗效.,护理措施,Nursing intervention,Risk for ImPaired Skin Integrity) 1) look for th

42、e origin of skin rash, observe its distribution and quality . 2) tell her not to scratch. 3) Emphasis basic nursing keep the skin clean . 4) turn over timely,keep the bed tidy. 5) use the topica as calamine lotion under supervision of a physician).,有皮肤完整性受损的危险 1)协助医生查找皮疹的原因，观察皮疹的分布范围、性质等 . 2)指导患者勿搔抓

43、皮肤. 3)加强基础护理，做好全身皮肤的清洁. 4)定时翻身，保持床单清洁平整 . 5) 遵医嘱正确使用炉甘石洗剂等外用药物 .,护理措施,Nursing intervention,Altered Nutrition： less Than Body Requirements assess gastric retention, bowel sound, whether there is stomachache or abdominal distention or not, observe defecation ,nasol feeding under supervision of a physi

44、cian.,营养失调：低于机体需要量 评估胃潴留、肠鸣音情况，注意患者有无腹痛、腹胀的主诉，观察排便情况，按医嘱给予鼻饲流质，保证能量供应。,护理措施,Nursing intervention,Altered Urinary Elimination 1) fix the urethral catheter to femoribus internus . 2) perinaeum nursing twice every day . 3) observe urine volume,colore,and quality,if it was abnormal ,report the doctor to

45、 handle with timely. 4)do urine culture under supervision of a physician.,排尿异常 1)妥善固定导尿管于大腿内侧. 2)每日2次会阴护理. 3)观察尿量，色，性质，发现异常及时报告医生处理. 4)按医嘱做好尿培养.,护理措施,Dynamic condition change May 19th,she was hospitalized into 7 bed in EICU at 18:12. Special care was ordered, gastric tube and nasol feeding was given

46、. She was assisted by mechanical ventilator through oral trachea cannula. Respiratory frequency was set to 12bpm. It was required to record the volume of input and output during the 24h.,Dynamic condition change May 19th,We used Tazocin for anti-infection. 1 milligram Prolonged action atropine were

47、used every 12 hours as nitramuscular injection. 2.5 milligram pyraloxime chloride were intervenous drop infused every 6 hours. 2.5 aminofilina were kept in 5 milliliter every hour by Micropump. The patient was agitated all the time. So we had to restrain her limbs. At 22 oclock there was a little sw

48、eaty on her chest. Sweating decreased after 1 milligram atropin given.,Dynamic condition change May 20th,The ultrasound of abdomen showed normal, so did X-ray of chest.The liver function results showed that the total protein 51.8g / L , albumin 28.3 g / L ; the rash on the face of the patient increa

49、sed, and the calamine lotion was used for external using. At about 6 oclock ,it was sweaty on the forehead of the patient, after being given 1mg of atropine, the patient became very irritable.,At 9 oclock,the doctor ordered to stop using the Penehyclidine,but the patient still kept agitated all the

50、night,she pulled out the gastric tube herself at about 1 oclock,and the oral trachea cannula was pulled out by herself at 6 oclock.With the help of hypnotic ,we intubated again as soon as possible.,Dynamic condition change May 20th,Dynamic condition change May 21th,The patient was relative quiet, sh

51、e can go with our treatment, and the hypnotic medication was stopped,but she was still very weak and sleepy. Some rash appeared on the arm besides the face. The Routine blood test showed WBC 12.9, RBC3.7 , Hb 109g / L, plt 382.,Dynamic condition change May 22th,The blood cholinesterase was 1153U / L

52、. 2.5 milligram pyraloxime chloride were changed to every 8 hours by intervenous drop infusion.The rash spread to the back,we still gave her the external medication.But it was no use.,Dynamic condition change May 23th,The Dermatologist was invited.The doctor advised that we should stop using Tazocin

53、. So Fortum took place for anti-infection.Blood gas analysis showed PH 7.421, PO2 128.7mmHg, PCO2 38.2mmHg, Respiratory frequency was adjust to 10bpm.,Dynamic condition change May 24th,The red rash was resolving.she can partner our treatment and communicate with us well through the writing board. Bl

54、ood gas analysis showed PH 7.40, PO2 137.8mmHg, PCO2 33.6mmHg, Respiratory frequency was adjust to 8bpm,Dynamic condition change May 25th,The blood cholinesterase was 2080 U / L. Blood gas analysis showed PH 7.37 ,PO2 159.3mmHg, PCO2 36.3mmHg, Respiratory frequency was adjust to 6bpm. 2.5 milligram

55、pyraloxime chloride were changed to every 12 hours by intervenous drop infusion. Aminofilina were stopped.We planned to pull out the oral trachea cannula the same day, but the muscle strength of the patient were lower,so we decided to delay the plan of extubation. The patient was a bit emotional aga

56、in. She refused our treatment and the effect of the psychological nursing was poor, we had to restrain her limbs.,Dynamic condition change May 26th,Blood gas analysis showed PH 7.415, PO2 157.4mmHg, PCO2 38mmHg, routine blood test showed WBC 15.2 X 109, RBC3.9 X 1012, Hb 109g / L, plt 352 X 1012.The

57、 doctor orderd to remove the oral tracheal cannula,and 10L/min oxygen through the mask was intaken, the breath was stable.After remove the gastric tube, she can take semi-flow diet by herself without bucking. She can urinate herself without the catheter. The rash all over the body disappeared. Her f

58、eeling was stable, she wished to stay with her family member and feel sorry for her bad behavior.,Dynamic condition change,On May 27th, she was transfered to ward 25 for the further treatment. On May 28th, the blood of cholinesterase showed normal. On June 3th,the chest CT showed no significant abno

59、rmal. The patient discharged.,5月19日18:12患者收住EICU7床，医嘱予EICU特护，鼻饲流质，经口气管插管处予接呼吸机辅助通气。呼吸次数设为12次/分。记24小时出入量，予特治星抗感染，长托宁1mg 肌注q12h，氯解磷定2.5 q6h 静滴，氨茶碱0.25 微泵5ml/L维持。患者一直比较烦躁，予双上肢约束。22点左右患者胸部有少许出汗，予阿托品1mg 静推后，出汗减少。,动态病情变化,动态病情变化,5月20日 腹部B超结果正常。胸片结果正常。肝功能结果示 总蛋白51.8g/L , 白蛋白28.3 g/L 患者脸面部皮疹有增多迹象，医嘱于炉甘石洗剂外涂 18：00患者额部出汗较多，予阿托品1mg 静推。 患者一直较烦躁，21：00 医嘱于停长期医嘱长托宁肌注 夜班患者仍较烦躁， 1：00自行拔出胃管，6：00自行拔除经口气管插管，予安定静推，异丙酚镇静后，重新插管,动态病情变化,5月21日 患者相对较安静，