脑出血个案护理查房We have many PowerPoint templates that has been specifically designed to help anyone that is stepping into the world of PowerPoint for the very first time.Intelligent medical treatment汇报:xxx
目录01概述print the presentation and make it into a wider field02护理评估print the presentation and make it into a wider field03护理诊断print the presentation and make it into a wider field04护理措施print the presentation and make it into a wider field
PART 01We have many PowerPoint templates that has been specifically designed to help anyone that is stepping into the world of PowerPoint for the very first time.概 述
脑出血(cerebral heamorrhage)是指非外伤性脑实质内出血,常形成大小不等的脑内血肿,有时穿破脑实质形成继发性脑室内及(或)蛛网膜下腔积血.脑出血发生于大脑半球者占80%,在脑干或小脑者约占20%。脑出血好发部位多在基底节、内囊和丘脑附近。脑出血的致残率和病死率均较高,脑疝形成是导致病人死亡的主要原因。护理概述
临床表现:突然头痛、头晕、恶心、呕吐,偏瘫,失语,意识障碍,大小便失禁等。诱因:排除外伤性脑出血,其中高血压是最常见的诱因,寒冷,炎热季节或乍冷乍热,气候变化剧烈之季多发,暴怒兴奋,重体力劳作也是其主要诱因。护理概述
PART 02We have many PowerPoint templates that has been specifically designed to help anyone that is stepping into the world of PowerPoint for the very first time.护理评估
无诱因下出现头晕,口齿不清,半右侧肢体乏力,呕吐胃内容物一次,无大小便失禁,无抽搐,无神志改变既往有高血压病史20余年,未遵医嘱服用降压药,喜欢食用腌制的咸菜类食品。护理评估
入抢救室治疗,患者神志清,精神萎,双侧瞳孔等大等圆直径约1.5mm,对光反射存在,右上肢肌力3级,右下肢肌力3级,脑膜刺激征呈阳性。Bp220/130mmHg,HR80次/分,SPO2100%,血常规白细胞8.2*109/L,血红蛋白139g/L,血小板194*109/L,电解质K:3.88mmoL/L,凝血功能凝血酶原时间13.4s,凝血酶时间28.6s,血糖6.6 mmoL/L。头颅CT示左侧基底节区脑出血复查头颅CT结果示出血量没有增加。转入神经内科住院治疗。护理评估
病人面对突然发生的感觉障碍与肢体瘫痪的残酷现实以及担心预后,表现为情绪沮丧、悲观绝望,对自己生活的能力和生存的价值丧失信心,且因失语或构音困难而不能表达情感,使病人内心苦闷,心情急躁。严重脑出血病人神志不清、病情危重,家属多处于紧张、恐惧的状态。护理评估
PART 03We have many PowerPoint templates that has been specifically designed to help anyone that is stepping into the world of PowerPoint for the very first time.护理诊断
护理诊断——呼吸道 清理无效与肺功能下降、无法咳嗽有关舒适的改变:头痛,与出血性脑血管病致颅内压增高有关 活动无耐力:与脑出血使锥体束受损导致肢体活动乏力有关皮肤完整性受损:与营养不良及机体抵抗力下降等因素有关营养失调,低于机体需要量: 与禁食和呕吐有关 知识缺乏(饮食、疾病、用药等):与信息来源受限有关有感染的危险:与绝对卧床有关;潜在并发症——脑疝;上消化道出血
护理措施患者取平卧头偏向一侧及时清除口鼻分泌物和呕吐物,随时给病人吸痰、翻身拍背,做好口腔护理,以防误吸对昏迷较深病人,口腔放置口咽通气管或用舌钳将舌头外拉,以防后坠造成窒息准备好气管切开或气管插管包,必要时配合医生进行气管切开或气管插管,做好相应的术后护理清理呼吸道无效
准备好气管切开或气管插管包,必要时配合医生进行气管切开或气管插管,做好相应的术后护理对昏迷较深病人,口腔放置口咽通气管或用舌钳将舌头外拉,以防后坠造成窒息患者取平卧头偏向一侧及时清除口鼻分泌物和呕吐物,随时给病人吸痰、翻身拍背,做好口腔护理,以防误吸活动无耐力
护理措施——皮肤完整性受损护理目标:患者皮肤完好,无压疮。 护理措施:每2~3小时协助翻身一次,避免骶尾部继续受压。 保持床单位平整、清洁、干燥、无渣屑,以免刺激皮肤。慎用热水袋,防止烫伤。按摩骨隆突处皮肤,以改善血液循环,预防压疮。
PART 04We have many PowerPoint templates that has been specifically designed to help anyone that is stepping into the world of PowerPoint for the very first time.护理措施
2护理措施 舒适的改变:头痛护理目标:病人头痛减轻或消失 提供安静、舒适、光线柔和的环境,安慰病人,耐心向病人解释头痛的原因,消除其紧张恐惧心理,鼓励病人树立战胜疾病的信心控制脑水肿、降低颅内压:病人须卧床,头抬高15°-30°,吸氧,头部放置冰袋甘露醇等脱水剂可快速有效降低颅内压。限制每天液体摄入量(一般禁食病人以尿量加500ml液体为宜
急性脑出血病人在发病1~2小时内禁食如生命体征平稳、无颅内压增高及上消化道出血,
297脑出血个案护理查房.pptx