院区-烧伤科二十病区

常州市第二NURSINGWARDROUNDOFABURNPATIENT一例烧 的护理查TheHospital-WideEnglishNursingWardRoundTHEDEPT.OF德技双 至Teammembers团队成Liu Dept.of Zhou FuZhenYuTangQi

Dept.ofCardiologyDept.ofTraumaticBengbuMedicalCollege蚌埠医学德技双 至MainContents主要内BASICKNOWLEDGEOF疾病基本知MEDICAL病NURSINGDIAGNOSISESAND护理诊断及措DISCHARGE出院指德技双 至MainContents主要内请周微为我们介绍疾病相关知德技双 至MainContents主要内BASICKNOWLEDGEOF疾病基本知MEDICAL病NURSINGDIAGNOSISESAND护理诊断及措DISCHARGE出院指德技双 至BasicKnowledge基本知Burn:Itgenerallyrefersthatthe(includinghotliquid, ,hotgas,fire,electricity,chemicalsandradiation,hotmetalliquidorsolid...)leadstotissuedamage.Itmainlyreferstothedamageoftheskinorthemucousmembrane,forseriousinjuryandotherorganizationsaswell.Theburnscausedbyhotliquidaretermedasthethermaldamageof

德技双 至BasicBurnarea：theChineseRuleof烧伤面积 中国新九分德技双 至335657131313

Basic (doublehandsdoubleforearmdoubleupperarm) doublefeet (frontbodybackbody Adultfemale'ship,doublefeetbothare双手双前臂双上臂臀部双足小腿大腿前躯干后躯干部 至BasicFirst-degreeburnisthelightest.Itusuallydamagetheskinstratumcor transparentlayer,granularlayer. 德技双 至BasicSuperficialseconddegreeburnincludetheentireepidermis,untilthegerminallayer,ordamagethedermalpapillalayer.德技双 至BasicDeepseconddegreeburnincludethepapillarydermisfollowingtheinjury,butthereisstillapartofthedermis. 德技双 至BasicThirddegreeburnincludefull-thicknessskindamage,epidermis,dermisanditsaccessoriesallhavebeendestroyed.德技双 至BasicFourthdegreeburndamagemuscleandevenbone,internalorgans,etc.德技双 至BasicDeterminationofburn 表皮真肌肉、肌腱、筋膜德技双 至Gradingofburn烧伤分Gradingofburndegreein1970NationalBurnMildburnThetotalarealessthan10%ofⅡdegreeModerateburnThetotalareaof11%-30%ordegreeburnareaunder轻度总面积10中度总面积11%-30%或Ⅲ度烧伤面积9德技双 至BasicGradingofburndegreein1970NationalBurnSevereburnThetotalareain31%-50%orⅢdegreeburnarea10%-19%orburnarealessthan31%，Butthereisoneofthefollowingsituations:(1)Wholebodyorseverecaseshaveshock(2)compoundinjury(severetrauma,defense,radiationinjury,chemicalpoisoning,etc.)(3)modera ysevererespiratorytractburn(respiratoryspreadbelowthethroat)重度总面积在31%-50%或Ⅲ度烧伤面积10%-19%或烧伤面积 呼吸道烧伤（呼吸道波及喉以下者德技双 至BasicGradingofburndegreein1970NationalBurnExtremelysevereThetotalareaof50%ormore,orⅢdegreeburnareaof20%andabove,orwithserious

44.特重烧伤德技双 至BasicBurnsfirstaid Mildburn:wash--takeoff--immerse--cover-- Severeburn:quicklyoutofheat,savelives,preventshock,protectsurfaceofburn,rapid

德技双 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSISESANDDISCHARGE德技双 至GeneralInformationBednumberAdmissionNumber

德技双 至GeneralDateofAdmission:2015-08-11Chiefcomplaint:multiplebodyhotoilburnswithpainforhalfanhourbodyhotoilburns,Ⅱ-Ⅲdegree,60%burnarea

度60%德技双 至General德技双 至DiseaseHistory疾病Presenthistory:InAugust11,around09:00,thepatientwasburnedbyhotoilonthebody,limbsandhips,feelingwoundpainwithagreatnumberofblistersformed,partialepidermalshedding.Aftertreatedwithcoldwaterwashing,thepatientwassenttoourhospitalimmedia Pasthistory:healthstatewas

现病史：患者8月既往史德技双 至一般情况一般情况TPRBPTPRBP德技双 至PhysicalSpecialistThebody,limbs,andhipswereburnedwithwoundswelling.Burnedskinhasdifferentdimensionalblisters,partialexfoliation,itwasredandwhiteinbasal,exudating.

肢和烫伤，创面德技双 至Laboratory 检Positive Tip:irritablyimpairedliverfunction,nootherabnormalcondition

γ-谷氨酰转移 乳酸脱氢 德技双馨 至TreatmentPlan治疗计系统的治疗包括：抗休克，抗 Systemictreatmentincludinganti-shock,anti-infection,improvingmicrocirculation，improvingthecellmetabolism，protectingthekidney，preventingtheoccurrenceofstressulcerandblood德技双 至TreatmentPlan重症监护、心24小时进出量，监测中心静脉压，患肢抬高，注意末intensecare,electrocardiogrammonitoring,bloodoxygensaturationmonitoring,recordingurinevolumeofperhourand24hours’intakeandouttakevolume,raisingtheaffectedlimbs,observingpatients’peripheralblood德技双 至TreatmentProcedure治疗08- 08- 09-Gothroughtheshock

Rotatingbed

翻身床治 出院指德技双 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSESAND护理诊断及措DISCHARGE德技双 至2015-08-12,TangGuirongwentthroughfirst24hinourburnsdepartment.Thepatientisinacuteshockstageatthistime，atthisstage,generalnursingdiagnosesandmeasuresasfollows:年月日，唐桂荣入我科第一个24小时，患者此德技双馨至Nursing Fluidvolumedeficitrelatedtolargeamountsofwoundexudate

护理诊体液不足与大量液体渗出有 relatedtoskindamage,dressingchangeAnxietyrelatedtosuddentrauma

焦

与皮肤受损与突 有 Self-caredeficitrelatedtobeingconfinedtobed,

自理缺陷与卧床 有德技双 至目标:患者生措施

Goal：thepatientwithstablevitalToevaluatepatient’sburnareaanddepth,toestimatevolumeofthewoundexudate,tocalculatetheamountofrehydrationcorrectlyWithin72hoursafterinjury,toobservetheurineoutputperhour,color,proportionofurineandrecordcarefully,accordingtotheamountofurine,toadjusttherehydrationrate德技双 至护理措施输入晶体、胶体,保水电解质平衡

NursingObservethepatient'sconsciousnessandtheexpression,skin,mucousmembrane,peripheralbloodcirculation.Observepatient'svitalsignsandcentralvenouspressureandrecordInputcrystal,colloidreasonably,keepthebalanceofwaterandelectrolyteinaccordancewithdoctor’s准确记录24小时 1.6Record24hours’intakeandouttake 德技双 至观察、评估、记

Goal：thepatientcantoleratethe2.1Observe，estimate，andrecordthenatureanddegreeof疼痛性质、程度、时间pain, 伴随

护理2.2Conductnursing避免不良的

carefullyandavoidbad gesicdrugsinaccordancewiththedoctor‘sadviceandobserveitsclinicaleffect德技双 至

Adjustcomfortablepostures,avoidlocalcompression

Explainthecauseofthepaintothepatient,withsymptomsandpreventivemeasuresCarryoutpsychologicalguidance,eliminatepsychologicalfactors德技双 至措施充分调动的积极性，对的焦虑

Goal：Thepatient'sanxietylightensEvaluate degree warmandcomfortablehospitalenvironmentFullyarousepatients’enthusiasm,understandpatients’anxiety德技双 至3.4向患者及家属

Introducethepatientandfamilywithmethodsofburntreatment,howtotakecareandprognosis,andemphasizetheimportanceoffacingtherealityandclosecooperationwithdoctorsandnursesIntroducesuccessful

confidence ethe德技双 至措施

Goal：NecessaryneedscanbemetduringlyinginbedEvaluatepatients’self-care协助生活护理，4.2Assistdailylife,provide腔清洁

helpin4.3Oralcaretwotimesaday,keepmouthclean，avoidcomplications发症的发 德技双 至EnglishNursingWardRoundFirstActNursesondutyareconductingnursingwardroundforthefirsttime......德技双 至EnglishNursingWardRoundFirstAct德技双 至Situational P:HiNb:HowdoyoufeelP:Iamwellnow,butalwaysthirstyand德技双 至SituationalNa:Ok!Letmehavealook…oh,yoururinevolumeperhour,bloodpressureareallfine,butyourwoundissohuge,exudateisverymuch,youcouldalsobeinimbalanceofwaterandelectrolyte.Don’tworry,wehavetakensomemeasurestorecoverthebalance.德技双 至Situationalhavingacheck?Nb:Now,IwillshowNb:Now,Iwillshowyouadrawing，itcanhelptotesthowmuchyouare德技双馨至

SituationalNb:Lookhere.Thereisalinefromzerototen.zeromeansnopain,tenrepresentsextremepain.AndyoucanlocateP:Ididnotsleepwelllastnight.IthinkmypainscoreisNa:Didyoutrytoconvertyourattention?Forexample,listeningtomusic,medicating.

德技双 至SituationalP:Ihave,butitdidnotNa:Youcanoftenchangeyourslee positioninordertoavoidpressingthewound.Nb:Youcanalsoraiseyourburnedlegsuptothelevelofyourheartinordertorelieveswelling.Ifyoustillcannotstandthepain, lus,wewillgiveyoursomepainkillersaccordingtodoctor'sadvice.P:Thank

德技双 至Atthesametime,nursescheckthetightnessofwounddressing,volumeandcolorofthewoundexudateandperipheralbloodcirculationoflowerlimbs,checkwhetherpipesareunobstructedandfastened,theyalsomakehealtheducation.德技双 至Afterdiscussion,theylistnursingInviewoftheabovenursingdiagnoses,weputforwardssometargetednursingmeasures,andthepatientwentthroughtheshockstagesmoothly德技双 至白细胞计 血红蛋血小 血 白蛋白 氯化EnglishNursingWardRoundSecondAct2015-08-15,threedaysafteradmission,thepatientwentthroughshockstagesmoothly,begantolieonrotatingbed……德技双 至EnglishNursingWardRoundSecondActInthisperiod,Infectionisthemostdistinguishingfeaturesothisperiodisalsocalledinfectivestage.此 是最显著的特点，所以也称之 期德技双 至体温变化曲线图入院第四

期温开始啦 时日9时

德技双 至EnglishNursingWardRoundSecondActThefollowingismainnursingdiagnosesandmeasuresattheinfectivestage。以下 期主要的护理诊断及措德技双 至护理诊断体温过高与创面等有营养缺乏

NursingHightemperaturerelatedtowoundinfectionNutritiondeficiencyrelatedtohighmetabolicHavethepotentialoftraumarelatedtolyingonrotatingbed德技双 至措施

temperatureisclosetothenormalrangehours,ifbodytemperaturerisesdrastically,reportto treatment,increasethefrequencyofmonitoringUseantibioticsaccordingtothedo advice德技双馨 保持室28-使用保

AssistdoctorstodealwiththewoundproperlyKeeproomtemperaturein28-32℃2.5.Followthedoctor'stohelppatientscool2.6Useprotectiveframe,roastlamp,keepthewounddry，avoidcompressingthewound.德技双 至向患者介营养治疗对于提供高

Goal：PatientscantakeinenoughIntroducetheimportancenutritionaltherapytopatientsitcanhelprepairwoundProvidehighcalorie,highprotein,richvitamin,digestive德技双 至

Encouragepatientstoeatfoodthroughthemouth;KeepthemouthNutritionsupporttreatmentinaccordancewiththedoctor'sadvice德技双 至

Goal：ThepatientdidnothaveatraumaticinjuryAssessthepatient'sriskfalling,completethemission,andmakerecordIntroducesignificanceandnotesofrotatingbedtreatmenttoCheckallofpartsofrotatingbedcarefullyanditssafety德技双 至3.4翻身前做好 时发现意外征

3.4EnoughpreparationbeforerotatingWhennecessary,usingprotectiveconstraintstrapsPatrolward,findsignsofaccidentsintime，eliminatesuddentroubles德技双 至Rotatingbed:Atpresent,therearetwokindsofrotatingbed,includingmanualandelectric.ItconsistsofProne,supinebedsheet,boardslimbs,operationbox德技双 至OperationprocedureNursesspreadmattress,placesmallspongepillowunderpatients’shoulders,doublesacroiliacjointFoldthetwobedsheetstightly,fixthemwiththreebracers德技双 至OperationMovedripstandfromonesidetotheotherside,twonursesstandateachsideofthebed,then,putdownsupportingfeet,nextstartingpower

德技双 至OperationprocedureChoosedirection,turnleftorright,liftsupportingfeetupinstantly,releasethethreebracers,unloadupperbedsheetassoonaspossible,placeallkindsofpipesproperlyandhelppatientstotaketheproperposition德技双 至SituationalNow,afternursingwardround,nursesarediscussinghowtopreventthepatientfromfallingdownfromtherotatingbedinthedemonstrationroom. 德技双 至Situational德技双 至SituationalNa:Firstofall,weshouldsatisfythebasicneedsofthepatient,forinstanceeating,drinking...Nb:Inmyview,weshouldobservehisconsciousness.Ifthepatientmovesrestlessly,wemustuserestraintstrapstokeepthepatientsafe. 德技双 至Situational前无前无需使用约束护士a：事实上concerned,currently,wedonotneedtouserestraintstraps.德技双 至SituationalNb:Wealsopaymoreattentiontopatient’spsychologicstatus,afterall,hisfamiliescan’t panywithhimeveryday,andheisplacedinasingleroom.Na:Right！Wealsoshouldaccessthestatementofpatientbeforeoperatingandmakesurethatthepressurebetweenthetwobedsheetsshouldbe

德技双 至Situational措施相应措施

Nursestookcorrespondingnursingmeasures,andthepatientdidnotfalldownfromtherotatingbedduringthis德技双 至MainBASICKNOWLEDGEOFMEDICALNURSINGDIAGNOSISESANDDISCHARGE出院德技双 至EnglishNursingWardRoundThirdActAfteronemonthoftreatment,thepatient’shealbasically,vitalsignsarestableandheisgoingtodischargetomorrow,nursesareguidingthepatienthowtotakecareofhisnewskin. 德技双 至EnglishNursingWardRoundThirdAct德技双 至Discharge患者：太好了！Tang,accordingtodoctor'sadvice,youaregoingtodischargetomorrow.Na:NowIamgoingtogiveyousomeadvicesabouthowtolookafteryourhealedwoundbecauseyournewskinisstillvulnerable.德技双 至DischargeP:HowshouldINa:Firstly,youshouldcontinuetostrengthennutritioninordertoincreaseyourbody’s.Then,youhavetoreducesunlight exposuretopreventpigmentation.P:Okay！Iwill患者

德技双 至DischargeNa:Andyournewskinisthin,nottootough,lackingofelasticity,andeasytoha