创伤病人护理课件

第九章创伤病人的护理Chapter9

NursingCareofPatientsExperiencingTraumaYanyanWangE-mail:Amywy创伤病人护理LearningOutcomes:Definethewordtrauma.Definethetypesoftrauma.Discussthecauses,effects,andinitialmanagementoftrauma.Describecollaborativeinterventionsforpatientsexperiencingtrauma.Usethenursingprocessasaframeworkforprovidingindividualizedcaretopatientsexperiencingtrauma.创伤病人护理DefinitionandIntroductionTraumaisdefinedasinjurytohumantissuesandorgansresultingfromtheabnormaltransferofenergyfromtheenvironment.

[创伤：是由于外界环境中各种力量（能量）的异常传递而造成的机体组织或器官损伤。]创伤病人护理【概述】

创伤(trauma)有广义和狭义之分，广义的是指机械、物理、化学或生物等因素造成的气伤；狭义的是指机械性致伤因素作用于机体所造成的组织结构完整性破坏或功能障碍。临床多见的是机械性致伤因素作用于机体所致的损伤，如工伤事故、交通事故等导致的却软组织破损、出血、脏器破裂、骨折、关节脱位等。创伤病人护理

Inthepast,thetermtraumahasbeenassociatedwiththewordaccident.Accident

meansthattheinjuryocurredwithoutintent,justaresultofrandomchance.Wenowknowthatconsiderablenumberofinjuriesarepreventableandnotofrandomchance.Intentionalandnonintentionaltraumaencompassesavarietyofinjuriesresultingfrommotorvehiclecrashes,pedestrianinjuries,gunshotwounds,falls,voilencetowardsothers,orself-inflictedviolence.

Theinjuries,disabilities,anddeathsresultingfromtheseactsconstituteamajorhealthcarechallenge.

创伤病人护理RoleofNurses

Traumausuallyoccurssuddenly,leavingthepatientandfamilywithlittletimetoprepareforitsconsequences.

Traumamayalterthepatient’spreviouswayoflife,potentiallyeffectingindependence,mobility,cognitivethinking,andappearance.

Nursesprovideavitallinkinboththephysicalandpsychosocialcarefortheinjuredpatientandfamily.Incaringforthepatientwhohasexperiencedtrauma,nursesmustconsidernotonlythe

initialphysicalinjury,butalsoitslong-termconsequences,includingrehabilitation.创伤病人护理由于创伤往往是突然发生的，患者和家属没有足够时间来应对创伤带来的各种不良后果。而护士对于患者及家属身体的、心理社会的安抚照料发挥着重大作用。护士在护理创伤患者过程中不仅要考虑其最初的身体伤害，还要拟定后期康复等长远护理计划，因为创伤对于患者的影响可能不单涉及到生活方式的改变，还可能潜在地影响其独立性，生活活动能力，认知能力以及外表形象。

创伤病人护理TypesofTrauma

Generally,traumacanbeclassifiedas:

minortraumamajortrauma创伤病人护理Minortrauma—causesinjurytoasinglepartorsystemofthebodyandisusuallytreatedinaphysician’sofficeorinthehospitalemergencydepartment.eg.afractureoftheclavicle,asmallsecond-degreeburn,andalaceration（撕裂伤）requiringsutures(缝合)

创伤病人护理MajororMultipletrauma—involvesserioussingle-systeminjury(suchasthetraumaticamputation截肢ofaleg)ormultiple-systeminjuries.创伤病人护理Specifically,traumaisfurtherclassifiedaseither

bluntorpenetrating创伤病人护理BlunttraumaBlunttrauma—occurswhenthereisnocommunicationbetweenthedamagedtissuesandtheoutsideenvironment.Bluntforcesoftencausemultipleinjuriesthatmayaffectthehead,spinalcord,bones,thorax(胸腔)，andabdomen.Blunttraumaisfrequentlycausedbymotorvehiclecrashes,falls,assaults,andsportsactivities.创伤病人护理BlunttraumaItincludes:contusion(挫伤)sprain（扭伤）crushinjury（挤压伤）concussion（震荡伤）luxationandsemiluxation（关节脱位和半脱位）closedfracture（闭合性骨折）closedinternalinjury（闭合性内脏损伤）

创伤病人护理Penetratingtrauma

Penetratingtrauma—occurswhen

aforeignobjectentersthebody,causingdamagetobodystructures.Structurescommonlyaffectedincludethebrain,lungs,heart,liver,spleen,theintestines,andthevascularsystem.Examplesofpenetratingtraumaare

gunshotorstabwounds(刺伤),impalement（穿刺）,andincisedinjury(切割伤).创伤病人护理OthertypesOthertypes：inhalationinjuriesfromgases,smoke,

steam,burnor

freezinginjuries

blastinjuries

fromexplosions创伤病人护理

ClassesofTrauma

Outcomestudiesshowacorrelationbetweensurvivalratesofmultipletraumavictimsandrapidresposetimesbypre-hospitalproviders,coupledwithappropriatedecisionmakingwithregardstotransportingvictims.

大量有关创伤的结局研究显示，多发伤患者的存活率与院前急救者的快速反应及采取正确急救措施相关。创伤病人护理ClassesofTrauma

TraumapatientsareclassifiedasClass1,2or3basedonfactors,including：mechanismofinjuries,vehiclespeed,heightoffalls,locationofpenetratinginjuries.创伤病人护理Class3trauma

—theleastsevere,withoutlossofconsciousnessorsignificantinjury.Class1trauma

—themostsevere,involveslife-threateninginjurieslikelytorequiremedicalspecialistsorimmediatesurgicalintervention.SowhatisClass2trauma?创伤病人护理AnyhospitalemergencydepartmentshouldbecapableofcaringforClass3traumapatients,patientsmeetingClass1or2shouldbetransportedtoadesignatedtraumacenterwhenpossible.创伤病人护理【病理生理】（一）局部反应损伤后，局部血管通透性增加、血浆成分外渗，白细胞等趋化因子迅速集聚于伤处以吞噬和清除致病菌或异物，出现疼痛、发热表现，其病理过程与一般炎症相同，一般3～5日后逐渐消退。（二）全身反应损伤可引起神经内分泌活动增强，组织功能和代谢发生应激性改变。1、发热：损伤释放炎性介质和细胞因子作用于下丘脑体温调节中枢引起机体发热。

创伤病人护理【病理生理】2、神经内分泌系统反应：疼痛、血容量不足，下丘脑-垂体-肾上腺皮质轴、交感神经—肾上腺髓质轴分泌大量儿茶酚胺，以及肾素-血管紧张素—醛固酮系统被激活，代偿性保证回心血量。3、代谢反应：基础代谢率增高，分解代谢增强导致负氮平衡；表现体重下降，疲乏无力、反应迟钝。水电解质代谢紊乱，可致水钠潴留。4、机体免疫力下降：严重损伤可致机体免疫防御能力下降（中性粒细胞、单核-巨噬细胞吞噬和杀菌能力减弱，淋巴细胞数量减少、功能降低等），易发生感染。创伤病人护理【病理生理】（三）损伤的修复１、修复的基本方式：

完全修复：即缺损组织完全由原来性质的组织细胞修。（愈后结构功能与原组织相同）

不完全修复：是由成纤维细胞增生替代代替原来的组织，而形成瘢痕愈合。

创伤病人护理２、损伤的修复过程（三阶段）：

（1）炎性反应阶段：约3～5天。主要为血管和细胞反应、免疫应答、血液凝固和纤维蛋白溶解，伤口由血凝块充填；而后，血浆纤维蛋白沉积构成网架，封闭创口，为组织再生和修复奠定基础。

（2）肉芽形成阶段：成纤维细胞、内皮细胞等经增殖、分化、迁移，形成肉芽组织充填伤口，形成瘢痕愈合。

（3）组织塑形阶段：胶原纤维交联和强度的增加，多余的胶原纤维被降解和吸收，过度丰富的毛细血管网逐步消退，伤口黏蛋白和水分减少，伤部外观和功能得到改善。

创伤病人护理３、损伤的愈合类型

（1）一期愈合：又称原发愈合。伤口修复以原来的细胞为主，仅含少量纤维组织，伤口边缘整齐、严密、呈线状，组织结构和功能修复良好。见于创伤轻、范围小、无感染的伤口。

（2）二期愈合：又称瘢痕愈合。伤口修复以纤维组织为主，需周围上皮逐渐覆盖或植皮后才能愈合。局部结构和功能有不同程度的影响，多见于组织缺损较大、感染或异物存留的伤口。创伤病人护理4、影响损伤愈合的因素（1）局部因素：①细菌感染；②创口内异物；③血运障碍；④特殊部位（如关节处）（2）全身性因素：①年龄（老年人）；②慢性疾病：如糖尿病、结核、肿瘤等；③营养状况：营养不良或肥胖；④药物：抑制细胞增生药(如皮质类固醇)；⑤免疫功能低下。创伤病人护理ClinicalManifestationSymptom:

painfeverSystemicInflammatoryResponseSyndrome(SIRS)

创伤病人护理【临床表现】（一）症状：

1、疼痛：

2、发热：

3、全身炎症反应综合征(SIRS)：表现：①体温>38OC或<36OC；②心率>90次／分钟；③呼吸>20次／分钟或过度通气，PaC02<4.3kPa(32mmHg)；④血白细胞计数>12X109／L或<4X109／L或未成熟细胞>0.1％。

4、其他：可伴有食欲减退、倦怠和失眠等创伤病人护理ClinicalManifestationSigns:

P↑、R↑、BP↓woundandhemorrhage

tenderness(压痛)andswelldysfunction

创伤病人护理【临床表现】（二）体征1、生命体征改变(P↑、R↑、BP↓）2、创口和出血3、压痛和肿胀

4、活动或功能障碍↓

↓

↓

创伤病人护理【辅助检查】（一）实验室检查

1、血常规和红细胞比容（失血、感染）。

2、尿常规、尿淀粉酶检查（泌尿系和胰腺的损伤）。

3、血生化检查：肾功能检查—肾损伤；淀粉酶检查—胰腺损伤；血电解质检测和血气分析。创伤病人护理【辅助检查】（二）影像学检查

1、X线透视或摄片：可证实有无骨折、脱位、金属异物存留和胸、腹腔内游离气体。

2、CT和MRI：主要用于颅脑损伤的检查。MRI对脊髓、颅底、骨盆底部等处损伤的诊断具优越性。

3、B超检查：实质性器官损伤和腔内积液。

创伤病人护理【辅助检查】（三）诊断性穿刺：内脏器官破裂、出血。（四）置管灌洗检查：诊断性穿刺不能明确诊断，可穿刺后置导管灌洗，抽取灌洗液作检查（如腹腔灌洗）。（五）监测中心静脉压可判断血容量和心功能。创伤病人护理EffectsofTraumaticInjury

创伤后效应和结果创伤病人护理Deathisacommonresultofserioustraumaticinjury,andmaybeimmediate,early,orlate.Immediate.Becauseoftheseriousconsequencesoftrauma,itisimportanttorapidlyidentifythepatient’sinjuriesandinstituteappropriateinterventionsquickly.创伤病人护理HeadandNeckEffectsThoracicEffects

Hemorrhage

AbdominalEffectsNeurologicEffects

MultipleOrganDysfunctionSyndromes(MODS)创伤病人护理HeadandNeckEffects

创伤病人护理HeadandNeckEffects

—AirwayObstruction

Maintenanceoftheairwayandcervicalspine（颈椎）

arethehighestpriorityinthetraumapatient.

HeadandNeckEffects

创伤病人护理Assessment

Assessment

includes：①determiningairwaypatency.

②reassesstheeffectivenessoftheintervention.

③assesstheeffectivenessofbreathing.

HeadandNeckEffects

创伤病人护理DeterminingairwaypatencyIfthepatientisunresponsive,manualopeningoftheairwayusinga

jawthrustmaneuver（托下颌法)isnecessary

ThejawthrustmaneuverisrecommendedinpatientswithactualandpotentialC-spineinjury.

HeadandNeckEffects

创伤病人护理DeterminingairwaypatencyOncetheairwayisopened,thepractitionermustidentifyanypotentialobstructionfromthetongue,

looseteeth,foreignbodies,bleeding,secretions,vomitus,oredema.

Ifthepatientisresponsiveandcanvocalize,thatisagoodindicationthattheairwayisclear.

HeadandNeckEffects

创伤病人护理ReassesstheeffectivenessoftheinterventionForexample,ifyousuction(吸，抽吸)theairwaytoremovevomitus,youwouldreassesstheairwayaftersuctioningtodetermineifthatinterventionwassuccessfulorifyouhavetore-suctiontheairwayasecondtime.HeadandNeckEffects

创伤病人护理ReassesstheeffectivenessoftheinterventionInadditiontosuctioning,otherairwayadjunctsavailableinclude

oralornasalpharyngeal(鼻咽部)airways,

laryngeal（喉部）airway

and

endotrachealintubation(气管内插管).

Intubationisthepreferredmethodofairwaymanagement.创伤病人护理Assesstheeffectivenessofbreathing

Assessmentshouldincludeifthepatienthasspontaneousbreathing（自主呼吸）,goodriseandfallofthechest,determinationofskincolor,generalrateanddepthofrespirations,abdominaloraccessorymuscleuse,positionofthetrachea（气管）,observationofchestwall（胸壁）integrity，presenceofjugularveindistension(颈静脉怒张)

aswellasthepresenceofanysurfacetrauma.创伤病人护理Traumapatientsmayexhibitseveralaspectsofairwaymanagementthatareuniqueandrequirespecialpreparationandprecautions.

Let’sdiscusstogether.HeadandNeckEffects

创伤病人护理Closedheadinjury

Changesinhemodynamics,oxygenation,andventilationshouldbeminimizedinordertomaintainadequatecerebralperfusionpressure(脑灌注压).ThegoalistomaintainaPaCO2of30-35mmHg.

HeadandNeckEffects

创伤病人护理ClosedheadinjuryButintubationcancauseamarkedincreasein

intracranialpressure(ICP,颅内压),andalsolidocaineadministered3-5minutespriortointubationcanblunt（使减弱）anincreaseinICPthatissecondarytolaryngealstimulation（喉部刺激）.Betablockers（普萘洛尔、阿替洛尔）

canbegiven2-3minutespriortointubationtoattenuatethe

sympathetic(交感神经的)response

inanormotensivepatient.HeadandNeckEffects

创伤病人护理Maxillofacialtrauma

颌面部创伤

Significantdistortionofnormalanatomyinfacialtraumaandrespiratorycompromise(呼吸道损害)isnotuncommon.Asurgicalairway

maybetheonlyalternative.HeadandNeckEffects

创伤病人护理Directairwaytrauma

Penetratingtraumatotheneckisassociatedwithahighdegreeofmorbidityandmortality.

Airwayinvolvementincludesdyspnea,cyanosis,subcutaneousemphysema,hoarseness.HeadandNeckEffects

dyspnea[disp‘ni:ə]呼吸困难，cyanosis[,saiə’nəusis]发绀，emphysema[,emfi‘si:mə]皮下气肿，hoarseness嘶哑创伤病人护理DirectairwaytraumaOrotrachealintubationisthetechniqueofchoice.Thekeyisearlyidentificationoftheneedforintubationbeforethepatienthasnoairwayatall.HeadandNeckEffects

Orotracheal[ɔrətrətʃi:l

]intubation口腔气管插管创伤病人护理Cervicalspineinjury

Approximately3%-6%ofmajortraumavictimshaveclinicallysignificantC-spineinjuries.Oralintubationwithmanualin-lineaxialheadandneckstabilization(MIAS，头颈部的轴向固定)isasafemethod.

HeadandNeckEffects

Cervicalspine颈椎，

axial[‘æksɪəl]轴向的

创伤病人护理Burns

Burnpatientswithairwaycompromiserequire

aggressivemanagement(紧急处理).

Upperairwayedemaassociatedwithinhalationcanprogressduringthepostburnphase.So

securinganairway

soonerthanlateristhegoal.HeadandNeckEffects

吸入性烧伤患者需要紧急处理。烧伤后期上呼吸道水肿导致呼吸不畅会越来越重，因此应尽早采取措施保护气道。创伤病人护理ThoracicEffects

Thoracic[θɔː‘ræsɪk]胸的创伤病人护理Tensionpneumothorax

Apneumothoraxresultswhenairentersthepotentialspacebetweentheparietalandvisceralpleura.Airpresentinthepleuralspacewilleventuallycollapsethelungs.Atensionpneumothorax

islife-threateningandrequiresimmediateintervention.ThoracicEffects

pneumothorax[,nju:mə‘θɔ:ræks]高压性气胸，张力性气胸，parietal[pə’raiitəl]腔壁的，visceral[‘visərəl]内脏的，pleura[’plurə]胸膜，thorax

[‘θɔːræks]胸廓，胸膛创伤病人护理TensionpneumothoraxOninspirationairentersthepleuralspace（胸膜腔）,doesnotescapeonexpiration,andincreasestheintrapleural(胸膜内的)pressure.

Thispressurecollapsestheinjuredlung,shiftsthemediastinalcontents，compressingtheheart,greatvessels,tracheaandeventuallytheuninjuredlung.Inturn,thiscausesthefollowingsignsandsymptoms:Severerespiratorydistress;Hypotension;Jugularveindistension;Trachealdeviation(气管偏移)towardtheuninjuredside;Cyanosis.ThoracicEffects

mediastinal[,mi:diæs'tinəl]纵隔的,trachea(气管),Cyanosis[,saiə'nəusis](发绀).创伤病人护理TensionpneumothoraxTheimmediateshort-termlife-savinginterventionisaneedlethoracostomy:insertingalargeboreovertheneedlecatheterintothesecondintercostalspace（第二肋间）

atthemid-clavicular（锁骨的)line(MCL,锁骨中线).ThoracicEffects

needlethoracostomy[,θɔ:rə‘kɔstəmi,,θəu-](胸腔穿刺造口术)，intercostal(肋间的)

创伤病人护理Flailchest连枷胸

Flailchest

isthefractureoftowormoreribsintwoormoreseparatelocations,leadingtoanunstablethoracicwall（胸壁）

segment.

Paradoxicalmovement（反常运动）

ofthechestwallisseenwiththeareasinkingintothechestcavity(胸腔)withinspirationandprotrusion（突出）withexpiration.Theareamustbesupportedquicklytore-establishthethoracicbellowseffect.（塌陷区域需要修复以重建胸廓的呼吸运动）ThoracicEffects

protrusion[prə‘truːʒn]突出创伤病人护理Hemorrhage

Hemorrhage[‘hemərɪdʒ]出血

创伤病人护理Hemorrhage

Whenthepatienthassufferedaninjurythatcausesexternalhemorrhage,suchassevering(切割，分离)ofanartery,thebleedingmustbecontrolledimmediately.Thismaybedonebyapplyingdirectpressureoverthewound

and

applyingpressureoverarterialpressurepoints.Oncethesourceofinternalhemorrhagehasbeenrecognized,interventionsareinitiated,including

operativecontrolofbleedingandcontinualassessmentofthepatient.Hemorrhagemayresultinhypovolemicshock(低血容量性休克).

Hemorrhage

创伤病人护理HemorrhageInternalhemorrhage

mayresultfromeitherbluntorpenetratingtraumaticinjury.Discoveringthecause

and

location

oftheinjury,aswellastheextentofrelatedbloodloss,arethemostimportantconcerns.Hemorrhage

创伤病人护理HemorrhageSeveralpotentialspacesinthebodycanaccommodatelargeamountsofbloodthatmayaccumulate(calledthirdspacing)followinginjury.Forexample,bleedingintothepleuralspacemayoccurwithchesttrauma(hemothorax,血胸)，andbleedingintotheabdominalcavitymayoccurwithabdominaltrauma.Apelvic

fracturemaycausemassivehemorrhageintheretroperitonealregion.Hemorrhage

pelvic[‘pelvik]骨盆的，retroperitoneal['retrəu,peritə'ni:əl]腹膜后的创伤病人护理AbdominalEffects

创伤病人护理AbdominalEffectsTheabdomencontainsboth

solidorgans

(liver,spleen,andpancreas)andholloworgans

(stomachandintestines):

Directtraumatotheabdomencanlacerate(撕碎)andcompressthesolidorgansandcause

burstinjuriestotheholloworgans.Bloodvesselsmaybetornandorgansmaybedisplacedfromtheirbloodsupply,producing

life-threateninghemorrhage.

AbdominalEffects

创伤病人护理AbdominalEffectsDamagetothemesentericvessels(肠系膜血管)supplyingthebowelcanresultinbowelischemiaandinfarction(梗塞).Injurytothestomach,pancreas,andsmallbowelmayallowdigestiveenzymes

toleakoutintotheabdominalcavity.Ruptureofthelargebowelresultsinescapeoffeces,whichcauses

peritonitis.AbdominalEffects

mesenteric[,mesən‘terik]肠系膜，infarction[in’fɑ:kʃən]梗塞，enzymes[‘enzaims]酶abdominalcavity腹腔，Rupture破裂，使破裂，peritonitis[,peritə'naitis]腹膜炎创伤病人护理NeurologicEffects创伤病人护理NeurologicEffects

Injuriestothespinalcord(脊髓)，resultinginlossof

neurologicfunction,aredevastatingoutcomesoftrauma,buttheyaremuchlesscommonthanheadinjuries.

Careofthepatientwithaneurologicinjuryisdiscussedinlaterunit.AbdominalEffects

创伤病人护理MultipleOrganDysfunctionSyndromes

(MODS)

创伤病人护理MODSMultipleorgandysfunctionsyndrome(MODS)isacommoncomplicationofsevereinjuryandafrequentcauseofdeathinintensiveunits.Itisaprogressiveimpairmentoftwoormoreorgansystems.

MultipleOrganDysfunctionSyndromes(MODS)

创伤病人护理MODSThisistheresultofanuncontrolledinflammatoryresponsetosevereinjuryorillness.PatientsatriskforMODSarethosewithadisturbanceinhomeostasisresultingfromoneoracombinationofthefollowingconditions:

infectioninjuryinflammationischemiaimmuneresponseintoxicationofsubstancesiatrogenic(医源性的)factors.

MultipleOrganDysfunctionSyndromes(MODS)

homeostasis[,həumiəu‘steisis]平衡，内稳态，iatrogenic[ai,ætrəu'dʒenik]医源性的创伤病人护理MODSTheprimarysystemsinvolvedinMODSaretherespiratory,renal,hepatic,hematologic,cardiovascular,gastrointestinal,andneurological.

Supportivetherapydependsontheidentificationofcorrectablecauses.Itmaybeoneoracombinationofseveraltherapies.Surgicalintervention,antibioticadministration,corticosteroidadministration（糖皮质激素的使用）,orcorrectioncoagulopathies(纠正凝血障碍)aresometherapiesusedforthiscondition.MODSfollowinginjuriesproducesmorethanhalfofthelatemortalityfollowingtrauma.MultipleOrganDysfunctionSyndromes(MODS)

Hematologic血液学的，antibiotic[,æntibai‘ɔtik]抗生素，corticosteroid[,kɔ:tikəu’stεərɔid]糖皮质激素coagulopathy[kəu,æɡju'lɔpəθi]凝血障碍创伤病人护理InterdisciplinaryCare

Pre-hospitalCare

EmergencyDepartmentCareMedications

EmergencySurgery

创伤病人护理Pre-hospitalCare创伤病人护理Pre-hospitalCareThemajorfunctionsofpre-hospitalcareinclude：

injuryidentificationcriticalinterventionrapidtransport.创伤病人护理Injuryidentification创伤病人护理Injuryidentification

Emergencycareofthepatientexperiencingtraumaisbasedonrapidassessmenttoidentifyinjuriesandbegin

appropriateinterventions.Pre-hospitalCare创伤病人护理InjuryidentificationInjuriesthatindicatetheneedfortraumacentercareincludethefollowing:

◆Penetratinginjuriestotheabdomen,pelvis,chest,neckorhead◆Spinalcordinjurieswithdeficit◆Crushing(粉碎性的)injuriestotheabdomen,chestorhead◆Majorburns◆InjuriesleadingtoairwaycompromiseorobstructionPre-hospitalCare创伤病人护理InjuryidentificationManymethodshelphealthcareprovidersdeterminetheseriousnessofthepatient’sinjuriesandthepotentialforsurvival.ScoringsystemssuchastheChampionRevisedTraumaScoringSystemcanbehelpful(Table1).

Aprimarytraumaassessmentfollowsanalphabetmnemonic:Pre-hospitalCare创伤病人护理Injuryidentification

◆Aisairwayassessment

(withC-spineimmobilization颈椎制动)todetermineiftheairwayispatent(通畅的),maintainable（可维持的）,ornonmaintainable.◆Bisbreathingevaluationforspontaneousrespirations(自主呼吸)orventilatoryimpedance（通气阻力）suchasbyribfracturesoracollapsedlung.◆Ciscirculatoryassessment

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