急诊科护理常规

急诊科护理常规 for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 急诊科护理常规 一、急诊急救护理常规 ,一,心肺脑复苏,CPCR,的急救护理 心脏骤停是指心脏病患者或非心脏病患者～在未能估计到的时间内～心搏突然停止～即应视为心脏骤停。心脏性猝死是指心脏原因引起的无法预测的自然死亡。患者过去可有或无心脏病史～在急性症状开始的1小时内,也有规定24小时～但以1小时最为常用,～心脏射血功能突然终止～即心脏骤停～导致脑血流中断～出现意识丧失～患者如经及时救治可获存活～否则将发生生物学死亡。 1、急救护理措施 ,1,复苏的护理措施 ?心肺脑复苏是一个连贯的、系统的急救技术～各个时期应紧密结合～不间断进行。首先护士应独立或配合医师快速准确进行“ABC”步骤心肺复苏～即保持气道通畅、人工呼吸、建立人工循环。 ?尽快建立心电监护和静脉通路。立即建立2条静脉通路～复苏时首选肘正中静脉～距心脏较近～可输入大量的液体。中心静脉可取股静脉～虽距心脏较远～但复苏抢救工作可以不必间断～并发症也较少。 ?对于发生室颤的患者应实施有效的非同步直流电除颤。一for computer software engineering GB/T50314-2000 of electrical installations code for construction and acceptance of GBJ232- 92 intelligent building weak design construction figure set GJBT-471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated wiring system (containing room network, communications part) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm system (containing public broadcast part) security technology prevention system security monitoring system out entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok information application system queued station ICU visitation system operation the system monitoring and training system call intercom system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communication component) computer network systems and voice communications systems Center of information on medical floor computer room located in the engine room. Voice communication system using a local telecommunications operator providing voice service, configuration-independent integrated services digital program-controlled switchboards. Operators providing communications ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to meet 般首次能量给予200J～第1次转复无效或转复成功又复颤时可将能量增至300J～如再不成功或复颤～能量可增至360J。如室颤为细颤～除颤前应给予0.1%肾上腺素1mg～使之转为粗颤后再行电除颤。 ?复苏给药途径应首选静脉给药～其次选择气管给药～只有在开胸心脏挤压的可见条件下才可选择心内注射给药。遵医嘱准确快速应用肾上腺素、阿托品、利多卡因、碳酸氢钠等复苏药物。 ?建立抢救特护记录～详细记录抢救用药、抢救措施、病情变化、出入量及生命体征等。 ,2,复苏后的护理措施 ?密切监测生命体征变化～观察有无呼吸急促、烦燥不安、皮肤潮红、多汗和二氧化碳潴留而致酸中毒的症状～并及时采取防治措施。 ?维持循环系统的稳定:复苏后心律不稳定～应予心电监护。同时注意观察脉搏、心率、血压、末梢循环,皮肤、口唇颜色～四肢温度、湿度～指/趾甲的颜色及静脉的充盈情况等,及尿量。 ?保持呼吸道畅通～加强呼吸道管理:注意呼吸道湿化和清除呼吸道分泌物。对应用人工呼吸机患者应注意呼吸机参数,潮气量、吸入氧浓度及呼吸频率等,的监测和记录～吸入气体的湿化～观察有无人工气道阻塞、管路衔接松脱、皮下气肿、通气不足或通气过度等现象。 ?加强基础护理～预防褥疮、肺部感染和泌尿系感染等并发 rs Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T503141atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer ro 症的发生。 ?保证足够的热量～昏迷患者可给予鼻饲高热量、高蛋白饮食。 ?定期监测动脉血气、水电解质平衡。 2、主要护理问 ,1,组织灌注改变:与心脏骤停、心肌血液灌流减少引起的心肌缺氧有关。 ,2,心排出量减少:与心脏骤停、回心血量减少有关。 ,3,组织灌注不足:心脏、脑组织、周围组织～与心脏骤停、心排出量减少有关。 ,4,气体交换受损:与心脏骤停、心排出量减少导致携氧量减少有关。 ,5,低效性呼吸型态:与心脏骤停导致中枢神经系统功能障碍有关。 ,6,呼吸道清除功能无效:与意识丧失无法自行将呼吸道分泌物排出有关。 ,二,休克病人的急救护理 休克是指感染、出血、脱水、心泵衰竭、过敏和严重创伤等强烈致病因素引起有效循环血量的急剧减少～导致全身性微循环功能障碍～使脏器的血流灌注不足～引起缺血、缺氧、代谢障碍及重要生命器官功能损害为特征的病理综合征。休克是一种危险急重症～一旦发生～必须立即采取有效措施。原则是迅速解除致 ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T503142eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer 休克因素～尽快恢复有效循环血量～纠正微循环障碍、改善心脏功能和恢复正常代谢～并根据病情作相应处理。 1、急救护理措施 ,1,体位:病人取平卧位时～头部抬高10，20?～下肢抬高20，30?～松解病人的领口、紧身衣服～避免不必要的搬动和翻身。 ,2,设专人护理:建立护理记录～详细记录病情变化及用药。 ,3,吸氧与保持呼吸道通畅:休克病人均有不同程度的缺氧症状～应立即给予高流量氧气吸入。为防止出现气道梗阻～应给予必要的急救护理措施～协助患者咳嗽、咳痰。昏迷患者头应偏向一侧～防止呕吐物吸入气管引起窒息及吸入性肺炎。及时清除口咽、气管内分泌物。必要时建立人工气道～可确保呼吸道通畅。 ,4,注意保温:适当加盖棉被、毛毯～但对持续高热患者可采用降温措施～降低机体对氧的消耗～采取物理降温～因药物降温引起出汗过多而加重休克。 ,5,保持安静～防止意外损伤:在休克早期患者常处于兴奋、烦躁状态～不配合治疗～应将输液肢体妥善固定～加备床挡～防止患者坠床。如患者频繁躁动～可适当用地西泮等镇静药物。伴有疼痛的病人审慎地给予可逆性麻醉剂～如吗啡,2，4mg静脉注射,极易控制严重的疼痛。 ,6,迅速建立静脉通路:最好建立2条或2条以上静脉通 om location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T503143atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, config 路～为保证液体顺利输注～现多主张安臵中心静脉导管。补液速度根据病情灵活掌握～一般成人每分钟60，80滴为宜。抗休克时～药物繁多～要注意药物间的配伍禁忌、药物浓度及滴速～用药后要及时记录。 ,7,应用血管活性药物:在血容量补足的基础上尽早采用血管活性药物～改善血压和微循环～但必须严密监测血压与尿量。因多巴胺、去甲肾上腺素等药物刺激性强～对注射局部容易产生坏死～而休克病人反应迟钝～故应用血管活性药物时宜选用中心静脉臵管～并应使用微量注射泵。 ,8,加强临床观察:休克是一个严重的变化多端的动态过程～要取得最佳治疗效果～必须加强临床护理中的动态观察。严密监测病人的意识状态、血压、心率、心律及呼吸等生命体征的动态变化并及时记录。此外～还需监测尿量、尿比重、酸碱度和血气等变化～以了解各脏器功能状态和体内代谢变化情况～以利于早发现、早处理、早纠正。应详细记录液体出入量～作为医师下一步诊治的参考。 ,9,注意心理护理:患者受到创伤、疼痛、失血、失液或感染等侵袭～往往现出烦躁不安～不与医护人员合作～这时对神志清醒者应给予安慰～尽量保持患者情绪稳定。 ,10,病因护理:各种类型休克应按其不同病因进行护理～例如～细菌性肺炎所致感染性休克～应及时做痰培养和药敏试验～并注意抗生素的使用～必要时遵医嘱做血培养。失血性休克要详 entrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T503144eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call int 细了解并记录患者的出血量～对于呕血、黑便者注意其一般状况、脉率、血压及肠鸣音等～并对原有疾病进行护理。心源性休克多见于急性心肌梗死～应紧急进行心脏监护～并对患者进行积极的心身护理。 2、主要护理问题 ,1,循环血容量减少:与体液或血液流失所引起的低血容量性休克有关。 ,2,心排出量减少:与心肌收缩力减弱、血容量减少及回心血量减少有关。 ,3,组织灌注不足:心脏、脑组织、周围组织～与心排出量减少有关。 ,4,气体交换受损:与心排出量减少导致携氧量减少有关。 ,5,体温过高:与细菌感染有关。 ,三,、昏迷病人的急救护理 昏迷是严重的意识障碍～其主要特征为随意运动丧失～对外界刺激失去正常反应并出现病理反射活动。它不是一种疾病而是各种疾病共同的结果。意识是机体对自身及外界环境感知并能作出正确反应的状态。 1、急救护理措施 ,1,判断昏迷程度:目前～通用的格拉斯哥昏迷分级,Glass-gow coma scale,GCS,计分法检查。 ,2,维持呼吸道通畅和足够的氧合 rs Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T503145atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer ro ?密切监测呼吸频率、形态的改变。 ?每4小时评估呼吸音的改变～监测是否出现肺不张或肺部 感染的体征～如湿啰音、哮鸣音、发热等现象。 ?维持呼吸道通畅～必要时气管插管～根据血气报告调节氧 气浓度。 GCS计分法 项目 反应 计分 睁眼反应 自动睁眼 4 呼唤睁眼 3 刺激睁眼 2 任何刺激不睁眼 1 语言反应 对人物、时间、地点方向准确 5 不能准确回答以上问题 4 胡言乱语、用词不当 3 能发出无法理解的声音 2 无语言能力 1 运动能力 能按指令动作 6 对刺痛能定位 5 对刺痛能躲避 4 刺痛时肢体屈曲,去皮层强直, 3 刺痛时肢体过伸,去大脑强直, 2 对刺痛无任何反应 1 注:正常人为15分～8分以下为昏迷～3分为深度昏迷。 ?拍背、吸痰以促进痰液的排出。 ?协助患者采取半坐卧位以利于胸廓的扩张。 ?密切监测呼吸机的使用情况～维持呼吸机的正常功能。 ,3,维持并促进神经功能的改善 ?密切评估并监测意识状态、瞳孔大小、对光反射、眼球活 ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T503146eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer 动等变化,并注意是否出现不安、躁动、头痛等情况。 ?监测颅压变化～避免增加颅压的活动～如弯曲颈部、疼痛刺激等。保护病人～避免意外伤害～使用床挡。减少诱发抽搐的因素～如高热、缺氧、电解质紊乱等。 ?维持血流动力学稳定及电解质平衡 a、密切注意是否出现容量不足的体征～如皮肤、粘膜干燥和尿量减少等。 b、建立静脉通路～遵医嘱给药～监测是否出现体液不足或过多的体征～并立即通知医师。 c、保留尿管～记录每小时尿量～以作为体液补充是否足够的指标。 d、准确记录摄入量和体重～以评估液体补充的情况。 e、密切监测电解质的变化～遵医嘱给药。 ?维持皮肤完整性～避免造成皮肤破损 a、每2小时翻身1次～按摩背部。 b、当病人出现尿、便失禁时～及时更换床单～以保持床单的清洁。 c、密切观察受压部位皮肤～对出现发红或皮肤干燥破裂等情况～增加翻身次数。 d、鼻饲或静脉补充足够的营养～保证能量供给。 e、每天注意对眼睛的护理～遵医嘱滴入人工泪液维持眼睛的湿润度～并用纱布覆盖～预防无法眨眼造成过度干燥引起的角膜 rs Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T503147atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer ro 损伤。 ?维持体温恒定 a、每4小时测量体温1次～出现异常立即报告医师。 b、体温过高时～采取物理降温。 c、体温过低时～采取保温措施。 2、主要护理问题 ,1,低效性呼吸形态:与中枢神经系统功能障碍有关。 ,2,呼吸道清除功能无效:与意识状态不清无法自行将呼吸道分泌物排出有关。 ,3,脑组织灌流改变:与头部病变有关。 ,4,潜在危险性体液容量缺少:与无法自行摄取水分有关。 ,5,潜在危险性皮肤完整性受损:与病人无法自行翻身有关。 ,6,体温恒定失常:与药物中毒或脑部病变有关。 ,四,急性中毒病人的急救护理 急性中毒是指机体受到毒物的作用～在短时间内发生功能性和器质性改变后出现疾病状态甚至死亡～是各种毒效作用的综合表现。最多见的中毒是药物中毒、有机磷农药中毒、一氧化碳中毒、动植物性毒物中毒。 1、急救护理措施 ,1,迅速清除毒物 ?立即脱离中毒环境～终止继续接触毒物。 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T503148eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration a、吸入性中毒:将患者迅速脱离中毒环境～移至空气新鲜处～必要时给予吸氧和人工呼吸～保持呼吸道通畅。 b、接触性中毒:应迅速脱去患者的一切污染衣物～彻底清洗污染部位。强酸类中毒用弱碱溶液清洗,如2%，5%的碳酸氢钠溶液、肥皂水等,,强碱类中毒用弱酸溶液洗,如食醋等,。无条件或不明毒物中毒应立即用大量流动水彻底冲洗～时间在15，30分钟或更长～不宜用热水。 c、强酸强碱腐蚀眼睛:立即用大量清水或等渗氯化钠溶液彻底清洗。 d、毒蛇咬伤或注射毒物:应在近心端扎止血带～每隔15，30分钟放松1分钟。局部制动、吸引或引流排毒～可用生理盐水、冷过氧化氢溶液或1:5000的高锰酸钾溶液冲洗。 ?洗胃:为减少毒物的继续吸收～神志清醒的病人～可采取口服催吐洗胃。昏迷患者以及服用大量药物者必须尽快采用洗胃管洗胃～一般在服用药物后4，6小时内洗胃效果最佳。如果服用药物量比较大～或药物体内吸收较慢～即使时间超过6小时～洗胃对于服药的多数病人也是非常必要的。洗胃时应注意: a、臵洗胃管时～患者取坐位或半坐位～如患者不能坐起或昏迷～采用侧卧位～头部稍低～保持口低于咽喉部～以预防胃液进入气管。将涂有石蜡油的胃管由口或鼻腔插入～同时嘱患者作吞咽动作～昏迷患者可用开口器撬开口腔～用弯钳将胃管缓缓送入胃内。洗胃时患者头偏向一侧～防止误吸。 ation component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T503149atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom loc b、胃管插好后～应先抽尽胃内容物并留取少量做毒物鉴定。如无胃内容物抽出～可用注射器注入少量清水或生理盐水～回抽后的液体也可留作鉴定。 c、根据毒物种类选择洗胃液～毒物不明时可选用生理盐水或温开水。 d、一般采用电动洗胃机洗胃～每次灌洗流量为300ml左右～不宜过多～防止毒物进入肠道或导致急性胃扩张。小儿可根据年龄决定入量～一般以50，200ml为宜～且不宜使用洗胃机。 e、洗胃的原则为快进快出～先出后入～出入量基本相等～反复清洗～直至排出液与灌入液色泽相同为止。如出现血性洗出液～应立即停止洗胃～并给予胃粘膜保护剂。 f、强酸强碱中毒切忌洗胃～可给予牛奶、蛋清及植物油等保护剂保护粘膜～减少强酸强碱等毒物的腐蚀作用。 ,2,留取标本做毒物鉴定:留取血、尿、洗胃液等标本～尽早做毒物鉴定～为抢救治疗提供准确依据。 ,3,密切观察意识状态、呼吸频率及类型、脉率、血压、瞳孔、尿量等变化并记录。详细记录出入液量。 ,4,保持呼吸道通畅～及时清除呼吸道分泌物～给予氧气吸入～必要时行气管插管、机械通气等。 ,5,生活护理:急性患者应卧床休息～注意保暖。昏迷病人要做好皮肤护理～防止褥疮发生,吞服腐蚀性毒物者应特别注意口腔护理～密切观察口腔粘膜的变化。 ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031410eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ,6,饮食护理:病情许可时～尽量鼓励病人进食～少食多餐。急性中毒病人的饮食应为高蛋白、高碳水化合物、高维生素的无渣饮食～腐蚀性毒物中毒者应早期给予乳类等流食。应保证患者足够的营养供应～必要时给予鼻饲营养或静脉营养。 ,7,安全护理:防止惊厥、抽搐、烦躁不安患者坠床和碰伤。对企图自杀的患者～应给予安全防范～并要有专人陪护。 ,8,心理护理:根据患者的中毒原因、社会文化背景以及对中毒的了解程度和心理需要～进行针对性的心理疏导～给予患者情感上的支持。 2、急性有机磷中毒的急救护理措施 ,1,清除毒物:尽快使患者脱离中毒现场～若是接触毒物中毒～应立即脱去被污染的衣物～肥皂水或清水冲洗污染部位。若是消化道中毒～应催吐～大量清水、碳酸氢钠或高锰酸钾洗胃～注意碳酸氢钠不能用于敌百虫中毒～高锰酸钾不能用于硫代硫酸酯类中毒。要重视洗胃～减少毒物的继续吸收。 ,2,配合医师采取有效的治疗措施:严重中毒者可出现多种并发症～注意维持水、电解质、酸碱平衡～保持呼吸道通畅～给予吸氧～必要时呼吸机辅助呼吸。心衰者可强心、利尿,肺水肿、脑水肿者可限制入液量～必要时给予甘露醇脱水治疗。详细记录患者的出入液量。 ,3,密切观察生命体征的变化～尤其要观察患者神志及瞳孔的改变～以防病情加重。 ystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031411atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve hou ,4,记录24小时出入量～警惕患者出现肺水肿和心衰、肾衰等并发症。 ,5,使用阿托品及胆碱酯酶复活剂过程中～要注意观察药物的毒副作用。阿托品中毒的症状包括兴奋、躁狂、阵发性强直性抽搐、高热等。胆碱酯酶复活剂常用解磷定和氯磷定～剂量过大可出现口苦、咽痛、恶心、血压升高等症状。 ,6,做好口腔护理:使用阿托品后～病人唾液分泌减少可有口干～清醒病人可用水漱口湿润口腔～口唇干裂者涂石蜡油或甘油。 ,7,加强昏迷患者的护理～患者呼吸道分泌物增多～应及时吸痰～勤翻身拍背～防止呼吸道阻塞和坠积性肺炎。 3、急性一氧化碳中毒的急救护理措施 ,1,脱离环境:将患者迅速脱离中毒环境～呼吸新鲜空气～清除口、鼻、咽部分泌物～保持呼吸道通畅。 ,2,纠正缺氧:给予吸氧治疗～必要时给予高压氧治疗。高压氧可迅速纠正缺氧～加速一氧化碳的清除～从而缩短病程～减少并发症～包括迟发性脑病的发生率。高压氧治疗宜早期应用～有条件者最好在中毒后4小时内治疗。轻度中毒可治疗5，7次～中度治疗10，20次～重度20，30次。 ,3,防止并发症:患者脑部病变最为突出～防止脑水肿非常重要。可给予20%甘露醇脱水治疗～也可用呋塞米利尿、皮质激素减轻脑水肿。注意水电解质平衡及防止肺部感染等并发症。 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031412eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration ,4,观察患者神志、瞳孔及生命体征的变化～记录出入量。 ,5,加强昏迷患者的护理～预防坠积性肺炎和褥疮发生。 4、急性强酸、强碱中毒的急救护理措施 临床上常见硫酸、硝酸、盐酸等强酸中毒,常见氢氧化钾、氢氧化钠、氢氧化铵,氨水,、氢氧化钙等强碱中毒。 ,1,冲洗创面:对强酸、强碱类中毒的患者～首选清水冲洗～冲洗时间稍长～然后选择合适的中和剂继续冲洗。 ,2,密切观察创面情况～注意有无发展～警惕坏死性深部溃疡形成。加强创面护理～防止创面感染。 ,3,严密观察病情变化～注意体温、脉搏、呼吸、血压及神志变化。 ,4,加强口腔护理:口服强酸强碱类毒物～口腔粘膜易致糜烂、出血、坏死～应立即用大量清水、中和剂冲洗。已引起口腔粘膜灼伤者～口腔分泌物增多～可用1%，4%过氧化氢擦洗口腔～防止厌氧菌感染～操作时动作要轻柔～尽量避开新鲜创面。急性期宜少漱口～以减少疼痛～避免再出血。 ,5,臵胃管时手法应轻柔～防止胃穿孔。 ,6,口服强酸、强碱类患者禁止洗胃～胃内可缓慢注入胃粘膜保护剂～用力不要过大～速度不宜过快～防止造成穿孔。 5、急性镇静安眠药中毒的急救护理措施 ,1,一般紧急处理:清醒者先用口服催吐法～意识不清者应尽快臵胃管～温开水洗胃。 om location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031413atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, config ,2,病情观察:定时测量生命体征～观察意识状态、瞳孔大小、对光反应、角膜反射～若瞳孔散大、血压下降、呼吸变浅或不规则～常提示病情恶化～应及时报告医师～采取紧急处理措施。注意记录出入量。 ,3,吸氧～保持呼吸道通畅。仰卧位时头偏向一侧～或侧卧位～防止舌后坠阻塞气道。呕吐物或痰液应及时吸出～必要时行气管插管、机械通气。 ,4,药物治疗的护理:遵医嘱应用解毒剂～可用美解眠50，100mg静滴～当患者出现恶心、呕吐或肌肉震颤等症状时必须停止注射该药。苯二氨卓类药物中毒的重症患者可用特异拮抗剂安易醒,氟马西尼,治疗。药物治疗过程中出现意外的兴奋反应～可给予地西泮5mg静注。 ,5,碱化尿液～利尿治疗:可用5%碳酸氢钠80，100ml静滴～直至尿液pH值达到7.5，8.0～也可以用乳酸钠碱化尿液。给予补液治疗～20%甘露醇或呋塞米治疗～使尿量至少保持在50ml/h以上～减少药物在肾小管的重吸收～促进药物的排泄。 ,6,加强护理～注意保暖～定时翻身、拍背～防止肺部感染和褥疮的发生。 6、急性阿片类药物中毒的急救护理措施 此类药物包括可待因、吗啡、哌替啶等用于缓解剧痛的药物～易成药物依赖～突然停药可出现戒断症状。 ,1,一般处理:阿片类药物消化道中毒时可用1:5000的高 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031414eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration 锰酸钾或温开水洗胃～2%活性炭口服～硫酸钠导泻。忌用吗啡催吐。消化道和皮下注射药物～均应给予补液、利尿～保持尿量在50ml/h以上～促进药物由肾脏排出。 ,2,应用解毒剂:纳洛酮是阿片受体特异性拮抗剂～可阻断啊片类药物对中枢神经系统、心血管和消化系统的作用～缓解症状～清醒意识。 ,3,监测病人意识状态、瞳孔变化、生命体征及尿量。中毒期患者可出现口唇发绀、面色苍白、皮肤温度低、感觉减退、嗜睡、昏睡、四肢乏力～呼吸每分钟8~10次～且瞳孔针尖样缩小是阿片类药物中毒的重要标记。可存在对光反射。应用纳洛酮后患者意识可恢复。 ,4,观察病情变化:此类药物对呼吸中枢的抑制作用较强～尤其应注意患者的呼吸情况。麻痹期的患者为深昏迷～呼吸可慢至每分钟2~4次～或表现为潮式呼吸～可出现呼吸衰竭。患者脉搏细弱～血压下降～甚至休克。体温降低～皮肤湿冷。排尿困难～各种深反射及瞳孔对光反射均消失～病理征阳性。患者死亡原因主要为呼吸和循环功能衰竭。患者呼吸抑制明显～甚至出现呼吸衰竭～可给予吸氧、呼吸兴奋剂治疗。紧急时可行气管插管及呼吸机辅助通气。同时应监测血气。 ,5,注意监测血电解质及肝、肾功能～监测血、尿及胃内容物内阿片类药物的含量。 ,6,药物依赖患者在治疗过程中可出现戒断反应～应注意 ystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031415atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve hou 观察患者是否出现哈欠、流涕、流泪、疲倦、烦躁、出汗、无力、发冷、呕吐、震颤、易激惹、心率加快、血压升高、呼吸加深加快等症状。 ,五,应用血滤机持续床旁血液滤过的护理 持续静-静脉血液滤过是利用一个中空纤维滤过器～将血液从静脉引出～当流经滤过器时水分和小、中分子代谢废物被滤出～而大分子物质和血液有形成分通过静脉回到体内的一项新的血液净化技术。 1、护理措施 ,1,预冲管路 ?血滤机自检4~6分钟～自检时要把血泵的门、传感器的门关好这样利于减少机器自检通过的时间。 ?根据机器面板上的图示～连接血滤的管路～注意紧密连接所有的接头处～关紧传感器的门～预冲液体选择袋装生理盐水～以减少管路中进气。 ?预冲管路的液体流速控制在60ml/h左右～预冲的流速越缓慢～管路和滤器预冲就越充分～管路在血滤过程中能够使用更长的时间。 ,2,血滤管路与中心静脉连接时的护理措施 ?消毒三腔中心静脉动脉端的端口～抽出管路内封管液后～连接血滤管路的动脉端。 ?当机器自检到血液时～消毒中心静脉静脉端的端口～抽出 ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031416eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer 管路内的封管液～连接血滤管路的静脉端。 ?用无菌纱布包裹外露的中心静脉管路～并将管路连接处暴露～利于观察。 ,3,持续血液滤过中的护理措施 ?有条件应把病人放臵于单间或者病人较少的房间内～设专人护理。 ?血滤过程中～准确记录每小时的滤出液量、前稀释液量,透析液,、后稀释液量、温度、肝素剂量等～观察病人生命体征的变化～每12小时总结一次出入量。 ?管路连接处最好暴露～不要遮盖～保持体外血液回路持续通畅～避免打折等人为阻塞。 ?严格无菌操作～预防发生院内感染～每日更换穿刺处敷料～并注意观察穿刺点有无发红、红肿、分泌物等炎症表现。 ?病人寒战或体温升至38.5?时～应留取血培养。 ?注意血滤机的报警提示～查找报警原因～及时处理～以保证血滤的顺利进行。 ?遵医嘱及时抽血化验电解质情况～防止发生电解质紊乱。 2、主要护理问题 ,1,体温过高:与长时间中心深静脉臵管可能导致的感染有关。 ,2,体温过低:与臵换液加温程度有关。 ,3,血压过低:与血液滤过的流速及前稀释、后稀释液量 om location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031417atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, config 的设臵有关。 ,4,有皮肤完整性受损的危险:与病人连续血液滤过长时间卧床有关。 二、急诊科常见病护理常规 ,一,、呼吸衰竭护理 呼吸衰竭是呼吸功能严重障碍～呼吸大气压空气时～缺氧/或二氧化碳潴留～氧分压低于60mmHg(8kPa)～二氧化碳分压高于50mmHg引起的一系列生理功能和代谢紊乱的临床综合症。 1、护理措施 ,1,急性呼吸衰竭应绝对卧床休息～慢性呼吸衰竭代偿期～可适当下床活动。 ,2,进富有营养、高蛋白质、易消化饮食。原则上少食多餐～不能自食者～给予鼻饲～以保证足够热量及水的摄入。 ,3,病情观察:除定时测体温、脉搏、呼吸、血压、观察瞳孔变化及唇、指,趾,甲发绀外～特别注意以下几项指示: ?神志:对缺氧伴二氧化碳潴留病人～在吸氧过程中～应密切观察神志的细小变化～注意有无呼吸抑制。 ?呼吸:注意呼吸的节律、快慢、深浅变化。发现异常～应及时通知医师。 ?痰液:观察痰量及性状～痰量多、黄稠～表示感染加重～应及时通知医师～留标本送检。 ,4,氧气疗法:依病情及病理、生理特点～采取不同给氧 system hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031418eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on med 方式～争取短时间内使氧分压高于50mmHg～氧饱和度在80%以上。 ,5,保持呼吸道畅通:神志清楚病人～鼓励其咳痰～被动变换体位～翻身拍背～促使痰液引流。不能自行排痰者～及时吸痰～每次吸痰时间不超过15秒～防止缺氧窒息。 ,6,观察呼吸兴奋剂作用:如给药过快、过多～可出现呼吸过快、面色潮红、出汗、呕吐、烦躁不安、肌肉颤动、抽搐、和呼吸中枢强烈兴奋后转入抑制～应减药或停药。 ,7,纠正酸中毒:使用5%碳酸氢钠时～注意病人有无二氧化碳潴留表现。 ,8,纠正肺水肿:应用脱水剂、利尿剂、注意观察疗效。心功能不全时～静脉点滴不宜过快、过多。 ,9,病情危重、长期卧床者～应做好皮肤护理、生活护理。做好护理记录～准确记录出入量。 ,10,备好抢救物品:如气管插管、气管切开包、人工呼吸器、吸痰器、氧气、强心剂、呼吸兴奋剂等。 ,11,应用呼吸器病人的护理 ?熟悉呼吸器性能～呼吸器发生故障或病情变化时～采取有效的应急措施。 ?严密观察:a、观察病人自主呼吸的恢复和均匀程度～以便适当调节呼吸频率、潮气量、呼吸时比,b、观察病人有无自主呼吸～与呼吸器是否同步。注意有无通气不足～呼吸道阻塞引起 om location component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031419atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, config 烦躁不安及管道衔接处是否漏气,c、监测体温、脉搏、呼吸、血压、神志、瞳孔的变化。正压吸气可使心排出量减少～血压下降。如心功能改善～心率、血压平稳～四肢暖～皮肤红润～无汗～说明呼吸器使用得当。 ?保持呼吸道通畅～掌握适宜的氧浓度～一般在40%以下～及时吸痰～防止痰栓形成～注意防止套囊脱落。 ?预防并发症:a、注意呼吸道湿化～防止异物阻塞而窒息,b、监测血气及电解质变化～防止缺氧、低血压、休克的发生。 ,12,出院指导 ?注意休息～生活健康～戒烟、酒～少去人多的场所。 ?进行适当的体育锻炼～避免剧烈运动。 ?加强营养～进食高蛋白、高热量、低脂肪的饮食。 ?坚持呼吸锻炼～改善肺功能。 2、主要问题 ,1,气体交换受损:与疾病致肺换气障碍有关。 ,2,清理呼吸道无效:与气管插管致不能咳痰有关。 ,3,生活自理能力缺陷:与长期卧床或气管插管有关。 ,4,营养失调:低于机体需要量～与慢性疾病消耗有关。 ,5,活动无耐力:与疾病致体力下降有关。 ,6,焦虑/恐惧:与担心疾病预后有关。 ,7,便秘:与长期卧床致肠蠕动减慢有关。 ,8,语言沟通障碍:与气管插管致失语有关。 -g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031420eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program ,9,有皮肤完整性受损的危险:与长期卧床有关。 ,二,心肌梗死护理 心肌梗死是在冠状动脉病变的基础上心肌缺血性坏死～发生冠状动脉血供急剧减少或中断～相应的心肌严重而持久地急性缺血所致。临床表现有持久的胸骨后剧烈疼痛、发热、白细胞计数和血清心肌酶增高以及心电图进行性改变,可发生心律失常、休克或心力衰竭～属冠心病的严重类型。 1、护理措施 ,1,入院后应住监护室～尽可能住单间～因监护室有各类抢救物品及药品～便于抢救。 ,2,立即缓解疼痛～给予吗啡等药物镇痛～如疼痛持续不缓解～可每隔5分钟重复给予。同时要注意生命体征的变化～尤其是呼吸情况。 ,3,急性期,发病后的前3日,要绝对卧床～尽量少搬动病人～非搬动不可时轻慢平缓。协助病人床上进食、排便等。满足病人的生活需要～限制探视～避免紧张及刺激。无并发症者～第四日可床上活动～无不适可床边活动。 ,4,给予持续的心电、血压、血氧监测至少3日～观察心率、心律、呼吸、血压。应用利多卡因时应注意心率、心律的变化～发现异常随时记录～以便及时处理～减少死亡率。 ,5,给予持续低流量吸氧,2~3L/min,,以改善心肌缺氧及提高血氧含量。 ation component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031421atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom loc ,6,准确记录出入量～如量不足或过多～尿量〈3ml/h,应及时通知医师。 ,7,保持排便通畅～病人长期卧床及不习惯床上排便～常会导致便秘～因此～常规每日给病人服用缓泻剂～避免排便用力而突然发生意外。 ,8,前3日进食清淡、易消化的流质饮食～以后逐渐过渡到低盐,2g/d,、低脂饮食～且应少食多餐～禁止摄取过冷、过热或刺激性食物～以减少心脏负担。 ,9,观察疼痛的部位、程度及伴随症状～遵医嘱用药～并注意观察各种常见并发症的出现,如心衰、休克、心律失常,～随时做好抢救工作。 ,10,急性期病人多表现虚弱、疲倦、依赖～担心以后能否正常生活～应给病人解释病情～并保证各种治疗的及时有效～缓解病人的焦虑情绪～以减轻心脏负担～同时保证足够的睡眠。 2、主要护理问题 ,1,疼痛:与心肌缺血、缺氧有关。 ,2,心排出量减少:与再灌注性心律失常有关。 ,3,体温过高:与心梗后吸收热有关。 ,4,潜在并发症:猝死～与心脏破裂或心律失常有关。 ,5,自理能力缺陷:与医嘱限制活动、长期补液或疼痛有关。 ,6,焦虑:与缺乏相关疾病知识及担心预后有关。 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031422eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration ,7,知识缺乏:与特定信息来源受限有关。 ,三,心力衰竭护理 心力衰竭指在静脉回流正常的情况下～原发的心脏损害引起心排出量减少～不能满足组织代谢需要的一种综合征。临床以肺循环和/或体循环淤血以及组织血液灌注不足为主要特征～又称充血性心力衰竭。 1、护理措施 ,1,环境:尽量安排病人住单人房间～加床挡～保持室内空气新鲜及适宜的温度、湿度～以利病人休息。 ,2,体立:半卧位或端坐位～急性期可采用下肢下垂或四肢轮扎～减少回心血量～改善肺淤血～同时注意病人安全～防止坠床。 ,3,皮肤情况:保持床铺整洁～无渣～骨隆突处垫褥疮垫～每2小时翻身1次～水肿部位应轻握轻碰。 ,4,病情观察:随时观察病情变化～及时处理～并做好记录。 ,5,出入量:严格记录24小时出入量。摄入量包括由口摄液、静脉补液,排出量包括尿量、呕吐物与引流液～必要时限制入量～补液可采用混合浓缩法以减少摄入量。每日测量腹围及定时测体重～以了解体内液体情况～摄入量过多或过少均应通知医师。 ,6,镇静:心衰病人多有烦躁不安～要经常巡视病人～安 ation component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031423atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom loc 慰病人～减轻病人的焦虑。必要时遵医嘱予地西洋,原称安定,或吗啡等镇定剂～以减少心肌耗氧量～缓解症状,但应注意吗啡会引起呼吸抑制～应监测病人呼吸状况,。 ,7,用药护理 ?利尿剂:尽量在白天用～防止病人夜尿过多～影响睡眠。用强利尿剂时注意电解质情况～并定期复查～防止低钾等电解质紊乱的发生。肌内注射应避开水肿部位。 ?洋地黄类:定期复查药物浓度～用药前先测心率～<60次/分～应停药并通知医师。静推去乙酰毛花苷时～速度要慢～并有第2人听心率～观察用药反应。 ?血管扩张剂:应用硝普钠时应避光～每4~6小时更换药物1次～以避免影响疗效。同时监测血压变化～防止低血压的发生。 ,8,吸氧:用鼻导管或面罩给氧～急性期4~6L/min～在湿化瓶中加入30-50%酒精～以消除泡沫。慢性心衰2~3L/min～以改善缺氧～并监测血氧浓度及血气变化。 ,9,补液速度:速度不可过快,20~40滴/分,～不可过多。防止发生急性肺水肿。 ,10,饮食:饮食宜清淡、低盐,限盐2g/d,、易消化～少食多餐～避免进食腌渍类、罐头、奶酪等食品。 ,11,休息:卧床期间应协助并满足病人的生活需要。 ,12,活动:每日进行适量的活动～开始在室内活动～逐渐到病房外活动～循序渐进～以不引起心率加快、血压升高、呼吸 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031424eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration 困难、疲乏等不适为度。 ,13,心理护理:病人常因病情反复而表现烦躁不安、紧张恐惧、悲观失望等～以致加重病情～因此～要鼓励、支持病人～讲明心理因素对疾病的影响～增强其治疗信心。 2、主要护理问题 ,1,气体交换受损:与肺淤血有关。 ,2,活动无耐力:与心排出量减少～氧气供需失衡有关。 ,3,心排出量减少:与心肌功能不良有关。 ,4,睡眠形态紊乱:与夜间呼吸困难或夜尿过多有关。 ,5,有皮肤完整性受损危险:与水肿、活动受限有关。 ,6,知识缺乏:与特定信息来源受限有关。 ,四, 脑梗死护理 脑梗死又称缺血性脑卒中～是指脑部血液供应障碍～缺血、缺氧引起的局限性脑组织的缺血性坏死或脑软化。临床常见类型有脑血栓形成、腔隙性梗死和脑栓塞等。发病原因为高血压、动脉粥样硬化。临床特点是起病较缓慢～常在夜间血流缓慢时和血压低时发病。神经系统局灶性症状多在发病后10多小时或1~2天内达到高峰。除脑干梗死和大面积梗死外～多数病人意识清楚或仅有轻度意识障碍。脑栓塞是指各种栓子随血流进入颅内动脉系统～使血管腔急性闭塞引起相应供血区脑组织缺血坏死及脑功能障碍。突然发病～且病情发展迅速。一般病人意识清楚～可有偏瘫、失语、吞咽困难等症状～严重者可有脑水肿、颅压增高、 rs Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031425atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer ro 昏迷等。 1、护理措施 ,1,脑梗死急性期绝对卧床休息～头位不宜过高～以利脑部血液供应。 ,2,注意保持呼吸道通畅～防止误吸～并发肺部感染者～定时更换卧位、拍背、吸痰～防止痰液坠积。 ,3,注意病人四肢出现多发性栓塞的可能～给病人翻身或活动肢体时～注意四肢动脉血管搏动情况及皮肤温度、颜色有否改变～做到早发现、早处理。 ,4,加强皮肤护理～每天给病人擦澡1次～2~3小时翻身一次～床铺要干净～及时更换尿垫～防止压疮的发生。 ,5,饮食方面:进食高蛋白、易消化食物。多食含粗纤维食物～防止发生便秘。 ,6,卧床期间应保持病人排便通畅～定时按摩腹部～养成良好的排便习惯。 ,7,病人在床上活动时～要加床挡防止坠床。 ,8,对瘫痪肢体应早期进行被动活动和按摩～病情稳定后～应鼓励病人多做主动锻炼～并逐渐加大活动量～以防患肢挛缩畸形、关节强直疼痛。促进神经活动功能恢复。失语病人应鼓励并加强语言功能方面的锻炼～如从简单的发音诱导病人。 ,9,应用抗凝药物应注意观察有无出血倾向。 2、主要护理问题 room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031426eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configurationfloor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical ,1,潜在并发症:出血～与溶栓治疗有关。 ,2,生活自理能力缺陷:与肢体偏瘫有关。 ,3,躯体移动障碍:与脑缺血～缺氧导致运动功能受损有关。 ,4,有误吸的危险:与吞咽困难有关。 ,5,语言沟通障碍:与脑缺血导致语言障碍有关。 ,6,有感染的危险:与长期卧床～吞咽功能障碍易引起坠积性肺炎有关。 ,7,便秘:与长期卧床～肠蠕动减少有关。 ,8,有皮肤完整性受损的危险:与偏瘫～感觉障碍有关。 ,五,脑出血护理 脑出血又称脑溢血～是指原发性非外伤性脑实质出血～可由多种原因引起～但临床多数病人主要源于高血压、动脉硬化。此病发病急骤～常在活动中发病～与情绪激动、饮酒、过于劳累～用力排便等诱因有关。临床表现:重症脑出血表现为剧烈头痛、呕吐、面色潮红、昏迷、尿便失禁。如脑室出血～出现肢体强直、抽搐、瞳孔散大或不等大、偏瘫、凝视麻痹等～同时伴有心血管病。急性期过后～又常留有不同程度的偏瘫、失语～甚至脑软化等后遗症。 1、护理措施 ,1,随时注意观察病情变化～如意识、瞳孔的变化～定时监测呼吸、体温、脉搏、血压等～发现异常,瞳孔不等大、呼吸 rs Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031427atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom location component) computer network systems and voice communications systems Center of information on medical floor computer ro 不规则、血压高、脉搏缓慢,～及时报告医师立即抢救。 ,2,绝对卧床休息～取头高位～15~30?～头臵冰袋可控制脑水肿～降低颅压～利于静脉回流。吸氧可改善脑缺氧～减轻脑水肿。翻身时动作要轻～尽量减少搬动～加床挡以防坠床。 ,3,神志清楚的病人～谢绝探视～以免情绪激动。 ,4,脑出血昏迷的病人24~48小时内禁食～以防止呕吐物反流至气管造成窒息或吸入性肺炎～以后按医嘱进行鼻饲。 ,5,加强尿便的护理:若病人有尿潴留或不能自行排尿～应进行导尿～并留臵尿管～定时更换尿袋～注意无菌操作～每日冲洗会阴1~2次～便秘时定期给予通便药或食用一些粗纤维的食物～嘱病人排便时勿用力过猛～以防再出血。 ,6,遵医嘱静脉输注脱水药物～降低颅压～适当使用降压药～使血压保持在正常水平～防止血压高引起再出血。 ,7,预防并发症 ?加强皮肤护理～每日小擦澡1~2次～定时翻身～每2~3小时翻身1次～床铺干净平整～对骨隆突处的皮肤要经常检查和按摩～防止发生压疮。 ?加强呼吸道管理～保持口腔清洁～口腔护理每日1~2次～病人有咳痰困难～要勤吸痰～保持呼吸道通畅～若病人呕吐～应让其头偏向一侧～以防发生肺炎。 (8)急性期应保持偏瘫肢体的生理功能位臵。恢复期应鼓励病人早期进行被动活动和按摩～每日2~3次～防止瘫痪肢体的 floor computer room located in the engine room. Voice communication system using a local telecommunications operator providinical room network, communication component) computer network systems and voice communications systems Center of information on medsystem hours, five hours Kok Kok intelligent integrated system of information system (1) cabling systems (including computer ercomormation application system queued station ICU visitation system operation the system monitoring and training system call intentrance control system car library management system hours three Kok building equipment monitoring system hours four Kok inf m outautomatically alarm system (containing public broadcast part) security technology prevention system security monitoring syste work, communications part) wired TV system information guide and the released system hours II Kok public security system firewiring system (containing room net471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -ction and acceptance of GBJ2322000 of electrical installations code for constru-for computer software engineering GB/T5031428eetcations ... If any compatibility requirements, by way of increased access to the Communications Board within the chassis to mcontrolled switchboards. Operators providing communi-independent integrated services digital program-g voice service, configuration 挛缩畸形和关节的强直疼痛～以促进神经功能的恢复～对失语的病人应进行语言方面的锻炼。 2、主要护理问题 ,1,疼痛:与颅压增高有关。 ,2,生活自理能力缺陷:与限制活动卧床有关。 ,3,躯体移动障碍:与偏瘫有关。 ,4,语言沟通障碍:与失语有关。 ,5,便秘:与长期卧床～肠蠕动减慢有关。 ,6,有皮肤完整性受损危险:与偏瘫～感觉障碍～尿失禁有关。 ,7,清理呼吸道无效:与肺部感染长期卧床、昏迷有关。 ,8,有误吸危险:与昏迷有关。 ,9,营养失调:低于机体需要量～与吞咽困难～昏迷有关。 ,10,有感染的危险:与长时间留臵尿管有关。 ,11,便秘:与长期卧床～肠蠕动减少有关。 ation component) computer network systems and voice communications systems Center of information on medical floor computer rors Kok Kok intelligent integrated system of information system (1) cabling systems (including computer room network, communicve houystem queued station ICU visitation system operation the system monitoring and training system call intercom system hours, fim car library management system hours three Kok building equipment monitoring system hours four Kok information application ssyste stem (containing public broadcast part) security technology prevention system security monitoring system out entrance controlrt) wired TV system information guide and the released system hours II Kok public security system fire automatically alarm sywiring system (containing room network, communications pa471 2. system description this times engineering weak design including: hours a Kok information facilities system integrated -92 intelligent building weak design construction figure set GJBT -GBJ232 2000 of electrical installations code for construction and acceptance of-for computer software engineering GB/T5031429atibility requirements, by way of increased access to the Communications Board within the chassis to meetcontrolled switchboards. Operators providing communications ... If any comp-independent integrated services digital program-urationated in the engine room. Voice communication system using a local telecommunications operator providing voice service, configom loc