本課的重點、難點： 1．病情觀察的方法 2．病情觀察的內(nèi)容 3．心肺復(fù)蘇術(shù) 4．人工呼吸機的使用 5．多功能心電監(jiān)護(hù)儀 6．危重病人的護(hù)理 教學(xué)目標(biāo)： 1．復(fù)述病情觀察的內(nèi)容。 2．列出心跳、呼吸停止的判斷標(biāo)準(zhǔn)及原因。 3．復(fù)述心肺復(fù)蘇的基本步驟。 4．描述胸外心臟按壓及人工呼吸的有效指標(biāo)。 5．描述洗胃的適應(yīng)癥、禁忌癥。 6．根據(jù)病人具體情況正確選擇洗胃方式和洗胃溶液。 7．復(fù)述人工呼吸機的使用方法。 8．為危重病人制定護(hù)理計劃。 9. 按操作規(guī)程進(jìn)行心肺復(fù)蘇與洗胃。 本次課應(yīng)用的教具： 1、自制多媒體課件 2、電腦、投影儀、等。 3、紅外線筆 主要教學(xué)內(nèi)容： Chapter 1 Observing the Patients’ Condition Methods of Observing Patient’s Condition Direct observation Direct observation is the solution that the patient is observed through sensory organs. Inspecting It is the essential method that the nurse should master. Lighting should be adequate during examination. Inspecting should include the appearance, behavior and consciousness of the patient and the systems’ variation of physiology and pathology. Auscultation Sounds caused by different positions of the patient can be differentiated with ears or stethoscope. It should be carried out with no disturbance. Palpation We can know the temperature, humidity, elasticity, and glossiness of skin and outward appearance, rigidity, movement of organs with tactile sensation. Percussion It is applied to assess the condition of chest and abdomen. We use percussion or slap to examine the special part of body. According to the vibration and sounds, we can know the shape, position and density of organs, e.g., lower boundary of lung, boundary of heart. Smelling Smelling can be used to distinguish all kinds of the patient’s odor in order to definite the patient’s health condition. ● The Respiratory system There is the absence or presence of abnormal odor, for example, fetid odor, rotte執(zhí)業(yè)醫(yī)師n or fruity. ● The Digestive system Is halitosis present or not? Can you find out special odor of stool? ● The Urinary and reproductive system There is the absence or presence of unusual odor, for example, fetid, sweet, musty. Has discharge of genitalia abnormal odor? ● Skin Has discharge of skin fetid odor? Contents of Observing the Patient’s Condition Patient’s general condition Development and bodily form Development is judged by age, height, weight, intelligence. Anthropometric measurements are used to determine body dimensions. They can give indirect measurements of body protein and fat stores. Height and Weight are the most common anthropometric measurements. Diet and nutrition Rational diet is important in the course of treating illness. The nurse should pay attention to observing the patient and gather information concerning appetite, food intake, reaction after dinner, custom and some addition. Facial features expression Normal expression is natural and relaxed. Some characteristic faces and expression will appear when the diseases are developing constantly. Commonly special faces are as follows: ● Acute facies ● Chronic facies ● Critical facies ● Mitral facies ● Anaemic facies (hippocrates facies) Position The patient’s position is intimately related to diseases. Posture and gait Rocking when walking is called wadding gait, which could result from congenital dislocation of the hip, rickets, hypoalimentation and so on. Sleep The nurse should interview the client to obtain a sleep history. Skin and mucosa Skin and mucosa can reflect some diseases. The nurse should observe the color, temperature, humidity, elasticity and absence or presence of hemorrhage, edema, rashes (skin eraption), cysts, subcucmeous nodules and so on. Lips, nail beds and conjunctive of anaemic patients are pallor. Cyanosis is blueness of the skin due to a lack of oxygen in the blood. It often occurs in the conditions of cor pulmonale (pulmonary heart disease) and heart failure. Jaundice is another change in the color of the patient’s skin. Edema (swelling) is the result of an abnormal amount of water in the tissue. Vomitus Emesis (vomiting) is a phenomenon that material in the stomach is spat out through esophagus and oral cavity. Emesis has many causes. It follows mental or emotional disturbance and has no physical cause. It may be due to the disturbance or obstruction of the alimentary tract; the vomited material may tell much about this. States of consciousness Disturbance of consciousness is the state of lacking normal response to the surroundings. It can be classified: Somnolence It is the slightest disturbance of consciousness. The patient keeps on the state of sleeping, but can be wakened by words or slight stimuli, and answer questions correctly and simply. Besides, the patient is slow in thought and reaction. Confusion The patient has partially or completely wrong orientation to time, place and person, slow in thought and reaction and use of simple, nontechnical words. Stupor The patient sleeps deeply and is difficult to be wakened. Strong stimulation can waken him and he will answer the question vaguely and even give an irrelevant answer. The patient will fall asleep at once after stropping stimulation. Coma It is the heaviest disturbance of consciousness. It can be classified: Observation of pupils Pupils always change because of brain diseases, poisoning, coma and so on. So a nurse should observe the change of pupils in order to find out the change of the patient’s condition. Normal pupils are round, equal diameter of two pupils and have sensitive light reflex. Chapter 2 Cardiopulmonary Resuscitation Relating to Concepts Basic life support: Basic life support includes a rapid entry into the emergency medical service (EMS) system, use of techniques to clear an obstructed airway, and performance of CPR. Cardiopulmonary resuscitation (CPR): Cardiopulmonary resuscitation is a technique that externally supports the circulation and ventilation (breathing) in a victim of cardiopulmonary arrest. It helps to provide oxygen to the brain, heart, lungs, and other organs, until advanced life support can be given. Cardiopulmonary Resuscitation (CPR) Cardiopulmonary resuscitation must be performed immediately after cardiac and respiratory arrest. Studies indicate that hospital discharge rates are highest when CPR is started within 4 minutes from the time of the cardiopulmonary arrest and in patients who also receive advanced life support within 8 minutes of the arrest. Assess lack of pulse and breathlessness ● Unresponsiveness or unconsciousness ● Breathlessness ● Lack of pulse, especially carotid pulse ● Pupils are larger than 5 mm. ● Skin is pale or in cyanosis ● Cardiac sound is disappear ● Wound is never bleeding ABC of CPR The nurse can assess patients in any emergency situation in an orderly manner by using the following memory help: A = Airway B = Breathing C = Circulation A: Airway Assess responsiveness The person must establish unresponsiveness, shake the person’s shoulder, cleagydjdsj.org.cn/yaoshi/r his pupils, and shout, “Are you okay?” Call for help Call out for someone to help you. You may need (1) to turn to the person or (2) to call the emergency medical system (EMS). Position the person The person must be in a supine (back-lying) position, a hard surface, if you are to perform CPR. Finger-sweep to remove foreign matter Any foreign matter, vomitus, or liquids should be removed from the airway before resuscitation begins. If a foreign body can be seen in the mouth, it should be removed with the fingers. Do not finger-sweep a child’s mouth! The tongue is the most common cause of obstructed airway in an unconscious victim. In many cases all that is needed is to open the patient’s airway to restore breathing. If dentures can be taken out, remove them. Open the airway If a neck injury is not suspected, you can: open the patient’s airway by placing your hand close to the patient’s head on the patient’s forehead, pressing back and down; and placing the fingers of your other hand under the bony part of the patient’s chin and lifting it up. If the nurse has a reason to believe that there may be a neck injury, the jaw-thrust method should be used to open the airway. This is done by positioning the hands at the angle of the patient’s jaw. The jaw is displaced forward while tilting the head backward. B: Breathing Determine if the person is breathing To assess the absence or presence of breathing, the nurse’s ear should be placed near the person’s nose and mouth while holding the person’s airway in an open position. Several ways are used to determine if the person is breathing, such as: (1) look at the chest, to see if it rises and falls; (2) listen for sounds of breathing; (3) feel for any air exchange against your cheek. If the nurse determines that the patient is not breathing, rescue breathing must be performed. Perform rescue breathing With the head positioned to keep the airway open, grasp the nose with the fingers of your hand on the person’s forehead. The nurse should take a breath and create an airtight seal with his or her lips around the person’s mouth. Breathe into the patient’s mouth twice. The nurse takes a new breath before each rescue breath. The patient is allowed to exhale passively between breaths. Ventilate the adult patient 14 to16 times a minute. The child should be ventilated 18 to 20 times a minute. This is called mouth-to-mouth ventilation. C: Circulation Check the pulse The nurse should gently palpate the pulse for 5 to 10 seconds, being careful not to compress the artery, and avoid reaching across the patient to palpate the carotid pulse. Take the pulse of only one carotid artery at a time. Resuscitation if the patient’s heart is beating If a pulse is present, keep on ventilating the patient. Continue to monitor the pulse, because it may stop. Resuscitation if the patient’s heart is not beating If there is no pulse, external chest compressions must be applied. ● Single-rescue CPR The adult chest is compressed from 3 to 5 cm, at the rate of 60 to 100 times a minute, with a ratio of 15 compressions to 2 breaths. This is continued for approximately 1 minute. After 1 minute the pulse is checked for 5 seconds. If a pulse is not found, CPR is continued for 4 to 5 minutes before the pulse is again checked. If no pulse is found, resume CPR. Recheck the pulse every few minutes. Standard for evaluating ● Respiration is resuming and heart is beating again. ● Pulse can be touched. ● The color of face, lips, nails and skin turns red. ● Sounds of breath can be heard during exhalation. ● Dilating pupils reduces. ● Consciousness resumes. ● Urine appears. ● ECG waveform alters. Chapter 3 Gastric Lavage Gastric lavage is the way that the stomach is washed down with some washing, via nasogastric cavity taken from oral cavity or nasal cavity to the stomach. The procedure, which is usually done within 6 hours, is most frequently carried out in case of poisoning. Otherwise, the stomach contents are removed that can relieve edema of gastric mucosa to the patient who has pyloric obstruction and prepare for some operations or examinations. The procedure is the same as nasogastric gavage. In an emergency or when the physician’s order is given, the nurse is responsible for carrying it out. | 
