危重病人的病情观察及抢救护理-课件2何为病情观察？何为病情观察？即护理人员在工作中积极启动视、即护理人员在工作中积极启动视、听、嗅、触等感觉器官及辅助工听、嗅、触等感觉器官及辅助工具来获得有关病人及其情境的信具来获得有关病人及其情境的信息过程；息过程；观察病情变化是护理工作的一观察病情变化是护理工作的一项重要内容，是一项系统工程，项重要内容，是一项系统工程，它贯穿于护理的全过程。它贯穿于护理的全过程。瞳孔1.1.形状、大小和形状、大小和对称性称性 2.2.对光反光反应 正常人瞳孔双侧等大，呈圆形居中，正常人瞳孔双侧等大，呈圆形居中，边缘整齐，在自然光线下直径约为边缘整齐，在自然光线下直径约为2.52.54mm4mm。瞳孔散大（直径。瞳孔散大（直径5mm5mm），常见于颠茄类药物反应、颅内压增高及濒死期病人；瞳孔），常见于颠茄类药物反应、颅内压增高及濒死期病人；瞳孔缩小（直径缩小（直径2mm2mm），常见于有机磷农药、巴比妥及吗啡类药物中），常见于有机磷农药、巴比妥及吗啡类药物中毒等；一侧瞳孔散大常见于脑疝、脑肿瘤、脑出血压迫一侧动眼毒等；一侧瞳孔散大常见于脑疝、脑肿瘤、脑出血压迫一侧动眼神经等。神经等。 正常人瞳孔对光反应灵敏，若瞳孔大小不随光线刺激而变化，称瞳正常人瞳孔对光反应灵敏，若瞳孔大小不随光线刺激而变化，称瞳孔对光反应消失，常见于深度昏迷或濒死期病人。孔对光反应消失，常见于深度昏迷或濒死期病人。 循循环功能的功能的观察察休克指数心率/收缩压的比值，表示血容量正常0.5为正常1为轻度休克，失血20301为休克1.5为严重休克，失血30502为重度休克，失血50%心肌耗氧=心率收缩压的积12000平均血压：舒张压+1/3脉压=60-100MMHG中心静脉压（VCP）正常值：5-12CMH2O小于5右心充盈不佳，血容量不足大于15-20右心功能不良，负荷过大呼吸功能呼吸功能监测肺泡通气量：是指静息状态下单位时间内进入肺泡的新鲜空气量肺泡通气量和血流比比值大灌注不足（无效通气）比值小通气不足（无效灌注）氧饱和指数动脉血气分析paO2（动脉血氧分压） 为80100mmHg。肺泡通气量：是指静息状态下单位时间内进入肺泡的新鲜空气量肺泡通气量和血流比比值大灌注不足（无效通气）比值小通气不足（无效灌注）氧饱和指数动脉血气分析paO2（动脉血氧分压） 为80100mmHg。脑功能功能监测颅内内压临床多用症状观察法：脑膜刺激症状、头痛、呕吐、球结膜水肿、视N乳头水肿等临床多用症状观察法：脑膜刺激症状、头痛、呕吐、球结膜水肿、视N乳头水肿等心理观察情绪状态的观察情绪状态的观察压力及应对的观察压力及应对的观察社会状况的观察社会状况的观察认知能力的观察认知能力的观察特殊检查和药物治后的观察特殊检查和药物治后的观察特殊检查后的观察：特殊检查后的观察：防止并发症的发生；防止并发症的发生；一些治疗方法时病人的观察：一些治疗方法时病人的观察：观察治疗是否有效、有无并发症；观察治疗是否有效、有无并发症；药物治疗病人的观察：观察药物治疗的效果药物治疗病人的观察：观察药物治疗的效果及毒副反应。及毒副反应。Cycle DiagramADD YOUR TITLETEXTTEXTTEXTTEXTTEXTTEXTDiagramYOUR TITLEYOUR TITLEYOUR TITLEwelcome to use these powerpoint templates, New Content design, 10 years experiencewelcome to use these powerpoint templates, New Content design, 10 years experiencewelcome to use these powerpoint templates, New Content design, 10 years experienceDiagramADD YOUR TITLEwelcome to use these powerpoint templateswelcome to use these powerpoint templateswelcome to use these powerpoint templateswelcome to use these powerpoint templatesDiagramwelcome to use these powerpoint templates, New Content design, 10 years experiencewelcome to use these powerpoint templates, New Content design, 10 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experience结束语结束语谢谢大家聆听！谢谢大家聆听！33