1、第九章 创伤病人的护理Chapter9 Nursing Care of Patients Experiencing Trauma,Yanyan Wang E-mail:A,Learning Outcomes:,Define the word trauma. Define the types of trauma. Discuss the causes, effects, and initial management of trauma. Describe collaborative interventions for patients experiencing trauma. Use the n
2、ursing process as a framework for providing individualized care to patients experiencing trauma.,Definition and Introduction,Trauma is defined as injury to human tissues and organs resulting from the abnormal transfer of energy from the environment.,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。,【概述】,创伤(tra
3、uma)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。,In the past, the term trauma has been associated with the word accident. Accident means that the injury ocurred without intent, just a result of random chance. We
4、now know that considerable number of injuries are preventable and not of random chance. Intentional and nonintentional trauma encompasses a variety of injuries resulting from motor vehicle crashes, pedestrian injuries, gunshot wounds, falls,voilence towards others, or self-inflicted violence. The in
5、juries,disabilities,and deaths resulting from these acts constitute a major healthcare challenge.,Role of Nurses,Trauma usually occurs suddenly, leaving the patient and family with little time to prepare for its consequences. Trauma may alter the patients previous way of life, potentially effecting
6、independence, mobility, cognitive thinking ,and appearance. Nurses provide a vital link in both the physical and psychosocial care for the injured patient and family. In caring for the patient who has experienced trauma, nurses must consider not only the initial physical injury, but also its long-te
7、rm consequences, including rehabilitation.,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。,Types of Trauma,Generally, trauma can be classified as: minor trauma major trauma,Minor
8、 traumacauses injury to a single part or system of the body and is usually treated in a physicians office or in the hospital emergency department. eg. a fracture of the clavicle, a small second-degree burn, and a laceration（撕裂伤） requiring sutures(缝合),Major or Multiple traumainvolves serious single-s
9、ystem injury(such as the traumatic amputation截肢 of a leg) or multiple-system injuries.,Specifically,trauma is further classified as eitherblunt orpenetrating,Blunt trauma,Blunt traumaoccurs when there is no communication between the damaged tissues and the outside environment. Blunt forces often cau
10、se multiple injuries that may affect the head, spinal cord, bones, thorax(胸腔)，and abdomen. Blunt trauma is frequently caused by motor vehicle crashes, falls, assaults, and sports activities.,Blunt trauma,It includes :contusion(挫伤)sprain（扭伤）crush injury（挤压伤）concussion（震荡伤）luxation and semiluxation（关节
11、脱位和半脱位）closed fracture（闭合性骨折）closed internal injury（闭合性内脏损伤）,Penetrating trauma,Penetrating traumaoccurs when a foreign object enters the body, causing damage to body structures. Structures commonly affected include the brain, lungs, heart, liver, spleen, the intestines, and the vascular system.Exam
12、ples of penetrating trauma are gunshot or stab wounds(刺伤) , impalement（穿刺）,and incised injury(切割伤).,Other types,Other types：inhalation injuries from gases, smoke,steam, burn or freezing injuriesblast injuries from explosions,Classes of Trauma,Outcome studies show a correlation between survival rates
13、 of multiple trauma victims and rapid respose times by pre-hospital providers, coupled with appropriate decision making with regards to transporting victims.,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。,Classes of Trauma,Trauma patients are classified as Class 1,2 or 3 based on factors, including：
14、mechanism of injuries,vehicle speed,height of falls,location of penetrating injuries.,Class 3 trauma the least severe, without loss of consciousness or significant injury.Class 1 trauma the most severe, involves life-threatening injuries likely to require medical specialists or immediate surgical in
15、tervention.,So what is Class 2 trauma?,Any hospital emergency department should be capable of caring for Class 3 trauma patients, patients meeting Class 1 or 2 should be transported to a designated trauma center when possible.,【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
16、，其病理过程与一般炎症相同，一般35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。,【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
17、减弱，淋巴细胞数量减少、功能降低等），易发生感染。,【病理生理】,（三）损伤的修复 、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。,、损伤的修复过程（三阶段）： （1）炎性反应阶段：约35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
18、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。,、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。,4、影响损伤愈合的因素（1）局部因素：细菌感染；创口内异物；血运障碍；特殊部位（如关节处）（2）全身性因素：年龄（老年人）；慢性疾病：如糖尿病、结核、
19、肿瘤等；营养状况：营养不良或肥胖；药物：抑制细胞增生药(如皮质类固醇)；免疫功能低下。,Clinical Manifestation,Symptom:painfeverSystemic Inflammatory Response Syndrome (SIRS),【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：体温38OC或90次分钟；呼吸20次分钟或过度通气， PaC0212X109L或0.1。 4、其他：可伴有食欲减退、倦怠和失眠等,Clinical Manifestation,Signs:P 、R、BPwound and hemorrhaget
20、enderness(压痛) and swelldysfunction,【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,【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。,【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
21、质性器官损伤和腔内积液。,【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。,Effects of Traumatic Injury创伤后效应和结果,Death is a common result of serious traumatic injury, and may be immediate, early, or late. Immediate.Because of the serious consequences of trauma, it
22、is important to rapidly identify the patients injuries and institute appropriate interventions quickly.,Head and Neck Effects Thoracic Effects Hemorrhage Abdominal Effects Neurologic Effects Multiple Organ Dysfunction Syndromes (MODS),Head and Neck Effects,Head and Neck Effects,Airway Obstruction Ma
23、intenance of the airway and cervical spine（颈椎） are the highest priority in the trauma patient.,Head and Neck Effects,Assessment,Assessment includes ：determining airway patency. reassess the effectiveness of the intervention. assess the effectiveness of breathing.,Head and Neck Effects,Determining ai
24、rway patency,If the patient is unresponsive, manual opening of the airway using a jaw thrust maneuver（托下颌法) is necessary The jaw thrust maneuver is recommended in patients with actual and potential C-spine injury.,Head and Neck Effects,Determining airway patency,Once the airway is opened, the practi
25、tioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear.,Head and Neck Effects,Reassess the effectiveness of the interventio
26、n,For example, if you suction(吸，抽吸) the airway to remove vomitus, you would reassess the airway after suctioning to determine if that intervention was successful or if you have to re-suction the airway a second time.,Head and Neck Effects,Reassess the effectiveness of the intervention,In addition to
27、 suctioning, other airway adjuncts available includeoral or nasal pharyngeal(鼻咽部) airways, laryngeal（喉部）airway and endotracheal intubation(气管内插管). Intubation is the preferred method of airway management.,Assess the effectiveness of breathing,Assessment should include if the patient has spontaneous b
28、reathing（自主呼吸）, good rise and fall of the chest, determination of skin color, general rate and depth of respirations, abdominal or accessory muscle use, position of the trachea（气管）, observation of chest wall（胸壁） integrity ，presence of jugular vein distension(颈静脉怒张) as well as the presence of any sur
29、face trauma.,Trauma patients may exhibit several aspects of airway management that are unique and require special preparation and precautions.,Lets discuss together.,Head and Neck Effects,Closed head injury,Changes in hemodynamics, oxygenation, and ventilation should be minimized in order to maintai
30、n adequate cerebral perfusion pressure(脑灌注压). The goal is to maintain a PaCO2 of 30-35mmHg.,Head and Neck Effects,Closed head injury,But intubation can cause a marked increase in intracranial pressure(ICP,颅内压), and also lidocaine administered 3-5minutes prior to intubation can blunt （使减弱）an increase
31、 in ICP that is secondary to laryngeal stimulation（喉部刺激）. Beta blockers（普萘洛尔、阿替洛尔） can be given 2-3 minutes prior to intubation to attenuate the sympathetic(交感神经的)response in a normotensive patient.,Head and Neck Effects,Maxillofacial trauma 颌面部创伤,Significant distortion of normal anatomy in facial t
32、rauma and respiratory compromise(呼吸道损害) is not uncommon. A surgical airway may be the only alternative.,Head and Neck Effects,Direct airway trauma,Penetrating trauma to the neck is associated with a high degree of morbidity and mortality.Airway involvement includes dyspnea, cyanosis, subcutaneous em
33、physema, hoarseness.,Head and Neck Effects,dyspnea dispni:呼吸困难， cyanosis ,sainusis发绀，emphysema ,emfisi:m皮下气肿， hoarseness嘶哑,Direct airway trauma,Orotracheal intubation is the technique of choice. The key is early identification of the need for intubation before the patient has no airway at all.,Head
34、and Neck Effects,Orotrachealr trt i:l intubation 口腔气管插管,Cervical spine injury,Approximately 3%-6% of major trauma victims have clinically significant C-spine injuries. Oral intubation with manual in-line axial head and neck stabilization(MIAS，头颈部的轴向固定) is a safe method.,Head and Neck Effects,Cervica
35、l spine 颈椎， axial ksl轴向的,Burns,Burn patients with airway compromise require aggressive management(紧急处理).Upper airway edema associated with inhalation can progress during the post burn phase. So securing an airway sooner than later is the goal.,Head and Neck Effects,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
36、越重，因此应尽早采取措施保护气道。,Thoracic Effects,Thoracic rsk 胸的,Tension pneumothorax,A pneumothorax results when air enters the potential space between the parietal and visceral pleura. Air present in the pleural space will eventually collapse the lungs.A tension pneumothorax is life-threatening and requires imm
37、ediate intervention.,Thoracic Effects,pneumothorax,nju:m:rks高压性气胸，张力性气胸， parietal praiitl腔壁的， visceral visrl内脏的， pleura plur胸膜， thorax rks 胸廓，胸膛,Tension pneumothorax,On inspiration air enters the pleural space（胸膜腔）, does not escape on expiration, and increases the intrapleural(胸膜内的) pressure. This p
38、ressure collapses the injured lung, shifts the mediastinal contents，compressing the heart, great vessels, trachea and eventually the uninjured lung. In turn, this causes the following signs and symptoms: Severe respiratory distress;Hypotension; Jugular vein distension;Tracheal deviation(气管偏移) toward
39、 the uninjured side; Cyanosis.,Thoracic Effects,mediastinal ,mi:distinl 纵隔的, trachea(气管), Cyanosis ,sainusis (发绀).,Tension pneumothorax,The immediate short-term life-saving intervention is a needle thoracostomy :inserting a large bore over the needle catheter into the second intercostal space（第二肋间）
40、at the mid-clavicular（锁骨的) line (MCL,锁骨中线).,Thoracic Effects,needle thoracostomy ,:rkstmi, ,u-(胸腔穿刺造口术)， intercostal(肋间的),Flail chest连枷胸,Flail chest is the fracture of tow or more ribs in two or more separate locations, leading to an unstable thoracic wall（胸壁） segment. Paradoxical movement（反常运动） of
41、the chest wall is seen with the area sinking into the chest cavity(胸腔) with inspiration and protrusion（突出）with expiration. The area must be supported quickly to re-establish the thoracic bellows effect.（塌陷区域需要修复以重建胸廓的呼吸运动）,Thoracic Effects,protrusionprtrun 突出,Hemorrhage,Hemorrhage hemrd 出血,Hemorrhag
42、e,When the patient has suffered an injury that causes external hemorrhage, such as severing(切割，分离) of an artery, the bleeding must be controlled immediately. This may be done by applying direct pressure over the wound and applying pressure over arterial pressure points. Once the source of internal h
43、emorrhage has been recognized, interventions are initiated, including operative control of bleeding and continual assessment of the patient. Hemorrhage may result in hypovolemic shock(低血容量性休克).,Hemorrhage,Hemorrhage,Internal hemorrhage may result from either blunt or penetrating traumatic injury. Di
44、scovering the cause and location of the injury, as well as the extent of related blood loss, are the most important concerns.,Hemorrhage,Hemorrhage,Several potential spaces in the body can accommodate large amounts of blood that may accumulate (called third spacing) following injury.For example, ble
45、eding into the pleural space may occur with chest trauma (hemothorax,血胸)，and bleeding into the abdominal cavity may occur with abdominal trauma. A pelvic fracture may cause massive hemorrhage in the retroperitoneal region.,Hemorrhage,pelvic pelvik骨盆的， retroperitoneal retru,peritni:l腹膜后的,Abdominal Ef
46、fects,Abdominal Effects,The abdomen contains both solid organs (liver, spleen, and pancreas) and hollow organs (stomach and intestines): Direct trauma to the abdomen can lacerate(撕碎) and compress the solid organs and cause burst injuries to the hollow organs. Blood vessels may be torn and organs may
47、 be displaced from their blood supply, producing life-threatening hemorrhage.,Abdominal Effects,Abdominal Effects,Damage to the mesenteric vessels(肠系膜血管) supplying the bowel can result in bowel ischemia and infarction(梗塞). Injury to the stomach, pancreas, and small bowel may allow digestive enzymes
48、to leak out into the abdominal cavity. Rupture of the large bowel results in escape of feces, which causes peritonitis.,Abdominal Effects,mesenteric ,mesnterik肠系膜， infarction inf:kn梗塞， enzymes enzaims 酶 abdominal cavity 腹腔， Rupture 破裂，使破裂， peritonitis ,peritnaitis腹膜炎,Neurologic Effects,Neurologic Ef
49、fects,Injuries to the spinal cord(脊髓)，resulting in loss of neurologic function, are devastating outcomes of trauma, but they are much less common than head injuries.Care of the patient with a neurologic injury is discussed in later unit.,Abdominal Effects,Multiple Organ Dysfunction Syndromes (MODS),MODS,Multiple organ dysfunction syndrome (MODS) is a common complication of severe injury and a frequent cause of death in intensive units. It is a progressive impairment of two or more organ systems.,
