MODS护理查房-课件.ppt

MODSMODS护理查房护理查房蚌埠医学院第一附属医院蚌埠医学院第一附属医院 重症医学科重症医学科The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine 患者胡某某，女，22岁，于2014.2.27顺产一活婴，2.28出现皮肤巩膜黄染、阴道持续流血（当地医院治疗，具体不详）。3.1阴道流血未改善，并出现尿少。于3.2 06:30入住我科“产后出血并发产后出血并发MODSMODS”The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine体格检查体格检查 神志清楚、贫血貌、口唇苍白 皮肤巩膜黄染、有多处瘀点瘀斑 双侧瞳孔等大等圆，对光反射灵敏 腹膨隆、腹水征阳性、肠鸣音2次/分 阴道血性恶露、量较多 四肢水肿明显T T：3636，HRHR：132132次次/分，分，R R：2424次次/分，分，BPBP：133/88mmHg133/88mmHgThe First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine实验室检查实验室检查白细胞（WBC）16.05109/L(4-10)红细胞（RBC）2.061012/L(3.5-5.1)血小板（PLT）59.0109/L(101-320)凝血酶原时间（PT）22.2s(9.6-12.7)活化部分凝血活酶时间（APTT）59.1s(24.5-35.2)The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine实验室检查实验室检查丙氨酸氨基转移酶（ALT）38U/L(5-35)天门冬氨酸转移酶（AST）37U/L(14-36)总胆红素（TBIL）93.3umol/L(2-22)肌酐（CR）327umol/L(25-104)尿素（UREA）10.99mmol/L(1.8-7.8)降钙素原测定（PCT）24.99ng/ml(24h。发生MODS前，机体器官功能基本正常，功能损害呈可逆性，一旦发病机制阻断、及时救治，器官功能有望恢复。The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine病死率病死率病病死死率率累及器官数（个）累及器官数（个）1234100307355MODSMODS病死率很高，并随衰竭器官的数目增加而增高病死率很高，并随衰竭器官的数目增加而增高The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine病因病因严严重重创创伤伤休休克克严严重重感感染染医医源源性性原原因因心心跳跳骤骤停停12345The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine机制机制主流的看法是失控的全身炎症反应综合征（主流的看法是失控的全身炎症反应综合征（SIRSSIRS）1 1）缺血再灌注损伤假说）缺血再灌注损伤假说 2 2）炎症失控假说）炎症失控假说 3 3）肠道细菌、毒素移位假说）肠道细菌、毒素移位假说 4 4）两次打击和双项预激假说）两次打击和双项预激假说 5 5）应激基因假说）应激基因假说 The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine诊断标准诊断标准器官或系统器官或系统诊断标准诊断标准循环系统收缩压90mmHg，持续1小时以上，或循环需要药物支持维持稳定呼吸系统急性起病，PaO2/FiO2200，X线胸片见双肺浸润肾脏血肌酐浓度177umol/L伴有少尿或无尿，或需要血液透析肝脏血清总胆红素34.2umol/L，血清转氨酶升高，或肝性脑病胃肠道上消化道出血，不能耐受食物血液系统血小板计数50109/L，或出现DIC代谢不能为机体提供所需能量，糖耐量降低中枢神经系统 GCS7分The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现循环循环 临床特征性表现：急性肺循环淤血和供 血不足 呼吸困难、咳嗽和咯血急性心功能不全急性心功能不全心源性休克心源性休克心搏骤停心搏骤停The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现呼吸呼吸 临床特征表现为：发绀和呼吸困难 血气分析检查常呈现为低氧血症 ARDS或急性呼吸功能不全吸氧吸氧机械通气机械通气The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现肾脏肾脏 临床特征性表现：氮质血症、少尿、无 尿和水、电解质及酸碱平衡紊乱氮质血症氮质血症CRRTCRRTThe First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现肝脏肝脏 临床特征性表现：细胞性黄疸，巩膜、皮肤黄染，尿色加深呈豆油样 血清生化：总胆红素升高、肝脏酶学水 平升高肝功能不全肝功能不全肝性脑病肝性脑病肝衰竭肝衰竭The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现胃肠胃肠 临床特征性表现：消化道出血及肠鸣音 减弱消化道出血消化道出血胃肠道蠕动减弱胃肠道蠕动减弱胃肠麻痹胃肠麻痹The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现凝血凝血 临床特征性表现：黏膜、皮肤形成花斑，皮下出血，注射部位或手术切口、创面自发性弥散性渗血，内脏器官及脑部的出血,DIC 化验检查：血小板计数呈进行性减少、凝血酶原时间延长皮肤黏膜出血皮肤黏膜出血内脏出血内脏出血大脑出血大脑出血The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine临床表现临床表现中枢神经系统中枢神经系统 临床特征性表现：意识障碍 瞳孔变化、神经系统的病理反射清醒清醒嗜睡嗜睡昏睡昏睡浅昏迷浅昏迷深昏迷深昏迷The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine治疗原则治疗原则 消除引起消除引起MOMODSDS的病因和诱因，治疗原发疾病的病因和诱因，治疗原发疾病 改善和维持组织充分氧合改善和维持组织充分氧合 保护肝、肾功能保护肝、肾功能 营养支持及代谢调理营养支持及代谢调理 合理应用抗生素合理应用抗生素 The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine病史病史3.2(第一天）12:50 意识清醒、紧急经鼻气管插管3.2(第一天）15:20 腹腔穿刺,引流出大量黄色液体3.3(第二天）08:00 意识昏睡、24h尿量50ml3.3(第二天）09:20 CRRT治疗3.4(第三天）24h尿量220ml3.5(第四天）24h尿量2620ml3.6(第五天）08:00 瞳孔不等大，昏迷状态，急查CT双侧大脑枕叶大面积脑梗塞伴出血The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine病史病史3.7(第六天)患者瞳孔等大，意识昏迷、皮肤巩膜黄染3.8(第七天)皮肤巩膜黄染明显，有多处瘀点、瘀斑3.9(第八天)考虑颅内静脉窦血栓形成(需磁共振确诊)3.10(第九天)拟进行“人工肝”治疗（血浆准备）3.10(第九天)23:30 出现心率血压的下降，升压药物处理，心率血压恢复，SPO2无改善，而后家属放弃治疗，自动出院The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine实验室检查实验室检查白细胞（WBC）16.05109/L(4-10)红细胞（RBC）2.061012/L(3.5-5.1)血小板（PLT）59.0109/L(101-320)凝血酶原时间（PT）22.2s(9.6-12.7)活化部分凝血活酶时间（APTT）59.1s(24.5-35.2)The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine实验室检查实验室检查丙氨酸氨基转移酶（ALT）38U/L(5-35)天门冬氨酸转移酶（AST）37U/L(14-36)总胆红素（TBIL）93.3umol/L(2-22)肌酐（CR）327umol/L(25-104)尿素（UREA）10.99mmol/L(1.8-7.8)降钙素原测定（PCT）24.99ng/ml(0.50)The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicineCTCT检查检查The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine出血出血低氧血症低氧血症肝肾功能不全肝肾功能不全胃肠功能紊乱胃肠功能紊乱心脏功能不全心脏功能不全脑组织病变脑组织病变M M O O D D S SThe First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine护理护理观察观察The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine呼吸功能障碍护理呼吸功能障碍护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine呼吸道护理呼吸道护理人工气道的管理人工气道的管理VAPVAP预防预防循环功能障碍护理循环功能障碍护理 The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine病情观察病情观察痰液的性状、量痰液的性状、量出入量的控制出入量的控制血流动力学的监测、护理血流动力学的监测、护理肾功能障碍护理肾功能障碍护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine尿量的变化尿量的变化肾功能化验结果肾功能化验结果CRRTCRRT护理护理肝功能障碍护理肝功能障碍护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine意识变化意识变化皮肤巩膜黄染程度皮肤巩膜黄染程度肝功能化验结果肝功能化验结果中枢神经系统功能障碍护理中枢神经系统功能障碍护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine意识的改变意识的改变瞳孔的变化瞳孔的变化镇静、镇痛镇静、镇痛胃肠功能障碍护理胃肠功能障碍护理 The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine胃液观察胃液观察大便观察大便观察肠内营养护理肠内营养护理凝血功能障碍护理凝血功能障碍护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine皮肤黏膜的观察皮肤黏膜的观察凝血功能化验结果凝血功能化验结果预防内脏及大脑的出血预防内脏及大脑的出血细节护理细节护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine心理护理心理护理The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine患者患者家属家属谢谢您的聆听！The First Affiliated Hospital of Bengbu Medical College in intensive medicineThe First Affiliated Hospital of Bengbu Medical College in intensive medicine