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(完整word版)急诊科护理常规.pdf

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1、急诊科护理常规一、心脏骤停的急救护理常规二、急性左心衰护理常规三、过敏性休克护理常规四、急性中毒抢救护理常规五、急性食物中毒护理常规六、急性有机磷农药中毒护理常规七、一氧化碳中毒抢救护理常规八、急性酒精中毒护理常规九、急性巴比妥类药物中毒护理常规十、急性亚硝酸盐中毒护理常规十一、急性鱼胆中毒护理常规十二、中暑抢救护理常规十三、电击伤抢救护理常规十四、溺水抢救护理常规十五、高血压病护理十六、急性心肌梗塞护理文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U

2、1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2

3、HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B

4、2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9

5、ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R

6、5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10

7、文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:C

8、O10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10十七、慢性阻塞性肺部疾患护理十八、上消化道出血护理十九、小儿高热惊厥的急救护理二十、严重复合伤病人的急救护理二十一、休克病人的急救护理心脏骤停的急救护理常规一、心肺复苏基本生命支持护理常规按急诊抢救患者护理常规【护理评估】1、迅速判断患者意识呼叫患者姓名，轻拍患者肩部，观察其对刺激有无反应，判断意识是否丧失，判断时间不超过10 秒。确认患者意识丧失，立即呼救

9、，寻求他人帮助。2、判断呼吸看：患者胸部有无起伏；感觉：面部贴近患者的口鼻，感觉有无气体呼出；听：耳听患者呼吸道内有无气流溢出的声音，判断有无呼吸，判断时间不超过 10 秒。无反应表示呼吸停止，应立即给予人工呼吸。3、判断患者颈动脉搏动术者用食指和中指指尖触及患者气管正中（相当于喉结部位），旁开两指，至胸锁乳头肌前缘凹陷处，判断时间不超过 10 秒。如无颈动脉搏动，应立即行胸外心脏按压。【护理措施】文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4

10、X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3

11、G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9

12、L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9

13、U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7

14、M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编

15、码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10

16、N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M101、一旦确诊心脏骤停，应立即向周围人员呼救并紧急呼叫值班医师，积极就地抢救，立即进行徒手心肺复苏术（CPR）。2、紧急实施徒手心肺复苏术，建立呼吸通道（1）将患者置于硬板床或背部坚实的平面（木板、地板、水泥等），取仰卧位，双腿伸直，解开上衣，放松裤带。（2）开放气道，清除呼吸道内异物：开放气道采用仰头抬颌法：患者仰卧，急救者一手放在患者前额，使头部后仰，另一手的食

17、指与中指置于下颌骨外向上抬颌。若呼吸道内有分泌物，应当及时清理呼吸道，取下活动义齿，在开放气道。（1）人工呼吸：人工呼吸采用口对口呼吸法：抢救者深吸气后，用口唇把患者的口全罩住呈密封状，缓慢吹气持续2 秒，确保胸廓隆起。送气时，用一手拇指与食指捏住患者鼻子防漏气；呼气时，两手指松开。通气频率为1012 分/分钟，每次吹气量为7001000ml。应用简易呼吸器法：将简易呼吸器连接氧气，氧流量810ml/min，一手以“EC”手法固定面罩，另一手挤压简易呼吸器，每次送气 400600ml,频率 1012 次/分钟。送气同时观察人工呼吸的有效指征，即见患者胸廓起伏。（2）胸外心脏按压：抢救者跪于患者

18、右侧，快速确定按压部位为胸骨中下 1/3 处。按压手法：以一手掌根部放于按压的准确部位，另一手平行重叠于此手背上，手指并拢，只以掌要部接触按压文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 H

19、G3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2

20、C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 Z

21、V9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5

22、K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文

23、档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO

24、10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10部位双臂位于患者胸骨正上方

25、，双肘关节伸直，利用上身重量垂直下压。按压幅度：使患者胸骨下陷成人为45cm，513岁儿童为 3cm，婴幼儿为 2cm。按压频率：100 次/分钟。胸外按压与人工呼吸比例为30:2。操作 5 个循环后再次判断颈动脉搏动及自主呼吸10 秒，如已恢复，进行进一步生命支持；如自主呼吸未恢复，继续上述操作 5 个循环再次判断，直至高级生命支持人员及仪器设备的到达。（3）心肺复苏的过程中密切观察有效指征：能摸到大动脉搏动，收缩压在 80Kpa（60mmHg）以上；发绀减退，面色、口唇、甲床及皮肤等色泽由灰转红；散大的瞳孔缩小；呼吸改善或出现自主呼吸；昏迷变浅或出现反射或挣扎；可以排尿；心电图波形改善。以

26、上只要出现前2 项指标，说明有效，应继续行CPR。胸外心脏按压的同时，可用面罩呼吸囊加压给氧，必要时立即行气管内插管或人工呼吸机辅助呼吸。3、迅速建立有效的静脉给药通路，遵医嘱及时准确给予各种抢救药物，纠正水、电解质和酸碱平衡失调，并密切观察药物的效果。4、进行心电监护。如出现室颤，经药物治疗无效，应尽快进行电除颤术【健康指导】1、安抚患者，确保患者情绪稳定，使患者配合治疗。2、与家属沟通，获得理解和支持。文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1

27、U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2

28、 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4

29、B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9

30、 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8

31、R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M1

32、0文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:

33、CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10心肺复苏高级和延续生命支持护理常规按急诊抢救患者护理常规【护理评估】1、严密监测生命体征、意识状态等变化。2、评估患者的皮肤是否完好。3、准确评估尿量，尤其是每小时的尿量。4、评估患者的心理反应，有无恐惧、害怕等。【护理措施】一、进行连续心电监护，每小时1530 分钟监测 1 次生命体征，严密观察意识、瞳孔等变化，出现异常立即通知医师处理。1、继续吸氧，密

34、切观察呼吸频率、节律的变化。行气管插管术能和使用呼吸机者，严密监测呼吸频率、深度、皮肤色泽、血气分析、血氧饱和度等。2、保持呼吸道通畅。气管插管者定时湿化气道和气管，及时抽吸气道及口腔内分泌物，防止呼吸道阻塞。吸引过程中严格无菌操作，气管切开者按气管切开护理常规护理。3、高热者按高热护理常规。4、保护脑组织，及早使用冰帽。遵医嘱给予脱水剂、激素、促进脑细胞代谢等药物，从而减轻脑缺氧，降低颅内压，防止脑水肿。5、记录 24 小时出入水量，注意每小时尿量的变化。文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9

35、L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9

36、U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7

37、M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编

38、码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10

39、N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4

40、X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3

41、G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M106、做好各项基础护理，预防压疮、肺部感染等并发症，做好各项记录。7、备好各种抢救用物，做好心脏骤停复发的抢救。【健康指导】1、安抚和鼓励患者，使其树立战胜疾病的信心。2、与家属沟通，取得家属理解与配合。急性左心衰护理常规按内科及心血管疾病一般护理常规。【护理常规】1、评估患者的神志、血压，了解脑灌注、脑组

42、织氧合情况。2、观察患者的呼吸变化，有无端坐呼吸和咳粉红色泡沫痰，预防肺水肿发生。3、评估患者有无发绀，是否缺氧，评价循环灌注及水电解质平衡情况。【护理措施】1、协助患者取半坐卧位或端坐位，限制体力活动，绝对卧床休息。2、高流量面罩吸氧，氧流量为56L/min，浓度为 40%60%，用 50%酒精做湿化吸氧。必要时，间歇或连续面罩下加压给氧或正压呼吸。3、立即建立静脉输液通路，遵医嘱予以药物对症治疗。4、持续进行心电监护，了解患者心率和心律变化，及时发现潜文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L

43、9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U

44、8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M

45、10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码

46、:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N

47、1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X

48、2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G

49、4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10在的致命性心律失常。5、加强口腔和皮肤护理，维持皮肤黏膜的完整性。6、准确记录 24 小时出入水量，根据水电解质平衡情况遵医嘱调整输液种类及总量。7、做好患者安全护理，防止坠床。8、供给低脂、低盐、低热量、富含维生素及易消化的饮食。【健康指导】1、保持乐观、开朗，避免心理压力。2、鼓励患者锻炼身体，增强抵抗

50、力。3、注意防寒保暖，防止过度疲劳。4、早期预防和控制基础疾病。过敏性休克护理常规按内科疾病及急诊抢救患者护理常规【护理评估】1、仔细评估患者的生命体征、神志、尿量。2、评估患者精身状况、皮肤的色泽、温度和湿度，了解微循环灌注的情况。3、观察有无支气管痉挛、脑水肿、肺水肿等。【护理措施】1、一旦确认患者发生过敏性休克，立即停用或消除引起过敏反应的物质。文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7M10文档编码:CO10N1U1M4X2 HG3G4B2C9L9 ZV9U8R5K7

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