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 Wysłany: Pią 8:39, 18 Mar 2011 Temat postu: Observation of severe traumatic brain injury and n |
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Observation of severe traumatic brain injury and nursing
36 back injury patients were male and 27 down, down 9 females; the ages of 16 to 82 years old asked. In clinical nursing practice, we deeply feel that the prognosis of patients and nurses quality care close observation and oranges off. Experience of nursing observation will now be summarized as follows. 1.1 l head injury observation Xiang conscious mind's view of whether or not is an important indicator of disease prognosis. Should pay attention to observe the dynamic analysis of consciousness. Such as sleepiness in patients with a hazy from irritability to coma and a moderate state of a shallow coma and gradually evolved a deep coma, suggesting that severe brain damage, the condition is deteriorating; If the patient to awake from the coma. Marks the condition was improving. If after injury after injury, conscious or unconscious of a coma, a coma is a clear prompt epidural hematoma; if unconscious of a coma after injury further increased, the subdural hematoma and other tips. 1.2 ■ View hsiang pupil hole head injury is the most important observation of the observations. Normal pupil diameter between the 2 ~ 6mm. So too and so round, ask received directly or sensitivity to light reflection. If the side of the mydriasis, disturbance of consciousness gradually worsened. Paralyzed limbs, indicating that bleeding is continuing. Did not improve, double commissions are dilated pupil, light reflex. Eye fixation, decerebrate rigidity, mostly for primary brain stem injury,[link widoczny dla zalogowanych], illness District 【insurance, you can die at any time if the bilateral miosis, the reaction of intracranial hypertension; if suddenly a large pupil suddenly small. Ai do not call the whole rhythm, suggesting that concurrent intracranial hematoma or herniation; if gradually dilated,[link widoczny dla zalogowanych], light reflection slow, compared with advanced brain cancer, loss of the small craniotomy, to remove the hematoma rescue opportunity. At this point the pupil in patients with rapidly changing, should be closely observed, so that early diagnosis and treatment. Prevention of hernia formation or early surgery to avoid the loss of rescue opportunities. l_3 concept of vital signs Xiang breathing, pulse, blood pressure changes are reflected in the importance of brain injury patients signs of illness. If breathing exploration slow, slow pulse, blood pressure, pupil ranging from large, cut prompted the formation of intracranial hematoma, or severe head injury, brain edema, hernia and other rescue treatment in time; if rapid weak pulse, rapid breathing, blood pressure, merger should be considered internal bleeding gouge, fractures bleeding and so on. Observation of these patients to fully understand the 77,6 / z. '}} I general condition. Such as rhythm, volume rate, mind, spirit, complexion,[link widoczny dla zalogowanych], eyes, skin, cold sweat, ear, nose or discharge effluent within the nature of the activities of the limbs, the color and quantity of vomit, so a small amount of color and so on. If there is pale, clammy body,[link widoczny dla zalogowanych], thin pulse, blood pressure, urine output decreased and cut out the shock symptoms. Cut out to speed up the infusion speed, correct shock, find out your mother trapped timely rescue. If the ear, nose out of bloody cerebrospinal fluid. Reflects a skull fracture; if the amount of fan prompt vomiting intracranial hypertension; vomit sauce-like liquid is reflected on the stress ulcer bleeding. Trapped in this body of vital signs and close observation of changes in circumstances, the ability to detect changes in condition, in time, effectively increase the success rate. 2 Brain Injury Care 2.1 to maintain airway patency supine, head to one side. Prevent accidental starting to attract suffocation. Bruise when necessary suction aspiration device. At the same time provide an effective oxygen inhalation. 4-6L/rr, ln. 2.2 The rapid establishment of intravenous trocar road 2 {} a transfusion or blood transfusion to ensure smooth flow, to supplement the blood volume to maintain effective blood circulation; another to ensure effective drug supply, such as boost the application of drugs and dehydrating agent, attention to protecting the blood vessels, increase the success rate of puncture. 2.3 agitation in patients with the care of such security files Pengdao a bed or bed bound with the body to be fixed, and let someone care. Necessary to give an appropriate sedative. Fluid outside the brain extract 2.4 nursing vend key measures is to prevent infection. Drain port in order to promote an early closure. Raise the head, head Xiadian sterile towel. With sterile gauze or cotton balls to gently throw into confusion to semen, regular washing with topical saline throw into confusion, ear and nasal washing is strictly prohibited. 2.5 indwelling catheter fixed flat to prevent slippage. Quantitative release of urine. El with 1:50 OO nitrofurazone each bladder washing 2 times, accurate records of urine output and color, time to send culture specimens from urine specimens. 2.6 Skin Care to keep beds dry,[link widoczny dla zalogowanych], smooth, regular massage follicles stand up position, to prevent bedsores from occurring. Received: 19oA-lO a pit 23 to the United States down adhesions and the occurrence of incisional hernia. Received: 19oA a 11-29 * 43
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