麻醉病人護(hù)理課件

麻醉病人的護(hù)理濟(jì)醫(yī)附院麻醉科于凱Anesthesia1麻醉病人的護(hù)理濟(jì)醫(yī)附院麻醉科Anesthesia1leaningobjectivememorize1、anesthesia2、generalanesthesia3、inhalationanesthesia4、intravenousanesthesia5、localanesthesia6、spinalanesthesia7、epiduralanesthesia8、basalanesthesia9、combinedanesthesia2leaningobjectivememorize2識記麻醉全身麻醉吸入麻醉靜脈麻醉局部麻醉椎管內(nèi)麻醉蛛網(wǎng)膜下腔麻醉硬膜外麻醉基礎(chǔ)麻醉復(fù)合麻醉3識記麻醉3

understandingcomparedifferentmethodofanesthesiaanalysiscomplicationpracticeprovidehealthguidancedealwithcomplicationmonitorpatient4understandingcomparediff主要內(nèi)容概述summarize麻醉前工作preanesthesia局部麻醉localanesthesia椎管內(nèi)麻醉intravertebralanesthesia全身麻醉generalanesthesia主要內(nèi)容概述summarize麻醉前工作preanesthesia局部麻醉localanesthesia椎管內(nèi)麻醉intravertebralanesthesia全身麻醉generalanesthesia5主要內(nèi)容概述summarize主要內(nèi)容概述summ概述summarize麻醉anesthesia是指用藥物或者其他方法使病人的整體或局部暫時失去感覺，以達(dá)到無痛的目的公元2世紀(jì)華佗“麻沸散”1846年Morton美國麻省總醫(yī)院乙醚麻醉現(xiàn)代麻醉學(xué)的開始6概述summarize麻醉anesthesia6Historyofmodernanesthesiology7Historyofmodernanesthesiolo“thisisnohumbug”MassachusettsGeneralHospital,Dr.WilliamT.G.Mortonperformedastartlingpublicdemonstration.InfrontofacrowdofskepticalonlookerswhichincludedtheeminentBostonsurgeonDr.JohnCollinsWarren,Dr.Mortonadministeredethervaporstoapatientabouttoundergosurgery.Momentslater,thesurgeonraisedascalpelandmadeanincisioninthepatient'sneck.Totheaudience'sastonishment,thepatientdidnotscream."Gentlemen,"Dr.Warrenproclaimed,"thisisnohumbug!".Anesthesiahadbeendiscovered8“thisisnohumbug”Massachuset麻醉分類中樞神經(jīng)意識喪失周圍神經(jīng)意識清醒吸入麻醉靜脈麻醉(generalanesthesia)(intrathecalanesthesia)局部麻醉(localanesthesia)9麻醉分類中樞神經(jīng)周圍神經(jīng)吸入麻醉(generalanest概述safetytoxicityconventionrecoveryanesthesia10概述safetytoxicityconventionreco麻醉前工作（一）麻醉前病情評估evaluation生理情況physicalstatus目前病情historyofpresentillness既往情況pasthistory判斷耐受力tolerance心理社會狀況Socialandpsychologicstatus11麻醉前工作（一）麻醉前病情評估evaluation11麻醉前評估一、ASA（Americansocietyofanesthesiologists）分級健康狀況第1級正常健康第2級有輕度系統(tǒng)性疾?。òǎ?0歲者或新生兒）第3級有嚴(yán)重系統(tǒng)性疾病，日常活動受限第4級嚴(yán)重系統(tǒng)性疾病，且經(jīng)常面臨威脅生命的危險第5級不論手術(shù)與否，生命均難以維持24小時的瀕死病人12麻醉前評估一、ASA（AmericansocietyASAphysicalstatusI.

Anormalhealthypatient

II.Apatientwithmildsystemicdisease

andnofunctionallimitation

III.Apatientwithmoderatetoseveresystemicdisease

thatresultsinsomefunctionlimitationIV.Apatientwithseveresystemicdiseasethatisaconstantthreattolife

andfunctionallyincapacitatingV.AmoribundpatientwhoisnotexpectedtosurvivewithouttheoperationVI.Adeclaredbrain-deadpatientwhoseorgansarebeingremovedfordonorpurposesETheadditionofan'E'indicatesemergencysurgery13ASAphysicalstatusI.

Anorma（二）麻醉前準(zhǔn)備病人準(zhǔn)備術(shù)前訪視介紹prepare心理準(zhǔn)備mentalpreparation緊張，焦慮，恐懼查明原因，對因治療藥物輔助治療或心理專家治療身體準(zhǔn)備Physicalpreparation糾正和改善生理狀態(tài)胃腸道準(zhǔn)備禁飲食14（二）麻醉前準(zhǔn)備病人準(zhǔn)備術(shù)前訪視介紹prepare禁飲食fasting成人adult禁食12小時，禁飲4-6小時兒童children禁固體食物禁奶8小時，禁飲清淡液體2小時（＞36月/＜36月6小時）嬰幼兒infant新生兒-1歲，禁清淡液體2小時15禁飲食fasting成人adult禁食12小局部麻醉localanesthesia局麻指用局部麻醉藥暫時地阻斷某些周圍神經(jīng)的傳導(dǎo)功能，使受這些神經(jīng)支配的相應(yīng)區(qū)域產(chǎn)生麻醉作用優(yōu)點安全有效safety病人意識清醒a(bǔ)wake適用于較表淺、局限手術(shù)shallow16局部麻醉localanesthesia局麻16局麻藥localanesthetics脂類普魯卡因、丁卡因、氯普魯卡因procaine、tetracaine、chloroprocaine酰胺類利多卡因、布比卡因、羅哌卡因lidocaine、bupivacaine、ropivacaine17局麻藥localanesthetics脂類17局麻藥不良反應(yīng)

毒性反應(yīng)toxicity原因cause用藥過量excessivedose誤入血管intravascularinjection全身情況差weak18局麻藥不良反應(yīng)毒性反應(yīng)toxicity18毒性反應(yīng)表現(xiàn)和治療featuresandtreatment中樞神經(jīng)系統(tǒng)CNS舌或口唇麻木、頭痛頭暈、耳鳴、視力模糊、語言不清、肌肉顫搐、意識不清、驚厥、昏迷、呼吸停止心血管系統(tǒng)cardiovascularsystem心律失常、心肌收縮減弱、心排血量減少、血壓下降甚至心跳停止19毒性反應(yīng)表現(xiàn)和治療featuresandtrea毒性反應(yīng)預(yù)防和處理預(yù)防prevent注意用藥劑量dose適當(dāng)應(yīng)用腎上腺素epinephrine預(yù)防應(yīng)用苯二氮卓類藥物或巴比妥類benzodiazepine處理treatment停藥stop維持呼吸、循環(huán)功能respiratory&circulation對癥處理并發(fā)癥complication20毒性反應(yīng)預(yù)防和處理預(yù)防prevent20常用方法表面麻醉局部浸潤麻醉區(qū)域麻醉神經(jīng)阻滯臂叢神經(jīng)阻滯、頸叢神經(jīng)阻滯、肋間神經(jīng)、指神經(jīng)阻滯brachialplexus、cervicalplexus、intercostalnerve、digitalnerve21常用方法表面麻醉21局部麻醉護(hù)理注意毒性反應(yīng)的觀察和護(hù)理膈神經(jīng)阻滯、喉返神經(jīng)阻滯、霍納綜合征、氣胸Phrenicnerveblock、Laryngealrecurrentnerveblock、Hornersyndrome、pneumothorax

22局部麻醉護(hù)理22眼部表面麻醉topicalanesthesia23眼部表面麻醉topicalanesthesia23局部浸潤麻醉localinfiltrationanesthesia24局部浸潤麻醉localinfiltrationane25252626椎管內(nèi)麻醉一、蛛網(wǎng)膜下腔阻滯spinalanesthesia

又稱脊椎麻醉或腰麻，是將局麻藥注入蛛網(wǎng)膜下腔，作用于脊神經(jīng)前根和后根，產(chǎn)生不同程度的阻滯27椎管內(nèi)麻醉一、蛛網(wǎng)膜下腔阻滯spinalanesthe蛛網(wǎng)膜下隙阻滯麻醉方法藥物：局麻藥給藥方法腰穿體位穿刺點28蛛網(wǎng)膜下隙阻滯28蛛網(wǎng)膜下腔麻醉藥物布比卡因、羅哌卡因（耐樂品）給藥體位position穿刺點puncturepoint負(fù)壓試驗Negativepressuretest29蛛網(wǎng)膜下腔麻醉藥物布比卡因、羅哌卡因（耐樂品）29麻醉平面調(diào)節(jié)穿刺間隙高低、體位、藥液比重、注藥速度、針尖斜面30麻醉平面調(diào)節(jié)30術(shù)中并發(fā)癥的觀察和護(hù)理一、血壓下降和心率減慢hypotension&bradycardia原因：麻醉區(qū)域血管擴(kuò)張、迷走神經(jīng)相對亢進(jìn)處理：血壓下降快速輸液必要時應(yīng)用麻黃堿心率下降阿托品31術(shù)中并發(fā)癥的觀察和護(hù)理31二、惡心嘔吐nausea&vomiting原因：低血壓，迷走神經(jīng)相對亢進(jìn)，手術(shù)牽拉處理：對因處理，止吐三、呼吸抑制respiratorydepression原因：麻醉平面過高，肋間肌麻痹，胸式呼吸減弱處理：吸氧，維持呼吸，必要時輔助通氣32二、惡心嘔吐nausea&vomiting32術(shù)后并發(fā)癥的觀察和護(hù)理頭痛headache原因：腦脊液丟失表現(xiàn)：術(shù)后1-3天，起床活動后枕部、頂部或顳部疼痛，呈搏動性預(yù)防：避免反復(fù)穿刺，保證液體入量；麻醉后去枕平臥6-8小時處理：休息；可硬膜外注射生理鹽水；自體血補(bǔ)丁33術(shù)后并發(fā)癥的觀察和護(hù)理33尿潴留urinaryretention原因：骶神經(jīng)阻滯后恢復(fù)慢不習(xí)慣床上排尿傷口疼痛處理：誘導(dǎo)排尿revulsiveemiction針刺穴位acupuncturepoints熱敷、按摩hotcompress、massage留置導(dǎo)尿catheterization34尿潴留urinaryretention34護(hù)理nursing麻醉期間監(jiān)護(hù)呼吸循環(huán)功能麻醉后去枕平臥6-8小時監(jiān)測生命體征注意并發(fā)癥跡象35護(hù)理nursing35硬膜外麻醉Epiduralanesthesia將局麻藥注入硬脊膜外間隙，阻滯脊神經(jīng)根，使其支配區(qū)域產(chǎn)生暫時性麻痹subarachnoidspaceepiduralspace36硬膜外麻醉Epiduralanesthesia將局硬脊膜外阻滯麻醉方法藥物：局麻藥給藥方法比較腰穿37硬脊膜外阻滯37anesthesialevel影響麻醉平面因素穿刺間隙局麻藥容積和注藥速度導(dǎo)管方向其他：藥液濃度、注藥方式、體位38anesthesialevel影響麻醉平面因素38常見并發(fā)癥complication1、全脊麻totalspinalanesthesia2、穿破硬膜duraltap3、異常廣泛阻滯massiveextraduralblock4、局麻藥毒性反應(yīng)intravenoustoxicity5、低血壓hypotension6、寒顫shivering7、惡心嘔吐nausea/vomiting39常見并發(fā)癥complication39護(hù)理麻醉期間監(jiān)護(hù)呼吸循環(huán)功能麻醉后監(jiān)測血壓、脈搏墊枕平臥4-6小時

40護(hù)理40全身麻醉Generalanesthesia四要素鎮(zhèn)靜sedation鎮(zhèn)痛analgesia遺忘amnestic肌松musclerelaxant41全身麻醉Generalanesthesia四要素41分類吸入麻醉inhalationanesthesia是將揮發(fā)性麻醉劑和氣體吸入肺內(nèi)，經(jīng)肺泡毛細(xì)血管吸收進(jìn)入血液循環(huán)，到達(dá)中樞神經(jīng)系統(tǒng)，產(chǎn)生麻醉效應(yīng)的一種方法靜脈麻醉intravenousanesthesia是經(jīng)靜脈注射進(jìn)入體內(nèi)，通過血液循環(huán)作用于中樞神經(jīng)系統(tǒng)而產(chǎn)生全身麻醉的方法42分類42InhalationanestheticagentsN2O、enflurance、isoflurance、sevofluranceIntravenousanestheticagentsthiopentone、ketamine、etomidate、midazolam、propofol43Inhalationanestheticagents43常用全身麻醉藥物肌肉松弛藥

去極化肌松藥非去極化肌松藥麻醉性鎮(zhèn)痛藥嗎啡、哌替啶、芬太尼44常用全身麻醉藥物44musclerelaxantdepolarizingmusclerelaxantnondepolarizingmusclerelaxantanalgesicmorphine、fentanyl、pethidine45musclerelaxant45全身麻醉深度判斷46全身麻醉深度判斷46ComplicationsduringanesthesiaARRHYTHMIASbradycardiatachycardiaHypotensionhypovolemiahaemorrhageHypertensionhypervolemia--myocardialischaemia47ComplicationsduringanesthesiRegurgitation&aspiration☆Upperairwayobstruction☆Lowerairwayobstruction☆48Regurgitation&aspiration☆48全麻期間并發(fā)癥心律失常心動過緩心動過速低血壓低血容量出血高血壓高血容量--心肌缺血

49全麻期間并發(fā)癥心律失常49反流與誤吸Regurgitation&aspiration處理：頭低腳高，頭偏向一側(cè)預(yù)防清醒前去枕平臥，頭偏向一側(cè)俯臥帶輕度俯傾50反流與誤吸Regurgitation&aspirati上呼吸道梗阻Upperairwayobstruction

原因舌后墜口腔分泌物阻塞異物阻塞喉頭水腫喉痙攣51上呼吸道梗阻Upperairwayobstructio上呼吸道梗阻表現(xiàn)呼吸困難并有鼾聲完全梗阻時有鼻翼扇動和三凹征52上呼吸道梗阻52上呼吸道梗阻處理查明原因，對因處理如下頜托起，放入口咽或鼻咽通氣道53上呼吸道梗阻53下呼吸道梗阻Lowerairwayobstruct