急危重癥護理學之急診分診

急危重癥護理學

Emergency

andCriticalCareNursing急診分診EmergencypatientsareuniqueNotallpatientareaswellastheyappearandnotallpatientsareassickastheythink.分診Triage分診Triage是指對病情種類和嚴重程度進行簡單、快速的評估與分類，確定就診的優(yōu)先次序，使病人因為恰當?shù)脑蛟谇‘數(shù)臅r間、恰當?shù)闹委焻^(qū)獲得恰當?shù)闹委熍c護理的過程.Thegoalforallpartsofhealthcarecontinuumis“rightpatient,rightplace,righttimewithrightcaregiver”.whatisTriage?Asortingprocessutilizingciriticalthinkinginwhichanexperiencednurseassessespatientsquicklyupontheirarrivalatanemergencysettingto:1.cesspatientsintoatriagecategory3.determineaccesstoappropriatetreatment4.effectivelyandefficientlyassignappropriatehumanhealthresourcesAvoidingTriageasablockThetriageprocessshouldnotbecomeablockorsignificantdelay,butratherawayof“streaming”patientstothemostappropriatecarearea.分診處的設置位置:面對急診科大門的明顯處物品:電話、電腦、平板車、輪椅、血壓計、聽診器、體溫計及各種表格等人員:急診護士,導診員或秘書急診分診程序

TriageprocessTriageprocessPatient'sarrivalCriticallookAairwayBBreathingCCirculationDDisability(neurological)急診護理評估1.Aairway氣道及頸椎氣道阻塞的原因？氣道阻塞如何處理？保持氣道通暢的方法？人工氣道分類常見非確定性緊急人工氣道技術(shù)

手法開放氣道：常用提頦和雙手抬頜法。口咽和鼻咽通氣管喉罩常見確定性緊急人工氣道技術(shù)

經(jīng)口氣管插管術(shù)經(jīng)鼻氣管插管術(shù)：纖維支氣管鏡引導氣管插管

氣管切開術(shù)人工氣道分類通氣導管口咽通氣導管鼻咽通氣導管喉罩氣管插管經(jīng)口氣管插管經(jīng)鼻氣管插管氣管切開置管經(jīng)皮穿刺氣管造口置管術(shù)環(huán)甲膜穿刺/切開術(shù)急診護理評估2.BBreathing呼吸功能呼吸功能評估包括哪些？呼吸功能異常如何處理？急診護理評估3.CCirculation循環(huán)功能循環(huán)功能評估包括哪些？循環(huán)功能異常如何處理？急診護理評估4.DDisability(neurological)神志狀況:AVUP法AlertVocalPainUnresponsive法5.暴露患者/環(huán)境控制TriageprocessInfectioncontrolSubjectiveAssessmentObjectiveAssessmentSelectingpresentingcomplaintTheTriageDecision病情嚴重程度分類系統(tǒng)CTASlevels國際“TRIAGE”分級Level1-ResuscitationCardiacarrestRespiratoryarrestMajortraumainshockShortnessofbreath(severerespritarydistress)Alteredlevelofconsciousness(unconscious,GCS3-9)心跳呼吸停止懷疑心肌梗死引起的胸痛嚴重心律失常中度燒傷呼吸道梗阻、呼吸窘迫嚴重創(chuàng)傷大出血張力性氣胸等過敏性休克DeterminingtheCTASlevelsFirstOrderModifiersVitalsignsRespiratoryDistressHemodynamicStatusLevelofConsciousnessTemperatureOthermodifiersPainscoreBleedingdisorderMechanismofinjurySecondOrderModifiersBloodGlucoseLevelDehydrationseverityBloodPressureMoreinformationisneededtodeterminetheCTASlevels.PatientsreassessmentguidelinesLevel1continuousnursingcareLevel2—every15minsLevel3—every30minsLevel4—every60minsLevel5—every120minsRoleofTriageNurseAssessingpatientsCommunicatingwiththepublicCommunicatingwithHealthprofessionalsAssigningresourcesInitiatingtreatmentprotocols/firstaidmeasuresMonitoringandreassessingPaticipatinginpatientflowDocumentingCharacteristicsoftheTriageNursewhatmakesagoodtriagenurse?

PersonaltraitsCognitivecharacteristicsBehavioralcharacteristics練習：forpersonalreflection我的強項我的弱項Personaltraits.2.3.Cognitivecharacteristics.2.3.Behavioralcharacteristcs.2.3.PersonaltraitsFlexibilityAutomomyGoodcommunicationskillsAssertivenessPatienceCompassionWillingnesstolistenandlearnwhatmakesagoodtriagenurse?

PersonaltraitsCognitivecharacteristicsBehavioralcharacteristicsCognitivecharacteristicsAdiverseknowledgebaseKnowingwhennottoactCriticalthinkingAbilitytomakedecisionquicklyAbilitytoprioritizeWhatmakesagoodtriagenurse?

PersonaltraitsCognitivecharacteristicsBehavioralcharacteristicsBehavioralcharacteristicsBeingapatientadvocateWorkingwellunderpressureBeingorganizedImprovisingasneededUsingintuitionDisplayingconfidenceinjudgementTrustingorrelyingonpeersSki