IABP護(hù)理查房課件ppt

一例心跳呼吸驟停使用IABP患者的護(hù)理查房主動(dòng)脈內(nèi)球囊反搏泵Intra-AorticBalloonPump————簡(jiǎn)稱IABP主動(dòng)脈內(nèi)球囊反搏泵ACAT1PLUS

AUTOCAT2AUTOCAT2WAVE反搏的原理心臟收縮前一瞬間（主動(dòng)脈開放時(shí)），球囊放氣，降低主動(dòng)脈內(nèi)舒張末壓，減少左心室做功，降低后負(fù)荷，減少心肌耗氧心臟舒張前一瞬間（主動(dòng)脈關(guān)閉時(shí)），球囊充氣，增加舒張期冠脈灌注壓力，增加心肌供氧冠脈分布示意圖使用科室應(yīng)用指征術(shù)前---國(guó)外：42-72%國(guó)內(nèi)：5%左右危重狀態(tài)或血液動(dòng)力學(xué)不穩(wěn)，爭(zhēng)取時(shí)間手術(shù)---PTCA，旋切，支架等失敗，或難以控制心律失常---心梗后并發(fā)癥---MI合并左室功能低下，低心排---心衰狀態(tài)的術(shù)前病人

心臟外科（冠脈搭橋術(shù)、心臟瓣膜置換術(shù)）心臟內(nèi)科（急診PTCA）急診科（急性心梗合并心源性休克）適應(yīng)癥一、各種原因引起的心泵衰竭急性原因引起的心泵衰竭圍手術(shù)期發(fā)生的心肌梗塞體外循環(huán)后低心排綜合癥心臟挫傷中毒性休克病毒性心肌炎二、急性心肌梗塞后發(fā)生的機(jī)械性并發(fā)癥室間隔穿孔乳頭肌斷裂致二尖瓣關(guān)閉不全大室壁瘤三、內(nèi)科治療無效的不穩(wěn)定型心絞痛四、心肌缺血而致的室性心律失常五、進(jìn)展性心肌梗塞六、圍手術(shù)期對(duì)重癥病人的支持和保護(hù)措施嚴(yán)重心肌缺血病人作冠脈造影、PTCA、溶栓術(shù)、麻醉誘導(dǎo)高危重癥病人作心導(dǎo)管檢查、心臟手術(shù)、普外手術(shù)七、心臟移植前后的輔助治療八、人工心臟的過渡治療九、手術(shù)中產(chǎn)生搏動(dòng)性血流IABP使用禁忌癥主動(dòng)脈瓣關(guān)閉不全主動(dòng)脈瘤或主動(dòng)脈血管性的疾病動(dòng)脈粥樣硬化與嚴(yán)重的周圍血管疾病腦死亡患者疾病末期如癌癥轉(zhuǎn)移IABP并發(fā)癥下肢缺血：由于經(jīng)皮穿刺，損傷小，無鞘導(dǎo)管的應(yīng)用，這類并發(fā)癥已屬少見血栓形成：應(yīng)保持ACT(激活全血凝固時(shí)間)在150-180秒主動(dòng)脈內(nèi)膜損傷，動(dòng)脈破裂血小板減少氣栓感染，敗血癥IABP停用指征多巴酚丁胺＜5ug/kg/min心臟指數(shù)＞2.5L/min／m2平均動(dòng)脈壓＞90mmHg尿量＞4ml/kg/小時(shí)手足暖，末稍循環(huán)好減慢反搏頻率時(shí)，上述指標(biāo)穩(wěn)定一般不超過3天CompanyLogoIABP球囊的位置位置:左鎖骨動(dòng)脈以下2-3cm（第二肋間）和腎動(dòng)脈開口之間的降主動(dòng)脈內(nèi).確定位置:

可通過胸部X光片觀察導(dǎo)管尖端是否位于第2-3肋間.接IABP機(jī)器IABP球囊的位置異?！穹胖梦恢眠^高

氣囊可能阻塞左鎖骨下動(dòng)脈的開口左上肢灌注不足●放置位置過低氣囊可能阻塞腎動(dòng)脈的開口腎動(dòng)脈灌注不足尿量減少阻斷主動(dòng)脈截面積：球囊充氣后的大小應(yīng)該是主動(dòng)脈直徑的80-90%。如果球囊的太大，會(huì)損傷主動(dòng)脈；而球囊的體積太小，反搏會(huì)無效。IABP導(dǎo)管阻塞面積DiastoleSystole<162cm<5’4”<182cm<6’0”>182cm>6’0”30cc40cc50ccIABP導(dǎo)管型號(hào)選擇IABP導(dǎo)管

BalloonMembraneProximalMarkerUniversalSheathSealSTAT-GARDSleeveY-fittingExtracorporealTubingDistalMarkerCatheterShaftSuturePadsInnerLumenPort遠(yuǎn)端標(biāo)記球囊膜近段標(biāo)記延長(zhǎng)管延伸管導(dǎo)管軸通用鞘STAT-GARD軸中心管內(nèi)腔Y型接口球囊導(dǎo)管耗材的組成

2.連接壓力傳感器中心腔血壓監(jiān)護(hù)的連接示意Y接頭加壓鹽水袋保持300mmHg壓力連續(xù)沖洗裝置測(cè)壓管路長(zhǎng)度不超過8Ft或240cm連接至球囊反搏泵的魯爾接頭處導(dǎo)管連接顯示面板H-----HELIUM（氦氣）E-----ECG（心電圖）A-----AP（動(dòng)脈血壓）R-----RESET（球囊氣量設(shè)置）

RATIO（反搏比率）T-----TRIGGER（觸發(fā)模式）TIMING（充放氣時(shí)機(jī)）

I.PowerOn打開電源

II.PatientConnect病人連接

III.PumpOn啟動(dòng)泵IABP操作快速上路安裝氦氣瓶；打開減壓閥；如左圖屏幕右下方顯示氦氣余量。氦氣供應(yīng)在反搏中更換氦氣時(shí)無需中斷反搏，即可自動(dòng)填充開機(jī)后，自動(dòng)執(zhí)行排氣動(dòng)作ECG導(dǎo)線ECG信號(hào)傳輸線ECG信號(hào)的輸入接口

連接心電圖導(dǎo)線心電圖是綠色波，以白色部分突出充放氣時(shí)間動(dòng)脈壓是紅色波，以白色部分突出充放氣時(shí)間球囊壓是藍(lán)色波,以mmHg為單位波形顯示PSP、PDP、EDP、MAP壓力測(cè)量線（游標(biāo)），可測(cè)量血壓和球囊壓力上的任一點(diǎn)的壓力值壓力信號(hào)自動(dòng)校正，可分段顯示提供AP輸入、輸出接口觸發(fā)時(shí)機(jī)圖同步顯示在血壓圖上，以白色標(biāo)識(shí)顯示血壓信號(hào)充氣量調(diào)節(jié)球囊充氣量球囊壓力波形123456789零基線球囊壓力基線快速充氣充氣機(jī)械波充氣后的穩(wěn)定壓力快速放氣放氣機(jī)械波回復(fù)基線球囊充/放氣周期時(shí)間CompanyLogo球囊壓力波形球囊充氣氣量的設(shè)置保證PDP與球囊的平臺(tái)壓力在25mmHg之間反搏比率1:1，1:2，1:4，1:8反搏頻率

1:1

1:2

1:3觸發(fā)模式ACTA1PLUS規(guī)范型（PATTERN）峰型（PEAK）自動(dòng)房顫（AFIB）心室起搏觸發(fā)（VPACE）心房起搏觸發(fā)（APACE）血壓觸發(fā)（AP）最低3-5mmHg觸發(fā)內(nèi)觸發(fā)（INT）觸發(fā)模式AUTOCAT2觸發(fā)時(shí)機(jī)圖示充、放氣時(shí)間在R-R間期的標(biāo)識(shí)R波-R波間期表示在R-R間期的35%充氣、90%放氣ECG和AP信號(hào)的自動(dòng)識(shí)別，選擇，轉(zhuǎn)換觸發(fā)模式的自動(dòng)選擇充放氣時(shí)間的自動(dòng)選擇觸發(fā)模式AUTOCAT2ECG導(dǎo)聯(lián)間的轉(zhuǎn)換監(jiān)護(hù)儀和病人經(jīng)皮采集信號(hào)間的轉(zhuǎn)換在必要時(shí)在ECG和AP觸發(fā)間轉(zhuǎn)換持續(xù)ECG增益自動(dòng)縮放AP波形比例自動(dòng)選擇ECG/AP信號(hào)來源從6種觸發(fā)模式中自動(dòng)選擇合適的觸發(fā)模式根據(jù)ECG信號(hào)情況自動(dòng)在ECG和AP觸發(fā)間轉(zhuǎn)換自動(dòng)觸發(fā)模式的選擇根據(jù)信號(hào)選擇模式自動(dòng)選擇合適充放氣點(diǎn)在心律不規(guī)則時(shí)R波自動(dòng)放氣早搏后長(zhǎng)間歇自動(dòng)補(bǔ)償充放氣時(shí)機(jī)的自動(dòng)調(diào)整IABP的護(hù)理保證充足氦氣供應(yīng)

術(shù)前注意擰開氦氣瓶總開關(guān)和小開關(guān)，并檢查氦氣表。IABP使用期間，要隨時(shí)檢查壓力表，當(dāng)指針指向紅線時(shí)要更換氦氣瓶。

CompanyLogoIABP的護(hù)理確保球囊位置正確

①術(shù)前預(yù)測(cè)量待置入球囊的長(zhǎng)度。②術(shù)后立即拍床邊胸片，確保球囊位置正確。

CompanyLogoIABP的護(hù)理采取正確舒適的臥位，避免導(dǎo)管曲折

①嚴(yán)格臥床休息，適當(dāng)限制術(shù)肢的活動(dòng)，病情允許者床頭搖高不超過30°，側(cè)臥位是不超過40°，術(shù)肢伸直，避免屈曲。②下肢做被動(dòng)功能鍛煉，即肢體按摩、拍打。加強(qiáng)皮膚護(hù)理，預(yù)防褥瘡。CompanyLogoIABP的護(hù)理密切觀察病情①注意病人心率、心律、有創(chuàng)動(dòng)脈壓、反搏壓的變化，如出現(xiàn)心律失常而致反搏比例不當(dāng)時(shí)，及時(shí)報(bào)告醫(yī)生。在醫(yī)生指導(dǎo)下，適當(dāng)調(diào)整反搏比或球囊充氣放氣時(shí)間。②術(shù)后患者需要達(dá)到全身肝素化（ACT250～300秒，凝血酶原時(shí)間18±2秒），防止血栓形成。注意傷口出血情況及皮膚粘膜、尿液等有無出血。③注意觀察IABP并發(fā)癥的臨床表現(xiàn)。如每小時(shí)尿量、24小時(shí)出入量、雙側(cè)足背動(dòng)脈搏動(dòng)情況。CompanyLogoIABP的護(hù)理保證管道通暢及密閉性

①注意導(dǎo)管各連接處有無松動(dòng)、脫開及血液返流等情況出現(xiàn)。各接口緊密銜接。妥善固定有創(chuàng)動(dòng)脈導(dǎo)管并保持其通暢。每小時(shí)用肝素鹽水（NS500ml+肝素5000u）沖管。②保證壓力換能器位置始終處于心臟水平。注意定時(shí)校正零位，確保測(cè)壓值正確反映患者情況及IABP使用效果。③注意保護(hù)導(dǎo)管。嚴(yán)禁經(jīng)導(dǎo)管抽血或進(jìn)行其他治療，以免損傷球囊導(dǎo)管。

CompanyLogoIABP的護(hù)理確保反搏觸發(fā)信號(hào)清晰

確保心電圖信號(hào)清晰做到以下幾點(diǎn)：①固定好電極片。②心電圖導(dǎo)聯(lián)選用標(biāo)準(zhǔn)肢導(dǎo)聯(lián)中R波高尖，T波低平的導(dǎo)聯(lián)。③操作時(shí)要注意心電圖情況，防止心電導(dǎo)聯(lián)及電極脫落。必要時(shí)在操作時(shí)將心電圖觸發(fā)改為壓力觸發(fā)，同時(shí)注意反搏波形。IABP使用期間，密切觀察反搏波形及其振幅、球囊充氣、放棄時(shí)間是否正確。CompanyLogoIABP的護(hù)理正常的球囊壓力波形球囊壓力波形的變化CompanyLogo

正常的球囊壓力波形

心率慢時(shí)心率快時(shí)心率的影響球囊壓力波形的變化

血壓高時(shí)血壓低時(shí)血壓的影響球囊壓力波形的變化

正常波形充氣受限充氣受限球囊壓力波形的變化

正常波形排氣受限排氣受限球囊壓力波形的變化

導(dǎo)管扭曲球囊壓力波形的變化

漏氣球囊壓力波形的變化

持續(xù)充盈球囊壓力波形的變化舒張期切跡（DN）平均壓收縮壓PulsePressure舒張壓12010080收縮期舒張期mmHg如何確定正確的充放氣時(shí)機(jī)通過動(dòng)脈壓力波形來判斷及調(diào)節(jié)動(dòng)脈壓力波形圖WithoutIABPWithIABPassist1:2EKG動(dòng)脈壓力波形圖充放氣時(shí)機(jī)的調(diào)整主要是觀察機(jī)器以1:2比率反搏時(shí)的血壓波形

1。PDP點(diǎn)是否高于PSP點(diǎn)10mmHg的壓力值以上。（虛線①）

2。PSP點(diǎn)是否略高于APSP點(diǎn)。（虛線②）

3。PAEDP點(diǎn)是否略高于BAEDP點(diǎn)。（虛線③）PSPAPSP反搏輔助后的收縮壓BAEDP球囊在主動(dòng)脈內(nèi)的末期舒張壓PAEDP病患的主動(dòng)脈末期舒張壓PDP①②③動(dòng)脈壓力波形圖PDP應(yīng)大于PSP（PDP>PSP）除非: 1.病人每搏量遠(yuǎn)遠(yuǎn)大于球囊容量 2.導(dǎo)管位置太低 3.嚴(yán)重低血容量 4.球囊充氣量太小 5.體循環(huán)阻力太低

PSPPDP動(dòng)脈壓力波形圖時(shí)相錯(cuò)位-充氣過早有反搏收縮壓反搏壓有反搏舒張壓末尾沒反搏收縮壓

球囊于主瓣關(guān)閉前充氣波形特點(diǎn):球囊在V型切口前充氣舒張壓侵占收縮期(可能難以分辨）生理效應(yīng):主動(dòng)脈瓣提前關(guān)閉每搏量/心輸出量減少前負(fù)荷增加增加加心肌耗氧時(shí)相錯(cuò)位-充氣過晚有反搏收縮壓反搏壓

V型切口有反搏舒張壓末尾

沒反搏收縮壓球囊于主瓣關(guān)閉后較晚充氣波形特點(diǎn): ? 球囊在V型切口后充氣 ? 缺乏尖V ? 反搏壓不足生理效應(yīng): ? 冠脈灌注不足時(shí)相錯(cuò)位-放氣過早有反搏收縮壓反搏壓有反搏舒張壓末尾沒反搏舒張壓末尾球囊于舒張期內(nèi)過早放期波形特點(diǎn): ? 反搏壓出現(xiàn)后馬上看到其急降 ? 反搏壓不足 ? 有反搏舒張壓末尾可能等于或小于沒反搏舒張壓 ? 有反搏收縮壓可能提高生理效應(yīng): ? 反搏壓不足 ? 可能出現(xiàn)冠脈和頸動(dòng)脈逆流 ? 由于冠脈血液逆流可引起心絞疼

? 沒足夠后負(fù)荷降低效果 ? 增加心肌耗氧時(shí)相錯(cuò)位-放氣過晚反搏壓有反搏舒張壓末壓沒反搏收縮壓外觀加寬有反搏收縮壓上升時(shí)間延長(zhǎng)當(dāng)主瓣開始打開時(shí)球囊才放氣波形特點(diǎn):

? 有反搏舒張壓末壓可能等于沒反搏舒張壓末壓

? 有反搏收縮壓上升時(shí)間延長(zhǎng)

? 反搏壓外觀看來加寬生理效應(yīng):

? 完全沒有減低后負(fù)荷

? 由于是左心室射血的阻力增加和等容收縮期延長(zhǎng)而增加心肌耗氧

? 球囊阻擋左室心排血而增加后負(fù)荷充放氣時(shí)機(jī)三部曲CompanyLogo

1. 在DN前充氣

如果在DN前>40ms–充氣過早

如果可見DN–充氣過晚

APSPPDPPSPPAEDPPAEDPBAEDPDN705580HypotheticalBP=90/70充放氣時(shí)機(jī)三部曲CompanyLogo2. BAEDP<PAEDP

如果BAEDP≥PAEDP–放氣過晚

3. APSP<PSP

如果APSP=PSP–放氣過早

CompanyLogoAPSPPDPPSPPAEDPPAEDPBAEDPDN705580CompanyLogo患者信息姓名苗XX性別女年齡21歲民族漢族職業(yè)學(xué)生入院日期2013-05-15主訴呼吸心跳驟停25分鐘，心肺復(fù)蘇術(shù)后6小時(shí)病史05-15凌晨1:40左右，同學(xué)發(fā)現(xiàn)其在床上翻動(dòng)后，出現(xiàn)雙上肢抽搐，當(dāng)時(shí)臉色、口唇蒼白，呼之不應(yīng)，訴觸頸動(dòng)脈搏動(dòng)減弱，立即送至我院急診。2:05到達(dá)我院急診室，當(dāng)時(shí)患者處于昏迷狀態(tài)，呼之不應(yīng)，頸動(dòng)脈搏動(dòng)未捫及，立即行心肺復(fù)蘇術(shù)及氣管插管、“胺碘酮300mg”靜推、電除顫4次等搶救措施后患者于2:15恢復(fù)自主心率，心率167次/分，再次出現(xiàn)室顫，立即予電除顫、心肺復(fù)蘇術(shù)，于2:21恢復(fù)自主心率，當(dāng)時(shí)心率123次/分，血氧飽和度91%。2:56查心電圖示竇性心率，頻發(fā)室早。9點(diǎn)復(fù)查電解質(zhì)示鉀3.43mmol/l，鈣1.85mmol/l，現(xiàn)為求進(jìn)一步治療，轉(zhuǎn)入EICU治療。CompanyLogo病史既往史：2006年4月在當(dāng)?shù)蒯t(yī)院診斷為“頻發(fā)室早”，入院治療后好轉(zhuǎn)。2009年2月因“頻發(fā)室早”在外院行“射頻消融術(shù)”，2012年11月先后有兩次暈厥病史，每次時(shí)間短，可自行恢復(fù)。2013年3月開始服用“普羅帕酮”，100mg，每天3次。近一月反復(fù)出現(xiàn)心悸。家族史：其父親有“二尖瓣關(guān)閉不全”。CompanyLogo入室評(píng)估T36.5℃P148次/分R18次/分Bp92/46mmHg神志處于鎮(zhèn)靜狀態(tài)，Ramsay評(píng)分5分。雙側(cè)瞳孔等大等圓，直徑約2.0mm，對(duì)光反射遲鈍。帶入氣管插管在位，兩肺呼吸音稍粗，未聞及明顯干、濕啰音。心律齊，未及明顯病理性雜音。脊柱、四肢無畸形。四肢肌張力不高。CompanyLogo實(shí)驗(yàn)室及輔助檢查血?dú)夥治觯?013-5-1502:26本院）PH7.333，PCO237.0mmHg，PO2612mmHg，HCO319.6mmol/l，BE-6mmol/l，SpO2100%。

電解質(zhì)（2013-5-153:31本院）鉀3.43mmol/l，鈣1.85mmol/l。

心肌酶譜（2013-5-153:49本院）肌酸激酶同工酶48.80umol/l。

血?dú)夥治觯?013-5-1508:52本院）PH7.456，PCO231.5mmHg，PO2118mmHg，HCO322.1mmol/l，BE-2mmol/l，SpO299%，Lac2.48mmol/l。

CompanyLogo24小時(shí)動(dòng)態(tài)心電圖（2013-3-26南京市第一醫(yī)院）1、竇性心率；2偶發(fā)房性早搏；3頻發(fā)室性早搏，短暫性室性心動(dòng)過速；4、T波改變。

心電圖（2013-5-152:56本院）竇性心率，頻發(fā)室早。

床旁胸片（2013-5-154:06本院）右肺胸腔少量積液，兩肺紋理增多。CompanyLogo實(shí)驗(yàn)室及輔助檢查護(hù)理問題心輸出量減少與心泵功能降低有關(guān)（05-15）組織灌注量改變與有效循環(huán)血量減少有關(guān)（05-15）不能維持自主呼吸與鎮(zhèn)靜藥，肌松藥使用有關(guān)（05-15）有感染的危險(xiǎn)與低溫治療及各種導(dǎo)管留置有關(guān)（05-15）有皮膚完整性受損的危險(xiǎn)與臥床，IABP治療移動(dòng)減少有關(guān)（05-15）CompanyLogo護(hù)理問題營(yíng)養(yǎng)失調(diào)低于機(jī)體需要量與不能進(jìn)食，疾病消耗有關(guān)（05-15）潛在并發(fā)癥心跳呼吸驟停﹑出血﹑墜積性肺炎﹑心律失常﹑血栓﹑動(dòng)脈破裂（05-15）CompanyLogo護(hù)理目標(biāo)患者能維持足夠的心輸出量，生命體征平穩(wěn)及尿量正?；颊呓M織灌注量能得到改善患者能漸漸恢復(fù)自主呼吸直至完全脫機(jī)患者導(dǎo)管留置及低溫治療階段無感染發(fā)生患者住院期間皮膚能維持完整，無壓瘡發(fā)生患者能得到機(jī)體所需的能量供應(yīng)住院期間防治各種并發(fā)癥的發(fā)生CompanyLogo護(hù)理措施24h心電監(jiān)護(hù)，密切觀察患者神志，瞳孔，意識(shí)，皮膚溫度，有無出血傾向。記錄24h生命體征及出入量。做好IABP的護(hù)理遵醫(yī)囑按時(shí)準(zhǔn)確使用各種藥物，并注意觀察療效及不良反應(yīng)。遵醫(yī)囑控制輸液速度。做好各項(xiàng)基礎(chǔ)護(hù)理。保持皮膚的完整性，防止凍傷。定時(shí)翻身。做好各種導(dǎo)管的護(hù)理，標(biāo)示清晰，嚴(yán)格無菌操作。保持呼吸道通暢，按需吸痰。CompanyLogo備好搶救車除顫儀，隨時(shí)準(zhǔn)備配合醫(yī)生搶救。定時(shí)檢測(cè)血糖。遵醫(yī)囑留取血標(biāo)本，及時(shí)查看結(jié)果。做好床邊交接班。班班調(diào)節(jié)心電監(jiān)護(hù)呼吸機(jī)等的報(bào)警線。肺部聽診。做好患者家屬的解釋溝通工作。CompanyLogo護(hù)理措施05-1612點(diǎn)開始復(fù)溫。偶見室早，05-1701:29至01:30可見頻發(fā)室早。呼吸機(jī)模式改為A/C新護(hù)理問題復(fù)溫并發(fā)癥（心律失常）與亞低溫復(fù)溫治療有關(guān)目標(biāo)患者復(fù)溫階段未發(fā)生休克，心律失常次數(shù)減少措施做好復(fù)溫階段的護(hù)理。遵醫(yī)囑用藥，密切監(jiān)測(cè)體溫變化，生命體征，記錄24出入量，CVP；監(jiān)測(cè)血糖防止體溫上升過快，由于血管擴(kuò)張，回心血量減少，血壓下降而發(fā)生低血容量休克；如體溫不升，可增加蓋被等。CompanyLogo05-1709點(diǎn)停萬可松，10:30球囊反搏調(diào)為1:2。15:45拔出球囊反搏置管。停亞低溫治療。停靜安？停去甲腎？患者可睜眼，能明白言語，神志清。痰液呈黃白色。停亞低溫治療。右下肢腫脹，皮溫高。新護(hù)理問題有發(fā)生血栓的危險(xiǎn)與IABP治療有關(guān)目標(biāo)患者住院期間溶栓成功或血栓未脫落措施定時(shí)測(cè)量雙側(cè)下肢大腿圍，觀察下肢皮溫，足背動(dòng)脈搏動(dòng)情況。防止右下肢肢體動(dòng)作過大。CompanyLogo05-1808:20試停呼吸機(jī)，08:30遵醫(yī)囑拔出氣管導(dǎo)管，給予雙腔鼻導(dǎo)管吸氧5L/分。18點(diǎn)T38.7x℃。17日血常規(guī)示白細(xì)胞計(jì)數(shù)14.44×10^9/L，中性粒細(xì)胞91.20%，中性粒細(xì)胞計(jì)數(shù)13.17×10^9/L，淋巴細(xì)胞4.60%。新護(hù)理問題體溫過高與感染有關(guān)目標(biāo)患者3天內(nèi)體溫下降至正常措施遵醫(yī)囑使用物理降溫，1小時(shí)后復(fù)測(cè)體溫。做好降溫護(hù)理CompanyLogo05-1909點(diǎn)停多巴胺。發(fā)生肛周失禁性皮炎。新護(hù)理問題肛周失禁性皮炎目標(biāo)患者一周內(nèi)皮炎恢復(fù)措施使用液體敷料噴涂。增加翻身次數(shù)。保持局部清潔干燥。CompanyLogo05-20右下肢腫脹好轉(zhuǎn)05-21肛周失禁性皮炎好轉(zhuǎn),右下肢腫脹消退。CompanyLogo護(hù)理評(píng)價(jià)（05-23）患者生命體征平穩(wěn)，尿量正常，但仍有心衰的可能患者完全恢復(fù)自主呼吸患者有感染發(fā)生，體溫暫正?；颊咦≡浩陂g無壓瘡發(fā)生患者能得到機(jī)體所需的能量供應(yīng)患者有室早的發(fā)生患者皮炎好轉(zhuǎn)，右下肢腫脹消退CompanyLogoYourcompanysloganThankYou!8686贈(zèng)送2套亮麗色表格可一鍵刪除折線圖/表格/數(shù)據(jù)關(guān)系Trending

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