體格檢查頭部檢查課件

匯報人：xxx20xx-03-15體格檢查頭部檢查ppt課件目錄頭部檢查概述頭皮與顱骨檢查面部器官檢查頸部檢查腦部神經(jīng)檢查頭部常見疾病與體征01頭部檢查概述Part評估頭部形態(tài)、結(jié)構(gòu)以及功能狀況，發(fā)現(xiàn)潛在疾病或異常情況。目的頭部檢查是體格檢查的重要組成部分，對于診斷顱內(nèi)疾病、神經(jīng)系統(tǒng)疾病等具有重要意義。意義頭部檢查目的與意義詢問病史→觀察頭顱形態(tài)→檢查頭皮及顱骨→檢查眼、耳、鼻、口等器官→進(jìn)行神經(jīng)系統(tǒng)檢查。流程包括視診、觸診、叩診、聽診等，必要時需借助輔助檢查設(shè)備如CT、MRI等。方法頭部檢查流程與方法以下附贈各項(xiàng)管理制度英文版（不需要可刪）急救藥品、器材管理制度:1.Rescuedrugsandequipmentshouldbe"fivefixed"(fixedquantityandvariety,designatedplacement,designatedpersonstorage,regulardisinfectionandsterilization,regularinspectionandmaintenance)and"twotimely"(timelyinspectionandmaintenance,timelyreceiptandsupplementation).Theitemisclearlymarkedandcannotbeusedarbitrarily.2.Thenecessaryrescueequipmentiscomplete,ingoodperformance,andinstandbycondition.3.Therescuedrugsarecomplete,withcleardruglabelsandnodiscoloration,deterioration,expiration,ordamage.Theyshouldbeplacedandusedintheorderofdrugexpirationdates(fromrighttoleft).4.Emergencydrugsanditemsforeachdepartment'srescuevehicleshallbeuniformlyequippedaccordingtorequirements.Specializedemergencydrugsanditemsmustbereviewedandapprovedbythedepartmentdirectortodeterminethetype,quantity,specifications,anddosagetobeequipped.Rescuevehiclesmustbeplacedindesignatedlocationsandmanagedbydesignatedpersonneltoensuresafetyandeaseofuse.5.Afterusingrescuedrugsandequipment,theyshouldbefullyreplenishedwithin24hours.Iftheycannotbereplenishedduetospecialreasons,theyshouldbenotedonthehandoverregistrationformandreportedtotheheadnurseforcoordinationandresolutiontoensuretimelyuseduringpatientrescue.6.Thereisaregistrationbookfortheprovisionofdrugsandequipment.Ensureconsistencybetweenaccountsandmaterials,andhandoverbetweenshifts.7.Managementofsealedrescuevehicles:Beforesealing,theheadnurse(ornurseincharge)andanothernurseshallcountthedrugsandequipmentaccordingtotheregistrationbookofdrugandequipmentequipment,verifytheiraccuracy,andsealthemwithaseal.Twopeopleshallsignandfillinthesealingtime.Nurseschecktheconditionofthesealsoncepershiftandcompletethehandover.Theresponsiblenursescheckonceaweek,andtheheadnurseandresponsiblenursesopenthesealsandinspectthedrugsandequipmentintheambulanceonceamonth,withrecordskept.8.Nonsealedrescuevehiclemanagement:Eachshiftshallcountthedrugsandequipmentaccordingtotheregistrationbookandcompletethehandover.Theresponsiblenurseshallinspectonceaweek,andtheheadnurseshallinspectonceeverytwoweeksandkeeprecords,ensuringthattheaccountsmatchthematerials.護(hù)理文書書寫制度:

1.Nursingstaffstrictlyfollowthelatestrequirementswhenwritingnursingmedicalrecords.2.Thecontentofnursingrecordsshouldbeobjective,truthful,accurate,timely,complete,andstandardized.3.Allnursingdocumentsshouldbewrittenwithablueblackorcarboninkpen.4.AllnursingdocumentsshouldbewritteninArabicnumeralsfordateandtime,withdatesinyears,months,anddays,usinga24-hoursystem,specifictominutes.5.WritingshoulduseChinese,medicalterminology,andcommonlyusedforeignlanguageabbreviations;Completerecorditems;Thetextisneat,thehandwritingisclear,andthelayoutisclean;Accurateexpression,fluentsentences,simpleandconcise:correctformatandpunctuation,notypos.6.Whenerrorsoccurduringthewritingprocess,doublelinethemonthewrongwords,keeptheoriginalrecordclearanddistinguishable,signthemodifier,indicatethemodificationtime,continuetowritethecorrectcontent,anddonotusescraping,sticking,paintingorothermethodstocoveruporremovetheoriginalhandwriting.Eachpageshouldbemodifiednomorethantwotimes,otherwisetheoriginalrecorderwillpromptlycopyagain(exceptformodificationsmadebysuperiors).7.Nursingrecordswrittenbyinternnurses,probationarynurses,orunregisterednursesshouldbereviewedandsignedbynurseswithlegalprofessionalqualificationsinthismedicalinstitution.8.Furthertrainingnursescanonlywritenursingdocumentsafterbeingrecognizedbythemedicalinstitutionreceivingthetrainingfortheirworkability.9.Superiornursingstaffhavetheresponsibilitytoreviewandmodifythewrittenrecordsofsubordinatenursingstaff.Whenmakingmodifications,reddoublelinesshouldbeusedtomarkerrors,writethemodifiedcontent,signandindicatethemodificationtime.10.Temperaturerecords,medicalorders,patientcarerecords,andsurgicalinventoryrecordsshouldbearchivedontime.頭部檢查注意事項(xiàng)環(huán)境安靜、光線適宜確保檢查環(huán)境安靜，光線適宜，有利于準(zhǔn)確觀察頭部情況。與患者保持良好溝通在檢查過程中與患者保持良好溝通，解釋檢查目的和方法，消除患者緊張情緒。尊重患者隱私在檢查過程中，應(yīng)尊重患者隱私，保護(hù)患者個人信息。注意檢查順序按照一定順序進(jìn)行檢查，避免遺漏重要部位或器官。02頭皮與顱骨檢查Part觀察頭皮顏色、有無腫脹、瘢痕、腫物或異常分泌物等。檢查頭皮的質(zhì)地、壓痛、包塊等，注意有無波動感或顱骨缺損。頭皮外觀與觸診觸診頭皮外觀顱骨形態(tài)觀察顱骨的輪廓、大小、形狀及對稱性，判斷有無顱骨畸形。壓痛檢查用適當(dāng)?shù)牧α堪磯猴B骨各部位，詢問患者有無疼痛感，以判斷顱骨及顱內(nèi)病變的可能性。顱骨形態(tài)與壓痛檢查顱縫檢查觸摸顱縫的閉合情況，判斷有無顱縫早閉或異常增寬。囟門檢查對于嬰幼兒，觀察前囟和后囟的閉合情況、大小、張力等，以評估顱內(nèi)壓及腦發(fā)育狀況。顱縫與囟門檢查03面部器官檢查Part1423眼部檢查眼瞼觀察眼瞼有無水腫、下垂，結(jié)膜有無充血、水腫。眼球檢查眼球運(yùn)動是否自如，有無凸出或凹陷，鞏膜有無黃染。瞳孔觀察瞳孔大小、形態(tài)，對光反射是否靈敏。視力檢查視力是否正常，有無近視、遠(yuǎn)視等屈光不正。耳部檢查耳廓觀察耳廓有無畸形、紅腫、結(jié)節(jié)。外耳道檢查外耳道有無分泌物、異物，鼓膜是否完整。聽力通過對話或音叉試驗(yàn)初步判斷聽力是否正常。STEP01STEP02STEP03鼻部檢查鼻外觀觀察呼吸時鼻翼是否煽動，判斷呼吸頻率和深度。鼻翼煽動鼻腔檢查鼻腔是否通暢，有無分泌物、異物或出血。觀察鼻部皮膚顏色、有無腫脹、畸形?？诖接^察口唇顏色、有無干裂、皰疹。牙齒檢查牙齒排列是否整齊，有無齲齒、殘根、缺牙。牙齦觀察牙齦顏色、有無腫脹、出血。口腔黏膜檢查口腔黏膜是否完整，有無潰瘍、白斑等異常表現(xiàn)。舌觀察舌體大小、形態(tài)，舌苔顏色、厚薄，舌質(zhì)顏色，伸舌是否居中，有無震顫。咽喉檢查咽喉部有無充血、水腫、分泌物，扁桃體大小、形態(tài)、有無化膿等?？谇粰z查04頸部檢查Part頸部外觀與觸診頸部外觀觀察頸部是否對稱，有無腫塊、瘢痕、瘺管等異常表現(xiàn)。頸部觸診通過觸摸檢查頸部肌肉、淋巴結(jié)、甲狀腺等結(jié)構(gòu)是否正常，有無壓痛、結(jié)節(jié)等異常體征。評估頸部前屈、后伸、側(cè)屈及旋轉(zhuǎn)等活動范圍是否正常?；顒臃秶^察頸部活動時是否平穩(wěn)、協(xié)調(diào)，有無疼痛、僵硬等異常表現(xiàn)?；顒淤|(zhì)量頸部活動度檢查VS通過觸診和聽診檢查頸部動脈、靜脈等血管是否正常，有無異常搏動、雜音等體征。神經(jīng)檢查評估頸部神經(jīng)支配區(qū)域的感覺、運(yùn)動功能是否正常，有無麻木、疼痛、肌力減退等異常表現(xiàn)。血管檢查頸部血管與神經(jīng)檢查05腦部神經(jīng)檢查Part按功能可分為感覺神經(jīng)、運(yùn)動神經(jīng)和混合神經(jīng)三類。常見損傷原因包括外傷、腫瘤、炎癥等，損傷后可出現(xiàn)相應(yīng)神經(jīng)功能障礙。腦神經(jīng)共有12對，左右成對發(fā)出，主要分布于頭面部，其中迷走神經(jīng)還分布到胸腹腔內(nèi)臟器官。12對腦神經(jīng)概述注意事項(xiàng)避免使用刺激性較強(qiáng)的溶液，如醋、酒精等。檢查方法讓患者閉目并用手指堵住一側(cè)鼻孔，然后用有氣味但無刺激性的溶液（如松節(jié)油、香水等）置于患者另一側(cè)鼻孔下，讓其說出所聞到的氣味。異常表現(xiàn)嗅神經(jīng)受損時，患者可出現(xiàn)嗅覺減退或喪失。嗅神經(jīng)檢查觀察患者眼球運(yùn)動及瞳孔變化，檢查視力及視野范圍。檢查方法注意事項(xiàng)異常表現(xiàn)在檢查視力時，應(yīng)讓患者遮擋一側(cè)眼睛，用另一側(cè)眼睛注視目標(biāo)。視神經(jīng)受損時，患者可出現(xiàn)視力下降、視野缺損等；視交叉受損時，可出現(xiàn)雙眼視野顳側(cè)偏盲。030201視神經(jīng)與視交叉檢查動眼神經(jīng)、滑車神經(jīng)、展神經(jīng)檢查位聽神經(jīng)檢查舌咽神經(jīng)、迷走神經(jīng)檢查副