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    ISPN总复习 皮肤系统 (II) Integumentary System
    日期:2015-12-11 14:04:04    来源:奥医教育
    Integumentary System (II)
    皮肤系统(II
     
    关键词:皮肤 表面积 防线 感染 感觉 表皮 真皮 皮下脂肪 细菌 遗传 体像 伤口 愈合 肤色 中毒 叮咬 冻伤 烧伤  
     
    对应章节:Saunders Chapter 50
     
    Contents  本章目录
    XX. BURN INJURIES  烧伤
    XXI. TYPES OF BURNS 烧伤种类
    XXII. INHALATION INJURY 吸入性损伤
    XXIII. PATHOPHYSIOLOGY OF BURNS 烧伤病理生理学
    XXIV. MANAGEMENT OF THE BURN INJURY 烧伤管理
     
    Focus  本章要点:
    The Pyramid to Success focuses on the concept that the integumentary system provides the first line of defense against infections. Focus on the protective measures necessary to prevent infection, including methicillin-resistant Staphylococcus aureus (MRSA). Pyramid Points address the risk factors related to the development of integumentary disorders, and the preventive measures related to skin cancer. Focus on the emergency measures related to a client with a burn, fluid resuscitation, monitoring for complications, and skin grafting. Psychosocial issues relate to the body image disturbances that can occur as a result of the integumentary disorder.
    本章重点了解皮肤系统对感染的一线防御作用,包括预防感染必需的保护性措施,如抗甲氧西林金黄色葡萄球菌(MRSA)。本章内容还包括皮肤疾病相关风险因素及皮肤癌相关预防措施,及与烧伤、体液复苏、并发症监测、皮肤移植等相关的急诊措施。皮肤疾病引起的本像障碍,其相关心理问题也是本章内容之一。
     
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    XX. BURN INJURIES (see Priority Nursing Actions) 烧伤(优先护理措施)

    PRIORITY NURSING ACTIONS
    Actions to Take in the Emergency Department for a Client With a Burn Injury
     急诊室处理烧伤患者时采取的行动。
    1. Assess for airway patency.  评估气道通畅性。
    2. Administer oxygen as prescribed. 按要求输氧。
    3. Obtain vital signs. 获得生命体征。
    4. Initiate an intravenous (IV) line and begin fluid replacement as prescribed.
     建议IV管路,按要求补液。
    5. Elevate the extremities if no fractures are obvious.
     无明显骨折时,抬高四肢。
    6. Keep the client warm and place the client on an NPO status.
     保持患者温暖,患者NPO。
      The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority action is to assess for an airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the physician. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken the nurse performs a complete assessment, stays with the client, and monitors the client closely. Additionally, tetanus toxoid may b e prescribed for prophylaxis.
      烧伤的主要护理目标是保持气道开放,IV输液,预防低血容量性休克,保护器官功能。因此,优先行动是评估气道是否开放并保持其开放。护士接着作好输氧准备。氧气输送系统类型由医生决定。氧气是组织和器官灌注的必须。应及时评估生命体征,获取基线数据,供液体复苏起动后后续生命体征比较用。护士建立IV管路,开始按规定补充液体。抬高肢体(若无明显骨折),协助防止休克出现。保持患者温暖(用无菌织物)、禁食,因为烧伤后出现胃肠功能改变。可插入福利导管,仔细监测液体复苏反应。采取上述行动后,护士进行完整的评估,陪伴患者,密切监测患者,此外,可处破伤风类毒素,起预防作用。
     




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