《心肺监护室护理手册》

引言1

Introduction1

TABLE OF CONTENTS CARDIOTHORACIC INTENSIVE CARE PROCEDURES FOR NURSING CARE1

Ⅰ．Patient Assessment2

Assessment Guidelines for the Intensive Care Unit Patient2

监护室（ICU）病人评估规则3

第一章 病人评估3

Patient Admission to Intensive Care6

病人进入监护室的操作程序7

Vital Signs10

生命体征11

Ⅱ．Respiratory Care14

Airway Management14

Airway Management14

气道管理15

气道管理15

第二章 呼吸护理15

Oxygen Support Devices18

给氧辅助设施19

Cough and Deep Breathing22

咳嗽和深呼吸23

Nasotracheal Suctioning30

鼻气管吸引31

Tracheostomy36

Tracheal Suctioning36

气管吸引法37

气管切开术37

Tracheostomy Care40

气管切开术的护理41

Assisting with Oral Endotracheal Intubation44

Endotracheal Intubation44

协助放置经口气管内插管45

气管内插管45

Mechanical Ventilation50

机械性通气51

Endotracheal Suctioning-Intubated Patient56

插管病人气管内吸痰57

Cuff Deflation and Inflation Using Minimal Occlusive Volume Technique62

用最小闭合容积（MOV）技术给套囊放气和充气63

Ventilation with a Manual Resuscitation Bag66

用人工急救气囊通气67

Weaning from Mechanical Ventilation70

脱离机械性通气71

Extubation76

拔管77

Chest Physiotherapy80

Chest Physiotherapy80

胸部物理治疗（CPT）81

胸部物理治疗81

Chest Physiotherapy-Intubated Patient84

插管病人CPT85

Chest Physiotherapy-Non-Intubated Patient88

无气管插管病人的CPT89

Pulse Oximetry92

Nellcor Pulse Oximeter92

脉冲式血氧定量法93

尼哥尔（Nellcor）脉冲式血氧计93

Novametrix Pulse Oximeter98

露华美（Novametrix）脉冲式血氧计99

Chest Drainage Systems106

Chest Drainage Systems106

胸腔引流系统107

胸腔引流系统107

Chest Tube Management-One Bottle System110

胸腔引流护理（一瓶）111

Ⅲ．Cardiac Care116

Hemodynamics116

Hemodynamic Monitoring116

血液动力117

血动力监测117

第三章 心脏护理117

Pressure Transducer System118

压力换能系统119

Arterial Blood Pressure Monitoring124

动脉血压监测125

Central Venous Pressure Monitoring130

中心静脉压监测131

Pulmonary Artery Pressure Monitoring134

肺动脉压监测135

Left Atrial Pressure Monitoring144

左心房压力监测145

Cardiac Output Measurement150

心输出量的测量151

Hemodynamic Line Care158

Pressure Monitoring-Static Calibration158

压力监测一静态测试159

血动力插管护理159

Arterial Puncture162

动脉穿刺163

Site Care-Pulmonary Artery,Central Venous Pressure Line and Arterial Line170

肺动脉、中心静脉及动脉插管穿刺点护理171

ECG Monitoring174

ECG Lead Systems174

心电图监测175

心电图导联系统175

12 Lead ECG180

12导联心电图181

Defibrillation188

除颤189

Cardioversion194

心律转变195

Temporary Pacemaker Therapy204

Temporary Pacemaker Therapy204

暂时性起搏器治疗205

暂时性起搏器治疗205

Use of A-V Sequential Pacemaker210

使用房一室顺序起搏器211

Ⅳ．IV Therapy214

IV Technique214

Placement of an IV Catheter214

第四章 静注护理215

静注技术215

放置静注管215

Removing an IV Catheter220

除去静注管221

IV Site Care222

静脉穿刺点护理223

Blood and Blood Product Administration-Transfusion Reactions226

Blood and Blood Administration226

血和血产品的输入227

Transfusion Reactions238

血和血产品的输入——病人出现输血反应239

IV Infusion Pumps240

Harvard Pump240

静脉输液泵241

哈佛（Harvard）泵241

Autosyringe Pump242

自动注射泵243

Ⅴ．Gastrointestinal Care244

Nasogastric Tube Insertion244

第五章 胃肠护理245

放置鼻胃管245

Tube Feeding Administration250

经管喂食251

Ⅵ．Renal Care254

Catheterization of the Urinary Bladder254

第六章 肾护理255

膀胱插管255

Urinary Catheter Care258

导尿管的护理259

Ⅶ．Wound Care260

Wound Carc260

第七章 伤口护理261

伤口护理261

Wound Care and Dressing Change264

伤口护理和更换敷料265

Ⅷ．Infection Control Guidelines268

第八章 控制感染的规则269

Drugs Used in Advanced Cardiopulmonary Resuscitation276

Ⅸ．Additional Nursing Care276

高级心肺复苏术（CPR）常用的药物277

第九章 其它护理277

Patient Teaching Form286

Ⅹ．Intensive Care Unit Preoperative Patient Teaching286

病人室教表287

第十章 监护室术前病人室教287

ICU Nurse Performance Checklist290

Ⅺ．Nursing orientation to the Intensive Care Unit290

第十一章 监护室护理指引291

监护室护士工作表291

ICU Examination300

监护室测验301

Answers for ICU Examination318

监护室测验答案318

References319

参考文献319