第十一章颅脑损伤病人的护理课件

andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies第十四章颅脑损伤病人的护理andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅脑损伤患者的护理头皮损伤颅骨骨折脑损伤andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头皮损伤类型andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头皮解剖结构硬脑膜颅骨4.硬脑膜外血肿骨膜帽状腱膜2.帽状腱膜下血肿：范围大，张力低1.皮下血肿：体积小，张力高3.骨膜下血肿：多伴颅骨骨折andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头皮损伤头皮血肿（scalphematoma）•处理原则较小的头皮血肿无需特殊处理；若血肿较大，则应在严格消毒下，穿刺抽吸后加压包扎减轻疼痛：早期冷敷，24～48小时后改用热敷。嘱病人勿用力揉搓预防并发症：观察病人的意识、生命体征和瞳孔有无变化，警惕合并颅骨骨折及脑损伤的可能andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头皮损伤头皮裂伤（scalplaceration）•临床特点出血多，可引起失血性休克•处理原则现场急救可局部压迫止血，争取24小时内清创缝合andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies头皮损伤头皮撕脱伤（scalpavulsion）•临床特点剧烈疼痛和大量出血而发生休克，有时合并颈椎损伤•急救与治疗现场加压包扎止血，抗休克，及早清创和抗感染治疗。完全撕脱的头皮用无菌敷料包裹，隔水放置于有冰块的容器内随病人一起速送医院，争取清创后再植andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅骨骨折分类按骨折形态分为线性骨折和凹陷性骨折凹陷性骨折线形骨折andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅骨骨折分类按骨折部位分为颅盖骨折和颅底骨折andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅底骨折•病因：颅盖骨折线延伸或间接暴力作用于颅底•临床表现：部位脑脊液漏瘀斑部位可能累及的脑神经前鼻漏眶周、球结膜下嗅神经、视神经（“熊猫眼”征）中鼻漏或耳漏乳突区（Battle征）面神经、听神经后无乳突和枕下部第9～12对脑神经咽后壁andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅前窝骨折•熊猫眼征、鼻漏andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅中窝骨折•乳突瘀斑（battle’ssign）、鼻漏/耳漏andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅骨骨折处理原则•颅盖骨折：线形骨折或凹陷性骨折下陷较轻，一般不需处理；大面积骨折片陷入颅腔，合并脑损伤者，需手术处理•颅底骨折：本身无特殊处理，重点是预防颅内感染，脑脊液漏一般在2周内愈合。脑脊液漏4周不自行愈合者，需作硬脑膜修补术andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅骨骨折护理措施•预防颅内感染体位：头高位卧位，头偏向患侧保持局部清洁*发生脑脊液漏时,不可堵塞或冲洗鼻腔及耳道，头高位卧床休息，避免用力咳嗽、打喷嚏和擤鼻，用抗生素和TAT防感染andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（一）概念脑膜、脑组织、脑血管及脑神经损伤。损伤机制•造成脑损伤的机制，概括为两种作用力：①接触力②惯性力andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤病因与分类开放性脑损伤闭合性脑损伤原发性脑损伤：暴力作用造成脑损伤（当时发生）继发性脑损伤：受伤后逐渐发生，加重andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（二）脑震荡临床表现•伤后立即出现意识障碍，不超过30分钟•逆行性遗忘•其他：可伴有皮肤苍白、出汗、血压下降、心动徐缓、呼吸浅慢、肌张力降低、生理反射迟钝或消失等自主神经和脑干功能紊乱的表现•神经系统检查无阳性体征andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（二）脑震荡辅助检查•脑脊液检查无红细胞，CT检查颅内亦无阳性发现处理原则•一般卧床休息1～2周，可适当给予镇痛、镇静药物•对症处理。多数病人2周内恢复正常andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（四）颅内血肿:最常见、最危险的继发性损害•硬脑膜外血肿•硬脑膜下血肿•脑内血肿硬脑膜外血肿硬脑膜下血肿脑内血肿硬脑膜andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（四）颅内血肿临床表现•硬脑膜外血肿意识障碍：有三种类型，典型的意识障碍是伤后昏迷有“中间清醒期”颅内压增高及脑疝表现andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（四）颅内血肿临床表现•硬脑膜下血肿急性硬脑膜下血肿：脑实质损伤较重，原发性昏迷时间长，少有“中间清醒期”，较早出现颅内压增高和脑疝症状慢性硬脑膜下血肿：有轻微头部外伤史，主要表现为慢性颅内压增高表现andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（四）颅内血肿临床表现脑内血肿：•进行性加重的意识障碍为主•病情进展快，易形成脑疝•局灶症状体征andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（四）颅内血肿处理原则•手术治疗颅内血肿一经确诊原则上手术治疗，行开颅血肿清除术并彻底止血慢性硬脑膜下血肿若已经形成完整的包膜，可采用颅骨钻孔引流术•非手术治疗若颅内血肿较小，可先采用脱水等非手术治疗。应做好手术前准备andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（三）脑挫裂伤临床表现•意识障碍立即出现，多数病人超过半小时，可长达数小时、数日不等，严重者长期持续昏迷•局灶症状和体征伤后立即出现相应的神经功能障碍症状或体征•生命体征改变andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（三）脑挫裂伤辅助检查•CT检查是首选项目，可了解脑挫裂伤的部位、范围及脑水肿的程度。MRI检查也有助于明确诊断•腰椎穿刺检查脑脊液含大量红细胞，同时可测量颅内压或引流血性脑脊液andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies脑损伤（三）脑挫裂伤处理原则•以非手术治疗为主。颅内压增高明显甚至出现脑疝迹象时，应及时手术治疗andHyperthermiaAssociatedwithPoisoningorandNeonatalRespiratoryCareEmbryologicDevelopmentBirthsObstetricEmergencies颅脑损伤患者护理【护理评估】【护理问题】【护理措施】现场急救•保持呼吸道通畅•妥善处理伤口andHyperthermiaAssociatedwithPoisoningorandNeon