内科护理学第6章第7节弥散性血管内凝血的护理.ppt

出版社 医学分社 内科护理学 * In patients with disseminated intravascular coagulation, fibrin is formed as a result of the generation of thrombin mediated by tissue factor. Tissue factor, expressed on the surface of activated mononuclear cells and endothelial cells, binds and activates factor VII. The complex of tissue factor and factor VIIa can activate factor X directly (black arrows) or indirectly (white arrows) by means of activated factor IX and factor VIII. Activated factor X, in combination with factor V, can convert prothrombin (factor II) to thrombin (factor IIa). Simultaneously, all three physiologic means of anticoagulation — antithrombin III, protein C, and tissue factor–pathway inhibitor (TFPI) — are impaired. The resulting intravascular formation of fibrin is not balanced by adequate removal of fibrin because endogenous fibrinolysis is suppressed by high plasma levels of plasminogen-activator inhibitor type 1 (PAI-1). The high levels of PAI-1 inhibit plasminogen-activator activity and consequently reduce the rate of formation of plasmin. The combination of increased formation of fibrin and inadequate removal of fibrin results in disseminated intravascular thrombosis. FDPs denotes fibrin-degradation products. * 第六章 第七节 弥散性血管内凝血的护理 * 病例导入 患者女性，48岁。因大面积烧伤2周，伴发感染性休克，护士在观察病情时发现其皮肤上有瘀点、瘀斑。该患者神志不清、脉搏细速、呼吸浅促、血压70/50mmHg、无尿。 实验室检查：血小板40x109/L，纤维蛋白原1.0g/L，凝血酶原时间延长，3P实验阳性。 问题: （1）该患者皮肤上出现有瘀点、瘀斑的原因是什么？ （2）为了控制病情，应采取哪些主要的护理措施？ 弥散性血管内凝血( disseminated intravascular coagulation，DIC)是由多种致病因素激活机体的凝血系统，导致机体弥漫性微血栓形成、凝血因子大量消耗并继发纤溶亢进，从而引起全身性出血、微循环障碍乃至单个或多个器官功能衰竭的一种临床综合征。本病多起病急，进展快，死亡率高，是临床急重症之一。 DIC概念 一、概 述 DIC的病因和发病机制 由多种病因引起,通过激活凝血和纤维蛋白溶解系统造成DIC 一、概 述 （一）组织严重破坏，启动凝血系统 原因：手术、创伤、产科意外、肿瘤，即本症患者常发生于严重感染（败血症、重症肝炎），严重创伤（挤压伤、体外循环），广泛性手术（扩大根治术、大面积灼伤），恶性肿瘤（广泛转移、早幼粒细胞白血病），产科意外（羊水栓塞、胎盘早期剥离），以及其他疾病（溶血性输血反应、呼吸窘迫综合征）等。 机制：III因子进入血液，启动凝血系统 （二）血管内皮受损 原因：内毒素、病毒、缺氧、炎性反应等 （三）血细胞