急救课件：急诊分诊.ppt

Level1-ResuscitationCardiacarrestRespiratoryarrestMajortraumainshockShortnessofbreath(severerespritarydistress)Alteredlevelofconsciousness(unconscious,GCS3-9)心跳呼吸停止怀疑心肌梗死引起的胸痛严重心律失常中度烧伤呼吸道梗阻、呼吸窘迫严重创伤大出血张力性气胸等过敏性休克《急危重症护理学》《急危重症护理学》《急救护理学》急诊分诊EmergencypatientsareuniqueNotallpatientareaswellastheyappearandnotallpatientsareassickastheythink.分诊Triage分诊Triage是指对病情种类和严重程度进行简单、快速的评估与分类，确定就诊的优先次序，使病人因为恰当的原因在恰当的时间、恰当的治疗区获得恰当的治疗与护理的过程.Thegoalforallpartsofhealthcarecontinuumis“rightpatient,rightplace,righttimewithrightcaregiver”.whatisTriage?Asortingprocessutilizingciriticalthinkinginwhichanexperiencednurseassessespatientsquicklyupontheirarrivalatanemergencysettingto:1.assessanddetermineseverityofpresentingproblems2.processpatientsintoatriagecategory3.determineaccesstoappropriatetreatment4.effectivelyandefficientlyassignappropriatehumanhealthresourcesAvoidingTriageasablockThetriageprocessshouldnotbecomeablockorsignificantdelay,butratherawayof“streaming”patientstothemostappropriatecarearea.分诊处的设置位置:面对急诊科大门的明显处物品:电话、电脑、平板车、轮椅、血压计、听诊器、体温计及各种表格等人员:急诊护士,导诊员或秘书急诊分诊程序

TriageprocessTriageprocessPatientsarrivalCriticallookAairwayBBreathingCCirculationDDisability(neurological)急诊护理评估1.Aairway气道及颈椎气道阻塞的原因？气道阻塞如何处理？保持气道通畅的方法？人工气道分类常见非确定性紧急人工气道技术手法开放气道：常用提颏和双手抬颌法。口咽和鼻咽通气管喉罩常见确定性紧急人工气道技术经口气管插管术经鼻气管插管术：纤维支气管镜引导气管插管气管切开术人工气道分类通气导管口咽通气导管鼻咽通气导管喉罩气管插管经口气管插管经鼻气管插管气管切开置管经皮穿刺气管造口置管术环甲膜穿刺/切开术急诊护理评估2.BBreathing呼吸功能呼吸功能评估包括哪些？呼吸功能异常如何处理？急诊护理评估3.CCirculation循环功能循环功能评估包括哪些？循环功能异常如何处理？急诊护理评估4.DDisability(neurological)神志状况:AVUP法AlertVocalPainUnresponsive法5.暴露患者/环境控制TriageprocessInfectioncontrolSubjectiveAssessmentObjectiveAssessmentSelectingpresentingcomplaintTheTriageDecision病情严重程度分类系统CTASlevels国际“TRIAGE”分级《急危重症护理学