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呼吸衰竭专科护理【PPT展示】

  • 2026-07-19 10:32:20
呼吸衰竭专科护理【PPT展示】
重症呼吸衰竭护理查房
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那天收了一个病人，CO₂潴留到呼吸机都打不进去，人已经昏了。家属问怎么突然就不行了。他说前两天还在家自己吸氧，流量开得很大，觉得吸了舒服。结果越吸越没力气，到送医院的时候，血CO₂分压已经冲到了90多，pH掉到了7.1。
这是典型的Ⅱ型呼衰病人高浓度吸氧之后的结果。不是氧不够，是给的氧太多了。呼吸中枢对高CO₂已经麻木了，完全靠低氧刺激维持呼吸。给了纯氧，这个刺激瞬间消失，呼吸就停了。CO₂排不出去，越积越多，最后CO₂麻醉、脑死亡。所以Ⅱ型呼衰的吸氧原则就是低流量，这个道理在RICU要反复跟家属解释清楚。
Ⅰ型和Ⅱ型呼衰的病理本质不一样。Ⅰ型是换气障碍——肺泡塌陷了或者弥散屏障加厚了，氧气过不去。血气表现为PaO₂低于60，但PaCO₂正常。Ⅱ型是通气障碍——气道堵了，气流进不去也出不来。血气PaO₂低于60同时PaCO₂高于50。这两种情况在RICU都常见，处理路径完全不同。
氧合指数是ARDS柏林分级的标准。轻度是200到300，中度是100到200，低于100就是重度。跌破100的时候，常规的呼吸机参数已经拉到头了，这时候要考虑的已经不是调高PEEP或者FiO₂，而是ECMO备机。
ARDS的核心病理是表面活性物质被炎症破坏，肺泡大面积塌陷。血液流经这些塌陷的肺泡时无法获氧，直接返回左心，形成右向左分流。这就是为什么有些ARDS病人给纯氧血氧也上不去——不是氧不够，是肺泡根本没有换气功能了。
护理诊断的优先级要排清楚。气体交换受损排第一，这是直接威胁生命的。清理呼吸道无效排第二，痰堵了通气就更差了。VAP和气胸是极高危并发症，插了管的病人要时刻盯着。还有潜在并发症——严重缺氧导致肺动脉高压，右心衰竭可能悄无声息地来。
无创通气有明确的界限。意识不清的、气道分泌物多到咳不出来的、频繁呕吐或者上消化道出血的，这些情况不能勉强上面罩。强行上只会延误插管时机。有些病人上了无创一两个小时，大汗淋漓，胸锁乳突肌剧烈收缩，呼吸肌已经到了极限。这时候还犹豫不插管，呼吸肌耗竭之后心跳骤停就可能发生在插管过程中。
插管的配合有一套固定流程。预充氧用纯氧给3到5分钟，建立氧储备。然后推镇静肌松药，消除反抗和咽反射。环状软骨按压要持续到气管插管到位，这个动作能压扁食管，防止反流误吸。从推药到插管成功，60秒内要完成。
肺保护性通气策略的核心是小潮气量和合适PEEP。潮气量控制在6ml/kg，防止大潮气量把残存的功能肺泡吹爆。PEEP设定在10到15cmH₂O，用气压把塌陷的肺泡撑开。但这个策略的代价就是CO₂排不出去，PaCO₂会升高。临床上接受允许性高碳酸血症，只要pH维持在7.20以上，机体能够代偿，不急于纠正CO₂。护士需要观察的是脑血管扩张导致的脑水肿体征，而不是盯着CO₂数值焦虑。
密闭式吸痰是另一个必须严格执行的操作。断开呼吸机5秒，失去PEEP支撑的肺泡就可能全部塌陷。所以插管的病人吸痰必须用密闭式吸痰管，保持通气环路密闭，PEEP不丢失。吸痰前后要给2分钟纯氧，防止操作过程中血氧掉下来。
俯卧位通气是改善ARDS氧合的有效手段。重力作用下，背侧那些原本被压实的肺泡重新张开，通气血流比改善。但翻身的过程风险极高。必须由高年资护士驻守头侧，固定气管插管和深静脉导管，脱管就是不可逆的后果。翻身前1小时暂停肠内营养，抽空胃液，防止翻身过程中腹压增高导致反流误吸。俯卧位要持续16小时，正面的承压点用高密度泡沫敷料保护，头部每2小时微调位置，防止颜面部压疮，颈部不能过度侧偏以免影响颈静脉回流。
ECMO是ARDS最后的手段。血液从股静脉引出，经过人工膜肺氧合和脱碳之后泵回心脏。低氧血症靠提高泵流量来解决，高碳酸血症靠提高气流量来吹走。两个参数独立调节，分开管理。
早期康复在RICU越来越被重视。血流动力学稳定之后就要开始被动活动，不能一直让病人瘫在床上。ICU获得性衰弱一旦形成，恢复起来非常困难。床边脚踏车、坐起、带机站立，都在康复的范围内。
撤机评估不只是看血氧。表面氧合再好，心脏功能不够、血磷太低、膈肌废用，一样撤不了机。脱机过程中出现濒死感，常常是心功能不全或者膈肌无力所致。血磷是呼吸肌收缩的能量来源，缺磷的时候呼吸肌没有力量对抗气道阻力，很快就会窒息。
经鼻高流量氧疗作为撤机后的过渡手段，能提供60L/min的恒温气体，冲刷鼻咽部死腔，减少CO₂重吸入，同时产生2到3cmH₂O的PEEP效应，帮助维持肺泡开放。
特护记录要写客观数据。呼吸机参数、血气结果、气道深度，写这些就够了。“呼吸平稳”“氧合可”这种话写在记录里，在法律上是没有价值的。质控审查的时候，只有数字能保护自己。
出院后的管理主要是长期氧疗和肺康复。家庭氧疗要明确流量和吸氧时间，不能随意开大。缩唇呼吸和腹式呼吸要教会，每天练习。肺功能不能完全恢复，但坚持训练能延缓下降的速度。
RICU的护理不是某一个操作特别难，而是所有操作叠加在一起的时候，还能保持每个细节不出错。吸氧浓度、翻身角度、管路固定、吸痰时机、镇静深度、俯卧时间——每一条线都在走钢丝，哪一根松了都会出事。护士在这些细节里钉住了，病人才能从呼吸机前活着走出去。
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  1. CONNECT:[ UseTime:0.001073s ] mysql:host=127.0.0.1;port=3306;dbname=h_sjds;charset=utf8mb4
  2. SHOW FULL COLUMNS FROM `fenlei` [ RunTime:0.001619s ]
  3. SELECT * FROM `fenlei` WHERE `fid` = 0 [ RunTime:0.000280s ]
  4. SELECT * FROM `fenlei` WHERE `fid` = 63 [ RunTime:0.000252s ]
  5. SHOW FULL COLUMNS FROM `set` [ RunTime:0.000613s ]
  6. SELECT * FROM `set` [ RunTime:0.000216s ]
  7. SHOW FULL COLUMNS FROM `article` [ RunTime:0.000856s ]
  8. SELECT * FROM `article` WHERE `id` = 537240 LIMIT 1 [ RunTime:0.005280s ]
  9. UPDATE `article` SET `lasttime` = 1785195539 WHERE `id` = 537240 [ RunTime:0.001099s ]
  10. SELECT * FROM `fenlei` WHERE `id` = 64 LIMIT 1 [ RunTime:0.000254s ]
  11. SELECT * FROM `article` WHERE `id` < 537240 ORDER BY `id` DESC LIMIT 1 [ RunTime:0.000478s ]
  12. SELECT * FROM `article` WHERE `id` > 537240 ORDER BY `id` ASC LIMIT 1 [ RunTime:0.000480s ]
  13. SELECT * FROM `article` WHERE `id` < 537240 ORDER BY `id` DESC LIMIT 10 [ RunTime:0.000699s ]
  14. SELECT * FROM `article` WHERE `id` < 537240 ORDER BY `id` DESC LIMIT 10,10 [ RunTime:0.001394s ]
  15. SELECT * FROM `article` WHERE `id` < 537240 ORDER BY `id` DESC LIMIT 20,10 [ RunTime:0.004459s ]
0.185231s