胸腔引流ppt課件

1、胸腔閉式引流,內(nèi)容提要,復(fù)習(xí)胸膜腔有關(guān)知識胸腔閉式引流的目的胸腔閉式引流的原理胸腔閉式引流的裝置胸腔閉式引流管的位置安放胸腔閉式引流的護理,胸膜腔有關(guān)知識,胸膜腔是由臟胸膜與壁胸膜之間形成的封閉腔隙腔內(nèi)呈負壓,助于肺組織膨脹、維持肺的通氣和換氣功能;增加上下腔靜脈的回心血量,氣體進入胸膜腔，造成積氣狀態(tài)，稱為氣胸（pneumothorax）。 正常胸腔內(nèi)沒有氣體，胸腔內(nèi)出現(xiàn)氣體僅在三種情況下發(fā)生： ⑴

2、肺泡和胸腔之間形成破口 ⑵胸壁創(chuàng)傷產(chǎn)生與胸腔的交通 ⑶胸腔內(nèi)有產(chǎn)氣的微生物,胸腔閉式引流的目的,排除胸膜腔內(nèi)積液排除胸膜腔內(nèi)積氣恢復(fù)和保持胸膜腔負壓，維持縱隔　的正常位置，促使術(shù)側(cè)肺迅速膨脹發(fā)現(xiàn)胸膜腔內(nèi)活動性出血，支氣管殘端瘺等．,適應(yīng)癥和禁忌癥,[適應(yīng)征]外傷性血氣胸，影響呼吸、循環(huán)功能者。 氣胸壓迫呼吸者（一般單側(cè)氣胸肺壓縮在20％以上時）。 切開胸膜腔者。[禁忌證] 結(jié)核性膿胸則禁忌。 Co

3、agulopathyPulmonary bullaePulmonary, pleural, or thoracic adhesionsLoculated pleural effusion or empyemaSkin infection over the chest tube insertion site,Chest tube drainage device with water seal (autotransfuser uni

4、t is an option)Suction source and tubingSterile glovesPreparatory solutionSterile drapesSurgical markerLidocaine 1% with epinephrineSyringes, 10-20 mL (2)Needle, 25 gauge (ga), 5/8 inNeedle, 23 ga, 1.5 in; or 27

5、 ga, 1.5 in; for instilling local anesthesiaBlade, No. 10, on a handleLarge and medium Kelly clampsLarge curved Mayo scissorsLarge straight suture scissorsSilk or nylon suture, 0 or 1-0Needle driverVaseline gauze

6、Gauze squares, 4 x 4 in (10)Sterile adhesive tape, 4 in wideChest tube of appropriate size: Man - 28-32F; woman - 28F; child - 12-28F; infant - 12-16F; neonate - 10-12F,PositioningThe patient should be positioned sup

7、ine or at a 45° angle. Elevating the patient lessens the risk of diaphragm elevation and consequent misplacement of the chest tube into the abdominal space.The arm on the affected side should be abducted and exter

8、nally rotated, simulating a position in which the palm of the hand is behind the patient's head.A soft restraint or silk tape can be used to secure the arm in this location. If a restraint is used, make sure that g

9、ood blood flow to the hand is present.,引流的原理,當(dāng)胸膜腔內(nèi)因積液或積氣形成高壓時，胸膜腔內(nèi)的液體或氣體可排至引流瓶內(nèi).當(dāng)胸膜腔內(nèi)恢復(fù)負壓時，水封瓶內(nèi)的液體被吸至引流管下端形成負壓水柱，阻止空氣進入胸膜腔.,引流的裝置,胸腔閉式引流管,水封瓶,一個無菌引流瓶，內(nèi)裝無菌蒸餾水或無菌生理鹽水；瓶口用帶兩個圓孔的橡皮塞封柱；長、短兩根玻璃管分別插入圓孔；長管應(yīng)在水面下3-4cm，且保持直立，另一端與病

10、人的胸腔引流管相連，短管作為空氣通路,,,引流管的位置安放,引流氣體一般選在鎖骨中線第2肋間或腋中線第3肋間插管 引流液體選在腋中線和腋后線之間的第6—8肋間插管,胸腔閉式引流管的植入,局部浸潤麻醉壁層胸膜后，進針少許，再行胸膜腔穿刺抽吸確診。沿肋間做2—3CM的切口，依次切開皮膚及皮下組織,胸腔閉式引流管的植入,用2把彎止血鉗交替鈍性分離胸壁肌層達肋骨上緣，于肋間穿破壁層胸膜進入胸膜腔，此時可有突破感，同時切口有液體或氣體溢出。

11、,胸腔閉式引流管的植入,立即將引流管順止血鉗進入胸膜腔; 側(cè)孔位于胸腔2~3CM.,切口間斷縫合1—2針，并結(jié)扎固定引流管;引流管結(jié)于水封瓶，各接口處必須嚴(yán)密，以防漏氣;,套管針穿刺置管,嚴(yán)格滅菌妥善固定,管道密封保持引流通暢注意觀察發(fā)生意外，及時處理拔管,胸腔閉式引流的護理,嚴(yán)格無菌操作，防止逆行感染,引流裝置保持無菌；保持傷口處敷料清潔干燥，一旦浸濕及時更換；引流瓶位置低于胸腔60cm~100cm，防止引流液逆流；定

12、時更換引流瓶；嚴(yán)格無菌操作。,妥善固定,管道密封,胸腔閉式引流主要是靠重力引流，水封瓶應(yīng)置于病人胸部水平下60~100cm，并應(yīng)放在特殊的架子上，防止被踢倒或抬高。各銜接處均要求密封引流管固定搬運病人前，先用兩把止血鉗雙重夾住引流管，將引流瓶放在病床上以利搬運。搬運后，先把引流瓶放于低于胸腔的位置，再松止血鉗。,保持引流通暢,術(shù)后病人血壓平穩(wěn),應(yīng)取半臥位. 鼓勵病人咳嗽及深呼吸運動。避免引流管受壓、折曲、阻塞。尤其病人躺向插管

13、側(cè)，注意不要壓迫胸腔引流管。,注意觀察,觀察玻璃管水柱隨呼吸波動的幅度觀察并記錄引流液量，顏色，性狀,發(fā)生意外，及時處理,水封瓶破裂或連接部位脫節(jié)應(yīng)立即用血管鉗夾閉軟質(zhì)的引流管。用手將其折疊后捏緊，勿使漏氣，立即更換新的無菌引流裝置。鼓勵病人咳嗽和深呼吸，排出胸膜腔內(nèi)的空氣和液體。引流管脫落應(yīng)及時用手指捏壓傷口，消毒后以無菌敷料封閉，報告醫(yī)生及時處理。絕不可擅自將脫出的引流管再插入胸膜腔內(nèi)，以免造成污染或損傷。,引流管的長度與固

14、定,引流管的長度以能將引流管固定在床緣，且能使它垂直降到引流瓶為宜。過長時易扭曲，還會增大死腔，影響通氣。過短時病人翻身或坐起時易牽拉到引流管。固定引流管時，可將引流管兩端的床單拉緊形成一凹槽，再用別針固定。,拔管,24小時引流液小于50ml，膿液小于10ml，無氣體溢出．病人無呼吸困難，聽診呼吸音恢復(fù)，X線檢查肺膨脹良好．,拔管方法,拔管時病人應(yīng)取半臥位或坐在床邊，鼓勵病人咳嗽，擠壓引流管后夾閉，囑病人深吸一口氣后屏住。病人屏氣時

15、拔管，拔管后立即用凡士林紗布覆蓋傷口。,拔管后，要觀察病人有無呼吸困難、氣胸和皮下氣腫。檢查流口覆蓋情況，是否繼續(xù)滲液，拔管后第二天應(yīng)更換敷料。,問題 Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure und

16、er normal conditions?A. It is always positive B. It is negative during inhalation; positive during exhalationC. It is positive during inhalation; negative during exhalationD. It is always nega

17、tive,If the chest tube is pulled out of the patient's chest, and the patient had an air leak from the lung, after asking a colleague to call a physician STAT, emergency nursing management is to: a.Cover the op

18、ening with a sterile dressing, taped on three sides b.Cover the opening with a sterile Vaseline gauze, taped securely on all sides c.Leave the opening alone and monitor the patient until a physician can ass

19、ess the situation d.Try to put the tube back in place as quickly as possible,Which of the following statements is true regarding patient movement while requiring chest drainage? (assume a physician order or protoc

20、ol exists)A. Patients may go only from bed to a chair while the chest tube is connected to a chest drainB. If patient must leave nursing unit, suction tubing should be clamped shut while chest drain is disc

21、onnected from suctionC. If a patient is ambulatory, the chest tube should be clamped shut while the chest drain is disconnected from suctionD. Patients may walk around once the nurse disconnects the drain f

22、rom suction as long as the drain remains below the chest,Chest tube clamping is only recommended for:a. Changing the drainage container and this should be done quickly and then promptly unclampedb. Whenever a patient

23、 leaves the nursing unit and cannot be monitoredc. When ambulating a postoperative patient with a chest tubed. It is never beneficial to clamp a patient's chest tube,New bubbling is observed in the water seal cha

24、mber after a patient with a pleural chest tube returns from a test. The nurse clamps the chest tube momentarily with a tubing clamp at the dressing site. When this is done, bubbling in the water seal stops. The next appr

25、opriate nursing action is to:A. Continue to monitor the water seal chamber for bubbling every hour for the next four hoursB. Do nothing. This bubbling is normal in patients with pleural chest tubesC. 

26、;Call the physician immediately and do not leave the patient's bedside because of the risk of respiratory failureD. Remove the chest tube dressing to see if one or more eyelets of the chest tube have been pull