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颅内压增高 increased intracranial pressure \n
侧卧位测量成年人平均脑脊液压力超过1.96kpa(相当200mm水柱)时,称为颅内压增高。颅内压增高是临床常见的许多疾病共有的一组症候群。颅内压增高有两种类型,即弥漫性颅内压增高和先局部性颅内压增高,再通过扩散波及全脑。弥漫性颅内压增高通常预后良好,能耐受的压力限度较高,可以通过生理调节而得到缓冲,压力解除后神经功能恢复较快,而局部性颅内压增高调节功能较差,可耐受的压力限度较低,压力解除后神经功能恢复较慢。
病理生理
1.正常与异常颅内压的界定
颅腔是一相对密封固定的、由骨性结构围绕形成的空腔,其中含有脑组织、脑脊液和血液。成人后颅骨无法伸缩,因此,颅腔内容物之间稍有变化就会互相影响。正常成人颅腔的内容物约1450ml,其中脑组织约占1300ml,脑脊液占65ml(不包括枕大孔以下的脑脊液),血液占110ml。根据monrose-keffie学说,在颅腔内总体容积不变的情况下,各组成成分的任何一种容量的增加都是需要以换取其它两种成分的减少为代价,或者导致颅内压的增高为结果。
颅内压会随着年龄的增长而变化,婴儿的颅内压完全不同于成人。正常成人的颅内压维持在80~180mmh2o,超过200mmh2o为颅内高压症。多数的情况下,当颅内压超过250~300h2o时就需要积极的治疗;颅内压超过500mmhg时病情已非常严重,随时危及患者的生命。
2.脑灌注压
脑部具有自动调节脑压的功能,以保证正常的脑血流灌注。脑灌注压(cpp)=平均动脉压(map)- \n颅内压(icp),脑灌注压在50~150mmhg(1 \nmmhg约等于13.6mmh2o)的范围内,脑能够维持正常的脑血流量需求。平均动脉压的下降,或者颅内压的增高,都会引起有效脑灌注压的迅速下降。当脑灌注压低于50mmhg时,脑的自动调节能力即失去代偿,脑血流量随脑灌注压的降低而被动下降,脑功能就会遭受到损害。
一、术前准备
1、心理护理 向患者解释手术的目的及手术后功能恢复情况,取得患者配合,家属同意,并嘱患者增加营养,注意休息、保暖,避免感冒。
2、备齐各项常规检查报告,如血常规、出凝血时间、肝、肾功能、心电图、x线片。
3、手术前1d,作青霉素、普鲁卡因皮肤试验,并做好记录。
4、皮肤准备认真做好手术野皮肤的清洁,术前可沐浴1次,并修剪指甲,减少术后感染。清洁范围:患手、患肢,如臂丛神经损伤者,增加患侧颈、胸部、腋下。
5、使患者掌握术后用石膏固定的体位及注意事项。
6、手术前日晚10时后禁食,必要时给予镇静药物。
7、手术晨,按医嘱给予术前用药。
二、术后护理
1、按臂丛麻醉或全麻术后护理。
2、定时观察、记录体温、脉搏、呼吸、血压,按病情需要,认真做好分级护理。
3、患侧肢体保持功能位阿适当抬高,并设法使石膏绷带快干(同石膏护理)。
4、用纱布或毛巾擦去患肢末梢周围的石膏粉末,一是减少对皮肤的刺激,二是便于观察。
5、注意患胶有无被石膏压迫的症状,如观察指端皮肤颜色、温度、肿胀及感觉运动情况。如果发现异常,及时向医师汇报。
6、臂丛神经损伤者,术后如上臂于内收位,屈肘置于胸前的固定者,应观察石膏是否过紧,影响呼吸。如发现异常,应向医师汇报,以便及早处理。
三、健康指导
1、经常活动患肢手指,防止关节僵硬。
2、术后应遵照医嘱长期应用神经营养药物,促进神经再生。
3、石膏绷带一般固定3~6周,去除石膏托或石膏简后逐步伸直操练。
4、在神经再生过程中,可同时进行物理治疗。
一、原因分析
尿崩症的发生是由于下丘脑的视上核、室旁核、灰白结节、神经纤维束通路和脑垂体的损害,影响抗利尿激素 \n(adh)的分泌、释放和贮存减少,导致adh缺乏或肾小管对 \nadh失去反应,从而出现每天排出大量稀释性尿液。头部外伤后尿崩症系下丘脑或垂体柄损伤所致,垂体柄在颅底相对固定,颅底骨折由于外伤当时的旋转和剪力机制引起下丘脑或垂体柄的损伤而发生尿崩症。
二、 护理
1 病情观察
生命体征、神志、瞳孔的观察: 30 \nmin/次,准确记录,颅脑外伤患者首先应该着眼于颅内病情尤其是颅内压的变化的观察,如有血压、心率的变化,同时应及时准确计算出入量是否平衡。如有尿量突然增多并且排除利尿等因素的影响,应注意补充液体,纠正低血容量和电解质的紊乱,使生命体征恢复正常;尿量、烦渴的观察:对于清醒患者有烦渴症状要引起足够的重视,监测尿量和尿比重,有尿崩症表现应该及时处理。昏迷患者注意记录每小时尿量,观察尿的颜色, \n发现尿液增多,颜色逐渐变淡提示多尿或尿崩症的出现,每小时尿量>200 m,l比重<1. \n006,应该及时处理,我们的经验是,清醒患者嘱其多饮水;昏迷患者从胃管内补充所失去的体液,或者从静脉补充,但应注意防止补液过多造成脑水肿或心脏负担过重;水电解质平衡的监测:遵医嘱及时准确的监测血中k+、na+、cl-、ca2+、血糖、尿比重及血浆渗透压, \n4 h/次~ 6 \nh/次。观察患者有无面色的改变、全身乏力、肢体抽搐及意识淡漠等变化。通过血生化的监测了解机体水电解质平衡状态,合理的补充,保持机体内环境的平衡。清醒患者可以口服的尽量口服补充,有胃管的尽量从胃管鼻饲,急性失液经静脉补充。
2 药物治疗的监测
危重患者在尿崩症初期均采用垂体后叶素4 u~8 u皮下注射, 6 h/次~8 h/次,尿量控制后改为弥凝片口服,根据病情调整用药剂量。患者均在10 \nd左右尿量得到很好的控制,改为口服弥凝片。在用药的过程中要注意药物反应,出现过敏现象的及时停药,还应该注意尿量的变化,少尿时及时的调整用药剂量或停药。
3 加强基础护理,预防并发症
呼吸道管理:颅脑损伤患者宜尽早做气管切开,并且使用带气囊的气管导管,以防止口腔的分泌物和痰误吸入气管造成窒息,呼吸道管理不好容易造成脑缺氧加重病情,同时也增加了肺部感染的机会。在临床护理过程中,应及时的清理呼吸道的分泌物,颅底骨折的血液,呕吐物等,注意翻身、叩背以防止痰液堵塞气管支气管造成窒息或感染;口腔、皮肤护理:尿崩症的患者往往口腔黏膜、舌头及皮肤干燥,弹性差,注意口腔护理,同时保持皮肤润滑, \n适当使用护肤品,勤换衣裤,保持床单清洁、平整;饮食护理: \n危重患者应从鼻饲中补充水分及必要的营养,避免高蛋白,鼻饲不足的要经静脉补充,便秘者酌情运用导泻药。
脑疝患者怎么护理
1.临床证实,对所有脑出血患者应用皮质类固醇治疗,并未显示任何好处,但仍需应用这类药物来预防继发的脑疝和最大可能地保持意识清醒。
2.临床推荐,初次剂量10mg~12mg地塞米松静注,随后每6小时给4mg。渗透性利尿剂甘露醇每4小时静脉快速滴入100g,预防因颅内压增高引起的急性脑疝。
宜与忌
1.观察患者神志意识,生命体征。
2.保持呼吸道通畅,必要时吸氧或进行人工换气。
3.如为钩回疝,应立即输注甘露醇、激素;如为小脑扁桃体疝,应立即人工辅助呼吸。紧急时作侧脑室空刺放液,并尽快查明病因,酌情手术切除病变部位或施行减压术。
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