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ICU FORUM 2008

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? t?p???t?s? t?? a???st?? st? s?st? ?at? pe??pt?s? ??s? p??e? ?a e?t??se? t?? ... Rupert DL & Frandsen G. Timby's Fundamental Nursing Skills and Concepts, 2005 ... – PowerPoint PPT presentation

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Title: ICU FORUM 2008


1
ICU FORUM 2008? ?at? p???s? s?st? ??s? t??
a???st?? st? ??T
  • ???S????S T???O??S
  • ??S??????S ??, Msc, Phd
  • ?.G.?. ???????

2
?e?????sµ??a e?e???t??? ded?µ??a ??a t??
te?µ????s? t?? s?st?? ??s?? t?? a???st??
  • ?e?µ????µ??? epa???? d??aµ??? t?? ep?d?as?? t??
    s?st?? ??s?? st? f???t?da
  • ? t?p???t?s? t?? a???st?? st? s?st? ?at?
    pe??pt?s? ??s? µp??e? ?a ße?t??se? t?? ??ßas?, ?a
    µe??se? t?? ???d??? ep?p????? ?a? ?a s?µß???e?
    st?? ep?t???a t?? ?e?ape?t???? pa?eµß?se??

3
?ate????t???a ?d???a st? f???t?da t?? ßa????
pas???t?? a???st??
  • ???a?? ??s??, ap? t?? ?pt?a ??s? ?at????s??, ???e
    d?? ??e?
  • Krishnagopalan S, Crit Care Med 2002, 30 2588

4
S?st? ??s? a???st???fa?µ??? ?a? s?µµ??f?s?
?ate????t???e? ?d???e?
S?st? ??s?
??e???? s?µµ??f?s?? pa?eµß?se??
???pe? ?a pe???aµß??eta? Se ???e
p??t?????? ?a?eµßat???? ? ?peµßat???? p?????
?f??? ap? t? s?st? ??s? ?a? ??e???t??? ded?µ??a
??a ?s????p???s? t?? ?ate????t????? ?d?????
5
S?µµ??f?s? p??s?p????
  • ???? t? 50 t?? e?d??e?µ???? p??s?p???? st?? ??T
    p?ste?e? ?t? ep?t?????eta? t? p??t?p? a??a???
    ??s?? t??????st?? st? 50 t?? pe??pt?se??
  • 3 Ge????? ??T st?? ???, 74 ????st??

Krishnagopalan S, Crit Care Med 2002, 30 2588
6
??t?e? µ? s?µµ??f?s??
  • ???e??? saf??? a???es?? t?? s???e???µ????
    ?a?????t??
  • ???e??? ?????? ?a? p??s?p????

??t?µat?p???s? µe e?d???? ????e?? ????s?
??st???
??pa?de?s? ? ???s?a??a ap?te??sµata ?????ß??a
d?ad??as?a ?p?p???? p??s?p???
Krishnagopalan S, Crit Care Med 2002, 30 2588
7
??d???? ????e? a?t?µat?? a??a??? ??s?? vs
?e???????t?? a??a??? ??s?? ???e 2 ??e?
  • ?e? ?p???e? a??????? d?af???
  • Traver GA J Crit Care 1995, 10 97
  • ??d???? ????e? ????? ?fe???
  • Gentilello L. Crit Care Med 1988,16 783
  • Summer WR J Crit Care 1989, 4 45
  • Fink MP Chest 1990, 97 132
  • Choi SC J Crit Care 1992, 7 57
  • Boisblanc BP Chest 1993, 103 1543
  • Sahn SA Chest 1991, 99 1263
  • Kelley R Stroke 1987, 18 638

?e??d??????? ???ß??µa ???? st? µe??t? t?? Traver
?a? s?? e?et?st??e ? s?µµ??f?s? t??
p??s?p???? ?a? te?µ???????e ? ?e???????t? a??a??
T?s?? gt67
8
St???? a??a??? ??s?? t?? a???st?? e?t?? t??
?pt?a? ??s?? ?at????s??
  1. ????t?p???s? ?a? pa????te?s? e????se??
  2. ??????? t?? p?e?µ???a? t?? a?ap?e?st??a
  3. ?e?t??s? t?? ??es?? t?? a???st??
  4. ??????? t?? e???? ?at????s??
  5. ?e?t??s? t?? ???????s?? t?? a?t???a??? a?µat??
  6. ?e??s? t?? ????? t?? a?ap???? a???s? t??
    ??t???? ????t???t?ta?
  7. ??e??????s? t?? ap??a?a?t?sµ?? ap? t? µ??a????
    ae??sµ?
  8. ??????? t?? ?ast????s?fa????? pa???d??µ?s??
  9. ??????? t?? e? t? ß??e? f?eß???? ???µß?s??

Thomas PJ. Aust. Crit. Care, 2006, 19 122
9
S????? ???S?S S??S ???F???S T?S??S
10
???????? pa??µet??? ??a t?? ep????? ?at???????
??s?? t?? a???st??
  1. ??t?????af?a ???a???
  2. ????as? p?e?µ????
  3. ??µ?? ae???? a?µat??
  4. ???µet??a
  5. ??µ?d??aµ??? sta?e??t?ta
  6. ????t?p???s? t?? e????se??
  • Thomas PJ. Aust. Crit. Care, 2006, 19 122

11
T?se?? a???st?? st?? ????? ??s??e?a?
  • Rupert DL Frandsen G
  • Timbys Fundamental Nursing Skills and Concepts,
    2005

12
??te?de??e?? t?p???t?s?? t?? a???st?? st??
?a??st? ??s?
  1. ?sta?? ?at??µata sp??d?????? st????
  2. ??d??????a p?es? gt 20cmH2O
  3. ?????? d?se?? ???t??p?? (Dopamine gt10mcg/kg/min,
    noradrenaline gt0,1 mcg/kg/min, dobutamine se
    ?p??ad?p?te d?s?)
  4. ??s? ??t???a?? ??es? lt 60mmHg
  5. ?a??? s???
  6. ??e?a ??a??? a????µ???
  7. ?????? ?p?st?????? µe ??

Thomas PJ. Aust. Crit. Care, 2006, 19 122
13
??te?de??e?? t?p???t?s?? t?? a???st?? st??
p????a ??s?
  1. ?sta?? ?at??µata sp??d?????? st????
  2. ??d??????a p?es? gt 20cmH2O
  3. ??s? ??t???a?? ??es? lt 60mmHg

Thomas PJ. Aust. Crit. Care, 2006, 19 122
14
SOS?? T?S? ???? ??T?S?
  • ?p?d?as? t?? ??s?? t?? a???st?? st??
  • ???????s? ??µ?d??aµ??? sta?e??t?ta

15
?a??se?? ??ap?e?st????
  • ????st? ???????s? ep?t?????eta? ?ta? ?? ?a??te?a
    ae????µe?e? pe?????? ????? ?a? t?? ?a??te??
    a?µ?t?s?
  • Yeaw. Am J Nursing 1992, 3 26
  • ? ?at?????? ??s? t?? a???st?? st?? ????? µp??e?
    ?a p????e? t?? ???????s? µe ????te?? t?a?µat???,
    ????te?? epeµßat??? ?a? ????te?? a???ß? t??p? ap
    ?t? pa?eµß?se?? µe ???s? ?????? te???????a?
  • Rowat. Nursing Times 2001, 97 30

16
T?s? a???st?? µe S??d??µ? ??e?a? ??ap?e?st????
??s???e?a? (ARDS)
  • ??e??e?t?µata p?????? ??s??
  • ??a?ata??µ? ae??sµ?? a?µ?t?s??
  • ?e??s? e?d?p?e?µ?????? d?af????
  • ?e?t??s? t?? ????? ae??sµ?? a?µ?t?s??
  • ???a??? st? ?e?t??????? ?p??e?p?µe?? ????t???t?ta
  • ??a?ata??µ? e??d??µat??
  • ?etaß???? pe???????? ????t???t?ta? t??
    d?af???µat??
  • ??te?de??e?? p?????? ??s??
  • ????µ??? e?d??????a p?es? gt25mmHg
  • ?at??µata a??e????? µ???a? t?? sp??d?????? st????
  • ??te???? ?s?a?µ?a
  • ?a???? ???µ??e?? µa?a??? µ????? t?? ß??ß??????
    ?a? ?????a??? ???a?
  • ?????t? t?a?µata, p???ap??? pa???ete?se??,
    p??sfate? ?e?????????? t?µ??

Murray TA, Crit Care Nurs 2002, 22 52 Curley MA,
Am J Crit Care 1999, 8 397
17
???a??sµ?? ße?t??s?? t?? ae??sµ?? st?? p???? ??s?
  • ? a?µ?t?s? e??a? µe?a??te?? st?? ?p?s??e? p?e????
    t?? p?e?µ????
  • ?a? ?t? ?? p?e?µ?????? ß??ße? ?a? t? ??d?µa st?
    ARDS e??a? µe?a??te?e? st?? ?p?s??e? pe??????,
    ?? ß??ße? de? e??a? ?µ???µ??fe?
  • ? p????? ??s? µetat?p??e? ???? ap? t?? ?p?s??e?
    st?? p??s??e? p?e???? ep?t??p??ta? st?? ???e??
    ???e??de? ?a ?eµ?s??? a??a
  • S??ep?? ße?t???eta? ? ae??sµ??
  • ?p?p???? ? p????? ??s? d?at??e? t?? a?µ?t?s?
  • ??a ße?t???e? t? ???? V/Q

Marion BS, Am J Nursing 2001, 101 26
18
G?at? de ???s?µ?p????µe t?? p???? ??s??
  • ??a?t???? d?s????e? ?a? e?d??asµ?? st? ?a
    t?p??et?s??µe ??a ßa??? p?s???ta ????st? se a?t?
    t? ??s?
  • ?????a t?? f?s??????a? ?a? t?? p?e??e?t?µ?t??
    a?t?? t?? ??s??
  • ???e??? p?e??e?t?µat?? st?? ep?ß??s? t?? a???st??

Meade M. Evidence Based Nursing 2002, 5 52
19
T?s? a???st?? µe S??d??µ? ??e?a? ??ap?e?st????
??s???e?a? (ARDS)
  • ???p?p???µ??? ??s? Fowler
  • ?e?t??s? t?? ???????s??
  • ? ????a 45º t?? p?d??? e???dete???e? t?? p?es?
    st?? ?????? ?a? st?? ß?se?? t?? p?e?µ????, ?
    ?p??a µe???e? t?? ap?te?esµat???t?ta t??
    ?µ??a??st?? ??s??
  • ??? ap?? st?? efa?µ??? ap? t?? p???? ??s?

???p?p???µ??? ??s? Fowler
Richard JCM, Intensive Care Med 2006, 32
1623 Messerole E, Am J Respir Crit Care Med 2002,
165 1359
20
T?s? a???st?? ??a t?? p?????? p?e?µ???a? t??
a?ap?e?st??a (VAP)
  • S??ep?? ?? p??te? ??e? µet? t? d?as?????s? e??a?
    ?? p?? ???s?µe? ??a t?p???t?s? t?? a???st?? se
    a?????p? ??s?
  • ?????? µe a???µ??? a???µ? pa?eµß?se?? ?a?
    a?µ?d??aµ??? ast??e?a
  • S?stas? CDC
  • ?????s? t?? ????? se ????a 30º ??? 45º
  • gt ???a??t?ta? p?e?µ???a? e?? ?pt?a ??s? t? p??t?
    24???

Tablan OC, MMWR Recomm Rep 2004, 53 1 Grap MJ,
Am J Crit Care 2005, 14 325
21
?µf?te??p?e??? p?e?µ????? ??s??
  • ?e??? ?????a T?s?
  • ? de???? p?e?µ??a? e??a? µe?a??te???, ßa??te???
    ?a? pe??ss?te?? a??e??ß????? ap? t?? a??ste??. ?
    ep?d?as? t?? ßa??t?ta? ße?t???e? t?? a?µ?t?s? t??
    e?a?t?µe??? p?e?µ??a ?a? ße?t???e? t? ????
    ae??sµ?? /a?µ?t?s??

Wheeler , Nursing in Critical Care, 1997, 2 129
Lasater, Erhard, Critical Care Nurse 1995, 15 31
22
?te??p?e??? ??e?µ????? ??s??
  • Te???a t??
  • ?????? p?e?µ??a p??? ta ??t?
  • ?d?a?te?? s?µas?a ??e? ? pa??????a t??
    p?e?µ?????? p???s?? (e?t?p?s? ?a? e???? ß??ß??)
    ?a? ? ap????s? st?? ??s??e?t???? pa?eµß?se??
  • ??te?de??e??
  • ??e?µ????? ap?st?µa (?ts? ?ste t? pe??e??µe?? ?a
    µ?? pa???ete?te? p??? t?? ???? p?e?µ??a)
  • ??µ???a??a
  • ???µes? eµf?s?µa (p?????? ?pe?d??tas??)

Yeaw, American J of Nursing 1992, 3 26
Moore, Nursing in Critical Care 2002, 7 278
23
??µ?d??aµ??? sta?e??t?ta - pa?a???????s?
  • ?? ßa??? p?s???te? ????st?? st?? ??T ß??s???ta?
    ?ata?e???µ???? st?? ?pt?a ??s? ep? µa???? ?a???
    a?t? ?e??e?ta? ? ?ata?????te?? ??a t??
    a?µ?d??aµ??? pa?a???????s? t?? a???st?? ?a? t?
    f???t?da t???

Chan and Jensen, Heart and Lung 1992, 21448
24
T?s? a???st?? µe ?p????a?µ??? ?atap????a
  • T?s? Trendelenburg
  • ????s? ??s?? ??t???a??? ??es?? (s?st?µat???
    a??e??s?spas?)
  • ????s? ??es?? ??sf???s?? (a???s? e?d????a?????
    p?es?? ???? ?efa????? µetat?p?s?? d?af???µat??)
  • ????s? S?st?µat???? ???e?a??? ??t?st?se??
  • ?µet?ß??t? ?a?d?a?? ?a????
  • ?e? e??s??eta? ? F?eß??? ?p?st??f? st?? ?a?d??

???p?p???µ??? ??s? Trendelenburg
?p?p????? ?e?????sµ?? d?af?a?µat????
????s?? ??ast??? tase??p?d????? pt?s? ??
  • Marino PL. ICU 2000,
  • Proehl JA, Emergency Nursing Procedures 1999

25
??e?µ????? ??d?µa
  • ?µ? Fowler ? 30
  • ????p???a (? ßa??t?ta a????e? t? ???? st???
    p?e?µ??e? ?a? ?at? s???pe?a t? ??d?µa, ?????? st?
    ???).
  • ? ?µ??a??st? ??s? µe???e? t? f?eß??? ep?st??f?
    ?a? d?e??????e? t?? a?ap???

26
???t?stefa??a?a ?a???aµ??
  • gt45 p????a ??s? s?µa?t??? µe??s? µ?s?? ??
  • ? a??ste?? p????a ??s? ep?ß??e? µ?a ?pe?d??aµ???
    ?at?stas? µe s?µa?t??? a???s? t?? e?d????a?????
    ????? a?µat??
  • ? de??? p????a ??s? e?att??e? t? p??f??t?? t??
    de???? ?????a? ?a? p??d?a??te? se ?p?tas?
  • ???te???µe?? ??s? ap? t?? p??te? 2-4 ??e? µt?
  • ??????p? ??s? 30
  • e?a????
  • µe p????a ??s? 30

De Laat E, J Clinical Nursing, 2007, 16 654
27
?a?et???asµ?? ?e?t????? f??ßa? ?a? µ?t??s? CVP
  • ?a?et???asµ??
  • ???s? s?µat?? µe t? ?ef??? 15 p??? ta ??t? ??a
    ?a e?asfa??ste? µ???st? p????s? µe a?µa t??
    a??e???
  • ??t??s? ?.F.?.
  • ????st?? ?ata?e???µ???? se ?pt?a ??s? µe t?
    ?efa???? µ???? ??????t?? ? a????µ???
  • ??? p??? ap? 30

Taylor RW, Crit Care Med 2007, 35 1390
28
??t??s? ?a?d?a??? ?a?????
  • S?µa?t??? µe??s? µet???µe??? t?µ?? st?? a?????p?
    ?at? 40 ??s?.
  • ?p?te??sµata a???p?sta ??? 20
  • T?s? ep?????? ?pt?a

Driscoll A, Heart Lung 1995, 24 38 Giuliano K,
Nurs Research 2003, 52 242
29
??t??s? p?es?? t?? p?e?µ?????? a?t???a?
  • S?st? t?p???t?s? µ??f?µetat??p?a
  • T?s? f?eß?stat???? ????a
  • ?es?ste????? ep?ped? st? de??? p????a ??s? (30)
  • ???ste?? pa?aste????? ???? st?? a??ste?? p????a
    ??s? (30)

T?s? ep?????? ?pt?a S?µa?t??? sf??µata se ???e?
??se??
Fu Jin Shih, Intern J Nurs Stud 1999, 36 497
30
??a???e??efa???? ????s?
  • ? ?pt?a ??s? ?a? ? a????t?p???s? t?? a???st??
    µp??e? ?a p???a??se? ?p??a?µ?a ?a? ?p?tas?. ??
    ????st?? µet? ap? t?a?µa st? ?ef??? ? e??efa????
    epe?s?d?? e??a? ?d?a?te?a e????t?? se ß??ße? ap?
    ?p?a ?p??a?µ?a ?a? ?p?tas?

Rowat. Nursing Times 2001, 97 30
31
T?s? a???st?? µe ??a???e??efa???? ????s?
  • ???? ??s? 30
  • ??e??????s? t?? f?eß???? ep?st??f??
  • ?d??stat??? µetat?p?s? ??? ap? t?? ??a??a??
    ?????t?ta st? ??t?a?? s????a
  • ????? gt 30
  • ?e???? ??µ?? ?s???? a???s? e?d??????a??? p?es??
    ? a???s? e?d??????a? p?es??
  • ?p??e?a a??e??????t???? t???? ??µ?as? f?eß????
    a?µat?? sta ???a ? µe??s? t?? p?es?? a?µ?t?s??
    t?? e??ef????

32
  • ??a?µa sp??d?????? st????
  • ?pt?a ??s? a?st??? a????t?p???s?
  • ???s?e?et???? pa??se??
  • ?????t?p???s? ?a? a????s? ?e???????µ???? ?????

33
SOS?? T?S? ???? ?????S? - ???????S?
Fa??????? a?a???f?s? ?µ? Fowler
????fa??????? a?a???f?s? T?s? ?sf??s?? (sniffing position)
??????? e??tas? ?????f?????? s?st?µat?? ?µ? Fowler
?a?a?e?t?se?? ???a?a ?µ? Fowler
?a????te?s? s??????? pe??t??a???? ?????t?ta? Fowler ? ?µ? Fowler
?sf????t?a?a pa?a???t?s? ?????a ??s? (µe ??µ?? ????? ?a? ?efa???)
?pe?????a?d?????f?µa ???ste?? p????a
??d?s??p?se?? pept???? ???ste?? p????a - ?pt?a
34
??e?te???? s?t?s?
  • ??????p? ??s? 30
  • ?µ??a??st? ??s?

Williams TA, Intens Crit Care Nurs 2004, 20 330
35
S??????S????
  • ? t?p???t?s? t?? a???st?? st? s?st? ??s? st??
    ????? t?? ??T e??a? µ?a ap?? ?a? a????d? p?a?t???
    p?? µp??e? ?a ??e? s?µa?t??? ?fe??? ??a t??
    ????st?
  • ?p?te?e? ap? µ??? t?? µ?a s?µa?t??? ?e?ape?t???
    pa??µßas?
  • ???pe? ?a e?at?µ??e?eta? ?a? ?a ?aµß????ta? ?p
    ??? ap? t? ?at????s??e?t??? p??s?p??? ??
    ?d?a?te??t?te? ?a? t? pa??f?s???????? ?p?ßa???
    t?? ?p??e?µe??? ??s??

36
S??????S????
  • ? ????? ep????? ??s?? µp??e? ??? µ??? ?a µ??
    ?fe??se? st?? ??ßas? t?? a???st??, ?p??
    a?aµ??eta?, a??? ?a ?d???se? ?a? st?? eµf???s?
    ep?p?????, ?? ?p??e? ?a p???a??s??? ??? ?a?
    a?epa?????te? ß??ße?!
  • ?p?te?e? s??ep??, s?µa?t??? e?????, ?????? t??
    ??s??e?t?? ?a? p??pe? ?a e?te?e?ta? µe ap???ta
    te?µ????µ??? t??p?, ?p?? ???e pa??µßas?!

37
???a??st? p???!
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