颅脑损伤患者躁动l59例的安全护理

目的初步探讨颅脑损伤患者躁动的表现、原因及躁动带来的不良后果,采取有效的护理措施,提高患者的救治率,减少或避免不安全隐患的发生。方法对159例颅脑损伤躁动患者的瞳孔、生命体征、躁动的表现、GCS评分与临床CT检查结果进行动态观察,分析躁动的原因,给予相应的护理措施。结果 94例为颅内血肿等颅内因素,通过手术、脱水、利尿、镇静及应用激素治疗得到控制,65例为尿潴留等非颅内因素,通过导尿、吸痰等护理措施后躁动消失,因躁动出现输液外渗132例次,拔除氧气管67例,拔除尿管2例,抓伤陪护人员手背皮肤9例,无一例发生坠床及皮肤擦伤。结论密切观察颅脑损伤患者的病情变化,及时分析躁动原因,采取预见性护理措施,有利于减少医疗事故和纠纷发生,提高护理质量。

Safe Nursing for 159 Cases of Agitated Patients with Brain Injury

Objective To preliminarily explore the performance,causes,and adverse consequences of agitated patients with traumatic brain,take effective nursing measures,improve the rate of treatment,and reduce or avoid unsafe hidden dangers.Methods 159 cases of agitated patients with traumatic brain were dynamically observed for the pupils,vital signs,agitation performance,GCS scores and clinical CT findings,the reasons for agitation were analyzed,and the appropriate nursing measures were taken.Results 94 cases were related to intracranial factors such as intracranial hematoma,controlled by surgery,dehydration,diuresis,sedation,and application of hormone therapy;65 cases were related to non-intracranial factors such as urinary retention,with agitation disappeared by nursing interventions such as catheterization,sputum suctioning.Infusion extravasation appeared 132 case times due to agitation,removal of the oxygen tube 67 cases,catheter removal 2 cases,scratched accompanying staff＇s hand back skin 9 cases,but no case of falling out of bed and skin abrasions occured.Conclusion Close observation of disease changes for agitated patients with traumatic brain,timely analysis of agitation reasons,and taking predictable nursing measures will help reduce medical incidents and disputes,and improve quality of nursing.