1、外科护理教研室外科护理教研室急危重症护理学急危重症护理学外科护理教研室外科护理教研室急危重症护理学急危重症护理学Emergency and Critical Care Nursing主讲人：袁华主讲人：袁华吉林大学护理学院吉林大学护理学院外科护理教研室外科护理教研室急危重症护理学急危重症护理学外科护理教研室外科护理教研室第六章第六章 急诊分诊急诊分诊外科护理教研室外科护理教研室急危重症护理学急危重症护理学外科护理教研室外科护理教研室Emergency patients are unique Not all patient are as well as they appear Not all p
2、atient are as well as they appear and not all patients are as sick as they think.and not all patients are as sick as they think.外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室分诊分诊 Triage外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室分诊分诊 Triage 是指对病情种类和严重程度进行简单、快速的评是指对病情种类和严重程度进行简单、快速的评估与分
3、类，估与分类，确定就诊的优先次序确定就诊的优先次序，使病人因为，使病人因为恰恰当的原因当的原因在在恰当的时间恰当的时间、恰当的治疗恰当的治疗区获得恰当区获得恰当的治疗与护理的过程的治疗与护理的过程.外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室 The goal for The goal for all parts of health care all parts of health care continuum continuum is is “right patient,right place,right time with“rig
4、ht patient,right place,right time with right care giver”.right care giver”.外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室what is Triage?A sorting process A sorting process utilizing ciritical thinking utilizing ciritical thinking in which an experienced nurse assesses in which an experienced n
5、urse assesses patients quickly upon their arrival at an patients quickly upon their arrival at an emergency setting to:emergency setting to:1.1.assess and determine severity of presenting problemsassess and determine severity of presenting problems2.process patients into a triage category2.process p
6、atients into a triage category3.determine 3.determine access to appropriate treatmentaccess to appropriate treatment4.effectively and efficiently 4.effectively and efficiently assign appropriate human health assign appropriate human health resourcesresources外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理
7、教研室外科护理教研室Avoiding Triage as a block The triage process should not become a The triage process should not become a block or significant delay,but rather a way block or significant delay,but rather a way of“of“streamingstreaming”patients to the most”patients to the most appropriate care area.appropri
8、ate care area.外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室分诊处的设置分诊处的设置 位置位置:面对急诊科大门的明显处面对急诊科大门的明显处 物品物品:电话、电脑、平板车、轮椅、血压计、听诊电话、电脑、平板车、轮椅、血压计、听诊器、体温计及各种表格等器、体温计及各种表格等 人员人员:急诊护士急诊护士,导诊员或秘书导诊员或秘书外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理
9、教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室急诊分诊程序急诊分诊程序Triage process外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室Triage process Patients arrival Patients arrival Critical lookCritical look A airwayA airway B BreathingB Breathing C CirculationC Circulation D Disability(neurologica
10、l)D Disability(neurological)外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室急诊护理评估急诊护理评估1.A airway 1.A airway 气道及颈椎气道及颈椎气道阻塞的原因？气道阻塞的原因？气道阻塞如何处理？气道阻塞如何处理？保持气道通畅的方法？保持气道通畅的方法？外科护理教研室外科护理教研室急危重症护理学急危重症护理学外科护理教研室外科护理教研室人工气道分类常见非确定性紧急人工气道技术常见非确定性紧急人工气道技术l 手法开放气道：常用提颏和双手抬颌法。l 口咽和鼻咽通气管 l 喉罩常见确定性紧急人工气道
11、技术常见确定性紧急人工气道技术 l 经口气管插管术 l 经鼻气管插管术：纤维支气管镜引导气管插管l 气管切开术外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室人工气道分类人工气道分类通气导管通气导管 口咽通气导管 鼻咽通气导管喉罩喉罩气管插管气管插管 经口气管插管 经鼻气管插管气管切开置管气管切开置管经皮穿刺气管造口置管术经皮穿刺气管造口置管术环甲膜穿刺环甲膜穿刺/切开术切开术外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室急诊护理评估急诊护理评估2.B Breathing 2.B
12、Breathing 呼吸功能呼吸功能呼吸功能评估包括哪些？呼吸功能评估包括哪些？呼吸功能异常如何处理？呼吸功能异常如何处理？外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室急诊护理评估急诊护理评估3.C Circulation 3.C Circulation 循环功能循环功能循环功能评估包括哪些？循环功能评估包括哪些？循环功能异常如何处理？循环功能异常如何处理？外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室急诊护理评估急诊护理评估4.D Disability(neurologica
13、l)4.D Disability(neurological)神志状况神志状况:AVUPAVUP法法Alert Alert VocalVocalPainPainUnresponsiveUnresponsive法法5.5.暴露患者暴露患者/环境控制环境控制外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室Triage process Infection controlInfection control Subjective AssessmentSubjective Assessment Objective AssessmentObjective
14、 Assessment Selecting presenting complaintSelecting presenting complaint The Triage Decision The Triage Decision 病情严重程度分类系统病情严重程度分类系统 CTAS levelsCTAS levels外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科
15、护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室国际国际“TRIAGE”分级分级外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室外科护理教研室外科护理教研室急危重症护理学急危重症护理学Level 1-Resuscitation Cardiac arrestCardiac arrest Respirato
16、ry arrestRespiratory arrest Major trauma in shockMajor trauma in shock Shortness of breath Shortness of breath(severe respritary(severe respritary distress)distress)Altered level of Altered level of consciousness consciousness(unconscious,GCS3-9)(unconscious,GCS3-9)心跳呼吸停止心跳呼吸停止 怀疑心肌梗死引起的胸痛怀疑心肌梗死引起的胸
17、痛 严重心律失常严重心律失常 中度烧伤中度烧伤 呼吸道梗阻、呼吸窘迫呼吸道梗阻、呼吸窘迫 严重创伤大出血严重创伤大出血 张力性气胸等张力性气胸等 过敏性休克过敏性休克外科护理教研室外科护理教研室急危重症护理学急危重症护理学Determining the CTAS levels First Order Modifiers Vital signs Respiratory Distress Hemodynamic Status Level of Consciousness Temperature Other modifiers Pain score Bleeding disorder Mechani
18、sm of injury Second Order Modifiers Blood Glucose Level Dehydration severity Blood PressureMore information is needed to determine the CTAS levels.外科护理教研室外科护理教研室急危重症护理学急危重症护理学Patients reassessment guidelines Level 1 continuous nursing careLevel 1 continuous nursing care Level 2every 15 minsLevel 2ev
19、ery 15 mins Level 3every 30 minsLevel 3every 30 mins Level 4every 60 minsLevel 4every 60 mins Level 5every 120 minsLevel 5every 120 mins外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室Role of Triage Nurse1.1.Assessing patientsAssessing patients2.2.Communicating with the publicCommunicating with
20、the public3.3.Communicating with Health professionalsCommunicating with Health professionals4.4.Assigning resourcesAssigning resources5.5.Initiating treatment protocols/first aid measuresInitiating treatment protocols/first aid measures6.6.Monitoring and reassessingMonitoring and reassessing7.7.Pati
21、cipating in patient flowPaticipating in patient flow8.8.Documenting Documenting 外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室Characteristics of the Triage Nursewhat makes a good triage nurse?Personal traitsPersonal traits Cognitive characteristicsCognitive characteristics Behavioral character
22、isticsBehavioral characteristics外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室练习：练习：for personal reflectionfor personal reflection我的强项我的强项我的弱项我的弱项Personal traits1.2.3.1.2.3.Cognitive characteristics1.2.3.1.2.3.Behavioral characteristcs1.2.3.1.2.3.外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科
23、护理教研室 Personal traitsPersonal traits FlexibilityFlexibility AutomomyAutomomy Good communication skillsGood communication skills AssertivenessAssertiveness PatiencePatience CompassionCompassion Willingness to listen and learnWillingness to listen and learn外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室
24、外科护理教研室what makes a good triage nurse?Personal traitsPersonal traits Cognitive characteristicsCognitive characteristics Behavioral characteristicsBehavioral characteristics外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室 Cognitive characteristics Cognitive characteristics A diverse knowledge bas
25、eA diverse knowledge base Knowing when not to actKnowing when not to act Critical thinkingCritical thinking Ability to make decision quicklyAbility to make decision quickly Ability to Ability to prioritize prioritize外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室What makes a good triage nurse?P
26、ersonal traitsPersonal traits Cognitive characteristicsCognitive characteristics Behavioral characteristicsBehavioral characteristics外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室 Behavioral characteristics Behavioral characteristics Being a patient advocateBeing a patient advocate Working wel
27、l under pressureWorking well under pressure Being organizedBeing organized Improvising as neededImprovising as needed Using intuitionUsing intuition Displaying confidence in judgementDisplaying confidence in judgement Trusting or relying on peersTrusting or relying on peers外科护理教研室外科护理教研室急危重症护理学急危重症护
28、理学急救护理学急救护理学外科护理教研室外科护理教研室Skills of Triage Nurse Public relations skillsPublic relations skills Interviewing skillsInterviewing skills Critical thinking skillsCritical thinking skills Communication skillsCommunication skills DocumentationDocumentation外科护理教研室外科护理教研室急危重症护理学急危重症护理学急救护理学急救护理学外科护理教研室外科护理教研室分诊时要注意以下情况分诊时要注意以下情况 需优先分诊的人需优先分诊的人 儿童儿童 老人老人 身体残疾或智力障碍的人身体残疾或智力障碍的人 意识不清者意识不清者 需要注意的人需要注意的人 有虐待或攻击倾向的病人有虐待或攻击倾向的病人 受酒精影响的病人受酒精影响的病人
