危重病人的康复.doc

CHAPTER 60 第60章 ADITI G. SATTI , MELISSA DERR , AND MARY L. FORNEK ADITI G. SATTI , MELISSA DERR , AND MARY L. FORNEK Rehabilitation in the Intensive Care Unit CHAPTER OUTLINE Learning Objectives Introduction Case Study: Part 1 Rehabilitative Issues in the Icu Patient Case Study: Part 2 Whole Body Rehabilitation Inspiratory Muscle Training Early Tracheostomy to Facilitate Mobilization Case Study: Part 3 Psychological Dysfunction Speech Swallowing Dysfunction Case Study: Part 4 Sleep Implementing an Early Mobility Program Initial Assessmen Specialized Unit Approach to Early Mobility Rehabilitation Strategies Rehabilitation Programs Special Considerations Summary Review Questions Answers References Additional Readings 重症监护病人的康复 章节梗概 学习目标 前言 个案研究：第一部分 重症监护病人康复内容 个案研究：第二部分 整体康复 吸气力训练 保持气道通畅，早期气管造口？？？ 个案研究：第三部分 心理障碍 语言障碍 吞咽障碍 个案研究：第四部分 睡眠障碍 实施早期活动方案 初始评估t 专门早期活动病房？？？？ 康复策略 康复程序 特别考虑 摘要 复习问题 答案 参考文献 附加读物 LEARNING OBJECTIVES After studying this chapter, you should be able to: ■ Understand the importance of the team approach and the process of care issues, which lead to successful implemention of rehabilitation in the ICU patient. ■ Understand the main neuromuscular, respiratory, and psychological conditions that affect rehabilitation in the ICU. ■ Develop a systematic approach for implementing early mobility of ventilated patients. ■ Execute effective measures to prevent complications in ventilated patients in the ICU. 学习目标 通过本章节，你应该： 理解在重症监护病人康复实施成功中团队合作、护理内容和护理过程的重要性。 理解影响重症监护病人康复的主要因素：神经肌肉、呼吸及心理状态。 为机械通气患者制定实施早期活动的系统化的方法。 采取有效的措施预防重症监护室机械通气患者并发症。 INTRODUCTION 介绍 The goal of rehabilitation is to improve physical, psychological,and social function within the constraints of the patient’s illness. Muscle fatigue and weakness were the major reasons given for patient’s persistent functional limitation. 康复的主要目的是在病人病情允许的范围内提高患者的身体、心理及社会功能。呼吸机疲劳无力是病人功能持续受限的原因。下边左侧 The global advancement in ICU care has improved survival of the critically ill patient. This improved survival has led to longer ICU lengths-of-stay and an awareness of the number and diversity of secondary complications. A prolonged ICU stay and chronic critical illness are associated with weakness, deconditioning, decreased function, and quality-of-life. The goal of rehabilitation is to improve physical, psychological, and social function within the constraints of the patient’s illness. ICU监护的全面（全球？？）进步提高危重病人的生存率。生存率的提高导致入住ICU时间延长和认知各种各样的继发并发症。ICU入住时间延长及慢性危重症和患者的身体虚弱、不适应？？？、各种功能及生活质量降低相关。康复的目的是在病人条件身体允许的范围内？？提高患者身体、心理及社会功能。 Acute respiratory distress syndrome (ARDS) is a common condition encountered in the ICU and is associated with long term psychological and functional disorders. In a study reviewing 109 survivors of ARDS, muscle fatigue and weakness were the major reasons. 第60章 重症监护室病人的康复 1193 CASE STUDY: PART 1 个案研究：第一部分 The patient, R.S., was a 54-year-old African American male with history of severe COPD; he was admitted with an acute exacerbation of COPD and hypoxemic respiratory failure. On admission,he was in acute respiratory distress, his respiratory rate was 37,pulse 136, blood pressure 100/62, and SpO 2 via pulse oximetry was 82%. On examination, R.S. had an increased work-of-breathing and was using accessory muscles. He had decreased air entry on lung exam. His initial chest X-ray showed hyperinflated lungs. The patient was intubated on admission and transferred to the ICU. During his stay he was treated with high-dose steroids for his COPD exacerbation and had to be sedated and paralyzed in order to maintain an oxygen saturation above 90% on ventilatory support. As the patient improved, the systemic corticosteroid dose was tapered and the sedation was weaned. Early in his hospital course, the patient was not a candidate for physical therapy due to his medical instability. At the present time, the patient’s body is rotated every 2 h by the nurse. Multipodus boots and hand splints were placed on the patient to prevent joint contractures. R.S.是一个54岁的非洲裔美国男性患者，有严重的COPD病史。入院时，存在COPD 急性加重和低氧性呼吸衰竭,入院后，患者存在急性呼吸窘迫综合征，呼吸频率为37次/分，脉搏为136次/分，血压为100/62mmHg，经皮血氧饱和度为82%，体检发现，R.S.呼吸功增加及应用辅助呼吸机呼吸，气体入肺量减少,X线示肺过度膨胀。,病人立即行气管插管并送往监护室，住院期间在应用呼吸机辅助通气时因COPD急性加重应用了大量的激素，为了保持血氧饱和度在90%以上，应用了镇静药物和肌松药物,随着病人病情的改善，系统应用激素量减少及镇静剂逐渐停用,在他早期的住院时期，这个病人因为它的医学不稳定性物理疗法不作为首选,目前，护士每2小时就给该患者翻一次身。给患者应用长筒靴及手夹板以避免关节挛缩。 given for patient’s persistent functional limitations. These functional limitations were evident in the lower than predicted distance walked in 6 min.1 Survivors of prolonged ventilation also experienced a marked impairment in their physical quality-of-life, even though their mental health was preserved. 2 There is an increased need for rehabilitation following a stay in the ICU because of the harmful consequences of prolonged bed rest. 急性肺损伤和急性呼吸窘迫综合征是在ICU中经常碰到，它长期的心理和功能紊乱相关。在回顾一个109个急性呼吸窘迫综合征存活患者的研究中，呼吸机疲劳及身体虚弱无力是病人持续性功能障碍主要原因。这些功能限制在预计6分钟步行实验较低的病人中更显著。机械通气时间延长的幸存者都经