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RN, DNSc.

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Title: RN, DNSc.

1
??????????

???
RN, DNSc.

2
????????
?
NH4
????
???
????
????
????
O2
????
????
CO2
H2O
3
????????
?
?
GI
?
?
NH4
????
???
????
????
???
????
O2
????
????
CO2
???
?
?
H2O
4
???????????
5
????????????????
Dysfunction
Critical level
S/S or Problems
Organ/system
hypoxia,
oxygenation
acute
Lung, Heart,
hypoperfusion
perfusion
Hgb, Volume,
metabolic acidosis
Acidobase
death
CO2 removal
Short-term
respiratory acidosis
Lung
NH4 removal
hepatic coma,
Kidney
uremic coma
nutrient intake
chronic
organ depletion
GI
organ/system failure
(MOFS, Sepsis)
6
?????????????

? ?????????
? ???????,???????
? ?????????
? ??????????????

7
?????????

?????(clinical observation)
?????(physical examination)
?????(patients complaints)
??????(Lab. Data)
????????(current treatment)
?????????
???

8
???????????

?????????????
??????????????
?????????
? ? ? ?
?????????
????

9
????????????

?????????????
?????????????
???????????????
?????
????????
??????????
???????

10
????
11
????
12
???????????????

?6??????????
?8??????????
?10???????????
?5?????????

13
????
14
?????
15
???????

?
ventilation, diffusion
?
pumping, perfusion
?? O2?CO2????????????

16
?????????

????? (Ventilation)
??????? (?)
?? (Diffusion)
(??)???????
?? (Carry) Hgb,
CaO21.34 X Hgb X SaO2 0.003XPaO2
?? (Perfusion)
???????? (?? O2 ? CO2)
???? (O2 demand)
BMR
Disease severity
Physical Activity

17
??????????????

Dyspnea
SOB
Orthopnea
Cyanosis

18
?????????????

??????
???????
??????
????????

Rib fructure, ?????
Bronchitis, Broncheoectasis,
asthma, (COPD)
Pneomothorax, Pleural effusion, Emphysema,
Pneumonia, Pulmonary edema, ARDS,

19
???????

??
?????, ?????????, ????,????
??
????, ????
??
???, ??
??
???, ????

20
??????????????

????
????????
?????????
??
???/?????
?????,
?????
????

21
????????????

????
????????????
??
?????? (minute ventilation)
by MV TV x RR
or by Rate over/under/critical value
?????????????
Chyne-Stoke resp.
Kussmaul's resp
Biot's resp.

22
????????
Chyne Stoke repiration
23
????????
Kussmauls
24
????????
No pattern
?
25
????????
Biots respiration
26
?????????????
Light reflex
Chyne-Stoke
Corneal reflex, Dolls sign
Kussmauls
?
Biots
Gag reflex
27
???????????

????
??????
??????????????
??????????
Risk group spinal cord injury
??????
One lung respiration
??????????????

28
????

????
??????chest trauma?????
??????????
????? (Tactile Fremitus, T/F)
??
????

29
????

1). ???(hyperresonance, tympanic)
??
risk group
COPD
2). ???, ??(dullness)
???????

30
????

??????
??????????????????
????
??????????

31
???

???? ? ?
?????
???????
????????
?????

32
Rale

??
(?)????????????
???Crackle
?????
Fine rales (???)
Medium rales(???)
(?Moist rales)
Coarse rales (???)

33
Rales??

????
????
????
????

34
Rhonchi/wheeze

??
?????????????????????
??
Rhonchi
Wheeze

35
Rhonchi/wheeze???

????
????
????
????

36
Pleural fiction rub

??
????
????

37
????????

????????,????????
??????
Pulse Oximetry
peripheral O2 saturationSpO2??Hgb
???,?Hgb????????O2????
Normal gt 96
Acceptable gt 90

38
???????

???????????
????????????
Blood volumeCVP
Cardiac pumpingSBP
Vascular toneDBP
??????????????????
????

39
?????????
Pul. veins
LA LV

Tissue
Perfusion take O2

(brain, kidney, heart .
Pul. cap.
JV
exit CO2
SVC

Liver
Pul. artery

Spleen
RV RA
IVC Oxygenation
Pumping
Bring O2, nutrients CO2
removal
Remove CO2,
metabolites (alveoli- capillary)
(ventricle)
(capillary bed)
40
???????????
-- impaired functions of the perfused organ

Brain change of LOC
Kidney decrease U/O
Heart myocardial ischemia?
Lung poor oxygenation results in vascular
constriction
Liver in congestion?????????
GI track ischemic
Limbspale and cold, thread pulse, poor capillary
refilling

41
????

????
????????????
????
????????
?????
???????????
?????????

42
??????

????(?)
?????(?)
?????(?)
??????(?)
??????(??)

43
??????
Albumin 3.55.5 d/L
BP 120/80 mmHg
Oncotic pressure 25 mmHg
???? 3545 mmHg
???? 1315 mmHg
Interstitial pressure 35 mmHg
Lymphatic drainage
44
?????
Oncotic pressure 25 mmHg
???
???
???? 2515 mmHg
???? lt12 mmHg
Interstitial pressure 35 mmHg
Lymphatic drainage
45
???????

46
??????????
47
????????????

?????
1.volume
2.pumping
3.vascular tone
????
1.??????
2.???

48
?????blood pressure

perfusion pressure(???)
?????????
systemic perfusion pressure(??????)
MBP-CVP
cerebral perfusion pressure (????)
MBP-ICP (50 mmHg, in injured brain gt 70 mmHg)
myocardial perfusion pressure (?????)
DBP-CVP (gt50 mmHg)
glumerular filtration pressure (????)
MBP-?????-?????

49
??????????????

1.??????heart failure?shock
pale, cold limbs
decrease urinary output
poor activity tolerance
pulmonary edemadyspnea?rales
limbs edema
congested liver and spleen
change of consciousness
2. palpitation????
3. chest pain?????????
4. Hypotension/ Hypertension

50
Hypertension

Hypertensive encephalophathy
MBP gt150 mmHg,??cerebral autoregulation??vasospasm
?ischemia?edema?hemorrhage?seizure
Malignant hypertension
DBPgt130mmHg,????end organ damage
LV hypertrophy, LV failure,?????,
hematuria?proteinuria, ?????
Threaten to life
S/S

51
Hypotension

inadequate perfusion to organ
MBPlt 70mmHg to brainMBPlt 60mmHg
to heartMBPlt 50mmHg to kidney

52
Shock

???????????????????

?? ???? ?? ?? Hypovolemic CVP?,JVD(-) vol
ume ??? ?? Cardiogenic CVP? ,JVD()
pumping heart Hx Distributive DBP?,
vascular tone Septic ???
infection Neurogenic
????
Restrictive CVP?
Cardiac temponade ??? ????
Pul. embolism SO2?? ????
Pneumothorax ???????? ??????
53
Cardiac tamponade

?????????,???????
Beck triad
Hypotension, Neck vein engorgement, Muffle heart
sound
early sign
Pulsus paradoxus???
Risk group
chest trauma
Cath. Procedureeg. PTCA,PTMV,EPS/Ablation,
Open Heart

54
Pulsus paradoxus
55
???

?????
????????????esp. ????
???????
??????????
?????????
????
??????????????,??????????,
??????????????????SaO2????

56
?????

Risk group Chest trauma
?????????,???????????,???????
????
????
??????
???????
?????

57
??????

????????,????????????
??volume,??pumping,??vascular tone
??MBP ??gt70 mmHg
???????- keep airway patent, increase FiO2,
correct anemia, SaO2
??????- hypothermia (32?if tolerable)

58
??????
Volume of blood loss change of vital signs
capillary refilling lt 15
BP?? HR? RR? lt 2
sec. 20-25 BP? HR gt 110 RRgt 25
gt 5sec 40-45 BP??? HRgt
110 RRgt 25 gt 5 sec

blood amount 70cc/kg
body reaction????? ? ?????? ? shock
In uncontrolled bleeding, maintain MBP not exceed
90 mmHg to prevent dislodge of clot.
In massive bleeding, replace volume by whole
blood is the best choice to prevent lethal anemia.

59
Change of skin color and temperature

in cardiac failure?
affect arterial flow first, then venous flow
pink, warm ? pale cold ?cyanosis, cold
in compartment syndrom?
affect venous flow first, then arteial flow?
pink, warm ? cyanotic, warm ? cyanotic, cold

60
?????????

HR and BP
bradycardia, tachycardia, arrhythmia,
systolic BP
diastolic BP
S3, S4 signs of heart pumping failure
JVD reflect the pressure in right atrium
Hepatojugular reflux
Pul. basal rales pumping function of left
heart
Abd. vessel auscultation
skin color and temperature
Pulse evaluation pulsus alternus, pulsus
paradoxus

61
Aortic dissection vs.
Malignant hypertension
62
Aortic dissection vs. AMI
Aortic dissection
Acute MI
????
?
??????
???
?
,
,
BP?
BP??
??????
?????
???????
???????
63
???????

????????????
????????
abd. pain, N/V, constipation, diarrhea
?????
gastroenteritis, intestinal obstruction, abd.
Distension, appenditis, cholecystitis,
pancrititis, peritonitis, abd. aortic aneurysm,
internal bleeding

64
?????????

??? ????
????????????
???? (spider nevi) ???????
?? (pulsation)
?? (peristalsis)
????? Cullen's sign, Grey Turner's sign

65
????????

???????????1)???????
2)???????3)????
????? ??? ??
?? ?? ?
?
?? ? ?
?,?
?? ????,?????,?????

66
????

????????
systolic bruit aortic aneyrysm
venous hum portal hypertension
??
soft/hard/firm
tenderness
rebound tenderness
??
??
????

67
????

????
Hepatojugular reflux
????
???
???
???

68
????????????

? ? ? ?
? ?
Acute Pancreatitis ??? T ()?RT ()
Acute Appenditis ??? T ()?RT() ?Psoa ()
Rovsing ()?obturator()?
Acute Cholecystitis ???? Murphy sign ()
Gastritis ??? T ()?RT (-)
Enteritis ???? T ()?RT (-) Bowel Sound?
Peritonitis Diffused T ()?RT()
Intestinal Obstruction Cramping?
BS??T(-)? Rebound Pain(-) in late
stage?Bowel Sound?
Abdominal distention ??

69
???????????

? ? ?
?
Acute gastroenteritis cramping, ???
(AGE)
GI bleeding cramping, ???
Colitis cramping, ???
egShigella-foul stool
Ameoba-mucus stool

70
???????

????????
headache, mental status change, LOC disturbance,
sensory function impairment, motor function
impairment, muscle tone, reflex
?????
head injury, intracranial tumor, CVA, spinal cord
injury peripheral nerve injury

71
???????(?)

?????
????(LOC) Level of consciousness
Glausgaw Coma Scale
eye open
verbal response
movement

72
???????(?)

????
????(MS) Mental status

JOMAC
Judgement
Orietation
Memory
Attentin, Abstract thinking
Calculation

ABC
Appearance
Bebavior
Communication

73
?????

Brain stem reflex
Light reflex
Corneal reflex
Doll signs
Caloric test
Gag reflex

74
?????

??????????
????
?????????
?????????
???????

75
???????

1.???????
???????????? ??????????
?????????
(eg.C3, C6, C7, C8, T4, T10, L1, L3, L5, S1, S5)

76
????
??
??
???,???????
???,??,???
77
????
??
??
???,???????
???,???????
???,??,???
???,??,???
78
????
??
??
???,???????
???,???????
???,??,???
???,??,???
79
????
??
??
???,???????
???,???????
???,??,???
???,??,???
80
C3
C3
T4
C6
T10
C8
L1
S5
C7
L3
L5
S1
81
????