repositioning, managing oxygen therapy, administering medications, and providing suctioning. Refer to Table 8.2b in the “Oxygenation Basic Concepts” section earlier in this chapter for information about these interventions. 重新摆放体位、管理氧疗、给药和吸痰。有关这些干预措施的信息，请参阅本章前面 "吸氧基本概念 "一节中的表 8.2b。
For additional details regarding managing oxygen therapy, see the “Oxygen Therapy” chapter in Open RN Nursing Skills. 有关氧疗管理的更多详情，请参阅《开放式注册护士护理技能》中的 "氧疗 "章节。
Read more information about respiratory medications in the “Respiratory” chapter in Open RN Nursing Pharmacology. 请阅读《开放式注册护士药理学》中 "呼吸系统 "一章中有关呼吸系统药物的更多信息。
Patients should also receive individualized health promotion patient education to enhance their respiratory status. Health promotion education includes encouraging activities such as the following: 患者还应接受个性化的健康促进患者教育，以改善其呼吸状况。健康促进教育包括以下鼓励性活动：
Receiving an annual influenza vaccine 接种年度流感疫苗
Receiving a pneumococcal vaccine every five years as indicated 根据需要每五年接种一次肺炎球菌疫苗
Stopping smoking 戒烟
Drinking adequate fluids to thin respiratory secretions 饮用足够的液体以稀释呼吸道分泌物
Participating in physical activity as tolerated 在可以忍受的情况下参加体育活动
Implementing Interventions 实施干预措施
When implementing interventions that have been planned to enhance oxygenation, it is always important to assess the patient’s current level of dyspnea and modify interventions based on the patient’s current status. For example, if dyspnea has worsened, some interventions may no longer be appropriate (such as ambulating), and additional interventions may be needed (such as consulting with a respiratory therapist or administering additional medication). 在实施为提高氧合而计划的干预措施时，评估患者当前的呼吸困难程度并根据患者当前的状况修改干预措施始终是非常重要的。例如，如果呼吸困难加重，某些干预措施可能不再合适（如步行），可能需要额外的干预措施（如咨询呼吸治疗师或服用额外药物）。
Evaluation 评估
After implementing interventions, the effectiveness of interventions should be documented and the overall nursing care plan evaluated. Focused 实施干预措施后，应记录干预措施的效果，并对整体护理计划进行评估。重点
reassessments for evaluating improvement of oxygenation status include analyzing the patient’s heart rate, respiratory rate, pulse oximetry reading, and lung sounds, in addition to asking the patient to rate their level of dyspnea. 用于评估氧合状态改善情况的评估包括分析患者的心率、呼吸频率、脉搏血氧饱和度读数和肺部听诊音，以及要求患者对其呼吸困难程度进行评分。
8.4 Putting It All Together 8.4 将所有内容整合在一起
The following patient care scenario applies information from this chapter to create an abbreviated nursing care plan and sample documentation note. 下面的患者护理情景应用了本章的信息，以创建简短的护理计划和文件记录样本。
Patient Scenario 患者情景
Mr. Smith is an 82-year-old patient in a long-term care facility and has a history of chronic obstructive pulmonary disease (COPD). 史密斯先生是一名 82 岁的病人，住在一家长期护理机构，有慢性阻塞性肺病 (COPD) 病史。
This morning Mr. Smith told the CNA as he was getting ready for breakfast, “I’m feeling short of breath and tired today.” The CNA obtained vital signs and reported them to you: respiratory rate 24,O224, \mathrm{O} 2 sat 86%86 \%, pulse 88 , and temperature 36.8 C . 今天早上，史密斯先生在准备早餐时告诉 CNA："我今天感觉气短、疲倦。CNA 获取了生命体征并向您报告：呼吸频率 24,O224, \mathrm{O} 2 ，饱和度 86%86 \% ，脉搏 88，体温 36.8 C。
Applying the Nursing Process 应用护理程序
Assessment: You auscultate Mr. Smith’s breath sounds and find scattered wheezing and rhonchi anteriorly, with diminished breath sounds in the posterior lower lobes. You ask Mr. Smith to rate his shortness of breath now on a scale from 0-10 and he reports it is a " 4 ," but usually a " 2 " during activity. While assessing Mr. Smith, you note he is using accessory muscles to breathe and is sitting up in the tripod position. He also has a barrel chest. You quickly check his chart and note the following orders and scheduled medications: 评估：您对史密斯先生的呼吸音进行听诊，发现其前部有分散的喘鸣声和哮鸣音，后下叶呼吸音减弱。您让史密斯先生用 0-10 分来评定他现在的气短程度，他说是 "4 分"，但在活动时通常是 "2 分"。在对史密斯先生进行评估时，您注意到他正在使用辅助肌肉呼吸，并以三脚架姿势坐立。他的胸部也呈桶状。您迅速查看了他的病历，注意到以下医嘱和计划用药：
Oxygen via nasal cannula at 1-2 L per minute as needed to maintain O2 saturation greater than 90% 根据需要通过鼻插管每分钟 1-2 升氧气，以维持氧气饱和度大于 90%。
Albuterol nebulizer as needed for wheezing 喘息时根据需要使用阿布特罗雾化器
Based on this information, you formulate the following nursing care plan: 根据这些信息，您制定了以下护理计划：
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and patient stating, “I’m feeling short of breath and tired today.” 护理诊断：无效呼吸模式与呼吸肌疲劳有关，表现为呼吸急促和使用辅助肌肉呼吸，病人说："我今天感到气短和疲倦"。
Overall Goal: The patient will have adequate movement of air into and out of the lungs. 总体目标：病人有足够的空气进出肺部。
SMART Expected Outcome: Mr. Smith’s reported level of dyspnea will be within his stated desired range of 7-2 by the end of the shift. SMART 预期成果：到轮班结束时，史密斯先生所报告的呼吸困难程度将在他所期望的 7-2 级范围内。
Planned Nursing Interventions with Rationale: 计划的护理干预措施及理由：
Interventions 干预措施
Rationale 理由
1. Implement NIC interventions for Respiratory Monitoring NIC (as outlined in Box 8.3 ). 1.1. 对呼吸监测 NIC 实施 NIC 干预措施（如方框 8.3 所述）。
Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. 确定当前的基线状态，并随着干预措施的实施继续监测其改善或恶化情况。
2. Implement NIC Interventions for Anxiety Reduction (as outlined in Box 8.3). 2.实施国家信息中心减少焦虑干预措施（如专栏 8.3 所述）。
Dyspnea creates feelings of anxiety. Decreasing the patient's anxiety levels will help decrease the feeling of dyspnea. 呼吸困难会让人产生焦虑感。降低患者的焦虑水平将有助于减少呼吸困难的感觉。
3. Place patient in high Fowler's or tripod position as needed to reduce feelings of dyspnea. 3.根据需要让病人采取高位福勒式或三脚架式体位，以减轻呼吸困难的感觉。
Positioning will assist in maximum expansion of lungs. 摆放姿势有助于最大限度地扩张肺部。
4. Apply oxygen via nasal cannula, starting at 1L//1 \mathrm{~L} / min and titrate until 90% pulse oximetry reading is obtained per standing order. 4.根据医嘱，从 1L//1 \mathrm{~L} / 分钟开始通过鼻导管供氧，直至获得 90% 的脉搏血氧饱和度读数。
Oxygen therapy will reduce the work of breathing. 氧气疗法可以减少呼吸的工作量。
5.管理计划药物和紧急备用药物：- 阿布特罗雾化器 - 噻托溴铵吸入器 - 氟替卡松吸入器
5. Administer scheduled and PRN medications:
- Albuterol nebulizer
- Tiotropium inhaler
- Fluticasone inhaler
5. Administer scheduled and PRN medications:
- Albuterol nebulizer
- Tiotropium inhaler
- Fluticasone inhaler| 5. Administer scheduled and PRN medications: |
| :--- |
| - Albuterol nebulizer |
| - Tiotropium inhaler |
| - Fluticasone inhaler |
Each medication has a different mechanism of action that will assist Mr. Smith's dyspnea.
- Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation.
- Tiotropium is a long-acting bronchodilator.
- Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways.
Each medication has a different mechanism of action that will assist Mr. Smith's dyspnea.
- Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation.
- Tiotropium is a long-acting bronchodilator.
- Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways.| Each medication has a different mechanism of action that will assist Mr. Smith's dyspnea. |
| :--- |
| - Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation. |
| - Tiotropium is a long-acting bronchodilator. |
| - Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways. |
6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. 6.鼓励史密斯先生使用抿唇呼吸法和胡夫咳嗽法。
Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. 噘起嘴唇呼吸有助于在呼气时保持呼吸道更长时间的开放，从而在吸气时吸入更多的空气。胡夫式咳嗽有助于清除分泌物。
7. Encourage fluids ( 2000mL//242000 \mathrm{~mL} / 24 hours) and monitor intake and output. 7.鼓励多喝水（ 2000mL//242000 \mathrm{~mL} / 24 小时），并监测摄入量和排出量。
Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly patients who have increased risk for developing fluid overload. 补充液体有助于稀释分泌物，使其更容易咳出。史密斯先生没有输液限制，但在鼓励输液时一定要监测摄入量/排出量，尤其是老年患者，因为他们发生液体超负荷的风险更高。
Interventions Rationale
1. Implement NIC interventions for Respiratory Monitoring NIC (as outlined in Box 8.3 ). Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented.
2. Implement NIC Interventions for Anxiety Reduction (as outlined in Box 8.3). Dyspnea creates feelings of anxiety. Decreasing the patient's anxiety levels will help decrease the feeling of dyspnea.
3. Place patient in high Fowler's or tripod position as needed to reduce feelings of dyspnea. Positioning will assist in maximum expansion of lungs.
4. Apply oxygen via nasal cannula, starting at 1L// min and titrate until 90% pulse oximetry reading is obtained per standing order. Oxygen therapy will reduce the work of breathing.
"5. Administer scheduled and PRN medications:
- Albuterol nebulizer
- Tiotropium inhaler
- Fluticasone inhaler" "Each medication has a different mechanism of action that will assist Mr. Smith's dyspnea.
- Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation.
- Tiotropium is a long-acting bronchodilator.
- Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways."
6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions.
7. Encourage fluids ( 2000mL//24 hours) and monitor intake and output. Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly patients who have increased risk for developing fluid overload.| Interventions | Rationale |
| :--- | :--- |
| 1. Implement NIC interventions for Respiratory Monitoring NIC (as outlined in Box 8.3 ). | Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. |
| 2. Implement NIC Interventions for Anxiety Reduction (as outlined in Box 8.3). | Dyspnea creates feelings of anxiety. Decreasing the patient's anxiety levels will help decrease the feeling of dyspnea. |
| 3. Place patient in high Fowler's or tripod position as needed to reduce feelings of dyspnea. | Positioning will assist in maximum expansion of lungs. |
| 4. Apply oxygen via nasal cannula, starting at $1 \mathrm{~L} /$ min and titrate until 90% pulse oximetry reading is obtained per standing order. | Oxygen therapy will reduce the work of breathing. |
| 5. Administer scheduled and PRN medications: <br> - Albuterol nebulizer <br> - Tiotropium inhaler <br> - Fluticasone inhaler | Each medication has a different mechanism of action that will assist Mr. Smith's dyspnea. <br> - Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation. <br> - Tiotropium is a long-acting bronchodilator. <br> - Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways. |
| 6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. | Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. |
| 7. Encourage fluids ( $2000 \mathrm{~mL} / 24$ hours) and monitor intake and output. | Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly patients who have increased risk for developing fluid overload. |
8. Schedule care activities to allow frequent rest periods. 8.安排护理活动，以便经常休息。
9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. 9.在氧气饱和度超过 90% 后，与 CNA 一起在走廊上鼓励病人在可以耐受的情况下行走。
Ambulation will help to mobilize the secretions so they can be removed. 多走动有助于移动分泌物，以便将其清除。
8. Schedule care activities to allow frequent rest periods. Resting frequently decreases oxygen demand.
9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. Ambulation will help to mobilize the secretions so they can be removed.| 8. Schedule care activities to allow frequent rest periods. | Resting frequently decreases oxygen demand. |
| :--- | :--- |
| 9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. | Ambulation will help to mobilize the secretions so they can be removed. |
Evaluation: 评估：
After administering medications and applying the oxygen, you reassess Mr. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1L//min1 \mathrm{~L} / \mathrm{min}. The wheezing and rhonchi in the anterior lungs have diminished. You ask Mr. Smith how he is feeling. He rates his current level of dyspnea as a " 2 " and states, “I feel less short of breath but I am still tired.” The SMART outcome was “met.” You encourage Mr. Smith to rest after eating breakfast, but encourage a walk in the hallway later that morning. You enter the following documentation note in the patient record. 用药和吸氧后，您对史密斯先生进行了重新评估，结果如下：呼吸频率 16，脉搏 78，氧饱和度 90%，NC 为 1L//min1 \mathrm{~L} / \mathrm{min} 。前肺的喘息和哮鸣音已经减弱。您询问史密斯先生感觉如何。他将目前的呼吸困难程度评为 "2 "级，并说："我感觉气短减轻了，但还是很累。SMART 结果为 "达到"。您鼓励史密斯先生吃完早餐后休息，但鼓励他当天早上晚些时候在走廊散步。您在病历中记录了以下内容。
Sample Documentation Note 文件说明样本
Upon awakening, the patient reported a dyspnea level of a " 4 " and stated, “I’m feeling short of breath and tired today.” Vital signs were respiratory rate 24,O224, \mathrm{O} 2 sat 86%86 \%, pulse 88 , and temperature 36.8 C. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Oxygen applied via nasal cannula at 7L//min7 \mathrm{~L} / \mathrm{min}; albuterol nebulizer and scheduled medications were administered. Patient was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Post albuterol administration, vital signs were respiratory rate 16, pulse 78 , and O 2 sat 90%90 \% on room air. The wheezing and rhonchi in the anterior lungs were diminished. Patient reported dyspnea decreased to a " 2 " but stated, “I feel less short of breath but I am still tired.” Encouraged patient to push fluids and ambulate as tolerated today, along with frequent rest breaks. Will continue to monitor respiratory rate, pulse, lung sounds, and reported level of dyspnea every four hours today. 醒来后，患者表示呼吸困难程度为 "4 "级，并称 "我今天感到气短和疲倦"。生命体征为呼吸频率 24,O224, \mathrm{O} 2 ，饱和度 86%86 \% ，脉搏 88，体温 36.8 摄氏度。前部有分散性喘息和哮鸣音，后下叶呼吸音减弱。在 7L//min7 \mathrm{~L} / \mathrm{min} 处通过鼻插管吸氧；使用了阿布特罗雾化器和预定药物。将患者置于床边的三脚架位置，鼓励患者采用抿唇呼吸和胡夫咳嗽。给药后，生命体征为呼吸频率 16，脉搏 78，O 2 饱和度 90%90 \% 。前肺的喘息和哮鸣音减弱。患者称呼吸困难程度降至 "2 "级，但表示 "我感觉不那么气短了，但还是很累"。鼓励患者今天在可以忍受的情况下多输液、多走动，并经常休息。今天将继续每四小时监测一次呼吸频率、脉搏、肺部听诊和呼吸困难程度。
Learning Activities 学习活动
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
You are providing care for Mrs. Jones, an 83-year-old female patient admitted to the medical surgical floor with worsening pneumonia. Upon auscultation of the patient’s lung fields, you note scattered crackles and diminished breath sounds throughout all lung fields. Mrs. Jones requires 4L O2 via nasal cannula to maintain an oxygen saturation of 94%. You have constructed a nursing care diagnosis of Ineffective Breathing Pattern. What nursing interventions might you consider to help improve the patient’s breathing pattern? 琼斯夫人是一名 83 岁的女性患者，因肺炎恶化入住内科手术楼层，您正在为她提供护理。在对患者的肺野进行听诊时，您注意到所有肺野都有散在的噼啪声和呼吸音减弱。琼斯夫人需要通过鼻插管获得 4 升氧气以维持 94% 的血氧饱和度。您做出的护理诊断是 "无效呼吸模式"。您可以考虑采取哪些护理干预措施来帮助改善患者的呼吸模式？
"Gas Exchange Case Study" by Susan Jepsen for Lansing Community College are licensed under CC BY 4.0 "气体交换案例研究 "由 Susan Jepsen 为兰辛社区学院创作，采用 CC BY 4.0 许可。
Apnea: Temporary cessation of breathing. When apnea occurs during sleep, it is often caused by the condition called Obstructive Sleep Apnea (OSA). 呼吸暂停：暂时停止呼吸。睡眠中发生呼吸暂停通常是由阻塞性睡眠呼吸暂停（OSA）引起的。
Arterial Blood Gas (ABG): Diagnostic test performed on an arterial sample of blood to determine its pH level, oxygenation status, and carbon dioxide status. 动脉血气 (ABG)：对动脉血样本进行的诊断测试，以确定其 pH 值、氧饱和度和二氧化碳状态。
Barrel chest: An increased anterior-posterior chest diameter, resulting from air trapping in the alveoli, that occurs in chronic respiratory disease. 桶状胸：胸廓前后直径增大：慢性呼吸系统疾病患者因肺泡内空气潴留而导致胸廓前后直径增大。
Bilevel Positive Airway Pressure (BiPAP): A BiPAP is an oxygenation device similar to a CPAP device in its use to prevent airways from collapsing, but it has two pressure settings. One setting occurs during inhalation and a lower pressure setting is used during exhalation. BiPAP devices may be used in the home to treat obstructive sleep apnea or in hospitals to treat patients in acute respiratory distress. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RN Nursing Skills. 双级气道正压（BiPAP）：双水平气道正压吸氧器（BiPAP）：双水平气道正压吸氧器是一种用于防止气道塌陷的吸氧设备，与 CPAP 设备类似，但它有两种压力设置。吸气时使用一个压力设置，呼气时使用一个较低的压力设置。BiPAP 设备可用于家庭治疗阻塞性睡眠呼吸暂停，也可用于医院治疗急性呼吸窘迫患者。更多信息，请参阅《开放式注册护士护理技能》中 "氧气疗法 "一章的 "吸氧设备 "部分。
Bradypnea: Decreased respiratory rate less than the normal range according to the patient’s age. 呼吸过缓：呼吸频率下降：根据患者的年龄，呼吸频率低于正常范围。
Cardiac output: The amount of blood the heart pumps in one minute. 心输出量：心脏一分钟泵出的血液量。
Continuous Positive Airway Pressure (CPAP): A CPAP is an oxygenation device is typically used for patients who are able to breath spontaneously but need assistance in keeping their airway unobstructed, such as those with obstructive sleep apnea. The CPAP device consists of a mask that covers the patient’s nose, or nose and mouth, and is attached to a machine that continuously applies mild air pressure to keep the airways from collapsing. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RN Nursing Skills. 持续气道正压（CPAP）：CPAP 是一种吸氧设备，通常用于能够自主呼吸但需要帮助以保持呼吸道通畅的患者，如阻塞性睡眠呼吸暂停患者。CPAP 设备由一个面罩组成，面罩遮住患者的鼻子或口鼻，面罩连接到一台机器上，机器会持续施加温和的气压，以防止气道塌陷。更多信息，请参阅《开放式注册护士护理技能》中 "氧气疗法 "一章的 "吸氧设备 "部分。
Clubbing: Enlargement of the fingertips that occurs with chronic hypoxia. 指尖畸形：指尖增大：长期缺氧导致指尖增大。
Coughing and deep breathing: A breathing technique where the patient is encouraged to take deep, slow breaths and then exhale slowly. After each set 咳嗽和深呼吸：这是一种呼吸技巧，鼓励病人做深而慢的呼吸，然后慢慢呼气。每做完一组
of breaths, the patient should cough. This technique is repeated 3 to 5 times every hour. 的呼吸时，患者应咳嗽。这种方法每小时重复 3 到 5 次。
Cyanosis: Bluish discoloration of the skin and mucous membranes. 发绀：皮肤和粘膜呈蓝色。
Dyspnea: A subjective feeling of not getting enough air. Depending on severity, dyspnea causes increased levels of anxiety. 呼吸困难：呼吸困难：一种呼吸不到足够空气的主观感觉。根据严重程度，呼吸困难会导致焦虑程度增加。
Endotracheal Tube (ET tube): An ET tube is inserted by an advanced practitioner to maintain a secure airway when a patient is experiencing respiratory failure or is receiving general anesthesia. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RN Nursing Skills. 气管插管（ET 管）：当患者出现呼吸衰竭或正在接受全身麻醉时，由高级医师插入 ET 管以保持呼吸道安全。更多信息，请参阅《开放式注册护士护理技能》中 "氧治疗 "一章的 "吸氧设备 "部分。
HCO3: Bicarbonate level of arterial blood indicated in an arterial blood gas (ABG) result. Normal range is 22-26. HCO3：动脉血气 (ABG) 结果中显示的动脉血碳酸氢盐水平。正常范围为 22-26。
Huffing technique: A technique helpful for patients who have difficulty coughing. Teach the patient to inhale with a medium-sized breath and then make a sound like “ha” to push the air out quickly with the mouth slightly open. 呼气技术：对咳嗽困难的患者很有帮助。教病人用中等大小的呼吸吸气，然后微微张开嘴发出 "哈 "的声音，将空气迅速排出。
Hypercapnia: Elevated level of carbon dioxide in the blood. 高碳酸血症：血液中二氧化碳含量升高。
Hypoxemia: A specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2) indicated in an arterial blood gas (ABG) result. 低氧血症：低氧血症：缺氧的一种特殊类型，指动脉血气（ABG）结果显示血液中氧气分压（PaO2）降低。
Hypoxia: A reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia. 缺氧：组织氧合水平降低。缺氧的原因很多，从呼吸和心脏疾病到贫血都有可能造成缺氧。
Incentive spirometer: A medical device commonly prescribed after surgery to reduce the buildup of fluid in the lungs and to prevent pneumonia. While sitting upright, the patient should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The patient should attempt to hold their breath for 5 seconds, or as long as tolerated, and 肺活量计：手术后常用的医疗设备，用于减少肺部积液和预防肺炎。患者坐直后，通过管道缓慢深吸气，目的是将活塞提高到指定水平。患者应试着屏住呼吸 5 秒钟，或在可承受的范围内屏住呼吸，并且
then rest for a few seconds. This technique should be repeated by the patient 10 times every hour while awake. 然后休息几秒钟。患者应在清醒状态下每小时重复此方法 10 次。
Mechanical ventilator: A mechanical ventilator is a machine attached to an endotracheal tube to assist or replace spontaneous breathing. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RN Nursing Skills. 机械呼吸机机械呼吸机是一种连接在气管插管上的机器，用于辅助或替代自主呼吸。更多信息，请参阅《开放式注册护士护理技能》中 "氧治疗 "一章的 "吸氧设备 "部分。
Orthopnea: Difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position. 正位呼吸困难：躺着时呼吸困难，换成直立姿势后即可缓解。
PaCO2: Partial pressure of carbon dioxide level in arterial blood indicated in an ABG result. Normal range is 35-45mmHg35-45 \mathrm{mmHg}. PaCO2：ABG 结果中显示的动脉血中二氧化碳的分压水平。正常范围为 35-45mmHg35-45 \mathrm{mmHg} 。
PaO2: Partial pressure of oxygen level in arterial blood indicated in an ABG result. Normal range is 80-100mmHg80-100 \mathrm{mmHg}. PaO2：ABG 结果中显示的动脉血氧分压水平。正常范围为 80-100mmHg80-100 \mathrm{mmHg} 。
Perfusion: The passage of blood through the arteries to an organ or tissue. 灌注：血液通过动脉到达器官或组织。
Pursed-lip breathing: A breathing technique that encourages a person to inhale through the nose and exhale through the mouth at a slow, controlled flow. 噘嘴呼吸法：一种鼓励人们用鼻子吸气、用嘴呼气的呼吸技巧，流速缓慢而有控制。
Purulent sputum: Yellow or green sputum that often indicates a respiratory infection. 脓痰：黄色或绿色的痰，通常表示呼吸道感染。
Respiration: Gas exchange occurs at the alveolar level where blood is oxygenated and carbon dioxide is removed. 呼吸气体交换发生在肺泡水平，在这里血液中的氧气和二氧化碳被排出。
SaO2: Calculated oxygen saturation level in an ABG result. Normal range is 95-100%. SaO2：ABG 结果中的计算氧饱和度水平。正常范围为 95-100%。
SpO2: Hemoglobin saturation level measured by pulse oximetry. Normal range is 94-98%. SpO2：通过脉搏氧饱和度测量仪测量的血红蛋白饱和度水平。正常范围为 94-98%。
Sputum: Mucus and other secretions that are coughed up from the mouth. 痰：从口中咳出的粘液和其他分泌物。
Tachypnea: Elevated respiratory rate above normal range according to the patient’s age. 呼吸过速：呼吸频率升高，超过与患者年龄相符的正常范围。
Tripod position: A position that enhances air exchange when a patient sits up and leans over by resting their arms on their legs or on a bedside table; also referred to as a three-point position. 三脚架体位：三脚架体位：当病人坐起并俯身时，将双臂放在腿上或床头柜上，以加强空气交换的一种体位；也称为三点式体位。
Ventilation: Mechanical movement of air into and out of the lungs. 通气：空气进出肺部的机械运动。
Vibratory Positive Expiratory Pressure (PEP) Therapy: Handheld devices such as flutter valves or Acapella devices used with patients who need assistance in clearing mucus from their airways. 振动正呼气压力疗法（PEP）：手持式设备，如扑动阀或 Acapella 设备，用于帮助需要帮助的患者清除呼吸道中的粘液。
INFECTION 感染
Learning Objectives 学习目标
Outline the factors that put patients at risk for infection 概述使患者面临感染风险的因素
Identify factors related to infection across the life span 确定与终生感染有关的因素
Outline personal practices that reduce the risk of infection transmission 概述可降低感染传播风险的个人做法
Base your care decision on the signs and symptoms of infection 根据感染的症状和体征做出护理决定
Base your response on an interpretation of the diagnostic tests related to patient’s infectious process 根据对与患者感染过程有关的诊断检查的解释做出回答
Detail the nursing interventions to support or minimize the physical and psychological effects of the infectious process 详细介绍护理干预措施，以支持或尽量减少感染过程对身体和心理的影响
Demonstrate the ability to correlate nursing interventions to methods used to prevent or disrupt the chain of infection 展示将护理干预措施与用于预防或破坏感染链的方法联系起来的能力
Follow industry standards for transmission-based precautions 遵循基于传输的预防措施的行业标准
Identify evidence-based practices 确定循证实践
Have you ever wondered how nurses can be exposed to patients with communicable diseases day after day and not become ill? There are many factors that affect the body’s ability to defend against infection and place some individuals at greater risk of developing an infection. When an infection does occur, early recognition is important to prevent it from spreading within the individual, as well as to others. Protecting people from developing an infection, as well as preventing the spread of infection, is a major concern for nurses. This chapter will discuss the physiology of the inflammation and infectious processes and nursing interventions to prevent the spread of infection. 您是否想过，护士为何能日复一日地接触患有传染病的病人而不生病？有许多因素会影响人体抵御感染的能力，并使某些人面临更大的感染风险。当感染发生时，及早识别对防止感染在个人体内传播和传染给他人非常重要。保护人们免受感染以及防止感染扩散是护士的主要关注点。本章将讨论炎症和感染过程的生理学以及预防感染扩散的护理干预措施。
Normal Flora and Microbiome 正常菌群和微生物群
Microorganisms occur naturally and are present everywhere in our environment. Some microorganisms live on the skin, in the nasopharynx, and in the gastrointestinal tract, but don’t become an infection unless the host becomes susceptible. These microorganisms are called normal flora . Over the past several years, it has been discovered that every human being carries their own individual suite of microorganisms in and on their body referred to as their microbiome. A person’s microbiome is acquired at birth and evolves over their lifetime. It is different across body sites and between individuals. A person’s gut microbiome has recently been found to impact their immune system.’. ^(1//2){ }^{1 / 2} 微生物是自然存在的，在我们的环境中随处可见。有些微生物生活在皮肤、鼻咽部和胃肠道中，除非宿主易感，否则不会造成感染。这些微生物被称为正常菌群。在过去的几年中，人们发现每个人体内和身上都携带着各自的微生物，这些微生物被称为微生物组。人的微生物群是在出生时获得的，并在一生中不断演变。不同身体部位和不同个体的微生物组是不同的。最近发现，一个人的肠道微生物群会影响其免疫系统。 ^(1//2){ }^{1 / 2} .
Pathogens 病原体
Microorganisms that cause disease are called pathogens. There are four common types of pathogens, including viruses, bacteria, fungi, and parasites. 致病微生物被称为病原体。常见的病原体有四种，包括病毒、细菌、真菌和寄生虫。
Viruses 病毒
Viruses are made up of a piece of genetic code, such as DNA or RNA, and are protected by a coating of protein. After a host (i.e., the person) becomes infected by a virus, the virus invades the body’s cells and uses the components of the cell to replicate and produce more viruses. After the virus replication cycle is complete, the new viruses are released into the body, causing damage or destruction of the host’s cells. ^(3){ }^{3} 病毒由一段遗传密码（如 DNA 或 RNA）组成，并由一层蛋白质保护。宿主（即人）感染病毒后，病毒侵入人体细胞，利用细胞的成分复制并产生更多病毒。病毒复制周期结束后，新病毒被释放到人体内，对宿主的细胞造成损害或破坏。 ^(3){ }^{3}
Antiviral medications can be used to treat some viral infections. Antibiotics do not kill viruses and are ineffective as a treatment for viral infections. See Figure 9.1^(4)9.1^{4} for an image of a virus. 抗病毒药物可用于治疗某些病毒感染。抗生素不能杀死病毒，对治疗病毒感染无效。病毒图片见图 9.1^(4)9.1^{4} 。
Figure 9.1 Coronavirus 图 9.1 冠状病毒
Bacteria 细菌
Bacteria are microorganisms made of a single cell. They are very diverse, have a variety of shapes and features, and have the ability to live in any environment, including your body. However, not all bacteria cause infections. Those that cause infection are called pathogenic bacteria. See Figure 9.2^(5)9.2^{5} for an image of a bacterium called Escherichia coli (E. coli). 细菌是由单细胞组成的微生物。它们种类繁多，具有各种形状和特征，能够生活在包括人体在内的任何环境中。然而，并非所有细菌都会导致感染。引起感染的细菌被称为致病细菌。请参阅图 9.2^(5)9.2^{5} ，了解一种叫做大肠杆菌（E. coli）的细菌的图像。
A patient is susceptible to bacterial infections when their immune system is compromised by chronic diseases or certain types of medications. Antibiotics 当患者的免疫系统因慢性疾病或某些类型的药物而受到损害时，就很容易受到细菌感染。抗生素
are used to treat bacterial infections. However, some strains of bacteria have become resistant to antibiotics, making them difficult to treat. For example, infections caused by methicillin-resistant Staphylococcus Aureus (MRSA) are resistant to many types of antibiotics and have the capability of producing severe and life-threatening infections. MRSA infections usually require IV antibiotics and may require treatment for long periods of time. 用于治疗细菌感染。然而，一些细菌菌株对抗生素产生了抗药性，使其难以治疗。例如，耐甲氧西林金黄色葡萄球菌（MRSA）引起的感染对许多种抗生素都有抗药性，能够产生严重的、危及生命的感染。MRSA 感染通常需要静脉注射抗生素，并可能需要长期治疗。
Figure 9.2 E. coli Bacteria 图 9.2 大肠杆菌
Fungi 真菌
There are millions of different fungal species on Earth. Fungi can be found 地球上有数百万种不同的真菌。真菌可以
everywhere in the environment, including indoors, outdoors, and on human skin, but only about 300 species cause infection when they overgrow. Candida albicans is a type of fungus that can cause oral thrush and vaginal yeast infections, especially in susceptible patients or those taking antibiotics. See Figure 9.3^(8)9.3^{8} for an image of oral thrush. 白色念珠菌在环境中无处不在，包括室内、室外和人体皮肤上，但只有大约 300 种会在过度生长时引起感染。白色念珠菌是真菌的一种，可引起口腔鹅口疮和阴道酵母菌感染，尤其是易感患者或服用抗生素的患者。口腔鹅口疮图片见图 9.3^(8)9.3^{8} 。
Fungi cells contain a nucleus and other components protected by a membrane and a thick cell wall. This structure can make them harder to kill. Some new strains of fungal infections are proving to be especially dangerous, such as Candida auris, which is difficult to diagnose and treat, and can cause outbreaks in health care facilities. ^(9){ }^{9} 真菌细胞含有细胞核和其他成分，并有一层膜和厚厚的细胞壁保护。这种结构使它们更难被杀死。事实证明，一些新的真菌感染菌株特别危险，例如白色念珠菌，它很难诊断和治疗，并可能在医疗机构中爆发。 ^(9){ }^{9}
7. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 7.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/7-introduction
8. “Human_tongue_infected_with_oral_candidiasis.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0 8.医学博士 James Heilman 的作品 "Human_tongue_infected_with_oral_candidiasis.jpg "采用 CC BY-SA 3.0 许可。
9. Manoylov, M. K. (2020, November 6). What are cytokines? Live Science. https://www.livescience.com/what-arecytokines.html 9.Manoylov, M. K. (2020, November 6).什么是细胞因子？Live Science. https://www.livescience.com/what-arecytokines.html
Parasites 寄生虫
Parasites are organisms that behave like tiny animals, living in or on a host, 寄生虫是一种像小动物一样的生物，生活在宿主体内或寄生在宿主身上、
and feeding at the expense of the host. Three main types of parasites can cause disease in humans. These include the following: 并以牺牲宿主的利益为代价。三大类寄生虫可导致人类疾病。它们包括以下几种：
Protozoa: Single-celled organisms that can live and multiply in your body 原生动物可在人体内生活和繁殖的单细胞生物
Helminths: Multi-celled organisms that can live inside or outside your body and are commonly known as worms 蠕虫多细胞生物，可生活在体内或体外，俗称蠕虫
Ectoparasites: Multi-celled organisms that live on or feed off skin, including ticks and mosquitos 外寄生虫生活在皮肤上或以皮肤为食的多细胞生物，包括蜱和蚊子
Parasites can be spread several ways, including through contaminated soil, water, food, and blood, as well as through sexual contact and insect bites. See Figure 9.4^(11)9.4^{11} for an image of a helminth infection causing intestinal obstruction in a child. 寄生虫可通过多种途径传播，包括被污染的土壤、水、食物和血液，以及性接触和昆虫叮咬。请参阅图 9.4^(11)9.4^{11} ，了解蠕虫感染导致儿童肠梗阻的图片。
10. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 10.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
11. “Piece_of_intestine,blocked_by_worms(16424898321).jpg” by SuSanA Secretariat is licensed under CC BY 2.0 11."Piece_of_intestine,blocked_by_worms(16424898321).jpg" by SuSanA Secretariat 采用 CC BY 2.0 许可。
Figure 9.4 Helminth Infection 图 9.4 螺旋虫感染
There are two basic ways the body defends against pathogens: nonspecific innate immunity and specific adaptive immunity. 人体抵御病原体有两种基本方式：非特异性先天性免疫和特异性适应性免疫。
Nonspecific Innate Immunity 非特异性先天免疫
Nonspecific innate immunity is a system of defenses in the body that targets invading pathogens in a nonspecific manner. It is called “innate” because it is present from the moment we are born. Nonspecific innate immunity includes physical defenses, chemical defenses, and cellular defenses. 非特异性先天性免疫是人体内的一种防御系统，它以非特异性的方式针对入侵的病原体。之所以称之为 "先天"，是因为它从我们出生时就存在。非特异性先天免疫包括物理防御、化学防御和细胞防御。
Physical Defenses 物理防御
Physical defenses are the body’s most basic form of defense against infection. They include physical barriers to microbes, such as skin and mucous membranes, as well as mechanical defenses that physically remove microbes and debris from areas of the body where they might cause harm or infection. In addition, a person’s microbiome provides physical protection against disease as normal flora compete with pathogens for nutrients and cellularbinding sites. ^(2){ }^{2} 物理防御是人体抵御感染的最基本形式。它们包括皮肤和粘膜等阻挡微生物的物理屏障，以及将微生物和碎片从可能造成伤害或感染的身体部位清除出去的机械防御。此外，由于正常菌群与病原体争夺营养物质和细胞结合位点，人体内的微生物群还提供了抵御疾病的物理保护。 ^(2){ }^{2}
SKIN 皮肤
One of the body’s most important physical barriers is the skin barrier, which is composed of three layers of closely packed cells. See Figure 9.5^(3)9.5^{3} for an illustration of the layers of skin. The topmost layer of skin called the epidermis consists of cells that are packed with keratin. Keratin makes the skin’s surface mechanically tough and resistant to degradation by bacteria. Infections can 皮肤屏障是人体最重要的物理屏障之一，它由三层紧密排列的细胞组成。请参阅图 9.5^(3)9.5^{3} ，了解皮肤层的示意图。皮肤的最上层称为表皮，由角蛋白细胞组成。角蛋白使皮肤表面具有机械韧性，并能抵抗细菌降解。感染可以
occur when the skin barrier is broken, allowing the entry of opportunistic pathogens that infect the skin tissue surrounding the wound and possibly spread to deeper tissues. ^(4){ }^{4} 当皮肤屏障被破坏时，机会性病原体就会进入伤口，感染伤口周围的皮肤组织，并可能扩散到更深的组织。 ^(4){ }^{4}
Figure 9.5 Layers of Skin 图 9.5 皮肤的层次
MUCUS MEMBRANES 粘膜
The mucous membranes lining the nose, mouth, lungs, and urinary and digestive tracts provide another nonspecific barrier against potential pathogens. Mucous membranes consist of a layer of epithelial cells bound by 鼻腔、口腔、肺部、泌尿道和消化道的黏膜是抵御潜在病原体的另一道非特异性屏障。粘膜由一层上皮细胞组成，上皮细胞被以下物质结合在一起
tight junctions. The epithelial cells secrete a moist, sticky substance called mucous. Mucous covers and protects the fragile cell layers beneath it and also traps debris, including microbes. Mucus secretions also contain antimicrobial peptides. ^(5){ }^{5} 紧密连接。上皮细胞会分泌一种叫做粘液的潮湿粘性物质。粘液覆盖并保护其下脆弱的细胞层，还能吸附包括微生物在内的碎屑。粘液分泌物还含有抗菌肽。 ^(5){ }^{5}
In many regions of the body, mechanical actions flush mucus (along with trapped or dead microbes) out of the body or away from potential sites of infection. For example, in the respiratory system, inhalation can bring microbes, dust, mold spores, and other small airborne debris into the body. This debris becomes trapped in the mucus lining the respiratory tract. The epithelial cells lining the upper parts of the respiratory tract have hair-like appendages known as cilia. Movement of the cilia propels debris-laden mucus out and away from the lungs. The expelled mucus is then swallowed and destroyed in the stomach, coughed up, or sneezed out. This system of removal is often called the mucociliary escalator. Disruption of the mucociliary escalator by the damaging effects of smoking can lead to increased colonization of bacteria in the lower respiratory tract and frequent infections, which highlights the importance of this physical barrier to host defenses. ^(6){ }^{6} See Figure 9.6^(7)9.6^{7} for an image of a magnified mucociliary escalator. 在人体的许多部位，机械作用会将粘液（连同被困或死亡的微生物）冲出体外或远离潜在的感染部位。例如，在呼吸系统中，吸入会将微生物、灰尘、霉菌孢子和其他空气中的小碎片带入体内。这些碎片会滞留在呼吸道内壁的粘液中。呼吸道上部的上皮细胞有被称为纤毛的毛状附属物。纤毛的运动会将含有碎屑的粘液排出肺部。排出的粘液会被吞咽并在胃中分解，或被咳出，或被喷嚏喷出。这种清除系统通常被称为 "粘液扶梯"。吸烟的破坏性影响破坏了粘液纤毛扶梯，会导致细菌在下呼吸道的定植增加，并导致频繁感染，这突出了这一物理屏障对宿主防御的重要性。 ^(6){ }^{6} 图 9.6^(7)9.6^{7} 为放大的黏膜纤毛扶梯图像。
Like the respiratory tract, the digestive tract is a portal of entry through which microbes enter the body, and the mucous membranes lining the digestive tract provide a nonspecific physical barrier against ingested microbes. The intestinal tract is lined with epithelial cells, interspersed with mucus-secreting goblet cells. This mucus mixes with material received from the stomach, trapping foodborne microbes and debris, and the mechanical action of 与呼吸道一样，消化道也是微生物进入人体的入口，消化道内壁的粘膜提供了一个非特异性的物理屏障，抵御摄入的微生物。肠道内壁是上皮细胞，其中夹杂着分泌粘液的鹅口疮细胞。这些粘液与胃中的物质混合，截留食源性微生物和碎屑，并在肠道中产生机械作用。
peristalsis (a series of muscular contractions in the digestive tract) moves this mixture through the intestines and excretes it in feces. ^(8){ }^{8} For this reason, feces can contain microorganisms that can cause the spread of infection; therefore, good hand hygiene is vital. 蠕动（消化道中的一系列肌肉收缩）使这种混合物通过肠道，并随粪便排出体外。 ^(8){ }^{8} 因此，粪便中可能含有导致感染传播的微生物；因此，良好的手部卫生至关重要。
ENDOTHELIA
The epithelial cells lining the urogenital tract, blood vessels, lymphatic vessels, and other tissues are known as endothelia. These tightly packed cells provide an effective frontline barrier against invaders. The endothelia of the bloodbrain barrier, for example, protects the central nervous system (CNS) from microorganisms. Infection of the CNS can quickly lead to serious and often fatal inflammation. The protection of the blood-brain barrier keeps the cerebrospinal fluid that surrounds the brain and spinal cord sterile. ^(9){ }^{9} See Figure 9.7^(10)9.7^{10} for an illustration of the blood-brain barrier. 尿道、血管、淋巴管和其他组织内衬的上皮细胞被称为内皮细胞。这些紧密排列的细胞为抵御入侵者提供了有效的前线屏障。例如，血脑屏障的内皮细胞可以保护中枢神经系统（CNS）免受微生物的侵袭。中枢神经系统受到感染会迅速引发严重的炎症，而且往往是致命的炎症。血脑屏障的保护作用使环绕大脑和脊髓的脑脊液保持无菌状态。 ^(9){ }^{9} 血脑屏障示意图见图 9.7^(10)9.7^{10} 。
Figure 9.7 Blood-Brain Barrier 图 9.7 血脑屏障
Mechanical Defenses 机械防御
In addition to physical barriers that keep microbes out, the body has several mechanical defenses that physically remove pathogens from the body and prevent them from taking up residence. For example, the flushing action of urine and tears serves to carry microbes away from the body. The flushing action of urine is responsible for the normally sterile environment of the urinary tract. The eyes have additional physical barriers and mechanical mechanisms for preventing infections. The eyelashes and eyelids prevent dust and airborne microorganisms from reaching the surface of the eye. Any microbes or debris that make it past these physical barriers are flushed out by the mechanical action of blinking, which bathes the eye in tears, washing 除了阻挡微生物的物理屏障外，人体还有几种机械防御功能，可以将病原体从体内清除，防止它们在体内定居。例如，尿液和眼泪的冲洗作用可将微生物带出体外。尿液的冲洗作用使泌尿道保持正常的无菌环境。眼睛还有其他防止感染的物理屏障和机械机制。睫毛和眼睑可以防止灰尘和空气中的微生物进入眼球表面。任何微生物或碎屑只要通过这些物理屏障，就会被眨眼的机械动作冲走。
debris away. ^(11){ }^{11} See Figure 9.8^(12)9.8^{12} for an image of an infant’s eyelashes that prevent dust from reaching the surface of the eye. 碎片。 ^(11){ }^{11} 见图 9.8^(12)9.8^{12} ，婴儿的睫毛可以防止灰尘进入眼球表面。
Figure 9.8 Eyelashes Are Mechanical Defenses 图 9.8 睫毛是机械防御装置
MICROBIOME 微生物
Normal flora that contribute to an individual’s microbiome serve as an important first-line defense against invading pathogens. Through their occupation of cellular binding sites and competition for available nutrients, normal flora prevent the early steps of pathogen attachment and proliferation required for the establishment of an infection. For example, in the vagina, normal flora compete with opportunistic pathogens like Candida albicans. This competition prevents yeast infection by limiting the availability of nutrients and inhibiting the growth of Candida, keeping its population in check. Similar competitions occur between normal flora and potential 正常菌群是人体微生物组的重要组成部分，是抵御病原体入侵的第一道防线。正常菌群通过占据细胞结合位点和争夺可用的营养物质，阻止病原体附着和增殖的早期步骤，而这正是感染形成的必要条件。例如，在阴道中，正常菌群与白色念珠菌等机会性病原体竞争。这种竞争通过限制营养物质的供应和抑制念珠菌的生长来防止酵母菌感染，从而控制念珠菌的数量。正常菌群和潜在病原体之间也存在类似的竞争。
pathogens on the skin, in the upper respiratory tract, and in the gastrointestinal tract. ^(13){ }^{13} 皮肤、上呼吸道和胃肠道中的病原体。 ^(13){ }^{13}
The importance of the normal flora in host defenses is highlighted by a person’s increased susceptibility to infectious diseases when their microbiome is disrupted or eliminated. For example, treatment with antibiotics can significantly deplete the normal flora of the gastrointestinal tract, providing an advantage for pathogenic bacteria such as Clostridium difficile (C-diff) to colonize and cause diarrheal infection. Diarrhea caused by C-diff can be severe and potentially lethal. In fact, a recent strategy for treating recurrent C-diff infections is fecal transplantation that involves the transfer of fecal material from a donor into the intestines of the patient as a method of restoring their normal flora. ^(14){ }^{14} 正常菌群在宿主防御中的重要性突出表现在，当一个人的微生物群被破坏或消除时，他对传染病的易感性就会增加。例如，使用抗生素治疗会大大消耗胃肠道的正常菌群，为艰难梭菌（C-diff）等致病菌的定植和引起腹泻感染提供了有利条件。由 C-diff 引起的腹泻可能很严重，并可能致命。事实上，最近治疗复发性 C-diff 感染的一种策略是粪便移植，即把捐献者的粪便转移到患者的肠道中，以此恢复患者的正常菌群。 ^(14){ }^{14}
Chemical Defenses 化学防御
In addition to physical defenses, our nonspecific innate immune system uses several chemical mediators that inhibit microbial invaders. The term chemical mediators encompasses a wide array of substances found in various fluids and tissues throughout the body. For example, sebaceous glands in the dermis secrete an oil called sebum that is released onto the skin surface through hair follicles. Sebum provides an additional layer of defense by helping seal off the pore of the hair follicle and preventing bacteria on the skin’s surface from invading sweat glands and surrounding tissue. Environmental factors can affect these chemical defenses of the skin. For example, low humidity in the winter makes the skin more dry and susceptible to pathogens normally inhibited by the skin’s low pH . Application of skin moisturizer restores moisture and essential oils to the skin and helps prevent dry skin from becoming infected. ^(15){ }^{15} 除了物理防御外，我们的非特异性先天免疫系统还使用多种化学介质来抑制微生物入侵。化学介质一词包含了在全身各种体液和组织中发现的多种物质。例如，真皮层中的皮脂腺会分泌一种叫做皮脂的油脂，通过毛囊释放到皮肤表面。皮脂提供了一个额外的防御层，有助于封闭毛囊孔隙，防止皮肤表面的细菌侵入汗腺和周围组织。环境因素会影响皮肤的这些化学防御功能。例如，冬季湿度低会使皮肤更加干燥，容易受到通常被皮肤的低 pH 值所抑制的病原体的感染。涂抹皮肤保湿霜可以恢复皮肤的水分和必需油脂，有助于防止干燥的皮肤受到感染。 ^(15){ }^{15}
13. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 13.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
14. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 14.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/7-introduction
15. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 15.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
Examples of other chemical defenses are enzymes, pH level, and chemical mediators. Enzymes in saliva and the digestive tract eliminate most pathogens that manage to survive the acidic environment of the stomach. In the urinary tract, the slight acidity of urine inhibits the growth of potential pathogens in the urinary tract. The respiratory tract also uses various chemical mediators in the nasal passages, trachea, and lungs that have antibacterial properties. ^(16){ }^{16} 其他化学防御措施包括酶、酸碱度和化学介质。唾液和消化道中的酶可以消灭大多数在胃酸环境中存活的病原体。在泌尿道中，尿液的微酸性可以抑制泌尿道中潜在病原体的生长。呼吸道也会在鼻腔、气管和肺部使用各种具有抗菌特性的化学介质。 ^(16){ }^{16}
PLASMA PROTEIN MEDIATORS 血浆蛋白介质
In addition to physical, mechanical, and chemical defenses, there are also nonspecific innate immune factors in plasma, the fluid portion of blood, such as acute-phase proteins, complement proteins, and cytokines. These plasma protein mediators contribute to the inflammatory response. ^(17){ }^{17} 除了物理、机械和化学防御外，血浆（血液的液体部分）中还存在非特异性先天性免疫因子，如急性期蛋白、补体蛋白和细胞因子。这些血浆蛋白介质有助于炎症反应。 ^(17){ }^{17}
An example of an acute-phase protein is C-reactive protein. High levels of Creactive protein indicate a serious infection or other medical condition that causes inflammation is occurring. 急性期蛋白的一个例子就是 C 反应蛋白。高水平的 C 反应蛋白表明正在发生严重感染或其他导致炎症的病症。
Complement proteins are always present in the blood and tissue fluids, allowing them to be activated quickly. They aid in the destruction of pathogens by piercing their outer membranes (cell lysis) or by making them more attractive to phagocytic cells such as macrophages. 补体蛋白始终存在于血液和组织液中，可以迅速激活。它们可以穿透病原体的外膜（细胞裂解），或使病原体对巨噬细胞等吞噬细胞更具吸引力，从而帮助消灭病原体。
Cytokines are proteins that affect interaction and communication between cells. When a pathogen enters the body, the first immune cell to notice the pathogen is like the conductor of an orchestra. That cell directs all the other immune cells by creating and sending out messages (cytokines) to the rest of 细胞因子是影响细胞间相互作用和交流的蛋白质。当病原体进入人体时，第一个发现病原体的免疫细胞就像管弦乐队的指挥。该细胞通过创造并向其他免疫细胞发送信息（细胞因子）来指挥所有其他免疫细胞。
16. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 16.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
17. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 17.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
18. This work is a derivative of Concepts of Biology - 1st Canadian Edition by Molnar & Gair and is licensed under CC BY 4.0. 18.本作品是 Molnar & Gair 所著《生物学概念--加拿大第 1 版》的衍生作品，采用 CC BY 4.0 许可。
19. Sproston, N. R., & Ashworth, J. J. (2018). Role of c-reactive protein at sites of inflammation and infection. Frontiers in Immunology, 9, 754. https://doi.org/10.3389/fimmu.2018.00754 19.Sproston, N. R., & Ashworth, J. J. (2018)。c 反应蛋白在炎症和感染部位的作用》。https://doi.org/10.3389/fimmu.2018.00754
the organs or cells in the body to respond to and initiate inflammation. Too many cytokines can have a negative effect and result in what’s known as a cytokine storm. ^(20,21){ }^{20,21} A cytokine storm is a severe immune reaction in which the body releases too many cytokines into the blood too quickly. A cytokine storm can occur as a result of an infection, autoimmune condition, or other disease. Signs and symptoms include high fever, inflammation, severe fatigue, and nausea. A cytokine storm can be severe or life-threatening and lead to multiple organ failure. For example, many COVID-19 complications and deaths were caused by a cytokine storm. ^(22,^(23)){ }^{22,{ }^{23}} 细胞因子能使体内的器官或细胞对炎症做出反应并引发炎症。细胞因子过多会产生负面影响，导致所谓的细胞因子风暴。 ^(20,21){ }^{20,21} 细胞因子风暴是一种严重的免疫反应，身体会过快地向血液中释放过多的细胞因子。细胞因子风暴可因感染、自身免疫状况或其他疾病而发生。体征和症状包括高烧、炎症、严重疲劳和恶心。细胞因子风暴可能很严重或危及生命，并导致多个器官衰竭。例如，COVID-19 的许多并发症和死亡都是由细胞因子风暴引起的。 ^(22,^(23)){ }^{22,{ }^{23}}
Inflammation 炎症
Inflammation is a response triggered by a cascade of chemical mediators and occurs when pathogens successfully breach the nonspecific innate immune system or when an injury occurs. Although inflammation is often perceived as a negative consequence of injury or disease, it is a necessary process that recruits cellular defenses needed to eliminate pathogens, remove damaged and dead cells, and initiate repair mechanisms. Excessive inflammation, however, can result in local tissue damage, and in severe cases, such as sepsis, it can become deadly. ^(24){ }^{24} 炎症是由一连串化学介质引发的反应，当病原体成功突破非特异性先天性免疫系统或发生损伤时就会出现炎症。虽然炎症通常被认为是损伤或疾病的负面后果，但它却是一个必要的过程，可调动细胞防御功能，以消灭病原体、清除受损和死亡的细胞并启动修复机制。然而，过度的炎症会导致局部组织损伤，严重时，如败血症，可能会致命。 ^(24){ }^{24}
An immediate response to tissue injury is acute inflammation. Vasoconstriction occurs to minimize blood loss if injury has occurred. Vasoconstriction is followed by vasodilation with increased permeability of the blood vessels due to the release of histamine by mast cells. Histamine contributes to the five observable signs of the inflammatory response: 组织损伤的直接反应是急性炎症。如果发生损伤，血管会收缩，以尽量减少失血。血管收缩后，由于肥大细胞释放组胺，血管舒张，血管通透性增加。组胺促成了炎症反应的五个可观察到的迹象：
20. Complement. (2018). In Britannica. https://www.britannica.com/science/complement-immune-systemcomponent 20.补充。(2018).In Britannica. https://www.britannica.com/science/complement-immune-systemcomponent
21. Arango Duque, G., & Descoteaux, A. (2014). Macrophage cytokines: Involvement in immunity and infectious diseases. Frontiers in Immunology, 5, 491. https://doi.org/10.3389/fimmu.2014.00491 21.Arango Duque, G., & Descoteaux, A. (2014)。巨噬细胞细胞因子：免疫学前沿》，5，491。免疫学前沿》，5，491。https://doi.org/10.3389/fimmu.2014.00491。
22. National Cancer Institute (n.d.) NCI Dictionary of Cancer Terms. https://www.cancer.gov/publications/ dictionaries/cancer-terms/def/cytokine-storm 22.National Cancer Institute (n.d.) NCI Dictionary of Cancer Terms. https://www.cancer.gov/publications/ dictionaries/cancer-terms/def/cytokine-storm
23. Hojyo, S., Uchida, M., Tanaka, K., et al. (2020). How COVID-19 induces cytokine storm with high mortality. Inflammation and Regeneration, 40(37). https://doi.org/10.1186/s41232-020-00146-3 23.Hojyo, S., Uchida, M., Tanaka, K., et al. (2020).COVID-19 如何诱导细胞因子风暴并导致高死亡率。Inflammation and Regeneration, 40(37). https://doi.org/10.1186/s41232-020-00146-3
24. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 24.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/1-introduction
erythema (redness), edema (swelling), heat, pain, and altered function. It is also associated with an influx of phagocytes at the site of injury and/or infection. See Figure 9.9^(25)9.9^{25} for an illustration of the inflammatory response, with (a) demonstrating when mast cells detect injury to nearby cells and release histamine, initiating an inflammatory response and (b) illustrating where histamine increases blood flow to the wound site and the associated increased vascular permeability allows fluid, proteins, phagocytes, and other immune cells to enter infected tissue. These events result in the swelling and reddening of the injured site. The increased blood flow to the injured site causes it to feel warm. Inflammation is also associated with pain due to these events stimulating nerve pain receptors in the tissue. Increasing numbers of neutrophils are then recruited to the area to fight pathogens. As the fight rages on, white blood cells are recruited to the area, and pus forms from the accumulation of neutrophils, dead cells, tissue fluids, and lymph. Typically, after a few days, macrophages clear out this pus. ^(26){ }^{26} During injury, if this nonspecific inflammatory process does not successfully kill the pathogens, infection occurs. 红斑（发红）、水肿（肿胀）、发热、疼痛和功能改变。它还与受伤和/或感染部位吞噬细胞的大量涌入有关。炎症反应示意图见图 9.9^(25)9.9^{25} ，其中(a)显示肥大细胞检测到附近细胞受伤并释放组胺，从而引发炎症反应；(b)显示组胺增加了伤口部位的血流量，相关的血管通透性增加使液体、蛋白质、吞噬细胞和其他免疫细胞进入受感染组织。这些事件导致受伤部位红肿。受伤部位的血流量增加会使其感觉发热。炎症还与疼痛有关，因为这些事件会刺激组织中的神经痛受体。随后，越来越多的中性粒细胞被招募到该区域，以对抗病原体。随着战斗的激烈进行，白细胞也会被征集到该区域，中性粒细胞、死亡细胞、组织液和淋巴的积聚会形成脓液。通常情况下，几天后，巨噬细胞会清除这些脓液。 ^(26){ }^{26} 在受伤期间，如果这种非特异性炎症过程不能成功杀死病原体，就会发生感染。
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26. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 26.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。可从 https://openstax.org/books/microbiology/pages/1-introduction 免费获取。
Figure 9.9 Inflammatory Response 图 9.9 炎症反应
Fever 发烧
A fever is part of the inflammatory response that extends beyond the site of infection and affects the entire body, resulting in an overall increase in body temperature. Like other forms of inflammation, a fever enhances the nonspecific innate immune defenses by stimulating white blood cells to kill pathogens. The rise in body temperature also inhibits the growth of many pathogens. During fever, the patient’s skin may appear pale due to vasoconstriction of the blood vessels in the skin to divert blood flow away from extremities, minimize the loss of heat, and raise the body’s core temperature. The hypothalamus also stimulates the shivering of muscles to generate heat and raise the core temperature. 发烧是炎症反应的一部分，它超越感染部位，影响全身，导致体温整体升高。与其他形式的炎症一样，发烧会刺激白细胞杀死病原体，从而增强非特异性先天性免疫防御能力。体温升高还能抑制许多病原体的生长。发烧时，病人的皮肤可能会显得苍白，这是因为皮肤血管收缩，使血液从四肢流走，最大限度地减少热量的散失，并提高身体的核心温度。下丘脑也会刺激肌肉颤抖以产生热量并提高核心温度。
A low-level fever is thought to help an individual overcome an illness. However, in some instances, this immune response can be too strong, causing tissue and organ damage and, in severe cases, even death. For example, Staphylococcus aureus and Streptococcus pyogenes are capable of producing superantigens that cause toxic shock syndrome and scarlet fever, 低烧被认为可以帮助患者战胜疾病。然而，在某些情况下，这种免疫反应可能过于强烈，导致组织和器官受损，严重时甚至会导致死亡。例如，金黄色葡萄球菌和化脓性链球菌能够产生超抗原，导致中毒性休克综合症和猩红热、
respectively. Both of these conditions are associated with extremely high fevers in excess of 42^(@)C(108^(@)F)42^{\circ} \mathrm{C}\left(108^{\circ} \mathrm{F}\right) that must be managed to prevent tissue injury and death. ^(28){ }^{28} 分别是这两种情况都会引起超过 42^(@)C(108^(@)F)42^{\circ} \mathrm{C}\left(108^{\circ} \mathrm{F}\right) 的极高烧，必须加以控制，以防止组织损伤和死亡。 ^(28){ }^{28}
When a fever breaks, the hypothalamus stimulates vasodilation, resulting in a return of blood flow to the skin and a subsequent release of heat from the body. The hypothalamus also stimulates sweating, which cools the skin as the sweat evaporates. ^(29){ }^{29} 发烧时，下丘脑会刺激血管扩张，导致血液回流到皮肤，随后体内的热量就会释放出来。下丘脑还会刺激出汗，当汗液蒸发时，皮肤会变得凉爽。 ^(29){ }^{29}
Specific Adaptive Immunity 特异性适应性免疫
Now that we have discussed several nonspecific innate defenses against a pathogen, let’s discuss specific adaptive immunity. Specific adaptive immunity is the immune response that is activated when the nonspecific innate immune response is insufficient to control an infection. There are two types of adaptive responses: the cell-mediated immune response, which is carried out by T cells, and the humoral immune response, which is controlled by activated BB cells and antibodies. ^(30){ }^{30} 既然我们已经讨论了针对病原体的几种非特异性先天性免疫防御，下面我们就来讨论一下特异性适应性免疫。特异性适应性免疫是在非特异性先天性免疫反应不足以控制感染时启动的免疫反应。适应性反应分为两种：一种是细胞介导的免疫反应，由 T 细胞执行；另一种是体液免疫反应，由活化的 BB 细胞和抗体控制。 ^(30){ }^{30}
B cells mature in the bone marrow. B cells make YY-shaped proteins called antibodies that are specific to each pathogen and lock onto its surface and mark it for destruction by other immune cells. The five classes of antibodies are lg G,lg M,lg A,lg D\lg G, \lg M, \lg A, \lg D, and lg E\lg E. They also turn into memory BB cells. ^(31){ }^{31} B 细胞在骨髓中成熟。B 细胞制造的 YY 形蛋白质被称为抗体，这种抗体对每种病原体都具有特异性，能锁定在病原体表面，并将其标记出来供其他免疫细胞消灭。五类抗体分别是 lg G,lg M,lg A,lg D\lg G, \lg M, \lg A, \lg D 和 lg E\lg E 。它们还会变成记忆细胞 BB 。 ^(31){ }^{31}
T cells mature in the thymus. T cells are categorized into three classes: helper T cells, regulatory T cells, and cytotoxic T cells. Helper T cells stimulate B cells to make antibodies and help killer cells develop. Killer T cells directly kill cells that have already been infected by a pathogen. T cells also use cytokines as T 细胞在胸腺中成熟。T 细胞分为三类：辅助性 T 细胞、调节性 T 细胞和细胞毒性 T 细胞。辅助性 T 细胞刺激 B 细胞制造抗体，帮助杀伤性细胞发育。杀伤性 T 细胞会直接杀死已被病原体感染的细胞。T 细胞还利用细胞因子作为
28. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 28.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。可从 https://openstax.org/books/microbiology/pages/7-introduction 免费获取。
29. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 29.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
30. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 30.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/7-introduction
31. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 31.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
messenger molecules to send chemical instructions to the rest of the immune system to ramp up its response. 信使分子向免疫系统的其他部分发出化学指令，以加强其反应。
Specific adaptive immunity also creates memory cells for each specific pathogen that provides the host with long-term protection from reinfection with that pathogen. On reexposure, these memory cells facilitate an efficient and quick immune response. For example, when an individual recovers from chicken pox, the body develops a memory of the varicella-zoster virus that will specifically protect it from reinfection if it is exposed to the virus again. 特异性适应性免疫还能为每种特定病原体创造记忆细胞，为宿主提供长期保护，防止再次感染该病原体。当再次接触时，这些记忆细胞会促进高效快速的免疫反应。例如，当一个人从水痘中康复后，机体会对水痘-带状疱疹病毒产生记忆，如果再次接触该病毒，记忆细胞就会专门保护机体免受再次感染。
See Figure 9.10^(34)9.10^{34} for an illustration of innate immunity and specific adaptive immunity that occurs in response to a pathogen entering the body through the nose. 请参阅图 9.10^(34)9.10^{34} ，了解先天性免疫和特异性适应性免疫对通过鼻腔进入人体的病原体的反应。
32. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 32.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/7-introduction
33. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 33.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。可从 https://openstax.org/books/microbiology/pages/7-introduction 免费获取。
34. “2211_Cooperation_Between_Innate_and_Immune_Responses.jpg” by OpenStax is licensed under CC BY 3.0. 34."2211_Cooperation_Between_Innate_and_Immune_Responses.jpg" by OpenStax 采用 CC BY 3.0 许可。
Figure 9.10 Innate Immunity and Specific Adaptive Immunity 图 9.10 先天性免疫和特异性适应性免疫
9.4 Infection 9.4 感染
An infection is the invasion and growth of a microorganism within the body. Infection can lead to disease that causes signs and symptoms resulting in a deviation from the normal structure or functioning of the host. Infection occurs when nonspecific innate immunity and specific adaptive immunity defenses are inadequate to protect an individual against the invasion of a pathogen. The ability of a microorganism to cause disease is called pathogenicity, and the degree to which a microorganism is likely to become a disease is called virulence. Virulence is a continuum. On one end of the spectrum are organisms that are not harmful, but on the other end are organisms that are highly virulent. Highly virulent pathogens will almost always lead to a disease state when introduced to the body, and some may even cause multi-organ and body system failure in healthy individuals. Less virulent pathogens may cause an initial infection, but may not always cause severe illness. Pathogens with low virulence usually result in mild signs and symptoms of disease, such as a low-grade fever, headache, or muscle aches, and some individuals may even be asymptomatic.’ 感染是指微生物在人体内的入侵和生长。感染可导致疾病，引起症状和体征，导致宿主的正常结构或功能发生偏差。当非特异性先天性免疫和特异性适应性免疫防御不足以保护个体免受病原体入侵时，就会发生感染。微生物致病的能力称为致病性，微生物可能致病的程度称为毒力。毒力是一个连续体。一端是无害的生物，另一端是毒力很强的生物。毒力强的病原体进入人体后几乎总是会导致疾病，有些甚至会导致健康人的多器官和身体系统衰竭。毒力较低的病原体可能会引起初次感染，但不一定会导致严重的疾病。毒力较低的病原体通常会导致轻微的疾病症状和体征，如低烧、头痛或肌肉酸痛，有些人甚至可能没有症状。
An example of a highly virulent microorganism is Bacillus anthracis, the pathogen responsible for anthrax. The most serious form of anthrax is inhalation anthrax. After B. anthracis spores are inhaled, they germinate. An active infection develops, and the bacteria release potent toxins that cause edema (fluid buildup in tissues), hypoxia (a condition preventing oxygen from reaching tissues), and necrosis (cell death and inflammation). Signs and symptoms of inhalation anthrax include high fever, difficulty breathing, vomiting, coughing up blood, and severe chest pains suggestive of a heart attack. With inhalation anthrax, the toxins and bacteria enter the bloodstream, which can lead to multi-organ failure and death of the patient. ^(2){ }^{2} 炭疽病的病原体炭疽杆菌就是高致病性微生物的一个例子。最严重的炭疽是吸入性炭疽。炭疽杆菌孢子被吸入后会发芽。感染活跃后，细菌会释放强效毒素，导致水肿（组织液积聚）、缺氧（氧气无法进入组织）和坏死（细胞死亡和发炎）。吸入性炭疽的体征和症状包括高烧、呼吸困难、呕吐、咳血和剧烈胸痛，提示心脏病发作。吸入性炭疽的毒素和细菌进入血液，可导致多器官衰竭和患者死亡。 ^(2){ }^{2}
Primary Pathogens Versus Opportunistic Pathogens 原发性病原体与机会性病原体
Pathogens can be classified as either primary pathogens or opportunistic pathogens. A primary pathogen can cause disease in a host regardless of the host’s microbiome or immune system. An opportunistic pathogen, by contrast, can cause disease only in situations that compromise the host’s defenses, such as the body’s protective barriers, immune system, or normal microbiome. Individuals susceptible to opportunistic infections include the very young, the elderly, women who are pregnant, patients undergoing chemotherapy, people with immunodeficiencies (such as acquired immunodeficiency syndrome [AIDS]), patients who are recovering from surgery, and those who have nonintact skin (such as a severe wound or burn). ^(3){ }^{3} 病原体可分为原发性病原体和机会性病原体。无论宿主的微生物群或免疫系统如何，原发性病原体都能在宿主体内致病。相比之下，机会性病原体只有在损害宿主的防御系统（如身体的保护屏障、免疫系统或正常微生物群）的情况下才能致病。易受机会性感染的人群包括幼童、老人、孕妇、接受化疗的患者、免疫缺陷患者（如获得性免疫缺陷综合征[AIDS]）、手术后恢复期患者以及皮肤非接触者（如严重伤口或烧伤）。 ^(3){ }^{3}
An example of a primary pathogen is enterohemorrhagic EE. coli that produces a toxin that leads to severe and bloody diarrhea, inflammation, and renal failure, even in patients with healthy immune systems. Staphylococcus epidermidis, on the other hand, is an opportunistic pathogen that is a frequent cause of health-care acquired infection. ^(4){ }^{4} S. epidermidis, often referred to as “staph,” is a member of the normal flora of the skin. However, in hospitals, it can grow in biofilms that form on catheters, implants, or other devices that are inserted into the body during surgical procedures. Once inside the body, it can cause serious infections such as endocarditis. ^(5){ }^{5} 肠出血性 EE 大肠杆菌就是原发性病原体的一个例子，它产生的毒素会导致严重的血性腹泻、炎症和肾功能衰竭，即使是免疫系统健康的病人也不例外。另一方面，表皮葡萄球菌是一种机会性病原体，是医护人员感染的常见原因。 ^(4){ }^{4} 表皮葡萄球菌通常被称为 "葡萄球菌"，是皮肤正常菌群的一员。然而，在医院里，它可以在导管、植入物或手术过程中插入人体的其他设备上形成的生物膜中生长。一旦进入人体，它就会引起严重的感染，如心内膜炎。 ^(5){ }^{5}
Other members of normal flora can cause opportunistic infections. For example, some microorganisms that reside harmlessly in one location of the body can cause disease if they are passed to a different body system. For 正常菌群中的其他成员也会导致机会性感染。例如，有些微生物寄居在身体的某个部位不会造成危害，但如果它们被传递到身体的另一个系统，就会导致疾病。例如
example, E. coli is normally found in the large intestine, but can cause a urinary tract infection if it enters the bladder. ^(6){ }^{6} 例如，大肠杆菌通常存在于大肠中，但如果进入膀胱就会引起尿路感染。 ^(6){ }^{6}
Normal flora can also cause disease when a shift in the environment of the body leads to overgrowth of a particular microorganism. For example, the yeast Candida is part of the normal flora of the skin, mouth, intestine, and vagina, but its population is kept in check by other organisms of the microbiome. When an individual takes antibiotics, bacteria that would normally inhibit the growth of Candida can be killed off, leading to a sudden growth in the population of Candida. An overgrowth of Candida can manifest as oral thrush (growth on mouth, throat, and tongue) or a vaginal yeast infection. Other scenarios can also provide opportunities for Candida to cause infection. For example, untreated diabetes can result in a high concentration of glucose in a patient’s saliva that provides an optimal environment for the growth of Candida, resulting in oral thrush. Immunodeficiencies, such as those seen in patients with HIV, AIDS, and cancer, also lead to Candida infections. ^(7){ }^{7} 当体内环境发生变化导致某种微生物过度生长时，正常菌群也会导致疾病。例如，念珠菌酵母是皮肤、口腔、肠道和阴道正常菌群的一部分，但它的数量受到微生物群中其他生物的控制。当一个人服用抗生素时，通常会抑制念珠菌生长的细菌会被杀死，导致念珠菌数量突然增加。念珠菌的过度生长可能表现为口腔鹅口疮（长在口腔、喉咙和舌头上）或阴道酵母菌感染。其他情况也会给念珠菌提供感染的机会。例如，未经治疗的糖尿病会导致患者唾液中葡萄糖浓度过高，为念珠菌的生长提供了最佳环境，从而导致口腔鹅口疮。免疫缺陷，如艾滋病病毒感染者、艾滋病患者和癌症患者，也会导致念珠菌感染。 ^(7){ }^{7}
Stages of Pathogenesis 发病阶段
To cause disease, a pathogen must successfully achieve four stages of pathogenesis to become an infection: exposure, adhesion (also called colonization), invasion, and infection. The pathogen must be able to gain entry to the host, travel to the location where it can establish an infection, evade or overcome the host’s immune response, and cause damage (i.e., disease) to the host. In many cases, the cycle is completed when the pathogen exits the host and is transmitted to a new host. ^(8){ }^{8} 要致病，病原体必须成功实现四个阶段的致病过程，才能成为一种感染：暴露、粘附（也称为定植）、入侵和感染。病原体必须能够进入宿主体内，到达可以建立感染的位置，躲避或克服宿主的免疫反应，并对宿主造成损害（即致病）。在许多情况下，当病原体离开宿主并传播给新的宿主时，这个循环就完成了。 ^(8){ }^{8}
Exposure 接触
An encounter with a potential pathogen is known as exposure. The food we eat and the objects we touch are all ways that we can come into contact with potential pathogens. Yet, not all contacts result in infection and disease. For a pathogen to cause disease, it needs to be able to gain access into host tissue. An anatomic site through which pathogens can pass into host tissue is called a portal of entry. Portals of entry are locations where the host cells are in direct contact with the external environment, such as the skin, mucous membranes, respiratory, and digestive systems. Portals of entry are illustrated in Figure 9.17. ^(9,10){ }^{9,10} 与潜在病原体的接触被称为 "暴露"。我们吃的食物和接触的物品都是我们接触潜在病原体的途径。然而，并非所有的接触都会导致感染和疾病。病原体要致病，就必须能够进入宿主组织。病原体可以进入宿主组织的解剖部位称为入口。入口是宿主细胞与外部环境直接接触的部位，如皮肤、粘膜、呼吸系统和消化系统。图 9.17 展示了进入门户。 ^(9,10){ }^{9,10}
Figure 9.11 Sites of Portal of Entry 图 9.11 入境口岸地点
Adhesion 附着力
Following initial exposure, the pathogen adheres at the portal of entry. The term adhesion refers to the capability of pathogenic microbes to attach to the cells of the body, also referred to as colonization." 在初次接触后，病原体会附着在入口处。粘附一词是指病原微生物附着在人体细胞上的能力，也称为定植"。
Invasion 入侵
After successful adhesion, the invasion proceeds. Invasion means the spread of a pathogen throughout local tissues or the body. Pathogens may also produce virulence factors that protect them against immune system defenses and determine the degree of tissue damage that occurs. Intracellular pathogens like viruses achieve invasion by entering the host’s cells and reproducing. ^(12){ }^{12} 粘附成功后，入侵就开始了。入侵是指病原体在局部组织或全身的传播。病原体还可能产生毒力因子，以抵御免疫系统的防御，并决定组织受损的程度。细胞内病原体（如病毒）通过进入宿主细胞并繁殖来实现入侵。 ^(12){ }^{12}
Infection 感染
Following invasion, successful multiplication of the pathogen leads to infection. Infections can be described as local, secondary, or systemic, depending on the extent of the infection. 入侵后，病原体成功繁殖导致感染。根据感染的程度，感染可分为局部感染、继发感染或全身感染。
A local infection is confined to a small area of the body, typically near the portal of entry. For example, a hair follicle infected by Staphylococcus aureus infection may result in a boil around the site of infection, but the bacterium is largely contained to this small location. Other examples of local infections that involve more extensive tissue involvement include urinary tract infections confined to the bladder or pneumonia confined to the lungs. Localized infections generally demonstrate signs of inflammation, such as redness, swelling, warmth, pain, and purulent drainage. However, extensive tissue involvement can also cause decreased functioning of the organ affected. ^(1//4){ }^{1 / 4} 局部感染仅限于身体的一小块区域，通常在入口附近。例如，金黄色葡萄球菌感染的毛囊可能会导致感染部位周围出现疖肿，但细菌基本上被控制在这个小范围内。其他涉及更广泛组织的局部感染包括局限于膀胱的尿路感染或局限于肺部的肺炎。局部感染一般会表现出炎症症状，如发红、肿胀、发热、疼痛和脓性排液。然而，广泛的组织受累也会导致受影响器官的功能下降。 ^(1//4){ }^{1 / 4}
In a secondary infection a localized pathogen, or the toxins it produces, can spread to a secondary location. For example, a dental hygienist nicking a patient’s gum with a sharp tool can cause a local infection in the gum by Streptococcus bacteria found in the oral normal flora. The Streptococcus 在继发感染中，局部病原体或其产生的毒素会扩散到继发部位。例如，牙科卫生员用锋利的工具划伤病人的牙龈，就会导致口腔正常菌群中的链球菌在牙龈上造成局部感染。链球菌
12. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 12.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
13. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 13.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
14. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 14.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
bacteria may then gain access to the bloodstream and make their way to other locations within the body such as the heart valves, resulting in a secondary infection. ^(15){ }^{15} 然后，细菌可能会进入血液，并到达身体的其他部位，如心脏瓣膜，从而造成二次感染。 ^(15){ }^{15}
When an infection becomes disseminated throughout the body, it is called a systemic infection. For example, infection by the varicella-zoster virus typically gains entry through a mucous membrane of the upper respiratory system. It then spreads throughout the body, resulting in a classic red rash associated with chicken pox. Because these lesions are not sites of initial infection, they are signs of a systemic infection. Systemic infections can cause fever, increased heart and respiratory rates, lethargy, malaise, anorexia, and tenderness and enlargement of the lymph nodes. 当感染扩散到全身时，就称为全身感染。例如，水痘-带状疱疹病毒通常通过上呼吸道黏膜进入人体。然后扩散到全身，出现与水痘相关的典型红色皮疹。由于这些皮损不是最初感染的部位，因此是全身感染的征兆。全身感染会导致发烧、心跳和呼吸频率加快、嗜睡、乏力、厌食以及淋巴结触痛和肿大。
Sometimes a primary infection can lead to a secondary infection by an opportunistic pathogen. For example, when a patient experiences a primary infection from influenza, it can damage and decrease the defense mechanisms of the lungs, making the patient more susceptible to a secondary pneumonia by a bacterial pathogen like Haemophilus influenzae. Additionally, treatment of the primary infection may lead to a secondary infection caused by an opportunistic pathogen. For example, antibiotic therapy targeting the primary infection alters the normal flora and creates an opening for opportunistic pathogens like Clostridium difficile or Candida Albicans to cause a secondary infection. ^(17){ }^{17} 有时，原发感染会导致机会性病原体的继发感染。例如，当患者受到流感的原发感染时，肺部的防御机制会受到损害并降低，从而使患者更容易受到流感嗜血杆菌等细菌病原体的继发肺炎。此外，治疗原发感染可能会导致机会性病原体引起继发感染。例如，针对原发感染的抗生素治疗会改变正常菌群，为艰难梭菌或白色念珠菌等机会性病原体造成继发感染创造机会。 ^(17){ }^{17}
Bacteremia, SIRS, Sepsis, and Septic Shock 菌血症、SIRS、败血症和脓毒性休克
When infection occurs, pathogens can enter the bloodstream. The presence 发生感染时，病原体会进入血液。出现
15. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 15.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/h-introduction 免费查阅。
16. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 16.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/h-introduction 免费查阅。
17. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 17.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/1-introduction 免费查阅。
of bacteria in blood is called bacteremia. If bacteria are both present and multiplying in the blood, it is called septicemia. ^(18){ }^{18} 血液中的细菌称为菌血症。如果细菌在血液中同时存在和繁殖，则称为败血症。 ^(18){ }^{18}
Systemic inflammatory response syndrome (SIRS) is an exaggerated inflammatory response that affects the entire body. It is the body’s reaction to a noxious stressor, including causes such as infection and acute inflammation, but other conditions can trigger it as well. Signs of SIRS are as follows: 全身炎症反应综合征（SIRS）是一种影响全身的夸张炎症反应。它是机体对有害应激源的反应，包括感染和急性炎症等原因，但其他情况也可能引发它。SIRS 的迹象如下：
Body temperature over 38 or under 36 degrees Celsius 体温超过 38 摄氏度或低于 36 摄氏度
Heart rate greater than 90 beats/minute 心率大于 90 次/分钟
Respiratory rate greater than 20 breaths/minute or PaCO2 less than 32 mmHg 呼吸频率大于 20 次/分钟或 PaCO2 小于 32 毫米汞柱
White blood cell count greater than 12,000 or less than 4,000 /microliters or over 10%10 \% of immature forms (bands) ^(19){ }^{19} 白细胞计数大于 12,000 或小于 4,000 / 毫升，或超过 10%10 \% 未成熟形态（带状） ^(19){ }^{19} 。
Even though the purpose of SIRS is to defend against a noxious stressor, the uncontrolled release of massive amounts of cytokines, called cytokine storm, can lead to organ dysfunction and even death. ^(20){ }^{20} 尽管 SIRS 的目的是抵御有害的应激源，但不受控制地释放大量细胞因子（称为细胞因子风暴）会导致器官功能障碍，甚至死亡。 ^(20){ }^{20}
Sepsis refers to SIRS that is caused by an infection. Sepsis occurs when an existing infection triggers an exaggerated inflammatory reaction throughout the body. If left untreated, sepsis causes tissue and organ damage. It can quickly spread to multiple organs and is a life-threatening medical emergency. 败血症是指由感染引起的 SIRS。败血症发生时，已有的感染会引发全身剧烈的炎症反应。如果不及时治疗，败血症会造成组织和器官损伤。败血症会迅速扩散到多个器官，是一种危及生命的紧急医疗状况。
Sepsis causing damage to one or more organs (such as the kidneys) is called severe sepsis. Severe sepsis can lead to septic shock, a life-threatening decrease in blood pressure (systolic pressure < 90mmHg<90 \mathrm{~mm} \mathrm{Hg} ) that prevents cells and other organs from receiving enough oxygen and nutrients, causing 导致一个或多个器官（如肾脏）受损的败血症称为严重败血症。严重败血症可导致脓毒性休克，这是一种危及生命的血压下降（收缩压 < 90mmHg<90 \mathrm{~mm} \mathrm{Hg} ），使细胞和其他器官无法获得足够的氧气和营养物质，从而导致死亡。
18. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 18.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/7-introduction
19. Mouton, C. P., Bazaldua, O., Pierce, B., & Espino, D. V. (2001). Common infections in older adults. American Family Physician, 63(2), 257-269. https://www.aafp.org/afp/2001/0115/p257.html 19.Mouton, C. P., Bazaldua, O., Pierce, B., & Espino, D. V. (2001)。老年人的常见感染。American Family Physician, 63(2), 257-269. https://www.aafp.org/afp/2001/0115/p257.html
20. Mouton, C. P., Bazaldua, O., Pierce, B., & Espino, D. V. (2001). Common infections in older adults. American Family Physician, 63(2), 257-269. https://www.aafp.org/afp/2001/0115/p257.html 20.Mouton, C. P., Bazaldua, O., Pierce, B., & Espino, D. V. (2001)。Common infections in older adults.American Family Physician, 63(2), 257-269. https://www.aafp.org/afp/2001/0115/p257.html
multi-organ failure and death. See Figure 9.12^(21)9.12^{21} for an illustration of the progression of sepsis from SIRS to septic shock. 多器官衰竭和死亡。脓毒症从 SIRS 发展到脓毒性休克的过程见图 9.12^(21)9.12^{21} 。
Unfortunately, almost any type of infection in any individual can lead to sepsis. Infections that lead to sepsis most often start in the lungs, urinary tract, gastrointestinal tract, or skin. Some people are especially at risk for developing sepsis, such as adults over age 65; children younger than one year old; people who are immunocompromised or have chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease; and survivors of a previous sepsis episode. ^(22){ }^{22} 不幸的是，几乎任何类型的感染都可能导致败血症。导致败血症的感染通常始于肺部、泌尿道、胃肠道或皮肤。有些人尤其容易患败血症，如 65 岁以上的成年人；1 岁以下的儿童；免疫力低下或患有慢性疾病（如糖尿病、肺病、癌症和肾病）的人；以及曾患败血症的幸存者。 ^(22){ }^{22}
In addition to exhibiting signs of SIRS, patients with sepsis may also have additional signs such as elevated fever and shivering, confusion, shortness of breath, pain or discomfort, and clammy or sweaty skin. Diligent nursing care is vital for recognizing when patients with a diagnosed infection are developing sepsis. It is important to know the early signs of SIRS and sepsis and to act quickly by notifying the health care provider and/or following sepsis protocols in place at your health care facility. 脓毒症患者除了表现出 SIRS 征兆外，还可能出现其他征兆，如高烧和颤抖、意识不清、呼吸急促、疼痛或不适、皮肤潮湿或出汗。勤奋的护理对于识别已确诊感染的患者何时出现败血症至关重要。了解 SIRS 和败血症的早期征兆并迅速采取行动，通知医疗服务提供者和/或遵循医疗机构的败血症规程非常重要。
21. This work is derivative of “Sepsis_Steps.png” by Hadroncastle and is licensed under CC BY-SA 4.0 21.本作品是 Hadroncastle 的 "Sepsis_Steps.png "的衍生作品，采用 CC BY-SA 4.0 许可。
22. Centers for Disease Control and Prevention. (2020, August 18). Sepsis. https://www.cdc.gov/sepsis/index.html 22.疾病控制和预防中心。(2020 年 8 月 18 日）。https://www.cdc.gov/sepsis/index.html
23. Centers for Disease Control and Prevention. (2020, August 18). Sepsis. https://www.cdc.gov/sepsis/index.html 23.美国疾病控制和预防中心。(2020 年 8 月 18 日）。https://www.cdc.gov/sepsis/index.html
Use the following hyperlinks to read more information about sepsis. 使用以下超链接阅读有关败血症的更多信息。
Read more information about sepsis at the CDC’s Sepsis web page. 在疾病预防控制中心的败血症网页上阅读有关败血症的更多信息。
Read the CDC infographic on Protect Your Patients from Sepsis. 阅读美国疾病控制与预防中心关于保护患者远离败血症的信息图表。
Read an article about caring for patients with sepsis titled Something Isn’t Right: The Subtle Changes of Early 阅读一篇有关脓毒症患者护理的文章，标题为 "不对劲"：早期败血症的微妙变化
Deterioration. 恶化。
Read more about the Surviving Sepsis Campaign with early recognition and treatment of sepsis using the Hour-1 Bundle. 了解更多有关 "脓毒症生存运动 "以及使用 "1 小时捆绑包 "早期识别和治疗脓毒症的信息。
Toxins 毒素
Some pathogens release toxins that are biological poisons that assist in their ability to invade and cause damage to tissues. For example, Botulinum toxin (also known as botox) is a neurotoxin produced by the gram-positive bacterium Clostridium botulinum that is an acutely toxic substance because it blocks the release of the neurotransmitter acetylcholine. The toxin’s blockage of acetylcholine results in muscle paralysis with the potential to stop breathing due to its effect on the respiratory muscles. This condition is referred to as botulism, a type of food poisoning that can be caused by improper sterilization of canned foods. However, because of its paralytic action, low concentrations of botox are also used for beneficial purposes such as cosmetic procedures to remove wrinkles and in the medical treatment of overactive bladder. 有些病原体会释放毒素，这些毒素是生物毒药，有助于它们入侵组织并造成损害。例如，肉毒杆菌毒素（又称肉毒素）是由革兰氏阳性菌肉毒梭状芽孢杆菌产生的一种神经毒素，是一种急性毒性物质，因为它会阻碍神经递质乙酰胆碱的释放。这种毒素对乙酰胆碱的阻断作用会导致肌肉麻痹，并可能因其对呼吸肌的影响而停止呼吸。这种情况被称为肉毒中毒，是一种食物中毒，可由罐头食品消毒不当引起。不过，由于肉毒杆菌毒素具有麻痹作用，低浓度的肉毒杆菌毒素也被用于有益的目的，如美容除皱和治疗膀胱过度活动症。
Another type of neurotoxin is tetanus toxin, which is produced by the grampositive bacterium Clostridium tetani. Tetanus toxin inhibits the release of GABA, resulting in permanent muscle contraction. The first symptom of tetanus is typically stiffness of the jaw. Violent muscle spasms in other parts of the body follow, typically culminating with respiratory failure and death. Because of the severity of tetanus, it is important for nurses to encourage 另一种神经毒素是破伤风毒素，它由革兰氏阳性细菌破伤风梭菌产生。破伤风毒素会抑制 GABA 的释放，导致肌肉永久性收缩。破伤风的第一个症状通常是下颌僵硬。随后身体其他部位的肌肉也会发生剧烈痉挛，最终导致呼吸衰竭和死亡。由于破伤风的严重性，护士必须鼓励病人
individuals to regularly receive tetanus vaccination boosters throughout their lifetimes. 个人终生定期接种破伤风疫苗。
Stages of Disease 疾病阶段
When a pathogen becomes an infection-causing disease, there are five stages of disease, including the incubation, prodromal, illness, decline, and convalescence periods. See Figure 9.13^(26)9.13^{26} for an illustration of the stages of disease. 当病原体感染致病后，疾病会分为五个阶段，包括潜伏期、前驱期、发病期、衰退期和康复期。疾病阶段示意图见图 9.13^(26)9.13^{26} 。
Periods of Disease 疾病时期
Figure 9.13 Progression of Infectious Disease 图 9.13 传染病的发展过程
25. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 25.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
26. “unknown image” by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax.org/books/ microbiology/pages/15-7-characteristics-of-infectious-disease 26."未知图像 "由 OpenStax 制作，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/ microbiology/pages/15-7-characteristics-of-infectious-disease。
Incubation Period 孵化期
The incubation period occurs after the initial entry of the pathogen into the host when it begins to multiply, but there are insufficient numbers of the pathogen present to cause signs and symptoms of disease. Incubation periods can vary from a day or two in acute disease to months or years in chronic disease, depending upon the pathogen. Factors involved in determining the length of the incubation period are diverse and can include virulence of the pathogen, strength of the host immune defenses, site of infection, and the amount of the pathogen received during exposure. During this incubation period, the patient is unaware that a disease is beginning to develop. ^(27){ }^{27} 潜伏期发生在病原体最初进入宿主体内之后，此时病原体开始繁殖，但病原体的数量不足以引起疾病的症状和体征。根据病原体的不同，潜伏期从急性疾病的一两天到慢性疾病的数月或数年不等。决定潜伏期长短的因素多种多样，包括病原体的毒力、宿主免疫防御能力的强弱、感染部位以及接触病原体时的感染量。在潜伏期内，病人并不知道疾病正在开始发展。 ^(27){ }^{27}
Prodromal Period 前驱期
The prodromal period occurs after the incubation period. During this phase, the pathogen continues to multiply, and the host begins to experience general signs and symptoms of illness caused from activation of the nonspecific innate immunity, such as not feeling well (malaise), low-grade fever, pain, swelling, or inflammation. These signs and symptoms are often too general to indicate a particular disease is occurring. 前驱期发生在潜伏期之后。在这一阶段，病原体继续繁殖，宿主开始出现由非特异性先天免疫激活引起的一般疾病症状和体征，如不舒服（不适）、低烧、疼痛、肿胀或炎症。这些症状和体征往往过于笼统，不足以表明某种疾病正在发生。
Acute Phase 急性期
Following the prodromal period is the period of acute illness, during which the signs and symptoms of a specific disease become obvious and can become severe. This period of acute illness is followed by the period of decline as the immune system overcomes the pathogen. The number of pathogen particles begins to decline and thus the signs and symptoms of illness begin to decrease. However, during the decline period, patients may become 前驱期之后是急性病期，在此期间，特定疾病的症状和体征会变得明显和严重。急性期之后是衰退期，因为免疫系统会战胜病原体。病原体颗粒的数量开始减少，因此疾病的症状和体征也开始减轻。然而，在衰退期，患者可能会变得
27. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 27.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
28. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 28.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。可从 https://openstax.org/books/microbiology/pages/1-introduction 免费获取。
susceptible to developing secondary infections because their immune systems have been weakened by the primary infection. ^(29){ }^{29} ^(29){ }^{29} 由于原发感染导致免疫系统功能减弱，因此容易继发感染。 ^(29){ }^{29}
Convalescent Period 疗养期
The final period of disease is known as the convalescent period. During this stage, the patient generally returns to normal daily functioning, although some diseases may inflict permanent damage that the body cannot fully repair. ^(30){ }^{30} For example, if a strep infection becomes systemic and causes a secondary infection of the patient’s heart valves, the heart valves may never return to full function and heart failure may develop. 疾病的最后阶段称为康复期。在这一阶段，病人一般都能恢复正常的日常功能，但有些疾病可能会造成永久性损伤，身体无法完全修复。 ^(30){ }^{30} 例如，如果链球菌感染成为全身性感染并导致患者的心脏瓣膜继发感染，心脏瓣膜可能永远无法恢复全部功能，并可能出现心力衰竭。
Infectious diseases can be contagious during all five of the periods of disease. The transmissibility of an infection during these periods depends upon the pathogen and the mechanisms by which the disease develops and progresses. For example, with many viral diseases associated with rashes (e.g., chicken pox, measles, rubella, roseola), patients are contagious during the incubation period up to a week before the rash develops. In contrast, with many respiratory infections (e.g., colds, influenza, diphtheria, strep throat, and pertussis) the patient becomes contagious with the onset of the prodromal period. Depending upon the pathogen, the disease, and the individual infected, transmission can still occur during the periods of decline, convalescence, and even long after signs and symptoms of the disease disappear. For example, an individual recovering from a diarrheal disease may continue to carry and shed the pathogen in feces for a long time, posing a risk of transmission to others through direct or indirect contact. ^(3){ }^{3} 传染病在五个发病期都有可能传染。传染病在这些时期的传播性取决于病原体以及疾病的发展和演变机制。例如，对于许多与皮疹相关的病毒性疾病（如水痘、麻疹、风疹、玫瑰疹），患者在皮疹出现前一周的潜伏期内具有传染性。相比之下，许多呼吸道感染（如感冒、流感、白喉、链球菌性咽喉炎和百日咳）患者在前驱期开始时就具有传染性。根据病原体、疾病和感染者的不同，在疾病衰退期、康复期，甚至在疾病症状和体征消失后的很长一段时间内，仍然可能发生传播。例如，从腹泻病中恢复过来的人可能会继续携带病原体并在粪便中脱落很长时间，这就构成了通过直接或间接接触传播给他人的风险。 ^(3){ }^{3}
29. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 29.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
30. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/h-introduction 30.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/h-introduction
31. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 31.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
Types of Infection 感染类型
Acute vs. Chronic 急性与慢性
Acute, self-limiting infections develop rapidly and generally last only 10-14 days. Colds and ear infections are considered acute, self-limiting infections. See Figure 9.14^(32)9.14^{32} for an image of an individual with an acute, self-limiting infection. Conversely, chronic infections may persist for months. Hepatitis and mononucleosis are examples of chronic infections. 急性自限性感染发展迅速，一般只持续 10-14 天。感冒和中耳炎属于急性自限性感染。急性自限性感染患者的图片见图 9.14^(32)9.14^{32} 。相反，慢性感染可能会持续数月。肝炎和单核细胞增多症就是慢性感染的例子。
32. “392131387-huge.jpg” by Alexandr Litovchenko is used under license from Shutterstock.com 32."392131387-huge.jpg" 作者 Alexandr Litovchenko 是在 Shutterstock.com 的许可下使用的。
33. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.O. Access for free at https://openstax.org/books/microbiology/pages/7-introduction 33.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.O 许可，可在 https://openstax.org/books/microbiology/pages/7-introduction 免费查阅。
Figure 9.14 Acute Infection 图 9.14 急性感染
Healthcare-Associated Infections 医疗保健相关感染
An infection that is contracted in a health care facility or under medical care is known as a healthcare-associated infection (HAI), formerly referred to as a nosocomial infection. On any given day, about one in 31 hospital patients has at least one healthcare-associated infection. HAls increase the cost of care and delay recovery and are associated with permanent disability, loss of wages, and even death. ^(34,35){ }^{34,35} 在医疗机构或在医疗护理过程中发生的感染被称为医疗相关感染（HAI），以前被称为院内感染。在任何一天，大约每 31 名医院病人中就有一人受到至少一种医疗相关感染。医源性感染会增加护理成本，延误康复，并导致终身残疾、工资损失甚至死亡。 ^(34,35){ }^{34,35}
34. Centers for Disease Control and Prevention. (2016, March 4). Healthcare-associated infections. https://www.cdc.gov/hai/index.html 34.疾病控制和预防中心。(2016, March 4).https://www.cdc.gov/hai/index.html。
35. U.S. Department of Health and Human Services. (2020, January 15). Health care-associated infections. https://health.gov/our-work/health-care-quality/health-care-associated-infections 35.美国卫生与公众服务部。(2020, January 15).https://health.gov/our-work/health-care-quality/health-care-associated-infections。
The U.S. Department of Health and Human Services (HHS) has established these goals to reduce these common healthcare-associated infections in health care institutions: 美国卫生与公众服务部（HHS）制定了这些目标，以减少医疗机构中这些常见的医疗相关感染：
Reduce central line-associated bloodstream infections (CLABSI) 减少中心静脉相关性血流感染 (CLABSI)
Read more about Health Care-Associated Infections. 了解更多有关医疗相关感染的信息。
Blood-borne Pathogens 血源性病原体
Blood-borne pathogens are potentially present in a patient’s blood and body fluids, placing other patients and health care providers at risk for infection if they are exposed. The most common blood-borne pathogens include hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). 血液传播的病原体可能存在于患者的血液和体液中，其他患者和医护人员一旦接触到就有可能受到感染。最常见的血液传播病原体包括乙型肝炎、丙型肝炎和人类免疫缺陷病毒（HIV）。
When a nurse or other health care worker experiences exposure due to a needlestick injury or the splashing of body fluids, it should be immediately reported so that careful monitoring can occur. When the source of the exposure is known, the health care worker and patient are initially tested. 当护士或其他医护人员因针刺伤或体液飞溅而接触到病毒时，应立即报告，以便进行仔细监测。当知道接触源时，应对医护人员和患者进行初步检测。
36. Centers for Disease Control and Prevention. (2016, March 4). Healthcare-associated infections. https://www.cdc.gov/hai/index.html 36.疾病控制和预防中心。(2016 年 3 月 4 日）。医疗保健相关感染。https://www.cdc.gov/hai/index.html。
37. U.S. Department of Health and Human Services. (2020, January 15). Health care-associated infections. https://health.gov/our-work/health-care-quality/health-care-associated-infections 37.美国卫生与公众服务部。(2020, January 15).https://health.gov/our-work/health-care-quality/health-care-associated-infections。
Repeat testing and medical prophylaxis may be warranted for the health care worker, depending on the results. ^(38,39){ }^{38,39} 根据检测结果，可能需要对医护人员进行重复检测和医学预防。 ^(38,39){ }^{38,39}
Needlesticks and sharps injuries are the most common causes of blood-borne pathogen exposure for nurses. The National Institute for Occupational Safety and Health (NIOSH) has developed a comprehensive Sharps Injury Prevention Program to decrease needle and sharps injury in health care workers. ^(40,41){ }^{40,41} 针刺和利器伤害是护士接触血液传播病原体的最常见原因。美国国家职业安全与健康研究所（NIOSH）制定了一项全面的利器伤害预防计划，以减少医护人员的针刺和利器伤害。 ^(40,41){ }^{40,41}
Needles are also used in the community, such as at home, work, in airports, or public restrooms as individuals use needles to administer prescribed medications or to inject illegal drugs. Nurses can help prevent needlestick and sharps injuries in their community by implementing a community needle disposal program. 针头也会在社区中使用，例如在家中、工作场所、机场或公共厕所，因为有人会使用针头来注射处方药或非法药物。护士可以通过实施社区针头处理计划来帮助预防社区内的针刺和利器伤害。
Read more about needlestick and sharps injury prevention in the “Aseptic Technique” chapter in Open RN Nursing Skills. 请阅读《开放式注册护士护理技能》中 "无菌技术 "一章中有关针刺和利器伤害预防的更多内容。
Centers for Disease Control and Prevention. (2016, October 5). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C; General resources on bloodborne pathogens. https://www.cdc.gov/niosh/topics/bbp/ genres.html 美国疾病控制和预防中心。(2016 年 10 月 5 日）。血源性传染病：艾滋病毒/艾滋病、乙型肝炎、丙型肝炎；有关血源性病原体的一般资源。https://www.cdc.gov/niosh/topics/bbp/ genres.html
Centers for Disease Control and Prevention. (2016, October 5). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C; Preventing needlesticks and sharps injuries. https://www.cdc.gov/niosh/topics/bbp/ sharps.html 美国疾病控制和预防中心。(2016 年 10 月 5 日）。血源性传染病：艾滋病毒/艾滋病、乙型肝炎、丙型肝炎；预防针刺和利器伤害。https://www.cdc.gov/niosh/topics/bbp/ sharps.html
Centers for Disease Control and Prevention. (2016, October 5). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C; General resources on bloodborne pathogens. https://www.cdc.gov/niosh/topics/bbp/ genres.html 美国疾病控制和预防中心。(2016 年 10 月 5 日）。血源性传染病：艾滋病毒/艾滋病、乙型肝炎、丙型肝炎；有关血源性病原体的一般资源。https://www.cdc.gov/niosh/topics/bbp/ genres.html
Centers for Disease Control and Prevention. (2016, October 5). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C; Preventing needlesticks and sharps injuries. https://www.cdc.gov/niosh/topics/bbp/ sharps.html 美国疾病控制和预防中心。(2016 年 10 月 5 日）。血源性传染病：艾滋病毒/艾滋病、乙型肝炎、丙型肝炎；预防针刺和利器伤害。https://www.cdc.gov/niosh/topics/bbp/ sharps.html
Antibiotics are used to treat bacterial infections. They either kill bacteria or stop them from reproducing, allowing the body’s natural defenses to eliminate the pathogens. Used properly, antibiotics can save lives. However, growing antibiotic resistance is curbing the effectiveness of these drugs. Taking an antibiotic as directed, even after symptoms disappear, is key to curing an infection and preventing the development of resistant bacteria. 抗生素用于治疗细菌感染。它们可以杀死细菌或阻止细菌繁殖，让人体的自然防御系统消灭病原体。正确使用抗生素可以挽救生命。然而，抗生素耐药性的不断增加正在抑制这些药物的有效性。遵医嘱服用抗生素，即使在症状消失后，也是治愈感染和防止耐药菌产生的关键。
Antibiotics do not work against viral infections such as colds or influenza. Antiviral drugs, which fight infection either by inhibiting a virus’s ability to reproduce or by strengthening the body’s immune response to the infection, are used for some viral infections. There are several different classes of drugs in the antiviral family, and each is used for specific kinds of viral infections. 抗生素对感冒或流感等病毒感染不起作用。抗病毒药物通过抑制病毒的繁殖能力或加强人体对感染的免疫反应来对抗感染，可用于某些病毒感染。抗病毒药物家族中有几类不同的药物，每一类药物都用于特定类型的病毒感染。
Antifungal medications are used to treat fungal and yeast infections. Antiparasitic medication is used to treat parasites, and anthelmintic medication is used to treat worm infections. 抗真菌药物用于治疗真菌和酵母菌感染。抗寄生虫药物用于治疗寄生虫，抗蠕虫药物用于治疗蠕虫感染。
Read more about antibiotic, antiviral, antifungal, and antihelminthic medication in the “Antimicrobials” chapter in Open RN Nursing Pharmacology. 请在《开放式注册护士护理药理学》的 "抗菌药物 "章节中阅读有关抗生素、抗病毒药物、抗真菌药物和抗蠕虫药物的更多信息。
Antibiotic Stewardship 抗生素管理
Microorganisms can quickly develop new features that make them resistant to the drugs that were once able to kill them. People infected with antibioticresistant organisms are more likely to have longer, more expensive hospital stays and may be more likely to die as a result of an infection.’ 微生物会迅速发展出新的特性，从而对曾经能够杀死它们的药物产生抗药性。感染了抗生素耐药生物的人更有可能住院时间更长、花费更多，也更有可能死于感染。
Misuse of antimicrobials is one of the world’s most pressing public health problems because of these consequences. Many factors contribute to 由于这些后果，滥用抗菌药物已成为全球最紧迫的公共卫生问题之一。导致滥用抗菌药物的因素有很多
resistance, including overprescription of antibiotics for nonbacterial infections, use of inappropriate antibiotics for the infectious microorganism, and lack of completion of prescribed antibiotic therapy. Some infections, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycinresistant Enterococci (VRE), are becoming increasingly hard to treat and some microorganisms cannot be effectively destroyed by any known antibiotic. ^(2){ }^{2} 抗药性的产生有多种原因，包括对非细菌性感染过量使用抗生素、对感染微生物使用不适当的抗生素，以及未按规定完成抗生素治疗。耐甲氧西林金黄色葡萄球菌（MRSA）和耐万古霉素肠球菌（VRE）等一些感染越来越难以治疗，而且一些微生物无法被任何已知的抗生素有效消灭。 ^(2){ }^{2}
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. The Centers for Disease Control (CDC) has developed core elements for antibiotic stewardship to serve as a guide to improve antibiotic use for improved patient safety and outcomes. ^(3){ }^{3} See Figure 9.15^(4)9.15^{4} for an image from the CDC explaining antibiotic resistance. 抗菌药物管理是一项协调计划，旨在促进抗菌药物（包括抗生素）的合理使用，改善患者预后，减少微生物耐药性，并减少耐多药生物引起的感染传播。美国疾病控制中心（CDC）制定了抗生素管理的核心要素，作为改善抗生素使用的指南，以提高患者的安全和治疗效果。 ^(3){ }^{3} 请参阅图 9.15^(4)9.15^{4} ，了解疾病控制中心解释抗生素耐药性的图片。
2. Centers for Disease Control and Prevention. (2019, August 15). Core elements of antibiotic stewardship. https://www.cdc.gov/antibiotic-use/core-elements/index.html 2.疾病控制和预防中心。(2019, August 15).抗生素监管的核心要素。https://www.cdc.gov/antibiotic-use/core-elements/index.html。
3. Centers for Disease Control and Prevention. (2019, August 15). Core elements of antibiotic stewardship. https://www.cdc.gov/antibiotic-use/core-elements/index.html 3.疾病控制和预防中心。(2019, August 15).抗生素监管的核心要素。https://www.cdc.gov/antibiotic-use/core-elements/index.html。
4. “HowAntibioticResistanceHappens.jpg” by CDC is licensed under CCO. Access for free at https://www.cdc.gov/ antibiotic-use/community/materials-references/graphics.html. 4.由 CDC 制作的 "HowAntibioticResistanceHappens.jpg "已获得 CCO 许可。可从 https://www.cdc.gov/ antibiotic-use/community/materials-references/graphics.html 免费获取。
Figure 9.15 Antibiotic Resistance 图 9.15 抗生素耐药性
The nurse plays an important role in antimicrobial stewardship through patient education. For example, many patients expect to receive an antibiotic when they seek treatment for an illness or symptom. However, because antibiotics are only effective in treating bacteria, the patient should be educated regarding effective treatment for the type of pathogen causing their symptoms. If an antibiotic is prescribed, patients should be advised to complete the entire course of therapy or contact their provider if they are unable to do so. For example, patients often feel better after a few days of treatment and decide not to take the remaining medication, or they may experience side effects from the antibiotic (such as nausea and diarrhea) and stop taking the medication. All of these behaviors can lead to antibiotic resistance and should be addressed when providing patient education regarding prescribed antibiotic therapy. 护士通过教育病人在抗菌药物管理方面发挥着重要作用。例如，许多患者在因疾病或症状寻求治疗时都希望得到抗生素。然而，由于抗生素只能有效治疗细菌，因此应向患者讲解针对引起其症状的病原体类型的有效治疗方法。如果开具了抗生素处方，应建议患者完成整个疗程，如果无法完成，则应联系医疗服务提供者。例如，患者往往在治疗几天后感觉好转，于是决定不再服用剩余的药物，或者他们可能会感受到抗生素的副作用（如恶心和腹泻）而停止服药。所有这些行为都可能导致抗生素耐药性，因此在提供有关处方抗生素治疗的患者教育时应加以注意。
9.6 Preventing Infection 9.6 预防感染
OPEN RESOURCES FOR NURSING (OPEN RN) 开放式护理资源（open rn）
In addition to recognizing signs of infection and educating patients about the treatment of their infection, nurses also play an important role in preventing the spread of infection. A cyclic process known as the chain of infection describes the transmission of an infection. By implementing interventions to break one or more links in the chain of infection, the spread of infection can be stopped. See Figure 9.16^(')9.16^{\prime} for an illustration of the links within the chain of infection. These links are described as the following: 除了识别感染迹象和教育病人如何治疗感染外，护士在预防感染传播方面也发挥着重要作用。被称为感染链的循环过程描述了感染的传播。通过实施干预措施，打破感染链中的一个或多个环节，就可以阻止感染的传播。请参见图 9.16^(')9.16^{\prime} ，了解感染链中的各个环节。这些环节描述如下：
Infectious Agent: A causative organism, such as bacteria, virus, fungi, parasite. 传染源：致病生物，如细菌、病毒、真菌、寄生虫。
Reservoir: A place where the organism grows, such as in blood, food, or a wound. 蓄水池：生物生长的地方，如血液、食物或伤口中。
Portal of Exit: The method by which the organism leaves the reservoir, such as through respiratory secretions, blood, urine, breast milk, or feces. 出境途径：病原体离开贮存库的方式，如通过呼吸道分泌物、血液、尿液、母乳或粪便。
Mode of Transmission: The vehicle by which the organism is transferred such as physical contact, inhalation, or injection. The most common vehicles are respiratory secretions spread by a cough, sneeze, or on the hands. A single sneeze can send thousands of virus particles into the air. 传播方式：生物体传播的媒介，如身体接触、吸入或注射。最常见的传播媒介是通过咳嗽、喷嚏或手传播的呼吸道分泌物。一个喷嚏就能将成千上万的病毒颗粒传播到空气中。
Portal of Entry: The method by which the organism enters a new host, such as through mucous membranes or nonintact skin. 进入门户：病原体进入新宿主体内的途径，如通过粘膜或非接触皮肤。
. Susceptible Host: The susceptible individual the organism has invaded. ^(2){ }^{2} .易感宿主：生物体入侵的易感个体。 ^(2){ }^{2} .
“Chain_of_Infection.png” by Genieieiop is licensed under CC BY-SA 4.0 Genieieiop 的 "Chain_of_Infection.png "以 CC BY-SA 4.0 许可发布。
Centers for Disease Control and Prevention. (2012, May 18). Lesson 1: Introduction to epidemiology. https://www.cdc.gov/csels/dsepd/ss1978/lesson7/section10.html 美国疾病控制和预防中心。(2012 年 5 月 18 日）。第 1 课：流行病学简介。https://www.cdc.gov/csels/dsepd/ss1978/lesson7/section10.html
Figure 9.16 Chain of Infection 图 9.16 感染链
For a pathogen to continue to exist, it must put itself in a position to be transmitted to a new host, leaving the infected host through a portal of exit. Similar to portals of entry, the most common portals of exit include the skin and the respiratory, urogenital, and gastrointestinal tracts. Coughing and sneezing can expel thousands of pathogens from the respiratory tract into the environment. Other pathogens are expelled through feces, urine, semen, and vaginal secretions. Pathogens that rely on insects for transmission exit the body in the blood extracted by a biting insect. ^(3){ }^{3} 病原体要想继续存在，就必须将自身置于可传播给新宿主的位置，通过出路离开受感染的宿主。与入口类似，最常见的出口包括皮肤、呼吸道、泌尿生殖道和胃肠道。咳嗽和打喷嚏可将成千上万的病原体从呼吸道排出到环境中。其他病原体则通过粪便、尿液、精液和阴道分泌物排出体外。依靠昆虫传播的病原体会通过叮咬昆虫提取的血液排出体外。 ^(3){ }^{3}
3. This work is a derivative of Microbiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax.org/books/microbiology/pages/1-introduction 3.本作品是 OpenStax 的《微生物学》的衍生作品，采用 CC BY 4.0 许可。免费访问：https://openstax.org/books/microbiology/pages/1-introduction
The pathogen enters a new individual via a portal of entry, such as mucous membranes or nonintact skin. If the individual has a weakened immune system or their natural defenses cannot fend off the pathogen, they become infected. 病原体通过入口（如粘膜或非接触皮肤）进入新的个体。如果个体的免疫系统较弱或其自然防御系统无法抵御病原体，他们就会受到感染。
Interventions to Break the Chain of Infection 打破感染链的干预措施
Infections can be stopped from spreading by interrupting this chain at any link. Chain links can be broken by disinfecting the environment, sterilizing medical instruments and equipment, covering coughs and sneezes, using good hand hygiene, implementing standard and transmission-based precautions, appropriately using personal protective equipment, encouraging patients to stay up-to-date on vaccines (including the flu shot), following safe injection practices, and promoting the optimal functioning of the natural immune system with good nutrition, rest, exercise, and stress management. 可以通过打断这一链条的任何一环来阻止感染的传播。可以通过消毒环境、消毒医疗器械和设备、掩盖咳嗽和喷嚏、良好的手部卫生、实施标准和基于传播的预防措施、适当使用个人防护设备、鼓励患者及时接种疫苗（包括流感疫苗）、遵循安全的注射方法，以及通过良好的营养、休息、锻炼和压力管理来促进天然免疫系统的最佳功能，来切断链条的各个环节。
Disinfection and Sterilization 消毒和灭菌
Disinfection and sterilization are used to kill microorganisms and remove harmful pathogens from the environment and equipment to decrease the chance of spreading infection. Disinfection is the removal of microorganisms. However, disinfection does not destroy all spores and viruses. Sterilization is a process used on equipment and the environment to destroy all pathogens, including spores and viruses. Sterilization methods include steam, boiling water, dry heat, radiation, and chemicals. Because of the harshness of these sterilization methods, skin can only be disinfected and not sterilized. ^(4){ }^{4} 消毒和灭菌用于杀死微生物，清除环境和设备中的有害病原体，以减少感染传播的机会。消毒就是清除微生物。然而，消毒并不能消灭所有孢子和病毒。灭菌是一种用于设备和环境的过程，可消灭所有病原体，包括孢子和病毒。灭菌方法包括蒸汽、沸水、干热、辐射和化学品。由于这些灭菌方法非常苛刻，皮肤只能消毒而不能灭菌。 ^(4){ }^{4}
Standard and Transmission-Based Precautions 标准预防措施和基于传播的预防措施
To protect patients and health care workers from the spread of pathogens, the CDC has developed precautions to use during patient care that address portals of exit, methods of transmission, and portals of entry. These 为了保护病人和医护人员免受病原体传播，疾病预防控制中心制定了在病人护理期间使用的预防措施，这些措施涉及出口、传播方式和入口。这些
precautions include standard precautions and transmission-based precautions. 预防措施包括标准预防措施和基于传播的预防措施。
Standard Precautions 标准预防措施
Standard precautions are used when caring for all patients to prevent healthcare-associated infections. According to the Centers for Disease Control and Prevention (CDC), standard precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These precautions are based on the principle that all blood, body fluids (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents. These standards reduce the risk of exposure for the health care worker and protect the patient from potential transmission of infectious organisms. See Figure 9.17^(6)9.17^{6} for an image of some of the components of standard precautions. 标准预防措施用于护理所有患者，以防止医疗保健相关感染。根据美国疾病控制和预防中心（CDC）的说法，标准预防措施是适用于所有患者护理的最低感染预防措施，无论患者是否疑似或确诊感染，在提供医疗保健服务的任何环境中均适用。这些预防措施所依据的原则是，所有血液、体液（汗液除外）、非接触性皮肤和粘膜都可能含有可传播的感染病原体。这些标准降低了医护人员的接触风险，并保护患者免受传染性病原体的潜在传播。请参阅图 9.17^(6)9.17^{6} ，了解标准预防措施的一些组成部分。
Current standard precautions according to the CDC include the following: 根据疾病预防控制中心的规定，目前的标准预防措施包括以下内容：
Appropriate hand hygiene 适当的手部卫生
Use of personal protective equipment (e.g., gloves, gowns, masks, eyewear) whenever infectious material exposure may occur 在可能接触传染性物质时使用个人防护设备（如手套、防护服、口罩、眼镜等
Appropriate patient placement and care using transmission-based precautions when indicated 适当安置和护理病人，必要时使用基于传播的预防措施
Respiratory hygiene/cough etiquette 呼吸道卫生/咳嗽礼仪
Proper handling and cleaning of environment, equipment, and devices 正确处理和清洁环境、设备和装置
Safe handling of laundry 安全处理衣物
Sharps safety (i.e., engineering and work practice controls) 利器安全（即工程和工作方法控制）
Aseptic technique for invasive nursing procedures such as parenteral medication administration ^(7){ }^{7} 侵入性护理程序的无菌技术，例如肠外给药 ^(7){ }^{7}
Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 《美国疾病控制和预防中心。(2016 年 1 月 26 日）。所有患者护理的标准预防措施》。https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html。
“hand-disinfection-4954840_960_720.jpg” by KlausHausmann is licensed under CCO "Hand-disinfection-4954840_960_720.jpg" by KlausHausmann is licensed under CCO
Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. 美国疾病控制和预防中心。(2016 年 1 月 26 日）。所有患者护理的标准预防措施。
Figure 9.17 Components of Standard Precautions 图 9.17 标准预防措施的组成部分
HAND HYGIENE 手部卫生
Hand hygiene, although simple, is still the best and most effective way to prevent the spread of infection. The 2021 National Patient Safety Goals from The Joint Commission encourages infection prevention strategy practices such as implementing the hand hygiene guidelines from the Centers for Disease Control. ^(8){ }^{8} Accepted methods for hand hygiene include using either soap and water or alcohol-based hand sanitizer. It is essential for all health care workers to use proper hand hygiene at the appropriate times, such as the following: 手部卫生虽然简单，但仍然是预防感染传播的最佳和最有效的方法。联合委员会制定的《2021 年国家患者安全目标》鼓励采取预防感染的策略，如执行美国疾病控制中心的手部卫生指南。 ^(8){ }^{8} 公认的手部卫生方法包括使用肥皂和水或酒精洗手液。所有医护人员都必须在适当的时候使用正确的手部卫生方法，例如以下方法：
Immediately before touching a patient 接触病人前
Before performing an aseptic task or handling invasive devices 在执行无菌任务或处理有创设备之前
Before moving from a soiled body site to a clean body site on a patient 在将患者身上的脏污部位移至清洁部位之前
After touching a patient or their immediate environment 接触病人或其周围环境后
After contact with blood, body fluids, or contaminated surfaces (with or without glove use) 接触血液、体液或受污染表面后（无论是否使用手套）
. Immediately after glove removal ^(9){ }^{9} .摘下手套后立即 ^(9){ }^{9} .
Hand hygiene also includes health care workers keeping their nails short with tips less than 0.5 inches and no nail polish. Nails should be natural, and artificial nails or tips should not be worn. Artificial nails and chipped nail polish have been associated with a higher level of pathogens carried on the hands of the nurse despite hand hygiene. ^(10){ }^{10} 手部卫生还包括医护人员保持指甲短，指甲尖小于 0.5 英寸，不涂指甲油。指甲应自然，不应佩戴人造指甲或指甲尖。人工指甲和指甲油脱落与护士手上携带的病原体水平较高有关，尽管手部卫生状况良好。 ^(10){ }^{10}
Read more about using appropriate hand hygiene in the “Aseptic Technique” chapter in Open RN Nursing Skills. 请阅读《开放式注册护士护理技能》中 "无菌技术 "一章中有关使用适当手部卫生的更多内容。
RESPIRATORY HYGIENE/COUGH ETIQUETTE 呼吸道卫生/咳嗽礼仪
Respiratory hygiene is targeted at patients, accompanying family members and friends, and staff members with undiagnosed transmissible respiratory infections. It applies to any person with signs of illness, including cough, congestion, or increased production of respiratory secretions when entering a health care facility. The elements of respiratory hygiene include the following: 呼吸道卫生针对的是患有未确诊的传染性呼吸道感染的病人、陪同家属和朋友以及工作人员。它适用于任何在进入医疗机构时出现咳嗽、鼻塞或呼吸道分泌物增多等疾病征兆的人。呼吸道卫生的要素包括以下内容：
Education of health care facility staff, patients, and visitors 对医疗机构工作人员、病人和来访者进行教育
Posted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends 用适合服务人群的语言张贴标语，向病人和陪同的家属或朋友提供说明
Source control measures for a coughing person (e.g., covering the mouth/ 对咳嗽者采取源控制措施（例如，捂住口/鼻）。
Centers for Disease Control and Prevention. (2019, April 29). Hand hygiene in healthcare settings. https://www.cdc.gov/handhygiene/ 美国疾病控制和预防中心。(2019 年 4 月 29 日）。医疗机构的手部卫生。https://www.cdc.gov/handhygiene/。
Blackburn, L., Acree, K., Bartley, J., DiGiannantoni, E., Renner, E., & Sinnott, L. T. (2020). Microbial growth on the nails of direct patient care nurses wearing nail polish. Nursing Oncology Forum, 47(2), 155-164. https://doi.org/ 10.1188/20.onf.155-164 Blackburn, L., Acree, K., Bartley, J., DiGiannantoni, E., Renner, E., & Sinnott, L. T. (2020)。涂指甲油的病人直接护理护士指甲上的微生物生长。护理肿瘤论坛》，47（2），155-164。https://doi.org/ 10.1188/20.onf.155-164。
nose with a tissue when coughing and prompt disposal of used tissues, or applying surgical masks on the coughing person to contain secretions) 咳嗽时用纸巾擦鼻涕，及时处理用过的纸巾，或给咳嗽者戴上外科口罩以防止分泌物进入鼻腔）。
Hand hygiene after contact with one’s respiratory secretions 接触呼吸道分泌物后的手部卫生
Spatial separation, ideally greater than 3 feet, of persons with respiratory infections in common waiting areas when possible" 在可能的情况下，在公共等候区将患有呼吸道感染的人分开，空间距离最好大于 3 英尺"。
Health care personnel are advised to wear a mask and use frequent hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Health care personnel who have a respiratory infection are advised to stay home or avoid direct patient contact, especially with highrisk patients. If this is not possible, then a mask should be worn while providing patient care. 建议医护人员在检查和护理有呼吸道感染症状和体征的患者时戴口罩并经常进行手部卫生。建议患有呼吸道感染的医护人员待在家里或避免直接接触病人，尤其是高危病人。如果做不到这一点，则应在护理病人时佩戴口罩。
PERSONAL PROTECTIVE EQUIPMENT 个人防护设备
Personal Protective Equipment (PPE) includes gloves, gowns, face shields, goggles, and masks used to prevent the spread of infection to and from patients and health care providers. See Figure 9.18^(13)9.18^{13} for an image of a nurse wearing PPE. Depending upon the anticipated exposure and type of pathogen, PPE may include the use of gloves, a fluid-resistant gown, goggles or a face shield, and a mask or respirator. When used while caring for a patient with transmission-based precautions, PPE supplies are typically stored in an isolation cart next to the patient’s room. 个人防护设备 (PPE) 包括手套、防护服、面罩、护目镜和口罩，用于防止病人和医护人员之间的感染传播。护士穿戴个人防护设备的图片见图 9.18^(13)9.18^{13} 。根据预期的接触情况和病原体类型，个人防护设备可能包括使用手套、防流体病服、护目镜或面罩以及口罩或呼吸器。在护理病人时使用基于传播的预防措施时，个人防护设备用品通常存放在病人房间旁边的隔离车中。
Figure 9.18 Personal Protective Equipment 图 9.18 个人防护设备
Read more about how to properly use personal protective equipment in the “Aseptic Technique” chapter in Open RN Nursing Skills. 请阅读 Open RN Nursing Skills 中 "无菌技术 "一章中有关如何正确使用个人防护设备的更多内容。
Transmission-Based Precautions 基于传播的预防措施
In addition to standard precautions, transmission-based precautions are used for patients with documented or suspected infection of highly-transmissible pathogens, such as C. difficile (C-diff), Methicillin-resistant Staphylococcus 除标准预防措施外，对于有记录或疑似感染高传播病原体的患者，如艰难梭菌（C-diff）、耐甲氧西林葡萄球菌（Methicillin-resistant Staphylococcus）、痢疾杆菌（C-diff）和耐甲氧西林葡萄球菌（Methicillin-resistant Staphylococcus）的患者，还采用基于传播的预防措施。
aureus (MRSA), Vancomycin-resistant enterococci (VRE), Respiratory Syncytial Virus (RSV), measles, and tuberculosis (TB). For patients with these types of pathogens, standard precautions are used along with specific transmissionbased precautions. ^(14){ }^{14} 金黄色葡萄球菌 (MRSA)、耐万古霉素肠球菌 (VRE)、呼吸道合胞病毒 (RSV)、麻疹和结核病 (TB)。对于携带这些病原体的病人，除了使用标准预防措施外，还使用基于特定传播的预防措施。 ^(14){ }^{14}
There are three categories of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. Transmissionbased precautions are used when the route(s) of transmission of a specific disease are not completely interrupted using standard precautions alone. 基于传播的预防措施分为三类：接触预防措施、飞沫预防措施和空气传播预防措施。当仅使用标准预防措施无法完全阻断特定疾病的传播途径时，就会使用基于传播的预防措施。
Some diseases, such as tuberculosis, have multiple routes of transmission so more than one transmission-based precaution category must be implemented. See Table 9.6 outlining the categories of transmission precautions with associated PPE and other precautions. When possible, patients with transmission-based precautions should be placed in a single occupancy room with dedicated patient care equipment (e.g., blood pressure cuffs, stethoscope, and thermometer stay in the patient’s room). A card is posted outside the door alerting staff and visitors to required precautions before entering the room. See Figure 9.19^(15)9.19^{15} for an example of signage used for a patient with contact precautions. Transport of the patient and unnecessary movement outside the patient room should be limited. When transmissionbased precautions are implemented, it is also important for the nurse to make efforts to counteract possible adverse effects of these precautions on patients, such as anxiety, depression, perceptions of stigma, and reduced contact with clinical staff. ^(16){ }^{16} 有些疾病（如结核病）有多种传播途径，因此必须采取不止一种基于传播的预防措施。请参见表 9.6，其中列出了与相关个人防护设备和其他预防措施有关的传播预防措施类别。在可能的情况下，应将采取基于传播的预防措施的病人安置在单人病房，并配备专用的病人护理设备（例如，血压袖带、听诊器和体温计放在病人的房间里）。门外张贴卡片，提醒工作人员和访客在进入病房前注意所需的预防措施。请参阅图 9.19^(15)9.19^{15} ，了解接触性预防措施患者所用标识的示例。应限制运送病人和在病房外不必要的移动。在实施基于传播的预防措施时，护士还必须努力消除这些预防措施可能对患者造成的不良影响，如焦虑、抑郁、耻辱感以及减少与临床工作人员的接触。 ^(16){ }^{16}
Table 9.6 Transmission-Based Precautions ^(17){ }^{17} 表 9.6 基于传播的预防措施 ^(17){ }^{17}
14. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 15. “Contact_Precautions_poster.pdf” by U.S. Centers for Disease Control and Prevention is in the Public Domain 16. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 14.Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee.(2019, July 22).2007 隔离预防指南：https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 15。"Contact_Precautions_poster.pdf" by U.S. Centers for Disease Control and Prevention is in the Public Domain 16.Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee.(2019, July 22).2007 隔离预防指南：https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
17. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2019, July 22). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 17.Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee.(2019, July 22).2007 隔离预防指南：https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
Precaution 注意事项
Implementation 实施
PPE and Other Precautions 个人防护设备和其他预防措施
Contact 联系方式
Known or suspected infections with increased risk for contact transmission (e.g., draining wounds, fecal incontinence) or with epidemiologically important organisms, such as C-diff, MRSA, VRE, or RSV 已知或疑似感染会增加接触传播的风险（如引流伤口、大便失禁），或感染具有流行病学意义的病原体，如 C-diff、MRSA、VRE 或 RSV。
注意：艰难梭菌感染患者的手部卫生只能使用肥皂和水。
Gloves
Gown
Dedicated equipment
Limit patient transport out of room
Prioritized disinfection of the room
Note: Use only soap and water for hand hygiene in patients with C. difficile infection.
Gloves
Gown
Dedicated equipment
Limit patient transport out of room
Prioritized disinfection of the room
Note: Use only soap and water for hand hygiene in patients with C. difficile infection.| Gloves |
| :--- |
| Gown |
| Dedicated equipment |
| Limit patient transport out of room |
| Prioritized disinfection of the room |
| Note: Use only soap and water for hand hygiene in patients with C. difficile infection. |
Droplet 液滴
Known or suspected infection with pathogens transmitted by large respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis 已知或疑似感染了通过咳嗽、打喷嚏或说话产生的大量呼吸道飞沫传播的病原体，如流感或百日咳
口罩 护目镜或面罩
Mask
Goggles or face shield
Mask
Goggles or face shield| Mask |
| :--- |
| Goggles or face shield |
Airborne 空降
Known or suspected infection with pathogens transmitted by small respiratory droplets, such as measles and coronavirus 已知或疑似感染通过小呼吸飞沫传播的病原体，如麻疹和冠状病毒
Precaution Implementation PPE and Other Precautions
Contact Known or suspected infections with increased risk for contact transmission (e.g., draining wounds, fecal incontinence) or with epidemiologically important organisms, such as C-diff, MRSA, VRE, or RSV "Gloves
Gown
Dedicated equipment
Limit patient transport out of room
Prioritized disinfection of the room
Note: Use only soap and water for hand hygiene in patients with C. difficile infection."
Droplet Known or suspected infection with pathogens transmitted by large respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis "Mask
Goggles or face shield"
Airborne Known or suspected infection with pathogens transmitted by small respiratory droplets, such as measles and coronavirus "Fit-tested N-95 respirator
Airborne infection isolation room
Single-patient room
Patient door closed
Restricted susceptible personnel room entry"| Precaution | Implementation | PPE and Other Precautions |
| :--- | :--- | :--- |
| Contact | Known or suspected infections with increased risk for contact transmission (e.g., draining wounds, fecal incontinence) or with epidemiologically important organisms, such as C-diff, MRSA, VRE, or RSV | Gloves <br> Gown <br> Dedicated equipment <br> Limit patient transport out of room <br> Prioritized disinfection of the room <br> Note: Use only soap and water for hand hygiene in patients with C. difficile infection. |
| Droplet | Known or suspected infection with pathogens transmitted by large respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis | Mask <br> Goggles or face shield |
| Airborne | Known or suspected infection with pathogens transmitted by small respiratory droplets, such as measles and coronavirus | Fit-tested N-95 respirator <br> Airborne infection isolation room <br> Single-patient room <br> Patient door closed <br> Restricted susceptible personnel room entry |
Several principles are used to guide transport of patients requiring transmission-based precautions. In the inpatient and residential settings, these principles include the following: 有几项原则用于指导运送需要采取传播预防措施的病人。在住院和寄宿环境中，这些原则包括以下内容：
Limit transport for essential purposes only, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s room 将转运仅限于必要目的，如无法在病房内进行的诊断和治疗程序
When transporting, use appropriate barriers on the patient consistent with the route and risk of transmission (e.g., mask, gown, covering the affected areas when infectious skin lesions or drainage is present) 转运时，根据传播途径和风险对患者使用适当的屏障（如口罩、隔离衣、出现传染性皮损或引流时遮盖患处等）
Notify health care personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission ^(18){ }^{18} 通知接收区域的医护人员病人即将到达，并通知他们采取必要的预防措施防止传播 ^(18){ }^{18} .
ENTERIC PRECAUTIONS 肠道预防措施
Enteric precautions are used when there is the presence, or suspected presence, of gastrointestinal pathogens such as Clostridium difficile (C-diff) or norovirus. These pathogens are present in feces, so health care workers should always wear a gown in the patient room to prevent inadvertent fecal contamination of their clothing from contact with contaminated surfaces. 当出现或怀疑出现艰难梭菌（C-diff）或诺如病毒等胃肠道病原体时，就需要采取肠道预防措施。这些病原体存在于粪便中，因此医护人员在病房内应始终穿着病号服，以防止他们的衣物因接触受污染的表面而不慎被粪便污染。
In addition to contact precautions, enteric precautions include the following: 除接触预防措施外，肠道预防措施还包括以下内容：
Using only soap and water for hand hygiene. Do not use hand sanitizer because it is not effective against C-diff. 只使用肥皂和水进行手部卫生。不要使用洗手液，因为它对 C-diff 无效。
Using a special disinfecting process. Special disinfecting should be used after patient discharge and includes disinfection of the mattress. 使用特殊消毒程序。病人出院后应进行特殊消毒，包括床垫消毒。
REVERSE ISOLATION 反向隔离
Reverse isolation, also called neutropenic precautions, is used for patients who have compromised immune systems and low neutrophil levels. This type 逆向隔离也称为中性粒细胞预防措施，用于免疫系统受损和中性粒细胞水平较低的患者。这种类型
of isolation protects the patient from pathogens in their environment. In addition to using contact precautions to protect the patient, reverse isolation precautions include the following: 反向隔离可保护病人免受环境中病原体的感染。除了使用接触预防措施保护病人外，反向隔离预防措施还包括以下内容：
Meticulous hand hygiene by all visitors, staff, and the patient 所有来访者、工作人员和病人都要注意手部卫生
Frequently monitoring for signs and symptoms of infection and sepsis 经常监测感染和败血症的症状和体征
Not allowing live plants, fresh flowers, fresh raw fruits or vegetables, sushi, deli foods, or cheese into the room due to bacteria and fungi 由于细菌和真菌的存在，禁止将活植物、新鲜花卉、新鲜生水果或蔬菜、寿司、熟食或奶酪带入室内
Placement in a private room or a positive pressure room 安置在单人病房或正压病房
Limited transport and movement of the patient outside of the room 病人在病房外的运送和移动受到限制
Masking of the patient for transport with a surgical mask ^(19){ }^{19} 用外科口罩为病人戴上口罩以便转运 ^(19){ }^{19}
Read additional information about Neutropenia and Risk for Infection. 阅读有关中性粒细胞减少症和感染风险的更多信息。
PSYCHOLOGICAL EFFECTS OF ISOLATION 隔离的心理影响
Although the use of transmission-based precautions is needed to prevent the spread of infection, it is important for nurses to be aware of the potential psychological impact on the patient. Research has shown that isolation can cause negative impact on patient mental well-being and behavior, including higher scores for depression, anxiety, and anger among isolated patients. It has also been found that health care workers spend less time with patients in isolation, resulting in a negative impact on patient safety. ^(20){ }^{20} 虽然需要使用基于传播的预防措施来防止感染传播，但护士必须意识到对病人的潜在心理影响。研究表明，隔离会对患者的心理健康和行为造成负面影响，包括隔离患者的抑郁、焦虑和愤怒评分较高。研究还发现，医护人员花在隔离病人身上的时间更少，从而对病人的安全产生负面影响。 ^(20){ }^{20}
Patient and family education at the time of instituting transmission-based precautions is a critical component of the process to reduce anxiety and distress. Patients often feel stigmatized when placed in isolation, so it is important for them to understand the rationale of the precautions to keep themselves and others free from the spread of disease. Preparing patients 在实施基于传播的预防措施时，对患者和家属进行教育是减少焦虑和痛苦的关键环节。患者在被隔离时往往会感到耻辱，因此让他们了解采取预防措施的理由，使自己和他人免受疾病传播的影响非常重要。让患者做好准备
19. Centers for Disease Control and Prevention. (n.d.). What you need to know: Neutropenia and risk for infection. https://www.cdc.gov/cancer/preventinfections/pdf/neutropenia.pdf 19.疾病控制和预防中心。(n.d.).你需要知道的：中性粒细胞减少症与感染风险。https://www.cdc.gov/cancer/preventinfections/pdf/neutropenia.pdf。
20. U.S. Department of Health and Human Services. (2020, January 15). Health care-associated infections. https://health.gov/our-work/health-care-quality/health-care-associated-infections 20.美国卫生与公众服务部。(2020, January 15).https://health.gov/our-work/health-care-quality/health-care-associated-infections
emotionally will also help decrease their anxiety and help them cope with isolation. ^(21){ }^{21} It is also important to provide distractions from boredom, such as music, television, video games, magazines, or books, as appropriate. 情绪化也有助于减少他们的焦虑，帮助他们应对孤独。 ^(21){ }^{21} 同样重要的是，要适当地转移他们的注意力，如音乐、电视、电子游戏、杂志或书籍。
Aseptic and Sterile Techniques 无菌和无菌技术
In addition to using standard precautions and transmission-based precautions, aseptic technique (also called medical asepsis) is used to prevent the transfer of microorganisms from one person or object to another during a medical procedure. For example, a nurse administering parenteral medication or performing urinary catheterization uses aseptic technique. When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. It is important to remember that potentially infectious microorganisms can be present in the environment, on instruments, in liquids, on skin surfaces, or within a wound. ^(22){ }^{22} 除了使用标准预防措施和基于传播的预防措施外，无菌技术（也称为医用无菌技术）还用于防止医疗过程中微生物从一个人或物体转移到另一个人或物体。例如，护士在给病人注射肠外药物或进行导尿时就会使用无菌技术。如果操作得当，无菌技术可以防止在常规护理或程序中，护理人员的手、物体表面和设备受到污染或将病原体传染给病人。重要的是要记住，潜在的传染性微生物可能存在于环境中、器械上、液体中、皮肤表面或伤口内。 ^(22){ }^{22}
There is often misunderstanding between the terms aseptic technique and sterile technique in the health care setting. Both asepsis and sterility are closely related with the shared concept being the removal of harmful microorganisms that can cause infection. In the most simplistic terms, aseptic technique involves creating a protective barrier to prevent the spread of pathogens, whereas sterile technique is a purposeful attack on microorganisms. Sterile technique (also called surgical asepsis) seeks to eliminate every potential microorganism in and around a sterile field while also maintaining objects as free from microorganisms as possible. Sterile fields are implemented during surgery, as well as during nursing procedures such as the insertion of a urinary catheter, changing dressings on open wounds, and performing central line care. See Figure 9.20^(23)9.20^{23} for an image of a 在医疗环境中，无菌技术和无菌技术这两个术语之间经常存在误解。无菌和无菌技术密切相关，共同的概念是清除可导致感染的有害微生物。用最简单的话来说，无菌技术就是建立一个保护屏障，防止病原体传播，而无菌技术则是有目的地攻击微生物。无菌技术（也称为外科无菌术）旨在消除无菌区域内和周围的所有潜在微生物，同时尽可能保持物体不含微生物。无菌区在外科手术以及插入导尿管、为开放性伤口更换敷料和进行中心静脉护理等护理程序中都要使用。请参阅图 9.20^(23)9.20^{23} 了解无菌区域的图像。
21. U.S. Department of Health and Human Services. (2020, January 15). Health care-associated infections. https://health.gov/our-work/health-care-quality/health-care-associated-infections 21.美国卫生与公众服务部。(2020, January 15).https://health.gov/our-work/health-care-quality/health-care-associated-infections
22. Centers for Disease Control and Prevention. (2020, August 10). Glossary of terms for infection prevention and control in dental settings. https://www.cdc.gov/oralhealth/infectioncontrol/glossary.htm 22.疾病控制和预防中心。(2020 年 8 月 10 日）。牙科感染预防与控制术语表》。https://www.cdc.gov/oralhealth/infectioncontrol/glossary.htm。
23. “226589236-huge.jpg” by TORWAISTUDIO is used under license from Shutterstock.com 23."226589236-huge.jpg "由 TORWAISTUDIO 在 Shutterstock.com 的许可下使用。
sterile field during surgery. Sterile technique requires a combination of meticulous hand washing, creating and maintaining a sterile field, using long-lasting antimicrobial cleansing agents such as Betadine, donning sterile gloves, and using sterile devices and instruments. 手术过程中的无菌区域。无菌技术要求将认真洗手、创建和维护无菌区域、使用长效抗菌清洁剂（如倍他丁）、佩戴无菌手套以及使用无菌设备和器械结合起来。
Figure 9.20 Surgical Asepsis 图 9.20 外科无菌操作
Read additional information about aseptic and sterile technique in the “Aseptic Technique” in Open RN Nursing Skills. 在开放式注册护士护理技能中的 "无菌技术 "中阅读有关无菌和无菌技术的更多信息。
24. This work is a derivative of StatPearls by Tennant and Rivers and is licensed under CC BY 4.0. 24.本作品是 Tennant 和 Rivers 的 StatPearls 的衍生作品，采用 CC BY 4.0 许可。
"Read a continuing education article about Sterile Technique and surgical scrubbing. "阅读有关无菌技术和手术擦洗的继续教育文章。
Other Hygienic Patient Care Interventions 其他病人护理卫生干预措施
In addition to implementing standard and transmission-based precautions and utilizing aseptic and sterile technique when performing procedures, nurses implement many interventions to place a patient in the best health possible to prevent an infection or treat infection. These interventions include actions like encouraging rest and good nutrition, teaching stress management, providing good oral care, encouraging daily bathing, and changing linens. It is also important to consider how gripper socks, mobile devices, and improper glove usage can contribute to the transmission of pathogens. 除了实施标准预防措施和基于传播的预防措施，以及在执行程序时使用无菌和无菌技术外，护士还实施许多干预措施，尽可能使病人处于最佳健康状态，以预防感染或治疗感染。这些干预措施包括鼓励休息和良好的营养、教导压力管理、提供良好的口腔护理、鼓励每天洗澡和更换床单等。同样重要的是要考虑抓握袜、移动设备和手套的不当使用会如何导致病原体的传播。
ORAL CARE 口腔护理
Patient hygiene is important in the prevention and spread of infection. Although oral care may be given a low priority, research has found that poor oral care is associated with the spread of infection, poor health outcomes, and poor nutrition. Oral care should be performed in the morning, after meals, and before bed. ^(25){ }^{25} 患者卫生对预防和传播感染非常重要。虽然口腔护理可能不被重视，但研究发现，不良的口腔护理与感染传播、不良的健康状况和营养不良有关。口腔护理应在早晨、饭后和睡前进行。 ^(25){ }^{25}
DAILY BATHING 每天沐浴
Daily bathing is another intervention that may be viewed as time-consuming and receive low priority, but it can have a powerful impact on decreasing the spread of infection. Studies have shown a significant decrease in healthcareassociated infections with daily bathing using chlorhexidine gluconate (CHG) 日常沐浴是另一项可能被视为耗时且优先级较低的干预措施，但它对减少感染传播有很大影响。研究表明，使用葡萄糖酸氯己定 (CHG) 进行日常沐浴可显著减少与医疗保健相关的感染。
wipes or solution. The use of traditional soap and water baths do not reduce infection rates as significantly as CHG products, and wash basins have also been shown to be a reservoir for pathogens. 抹布或溶液。使用传统的肥皂和水浴盆并不能像使用 CHG 产品那样显著降低感染率，而且洗脸盆也被证明是病原体的储存库。
LINENS 床单
Changing bed linens, towels, and a gown regularly eliminates potential reservoirs of bacteria. Fresh linens also promote patient comfort. 定期更换床单、毛巾和病号服可消除潜在的细菌库。新鲜的床单还能提高病人的舒适度。
GRIPPER SOCKS 防滑袜
Have you ever thought about what happens to the bed linens when a patient returns from a walk in the hallway with gripper socks and gets back into bed with these socks? Research demonstrates that pathogens from the floor are transferred to the patient bed linens from the gripper socks. Nurses should remove gripper socks that were used for walking before patients climb into bed. They should also throw the socks away when the patient is discharged instead of sending them home. ^(27){ }^{27} 您是否想过，当病人穿着抓袜在走廊里走了一圈后回到床上时，床单会发生什么变化？研究表明，地板上的病原体会从抓握袜转移到病人的床单上。护士应在病人爬上床之前脱掉用于行走的抓握袜。病人出院时，护士也应将袜子扔掉，而不是送回家。 ^(27){ }^{27}
CELLULAR PHONES AND MOBILE DEVICES 手机和移动设备
Research has shown that cell phones and mobile devices carry many pathogens and are dirtier than a toilet seat or the bottom of a shoe. Patients, staff, and visitors routinely bring these mobile devices into health care facilities, which can cause the spread of disease. Nurses should frequently wipe mobile devices with disinfectant. They should encourage patients and visitors to disinfect phones frequently and avoid touching the face after having touched a mobile device. 研究表明，手机和移动设备携带多种病原体，比马桶盖或鞋底还脏。病人、员工和访客经常将这些移动设备带入医疗机构，这可能会导致疾病传播。护士应经常用消毒剂擦拭移动设备。他们应鼓励患者和来访者经常消毒手机，并避免在接触过移动设备后触摸面部。
26. Salamone, K., Yacoub, E., Mahoney, A. M., & Edward, K. L. (2013). Oral care of hospitalised older patients in the acute medical setting. Nursing Research and Practice, 2013, 827670. https://doi.org/10.1155/2013/827670 26.Salamone, K., Yacoub, E., Mahoney, A. M., & Edward, K. L. (2013)。急性病住院老年患者的口腔护理》。护理研究与实践》，2013 年，827670。https://doi.org/10.1155/2013/827670。
27. Welle, M. K., Bliha, M., DeLuca, J., Frauhiger, A., & Lamichhane-Khadka, R. Bacteria on the soles of patientissued nonskid slipper socks: An overlooked pathogen spread threat? Orthopedic Nursing, 38(1), 33-40. https://doi.org/10.1097/nor.0000000000000516 27.Welle, M. K., Bliha, M., DeLuca, J., Frauhiger, A., & Lamichhane-Khadka, R. Bacteria on the soles of patientissued nonskid slipper socks：被忽视的病原体传播威胁？骨科护理》，38（1），33-40。https://doi.org/10.1097/nor.0000000000000516。
28. Morubagal, R. R., Shivappa, S. G., Mahale, R. P., & Neelambike, S. M. (2017). Study of bacterial flora associated with mobile phones of healthcare workers and non-healthcare workers. Iranian Journal of Microbiology, 9(3), 143-151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719508/ 28.Morubagal, R. R., Shivappa, S. G., Mahale, R. P., & Neelambike, S. M. (2017)。医护人员和非医护人员手机相关细菌菌群研究》。Iranian Journal of Microbiology, 9(3), 143-151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719508/
GLOVES 手套
Although gloves are used to prevent the spread of infection, they can also contribute to the spread of infection if used improperly. For example, research has shown that hand hygiene opportunities are being missed because of the overuse of gloves. For example, a nurse may don gloves to suction a patient but neglect to remove them and perform hand hygiene before performing the next procedure on the same patient. This can potentially cause the spread of secondary infection. The World Health Organization (WHO) states that gloves should be worn when there is an expected risk of exposure to blood or body fluids or to protect the hands from chemicals and hazardous drugs, but hand hygiene is the best method of disease prevention and is preferred over wearing gloves when the exposure risk is minimal. Nurses have the perception that wearing gloves provides extra protection and cleanliness. However, the opposite is true. Nonsterile gloves have a high incidence of contamination with a range of bacteria, which means that a gloved hand is dirtier than a washed hand. Research has shown that nearly 40% of the times that gloves are used in patient care, there is cross contamination. The most striking example of cross contamination includes situations when gloves are used for toileting a patient and not being removed before touching other surfaces or the patient. ^(29,30,31){ }^{29,30,31} 虽然手套是用来防止感染传播的，但如果使用不当，也会造成感染传播。例如，研究表明，由于过度使用手套，手部卫生的机会被错过了。例如，护士可能会戴上手套为病人吸痰，但却忽略了在为同一病人进行下一个程序之前摘下手套并进行手部卫生。这有可能造成二次感染。世界卫生组织（WHO）指出，当预计有接触血液或体液的风险时，或为了保护双手免受化学品和危险药物的伤害时，应佩戴手套，但手部卫生是预防疾病的最佳方法，当接触风险很小时，最好不要佩戴手套。护士们认为戴手套能提供额外的保护和清洁。然而，事实恰恰相反。未经消毒的手套很容易受到各种细菌的污染，这意味着戴手套的手比洗过的手更脏。研究表明，在病人护理过程中，近 40% 的手套会造成交叉感染。交叉感染最明显的例子包括在给病人上厕所时使用手套，但在接触其他物体表面或病人之前没有摘下手套。 ^(29,30,31){ }^{29,30,31}
Glove-related contact dermatitis has also become an important issue in recent years as more and more nurses are experiencing damage to the hands. Contact dermatitis can develop from repeated use of gloves and develops as dry, itchy, irritated areas on the skin of the hands. See Figure 9.21^(32)9.21^{32} for an image of contact dermatitis from gloves. Because the skin is the first 近年来，随着越来越多的护士手部受到损伤，与手套有关的接触性皮炎也成为一个重要问题。接触性皮炎可因反复使用手套而产生，表现为手部皮肤出现干燥、瘙痒和刺激性区域。手套引起接触性皮炎的图片见图 9.21^(32)9.21^{32} 。因为皮肤是第一个
29. Burdsall, D. P., Gardner, S. E., Cox, T., Schweizer, M., Culp, K. R., Steelman, V. M., & Herwaldt, L. A. (2017). Exploring inappropriate certified nursing assistant glove use in long-term care. American Journal of Infection Control, 45(9), 940-945. https://doi.org/10.1016/j.ajic.2017.02.017 29.Burdsall, D. P., Gardner, S. E., Cox, T., Schweizer, M., Culp, K. R., Steelman, V. M., & Herwaldt, L. A. (2017).探究长期护理中护理助理手套的不当使用。美国感染控制杂志》，45（9），940-945。https://doi.org/10.1016/j.ajic.2017.02.017。
30. Jain, S., Clezy, K., & McLaws, M. L. Glove: Use for safety or overuse? American Journal of Infection Control, 45(12), 1407-1410. https://doi.org/10.1016/j.ajic.2017.08.029 30.Jain, S., Clezy, K., & McLaws, M. L. Glove：安全使用还是过度使用？美国感染控制杂志》，45（12），1407-1410。https://doi.org/10.1016/j.ajic.2017.08.029。
31. Welle, M. K., Bliha, M., DeLuca, J., Frauhiger, A., & Lamichhane-Khadka, R. Bacteria on the soles of patientissued nonskid slipper socks: An overlooked pathogen spread threat? Orthopedic Nursing, 38(1), 33-40. https://doi.org/10.1097/nor.0000000000000516 31.Welle, M. K., Bliha, M., DeLuca, J., Frauhiger, A., & Lamichhane-Khadka, R. Bacteria on the soles of patientissued nonskid slipper socks：被忽视的病原体传播威胁？骨科护理》，38（1），33-40。https://doi.org/10.1097/nor.0000000000000516。
32. “Dermatitis2015.jpg” by James Heilman, MD is licensed under CC BY-SA 4.0 32."皮炎 2015.jpg "由医学博士詹姆斯-海尔曼（James Heilman）以 CC BY-SA 4.0 许可发布。
line of defense in preventing pathogens from entering the body, maintaining intact skin is very important to prevent nurses from exposure to pathogens. 皮肤是防止病原体进入人体的第一道防线，因此保持皮肤完好对防止护士接触病原体非常重要。
Now that we have discussed the pathophysiology of our immune system and interventions to treat and prevent infection, let’s apply this information to using the nursing process when providing patient care. 现在，我们已经讨论了免疫系统的病理生理学以及治疗和预防感染的干预措施，让我们在为患者提供护理时将这些信息应用到护理流程中。
Assessment 评估
When assessing an individual who is feeling ill but has not yet been diagnosed with an infection, general symptoms associated with the prodromal period of disease may be present due to the activation of the immune system. These symptoms include a feeling of malaise (not feeling well), headache, fever, and lack of appetite. As an infection moves into the acute phase of disease, more specific symptoms and signs related to the specific type of infection will occur. 在对感觉不适但尚未确诊感染的患者进行评估时，由于免疫系统的激活，可能会出现与疾病前驱期相关的一般症状。这些症状包括乏力（不舒服）、头痛、发烧和食欲不振。当感染进入疾病的急性期时，会出现与特定感染类型有关的更具体的症状和体征。
A fever is a common sign of inflammation and infection. A temperature of 38 degrees Celsius ( 100.4 degrees F) is generally considered a low-grade fever, and a temperature of 38.3 degrees Celsius ( 101 degrees FF ) is considered a fever. As discussed earlier in this chapter, fever is part of the nonspecific innate immune response and can be beneficial in destroying pathogens. However, extremely elevated temperatures can cause cell and organ damage, and prolonged fever can cause dehydration. 发烧是炎症和感染的常见征兆。体温达到 38 摄氏度（100.4 华氏度）通常被认为是低烧，体温达到 38.3 摄氏度（101 FF ）则被认为是发烧。正如本章前面所讨论的，发烧是非特异性先天性免疫反应的一部分，有利于消灭病原体。但是，极度升高的温度会造成细胞和器官损伤，长期发烧会导致脱水。
Infection raises the metabolic rate, causing an increased heart rate. The respiratory rate may also increase as the body rids itself of carbon dioxide created during increased metabolism. However, be aware that an elevated heart rate above 90 and a respiratory rate above 20 are also criteria for systemic inflammatory response syndrome (SIRS) in patients with an existing infection. 感染会提高新陈代谢率，导致心率加快。当人体排出新陈代谢增加时产生的二氧化碳时，呼吸频率也会增加。但要注意的是，心率升高超过 90 和呼吸频率超过 20 也是已有感染的患者出现全身炎症反应综合征（SIRS）的标准。
As an infection develops, the lymph nodes that drain that area often become 随着感染的发展，引流该区域的淋巴结通常会变得
enlarged and tender. The swelling indicates that the lymphocytes and macrophages in the lymph node are fighting the infection. If a skin infection is developing, general signs of inflammation, such as redness, warmth, swelling, and tenderness, will occur at the site. As white blood cells migrate to the site, purulent drainage may occur. 肿大和触痛。肿胀表明淋巴结中的淋巴细胞和巨噬细胞正在与感染作斗争。如果正在发生皮肤感染，感染部位会出现发红、发热、肿胀和触痛等一般炎症症状。随着白细胞迁移到感染部位，可能会出现脓性引流。
Some viruses, bacteria, and toxins cause gastrointestinal inflammation, resulting in loss of appetite, nausea, vomiting, and diarrhea. 一些病毒、细菌和毒素会引起胃肠道炎症，导致食欲不振、恶心、呕吐和腹泻。
See Table 9.7a for a comparison of expected findings on physical assessment versus unexpected findings indicating a new infectious process that requires notification of the health care provider. 请参见表 9.7a，比较身体评估的预期结果与表明需要通知医疗服务提供者的新感染过程的意外结果。
Table 9.7a Expected Versus Unexpected Findings on Assessment Related to Infection 表 9.7a 与感染有关的预期评估结果和意外评估结果
Assessment 评估
Expected Findings 预期结果
Unexpected Findings to Report to Health Care Provider 向医护人员报告意外发现
Vital Signs 生命体征
Within normal range 在正常范围内
New temperature over 100.4 F or 38 C. 新温度超过 100.4 华氏度或 38 摄氏度。
Neurological 神经系统
Within baseline level of consciousness 在基线意识水平内
New confusion and/or worsening level of consciousness. 新的意识模糊和/或意识水平恶化。
Wound or Incision 伤口或切口
Progressive healing of a wound with no signs of infection 伤口逐渐愈合，无感染迹象
New redness, warmth, tenderness, or purulent drainage from a wound. 伤口出现新的发红、发热、触痛或脓性分泌物。
Respiratory 呼吸系统
No cough or production of sputum 不咳嗽、不咳痰
New cough and/or productive cough of purulent sputum. Adventitious breath sounds (crackles, rhonchi, wheezing). New dyspnea. 新的咳嗽和/或有脓痰的有痰咳嗽。出现呼吸音（噼啪声、哮鸣音、喘鸣音）。新的呼吸困难。
Genitourinary 泌尿生殖系统
Urine clear, light yellow without odor 尿液清澈，淡黄色，无异味
Malodorous, cloudy, bloody urine, with increased frequency, urgency, or pain with urination. 尿液恶臭、混浊、带血，尿频、尿急或尿痛加剧。
Gastrointestinal 胃肠道
Good appetite and food intake; feces formed and brown 食欲和进食量良好；粪便成形且呈棕色
Loss of appetite. Nausea and vomiting. Diarrhea; discolored or unusually malodorous feces. 食欲不振。恶心和呕吐。腹泻；粪便变色或异常恶臭。
Assessment Expected Findings Unexpected Findings to Report to Health Care Provider
Vital Signs Within normal range New temperature over 100.4 F or 38 C.
Neurological Within baseline level of consciousness New confusion and/or worsening level of consciousness.
Wound or Incision Progressive healing of a wound with no signs of infection New redness, warmth, tenderness, or purulent drainage from a wound.
Respiratory No cough or production of sputum New cough and/or productive cough of purulent sputum. Adventitious breath sounds (crackles, rhonchi, wheezing). New dyspnea.
Genitourinary Urine clear, light yellow without odor Malodorous, cloudy, bloody urine, with increased frequency, urgency, or pain with urination.
Gastrointestinal Good appetite and food intake; feces formed and brown Loss of appetite. Nausea and vomiting. Diarrhea; discolored or unusually malodorous feces.| Assessment | Expected Findings | Unexpected Findings to Report to Health Care Provider |
| :--- | :--- | :--- |
| Vital Signs | Within normal range | New temperature over 100.4 F or 38 C. |
| Neurological | Within baseline level of consciousness | New confusion and/or worsening level of consciousness. |
| Wound or Incision | Progressive healing of a wound with no signs of infection | New redness, warmth, tenderness, or purulent drainage from a wound. |
| Respiratory | No cough or production of sputum | New cough and/or productive cough of purulent sputum. Adventitious breath sounds (crackles, rhonchi, wheezing). New dyspnea. |
| Genitourinary | Urine clear, light yellow without odor | Malodorous, cloudy, bloody urine, with increased frequency, urgency, or pain with urination. |
| Gastrointestinal | Good appetite and food intake; feces formed and brown | Loss of appetite. Nausea and vomiting. Diarrhea; discolored or unusually malodorous feces. |
*CRITICAL CONDITIONS requiring immediate notification of the provider and/or implementation of a sepsis protocol:
Two or more of the following criteria in a patient with an existing infection indicate SIRS:
- Body temperature over 38 or under 36 degrees Celsius
- Heart rate greater than 90 beats/minute
- Respiratory rate greater than 20
*CRITICAL CONDITIONS requiring immediate notification of the provider and/or implementation of a sepsis protocol:
Two or more of the following criteria in a patient with an existing infection indicate SIRS:
- Body temperature over 38 or under 36 degrees Celsius
- Heart rate greater than 90 beats/minute
- Respiratory rate greater than 20| *CRITICAL CONDITIONS requiring immediate notification of the provider and/or implementation of a sepsis protocol: |
| :--- |
| Two or more of the following criteria in a patient with an existing infection indicate SIRS: |
| - Body temperature over 38 or under 36 degrees Celsius |
| - Heart rate greater than 90 beats/minute |
| - Respiratory rate greater than 20 |
"*CRITICAL CONDITIONS requiring immediate notification of the provider and/or implementation of a sepsis protocol:
Two or more of the following criteria in a patient with an existing infection indicate SIRS:
- Body temperature over 38 or under 36 degrees Celsius
- Heart rate greater than 90 beats/minute
- Respiratory rate greater than 20"| | | *CRITICAL CONDITIONS requiring immediate notification of the provider and/or implementation of a sepsis protocol: <br> Two or more of the following criteria in a patient with an existing infection indicate SIRS: <br> - Body temperature over 38 or under 36 degrees Celsius <br> - Heart rate greater than 90 beats/minute <br> - Respiratory rate greater than 20 |
| :--- | :--- | :--- |
Life Span Considerations 寿命考虑因素
Infants do not have well-developed immune systems, placing this group at higher risk of infection. Breastfeeding helps protect infants from some infectious diseases by providing passive immunity until their immune system matures. New mothers should be encouraged to breastfeed their newborns. ^(2){ }^{2} 婴儿的免疫系统尚未发育完善，因此感染风险较高。在婴儿的免疫系统发育成熟之前，母乳喂养可提供被动免疫，从而保护婴儿免受某些传染病的感染。应鼓励新妈妈用母乳喂养新生儿。 ^(2){ }^{2}
On the other end of the continuum, the immune system gradually decreases in effectiveness with age, making older adults also more vulnerable to infection. Early detection of infection can be challenging in older adults because they may not have a fever or increased white blood cell count (WBC), but instead develop subtle changes like new mental status changes. ^(3){ }^{3} The 另一方面，随着年龄的增长，免疫系统的有效性会逐渐下降，这也使得老年人更容易受到感染。由于老年人可能不会出现发烧或白细胞计数（WBC）升高的症状，而是会出现一些微妙的变化，如新的精神状态变化，因此对老年人进行早期感染检测具有挑战性。 ^(3){ }^{3}
2. Centers for Disease Control and Prevention. (2020, May 28). Breastfeeding, Frequently asked questions (FAQs). https://www.cdc.gov/breastfeeding/faq/index.htm 2.美国疾病控制和预防中心。(2020, May 28).母乳喂养，常见问题（FAQs）。https://www.cdc.gov/breastfeeding/faq/index.htm。
3. Centers for Disease Control and Prevention. (2020, May 28). Breastfeeding, Frequently asked questions (FAQs). https://www.cdc.gov/breastfeeding/faq/index.htm 3.疾病控制和预防中心。(2020, May 28).母乳喂养，常见问题（FAQs）。https://www.cdc.gov/breastfeeding/faq/index.htm。
most common infections in older adults are urinary tract infections (UTI), bacterial pneumonia, influenza, and skin infections. 老年人最常见的感染是尿路感染（UTI）、细菌性肺炎、流感和皮肤感染。
Diagnostic Tests 诊断测试
Several types of diagnostic tests may be ordered by a health care provider when a patient is suspected of having an infection, such as complete blood count with differential, Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), serum lactate levels, and blood cultures (if sepsis is suspected). Other cultures may be obtained based on the site of the suspected infection. 当患者被怀疑感染时，医疗服务提供者可能会要求患者进行几种诊断性检查，如全血细胞计数（含差值）、红细胞沉降率（ESR）、C-反应蛋白（CRP）、血清乳酸盐水平和血液培养（如果怀疑有败血症）。还可根据疑似感染部位进行其他培养。
CBC WITH DIFFERENTIAL 带差分的 cbc
When an infection is suspected, a complete blood count with differential is usually obtained. 怀疑感染时，通常要进行全血细胞计数和差值检查。
A complete blood count (CBC) includes the red blood cell count (RBC), white blood cell count (WBC), platelets, hemoglobin, and hematocrit values. A differential provides additional information, including the relative percentages of each type of white blood cell. See Figure 9.22^(4)9.22^{4} for an illustration of a complete blood count with differential. 全血细胞计数（CBC）包括红细胞计数（RBC）、白细胞计数（WBC）、血小板、血红蛋白和血细胞比容值。差值可提供更多信息，包括各类白细胞的相对百分比。请参阅图 9.22^(4)9.22^{4} ，了解带差值的全血细胞计数。
Figure 9.22 Components of a Complete Blood Count with Differential 图 9.22 带差异的全血细胞计数的组成部分
When there is an infection or an inflammatory process somewhere in the body, the bone marrow produces more WBCs (also called leukocytes), releasing them into the blood where they move to the site of infection or inflammation. An increase in white blood cells is known as leukocytosis and is a sign of the inflammatory response. The normal range of WBC varies slightly from lab to lab but is generally 4,500-11,000 for adults, reported as 4.5-11.0 x 10^(9)10^{9} per liter (L). ^(5){ }^{5} 当身体某处出现感染或炎症过程时，骨髓会产生更多的白细胞（也称为白血球），并将它们释放到血液中，然后移动到感染或炎症部位。白细胞增多被称为白细胞增多症，是炎症反应的一种表现。不同实验室的白细胞正常范围略有不同，但成人一般为 4,500-11,000，即每升（L）4.5-11.0 x 10^(9)10^{9} 。 ^(5){ }^{5}
There are five types of white blood cells, each with different functions. The differential blood count gives the relative percentage of each type of white 白细胞有五种类型，每种类型都有不同的功能。差异血细胞计数显示了每种白细胞的相对百分比。
blood cell and also reveals abnormal white blood cells. The five types of white blood cells are as follows: 白细胞检查还能发现异常的白细胞。白细胞有以下五种类型：
Neutrophils 中性粒细胞
Eosinophils 嗜酸性粒细胞
Basophils 嗜碱性粒细胞
Lymphocytes 淋巴细胞
Monocytes 单核细胞
Neutrophils make up the largest number of circulating WBCs. They move into an area of damaged or infected tissue where they engulf and destroy bacteria or sometimes fungi. An elevated neutrophil count is called neutrophilia, and decreased neutrophil count is called neutropenia. ^(7){ }^{7} 中性粒细胞是循环中数量最多的白细胞。它们进入受损或受感染的组织区域，吞噬并消灭细菌，有时也会消灭真菌。中性粒细胞计数升高称为中性粒细胞增多症，中性粒细胞计数降低称为中性粒细胞减少症。 ^(7){ }^{7}
Eosinophils respond to infections caused by parasites, play a role in allergic reactions (hypersensitivities), and control the extent of immune responses and inflammation. Elevated levels of eosinophils are referred to as eosinophilia. ^(8){ }^{8} 嗜酸性粒细胞会对寄生虫引起的感染做出反应，在过敏反应（过度敏感）中发挥作用，并控制免疫反应和炎症的程度。嗜酸性粒细胞水平升高被称为嗜酸性粒细胞增多症。 ^(8){ }^{8} 嗜酸性粒细胞
Basophils make up the fewest number of circulating WBCs and are thought to be involved in allergic reactions. ^(9){ }^{9} 嗜碱性粒细胞在循环白细胞中数量最少，被认为与过敏反应有关。 ^(9){ }^{9} 嗜碱性粒细胞
Lymphocytes include three types of cells, although the differential count does not distinguish among them: 淋巴细胞包括三种类型的细胞，但差分计数并不区分它们：
B lymphocytes (B cells) produce antibodies that target and destroy bacteria, viruses, and other “non-self” foreign antigens. B 淋巴细胞（B 细胞）可产生抗体，针对并消灭细菌、病毒和其他 "非自身 "外来抗原。
T lymphocytes (T cells) mature in the thymus and consist of a few T 淋巴细胞（T 细胞）在胸腺中发育成熟，由少数几个细胞组成。
Centers for Disease Control and Prevention. (2021, January 19). Candida auris. https://www.cdc.gov/fungal/ candida-auris/index.html 疾病控制和预防中心。(2021 年 1 月 19 日）。Candida auris. https://www.cdc.gov/fungal/ candida-auris/index.html
LabTestsOnline.org. (2021, January 27). White blood cell count (WBC). https://labtestsonline.org/tests/white-blood-cell-count-wbc LabTestsOnline.org.(2021 年 1 月 27 日）。白细胞计数（WBC）。https://labtestsonline.org/tests/white-blood-cell-count-wbc。
different types. Some T cells help the body distinguish between “self” and “non-self” antigens; some initiate and control the extent of an immune response, boosting it as needed and then slowing it as the condition resolves; and other types of T cells directly attack and neutralize virusinfected or cancerous cells. 不同类型。一些 T 细胞帮助人体区分 "自身 "和 "非自身 "抗原；一些 T 细胞启动并控制免疫反应的程度，在需要时增强免疫反应，然后在病情缓解时减缓免疫反应；还有一些 T 细胞直接攻击并中和病毒感染或癌细胞。
Natural killer cells (NK cells) directly attack and kill abnormal cells such as cancer cells or those infected with a virus. 自然杀伤细胞（NK 细胞）直接攻击并杀死异常细胞，如癌细胞或感染病毒的细胞。
Monocytes, similar to neutrophils, move to an area of infection and engulf and destroy bacteria. They are associated with chronic rather than acute infections. They are also involved in tissue repair and other functions involving the immune system." 单核细胞与中性粒细胞相似，会移动到感染区域，吞噬并消灭细菌。它们与慢性而非急性感染有关。它们还参与组织修复和涉及免疫系统的其他功能。
Care must be taken when interpreting the results of a differential. A health care provider will consider an individual’s signs and symptoms and medical history, as well as the degree to which each type of cell is increased or decreased. A number of factors can cause a transient rise or drop in the number of any type of cell. For example, bacterial infections usually produce an increase in neutrophils, but a severe infection, like sepsis, can use up the available neutrophils, causing a low number to be found in the blood. Eosinophils are often elevated in parasitic and allergic responses. Acute viral infections often cause an increased level of lymphocytes (referred to as lymphocytosis). ^(12){ }^{12} 在解释鉴别结果时必须小心谨慎。医疗服务提供者会考虑个人的体征和症状、病史以及每种类型细胞的增减程度。许多因素都可能导致任何类型细胞数量的短暂上升或下降。例如，细菌感染通常会导致中性粒细胞增多，但败血症等严重感染会耗尽可用的中性粒细胞，从而导致血液中的中性粒细胞数量减少。嗜酸性粒细胞通常在寄生虫和过敏反应中升高。急性病毒感染通常会导致淋巴细胞水平升高（称为淋巴细胞增多症）。 ^(12){ }^{12}
ERYTHROCYTE SEDIMENTATION RATE (ESR) 红细胞沉降率（ESR）
An erythrocyte sedimentation rate (ESR) is a test that indirectly measures inflammation. This test measures how quickly erythrocytes or red blood cells (RBCs) settle at the bottom of a test tube that contains a blood sample. When 红细胞沉降率（ESR）是一种间接测量炎症的检测方法。该检测可测量红细胞或红血球（RBC）在盛有血液样本的试管底部沉降的速度。当
10. LabTestsOnline.org. (2021, January 27). White blood cell count (WBC). https://labtestsonline.org/tests/white-blood-cell-count-wbc 10.LabTestsOnline.org.(2021 年 1 月 27 日）。白细胞计数（WBC）。https://labtestsonline.org/tests/white-blood-cell-count-wbc。
11. LabTestsOnline.org. (2021, January 27). White blood cell count (WBC). https://labtestsonline.org/tests/white-blood-cell-count-wbc 11.LabTestsOnline.org.(2021 年 1 月 27 日）。白细胞计数（WBC）。https://labtestsonline.org/tests/white-blood-cell-count-wbc。
12. LabTestsOnline.org. (2021, January 27). White blood cell count (WBC). https://labtestsonline.org/tests/white-blood-cell-count-wbc 12.LabTestsOnline.org.(2021 年 1 月 27 日）。白细胞计数（WBC）。https://labtestsonline.org/tests/white-blood-cell-count-wbc。
a sample of blood is placed in a tube, the red blood cells normally settle out relatively slowly, leaving a small amount of clear plasma. The red cells settle at a faster rate when there is an increased level of proteins, such as C-reactive protein (CRP), that increases in the blood in response to inflammation. The ESR test is not diagnostic; it is a nonspecific test indicating the presence or absence of an inflammatory condition. ^(13){ }^{13} 将血液样本放入试管中，红细胞通常会相对缓慢地沉淀下来，留下少量透明的血浆。当血液中因炎症而增加的蛋白质（如 C 反应蛋白 (CRP)）水平升高时，红细胞的沉降速度就会加快。血沉检测不具有诊断性；它是一种非特异性检测，可显示是否存在炎症。 ^(13){ }^{13}
C-REACTIVE PROTEIN (CRP) C 反应蛋白（CRP）
C-Reactive Protein (CRP) levels in the blood increase when there is a condition causing inflammation somewhere in the body. CRP is a nonspecific indicator of inflammation and one of the most sensitive acute phase reactants, meaning it is released into the blood within a few hours after the start of an infection or other cause of inflammation. The level of CRP can jump as much as a thousand-fold in response to a severe bacterial infection, and its rise in the blood can precede symptoms of fever or pain. ^(14){ }^{14} 当身体某个部位出现炎症时，血液中的 C 反应蛋白（CRP）水平就会升高。CRP 是炎症的非特异性指标，也是最敏感的急性期反应物之一，这意味着它会在感染或其他炎症原因开始后的几小时内释放到血液中。在发生严重细菌感染时，CRP 的水平可骤然升高一千倍，其在血液中的升高可先于发烧或疼痛症状。 ^(14){ }^{14}
LACTATE 乳酸
Serum lactate levels are measured when sepsis is suspected in a patient with an existing infection. Sepsis can quickly lead to septic shock and death due to multi-organ failure so early recognition is crucial. 当怀疑已有感染的患者出现败血症时，就需要测量血清乳酸水平。败血症可迅速导致脓毒性休克，并因多器官功能衰竭而死亡，因此早期识别至关重要。
Lactate is one of the substances produced by cells as the body turns food into energy (i.e., cellular metabolism), with the highest level of production occurring in the muscles. Normally, the level of lactate in blood is low. Lactate is produced in excess by muscle cells and other tissues when there is insufficient oxygen at the cellular level. 乳酸盐是人体将食物转化为能量（即细胞新陈代谢）时细胞产生的物质之一，其中肌肉中的乳酸盐含量最高。正常情况下，血液中的乳酸盐含量较低。当细胞水平的氧气不足时，肌肉细胞和其他组织会产生过量的乳酸。
Lactic acid can accumulate in the body and blood when it is produced faster than the liver can break it down, which can lead to lactic acidosis. Excess 当乳酸的产生速度超过肝脏的分解速度时，乳酸就会在体内和血液中积聚，从而导致乳酸中毒。过量
13. LabTestsOnline.org. (2020, July 29). Erythrocyte sedimentation rate (ESR). https://labtestsonline.org/tests/ erythrocyte-sedimentation-rate-esr 13.LabTestsOnline.org.(2020 年 7 月 29 日）。红细胞沉降率（ESR）。https://labtestsonline.org/tests/ erythrocyte-sedimentation-rate-esr
14. LabTestsOnline.org. (2020, August 12). C-Reactive protein (CRP). https://labtestsonline.org/tests/c-reactive-protein-crp 14.LabTestsOnline.org.(2020, August 12).C-Reactive protein (CRP). https://labtestsonline.org/tests/c-reactive-protein-crp
lactate may be produced due to several medical conditions that cause decreased transport of oxygen to the tissues, such as sepsis, hypovolemic shock, heart attack, heart failure, or respiratory distress. 乳酸的产生可能是由于多种疾病导致向组织输送氧气的能力下降，如败血症、低血容量休克、心脏病发作、心力衰竭或呼吸窘迫。
BLOOD CULTURE 血液文化
Blood cultures are ordered when sepsis is suspected. In many facilities, lab personnel draw the blood samples for blood cultures to avoid contamination of the sample. With some infections, pathogens are only found in the blood intermittently, so a series of three or more blood cultures, as well as blood draws from different veins, may be performed to increase the chance of finding the infection. 怀疑发生败血症时，需要进行血液培养。在许多机构中，实验室人员会抽取血液样本进行血培养，以避免样本受到污染。对于某些感染，病原体只会间歇性地出现在血液中，因此可能需要进行三次或三次以上的血液培养，并从不同的静脉抽血，以增加发现感染的几率。
Blood cultures are incubated for several days before being reported as negative. Some types of bacteria and fungi grow more slowly than others and/or may take longer to detect if initially present in low numbers. 血液培养物经过几天培养后才会报告为阴性。某些类型的细菌和真菌生长速度比其他细菌和真菌慢，并且/或者如果最初出现的细菌和真菌数量较少，可能需要更长时间才能检测到。
A positive result indicates bacteria have been found in the blood (bacteremia). Other types of pathogens, such as a fungus or a virus, may also be found in a blood culture. When a blood culture is positive, the specific microbe causing the infection is identified and susceptibility testing is performed to inform the health care provider which antibiotics or other medications are most likely to be effective for treatment. 阳性结果表明血液中发现了细菌（菌血症）。血液培养中也可能发现其他类型的病原体，如真菌或病毒。当血液培养呈阳性时，就会确定引起感染的特定微生物，并进行药敏试验，以告知医疗服务提供者哪种抗生素或其他药物最有可能有效治疗。
It is important for nurses to remember that when new orders for both antibiotics and a blood culture are received, antibiotics should not be administered until after the blood culture is drawn. Administering antibiotics before the blood culture is drawn will impact the results and adversely affect the treatment plan. 护士必须牢记，在收到抗生素和血液培养的新医嘱时，应在抽血培养后再使用抗生素。在抽血培养之前使用抗生素会影响结果，并对治疗计划产生不利影响。
CULTURES AND OTHER DIAGNOSTIC TESTS 培养和其他诊断检测
Several types of swabs and cultures may be ordered based on the site of a suspected infection, such as a nasal swab, nasopharyngeal swab, sputum 根据疑似感染的部位，可能需要进行多种类型的拭子和培养，如鼻拭子、鼻咽拭子、痰拭子等。
culture, urine culture, and wound culture. If a lower respiratory tract infection is suspected, a chest X -ray may be ordered. 培养、尿液培养和伤口培养。如果怀疑是下呼吸道感染，可能需要进行胸部 X 射线检查。
Read additional information about the following topics in Open RN Nursing Skills: 阅读 Open RN Nursing Skills 中有关以下主题的更多信息：
Specimen Collection 样本采集
Collecting urine cultures in “Facilitation of Elimination” 在 "促进排尿 "中收集尿培养物
Collecting wound cultures in “Wound Care” 在 "伤口护理 "中收集伤口培养物
THERAPEUTIC DRUG MONITORING 治疗药物监测
When antibiotics are prescribed to treat an infection, some types of antibiotics require blood tests to ensure the dosage of the medication reaches and stays within therapeutic ranges in the blood. These tests are often referred to as peak and/or trough levels. The nurse must be aware of these orders because they impact the timing of administration of antibiotics. 在处方抗生素治疗感染时，某些类型的抗生素需要进行血液检测，以确保药物剂量在血液中达到并保持在治疗范围内。这些检测通常被称为峰值和/或谷值。护士必须了解这些医嘱，因为它们会影响抗生素的用药时间。
Read about therapeutic drug monitoring in the “Medication Safety” section of the “Kinetics and Dynamics” chapter in Open RN Nursing Pharmacology. 请阅读 Open RN Nursing Pharmacology 中 "Kinetics and Dynamics "一章的 "Medication Safety"（用药安全）部分中有关治疗药物监测的内容。
Diagnoses 诊断
There are many NANDA-I nursing diagnoses applicable to infection. Nursing diagnoses associated with actual infections are customized based on the signs and symptoms of the specific infection (e.g., a patient with pneumonia may have an actual nursing diagnosis of Ineffective Airway Clearance). Review a nursing care planning source for a list of current NANDA-I approved nursing diagnoses based on the type of infection occurring. 有许多 NANDA-I 护理诊断适用于感染。与实际感染相关的护理诊断是根据特定感染的体征和症状定制的（例如，肺炎患者的实际护理诊断可能是无效气道通畅）。请查阅护理计划资料，以了解当前 NANDA-I 批准的基于感染类型的护理诊断列表。
16. Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (17th ed.). Thieme Publishers. pp. 382, 405. 16.Herdman, T., & Kamitsuru, S. (2017).NANDA 国际护理诊断：Definitions & classification 2018-2020 (17th ed.).Thieme Publishers. pp.382, 405.
Two common risk diagnoses are Risk for Infection for patients at risk for developing an infection and Risk for Shock for patients with an existing infection who are at risk for developing sepsis and septic shock. See Table 9.7b for the risk diagnoses of Risk for Infection and Risk for Shock. 两种常见的风险诊断是感染风险和休克风险，前者针对有感染风险的患者，后者针对已有感染但有发生败血症和脓毒性休克风险的患者。感染风险和休克风险的风险诊断见表 9.7b。
Risk Factors
- Alteration in skin integrity
- Inadequate vaccination
- Malnutrition
- Obesity
- Alteration in peristalsis
- Smoking
- Stasis of body fluid| Risk Factors |
| :--- |
| - Alteration in skin integrity |
| - Inadequate vaccination |
| - Malnutrition |
| - Obesity |
| - Alteration in peristalsis |
| - Smoking |
| - Stasis of body fluid |
Risk of Shock 休克风险
Susceptible to inadequate blood flow to the body's tissues that may lead to life-threatening cellular dysfunction, which may compromise health 身体组织容易因血流不足而导致细胞功能障碍，危及生命，损害健康
NANDA-I Diagnosis Definition Other
Risk for Infection Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health "Risk Factors
- Alteration in skin integrity
- Inadequate vaccination
- Malnutrition
- Obesity
- Alteration in peristalsis
- Smoking
- Stasis of body fluid"
Risk of Shock Susceptible to inadequate blood flow to the body's tissues that may lead to life-threatening cellular dysfunction, which may compromise health "Associated Conditions
- Infection
- Systemic inflammatory response syndrome (SIRS)
- Sepsis"| NANDA-I Diagnosis | Definition | Other |
| :--- | :--- | :--- |
| Risk for Infection | Susceptible to invasion and multiplication of pathogenic organisms, which may compromise health | Risk Factors <br> - Alteration in skin integrity <br> - Inadequate vaccination <br> - Malnutrition <br> - Obesity <br> - Alteration in peristalsis <br> - Smoking <br> - Stasis of body fluid |
| Risk of Shock | Susceptible to inadequate blood flow to the body's tissues that may lead to life-threatening cellular dysfunction, which may compromise health | Associated Conditions <br> - Infection <br> - Systemic inflammatory response syndrome (SIRS) <br> - Sepsis |
Examples 实例
For example, a nurse caring for a patient with an open wound assesses the wound regularly because patients with nonintact skin are always at increased risk for developing infection. A sample PES statement would be the following: “Risk for Infection as evidenced by alteration in skin integrity and insufficient knowledge to avoid exposure to pathogens.” The nurse plans to provide patient education regarding care of the wound to prevent bacterial contamination during dressing changes. 例如，一名护士在护理一名有开放性伤口的患者时，会定期对伤口进行评估，因为皮肤不完整的患者发生感染的风险总是会增加。PES 声明样本如下："感染风险表现为皮肤完整性的改变以及缺乏避免接触病原体的足够知识"。护士计划对患者进行伤口护理方面的教育，以防止换药过程中的细菌污染。
Whenever caring for a patient with an existing infection, nurses know it is important to closely monitor for signs of developing SIRS and sepsis. A sample PES statement for a patient with an existing infection is as follows: “Risk for Shock as evidenced by the associated condition of infection.” 护士们知道，在护理已有感染的患者时，密切监测 SIRS 和败血症的发展迹象非常重要。针对现有感染患者的 PES 声明样本如下："相关感染情况表明存在休克风险"。
Note: Recall that in NANDA-I risk diagnoses, there are no etiological factors because a vulnerability reflects the potential for developing a problem. Read more about creating PES statements for risk diagnoses in the “Nursing Process” chapter. 注意：请记住，在 NANDA-I 风险诊断中，没有病因因素，因为脆弱性反映了出现问题的可能性。请在 "护理程序 "一章中阅读有关为风险诊断创建 PES 声明的更多信息。
Outcomes 成果
An example of a broad goal for all patients is the following: “The patient will remain free from infection during their health care stay.” ^(17){ }^{17} 以下是一个针对所有病人的广泛目标的例子："患者在接受医疗服务期间不受感染"。 ^(17){ }^{17}
An example of a SMART expected outcome to prevent infection is: “The patient will demonstrate how to perform dressing changes using aseptic technique prior to discharge from the hospital.” ^(18){ }^{18} 预防感染的 SMART 预期结果的示例是："患者将演示如何在出院前使用无菌技术进行换药"。 ^(18){ }^{18}
Read more about creating SMART outcomes in the “Nursing Process” chapter. 阅读 "护理过程 "一章中有关创建 SMART 成果的更多信息。
17. Centers for Disease Control and Prevention. (2016, January 26). Standard precautions for all patient care. https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html 17.疾病控制和预防中心。(2016 年 1 月 26 日）。所有病人护理的标准预防措施。https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html。
18. Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012). NOC and NIC linkages to NANDA-I and clinical conditions: Supporting critical reasoning and quality care. Elsevier. p. 268. 18.Johnson, M., Moorhead, S., Bulechek, G., Butcher, H., Maas, M., & Swanson, E. (2012)。NOC 和 NIC 与 NANDA-I 和临床条件的联系：支持关键推理和优质护理。第 268 页。
Planning Interventions 规划干预措施
When planning interventions for a patient who is at risk for developing an infection, the nurse selects interventions such as those listed in the following box for “Infection Protection.” 在为有感染风险的患者制定干预计划时，护士会选择一些干预措施，例如下框中列出的 "感染防护 "措施。
Interventions for Infection Prevention ^(19,20){ }^{19,20} 预防感染的干预措施 ^(19,20){ }^{19,20}
Monitor vital signs for signs of infection 监测生命体征，以发现感染迹象
Monitor for early signs of localized and systemic infection for patients at risk 监测高危患者局部和全身感染的早期迹象
Screen all visitors for communicable disease 对所有访客进行传染病筛查
Encourage respiratory hygiene for patients, visitors, and staff members 鼓励患者、来访者和工作人员保持呼吸道卫生
Maintain aseptic technique during nursing procedures 在护理过程中保持无菌技术
Use sterile technique for invasive procedures or care of open wounds 使用无菌技术进行侵入性操作或护理开放性伤口
Use standard precautions with all patients to prevent the spread of infection 对所有病人采取标准预防措施，防止感染传播
Initiate transmission-based precautions for patients suspected of communicable infection, as appropriate 酌情为疑似传染性感染患者启动基于传播的预防措施
Promote sufficient nutritional intake 促进充足的营养摄入
Encourage fluid intake, as appropriate 酌情鼓励摄入液体
Encourage rest 鼓励休息
Encourage frequent ambulation or turn immobilized patients frequently 鼓励病人经常走动或经常翻动固定不动的病人
Ensure appropriate hygienic care, including proper hand 确保适当的卫生护理，包括适当的手部护理。
Wilson, J., Bak, A., & Loveday, H. P. Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. American Journal of Infection Control, 45(7), 779-786. https://doi.org/10.1016/ j.ajic.2017.02.019. Wilson, J., Bak, A., & Loveday, H. P. 将人为因素和人体工程学应用于急症护理中非无菌临床手套的滥用。美国感染控制杂志》，45（7），779-786。https://doi.org/10.1016/ j.ajic.2017.02.019。
hygiene, daily bathing, oral care, and perineal care performed by either the nurse or the patient, as appropriate 由护士或病人酌情进行个人卫生、日常沐浴、口腔护理和会阴护理
Moisturize dry skin to keep it intact 为干燥皮肤保湿，使其保持完整
Use strategies to prevent healthcare-acquired respiratory infection, such as incentive spirometry, coughing and deep breathing, positional changes, and early ambulation as appropriate 使用预防医护人员获得性呼吸道感染的策略，如激励肺活量测定、咳嗽和深呼吸、体位改变，以及酌情尽早下床活动。
Use strategies to prevent wound infection such as changing saturated dressings to reduce the potential reservoir of bacteria 使用预防伤口感染的策略，如更换饱和敷料，以减少潜在的细菌库
Teach the patient and family members the importance of a nutritious diet, exercise, and adequate rest to promote healing and health at home 向病人和家属传授营养饮食、运动和充分休息的重要性，以促进在家康复和健康
Teach the patient and family about signs and symptoms of infection and when to report them to the health care provider 向病人和家属讲解感染的迹象和症状，以及何时向医疗服务提供者报告这些迹象和症状
Encourage the annual influenza vaccine and keeping other recommended vaccinations up-to-date 鼓励每年接种流感疫苗，并及时更新其他推荐疫苗
If a patient smokes, encourage smoking cessation because smoking damages the mucociliary escalator and places the patient at increased risk for infection 如果患者吸烟，应鼓励其戒烟，因为吸烟会破坏黏膜纤毛扶梯，增加患者感染的风险
Report signs and symptoms of suspected infection or sepsis to the health care provider 向医护人员报告疑似感染或败血症的体征和症状
Suspect an infection if an older adult patient has new signs of lethargy or confusion 如果老年患者出现嗜睡或神志不清的新症状，则应怀疑是否受到感染
If a patient has an infection with a fever, the nursing diagnosis Hyperthermia may be applicable. See the following box for interventions for patients with fever/hyperthermia. 如果病人感染并发烧，护理诊断可能适用于高热。有关对发热/高热病人的干预措施，请参阅下框。
Interventions for Hyperthermia 高热干预
Assess for associated symptoms such as diaphoresis, shaking chills (rigors) 评估相关症状，如舒张、寒颤（僵直）
Monitor level of consciousness 监测意识水平
Adjust room temperature to the patient’s comfort without inducing chilling 根据病人的舒适度调节室温，不会引起寒颤
Administer antipyretics, as appropriate (e.g., acetaminophen, ibuprofen) 酌情使用退烧药（如对乙酰氨基酚、布洛芬等）
Apply external cooling methods as needed (cold packs or cool sponge bath) 根据需要采用外部降温方法（冷敷或冷海绵浴）
Encourage fluid intake 鼓励摄入液体
Monitor for signs of dehydration 监测脱水迹象
Implementing Interventions 实施干预措施
When caring for a patient with an active infection, transmission-based precautions may be required based on the specific type of pathogen. Antibiotics and/or other antimicrobials are administered as prescribed, and the patient and family are instructed how to take prescribed antibiotics with measures to prevent antibiotic resistance (i.e., complete prescribed length of therapy even if they feel better in a few days). 在护理活动性感染患者时，可能需要根据病原体的具体类型采取基于传播的预防措施。按照处方使用抗生素和/或其他抗菌药物，并指导患者和家属如何服用处方抗生素，同时采取预防抗生素耐药性的措施（例如，即使几天后感觉好转，也要完成规定的疗程）。
If cultures have been obtained, it is important to monitor and report new results to the provider to ensure the prescribed antibiotic therapy is appropriate based on susceptibility results. 如果已经进行了培养，则必须进行监测并向医疗服务提供者报告新的结果，以确保根据药敏结果对处方抗生素进行适当的治疗。
It is important to continually monitor patients with an existing infection for signs of SIRS/sepsis: 必须持续监测已有感染的患者是否出现 SIRS/败血症迹象：
Carefully monitor vital signs. Immediately notify the provider for two or more of the following indicators that suggest SIRS: heart rate greater than 仔细观察生命体征。如果出现以下两个或两个以上提示 SIRS 的指标，应立即通知医疗服务提供者：心率超过
90 beats per minute, temperature greater than 38 degrees CC or less than 36 degrees C, systolic blood pressure less than 90 mm Hg , respiratory rate greater than 20, or a white blood cell count greater than 12,000 or less than 4,000. ^(21){ }^{21} Anticipate new orders for a lactate level and blood cultures for early diagnosis of sepsis. CC 每分钟心跳 90 次，体温高于 38 摄氏度 CC 或低于 36 摄氏度，收缩压低于 90 毫米汞柱，呼吸频率高于 20 次，或白细胞计数高于 12,000 或低于 4,000。 ^(21){ }^{21} 预计会出现乳酸水平和血液培养的新订单，以便早期诊断败血症。
Monitor for signs of new decreased mental status, especially in older adults, that can indicate decreased oxygenation or tissue perfusion associated with sepsis and septic shock. 监测新出现的精神状态减退迹象，尤其是老年人，这可能预示着与败血症和脓毒性休克相关的氧合或组织灌注减少。
For patients presenting with early signs of shock, administer oxygen immediately to maintain oxygen saturation greater than 90%. Administer prescribed antibiotics within an hour after diagnosis for improved survival. Be aware that IV fluids and vasopressor medications may be required to treat shock. ^(22){ }^{22} 对于出现休克早期症状的患者，应立即吸氧，以保持血氧饱和度大于 90%。在确诊后一小时内使用处方抗生素，以提高存活率。注意可能需要静脉输液和血管加压药物来治疗休克。 ^(22){ }^{22}
Read about different classes of antimicrobial agents in the “Antimicrobials” chapter in Open RN Nursing Pharmacology. 请阅读 Open RN Nursing Pharmacology 中的 "抗菌药物 "一章，了解不同类别的抗菌药物。
Evaluation 评估
It is always important to evaluate the effectiveness of interventions used to prevent and treat infection. Evaluation helps the nurse determine whether the established outcomes have been met and if the planned interventions are still appropriate for the patient at the time of implementation. If outcomes are not met, interventions may need to be added or revised to help the patient meet their goals. 评估用于预防和治疗感染的干预措施的有效性始终非常重要。评估有助于护士确定是否达到了既定的效果，以及在实施干预措施时，计划的干预措施是否仍然适合患者。如果没有达到预期效果，则可能需要增加或修改干预措施，以帮助患者达到目标。
21. Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 382, 405. 21.Herdman, T., & Kamitsuru, S. (2017).NANDA 国际护理诊断：Definitions & classification 2018-2020 (11th ed.).Thieme Publishers. pp.382, 405.
22. This work is a derivative of StatPearls by Chakraborty & Burns and is licensed under CC BY 4.0 22.本作品是 Chakraborty & Burns 的 StatPearls 的衍生作品，采用 CC BY 4.0 许可。
9.8 Putting It All Together 9.8 将所有内容整合在一起
Patient Scenario 患者情景
Mrs. Charles is a 74-year-old woman admitted to the medical surgical floor with pneumonia. She has a history of right sided hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing) as a result of a cerebral vascular accident three years ago. Upon assessment, the patient has a RR of 22, and rhonchi in her upper lobes. Her oxygenation saturation is 89%89 \% on room air, and she is utilizing accessory muscles during respiration. 查尔斯夫人是一名 74 岁的妇女，因肺炎入住内外科病房。她有右侧偏瘫（身体一侧瘫痪）和吞咽困难（吞咽困难）病史，病因是三年前的一次脑血管意外。经评估，患者的 RR 值为 22，上叶有啰音。她在室内空气中的血氧饱和度为 89%89 \% ，呼吸时使用辅助肌肉。
Applying the Nursing Process 应用护理程序
Assessment: The nurse notes that the patient demonstrates tachypnea, hypoxemia, and abnormal breath sounds. She has a history of hemiplegia and dysphagia. 评估：护士注意到患者呼吸急促、低氧血症和呼吸音异常。她有偏瘫和吞咽困难的病史。
Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Charles. 根据收集到的评估信息，为查尔斯夫人制定了以下护理计划。
Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus as evidenced by adventitious breath sounds and alteration in respiratory rate. 护理诊断：呼吸道通畅不良与粘液过多有关，表现为呼吸音减弱和呼吸频率改变。
Overall Goal: The patient will maintain patent airway at all times. 总体目标： 患者的气道始终保持通畅。
SMART Expected Outcome: Mrs. Charles will effectively clear secretions throughout the hospitalization. SMART 预期成果：查尔斯夫人将在整个住院期间有效清除分泌物。
Planning and Implementing Nursing Interventions: 规划和实施护理干预：
The nurse will assess the patient’s respiratory rate, rhythm, and depth of respiration. The nurse will assess and instruct the patient on the methods of appropriate cough and deep breathing. The nurse will auscultate lung fields to identify areas of worsening airflow. The nurse will elevate the patient’s head of bed and encourage hydration to thin secretions. The nurse will instruct the 护士将评估患者的呼吸频率、节奏和呼吸深度。护士将评估并指导患者适当咳嗽和深呼吸的方法。护士将对肺野进行听诊，以确定气流恶化的区域。护士将抬高患者的床头，鼓励患者补充水分以稀释分泌物。护士将指导患者
patient regarding proper deep breathing exercises and encourage assisted ambulation to mobilize secretions. 向患者讲解正确的深呼吸运动，并鼓励患者在辅助下行走以排出分泌物。
Sample Documentation: 文件样本：
Mrs. Charles has ineffective airway clearance as a result of aspiration pneumonia secondary to dysphagia. The patient has rhonchi in bilateral upper lobes, decreased oxygenation, and tachypnea. In order to enhance airway clearance and mobilize secretions, the patient has received instruction to maintain fluid intake, increase ambulation, and cough and deep breathe. The patient will maintain an elevated head of bed to encourage ease of respiration and will be assessed frequently for worsening respiratory status. 查尔斯夫人因吞咽困难继发吸入性肺炎，导致气道通畅不佳。患者双侧上叶有啰音，血氧饱和度下降，呼吸急促。为了提高气道通畅度并清除分泌物，患者接受了保持液体摄入量、增加活动量、咳嗽和深呼吸的指导。患者将保持床头抬高，以促进呼吸顺畅，并经常评估呼吸状况是否恶化。
Evaluation: 评估：
During the patient’s hospitalization, she maintains a patent airway and effectively clears secretions resulting in improved respiratory effort and overall function. The SMART outcome was “met.” 在患者住院期间，她保持了呼吸道通畅，并有效清除了分泌物，从而改善了呼吸强度和整体功能。SMART 结果 "达到"。
9.9 Learning Activities 9.9 学习活动
Learning Activities 学习活动
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
Ms. Jamison is a 37-year-old patient presenting to the emergency department with an ongoing fever and chills for the last three days. She recently received treatment for a urinary tract infection but confesses that she stopped her antibiotic regimen when her symptoms resolved. Upon assessment, her vital signs are T - 101.6 F, HR 115, RR 20, BP 96/54. The admitting physician has ordered a Basic Metabolic Profile, Complete Blood Cell Count, and Urinalysis. The results are still pending. Based upon what is known about Ms. Jamison at this time, how would you characterize her condition? What characteristics lead you to suspect your diagnosis? Jamison 女士是一名 37 岁的患者，因过去三天持续发烧和发冷而到急诊科就诊。她最近接受了尿路感染治疗，但她承认症状缓解后就停止了抗生素治疗。经评估，她的生命体征为 T - 101.6 F，HR 115，RR 20，BP 96/54。入院医生为她做了基础代谢测定、全血细胞计数和尿液分析。结果还未出来。根据目前对贾米森女士的了解，您如何描述她的病情？哪些特征使您怀疑自己的诊断？
Infection control practices are integral to health care workers and the patients and families that they serve. Proper infection control techniques enhance patient safety and are foundational to quality patient care. Partnering to Heal is a computer-based, video-simulation training program on infection control practices for clinicians, health professional students, and patient advocates. Visit these web simulations to review infection control scenarios and the implications of various care decisions. 感染控制措施是医护人员及其服务的患者和家属不可或缺的一部分。正确的感染控制技术能提高患者的安全，是为患者提供优质护理的基础。携手医治 "是一项基于计算机的感染控制实践视频模拟培训计划，面向临床医生、卫生专业学生和患者权益倡导者。访问这些网络模拟，查看感染控制情景和各种护理决策的影响。
Interested in testing your knowledge regarding the chain of infection? Visit WISC-Online “Chain of Infection” for a fun interactive quiz. 有兴趣测试您对感染链的了解程度吗？请访问 WISC-在线 "感染链"，进行有趣的互动测验。
은 是
An interactive H5P element has been excluded from this version of the text. You can view it online here: 本版本文本中不包括互动式 H5P 元素。您可在此处在线查看： https://wtcs.pressbooks.pub/nursingfundamentals/?p=7568#h5p-98
“Infection Case Study” by Susan Jepsen for Lansing Community College are licensed under CC BY 4.0 "感染案例研究 "由 Susan Jepsen 为兰辛社区学院创作，采用 CC BY 4.0 许可。
Acute, self-limiting infections: Infections that develop rapidly and generally last only 10-14 days. Colds, ear infections, and coughs are considered acute, self-limiting infections. 急性自限性感染：发展迅速、一般只持续 10-14 天的感染。感冒、中耳炎和咳嗽都属于急性自限性感染。
Antibodies: YY proteins created by BB cells that are specific to each pathogen and lock onto its surface and mark it for destruction by other immune cells. The five classes of antibodies are IgG, IgM, IgA, IgD, and IgE. 抗体： YY 由 BB 细胞产生的蛋白质，对每种病原体具有特异性，并锁定在病原体表面，标记为其他免疫细胞所要消灭的病原体。抗体分为五类：IgG、IgM、IgA、IgD 和 IgE。
Aseptic technique: The purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure. For example, a nurse administering parenteral medication or performing urinary catheterization uses aseptic technique. When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment during routine care or procedures. 无菌技术：有目的地减少病原体，以防止在医疗过程中微生物从一个人或物体转移到另一个人或物体。例如，护士在给病人注射肠外药物或进行导尿时，就需要使用无菌技术。如果操作得当，无菌技术可以防止在常规护理或程序中，护理人员的手、物体表面和设备受到污染并将病原体转移到病人身上。
B cells: Immune cells that mature in the bone marrow. B cells make YY-shaped proteins called antibodies that are specific to each pathogen and lock onto its surface and mark it for destruction by other immune cells. B 细胞：在骨髓中成熟的免疫细胞。B 细胞制造称为抗体的 YY 形蛋白质，这种蛋白质对每种病原体都具有特异性，能锁定在病原体表面，并标记为其他免疫细胞所要消灭的病原体。
Bacteremia: The presence of bacteria in blood. 菌血症：血液中存在细菌。
Chronic infections: Infections that may persist for months. Hepatitis and mononucleosis are examples of chronic infections. 慢性感染：可持续数月的感染。肝炎和单核细胞增多症就是慢性感染的例子。
Cytokines: Plasma proteins that communicate with other body organs and cells in the body to respond to and initiate inflammation. 细胞因子：血浆蛋白：能与身体其他器官和细胞沟通，对炎症做出反应并引发炎症。
Cytokine storm: A severe immune reaction in which the body releases too many cytokines into the blood too quickly. A cytokine storm can occur as a result of an infection, autoimmune condition, or other disease. Signs and symptoms include high fever, inflammation, severe fatigue, and nausea. A 细胞因子风暴细胞因子风暴：一种严重的免疫反应，机体过快地向血液中释放过多的细胞因子。细胞因子风暴可因感染、自身免疫状况或其他疾病而发生。体征和症状包括高烧、发炎、严重疲劳和恶心。A
cytokine storm can be severe or life-threatening and lead to multiple organ failure.’ 细胞因子风暴可能很严重或危及生命，并导致多器官衰竭。
Disease: Infections can lead to disease that causes signs and symptoms resulting in a deviation from the normal structure or functioning of the host. 疾病：感染可导致疾病，引起症状和体征，导致宿主的正常结构或功能发生偏差。
Disinfection: Removal of organisms from inanimate objects and surfaces. However, disinfection does not typically destroy all spores and viruses. 消毒：去除无生命物体和表面上的生物。不过，消毒通常不会消灭所有孢子和病毒。
Exposure: An encounter with a potential pathogen. 接触：与潜在病原体的接触。
Hand hygiene: Cleaning the hands by either washing hands with soap and water or using hand sanitizer. 手部卫生：用肥皂和水洗手或使用洗手液清洁双手。
Healthcare-Associated Infection (HAI): An infection that is contracted in a health care facility or under medical care. 医疗相关感染 (HAI)：在医疗机构或医疗护理过程中感染。
Incubation period: The period of a disease after the initial entry of the pathogen into the host but before symptoms develop. 潜伏期：疾病潜伏期：病原体最初进入宿主体内后，症状出现前的一段时间。
Infection: The invasion and growth of a microorganism within the body. 感染：微生物在体内的入侵和生长。
Inflammation: A response triggered by a cascade of chemical mediators that occur when pathogens successfully breach the nonspecific physical defenses of the immune system or when an injury occurs. 炎症：当病原体成功突破免疫系统的非特异性物理防御或发生损伤时，由一连串化学介质引发的反应。
Invasion: The spread of a pathogen throughout local tissues or the body. 入侵：病原体在局部组织或全身扩散。
Local infection: Infection confined to a small area of the body, typically near the portal of entry, and usually presents with signs of redness, warmth, swelling, warmth, and pain. Purulent drainage may be present and extensive tissue involvement can cause decreased function. 局部感染：感染局限于身体的一个小区域，通常在入口附近，通常表现为发红、发热、肿胀、发热和疼痛。可能会出现脓性引流，广泛的组织受累会导致功能减退。
Microbiome: Every human being carries their own individual suite of microorganisms in and on their body referred to as their microbiome. A 微生物组每个人体内和身上都携带着各自的微生物群，称为微生物群。A
person’s microbiome is acquired at birth and evolves over their lifetime. It is different across body sites and between individuals. 人的微生物群是在出生时获得的，并在一生中不断演变。不同身体部位和不同个体的微生物组都不尽相同。
Mode of transmission: The vehicle by which the organism is transferred such as physical contact, droplets, or airborne. The most common vehicles are a cough, sneeze, or on the hands. 传播方式：病原体传播的媒介，如身体接触、飞沫或空气传播。最常见的传播媒介是咳嗽、喷嚏或手。
Nonspecific innate immunity: A system of defenses in the body that targets invading pathogens in a nonspecific manner that is present from the moment we are born. Nonspecific innate immunity includes physical defenses, chemical defenses, and cellular defenses. 非特异性先天免疫：人体中以非特异性方式针对入侵病原体的防御系统，从我们出生的那一刻起就已经存在。非特异性先天免疫包括物理防御、化学防御和细胞防御。
Normal flora: Microorganisms that live on our skin and in the nasopharynx and gastrointestinal tracts and don’t cause an infection unless the host becomes susceptible. 正常菌群：正常菌群：生活在皮肤、鼻咽和胃肠道中的微生物，除非宿主易感，否则不会引起感染。
Opportunistic pathogen: A pathogen that only causes disease in situations that compromise the host’s defenses, such as the body’s protective barriers, immune system, or normal microbiota. Individuals susceptible to opportunistic infections include the very young, the elderly, women who are pregnant, patients undergoing chemotherapy, people with immunodeficiencies (such as acquired immunodeficiency syndrome [AIDS]), patients who are recovering from surgery, and those who have had a breach of protective barriers (such as a severe wound or burn). 机会性病原体：机会性病原体：只在损害宿主防御系统（如身体的保护屏障、免疫系统或正常微生物群）的情况下才会致病的病原体。机会性感染的易感人群包括幼童、老人、孕妇、化疗患者、免疫缺陷患者（如获得性免疫缺陷综合征[AIDS]）、手术后恢复期患者以及保护屏障受损者（如严重创伤或烧伤）。
Pathogen: Microorganisms that cause disease. 病原体：致病微生物：导致疾病的微生物。
Pathogenicity: The ability of a microorganism to cause disease. 致病性：微生物致病的能力。
Peristalsis: A series of muscular contractions in the digestive tract that moves digested material and microbes through the intestine and excretes it in the feces. 蠕动消化道内的一系列肌肉收缩，将消化物和微生物通过肠道并随粪便排出体外。
Personal Protective Equipment (PPE): Gloves, gowns, face shields, goggles, and masks used to prevent the spread of infection to and from patients and health care providers. 个人防护设备 (PPE)：手套、防护服、面罩、护目镜和口罩，用于防止病人和医护人员之间的感染传播。
Portal of entry: An anatomic site through which pathogens can pass into a host, such as mucous membranes, skin, respiratory, or digestive systems. 入口：病原体进入宿主体内的解剖部位，如粘膜、皮肤、呼吸系统或消化系统。
Portal of exit: The method by which the organism leaves the reservoir as through secretions, blood, urine, breast milk, or feces. 出境途径：生物体通过分泌物、血液、尿液、母乳或粪便离开贮存库的方式。
Primary pathogen: A pathogen that can cause disease in a host regardless of the host’s resident microbiota or immune system. 原发性病原体：无论宿主的常驻微生物群或免疫系统如何，都能在宿主体内致病的病原体。
Prodromal period: The disease stage after the incubation period when the pathogen continues to multiply and the host begins to experience general signs and symptoms of illness that result from activation of the immune system, such as fever, pain, soreness, swelling, or inflammation. Usually, such signs and symptoms are too general to indicate a particular disease. 前驱期：潜伏期后的疾病阶段，此时病原体继续繁殖，宿主开始出现因免疫系统激活而导致的一般疾病症状和体征，如发烧、疼痛、酸痛、肿胀或炎症。通常情况下，这些症状和体征过于笼统，不能说明是某种疾病。
Reservoir: The place the organism grows such as a wound, blood, or food. 蓄水池：生物生长的地方，如伤口、血液或食物。
Secondary infection: A localized pathogen that spreads to a secondary location. 继发感染：局部病原体扩散到次要部位。
Sepsis: An existing infection that triggers an exaggerated inflammatory reaction called SIRS throughout the body. If left untreated, sepsis causes tissue damage and quickly spreads to multiple organs. It is a life-threatening medical emergency. 败血症：败血症：一种引发全身夸张炎症反应（称为 SIRS）的现有感染。如果不及时治疗，败血症会造成组织损伤，并迅速扩散到多个器官。这是一种危及生命的紧急医疗状况。
Septicemia: Bacteria that are both present and multiplying in the blood. 败血症细菌在血液中存在和繁殖。
Septic shock: Severe sepsis that leads to a life-threatening decrease in blood pressure (systolic pressure < 90mmHg<90 \mathrm{~mm} \mathrm{Hg} ), preventing cells and other organs from receiving enough oxygen and nutrients. It can cause multi-organ failure and death. 败血症休克：严重的败血症会导致血压下降（收缩压 < 90mmHg<90 \mathrm{~mm} \mathrm{Hg} ），使细胞和其他器官无法获得足够的氧气和营养，从而危及生命。它可导致多器官衰竭和死亡。
Specific adaptive immunity: The immune response that is activated when the nonspecific innate immune response is insufficient to control an infection. There are two types of adaptive responses: the cell-mediated immune response, which is carried out by T cells, and the humoral immune response, which is controlled by activated B cells and antibodies. 特异性适应性免疫：当非特异性先天性免疫反应不足以控制感染时启动的免疫反应。适应性反应分为两种：一种是细胞介导的免疫反应，由 T 细胞执行；另一种是体液免疫反应，由活化的 B 细胞和抗体控制。
Standard precautions: The minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. 标准预防措施：最低限度的感染预防措施，适用于提供医疗保健服务的任何环境中的所有病人护理，无论病人是否疑似或确诊感染。
Sterile technique: A process, also called surgical asepsis, used to eliminate every potential microorganism in and around a sterile field while also maintaining objects as free from microorganisms as possible. It is the standard of care for surgical procedures, invasive wound management, and central line care. Sterile technique requires a combination of meticulous hand washing, creating a sterile field, using long-lasting antimicrobial cleansing agents such as Betadine, donning sterile gloves, and using sterile devices and instruments. 无菌技术：又称外科无菌术，用于消除无菌区域内和周围的所有潜在微生物，同时尽可能保持物体不含微生物。这是外科手术、侵入性伤口处理和中心静脉护理的护理标准。无菌技术要求将认真洗手、建立无菌区域、使用长效抗菌清洁剂（如倍他丁）、戴上无菌手套以及使用无菌设备和器械结合起来。
Sterilization: A process used to destroy all pathogens from inanimate objects, including spores and viruses. 灭菌：用于消灭无生命物体中所有病原体（包括孢子和病毒）的过程。
Susceptible host: The person whose body the organism has entered. 易感宿主：生物体进入其体内的人。
Systemic infection: An infection that becomes disseminated throughout the body. 全身感染：扩散到全身的感染。
Systemic Inflammatory Response Syndrome (SIRS): An exaggerated inflammatory response to a noxious stressor (including, but not limited to, infection and acute inflammation) that affects the entire body. 全身炎症反应综合征（SIRS）：对有害压力源（包括但不限于感染和急性炎症）的一种夸张的炎症反应，影响全身。
T cells: Immune cells that mature in the thymus. T cells are categorized into three classes: helper T cells, regulatory T cells, and cytotoxic T cells. Helper T cells stimulate B cells to make antibodies and help killer cells develop. Killer T cells directly kill cells that have already been infected by a pathogen. T cells also use cytokines as messenger molecules to send chemical instructions to the rest of the immune system to ramp up its response. T 细胞：在胸腺中成熟的免疫细胞。T 细胞分为三类：辅助性 T 细胞、调节性 T 细胞和细胞毒性 T 细胞。辅助性 T 细胞刺激 B 细胞制造抗体，帮助杀伤性细胞发育。杀伤性 T 细胞会直接杀死已被病原体感染的细胞。T 细胞还使用细胞因子作为信使分子，向免疫系统的其他部分发出化学指令，以加强其反应。
Transmission-based precautions: Precautions used for patients with documented or suspected infection, or colonization, of highly-transmissible pathogens, such as C. difficile (C-diff), Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), Respiratory Syncytial Virus (RSV), measles, and tuberculosis (TB). Three categories of transmission- 基于传播的预防措施：用于有记录或疑似感染或定植高传播病原体的病人的预防措施，如艰难梭菌（C-diff）、耐甲氧西林金黄色葡萄球菌（MRSA）、耐万古霉素肠球菌（VRE）、呼吸道合胞病毒（RSV）、麻疹和结核病（TB）。三类传播
based precautions are contact precautions, droplet precautions, and airborne precautions. 预防措施包括接触预防措施、飞沫预防措施和空气传播预防措施。
Virulence: The degree to which a microorganism is likely to become a disease. 病毒性：微生物可能致病的程度。
Learning Objectives 学习目标
Identify the patients at risk for impaired skin integrity 识别皮肤完整性可能受损的患者
Identify factors related to alterations in the integumentary system across the life span 确定与整个生命周期中皮肤系统变化有关的因素
Assess a patient’s skin integrity 评估患者皮肤的完整性
Note normal from abnormal findings 注意正常与异常结果
Assess the characteristics of the wound 评估伤口特征
Apply correct terminology in the description of wounds 在描述伤口时使用正确的术语
Adapt care based on integumentary assessment data gathered 根据收集到的皮肤评估数据调整护理方法
Identify evidence-based practices 确定循证实践
The integumentary system includes skin, hair, and nails. The skin is the largest organ of the body and has many purposes. Our skin keeps us warm and contains nerve endings that control the ability to feel the sensations of hot, cold, pain, and pressure. Our skin also keeps harmful things out of the body, such as dirt, bacteria, and viruses, and keeps helpful things in like moisture. Maintaining intact skin is important to prevent infection and maintain health. This chapter will review the anatomy and physiology of the integumentary system, factors that affect healthy skin and healing, and interventions that nurses perform to repair and protect this vital organ. 皮肤是人体最大的器官，有许多用途。皮肤是人体最大的器官，具有多种功能。皮肤可以保暖，并含有控制冷热、疼痛和压力感觉的神经末梢。皮肤还能将有害物质（如灰尘、细菌和病毒）阻挡在体外，并将有益物质（如水分）阻挡在体内。保持皮肤完整对于预防感染和维持健康非常重要。本章将回顾人体皮肤系统的解剖学和生理学、影响皮肤健康和愈合的因素，以及护士为修复和保护这一重要器官而采取的干预措施。
Skin 皮肤
Skin is made up of three layers: epidermis, dermis, and hypodermis. See Figure 10.1 ’ for an illustration of skin layers. The epidermis is the thin, topmost layer of the skin. It contains sweat gland duct openings and the visible part of hair known as the hair shaft. Underneath the epidermis lies the dermis where many essential components of skin function are located. The dermis contains hair follicles (the roots of hair shafts), sebaceous oil glands, blood vessels, endocrine sweat glands, and nerve endings. The bottommost layer of skin is the hypodermis (also referred to as the subcutaneous layer). It mostly consists of adipose tissue (fat), along with some blood vessels and nerve endings. Beneath the hypodermis layer lies bone, muscle, ligaments, and tendons. 皮肤由表皮、真皮和皮下三层组成。请参见图 10.1'，了解皮肤层的图示。表皮是皮肤最薄的一层。它包含汗腺导管开口和被称为毛干的头发可见部分。表皮下面是真皮层，皮肤功能的许多重要组成部分都位于真皮层。真皮层包含毛囊（毛发的根部）、皮脂腺、血管、内分泌汗腺和神经末梢。皮肤的最底层是真皮下层（也称皮下层）。它主要由脂肪组织（脂肪）以及一些血管和神经末梢组成。真皮下层下面是骨骼、肌肉、韧带和肌腱。
Figure 10.1 Layers of the Skin 图 10.1 皮肤的层次
There are several common skin disorders that a nurse may find when assessing a patient’s skin. 护士在评估病人皮肤时可能会发现几种常见的皮肤病。
Read more about common skin disorders in the “Common Integumentary Conditions” section of the “Integumentary Assessment” chapter of the Open RN Nursing Skills textbook. 在《开放式注册护士护理技能》教科书 "整体评估 "一章的 "常见皮肤病 "部分，阅读更多有关常见皮肤病的信息。
Hair 头发
Hair is a filament that grows from a hair follicle in the dermis of the skin. See 毛发是从皮肤真皮层的毛囊中长出来的细丝。参见
Figure 10.2^(2)10.2^{2} for an illustration of a hair follicle. It consists mainly of tightly packed, keratin-filled cells called keratinocytes. The human body is covered with hair follicles except for the mucous membranes, lips, palms of the hands, and soles of the feet. The part of the hair that is located within the follicle is called the hair root, the only living part of the hair. The part of the hair that is visible above the surface of the skin is the hair shaft. The shaft of the hair has no biochemical activity and is considered dead. 图 10.2^(2)10.2^{2} 为毛囊示意图。毛囊主要由紧密排列、充满角蛋白的细胞（称为角质细胞）组成。除粘膜、嘴唇、手掌和脚底外，人体全身都布满了毛囊。头发位于毛囊内的部分称为发根，是头发唯一有生命的部分。头发在皮肤表面以上可见的部分是毛干。毛干没有生化活动，被认为是死的。
2. “506 Hair.jpg” by OpenStax is licensed under CC BY 3.0. Access for free at https://openstax.org/books/ anatomy-and-physiology/pages/5-2-accessory-structures-of-the-skin. 2."506 Hair.jpg" by OpenStax 采用 CC BY 3.0 许可。免费访问：https://openstax.org/books/ anatomy-and-physiology/pages/5-2-accessory-structures-of-the-skin.
Figure 10.2 Hair Follicle 图 10.2 毛囊
Functions of Hair 头发的功能
The functions of head hair are to provide insulation to retain heat and to protect the skin from damage by UV light. The function of hair in other locations on the body is debated. One idea is that body hair helps to keep us 头部毛发的功能是隔热和保护皮肤免受紫外线伤害。关于身体其他部位的毛发的功能则存在争议。一种观点认为，体毛可以帮助我们保持
warm in cold weather. When the body is cold, the arrector pili muscles contract, causing hairs to stand up and trapping a layer of warm air above the epidermis. However, this action is more effective in mammals that have thick hair than it is in relatively hairless human beings. 在寒冷的天气里保暖。当身体寒冷时，韧带肌肉会收缩，导致毛发竖起，在表皮上形成一层暖空气。不过，这种作用在毛发浓密的哺乳动物身上比在相对无毛的人类身上更有效。
Human hair has an important sensory function as well. Sensory receptors in the hair follicles can sense when the hair moves, whether it is because of a breeze or the touch of a physical object. Some hairs, such as the eyelashes, are especially sensitive to the presence of potentially harmful matter. The eyebrows protect the eyes from dirt, sweat, and rain. In addition, the eyebrows play a key role in nonverbal communication by expressing emotions such as sadness, anger, surprise, and excitement. ^(3){ }^{3} 人类的头发还有一个重要的感官功能。毛囊中的感官受体可以感知毛发的运动，无论是微风还是实物的触碰。有些毛发，如睫毛，对潜在有害物质的存在特别敏感。眉毛可以保护眼睛免受灰尘、汗水和雨水的伤害。此外，眉毛还在非语言交流中扮演着重要角色，它可以表达悲伤、愤怒、惊讶和兴奋等情绪。 ^(3){ }^{3}
Nails 指甲
Nails are accessory organs of the skin. They are made of sheets of dead keratinocytes and are found on the distal ends of the fingers and toes. The keratin in nails makes them hard but flexible. Nails serve a number of purposes, including protecting the fingers, enhancing sensations, and acting like tools. A nail has three main parts: root, plate, and free margin. Other structures around or under the nail include the nail bed, cuticle, and nail fold. See Figure 10.3 for an illustration of the structure of a nail. ^(4.5){ }^{4.5} The top diagram in this figure shows the external, visible part of the nail and the cuticle. The bottom diagram shows internal structures in a cross-section of the nail and nail bed. 指甲是皮肤的附属器官。指甲由死亡的角质细胞构成，位于手指和脚趾的远端。指甲中的角蛋白使其坚硬但富有弹性。指甲有多种功能，包括保护手指、增强感觉和充当工具。指甲有三个主要部分：甲根、甲板和游离缘。指甲周围或下方的其他结构包括甲床、角质层和甲沟。指甲结构示意图见图 10.3。 ^(4.5){ }^{4.5} 图中上图显示了指甲的外部可见部分和角质层。下图显示的是指甲和甲床横截面的内部结构。
3. This work is a derivative of Human Biology by Wakim and Grewal and is licensed under CC-BY-NC 4.0 3.本作品是 Wakim 和 Grewal 所著《人类生物学》的衍生作品，采用 CC-BY-NC 4.0 许可协议进行许可。
4. “Blausen_0406_FingerNailAnatomy.png” by BruceBlaus is licensed under CC BY 3.0 4.BruceBlaus 制作的 "Blausen_0406_FingerNailAnatomy.png" 采用 CC BY 3.0 许可。
5. This work is a derivative of Human Biology by Wakim and Grewal and is licensed under CC-BY-NC 4.0 5.本作品是 Wakim 和 Grewal 所著《人类生物学》的衍生作品，采用 CC-BY-NC 4.0 许可。
Impaired Skin and Tissue Integrity 皮肤和组织完整性受损
Skin integrity is a medical term that refers to skin health. Impaired skin integrity is a NANDA-I nursing diagnosis defined as, “Altered epidermis/or dermis.” ^(6){ }^{6} However, when deeper layers of the skin or integumentary structures are damaged, it is referred to as impaired tissue integrity. The NANDA-I definition of impaired tissue integrity is, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” ^(7){ }^{7} 皮肤完整性是一个医学术语，指皮肤健康。皮肤完整性受损是一种 NANDA-I 护理诊断，定义为 "表皮/或真皮发生变化"。 ^(6){ }^{6} 然而，当皮肤深层或整体结构受损时，则称为组织完整性受损。NANDA-I 对组织完整性受损的定义是："粘膜、角膜、皮肤系统、肌肉筋膜、肌肉、肌腱、骨骼、软骨、关节囊和/或韧带受损"。 ^(7){ }^{7}
Risk Factors Affecting Skin Health and Wound Healing 影响皮肤健康和伤口愈合的风险因素
There are several risk factors that place a patient at increased risk for altered skin health and delayed wound healing. Risk factors include impaired circulation and oxygenation, impaired immune function, diabetes, inadequate nutrition, obesity, exposure to moisture, smoking, and age. Each of these risk factors is discussed in more detail in the following subsections. 有几种风险因素会增加患者皮肤健康改变和伤口延迟愈合的风险。风险因素包括血液循环和氧合作用受损、免疫功能受损、糖尿病、营养不足、肥胖、受潮、吸烟和年龄。下文将对这些风险因素逐一进行详细讨论。
Impaired Circulation and Oxygenation 血液循环和氧合作用受损
Skin, like every other organ in the body, depends on good blood perfusion to keep it healthy and functioning correctly. Cardiovascular circulation delivers important oxygen, nutrients, infection-fighting cells, and clotting factors to tissues. These elements are needed by skin, tissues, and nerves to properly grow, function, and repair damage. Without good cardiovascular circulation, skin becomes damaged. Damage can occur from poor blood perfusion from the arteries, as well as from poor return of blood through the veins to the heart. Common medical conditions that decrease cardiovascular circulation include cardiac disease, diabetes, and peripheral vascular disease (PVD). PVD 皮肤和身体的其他器官一样，都需要良好的血液灌流来保持健康和正常功能。心血管循环为组织输送重要的氧气、营养物质、抗感染细胞和凝血因子。皮肤、组织和神经需要这些元素来正常生长、运作和修复损伤。没有良好的心血管循环，皮肤就会受损。动脉血液灌流不畅以及静脉血液回流心脏不畅都会导致皮肤受损。降低心血管循环的常见疾病包括心脏病、糖尿病和外周血管疾病（PVD）。外周血管疾病
includes two medical conditions called arterial insufficiency and venous insufficiency. 包括动脉供血不足和静脉供血不足两种病症。
ARTERIAL INSUFFICIENCY 动脉供血不足
Arterial insufficiency refers to a lack of adequately oxygenated blood movement in arteries to specific tissues. Arterial insufficiency can be a sudden, acute lack of oxygenated blood, such as when a blood clot in an artery blocks blood flow to a specific area. Arterial insufficiency can also be a chronic condition caused by peripheral vascular disease (PVD). As a person’s arteries become blocked with plaque due to atherosclerosis, there is decreased blood flow to the tissues. Signs of arterial insufficiency are cool skin temperature, pale skin color, pain that increases with exercise, and possible arterial ulcers. 动脉供血不足是指动脉中缺乏足够的含氧血液流向特定组织。动脉供血不足可以是突然、急性的含氧血液缺乏，例如动脉中的血栓阻塞了流向特定区域的血流。动脉供血不足也可能是由外周血管疾病（PVD）引起的慢性疾病。当动脉粥样硬化导致斑块堵塞时，流向组织的血液就会减少。动脉供血不足的症状包括皮肤温度低、肤色苍白、运动时疼痛加剧以及可能出现动脉溃疡。
When oxygenated blood flow to tissues becomes inadequate, the tissue dies. This is called necrosis. Tissue death causes the skin and tissue to become necrotic (black). Necrotic tissue does not heal, so surgical debridement or amputation of the extremity becomes necessary for healing. See Figure 10.4^(8)10.4^{8} for images of an arterial insufficiency ulcer and necrotic toes. 当流向组织的含氧血流不足时，组织就会坏死。这就是所谓的坏死。组织死亡会导致皮肤和组织坏死（变黑）。坏死的组织不会愈合，因此必须通过手术清创或截肢才能愈合。动脉供血不足溃疡和坏死脚趾的图片见图 10.4^(8)10.4^{8} 。
Venous insufficiency occurs when the cardiovascular system cannot adequately return blood and fluid from the extremities to the heart. Venous insufficiency can cause stasis dermatitis when blood pools in the lower legs and leaks out into the skin and other tissues. Signs of venous insufficiency are edema, a brownish-leathery appearance to skin in the lower extremities, and venous ulcers that weep fluid. ^(9){ }^{9} See Figure 10.5^(10)10.5^{10} for an image of stasis dermatitis. 当心血管系统无法将血液和液体从四肢充分回流到心脏时，就会发生静脉功能不全。当血液淤积在小腿并渗漏到皮肤和其他组织时，静脉功能不全会引起淤积性皮炎。静脉功能不全的体征是水肿、下肢皮肤呈褐色皮革样外观以及流出液体的静脉溃疡。 ^(9){ }^{9} 瘀积性皮炎图片见图 10.5^(10)10.5^{10} 。
Figure 10.5 Stasis Dermatitis Due to Venous Insufficiency 图 10.5 静脉功能不全导致的瘀积性皮炎
Impaired Immune Function 免疫功能受损
Skin contributes to the body’s immune function and is also affected by the immune system. Intact skin provides an excellent first line of defense against foreign objects entering the body. This is why it is essential to keep skin intact. If skin does break down, the next line of defense is a strong immune system that attacks harmful invading organisms. However, if the immune system is not working well, the body is much more susceptible to infections. This is why maintaining intact skin, especially in the presence of an impaired immune system, is imperative to decrease the risk of infections. 皮肤有助于人体的免疫功能，同时也会受到免疫系统的影响。完整的皮肤是抵御异物进入人体的第一道防线。因此，保持皮肤完整至关重要。如果皮肤破损，下一道防线就是强大的免疫系统，它可以攻击入侵的有害生物。然而，如果免疫系统工作不力，人体就更容易受到感染。这就是为什么保持皮肤完好，尤其是在免疫系统受损的情况下，是降低感染风险的当务之急。
Stress can cause an impaired immune response that results in delayed wound healing." Being hospitalized or undergoing surgery triggers the stress response in many patients. Medications, such as corticosteroids, also affect a patient’s immune function and can impair wound healing. ^(12){ }^{12} When assessing a chronic wound that is not healing as expected, it is important to consider the potential effects of stress and medications. 压力会导致免疫反应受损，从而导致伤口愈合延迟"。住院或接受手术会引发许多患者的应激反应。皮质类固醇等药物也会影响患者的免疫功能，并损害伤口愈合。 ^(12){ }^{12} 在评估未按预期愈合的慢性伤口时，必须考虑压力和药物的潜在影响。
Diabetes 糖尿病
Diabetes can cause wounds to develop, as well as cause delayed wound healing. Nurses provide vital patient education to patients with diabetes to help them effectively manage the disease and prevent complications. 糖尿病会导致伤口形成，也会造成伤口延迟愈合。护士为糖尿病患者提供重要的患者教育，帮助他们有效控制病情，预防并发症。
"Read more about diabetes in the “Antidiabetics” section of the “Endocrine” chapter in Open RN Nursing Pharmacology. "在《开放式注册护士护理药理学》中的 "内分泌 "章节的 "抗糖尿病药 "部分阅读更多有关糖尿病的内容。
Inadequate Nutrition 营养不足
A healthy diet is essential for maintaining healthy skin, as well as maintaining an appropriate weight. Nutrients that are particularly important for skin health include protein; vitamins A, C, D, and E; and minerals such as selenium, copper, and zinc. ^(13){ }^{13} 健康的饮食对保持皮肤健康和适当的体重至关重要。对皮肤健康尤为重要的营养素包括蛋白质、维生素 A、C、D 和 E 以及硒、铜和锌等矿物质。 ^(13){ }^{13}
Nutritional deficiencies can have a profound impact on wound healing and must be addressed for chronic wounds to heal. Protein is one of the most important nutritional factors affecting wound healing. For example, in patients with pressure injuries, 30 to 35kcal//kg35 \mathrm{kcal} / \mathrm{kg} of calorie intake with 1.25 to 1.5g//kg1.5 \mathrm{~g} / \mathrm{kg} of protein and micronutrients supplementation are recommended daily. ^(14){ }^{14} In addition, vitamin C and zinc have many roles in wound healing. It is important to collaborate with a dietician to identify and manage nutritional deficiencies when a patient is experiencing poor wound healing. ^(15){ }^{15} 营养缺乏会对伤口愈合产生深远影响，因此必须解决营养缺乏问题，慢性伤口才能愈合。蛋白质是影响伤口愈合的最重要营养因素之一。例如，对于压力性损伤患者，建议每天摄入 30 至 35kcal//kg35 \mathrm{kcal} / \mathrm{kg} 热量，并补充 1.25 至 1.5g//kg1.5 \mathrm{~g} / \mathrm{kg} 蛋白质和微量元素。 ^(14){ }^{14} 此外，维生素 C 和锌对伤口愈合也有很多作用。当患者伤口愈合不良时，与营养师合作识别和处理营养缺乏问题非常重要。 ^(15){ }^{15}
13. Park, K. (2015). Role of micronutrients in skin health and function. Biomolecules & Therapeutics, 23(3), 207-217. https://doi.org/10.4062/biomolther.2015.003 13.Park, K. (2015).微量营养素在皮肤健康和功能中的作用。生物分子与治疗学》，23（3），207-217。https://doi.org/10.4062/biomolther.2015.003。
14. Cox, J. (2019). Wound care 101. Nursing, 49(10), 32-39. https://doi.org/10.1097/01.nurse.0000580632.58318.08 14.Cox, J. (2019).伤口护理 101。Nursing, 49(10), 32-39. https://doi.org/10.1097/01.nurse.0000580632.58318.08
15. Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219-229. https://doi.org/10.1177/0022034509359125 15.Guo, S., & Dipietro, L. A. (2010)。影响伤口愈合的因素。牙科研究杂志》，89（3），219-229。https://doi.org/10.1177/0022034509359125。
To read more about nutritional deficiencies and related nursing interventions, go to the “Nutrition” chapter. 如需进一步了解营养缺乏症和相关护理干预措施，请参阅 "营养 "章节。
Obesity 肥胖症
In the same way a balanced diet is vital for healthy skin, a healthy weight is also imperative. Obese individuals are at increased risk for fungal and yeast infections in skin folds caused by increased moisture and friction. See Figure 10.6^(16)10.6^{16} for an image of a fungal infection in the groin. ^(17){ }^{17} Symptoms of yeast and fungal infection include redness and scaliness of the skin associated with itching. 均衡的饮食对皮肤健康至关重要，同样，健康的体重也是必不可少的。肥胖者皮肤褶皱处的真菌和酵母菌感染的风险会增加，因为皮肤褶皱处的水分和摩擦会增加。腹股沟真菌感染图片见图 10.6^(16)10.6^{16} 。 ^(17){ }^{17} 酵母菌和真菌感染的症状包括皮肤发红和鳞屑，伴有瘙痒。
Obese patients also are at higher risk for wound complications due to a decreased supply of oxygenated blood flow to adipose tissue. Potential complications include infection, dehiscence (separation of the edges of a surgical wound), hematoma formation, pressure injuries, and venous ulcers. Evisceration is a rare but severe complication when an abdominal surgical incision separates and the abdominal organs protrude or come out of the incision. Nurses can educate patients about making healthy lifestyle choices 由于脂肪组织供氧血流减少，肥胖患者出现伤口并发症的风险也较高。潜在的并发症包括感染、开裂（手术伤口边缘分离）、血肿形成、压伤和静脉溃疡。开裂是一种罕见但严重的并发症，是指腹部手术切口分离，腹部器官从切口突出或脱出。护士可以教育病人选择健康的生活方式
to reduce obesity and the risk of dehiscence. See Figure 10.7^(19)10.7^{19} for an image of a dehiscence in an abdominal surgical wound of an obese patient. 以减少肥胖和伤口开裂的风险。肥胖病人腹部手术伤口开裂的图片见图 10.7^(19)10.7^{19} 。
Figure 10.7 Dehiscence 图 10.7 开裂
Exposure to Moisture 接触湿气
Healthy skin needs good moisture balance. If too much moisture (i.e., sweat, urine, or water) is left on the skin for extended periods of time, the skin will become soggy, wrinkly, and turn whiter than usual and is called maceration. A simple example of maceration is when you spend too much time in a bathtub and your fingers and toes turn white and get “pruny.” See Figure 10.8^(20)10.8^{20} for an image of maceration. If healthy skin is exposed to moisture for an extended period of time, such as when a moist wound dressing is incorrectly applied on healthy skin, the skin will break down. This type of skin breakdown is called excoriation. Excoriation refers to redness and removal of the topmost surface of the skin. See Figure 10.9^(21)10.9^{21} for an image of excoriation. 健康的皮肤需要良好的水分平衡。如果过多的水分（如汗液、尿液或水）长时间留在皮肤上，皮肤就会变得潮湿、起皱、变白，这就是所谓的浸渍。浸渍的一个简单例子是，当你在浴缸里泡得太久，手指和脚趾就会变白，变得 "刺刺的"。浸渍的图片见图 10.8^(20)10.8^{20} 。如果健康皮肤长时间暴露在潮湿环境中，例如在健康皮肤上错误地使用潮湿的伤口敷料，皮肤就会破损。这种类型的皮肤破损称为剥脱。剥脱是指皮肤最表层发红和脱落。请参阅图 10.9^(21)10.9^{21} ，了解剥脱的图像。
19. “Bogota bag.png” by Suarez-Grau, J. M., Guadalajara Jurado, J. F., Gómez Menchero, J., & Bellido Luque, J. A. is licensed under CC BY 4.0 19."Bogota bag.png" by Suarez-Grau, J. M., Guadalajara Jurado, J. F., Gómez Menchero, J., & Bellido Luque, J. A. 采用 CC BY 4.0 许可。
20. “Trench_foot.jpg” by Mehmet Karatay is licensed under CC BY-SA 3.0 20."Trench_foot.jpg" by Mehmet Karatay 采用 CC BY-SA 3.0 许可协议发布。
21. “Dermatomyositis15.jpg” by Elizabeth M. Dugan, Adam M. Huber, Frederick W. Miller, and Lisa G. Rider is licensed under CC BY-SA 3.0 21."皮肌炎 15.jpg "由 Elizabeth M. Dugan、Adam M. Huber、Frederick W. Miller 和 Lisa G. Rider 许可。Rider 采用 CC BY-SA 3.0 许可。
Figure 10.9 Excoriation 图 10.9 剥蚀
The opposite occurs when skin lacks proper moisture. Skin becomes flaky, itchy, and cracked when it becomes too dry. Conditions such as decreased moisture in the air during cold winter months or bathing in hot water can worsen skin dryness. Dry skin, especially when accompanied with cracking, breaks the protective barrier and increases the risk of infection. It is important for nurses to apply emollient cream to patients’ areas of dry skin to maintain the protective skin barrier. 如果皮肤缺乏适当的水分，则会出现相反的情况。皮肤过于干燥时会出现脱皮、瘙痒和皲裂。寒冷冬季空气中的水分减少或用热水洗澡等情况都会加剧皮肤干燥。皮肤干燥，尤其是伴有皲裂时，会破坏保护屏障，增加感染的风险。护士必须在患者皮肤干燥的部位涂抹润肤霜，以保持皮肤的保护屏障。
Smoking 吸烟
Smoking impacts the inflammatory phase of the wound healing process, which can result in poor wound healing and an increased risk of infection. Patients who smoke should be encouraged to stop smoking. 吸烟会影响伤口愈合过程中的炎症阶段，导致伤口愈合不良和感染风险增加。应鼓励吸烟患者戒烟。
Age 年龄
Older adults have thin, less elastic skin that is at increased risk for injury. They also have an altered inflammatory response that can impair wound healing. Nurses can educate older patients about the importance of exercise for skin health and improved wound healing as appropriate. ^(23){ }^{23} 老年人的皮肤较薄、弹性较差，受伤的风险较高。他们的炎症反应也会发生改变，从而影响伤口愈合。护士可以教育老年患者运动对皮肤健康和改善伤口愈合的重要性。 ^(23){ }^{23}
Phases of Wound Healing 伤口愈合阶段
When skin is injured, there are four phases of wound healing that take place: hemostasis, inflammatory, proliferative, and maturation. See Figure 10.10^(')10.10^{\prime} for an illustration of wound healing demonstrating hemostasis/inflammation, proliferation, and maturation. 皮肤受伤后，伤口愈合分为四个阶段：止血、炎症、增殖和成熟。请参阅图 10.10^(')10.10^{\prime} ，了解显示止血/炎症、增殖和成熟的伤口愈合图。
To illustrate the phases of wound healing, imagine that you accidentally cut your finger with a knife as you were slicing an apple for a snack. Immediately after the injury occurs, blood vessels constrict and clotting factors are activated. This is referred to as the hemostasis phase. Clotting factors are released to form clots and to stop the bleeding. Platelets release growth factors that alert various cells to start the repair process at the wound 为了说明伤口愈合的各个阶段，想象一下你在切苹果吃时不小心被刀割伤了手指。受伤后，血管立即收缩，凝血因子被激活。这就是所谓的止血阶段。凝血因子被释放以形成血块并止血。血小板释放生长因子，提醒各种细胞开始伤口修复过程
location. The hemostasis phase lasts up to 60 minutes, depending on the severity of the injury. ^(2,3){ }^{2,3} 位置。止血阶段持续长达 60 分钟，具体取决于损伤的严重程度。 ^(2,3){ }^{2,3}
After the hemostasis phase, the inflammatory phase begins. Vasodilation occurs so that white blood cells in the bloodstream can move to the location of the wound and start cleaning the wound bed. The inflammatory process appears as edema (swelling), erythema (redness), and exudate. Exudate is fluid that oozes out of a wound and is commonly called pus or drainage. ^(4.5){ }^{4.5} 止血阶段结束后，炎症阶段开始。血管扩张使血液中的白细胞可以移动到伤口位置并开始清洁伤口床。炎症过程表现为水肿（肿胀）、红斑（发红）和渗出物。渗出液是伤口渗出的液体，通常称为脓液或引流液。 ^(4.5){ }^{4.5}
The proliferative phase of wound healing begins within a few days after the injury and includes four important processes: epithelialization, angiogenesis, collagen formation, and contraction. Epithelialization refers to the development of new epidermis and granulation tissue. Granulation tissue is new connective tissue with new, fragile, thin-walled capillaries. Collagen is also formed to provide strength and integrity to the wound. At the end of the proliferation phase, the wound begins to contract in size., ^(6,7){ }^{6,7} 伤口愈合的增殖期在受伤后几天内开始，包括四个重要过程：上皮化、血管生成、胶原蛋白形成和收缩。上皮化是指新表皮和肉芽组织的发育。肉芽组织是新的结缔组织，带有新的、脆弱的薄壁毛细血管。胶原蛋白也会形成，为伤口提供强度和完整性。在增殖阶段结束时，伤口开始收缩。
Capillaries begin to develop within the wound 24 hours after injury during a process called angiogenesis. These capillaries bring more oxygen and nutrients to the wound for healing. When performing dressing changes, it is essential for the nurse to protect this granulation tissue and the associated new capillaries. Healthy granulation tissue appears pink due to the new capillary formation. It is moist, painless to the touch, and may appear “bumpy.” Conversely, unhealthy granulation tissue is dark red and painful. It bleeds easily with minimal contact and may be covered by shiny white or yellow fibrous tissue, referred to as biofilm, that must be removed because it 受伤 24 小时后，伤口内的毛细血管开始生长，这一过程被称为血管生成。这些毛细血管为伤口的愈合带来更多的氧气和养分。换药时，护士必须保护肉芽组织和相关的新生毛细血管。由于新生毛细血管的形成，健康的肉芽组织呈现粉红色。肉芽组织湿润，触摸无痛，可能会出现 "凹凸不平 "的情况。相反，不健康的肉芽组织则呈暗红色，并伴有疼痛。稍有接触就容易出血，可能会被发亮的白色或黄色纤维组织（称为生物膜）覆盖，必须将其去除，因为它
impedes healing. Unhealthy granulation tissue is often caused by an infection, so wound cultures should be obtained when infection is suspected. ^(8){ }^{8} 妨碍伤口愈合。不健康的肉芽组织通常是由感染引起的，因此在怀疑感染时应进行伤口培养。 ^(8){ }^{8}
During the maturation phase, collagen continues to be created to strengthen the wound. Collagen contributes strength to the wound to prevent it from reopening. A wound typically heals within 4-5 weeks and often leaves behind a scar. The scar tissue is initially firm, red, and slightly raised from the excess collagen deposition. Over time, the scar begins to soften, flatten, and become pale in about nine months. ^(9,10){ }^{9,10} 在成熟阶段，胶原蛋白会继续生成，以巩固伤口。胶原蛋白能增强伤口的强度，防止伤口再次裂开。伤口一般在 4-5 周内愈合，通常会留下疤痕。由于胶原蛋白沉积过多，疤痕组织最初坚硬、发红并略微隆起。随着时间的推移，疤痕会开始变软、变平，并在大约九个月后变得苍白。 ^(9,10){ }^{9,10}
Types of Wound Healing 伤口愈合的类型
There are three types of wound healing: primary intention, secondary intention, and tertiary intention. Healing by primary intention means that the wound is sutured, stapled, glued, or otherwise closed so the wound heals beneath the closure. This type of healing occurs with clean-edged lacerations or surgical incisions, and the closed edges are referred to as approximated. See Figure 10.11^(11)10.11^{11} for an image of a surgical wound healing by primary intention with approximated edges. 伤口愈合有三种类型：一级意向愈合、二级意向愈合和三级意向愈合。原发意向愈合是指通过缝合、钉合、粘合或其他方式闭合伤口，使伤口在闭合处愈合。这种类型的愈合发生在边缘干净的撕裂伤或手术切口，闭合的边缘被称为近似边缘。请参阅图 10.11^(11)10.11^{11} ，了解边缘近似的原发意向愈合的手术伤口图像。
8. McKay, M. (1990). The dermatologic history. In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed.). https://www.ncbi.nlm.nih.gov/books/NBK207/ 8.McKay, M. (1990).The dermatologic history.In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods：https://www.ncbi.nlm.nih.gov/books/NBK207/。
9. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and licensed under CC BY 4.0 9.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
10. This work is a derivative of StatPearls by Grubbs & Manna and is licensed under CC BY 4.0 10.本作品是 Grubbs & Manna 的 StatPearls 的衍生作品，采用 CC BY 4.0 许可。
11. “Ventriculoperitoneal shunt - surgical wound healing - belly - day 12.jpg” by Hansmuller is licensed under CC BY-SA 4.0 11."脑室腹腔分流术--手术伤口愈合--腹部--第 12 天.jpg" by Hansmuller 采用 CC BY-SA 4.0 许可发布。
Secondary intention occurs when the edges of a wound cannot be approximated (brought together), so the wound heals by filling in from the bottom up with the production of granulation tissue. Examples of common wounds that heal by secondary intention are pressure injuries and skin tears. Wounds that heal by secondary infection are at higher risk for infection and must be protected from contamination. See Figure 10.12^(12)10.12^{12} for an image of a wound healing by secondary intention. 二次意向是指伤口边缘无法靠拢（合拢），因此伤口会随着肉芽组织的生成自下而上地愈合。通过继发感染愈合的常见伤口包括压力伤和皮肤撕裂。通过继发感染愈合的伤口感染风险较高，必须防止污染。请参阅图 10.12^(12)10.12^{12} ，了解伤口通过继发意向愈合的图像。
Tertiary intention refers to the healing of a wound that has had to remain open or has been reopened, often due to severe infection. The wound is typically closed at a later date when infection has resolved. Wounds that heal 第三意向是指通常由于严重感染而不得不保持开放或重新开放的伤口的愈合。伤口一般在感染消退后再缝合。愈合的伤口
by secondary and tertiary intention have delayed healing times and increased scar tissue. 通过二级和三级意向治疗会延迟愈合时间，增加疤痕组织。
There are many common types of wounds that nurses care for, such as skin tears, venous ulcers, arterial ulcers, diabetic ulcers, and pressure injuries. 护士护理的常见伤口类型很多，如皮肤裂伤、静脉溃疡、动脉溃疡、糖尿病溃疡和压力伤。
Wound Care 伤口护理
Wound care includes assessing and cleansing wounds, performing dressing changes, and implementing interventions to promote wound healing. Assessing wounds and implementing interventions to promote wound 伤口护理包括评估和清洁伤口、更换敷料以及实施促进伤口愈合的干预措施。评估伤口并采取干预措施促进伤口愈合
healing are further discussed in the “Applying the Nursing Process” section later in this chapter. 本章后面的 "应用护理程序 "部分将进一步讨论愈合问题。
See the “Wound Care” chapter in Open RN Nursing Skills for additional information about cleansing wounds and performing dressing changes. 有关清洁伤口和换药的更多信息，请参阅《开放式注册护士护理技能》中的 "伤口护理 "章节。
10.4 Pressure Injuries 10.4 压力伤害
The remainder of this chapter will focus on applying the nursing process to a specific type of wound called a pressure injury. Pressure injuries are defined as, “Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear.” (Note that the 2016 NPUAP Pressure Injury Staging System now uses the term “pressure injury” instead of the historic term “pressure ulcer” because a pressure injury can occur without an ulcer present.) Pressure injuries commonly occur on the sacrum, heels, ischia, and coccyx and form when the skin layer of tissue gets caught between an external hard surface, such as a bed or chair, and the internal hard surface of a bone. 本章其余部分将重点介绍如何将护理程序应用于一种特殊类型的伤口，即压迫性损伤。压迫性损伤的定义是："皮肤或下层软组织的局部损伤，通常发生在骨性突出部位，是由于强力、长时间的压力和剪切力共同作用的结果"。(请注意，2016 年 NPUAP 压力损伤分期系统现在使用的术语是 "压力损伤"，而不是历史术语 "压疮"，因为压力损伤可能在没有溃疡的情况下发生）。压伤通常发生在骶骨、脚跟、骶尾骨和尾骨上，当皮肤组织层被夹在床或椅子等外部坚硬表面和骨骼内部坚硬表面之间时就会形成压伤。
Shear occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. For example, when a patient slides down in bed, the outer layer of skin remains immobile because it remains attached to the sheets due to friction. However, the deeper layer of tissue (attached to bone) moves as the patient slides down. This opposing movement of the outer layer of skin and the underlying tissues causes the capillaries to stretch and tear, which then causes decreased blood flow and oxygenation of the surrounding tissues resulting in a pressure injury. 当组织层相互移动时会产生剪切力，导致血管在穿过皮下组织时拉伸和断裂。例如，当病人在床上滑倒时，外层皮肤由于摩擦力而紧贴床单，因此不会移动。然而，深层组织（附着在骨头上）会随着病人的下滑而移动。外层皮肤和深层组织的这种对立运动会导致毛细血管拉伸和撕裂，进而导致周围组织的血流量和含氧量减少，造成压力损伤。
Friction refers to rubbing the skin against a hard object, such as the bed or the arm of a wheelchair. This rubbing causes heat, which can remove the top layer of skin and often results in skin damage. See Figure 10.13^(2)10.13^{2} for an illustration of shear and friction forces in the development of pressure injuries. 摩擦是指皮肤与床或轮椅扶手等硬物摩擦。这种摩擦会产生热量，导致表层皮肤脱落，通常会造成皮肤损伤。请参阅图 10.13^(2)10.13^{2} ，了解压力伤害发生过程中的剪切力和摩擦力。
Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585-597. https://doi.org/10.1097/WON.0000000000000281 Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016)。经修订的国家压疮顾问小组压伤分期系统：修订版压伤分期系统。伤口、造口和失禁护理杂志》：伤口、造口和失禁护士协会的官方出版物，43（6），585-597。https://doi.org/10.1097/WON.0000000000000281。
“Shear Force” and “Shear Force Closeup” by Meredith Pomietlo at Chippewa Valley Technical College are licensed under CC BY 4.0 "剪切力 "和 "剪切力特写 "均由奇佩瓦山谷技术学院的 Meredith Pomietlo 以 CC BY 4.0 许可。
Hospital-acquired or worsening pressure injuries during hospitalization are considered “never events” meaning they are a serious, preventable medical errors that should never occur and require reporting to The Joint Commission. Additionally, the Centers for Medicare and Medicaid Services (CMS) and many private insurers will no longer pay for additional costs associated with “never events.”, ^(3,4){ }^{3,4} Pressure injuries can be prevented with diligent assessment and nursing interventions. 医院获得的或住院期间恶化的压伤被视为 "从未发生的事件"，这意味着它们是一种严重的、可预防的医疗失误，根本不应该发生，需要向联合委员会报告。此外，医疗保险和医疗补助服务中心（CMS）以及许多私人保险公司将不再支付与 "从未发生事件 "相关的额外费用。
Staging 分期
When assessed, pressure injuries are staged from 1 through 4 based on the extent of tissue damage. For example, Stage 1 pressure injuries have the least amount of tissue damage as evidenced by reddened, intact skin, whereas Stage 4 pressure injuries have the greatest amount of damage with deep, open ulcers affecting underlying tissue, muscle, ligaments, or tendons. See 在进行评估时，会根据组织损伤的程度将压力损伤分为 1 到 4 级。例如，1 级压力伤害的组织损伤程度最低，表现为皮肤发红、完整无损；而 4 级压力伤害的组织损伤程度最高，会出现影响下层组织、肌肉、韧带或肌腱的深层开放性溃疡。参见
3. Agency for Healthcare Research and Quality. (2019, September). Never events. psnet.ahra.gov/primer/neverevents 3.医疗保健研究与质量机构。(2019, September).psnet.ahra.gov/primer/neverevents.
4. AMN Healthcare Education Services. (2020). Pressure injury: Never event. rn.com/clinical-insight-pressureinjuryl 4.AMN 医疗保健教育服务。(2020).压迫性损伤：rn.com/clinical-insight-pressureinjuryl.
Figure 10.14^(5)10.14^{5} for images of four stages of pressure injuries. ^(6){ }^{6} Each stage is further described in the following subsections. 图 10.14^(5)10.14^{5} 为压力伤害四个阶段的图像。 ^(6){ }^{6} 每个阶段将在下面的小节中进一步说明。
Figure 10.14 Four Stages of Pressure Injuries 图 10.14 压力伤害的四个阶段
Stage 1 Pressure Injuries 第 1 阶段压力伤害
Stage 1 pressure injuries are intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred. Nonblanchable erythema is a medical term used to describe an area of reddened skin that does not turn white when pressed. See Figure 10.15^(7)10.15^{7} for an illustration of a Stage 1 pressure injury. 第一阶段压力伤是指皮肤完好，但局部出现非灼痛性红斑，且长时间受压。非焯性红斑是一个医学术语，用于描述受压时不会变白的发红皮肤区域。请参阅图 10.15^(7)10.15^{7} ，了解第 1 阶段压力损伤。
5. “Wound stage.jpg” by Babagolzadeh is licensed under CC BY-SA 3.0 5."Wound stage.jpg" by Babagolzadeh 采用 CC BY-SA 3.0 许可协议发布。
6. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585-597. https://doi.org/10.1097/WON.0000000000000281 6.Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016)。经修订的国家压疮顾问小组压伤分期系统：修订版压伤分期系统。伤口、造口和失禁护理杂志》：伤口、造口和失禁护士协会的官方出版物，43（6），585-597。https://doi.org/10.1097/WON.0000000000000281。
7. “Stagel-Darkly_Pigmented” and “Skin_01__healthy_skin_-_I_pigmen.jpg” provided by National Pressure Injury Advisory Panel are used with permission for educational purposes. Access for free at https://npiap.com/page/ PressurelnjuryStages 7.国家压力伤害咨询小组提供的 "Stagel-Darkly_Pigmented "和 "Skin_01__healthy_skin_-_I_pigmen.jpg "经许可用于教育目的。免费访问 https://npiap.com/page/ PressurelnjuryStages
Stage 2 Pressure Injuries 第 2 阶段压力伤害
Stage 2 pressure injuries are partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear like an intact or ruptured blister. ^(8){ }^{8} See Figure 10.16^(9)10.16^{9} for an illustration of a Stage 2 pressure injury. 第二阶段压力伤是皮肤部分厚度脱落，真皮外露。伤口床可以存活，看起来像一个完整或破裂的水泡。 ^(8){ }^{8} 请参阅图 10.16^(9)10.16^{9} ，了解第 2 阶段压力损伤。
8. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585-597. https://doi.org/10.1097/WON.0000000000000281 8.Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016)。经修订的国家压疮顾问小组压伤分期系统：修订版压伤分期系统。伤口、造口和失禁护理杂志》：伤口、造口和失禁护士协会的官方出版物，43（6），585-597。https://doi.org/10.1097/WON.0000000000000281。
9. “20201202_114031_31850.jpg” and “stage_2_april_2020.jpg” provided by National Pressure Injury Advisory Panel are used with permission for educational purposes. Access for free at https://npiap.com/page/ PressurelnjuryStages. 9."20201202_114031_31850.jpg "和 "stage_2_april_2020.jpg "由国家压力伤害顾问团提供，经许可用于教育目的。可免费访问 https://npiap.com/page/ PressurelnjuryStages。
Stage 3 Pressure Injuries 第 3 阶段压力伤害
Stage 3 pressure injuries are full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. The depth of tissue damage varies by anatomical location. See Figure 10.17^(10)10.17^{10} for an illustration of a Stage 3 pressure injury. 第三阶段的压力损伤是全厚度的组织损失，其中脂肪可见，但软骨、肌腱、韧带、肌肉和骨骼没有暴露。组织损伤的深度因解剖位置而异。请参阅图 10.17^(10)10.17^{10} ，了解第 3 阶段压力损伤。
Undermining and tunneling may occur in Stage 3 and 4 pressure injuries. 在第 3 和第 4 阶段压力伤害中，可能会出现暗挖和隧道挖掘。
Undermining occurs when the tissue under the wound edge becomes eroded, resulting in a pocket beneath the skin. Tunneling refers to passageways underneath the skin surface that extend from a wound and can take twists and turns. 当伤口边缘下的组织被侵蚀，导致皮肤下出现袋状物时，就会出现破坏。隧道指的是皮肤表面下的通道，这些通道从伤口延伸出来，可以曲折蜿蜒。
Slough and eschar may also be present in Stage 3 and 4 pressure injuries. Slough is inflammatory exudate that is usually light yellow, soft, and moist. Eschar is dark brown/black, dry, thick, and leathery dead tissue. If slough or eschar obscures the wound so that tissue loss cannot be assessed, the 第 3 和第 4 阶段的压力性损伤也可能出现蜕皮和焦痂。蜕皮是炎性渗出物，通常呈淡黄色、柔软、潮湿。焦痂是深褐色/黑色、干燥、厚实、革质的坏死组织。如果淤血或炭化物遮盖了伤口，导致无法评估组织损失，则需要
pressure injury is referred to as unstageable." In most wounds, slough and eschar must be removed by debridement for healing to occur. 压力性伤害被称为非阶段性创伤"。在大多数伤口中，必须通过清创去除痂皮才能痊愈。
Figure 10.17 Stage 3 Pressure Injury. Used with permission. 图 10.17 第 3 阶段压力损伤。经许可使用。
Figure 10.18 Stage 4 Pressure Injury. Used with permission. 图 10.18 第 4 阶段压力损伤。经许可使用。
Unstageable Pressure Injuries 非阶段性压力伤害
Unstageable pressure injuries are full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar were to be removed, a Stage 3 or Stage 4 pressure injury would likely be revealed. However, dry and adherent eschar on the heel or ischemic limb is not typically removed. ^(1//4){ }^{1 / 4} See Figure 10.19^(15)10.19^{15} for an illustration of an unstageable pressure ulcer due to the presence of eschar (on the left side of the wound) and slough (on the right side of the wound). 无法分期的压力性损伤是指全层皮肤和组织缺损，溃疡内的组织损伤程度因被痂皮或粘液遮盖而无法确认。如果去除痂皮或粘液，很可能会发现第 3 或第 4 阶段的压力性损伤。但是，足跟或缺血肢体上干燥和粘连的焦痂通常不会被去除。 ^(1//4){ }^{1 / 4} 请参阅图 10.19^(15)10.19^{15} ，了解由于存在焦炭（位于伤口左侧）和痂皮（位于伤口右侧）而导致的不可分期压疮。
14. A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Stasis dermatitis and ulcers; [updated 2020, Dec 3; reviewed 2018, Oct 14; cited 2020, Dec 10]. https://medlineplus.gov/ency/article/ 000834.htm 14.A.D.A.M. 医学百科全书 [互联网]。Atlanta (GA)：A.D.A.M., Inc.; c1997-2020.瘀积性皮炎和溃疡；[更新时间：2020 年 12 月 3 日；审校时间：2018 年 10 月 14 日；引用时间：2020 年 12 月 10 日]。https://medlineplus.gov/ency/article/ 000834.htm
15. “Unstageable- Darkly Pigmented_Skin.jpg” and “unstageable-halfslough__1_.jpg” provided by National Pressure Injury Advisory Panel are used with permission for educational purposes. Access for free at https://npiap.com/page/PressurelnjuryStages 15.国家压力伤害咨询小组提供的 "不可分期--深色色素沉着_皮肤.jpg "和 "不可分期--halfslough__1_.jpg "经许可用于教育目的。免费访问 https://npiap.com/page/PressurelnjuryStages
Deep Tissue Pressure Injuries 深层组织压力伤害
Deep tissue pressure injuries consist of persistent nonblanchable and deep red, maroon, or purple discoloration of an area. These discolorations typically reveal a dark wound bed or blood-filled blister. Be aware that the discoloration may appear differently in darkly pigmented skin. Deep tissue injury results from intense and/or prolonged pressure, as well as shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or it may resolve without tissue loss. ^(16,17){ }^{16,17} See Figure 10.20 for an illustration of a deep tissue injury. 深层组织压力损伤是指某一区域出现持续的不褪色的深红色、褐红色或紫色变色。这些变色通常会显示出深色的伤口床或充血的水泡。需要注意的是，深色皮肤的变色可能会有所不同。深层组织损伤源于强烈和/或长时间的压力，以及骨-肌肉界面的剪切力。伤口可能会迅速发展以显示组织损伤的实际程度，也可能在没有组织损失的情况下愈合。 ^(16,17){ }^{16,17} 深层组织损伤示意图见图 10.20。
16. Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585-597. https://doi.org/10.1097/WON.0000000000000281 16.Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016)。经修订的国家压疮顾问小组压伤分期系统：修订版压伤分期系统。伤口、造口和失禁护理杂志》：伤口、造口和失禁护士协会的官方出版物，43（6），585-597。https://doi.org/10.1097/WON.0000000000000281。
17. “DTPI-Darkly Pigmented Skin” and “deep_tissue_pressure_injury_.jpg” provided by National Pressure Injury Advisory Panel are used with permission for educational purposes. Access for free at https://npiap.com/page/ PressurelnjuryStages 17."DTPI-深色皮肤 "和 "deep_tissue_pressure_injury_.jpg "由国家压力伤害顾问团提供，经授权用于教育目的。免费访问 https://npiap.com/page/ PressurelnjuryStages
Video Review of Assessing Pressure Injuries 压伤评估视频回顾
One or more interactive elements has been excluded from this version of the text. You can view them online here: https://wtcs.pressbooks.pub/nursingfundamentals/?p=566#oembed-1 本版本文本中排除了一个或多个互动元素。您可在此处在线查看： https://wtcs.pressbooks.pub/nursingfundamentals/?p=566#oembed-1
18. RegisteredNurseRN. (2018, March 7). Pressure ulcers (injuries) stages, prevention, assessment | Stage 1, 2, 3, 4 unstageable NCLEX. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/MDtPik7UE6k 18.RegisteredNurseRN.(2018, March 7).压疮（伤害）的阶段、预防、评估 | Stage 1, 2, 3, 4 unstageable NCLEX.[Video].YouTube.保留所有权利。视频经许可使用。https://youtu.be/MDtPik7UE6k
Several factors place a patient at risk for developing a pressure injury, in addition to shear and friction. These factors include decreased sensory perception, increased moisture, decreased activity, impaired mobility, and inadequate nutrition. The Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries. See Figure 10.21^(1)10.21^{1} for an image of a Braden Scale. Risk factors are rated on a scale from 1 to 4, with 1 being “completely limited” and 4 being “no impairment.” The scores from the six categories are added, and the total score indicates a patient’s risk for developing a pressure injury based on these ranges: 除了剪切力和摩擦力之外，还有几个因素会使病人面临发生压伤的风险。这些因素包括感觉减退、湿度增加、活动减少、行动不便和营养不足。布莱登量表是一种标准化的循证评估工具，通常用于医疗保健领域，以评估和记录患者发生压力损伤的风险。布莱登量表图片见图 10.21^(1)10.21^{1} 。风险因素按 1 到 4 级评分，1 级表示 "完全受限"，4 级表示 "无损害"。将六个类别的分数相加，得出的总分就表明了患者在这些范围内发生压力损伤的风险：
Mild risk: 15-18 轻度风险：15-18
Moderate risk: 13-14 中度风险：13-14
High risk: 10-12 高风险：10-12
Severe risk: less than 9 严重风险：低于 9
BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK 用于预测压疮风险的布拉登量表
Patient's Name qquad\qquad 病人姓名 qquad\qquad
Evaluator's Name 评估员姓名
Date of Assessment 评估日期
SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 对压力相关不适做出有意义反应的能力
1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body 1.完全受限 由于意识减退或镇静，对疼痛刺激反应迟钝（不呻吟、不退缩或不抓握）。或身体大部分部位感觉疼痛的能力有限
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness
OR
has a sensory impairment which limits the ability to feel pain or discomfort over 1//21 / 2 of body.
2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness
OR
has a sensory impairment which limits the ability to feel pain or discomfort over 1//2 of body.| 2. Very Limited |
| :--- |
| Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness |
| OR |
| has a sensory impairment which limits the ability to feel pain or discomfort over $1 / 2$ of body. |
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
3. Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.| 3. Slightly Limited |
| :--- |
| Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. |
| OR |
| has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. |
4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4.无障碍 对口令有反应。没有感官缺陷，不会限制感受或表达疼痛或不适的能力。
水分 皮肤接触水分的程度
MOISTURE
degree to which skin is exposed to moisture
MOISTURE
degree to which skin is exposed to moisture| MOISTURE |
| :--- |
| degree to which skin is exposed to moisture |
1.持续潮湿 皮肤因汗液、尿液等几乎持续保持潮湿。每次移动或翻身都会发现潮湿。
1. Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
1. Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.| 1. Constantly Moist |
| :--- |
| Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. |
2.非常潮湿 皮肤经常潮湿，但并非总是潮湿。床单必须至少每班更换一次。
2. Very Moist
Skin is often, but not always moist. Linen must be changed at least once a shift.
2. Very Moist
Skin is often, but not always moist. Linen must be changed at least once a shift.| 2. Very Moist |
| :--- |
| Skin is often, but not always moist. Linen must be changed at least once a shift. |
3.偶尔潮湿：皮肤偶尔潮湿，大约需要每天额外更换一次床单。
3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change approximately once a day.
3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change approximately once a day.| 3. Occasionally Moist: |
| :--- |
| Skin is occasionally moist, requiring an extra linen change approximately once a day. |
4.很少潮湿 皮肤通常比较干燥，只需定期更换床单。
4. Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.
4. Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.| 4. Rarely Moist |
| :--- |
| Skin is usually dry, linen only requires changing at routine intervals. |
运动量
ACTIVITY
degree of physical activity
ACTIVITY
degree of physical activity| ACTIVITY |
| :--- |
| degree of physical activity |
1. Bedfast Confined to bed. 1.卧床不起 卧床不起。
2.行走能力严重受限或丧失。无法承受自身重量和/或必须在他人搀扶下坐在椅子或轮椅上。
2. Chairfast
Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
2. Chairfast
Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.| 2. Chairfast |
| :--- |
| Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. |
3.偶尔行走 白天偶尔行走，但距离很短，无论是否有人搀扶。每班大部分时间躺在床上或椅子上
3. Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair
3. Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair| 3. Walks Occasionally |
| :--- |
| Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair |
4.经常走动 每天至少两次在室外走动，清醒时至少每两小时在室内走动一次
4. Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours
4. Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours| 4. Walks Frequently |
| :--- |
| Walks outside room at least twice a day and inside room at least once every two hours during waking hours |
移动能力 改变和控制身体位置的能力
MOBILITY
ability to change and control body position
MOBILITY
ability to change and control body position| MOBILITY |
| :--- |
| ability to change and control body position |
1. Completely Immobile Does not make even slight changes in body or extremity position without assistance 1.完全不能动 在没有帮助的情况下，身体或四肢的位置甚至不能做轻微的改变
2.非常有限 偶尔轻微改变身体或四肢的位置，但无法独立频繁或显著地改变。
2. Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
2. Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.| 2. Very Limited |
| :--- |
| Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. |
3.轻微受限 能够独立频繁但轻微地改变身体或四肢的位置。
3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently.
3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently.| 3. Slightly Limited |
| :--- |
| Makes frequent though slight changes in body or extremity position independently. |
4.无限制 在没有帮助的情况下，频繁地大幅度变换位置。
4. No Limitation
Makes major and frequent changes in position without assistance.
4. No Limitation
Makes major and frequent changes in position without assistance.| 4. No Limitation |
| :--- |
| Makes major and frequent changes in position without assistance. |
Never eats a complete meal. Rarely eats more than 1//21 / 2 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
is NPO and/or maintained on clear liquids or IV's for more than 5 days.
1. Very Poor
Never eats a complete meal. Rarely eats more than 1//2 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
is NPO and/or maintained on clear liquids or IV's for more than 5 days.| 1. Very Poor |
| :--- |
| Never eats a complete meal. Rarely eats more than $1 / 2$ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement |
| OR |
| is NPO and/or maintained on clear liquids or IV's for more than 5 days. |
Rarely eats a complete meal and generally eats only about 1//21 / 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day.
Occasionally will take a dietary supplement.
OR receives less than optimum amount of liquid diet or tube feeding
2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 1//2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day.
Occasionally will take a dietary supplement.
OR receives less than optimum amount of liquid diet or tube feeding| 2. Probably Inadequate |
| :--- |
| Rarely eats a complete meal and generally eats only about $1 / 2$ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. |
| Occasionally will take a dietary supplement. |
| OR receives less than optimum amount of liquid diet or tube feeding |
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered
OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs
3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered
OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs| 3. Adequate |
| :--- |
| Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered |
| OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs |
Usually eats a total of 4 or more servings of meat and dairy products.
Occasionally eats between meals. Does not require supplementation.
4. Excellent
Eats most of every meal. Never refuses a meal.
Usually eats a total of 4 or more servings of meat and dairy products.
Occasionally eats between meals. Does not require supplementation.| 4. Excellent |
| :--- |
| Eats most of every meal. Never refuses a meal. |
| Usually eats a total of 4 or more servings of meat and dairy products. |
| Occasionally eats between meals. Does not require supplementation. |
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction
1. Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction| 1. Problem |
| :--- |
| Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction |
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
2. Potential Problem
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.| 2. Potential Problem |
| :--- |
| Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. |
3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 3.无明显问题 可独立在床上和椅子上移动，并有足够的肌肉力量在移动过程中完全抬起。在床上或椅子上保持良好姿势。
- Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved - 版权所有 Barbara Braden 和 Nancy Bergstrom，1988 年 保留所有权利
Total Score 总分
Patient's Name qquad Evaluator's Name Date of Assessment
SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body "2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness
OR
has a sensory impairment which limits the ability to feel pain or discomfort over 1//2 of body." "3. Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities." 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
"MOISTURE
degree to which skin is exposed to moisture" "1. Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned." "2. Very Moist
Skin is often, but not always moist. Linen must be changed at least once a shift." "3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change approximately once a day." "4. Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals."
"ACTIVITY
degree of physical activity" 1. Bedfast Confined to bed. "2. Chairfast
Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair." "3. Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair" "4. Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours"
"MOBILITY
ability to change and control body position" 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance "2. Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently." "3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently." "4. No Limitation
Makes major and frequent changes in position without assistance."
"NUTRITION
usual food intake pattern" "1. Very Poor
Never eats a complete meal. Rarely eats more than 1//2 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
is NPO and/or maintained on clear liquids or IV's for more than 5 days." "2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 1//2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day.
Occasionally will take a dietary supplement.
OR receives less than optimum amount of liquid diet or tube feeding" "3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered
OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs" "4. Excellent
Eats most of every meal. Never refuses a meal.
Usually eats a total of 4 or more servings of meat and dairy products.
Occasionally eats between meals. Does not require supplementation."
FRICTION & SHEAR "1. Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction" "2. Potential Problem
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down." 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
- Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Total Score | Patient's Name $\qquad$ | | Evaluator's Name | | Date of Assessment | | | | |
| :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- |
| SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort | 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation. OR limited ability to feel pain over most of body | 2. Very Limited <br> Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness <br> OR <br> has a sensory impairment which limits the ability to feel pain or discomfort over $1 / 2$ of body. | 3. Slightly Limited <br> Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. <br> OR <br> has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. | 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. | | | | |
| MOISTURE <br> degree to which skin is exposed to moisture | 1. Constantly Moist <br> Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. | 2. Very Moist <br> Skin is often, but not always moist. Linen must be changed at least once a shift. | 3. Occasionally Moist: <br> Skin is occasionally moist, requiring an extra linen change approximately once a day. | 4. Rarely Moist <br> Skin is usually dry, linen only requires changing at routine intervals. | | | | |
| ACTIVITY <br> degree of physical activity | 1. Bedfast Confined to bed. | 2. Chairfast <br> Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. | 3. Walks Occasionally <br> Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair | 4. Walks Frequently <br> Walks outside room at least twice a day and inside room at least once every two hours during waking hours | | | | |
| MOBILITY <br> ability to change and control body position | 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance | 2. Very Limited <br> Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. | 3. Slightly Limited <br> Makes frequent though slight changes in body or extremity position independently. | 4. No Limitation <br> Makes major and frequent changes in position without assistance. | | | | |
| NUTRITION <br> usual food intake pattern | 1. Very Poor <br> Never eats a complete meal. Rarely eats more than $1 / 2$ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement <br> OR <br> is NPO and/or maintained on clear liquids or IV's for more than 5 days. | 2. Probably Inadequate <br> Rarely eats a complete meal and generally eats only about $1 / 2$ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. <br> Occasionally will take a dietary supplement. <br> OR receives less than optimum amount of liquid diet or tube feeding | 3. Adequate <br> Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered <br> OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs | 4. Excellent <br> Eats most of every meal. Never refuses a meal. <br> Usually eats a total of 4 or more servings of meat and dairy products. <br> Occasionally eats between meals. Does not require supplementation. | | | | |
| FRICTION & SHEAR | 1. Problem <br> Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction | 2. Potential Problem <br> Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. | 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. | | | | | |
| - Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved | | | | Total Score | | | | |
Figure 10.21 Braden Scale 图 10.21 布莱登量表
How to Score the Braden Scale 如何进行布莱登量表评分
Each risk factor on the Braden Scale is rated from 1 to 4 based on the patient’s assessment findings. When using the Braden Scale, start with the first category and review each description listed across the row for each of the ratings from 1 to 4, and choose the one that best describes the patient’s current status. Continue this process for all rows. Add all six numbers to determine a total score, and then use the total score to determine if the patient is at mild, moderate, high, or severe risk for developing a pressure injury. The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing interventions are implemented based on the rating in each category. The higher the score, the more aggressive actions 布莱登量表中的每个风险因素都根据患者的评估结果从 1 到 4 进行评级。使用布莱登量表时，从第一个类别开始，查看每行所列的 1 到 4 级的每项描述，然后选择最能描述患者当前状况的一项。对所有行继续执行此过程。将所有六个数字相加得出总分，然后根据总分确定患者发生压力损伤的风险是轻度、中度、高度还是重度。分数越低，压伤风险越高。此外，还会根据每个类别的评分实施定制的护理干预措施。分数越高，采取的措施就越积极
are taken to prevent or heal a pressure injury. Descriptions of the ratings from 1-4 for each risk factor, along with targeted interventions for each rating, are further described in the following subsections. 为预防或治愈压力性损伤而采取的措施。以下各小节将进一步说明每个风险因素的 1-4 级评分以及针对每个评分的干预措施。
Sensory Perception 感官认知
The sensory perception risk factor is defined as the ability to respond meaningfully to pressure-related discomfort. If a patient is unable to feel pressure-related discomfort and respond to it appropriately by moving or reporting pain, they are at high risk of developing a pressure injury. This risk category describes two different issues that affect sensory perception. The first description refers to the patient’s level of consciousness, and the second description refers to the patient’s ability to feel cutaneous sensation. See Table 10.5a for a description of each level of risk from 1-4 with associated interventions for each level. ^(2){ }^{2} 感觉风险因素被定义为对压力相关不适做出有意义反应的能力。如果病人无法感觉到与压力相关的不适，并通过移动或报告疼痛来做出适当的反应，那么他们就很有可能受到压力伤害。这一风险类别描述了影响感觉的两个不同问题。第一个问题是指患者的意识水平，第二个问题是指患者的皮肤感觉能力。请参见表 10.5a，了解从 1 到 4 的各个风险等级的描述，以及每个等级的相关干预措施。 ^(2){ }^{2}
Table 10.5a Descriptions and Interventions by Level of Risk for Sensory Perception 表 10.5a 按感知风险等级分列的说明和干预措施
Assessment Category 评估类别
Rating Description 评级说明
Interventions 干预措施
Sensory Perception 感官认知
4-无障碍 对口令有反应。感觉器官无缺陷，不会限制其感受或表达疼痛或不适的能力。
4-No Impairment
Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.
4-No Impairment
Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.| 4-No Impairment |
| :--- |
| Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort. |
- 鼓励患者报告骨突部位的疼痛。- 每天检查脚跟。
- Encourage the patient to report pain over bony prominences.
- Check heels daily.
- Encourage the patient to report pain over bony prominences.
- Check heels daily.| - Encourage the patient to report pain over bony prominences. |
| :--- |
| - Check heels daily. |
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities.
3-Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities.| 3-Slightly Limited |
| :--- |
| Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. |
| OR |
| Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities. |
- 每班评估和检查皮肤。注意脚跟。- 抬高脚跟并使用保护器。
- Assess and inspect skin every shift. Pay attention to heels.
- Elevate heels and use protectors.
- Assess and inspect skin every shift. Pay attention to heels.
- Elevate heels and use protectors.| - Assess and inspect skin every shift. Pay attention to heels. |
| :--- |
| - Elevate heels and use protectors. |
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
OR
Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body.
2-Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
OR
Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body.| 2-Very Limited |
| :--- |
| Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. |
| OR |
| Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body. |
考虑使用特制床垫或床。
All interventions mentioned in 3-Slightly Limited plus:
- Consider specialty mattress or bed.
All interventions mentioned in 3-Slightly Limited plus:
- Consider specialty mattress or bed.| All interventions mentioned in 3-Slightly Limited plus: |
| :--- |
| - Consider specialty mattress or bed. |
Assessment Category Rating Description Interventions
Sensory Perception "4-No Impairment
Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort." "- Encourage the patient to report pain over bony prominences.
- Check heels daily."
Sensory Perception "3-Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities." "- Assess and inspect skin every shift. Pay attention to heels.
- Elevate heels and use protectors."
Sensory Perception "2-Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
OR
Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body." "All interventions mentioned in 3-Slightly Limited plus:
- Consider specialty mattress or bed."| Assessment Category | Rating Description | Interventions |
| :--- | :--- | :--- |
| Sensory Perception | 4-No Impairment <br> Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort. | - Encourage the patient to report pain over bony prominences. <br> - Check heels daily. |
| Sensory Perception | 3-Slightly Limited <br> Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. <br> OR <br> Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities. | - Assess and inspect skin every shift. Pay attention to heels. <br> - Elevate heels and use protectors. |
| Sensory Perception | 2-Very Limited <br> Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. <br> OR <br> Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body. | All interventions mentioned in 3-Slightly Limited plus: <br> - Consider specialty mattress or bed. |
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
OR
Limited ability to feel pain over most of the body.
1-Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
OR
Limited ability to feel pain over most of the body.| 1-Completely Limited |
| :--- |
| Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. |
| OR |
| Limited ability to feel pain over most of the body. |
在膝盖和骨突之间使用枕头，避免直接接触。
All interventions mentioned in 2-Very Limited plus:
- Use pillows between knees and bony prominences to avoid direct contact.
All interventions mentioned in 2-Very Limited plus:
- Use pillows between knees and bony prominences to avoid direct contact.| All interventions mentioned in 2-Very Limited plus: |
| :--- |
| - Use pillows between knees and bony prominences to avoid direct contact. |
Sensory Perception "1-Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
OR
Limited ability to feel pain over most of the body." "All interventions mentioned in 2-Very Limited plus:
- Use pillows between knees and bony prominences to avoid direct contact."| Sensory Perception | 1-Completely Limited <br> Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. <br> OR <br> Limited ability to feel pain over most of the body. | All interventions mentioned in 2-Very Limited plus: <br> - Use pillows between knees and bony prominences to avoid direct contact. |
| :--- | :--- | :--- |
Moisture 水分
The moisture risk factor is defined as the degree to which skin is exposed to moisture. Prolonged exposure to moisture increases the probability of skin breakdown. Moisture can come from several sources, such as perspiration, urine incontinence, stool incontinence, or wound drainage. Frequent surveillance, removal of wet or soiled linens, and use of protective skin barriers greatly reduce this risk factor. See Table 10.5b for specific interventions for each level of risk. ^(3){ }^{3} 潮湿风险因素的定义是皮肤受潮的程度。长期暴露在潮湿环境中会增加皮肤破损的几率。湿气有多种来源，如汗液、尿失禁、大便失禁或伤口引流。经常进行监测、清除潮湿或弄脏的床单以及使用皮肤保护屏障可大大降低这一风险因素。各风险等级的具体干预措施见表 10.5b。 ^(3){ }^{3}
Table 10.5b Interventions by Level of Risk for Moisture 表 10.5b 按潮湿风险等级分列的干预措施
Rating Description 评级说明
Interventions 干预措施
Moisture 水分
4-罕见湿润 皮肤通常比较干燥，只需定期更换床单。
4-Rarely Moist
Skin is usually dry; linen only requires changing at routine intervals.
4-Rarely Moist
Skin is usually dry; linen only requires changing at routine intervals.| 4-Rarely Moist |
| :--- |
| Skin is usually dry; linen only requires changing at routine intervals. |
- 鼓励患者使用润肤露以防止皮肤裂开。- 鼓励患者报告任何潮湿问题（如乳房下）。
- Encourage the patient to use lotion to prevent skin cracks.
- Encourage the patient to report any moisture problem (such as under breasts).
- Encourage the patient to use lotion to prevent skin cracks.
- Encourage the patient to report any moisture problem (such as under breasts).| - Encourage the patient to use lotion to prevent skin cracks. |
| :--- |
| - Encourage the patient to report any moisture problem (such as under breasts). |
Moisture 水分
3-偶尔潮湿 皮肤偶尔潮湿，大约每天需要额外更换一次床单。
3-Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once per day.
3-Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once per day.| 3-Occasionally Moist |
| :--- |
| Skin is occasionally moist, requiring an extra linen change approximately once per day. |
All interventions mentioned in 4-Rarely Moist plus:
- Use moisture barrier ointments (protective skin barriers).
- Moisturize dry unbroken skin.
- Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
- Routinely check incontinence pads.
- Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed.
- If stool incontinence, consider bowel training and toileting after meals.
All interventions mentioned in 4-Rarely Moist plus:
- Use moisture barrier ointments (protective skin barriers).
- Moisturize dry unbroken skin.
- Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
- Routinely check incontinence pads.
- Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed.
- If stool incontinence, consider bowel training and toileting after meals.| All interventions mentioned in 4-Rarely Moist plus: |
| :--- |
| - Use moisture barrier ointments (protective skin barriers). |
| - Moisturize dry unbroken skin. |
| - Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes. |
| - Routinely check incontinence pads. |
| - Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed. |
| - If stool incontinence, consider bowel training and toileting after meals. |
Moisture 水分
2-经常湿润 皮肤经常湿润，但不总是湿润。每班至少要更换一次床单。
2-Often Moist
Skin is often but not always moist. Linen must be changed at least once per shift.
2-Often Moist
Skin is often but not always moist. Linen must be changed at least once per shift.| 2-Often Moist |
| :--- |
| Skin is often but not always moist. Linen must be changed at least once per shift. |
经常检查失禁垫（每 2-3 小时检查一次）。- 考虑使用低空气流失床。
All interventions mentioned in 3-Occasionally Moist plus:
All interventions mentioned in 3-Occasionally Moist plus:
- Check incontinence pads frequently (every 2-3 hours).
- Consider a low air loss bed.| All interventions mentioned in 3-Occasionally Moist plus: |
| :--- |
| - Check incontinence pads frequently (every 2-3 hours). |
| - Consider a low air loss bed. |
Rating Description Interventions
Moisture "4-Rarely Moist
Skin is usually dry; linen only requires changing at routine intervals." "- Encourage the patient to use lotion to prevent skin cracks.
- Encourage the patient to report any moisture problem (such as under breasts)."
Moisture "3-Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once per day." "All interventions mentioned in 4-Rarely Moist plus:
- Use moisture barrier ointments (protective skin barriers).
- Moisturize dry unbroken skin.
- Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
- Routinely check incontinence pads.
- Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed.
- If stool incontinence, consider bowel training and toileting after meals."
Moisture "2-Often Moist
Skin is often but not always moist. Linen must be changed at least once per shift." "All interventions mentioned in 3-Occasionally Moist plus:
- Check incontinence pads frequently (every 2-3 hours).
- Consider a low air loss bed."| | Rating Description | Interventions |
| :--- | :--- | :--- |
| Moisture | 4-Rarely Moist <br> Skin is usually dry; linen only requires changing at routine intervals. | - Encourage the patient to use lotion to prevent skin cracks. <br> - Encourage the patient to report any moisture problem (such as under breasts). |
| Moisture | 3-Occasionally Moist <br> Skin is occasionally moist, requiring an extra linen change approximately once per day. | All interventions mentioned in 4-Rarely Moist plus: <br> - Use moisture barrier ointments (protective skin barriers). <br> - Moisturize dry unbroken skin. <br> - Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes. <br> - Routinely check incontinence pads. <br> - Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed. <br> - If stool incontinence, consider bowel training and toileting after meals. |
| Moisture | 2-Often Moist <br> Skin is often but not always moist. Linen must be changed at least once per shift. | All interventions mentioned in 3-Occasionally Moist plus: <br> - Check incontinence pads frequently (every 2-3 hours). <br> - Consider a low air loss bed. |
Moisture 水分
1-持续潮湿 皮肤通过汗液、尿液等几乎持续保持潮湿。每次移动或翻身都会发现皮肤潮湿。
1-Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned.
1-Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned.| 1-Constantly Moist |
| :--- |
| Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. |
All interventions mentioned in 2-Often Moist plus:
- Assess and inspect skin every shift.
- Check incontinence pads frequently (every 2-3 hours) and change as needed.
- Apply condom catheter if appropriate.
- If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.
All interventions mentioned in 2-Often Moist plus:
- Assess and inspect skin every shift.
- Check incontinence pads frequently (every 2-3 hours) and change as needed.
- Apply condom catheter if appropriate.
- If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.| All interventions mentioned in 2-Often Moist plus: |
| :--- |
| - Assess and inspect skin every shift. |
| - Check incontinence pads frequently (every 2-3 hours) and change as needed. |
| - Apply condom catheter if appropriate. |
| - If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate. |
Moisture "1-Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned." "All interventions mentioned in 2-Often Moist plus:
- Assess and inspect skin every shift.
- Check incontinence pads frequently (every 2-3 hours) and change as needed.
- Apply condom catheter if appropriate.
- If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate."| Moisture | 1-Constantly Moist <br> Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. | All interventions mentioned in 2-Often Moist plus: <br> - Assess and inspect skin every shift. <br> - Check incontinence pads frequently (every 2-3 hours) and change as needed. <br> - Apply condom catheter if appropriate. <br> - If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate. |
| :--- | :--- | :--- |
Activity 活动
The activity risk factor is defined as the degree of physical activity. For example, walking or moving from a bed to a chair reduces a patient’s risk of developing a pressure injury by redistributing pressure points and increasing blood and oxygen flow to areas at risk. 活动风险因素被定义为身体活动的程度。例如，步行或从床上搬到椅子上，可以重新分配压力点，增加危险区域的血液和氧气流量，从而降低病人发生压力损伤的风险。
Level of activity is defined by how frequently the patient is able to get out of bed, move into a chair, or ambulate with or without help. See Table 10.5c for a description of each level of risk from 1-4 with associated interventions for each. ^(4){ }^{4} 活动水平是指病人能够下床、搬到椅子上或在有人或无人帮助的情况下行走的频率。请参见表 10.5c，了解从 1 到 4 的各个风险等级及相关干预措施。 ^(4){ }^{4}
Table 10.5c Descriptions and Interventions by Level of Risk for Activity ^(5){ }^{5} 表 10.5c 按活动风险等级分列的说明和干预措施 ^(5){ }^{5}
4. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm 4.医疗保健研究与质量机构。(2014).预防医院压疮。https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm。
5. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm 5.医疗保健研究与质量机构。(2014).预防医院压疮。https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm。
Assessment Category 评估类别
Rating Description 评级说明
Interventions 干预措施
Activity 活动
4-经常行走 每天至少两次在室外行走，清醒时至少每两小时在室内行走一次。
4-Walks Frequently
Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours.
4-Walks Frequently
Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours.| 4-Walks Frequently |
| :--- |
| Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours. |
- 鼓励在室外活动。- 每天检查皮肤。- 监测平衡和耐力。
- Encourage ambulation outside the room.
- Check skin daily.
- Monitor balance and endurance.
- Encourage ambulation outside the room.
- Check skin daily.
- Monitor balance and endurance.| - Encourage ambulation outside the room. |
| :--- |
| - Check skin daily. |
| - Monitor balance and endurance. |
Activity 活动
3-偶尔行走 白天偶尔行走，但距离很短，无论是否有人搀扶。每次轮班的大部分时间都躺在床上或椅子上。
3-Walks Occasionally
Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair.
3-Walks Occasionally
Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair.| 3-Walks Occasionally |
| :--- |
| Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair. |
- 提供结构化的移动计划。- 考虑使用椅垫。- 考虑物理治疗咨询。
- Provide a structured mobility plan.
- Consider a chair cushion.
- Consider physical therapy consult.
- Provide a structured mobility plan.
- Consider a chair cushion.
- Consider physical therapy consult.| - Provide a structured mobility plan. |
| :--- |
| - Consider a chair cushion. |
| - Consider physical therapy consult. |
Assessment Category Rating Description Interventions
Activity "4-Walks Frequently
Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours." "- Encourage ambulation outside the room.
- Check skin daily.
- Monitor balance and endurance."
Activity "3-Walks Occasionally
Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair." "- Provide a structured mobility plan.
- Consider a chair cushion.
- Consider physical therapy consult."| Assessment Category | Rating Description | Interventions |
| :--- | :--- | :--- |
| Activity | 4-Walks Frequently <br> Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours. | - Encourage ambulation outside the room. <br> - Check skin daily. <br> - Monitor balance and endurance. |
| Activity | 3-Walks Occasionally <br> Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair. | - Provide a structured mobility plan. <br> - Consider a chair cushion. <br> - Consider physical therapy consult. |
Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair.
2-Chair fast
Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair.| 2-Chair fast |
| :--- |
| Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair. |
- Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs.
- Instruct the patient to reposition every 15 minutes when in the chair.
- Stand every hour.
- Pad bony prominences with foam wedges, rolled blankets, or towels.
- Consider physical therapy consult for conditioning and wheelchair assessment.
- Consider a specialty chair pad.
- Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs.
- Instruct the patient to reposition every 15 minutes when in the chair.
- Stand every hour.
- Pad bony prominences with foam wedges, rolled blankets, or towels.
- Consider physical therapy consult for conditioning and wheelchair assessment.| - Consider a specialty chair pad. |
| :--- |
| - Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs. |
| - Instruct the patient to reposition every 15 minutes when in the chair. |
| - Stand every hour. |
| - Pad bony prominences with foam wedges, rolled blankets, or towels. |
| - Consider physical therapy consult for conditioning and wheelchair assessment. |
Activity "2-Chair fast
Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair." "- Consider a specialty chair pad.
- Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs.
- Instruct the patient to reposition every 15 minutes when in the chair.
- Stand every hour.
- Pad bony prominences with foam wedges, rolled blankets, or towels.
- Consider physical therapy consult for conditioning and wheelchair assessment."| Activity | 2-Chair fast <br> Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair. | - Consider a specialty chair pad. <br> - Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs. <br> - Instruct the patient to reposition every 15 minutes when in the chair. <br> - Stand every hour. <br> - Pad bony prominences with foam wedges, rolled blankets, or towels. <br> - Consider physical therapy consult for conditioning and wheelchair assessment. |
| :--- | :--- | :--- |
Activity 活动
1-早餐 卧床休息。
1-Bedfast
Confined to bed.
1-Bedfast
Confined to bed.| 1-Bedfast |
| :--- |
| Confined to bed. |
- Perform skin assessment and inspection every shift.
- Position prone if appropriate or elevate head of bed no more than 30 degrees.
- Position with pillows to elevate pressure points off the bed.
- Consider specialty beds.
- Elevate heels off bed and/or use heel protectors.
- Consider physical therapy consult for conditioning and wheelchair assessment.
- Turn/reposition every 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight.
- Perform skin assessment and inspection every shift.
- Position prone if appropriate or elevate head of bed no more than 30 degrees.
- Position with pillows to elevate pressure points off the bed.
- Consider specialty beds.
- Elevate heels off bed and/or use heel protectors.
- Consider physical therapy consult for conditioning and wheelchair assessment.
- Turn/reposition every 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight.| - Perform skin assessment and inspection every shift. |
| :--- |
| - Position prone if appropriate or elevate head of bed no more than 30 degrees. |
| - Position with pillows to elevate pressure points off the bed. |
| - Consider specialty beds. |
| - Elevate heels off bed and/or use heel protectors. |
| - Consider physical therapy consult for conditioning and wheelchair assessment. |
| - Turn/reposition every 1-2 hours. |
| - Post turning schedule. |
| - Teach or do frequent small shifts of body weight. |
Activity "1-Bedfast
Confined to bed." "- Perform skin assessment and inspection every shift.
- Position prone if appropriate or elevate head of bed no more than 30 degrees.
- Position with pillows to elevate pressure points off the bed.
- Consider specialty beds.
- Elevate heels off bed and/or use heel protectors.
- Consider physical therapy consult for conditioning and wheelchair assessment.
- Turn/reposition every 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight."| Activity | 1-Bedfast <br> Confined to bed. | - Perform skin assessment and inspection every shift. <br> - Position prone if appropriate or elevate head of bed no more than 30 degrees. <br> - Position with pillows to elevate pressure points off the bed. <br> - Consider specialty beds. <br> - Elevate heels off bed and/or use heel protectors. <br> - Consider physical therapy consult for conditioning and wheelchair assessment. <br> - Turn/reposition every 1-2 hours. <br> - Post turning schedule. <br> - Teach or do frequent small shifts of body weight. |
| :--- | :--- | :--- |
Mobility 流动性
The mobility risk factor is defined as the patient’s ability to change or control their body position. For example, healthy people frequently change body position by rolling over in bed, shifting weight in a chair after sitting too long, or by moving their extremities. However, tissue damage will occur if a patient is unable to reposition on their own power unless caregivers frequently 移动性风险因素是指患者改变或控制身体姿势的能力。例如，健康人经常通过在床上翻身、在椅子上久坐后转移重心或移动四肢来改变体位。但是，如果病人无法依靠自己的力量调整体位，就会造成组织损伤，除非护理人员经常
change their position. See Table 10.5d for interventions for each level of risk from 7-4. 改变其立场。7-4 各风险等级的干预措施见表 10.5d。
Table 10.5d Interventions by Level of Risk for Mobility ^(7){ }^{7} 表 10.5d 按流动风险等级分列的干预措施 ^(7){ }^{7}
Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. 医疗保健研究与质量机构。(2014).预防医院压疮。
Assessment Category 评估类别
Rating Description 评级说明
Interventions 干预措施
Mobility 流动性
4-无限制 在没有帮助的情况下，频繁地大幅度变换位置。
4-No Limitations
Makes major and frequent changes in position without assistance.
4-No Limitations
Makes major and frequent changes in position without assistance.| 4-No Limitations |
| :--- |
| Makes major and frequent changes in position without assistance. |
- 每天检查皮肤。- 鼓励每天至少两次到室外活动。- 无需干预。
- Check skin daily.
- Encourage ambulation outside the room at least twice daily.
- No interventions required.
- Check skin daily.
- Encourage ambulation outside the room at least twice daily.
- No interventions required.| - Check skin daily. |
| :--- |
| - Encourage ambulation outside the room at least twice daily. |
| - No interventions required. |
Mobility 流动性
3-轻微受限 能够独立频繁但轻微地改变身体或四肢的位置。
3-Slightly Limited
Makes frequent though slight changes in body or extremity position independently.
3-Slightly Limited
Makes frequent though slight changes in body or extremity position independently.| 3-Slightly Limited |
| :--- |
| Makes frequent though slight changes in body or extremity position independently. |
- Consult physical therapy for strengthening/ conditioning.
- Use a gait belt for assistance.
- Check skin daily.
- Turn/reposition frequently.
- Teach frequent small shifts of body weight.
- Consult physical therapy for strengthening/ conditioning.
- Use a gait belt for assistance.| - Check skin daily. |
| :--- |
| - Turn/reposition frequently. |
| - Teach frequent small shifts of body weight. |
| - Consult physical therapy for strengthening/ conditioning. |
| - Use a gait belt for assistance. |
Assessment Category Rating Description Interventions
Mobility "4-No Limitations
Makes major and frequent changes in position without assistance." "- Check skin daily.
- Encourage ambulation outside the room at least twice daily.
- No interventions required."
Mobility "3-Slightly Limited
Makes frequent though slight changes in body or extremity position independently." "- Check skin daily.
- Turn/reposition frequently.
- Teach frequent small shifts of body weight.
- Consult physical therapy for strengthening/ conditioning.
- Use a gait belt for assistance."| Assessment Category | Rating Description | Interventions |
| :--- | :--- | :--- |
| Mobility | 4-No Limitations <br> Makes major and frequent changes in position without assistance. | - Check skin daily. <br> - Encourage ambulation outside the room at least twice daily. <br> - No interventions required. |
| Mobility | 3-Slightly Limited <br> Makes frequent though slight changes in body or extremity position independently. | - Check skin daily. <br> - Turn/reposition frequently. <br> - Teach frequent small shifts of body weight. <br> - Consult physical therapy for strengthening/ conditioning. <br> - Use a gait belt for assistance. |
Mobility 流动性
2-非常有限 偶尔轻微改变身体或四肢的位置，但无法独立频繁或显著地改变。
2-Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
2-Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.| 2-Very Limited |
| :--- |
| Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. |
- Perform skin assessment and inspection every shift.
- Turn/reposition 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight.
- Elevate heels.
- Consider a specialty bed.
- Perform skin assessment and inspection every shift.
- Turn/reposition 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight.
- Elevate heels.
- Consider a specialty bed.| - Perform skin assessment and inspection every shift. |
| :--- |
| - Turn/reposition 1-2 hours. |
| - Post turning schedule. |
| - Teach or do frequent small shifts of body weight. |
| - Elevate heels. |
| - Consider a specialty bed. |
Mobility 流动性
1-完全不能动 在没有帮助的情况下，身体或四肢的姿势甚至连轻微的变化都不能做。
1-Completely Immobile
Does not make even slight changes in body or extremity position without assistance.
1-Completely Immobile
Does not make even slight changes in body or extremity position without assistance.| 1-Completely Immobile |
| :--- |
| Does not make even slight changes in body or extremity position without assistance. |
Same interventions as for 2-Very Limited 干预措施与 2-非常有限相同
Mobility "2-Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently." "- Perform skin assessment and inspection every shift.
- Turn/reposition 1-2 hours.
- Post turning schedule.
- Teach or do frequent small shifts of body weight.
- Elevate heels.
- Consider a specialty bed."
Mobility "1-Completely Immobile
Does not make even slight changes in body or extremity position without assistance." Same interventions as for 2-Very Limited| Mobility | 2-Very Limited <br> Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. | - Perform skin assessment and inspection every shift. <br> - Turn/reposition 1-2 hours. <br> - Post turning schedule. <br> - Teach or do frequent small shifts of body weight. <br> - Elevate heels. <br> - Consider a specialty bed. |
| :--- | :--- | :--- |
| Mobility | 1-Completely Immobile <br> Does not make even slight changes in body or extremity position without assistance. | Same interventions as for 2-Very Limited |
Nutrition 营养学
Adequate nutrition and fluid intake are vital for maintaining healthy skin. Protein intake, in particular, is very important for healthy skin and wound healing. The nutrition risk factor is defined by two categories of descriptions. The first category measures the amount and type of oral intake. The second category is used for patients receiving tube feeding, total parenteral nutrition (TPN), or are prescribed clear liquid diets or nothing by mouth (NPO). See Table 10.5e for interventions for each level of risk from 1-4. ^(8){ }^{8} 充足的营养和液体摄入对保持皮肤健康至关重要。尤其是蛋白质的摄入对皮肤健康和伤口愈合非常重要。营养风险因素由两类描述来定义。第一类用于测量口服摄入量和类型。第二类用于接受管饲、全胃肠外营养（TPN）或处方清流食或口服无营养（NPO）的患者。有关 1-4 级风险的干预措施，请参见表 10.5e。 ^(8){ }^{8}
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
4-Excellent
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.| 4-Excellent |
| :--- |
| Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. |
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake.
- Move the patient out of bed for all meals.
- Provide food choices.
- Offer nutrition supplements.
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake.| - Move the patient out of bed for all meals. |
| :--- |
| - Provide food choices. |
| - Offer nutrition supplements. |
| - Discuss a plan with the provider if the patient is NPO for greater than 24 hours. |
| - Record dietary intake. |
Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered
OR
Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs
3-Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered
OR
Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs| 3-Adequate |
| :--- |
| Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered |
| OR |
| Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs |
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake and I&O if appropriate.
- Observe and monitor nutritional intake.
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake and I&O if appropriate.| - Observe and monitor nutritional intake. |
| :--- |
| - Discuss a plan with the provider if the patient is NPO for greater than 24 hours. |
| - Record dietary intake and I&O if appropriate. |
Assessment Category Rating Description Interventions
Nutrition "4-Excellent
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation." "- Move the patient out of bed for all meals.
- Provide food choices.
- Offer nutrition supplements.
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake."
Nutrition "3-Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered
OR
Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs" "- Observe and monitor nutritional intake.
- Discuss a plan with the provider if the patient is NPO for greater than 24 hours.
- Record dietary intake and I&O if appropriate."| Assessment Category | Rating Description | Interventions |
| :--- | :--- | :--- |
| Nutrition | 4-Excellent <br> Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. | - Move the patient out of bed for all meals. <br> - Provide food choices. <br> - Offer nutrition supplements. <br> - Discuss a plan with the provider if the patient is NPO for greater than 24 hours. <br> - Record dietary intake. |
| Nutrition | 3-Adequate <br> Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered <br> OR <br> Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs | - Observe and monitor nutritional intake. <br> - Discuss a plan with the provider if the patient is NPO for greater than 24 hours. <br> - Record dietary intake and I&O if appropriate. |
Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement
OR
Receives less than optimum amount of liquid diet or tube feeding.
2-Probably Inadequate
Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement
OR
Receives less than optimum amount of liquid diet or tube feeding.| 2-Probably Inadequate |
| :--- |
| Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement |
| OR |
| Receives less than optimum amount of liquid diet or tube feeding. |
Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
Is NPO and/or maintained on clear liquids or IV for more than 5 days.
1-Very Poor
Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
Is NPO and/or maintained on clear liquids or IV for more than 5 days.| 1-Very Poor |
| :--- |
| Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement |
| OR |
| Is NPO and/or maintained on clear liquids or IV for more than 5 days. |
每班进行皮肤评估和检查。
All interventions mentioned in 2-Probably Inadequate plus:
- Perform skin assessment and inspection every shift.
All interventions mentioned in 2-Probably Inadequate plus:
- Perform skin assessment and inspection every shift.| All interventions mentioned in 2-Probably Inadequate plus: |
| :--- |
| - Perform skin assessment and inspection every shift. |
Nutrition "2-Probably Inadequate
Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement
OR
Receives less than optimum amount of liquid diet or tube feeding." "All interventions mentioned in 3-Adequate plus:
- Encourage fluid intake as appropriate.
- Obtain nutritional/ dietary consult.
- Offer nutrition supplements and water.
- Encourage family to bring favorite foods.
- Provide small, frequent meals."
Nutrition "1-Very Poor
Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement
OR
Is NPO and/or maintained on clear liquids or IV for more than 5 days." "All interventions mentioned in 2-Probably Inadequate plus:
- Perform skin assessment and inspection every shift."| Nutrition | 2-Probably Inadequate <br> Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement <br> OR <br> Receives less than optimum amount of liquid diet or tube feeding. | All interventions mentioned in 3-Adequate plus: <br> - Encourage fluid intake as appropriate. <br> - Obtain nutritional/ dietary consult. <br> - Offer nutrition supplements and water. <br> - Encourage family to bring favorite foods. <br> - Provide small, frequent meals. |
| :--- | :--- | :--- |
| Nutrition | 1-Very Poor <br> Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement <br> OR <br> Is NPO and/or maintained on clear liquids or IV for more than 5 days. | All interventions mentioned in 2-Probably Inadequate plus: <br> - Perform skin assessment and inspection every shift. |
Friction/Shear 摩擦/剪切
Friction and shear are significant risk factors for producing pressure injuries. This category only has three ratings, unlike the other categories that have four ratings, and is rated by whether the patient has a problem, potential problem, 摩擦和剪切是造成压力伤害的重要风险因素。这个类别只有三个评级，与其他类别的四个评级不同，它是根据病人是否存在问题或潜在问题来评级的、
or no apparent problem in this area. See Table 10.5 f10.5 f for interventions for each level of risk. ^(10){ }^{10} 或在这方面没有明显问题。各风险等级的干预措施见表 10.5 f10.5 f 。 ^(10){ }^{10}
Table 10.5f Descriptions and Interventions by Level of Risk for Friction/Shear" ^("" "){ }^{\text {" }} 表 10.5f 按摩擦/剪切风险等级分列的说明和干预措施" ^("" "){ }^{\text {" }}
Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
3-No Apparent Problem
Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.| 3-No Apparent Problem |
| :--- |
| Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. |
Keep bed linens clean, dry, and wrinkle free. 保持床单干净、干燥、无褶皱。
Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down.
2-Potential Problem
Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down.| 2-Potential Problem |
| :--- |
| Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down. |
避免按摩受压点。- 在肘部和脚后跟的完整皮肤上使用透明敷料或护肘/护轮。
All interventions mentioned in 3-No Apparent Problem plus:
- Avoid massaging pressure points.
- Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels.
All interventions mentioned in 3-No Apparent Problem plus:
- Avoid massaging pressure points.
- Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels.| All interventions mentioned in 3-No Apparent Problem plus: |
| :--- |
| - Avoid massaging pressure points. |
| - Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels. |
Assessment Category Rating Description Interventions
Friction/Shear "3-No Apparent Problem
Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times." Keep bed linens clean, dry, and wrinkle free.
Friction/Shear "2-Potential Problem
Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down." "All interventions mentioned in 3-No Apparent Problem plus:
- Avoid massaging pressure points.
- Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels."| Assessment Category | Rating Description | Interventions |
| :--- | :--- | :--- |
| Friction/Shear | 3-No Apparent Problem <br> Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. | Keep bed linens clean, dry, and wrinkle free. |
| Friction/Shear | 2-Potential Problem <br> Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down. | All interventions mentioned in 3-No Apparent Problem plus: <br> - Avoid massaging pressure points. <br> - Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels. |
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.
1-Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.| 1-Problem |
| :--- |
| Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. |
All interventions mentioned in 2-Potential Problem plus:
- Perform skin assessment and inspection every shift.
- Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed.
- Keep bed linens clean, dry, and wrinkle free.
- Apply elbow/heel protectors to intact skin over elbows and heels.
- Elevate head of bed 30 degrees or less to reduce shear when feasible.
All interventions mentioned in 2-Potential Problem plus:
- Perform skin assessment and inspection every shift.
- Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed.
- Keep bed linens clean, dry, and wrinkle free.
- Apply elbow/heel protectors to intact skin over elbows and heels.
- Elevate head of bed 30 degrees or less to reduce shear when feasible.| All interventions mentioned in 2-Potential Problem plus: |
| :--- |
| - Perform skin assessment and inspection every shift. |
| - Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed. |
| - Keep bed linens clean, dry, and wrinkle free. |
| - Apply elbow/heel protectors to intact skin over elbows and heels. |
| - Elevate head of bed 30 degrees or less to reduce shear when feasible. |
Friction/Shear "1-Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction." "All interventions mentioned in 2-Potential Problem plus:
- Perform skin assessment and inspection every shift.
- Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed.
- Keep bed linens clean, dry, and wrinkle free.
- Apply elbow/heel protectors to intact skin over elbows and heels.
- Elevate head of bed 30 degrees or less to reduce shear when feasible."| Friction/Shear | 1-Problem <br> Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. | All interventions mentioned in 2-Potential Problem plus: <br> - Perform skin assessment and inspection every shift. <br> - Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed. <br> - Keep bed linens clean, dry, and wrinkle free. <br> - Apply elbow/heel protectors to intact skin over elbows and heels. <br> - Elevate head of bed 30 degrees or less to reduce shear when feasible. |
| :--- | :--- | :--- |
Team Member Roles to Prevent Pressure Injuries 团队成员在预防压力伤害方面的作用
Each member of the health care team has an important role in preventing the development of pressure injuries in at-risk patients. A registered nurse can delegate many interventions for preventing and treating a pressure injury to a licensed practical nurse (LPN) or to unlicensed assistive personnel such as a certified nursing assistant (CNA). See Table 10.5 g for an explanation of the role of the RN in preventing pressure injuries, as well as tasks that can be delegated to LPNs and CNAs. 医护团队的每位成员在预防高危患者发生压伤方面都扮演着重要角色。注册护士可以将许多预防和治疗压伤的干预措施委托给持证执业护士 (LPN) 或无证辅助人员，如注册护士助理 (CNA)。请参见表 10.5 g，了解注册护士在预防压力性损伤中的作用，以及可以委托给 LPN 和 CNA 的任务。
Table 10.5g Team Member Roles in Preventing Pressure Injuries ^(12){ }^{12} 表 10.5g 小组成员在预防压力伤害方面的作用 ^(12){ }^{12}
- Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs or supervises performance of care plan procedures or treatments
- Collaborates with other staff to ensure timely and accurate reporting of any skin issues
- Notifies wound nurse of any skin conditions or high-risk patients
- Notifies physician of any skin problems
- Educates patient/family about risk factors
- Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs or supervises performance of care plan procedures or treatments
- Collaborates with other staff to ensure timely and accurate reporting of any skin issues
- Notifies wound nurse of any skin conditions or high-risk patients
- Notifies physician of any skin problems
- Educates patient/family about risk factors| - Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy) |
| :--- |
| - Documents care plan tied to identified risk: |
| - Sensory perception |
| - Moisture |
| - Activity |
| - Mobility |
| - Nutrition |
| - Friction/Shear |
| - Performs or supervises performance of care plan procedures or treatments |
| - Collaborates with other staff to ensure timely and accurate reporting of any skin issues |
| - Notifies wound nurse of any skin conditions or high-risk patients |
| - Notifies physician of any skin problems |
| - Educates patient/family about risk factors |
- Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs care for risk as needed
- Informs RN of any skin issues
- Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs care for risk as needed
- Informs RN of any skin issues| - Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy) |
| :--- |
| - Documents care plan tied to identified risk: |
| - Sensory perception |
| - Moisture |
| - Activity |
| - Mobility |
| - Nutrition |
| - Friction/Shear |
| - Performs care for risk as needed |
| - Informs RN of any skin issues |
Role Tasks
RN "- Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs or supervises performance of care plan procedures or treatments
- Collaborates with other staff to ensure timely and accurate reporting of any skin issues
- Notifies wound nurse of any skin conditions or high-risk patients
- Notifies physician of any skin problems
- Educates patient/family about risk factors"
LPN "- Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy)
- Documents care plan tied to identified risk:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/Shear
- Performs care for risk as needed
- Informs RN of any skin issues"| Role | Tasks |
| :--- | :--- |
| RN | - Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy) <br> - Documents care plan tied to identified risk: <br> - Sensory perception <br> - Moisture <br> - Activity <br> - Mobility <br> - Nutrition <br> - Friction/Shear <br> - Performs or supervises performance of care plan procedures or treatments <br> - Collaborates with other staff to ensure timely and accurate reporting of any skin issues <br> - Notifies wound nurse of any skin conditions or high-risk patients <br> - Notifies physician of any skin problems <br> - Educates patient/family about risk factors |
| LPN | - Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy) <br> - Documents care plan tied to identified risk: <br> - Sensory perception <br> - Moisture <br> - Activity <br> - Mobility <br> - Nutrition <br> - Friction/Shear <br> - Performs care for risk as needed <br> - Informs RN of any skin issues |
Checks skin each time person is turned or cleaned or bed is changed 每次翻身、清洁或更换床铺时都要检查皮肤
Reports any skin issues to nurse 向护士报告任何皮肤问题
Turns/repositions patient as ordered 按医嘱为病人翻身/复位
Offers liquids each time in room 每次在房间里都提供液体
Keeps skin clean and reapplies protective skin barrier 保持皮肤清洁，重新涂抹皮肤保护屏障
Applies products (lotion, cream, skin sealant, etc.) as needed 根据需要涂抹产品（乳液、面霜、皮肤密封剂等
Assessment 评估
Subjective Assessment 主观评估
During a subjective assessment of a patient’s integumentary system, begin by asking about current symptoms such as itching, rashes, or wounds. If a patient has a wound, it is important to determine if a patient has pain associated with the wound so that pain management can be implemented. For patients with chronic wounds, it is also important to identify factors that delay wound healing, such as nutrition, decreased oxygenation, infection, stress, diabetes, obesity, medications, alcohol use, and smoking. See Table 10.6a for a list of suggested interview questions to use when assessing a patient with a wound. 在对患者的皮肤系统进行主观评估时，首先要询问患者目前的症状，如瘙痒、皮疹或伤口。如果患者有伤口，则必须确定患者是否有与伤口相关的疼痛，以便实施疼痛管理。对于有慢性伤口的患者，确定延迟伤口愈合的因素也很重要，如营养、氧饱和度降低、感染、压力、糖尿病、肥胖、药物、饮酒和吸烟。有关评估伤口患者时建议使用的访谈问题列表，请参见表 10.6a。
If a patient has a chronic wound or is experiencing delayed wound healing, it is important for the nurse to assess the impact of the wound on their quality of life. Several studies have shown that patients with nonhealing wounds have a decreased quality of life. Reasons for this include the frequency and regularity of dressing changes, which affect daily routine; a feeling of continued fatigue due to lack of sleep; restricted mobility; pain; odor; and the side effects of multiple medications. The loss of independence associated with functional decline can also lead to changes in overall health and wellbeing. These changes include altered eating habits, depression, social isolation, and a gradual reduction in activity levels. ^(2){ }^{2} 如果患者有慢性伤口或伤口愈合延迟，护士必须评估伤口对其生活质量的影响。多项研究表明，伤口不愈合的患者生活质量会下降。造成这种情况的原因包括：更换敷料的频率和规律性影响了日常生活；睡眠不足导致持续疲劳感；行动受限；疼痛；异味；以及多种药物的副作用。功能衰退带来的独立性丧失也会导致整体健康和福祉发生变化。这些变化包括饮食习惯改变、抑郁、社交孤立以及活动量逐渐减少。 ^(2){ }^{2}
Table 10.6a Interview Questions Related to Integumentary Disorders 表 10.6a 与皮肤疾病有关的访谈问题
Symptoms 症状
Questions 问题
Follow-up Questions 后续问题
Current Symptoms 当前症状
Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole? 您目前是否有任何皮肤症状，如瘙痒、皮疹或异常痣？
Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury?
If a wound is present:
- Is the wound painful?
- Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound?
Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury?
If a wound is present:
- Is the wound painful?
- Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound?| Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury? |
| :--- |
| If a wound is present: |
| - Is the wound painful? |
| - Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound? |
Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the "Pain Assessment Methods" section of the "Comfort" chapter.
Please describe.
Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the "Pain Assessment Methods" section of the "Comfort" chapter.| Please describe. |
| :--- |
| Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the "Pain Assessment Methods" section of the "Comfort" chapter. |
Medical History 病史
Have you ever been diagnosed with a wound related to diabetes, heart disease, or peripheral vascular disease? 您是否曾被诊断出患有与糖尿病、心脏病或外周血管疾病有关的伤口？
Please describe. 请描述。
If chronic wounds or wounds with delayed healing are present: 如果存在慢性伤口或延迟愈合的伤口：
Medications 药物
Are you taking any medications that can affect wound healing, such as oral steroids to treat inflammation or help you breathe? 您是否正在服用任何可能影响伤口愈合的药物，例如治疗炎症或帮助呼吸的口服类固醇？
Please describe. 请描述。
Treatments 治疗
What have you used to try to treat this wound? 你用什么方法治疗这个伤口？
What was successful? Unsuccessful? 什么是成功的？不成功？
Symptoms Questions Follow-up Questions
Current Symptoms Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole? Please describe.
Wounds "Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury?
If a wound is present:
- Is the wound painful?
- Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound?" "Please describe.
Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the "Pain Assessment Methods" section of the "Comfort" chapter."
Medical History Have you ever been diagnosed with a wound related to diabetes, heart disease, or peripheral vascular disease? Please describe.
If chronic wounds or wounds with delayed healing are present:
Medications Are you taking any medications that can affect wound healing, such as oral steroids to treat inflammation or help you breathe? Please describe.
Treatments What have you used to try to treat this wound? What was successful? Unsuccessful?| Symptoms | Questions | Follow-up Questions |
| :--- | :--- | :--- |
| Current Symptoms | Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole? | Please describe. |
| Wounds | Do you have any current wounds such as a surgical incision, skin tear, arterial ulcer, venous ulcer, diabetic or neuropathic ulcer, or a pressure injury? <br> If a wound is present: <br> - Is the wound painful? <br> - Do you have any symptoms of infection in the wound, such as increased redness, drainage, warmth, or tenderness around the wound? | Please describe. <br> Use the PQRSTU method to comprehensively assess pain. Read more about the PQRSTU method in the "Pain Assessment Methods" section of the "Comfort" chapter. |
| Medical History | Have you ever been diagnosed with a wound related to diabetes, heart disease, or peripheral vascular disease? | Please describe. |
| If chronic wounds or wounds with delayed healing are present: | | |
| Medications | Are you taking any medications that can affect wound healing, such as oral steroids to treat inflammation or help you breathe? | Please describe. |
| Treatments | What have you used to try to treat this wound? | What was successful? Unsuccessful? |
Symptoms of Infection (pain, purulent drainage, etc.) 感染症状（疼痛、脓性引流等）
Are you experiencing any symptoms of infection related to this wound such as increased pain or yellow/green drainage? 您的伤口是否出现任何感染症状，如疼痛加剧或流出黄色/绿色分泌物？
Please describe. 请描述。
Stress 压力
Have you experienced any recent stressors such as surgery, hospitalization, or a change in life circumstances? 您最近是否经历过任何压力，如手术、住院或生活环境的改变？
How do you cope with stress in your life? 您如何应对生活中的压力？
Smoking 吸烟
Do you smoke? 你吸烟吗？
How many cigarettes do you smoke a day? How long have you smoked? Have you considered quitting smoking? 您每天抽多少支烟？您吸烟多久了？您是否考虑过戒烟？
Quality of Life 生活质量
Has this wound impacted your quality of life? 这种伤口是否影响了您的生活质量？
Have you had any changes in eating habits, feelings of depression or social isolation, or a reduction in your usual activity levels? 您的饮食习惯是否有任何改变，是否有抑郁或社交孤立感，或平时的活动量是否减少？
Symptoms of Infection (pain, purulent drainage, etc.) Are you experiencing any symptoms of infection related to this wound such as increased pain or yellow/green drainage? Please describe.
Stress Have you experienced any recent stressors such as surgery, hospitalization, or a change in life circumstances? How do you cope with stress in your life?
Smoking Do you smoke? How many cigarettes do you smoke a day? How long have you smoked? Have you considered quitting smoking?
Quality of Life Has this wound impacted your quality of life? Have you had any changes in eating habits, feelings of depression or social isolation, or a reduction in your usual activity levels?| Symptoms of Infection (pain, purulent drainage, etc.) | Are you experiencing any symptoms of infection related to this wound such as increased pain or yellow/green drainage? | Please describe. |
| :--- | :--- | :--- |
| Stress | Have you experienced any recent stressors such as surgery, hospitalization, or a change in life circumstances? | How do you cope with stress in your life? |
| Smoking | Do you smoke? | How many cigarettes do you smoke a day? How long have you smoked? Have you considered quitting smoking? |
| Quality of Life | Has this wound impacted your quality of life? | Have you had any changes in eating habits, feelings of depression or social isolation, or a reduction in your usual activity levels? |
Objective Assessment 客观评估
When performing an objective integumentary assessment on a patient receiving inpatient care, it is important to perform a thorough exam on admission to check for existing wounds, as well as to evaluate their risk of skin breakdown using the Braden Scale. Agencies are not reimbursed for care of pressure injuries received during a patient’s stay, so existing wounds on admission must be well-documented. Routine skin assessment should continue throughout a patient’s stay, usually on a daily or shift-by-shift basis based on the patient’s condition. If a wound is present, it is assessed during every dressing change for signs of healing. See Table 10.6b for components to include in a wound assessment. See Figure 10.22^(3)10.22^{3} for an image of a common tool used to document the location of a skin concern found during assessment. 在对接受住院治疗的患者进行客观的全身评估时，必须在患者入院时对其进行彻底检查，以检查是否存在伤口，并使用布莱登量表评估其皮肤破损的风险。如果患者在住院期间出现压伤，护理机构将不予报销，因此必须对患者入院时的现有伤口进行详细记录。在患者住院期间应持续进行常规皮肤评估，通常根据患者的情况每天或每班进行一次评估。如果有伤口，每次换药时都要评估伤口是否有愈合迹象。有关伤口评估的内容，请参见表 10.6b。请参阅图 10.22^(3)10.22^{3} ，了解用于记录评估过程中发现的皮肤问题位置的常用工具。
Read more information about performing an overall integumentary assessment in the “Integumentary Assessment” chapter in Open RN Nursing Skills. 请阅读《开放式注册护士护理技能》中 "整体器官评估 "一章中有关进行整体器官评估的更多信息。
For additional discussion regarding assessing wounds, go to the “Assessing Wounds” section of the “Wound Care” chapter in Open RN Nursing Skills. 有关评估伤口的其他讨论，请参阅《开放式注册护士护理技能》中 "伤口护理 "一章的 "评估伤口 "部分。
Table 10.6b Wound Assessment 表 10.6b 伤口评估
Wound Assessment 伤口评估
Type 类型
Types of wounds may include abrasions, lacerations, burns, surgical incisions, pressure injuries, skin tears, arterial ulcers, or venous ulcers. It is important to understand the type of wound present to select appropriate interventions. 伤口类型可能包括擦伤、撕裂伤、烧伤、手术切口、压伤、皮肤撕裂、动脉溃疡或静脉溃疡。了解伤口类型对于选择适当的干预措施非常重要。
Location 地点
The location of the wound should be documented precisely. A body diagram template is helpful to demonstrate exactly where the wound is located. 应准确记录伤口的位置。体表图模板有助于准确显示伤口的位置。
Size 尺寸
Wound size should be measured regularly to determine if the wound is increasing or decreasing in size. Length is measured using the head-to-toe axis, and width is measured laterally. If tunneling or undermining is present, their depth should be assessed using a sterile, cotton-tipped applicator and documented using the clock method. 应定期测量伤口大小，以确定伤口是增大还是缩小。长度以头到趾为轴进行测量，宽度以侧面为轴进行测量。如果出现隧道或下穿，应使用无菌棉签涂抹器评估其深度，并用时钟法记录。
Wounds are classified as partial-thickness (meaning the epidermis and dermis are affected) or full-thickness (meaning the subcutaneous and deeper layers are affected). See Figure 10.1 in the "Basic Concepts" section for an image of the layers of skin.
For pressure injuries, it is important to assess the stage of the injury (see information on staging under the "Pressure Injuries" subsection).
Wounds are classified as partial-thickness (meaning the epidermis and dermis are affected) or full-thickness (meaning the subcutaneous and deeper layers are affected). See Figure 10.1 in the "Basic Concepts" section for an image of the layers of skin.
For pressure injuries, it is important to assess the stage of the injury (see information on staging under the "Pressure Injuries" subsection).| Wounds are classified as partial-thickness (meaning the epidermis and dermis are affected) or full-thickness (meaning the subcutaneous and deeper layers are affected). See Figure 10.1 in the "Basic Concepts" section for an image of the layers of skin. |
| :--- |
| For pressure injuries, it is important to assess the stage of the injury (see information on staging under the "Pressure Injuries" subsection). |
Color of Wound Base 伤口基底的颜色
Assess the base of the wound for the presence of healthy, pink/red granulation tissue. Note the unhealthy appearance of dark red granulation tissue, white or yellow slough, or brown or black necrotic tissue. 评估伤口底部是否有健康的粉红色/红色肉芽组织。注意暗红色肉芽组织、白色或黄色蜕皮、棕色或黑色坏死组织的不健康外观。
Wound Assessment
Type Types of wounds may include abrasions, lacerations, burns, surgical incisions, pressure injuries, skin tears, arterial ulcers, or venous ulcers. It is important to understand the type of wound present to select appropriate interventions.
Location The location of the wound should be documented precisely. A body diagram template is helpful to demonstrate exactly where the wound is located.
Size Wound size should be measured regularly to determine if the wound is increasing or decreasing in size. Length is measured using the head-to-toe axis, and width is measured laterally. If tunneling or undermining is present, their depth should be assessed using a sterile, cotton-tipped applicator and documented using the clock method.
Degree of Tissue Injury "Wounds are classified as partial-thickness (meaning the epidermis and dermis are affected) or full-thickness (meaning the subcutaneous and deeper layers are affected). See Figure 10.1 in the "Basic Concepts" section for an image of the layers of skin.
For pressure injuries, it is important to assess the stage of the injury (see information on staging under the "Pressure Injuries" subsection)."
Color of Wound Base Assess the base of the wound for the presence of healthy, pink/red granulation tissue. Note the unhealthy appearance of dark red granulation tissue, white or yellow slough, or brown or black necrotic tissue.| | Wound Assessment |
| :--- | :--- |
| Type | Types of wounds may include abrasions, lacerations, burns, surgical incisions, pressure injuries, skin tears, arterial ulcers, or venous ulcers. It is important to understand the type of wound present to select appropriate interventions. |
| Location | The location of the wound should be documented precisely. A body diagram template is helpful to demonstrate exactly where the wound is located. |
| Size | Wound size should be measured regularly to determine if the wound is increasing or decreasing in size. Length is measured using the head-to-toe axis, and width is measured laterally. If tunneling or undermining is present, their depth should be assessed using a sterile, cotton-tipped applicator and documented using the clock method. |
| Degree of Tissue Injury | Wounds are classified as partial-thickness (meaning the epidermis and dermis are affected) or full-thickness (meaning the subcutaneous and deeper layers are affected). See Figure 10.1 in the "Basic Concepts" section for an image of the layers of skin. <br> For pressure injuries, it is important to assess the stage of the injury (see information on staging under the "Pressure Injuries" subsection). |
| Color of Wound Base | Assess the base of the wound for the presence of healthy, pink/red granulation tissue. Note the unhealthy appearance of dark red granulation tissue, white or yellow slough, or brown or black necrotic tissue. |
The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Drainage from wounds is often described as scant, small/minimal, moderate, and large/ copious amounts. Use the following descriptions to select the appropriate terms: ^(4){ }^{4}
- No exudate present: The wound base is dry.
- Scant amount of exudate present: The wound is moist but no measurable amount of exudate appears on the dressing.
- Minimal amount of exudate on the dressing: Exudate covers less than 25%25 \% of the bandage.
- Moderate amount of drainage: Wound tissue is wet, and drainage covers 25%25 \% to 75%75 \% of the bandage.
- Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75%75 \% of the bandage.
The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent:
- Sanguineous: Sanguineous exudate is fresh bleeding.
- Serous: Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. ^(6){ }^{6}
- Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present. ^(7){ }^{7}
- Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown in color. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. ^(8){ }^{8} See Figure 10.23^(9)10.23^{9} for an image of purulent drainage.
The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Drainage from wounds is often described as scant, small/minimal, moderate, and large/ copious amounts. Use the following descriptions to select the appropriate terms: ^(4)
- No exudate present: The wound base is dry.
- Scant amount of exudate present: The wound is moist but no measurable amount of exudate appears on the dressing.
- Minimal amount of exudate on the dressing: Exudate covers less than 25% of the bandage.
- Moderate amount of drainage: Wound tissue is wet, and drainage covers 25% to 75% of the bandage.
- Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.
The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent:
- Sanguineous: Sanguineous exudate is fresh bleeding.
- Serous: Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. ^(6)
- Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present. ^(7)
- Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown in color. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. ^(8) See Figure 10.23^(9) for an image of purulent drainage.| The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Drainage from wounds is often described as scant, small/minimal, moderate, and large/ copious amounts. Use the following descriptions to select the appropriate terms: ${ }^{4}$ |
| :--- |
| - No exudate present: The wound base is dry. |
| - Scant amount of exudate present: The wound is moist but no measurable amount of exudate appears on the dressing. |
| - Minimal amount of exudate on the dressing: Exudate covers less than $25 \%$ of the bandage. |
| - Moderate amount of drainage: Wound tissue is wet, and drainage covers $25 \%$ to $75 \%$ of the bandage. |
| - Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than $75 \%$ of the bandage. |
| The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent: |
| - Sanguineous: Sanguineous exudate is fresh bleeding. |
| - Serous: Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. ${ }^{6}$ |
| - Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present. ${ }^{7}$ |
| - Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown in color. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. ${ }^{8}$ See Figure $10.23^{9}$ for an image of purulent drainage. |
Tubes or Drains 管道或排水管
Check for patency and if they are attached correctly. 检查是否通畅，是否连接正确。
Drainage "The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Drainage from wounds is often described as scant, small/minimal, moderate, and large/ copious amounts. Use the following descriptions to select the appropriate terms: ^(4)
- No exudate present: The wound base is dry.
- Scant amount of exudate present: The wound is moist but no measurable amount of exudate appears on the dressing.
- Minimal amount of exudate on the dressing: Exudate covers less than 25% of the bandage.
- Moderate amount of drainage: Wound tissue is wet, and drainage covers 25% to 75% of the bandage.
- Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than 75% of the bandage.
The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent:
- Sanguineous: Sanguineous exudate is fresh bleeding.
- Serous: Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. ^(6)
- Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present. ^(7)
- Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown in color. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. ^(8) See Figure 10.23^(9) for an image of purulent drainage."
Tubes or Drains Check for patency and if they are attached correctly.| Drainage | The color, consistency, and amount of exudate (drainage) should be assessed and documented at every dressing change. Drainage from wounds is often described as scant, small/minimal, moderate, and large/ copious amounts. Use the following descriptions to select the appropriate terms: ${ }^{4}$ <br> - No exudate present: The wound base is dry. <br> - Scant amount of exudate present: The wound is moist but no measurable amount of exudate appears on the dressing. <br> - Minimal amount of exudate on the dressing: Exudate covers less than $25 \%$ of the bandage. <br> - Moderate amount of drainage: Wound tissue is wet, and drainage covers $25 \%$ to $75 \%$ of the bandage. <br> - Large or copious amount of drainage: Wound tissue is filled with fluid, and exudate covers more than $75 \%$ of the bandage. <br> The type of wound drainage should be described using medical terms such as serosanguinous, sanguineous, serous, or purulent: <br> - Sanguineous: Sanguineous exudate is fresh bleeding. <br> - Serous: Serous drainage is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. ${ }^{6}$ <br> - Serosanguinous: Serosanguineous exudate contains serous drainage with small amounts of blood present. ${ }^{7}$ <br> - Purulent: Purulent exudate is thick and opaque. It can be tan, yellow, green, or brown in color. It is never considered normal in a wound bed, and new purulent drainage should always be reported to the health care provider. ${ }^{8}$ See Figure $10.23^{9}$ for an image of purulent drainage. |
| :--- | :--- |
| Tubes or Drains | Check for patency and if they are attached correctly. |
Assess for signs and symptoms of infection, which include the following:
- Redness
- Warmth of surrounding tissue
- Swelling
- Tenderness or pain
- Purulent drainage
- Fever
- Increased white blood cell count
Assess for signs and symptoms of infection, which include the following:
- Redness
- Warmth of surrounding tissue
- Swelling
- Tenderness or pain
- Purulent drainage
- Fever
- Increased white blood cell count| Assess for signs and symptoms of infection, which include the following: |
| :--- |
| - Redness |
| - Warmth of surrounding tissue |
| - Swelling |
| - Tenderness or pain |
| - Purulent drainage |
| - Fever |
| - Increased white blood cell count |
Wound Edges and Periwound 伤口边缘和伤口周围
Assess the surrounding skin for maceration or signs of infection. 评估周围皮肤有无浸渍或感染迹象。
Pain 疼痛
Assess for pain in the wound or during dressing changes. If pain is present, use the PQRSTU or OLDCARTES method to obtain a comprehensive pain assessment. 评估伤口或更换敷料时是否疼痛。如果存在疼痛，可使用 PQRSTU 或 OLDCARTES 方法进行全面的疼痛评估。
Signs and Symptoms of Infection "Assess for signs and symptoms of infection, which include the following:
- Redness
- Warmth of surrounding tissue
- Swelling
- Tenderness or pain
- Purulent drainage
- Fever
- Increased white blood cell count"
Wound Edges and Periwound Assess the surrounding skin for maceration or signs of infection.
Pain Assess for pain in the wound or during dressing changes. If pain is present, use the PQRSTU or OLDCARTES method to obtain a comprehensive pain assessment.| Signs and Symptoms of Infection | Assess for signs and symptoms of infection, which include the following: <br> - Redness <br> - Warmth of surrounding tissue <br> - Swelling <br> - Tenderness or pain <br> - Purulent drainage <br> - Fever <br> - Increased white blood cell count |
| :--- | :--- |
| Wound Edges and Periwound | Assess the surrounding skin for maceration or signs of infection. |
| Pain | Assess for pain in the wound or during dressing changes. If pain is present, use the PQRSTU or OLDCARTES method to obtain a comprehensive pain assessment. |
PRESSURE ULEER IDENTIFICATION POCKET PAD 压力表识别袖珍垫
Place the patient’s/resident’s name on the top of the pad, date it and place an " XX " on the area on the body where you see the skin concern. Give this to the nurse and ask him or her to check the patient/resident. They will follow up as needed. 将患者/住院患者的姓名写在便笺的顶部，注明日期，并在您发现皮肤问题的部位打上" XX "。将此交给护士，请他/她检查病人/住院患者。他们将根据需要进行跟进。
Color: appropriate for ethnicity
Temperature: warm to touch
Texture: smooth, soft, and supple
Turgor: resilient
Integrity: no wounds or lesions noted
Sensory: no pain or itching noted| Color: appropriate for ethnicity |
| :--- |
| Temperature: warm to touch |
| Texture: smooth, soft, and supple |
| Turgor: resilient |
| Integrity: no wounds or lesions noted |
| Sensory: no pain or itching noted |
Color: pale, white, red, yellow, purple, black and blue
Temperature: cool or hot to touch
Texture: rough, scaly or thick; thin and easily torn; dry and cracked
Turgor: tenting noted
Integrity: rashes, lesions, abrasions, burns, lacerations, surgical wounds, pressure injuries noted
Pain or pruritus (itching) present| Color: pale, white, red, yellow, purple, black and blue |
| :--- |
| Temperature: cool or hot to touch |
| Texture: rough, scaly or thick; thin and easily torn; dry and cracked |
| Turgor: tenting noted |
| Integrity: rashes, lesions, abrasions, burns, lacerations, surgical wounds, pressure injuries noted |
| Pain or pruritus (itching) present |
Hair 头发
Full distribution of hair on the head, axilla, and genitalia 头部、腋窝和生殖器上的毛发全面分布
Alopecia (hair loss), hirsutism (excessive hair growth over body), lice and/or nits, or lesions under hair 脱发（毛发脱落）、多毛症（全身毛发生长过多）、虱子和/或虱卵，或毛发下的病变
Nails 指甲
Smooth, well-shaped, and firm but flexible 光滑、形状良好、坚固但有弹性
Cracked, chipped, or splitting nail; excessively thick; presence of clubbing; ingrown nails 指甲开裂、碎裂或劈裂；指甲过厚；出现倒刺；指甲内生
Skin Integrity 皮肤完整性
Skin intact with no wounds or pressure injuries. Braden Scale is 23 皮肤完好无损，没有伤口或压伤。布莱登评分为 23
A wound or pressure injury is present, or there is risk of developing a pressure injury with a Braden scale score of less than 23 存在伤口或压伤，或有发生压伤的风险，布莱登量表评分低于 23 分
Assessment Expected Findings Unexpected Findings
Skin "Color: appropriate for ethnicity
Temperature: warm to touch
Texture: smooth, soft, and supple
Turgor: resilient
Integrity: no wounds or lesions noted
Sensory: no pain or itching noted" "Color: pale, white, red, yellow, purple, black and blue
Temperature: cool or hot to touch
Texture: rough, scaly or thick; thin and easily torn; dry and cracked
Turgor: tenting noted
Integrity: rashes, lesions, abrasions, burns, lacerations, surgical wounds, pressure injuries noted
Pain or pruritus (itching) present"
Hair Full distribution of hair on the head, axilla, and genitalia Alopecia (hair loss), hirsutism (excessive hair growth over body), lice and/or nits, or lesions under hair
Nails Smooth, well-shaped, and firm but flexible Cracked, chipped, or splitting nail; excessively thick; presence of clubbing; ingrown nails
Skin Integrity Skin intact with no wounds or pressure injuries. Braden Scale is 23 A wound or pressure injury is present, or there is risk of developing a pressure injury with a Braden scale score of less than 23| Assessment | Expected Findings | Unexpected Findings |
| :--- | :--- | :--- |
| Skin | Color: appropriate for ethnicity <br> Temperature: warm to touch <br> Texture: smooth, soft, and supple <br> Turgor: resilient <br> Integrity: no wounds or lesions noted <br> Sensory: no pain or itching noted | Color: pale, white, red, yellow, purple, black and blue <br> Temperature: cool or hot to touch <br> Texture: rough, scaly or thick; thin and easily torn; dry and cracked <br> Turgor: tenting noted <br> Integrity: rashes, lesions, abrasions, burns, lacerations, surgical wounds, pressure injuries noted <br> Pain or pruritus (itching) present |
| Hair | Full distribution of hair on the head, axilla, and genitalia | Alopecia (hair loss), hirsutism (excessive hair growth over body), lice and/or nits, or lesions under hair |
| Nails | Smooth, well-shaped, and firm but flexible | Cracked, chipped, or splitting nail; excessively thick; presence of clubbing; ingrown nails |
| Skin Integrity | Skin intact with no wounds or pressure injuries. Braden Scale is 23 | A wound or pressure injury is present, or there is risk of developing a pressure injury with a Braden scale score of less than 23 |
Diagnostic and Lab Work 诊断和实验室工作
When a chronic wound is not healing as expected, laboratory test results can provide additional clues for the delayed healing. See Table 10.6d for a summary of lab results that offer clues to systemic issues causing delayed wound healing. ^(10){ }^{10} 当慢性伤口未按预期愈合时，实验室检查结果可为延迟愈合提供更多线索。请参见表 10.6d，了解可提供导致伤口愈合延迟的系统性问题线索的实验室结果摘要。 ^(10){ }^{10}
Low hemoglobin indicates less oxygen is transported to the wound site. 血红蛋白偏低表明输送到伤口部位的氧气减少。
Elevated white blood cells (WBC) 白细胞（WBC）升高
Increased WBC indicates infection is occurring. 白细胞增加表明正在发生感染。
Low platelets 血小板低
Platelets have an important role in the creation of granulation tissue. 血小板在肉芽组织的形成过程中发挥着重要作用。
Low albumin 白蛋白低
Low albumin indicates decreased protein levels. Protein is required for effective wound healing. 白蛋白低表明蛋白质水平下降。有效的伤口愈合需要蛋白质。
Elevated blood glucose or hemoglobin AIC 血糖或血红蛋白 AIC 升高
Elevated blood glucose and hemoglobin A1C levels indicate poor management of diabetes mellitus, a disease that negatively impacts wound healing. 血糖和血红蛋白 A1C 水平升高表明糖尿病管理不善，这种疾病会对伤口愈合产生负面影响。
Elevated serum BUN and creatinine 血清 BUN 和肌酐升高
BUN and creatinine levels are indicators of kidney function, with elevated levels indicating worsening kidney function. Elevated BUN (blood urea nitrogen) levels impact wound healing. 血尿素氮和肌酐水平是肾功能的指标，水平升高表明肾功能恶化。BUN（血尿素氮）水平升高会影响伤口愈合。
Positive wound culture 伤口培养阳性
Positive wound cultures indicate an infection is present and provide additional information including the type and number of bacteria present, as well as identifying antibiotics the bacteria is susceptible to. The nurse reviews this information when administering antibiotics to ensure the prescribed therapy is effective for the type of bacteria present. 伤口培养阳性表明存在感染，并可提供更多信息，包括存在的细菌类型和数量，以及确定细菌易感的抗生素。护士在使用抗生素时会查看这些信息，以确保处方疗法对存在的细菌类型有效。
Abnormal Lab Value Rationale
Low hemoglobin Low hemoglobin indicates less oxygen is transported to the wound site.
Elevated white blood cells (WBC) Increased WBC indicates infection is occurring.
Low platelets Platelets have an important role in the creation of granulation tissue.
Low albumin Low albumin indicates decreased protein levels. Protein is required for effective wound healing.
Elevated blood glucose or hemoglobin AIC Elevated blood glucose and hemoglobin A1C levels indicate poor management of diabetes mellitus, a disease that negatively impacts wound healing.
Elevated serum BUN and creatinine BUN and creatinine levels are indicators of kidney function, with elevated levels indicating worsening kidney function. Elevated BUN (blood urea nitrogen) levels impact wound healing.
Positive wound culture Positive wound cultures indicate an infection is present and provide additional information including the type and number of bacteria present, as well as identifying antibiotics the bacteria is susceptible to. The nurse reviews this information when administering antibiotics to ensure the prescribed therapy is effective for the type of bacteria present.| Abnormal Lab Value | Rationale |
| :--- | :--- |
| Low hemoglobin | Low hemoglobin indicates less oxygen is transported to the wound site. |
| Elevated white blood cells (WBC) | Increased WBC indicates infection is occurring. |
| Low platelets | Platelets have an important role in the creation of granulation tissue. |
| Low albumin | Low albumin indicates decreased protein levels. Protein is required for effective wound healing. |
| Elevated blood glucose or hemoglobin AIC | Elevated blood glucose and hemoglobin A1C levels indicate poor management of diabetes mellitus, a disease that negatively impacts wound healing. |
| Elevated serum BUN and creatinine | BUN and creatinine levels are indicators of kidney function, with elevated levels indicating worsening kidney function. Elevated BUN (blood urea nitrogen) levels impact wound healing. |
| Positive wound culture | Positive wound cultures indicate an infection is present and provide additional information including the type and number of bacteria present, as well as identifying antibiotics the bacteria is susceptible to. The nurse reviews this information when administering antibiotics to ensure the prescribed therapy is effective for the type of bacteria present. |
Life Span and Cultural Considerations 生命周期和文化因素
NEWBORNS AND INFANTS 新生儿和婴儿
Newborn skin is thin and sensitive. It tends to be easy to scratch and bruise and is susceptible to rashes and irritation. Common rashes seen in newborns 新生儿的皮肤薄而敏感。很容易抓伤和擦伤，也很容易出疹子和受到刺激。新生儿常见的皮疹
11. Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. BMJ (Clinical research ed.), 332(7536), 285-288. https://doi.org/10.1136/bmj.332.7536.285 11.Grey, J. E., Enoch, S., & Harding, K. G. (2006).伤口评估。BMJ (Clinical research ed.), 332(7536), 285-288. https://doi.org/10.1136/bmj.332.7536.285
and infants include diaper rash (contact dermatitis), cradle cap (seborrheic dermatitis), newborn acne, and prickly heat. 婴幼儿常见的皮肤病包括尿布疹（接触性皮炎）、摇篮帽（脂溢性皮炎）、新生儿痤疮和痱子。
TODDLERS AND PRESCHOOLERS 幼儿和学龄前儿童
Because of high levels of activity and increasing mobility, this age group is more prone to accidents. Issues like lacerations, abrasions, burns, and sunburns can occur frequently. It is important to be highly aware of the potential for accidents and implement safety precautions as needed. 由于这个年龄段的孩子活动量大，活动能力增强，因此更容易发生意外。撕裂伤、擦伤、烧伤和晒伤等问题可能会经常发生。因此，高度警惕潜在的意外事故并采取必要的安全预防措施非常重要。
SCHOOL-AGED CHILDREN AND ADOLESCENTS 学龄儿童和青少年
Skin rashes tend to affect skin within this age group. Impetigo, scabies, and head lice are commonly seen and may keep children home from school. Acne vulgaris typically begins during adolescence and can alter physical appearance, which can be very upsetting to this age group. Another change during adolescence is the appearance of axillary, pubic, and other body hair. Also, as these children spend more time out of doors, sunburns are more common, and care should be given to encourage sunscreen and discourage the use of tanning beds. 这个年龄段的儿童多发皮疹。疱疹、疥疮和头虱是常见病，可能会让孩子们辍学在家。寻常性痤疮通常始于青春期，会改变外貌，这可能会让这个年龄段的孩子非常苦恼。青春期的另一个变化是腋毛、阴毛和其他体毛的出现。此外，由于这些孩子外出的时间较长，晒伤也比较常见，因此应注意鼓励他们涂抹防晒霜，并不鼓励他们使用日光浴床。
ADULTS AND OLDER ADULTS 成人和老年人
As skin ages, many changes take place. Because aging increases the loss of subcutaneous fat and collagen breakdown, skin becomes thinner and wrinkles deepen. Decreased sweat gland activity leads to drier skin and pruritus (itching). Healing is slowed because of reduced circulation and the inability of proteins and proper nutrients to arrive at injury sites. Hair loses pigmentation and turns gray or white. Nails become thicker and are more difficult to cut. Age or liver spots become darker and more noticeable. The number of skin growths increases and includes skin tags and keratoses. There is often delayed wound healing in older adults. 随着年龄的增长，皮肤会发生许多变化。由于衰老会增加皮下脂肪的流失和胶原蛋白的分解，皮肤会变得更薄，皱纹也会加深。汗腺活动减少导致皮肤更加干燥和瘙痒。由于血液循环减少，蛋白质和适当的营养物质无法到达受伤部位，因此愈合速度减慢。头发失去色素，变成灰色或白色。指甲变厚，更难修剪。老年斑或肝斑变得更深、更明显。皮肤增生增多，包括皮赘和角化病。老年人的伤口愈合通常会延迟。
Diagnoses 诊断
There are several NANDA-I nursing diagnoses related to patients experiencing 有几种 NANDA-I 护理诊断与经历以下情况的病人有关
skin alterations or those at risk of developing a skin injury. See Table 10.6e for common NANDA-I nursing diagnoses and their definitions. ^(12){ }^{12} 皮肤改变或有发生皮肤损伤风险的人。有关常见的 NANDA-I 护理诊断及其定义，请参见表 10.6e。 ^(12){ }^{12}
Table 10.6e Common NANDA-I Nursing Diagnoses Related to Integumentary Disorders ^(13){ }^{13} 表 10.6e 与全身性疾病有关的常见 NANDA-I 护理诊断 ^(13){ }^{13}
Risk for Pressure Injury: "Susceptible to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear." 压伤风险："由于压力或压力与剪切力的共同作用，皮肤和/或下层组织（通常在骨突处）容易受到局部伤害"。
Risk for Impaired Skin Integrity: "Susceptible to alteration in epidermis and/or dermis, which may compromise health." 皮肤完整性受损的风险："表皮和/或真皮容易发生变化，可能损害健康"。
Risk for Impaired Tissue Integrity: "Susceptible to damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament, which may compromise health." 组织完整性受损的风险："容易损坏粘膜、角膜、皮肤系统、肌肉筋膜、肌肉、肌腱、骨骼、软骨、关节囊和/或韧带，从而损害健康"。
Risk for Pressure Injury: "Susceptible to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear."
Impaired Skin Integrity: "Altered epidermis and/or dermis."
Risk for Impaired Skin Integrity: "Susceptible to alteration in epidermis and/or dermis, which may compromise health."
Impaired Tissue Integrity: "Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament."
Risk for Impaired Tissue Integrity: "Susceptible to damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament, which may compromise health."| Risk for Pressure Injury: "Susceptible to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear." |
| :--- |
| Impaired Skin Integrity: "Altered epidermis and/or dermis." |
| Risk for Impaired Skin Integrity: "Susceptible to alteration in epidermis and/or dermis, which may compromise health." |
| Impaired Tissue Integrity: "Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament." |
| Risk for Impaired Tissue Integrity: "Susceptible to damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament, which may compromise health." |
A commonly used NANDA-I nursing diagnosis for patients experiencing alterations in the integumentary system is Impaired Tissue Integrity, defined as, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” 对于出现全身系统改变的患者，常用的 NANDA-I 护理诊断是 "组织完整性受损"，定义为 "粘膜、角膜、全身系统、肌肉筋膜、肌肉、肌腱、骨、软骨、关节囊和/或韧带受损"。
To verify accuracy of this diagnosis for a patient, the nurse compares assessment findings with defining characteristics of that diagnosis. Defining characteristics for Impaired Tissue Integrity include the following: 为了验证患者诊断的准确性，护士要将评估结果与该诊断的定义特征进行比较。组织完整性受损的定义特征包括以下内容：
Acute pain 急性疼痛
Bleeding 出血
Destroyed tissue 被破坏的组织
Hematoma 血肿
Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 404, 406, 407, 412, 413. Herdman, T., & Kamitsuru, S. (2017).NANDA 国际护理诊断：定义与分类 2018-2020》（第 11 版）。Thieme Publishers. pp.404, 406, 407, 412, 413.
Herdman, T., & Kamitsuru, S. (2017). NANDA international nursing diagnoses: Definitions & classification 2018-2020 (11th ed.). Thieme Publishers. pp. 404, 406, 407, 412, 413. Herdman, T., & Kamitsuru, S. (2017).NANDA 国际护理诊断：定义与分类 2018-2020》（第 11 版）。Thieme Publishers. pp.404, 406, 407, 412, 413.
Localized area hot to touch 局部区域触摸时发热
Redness 发红
Tissue damage 组织损伤
A sample NANDA-I diagnosis in current PES format would be: “Impaired Tissue Integrity related to insufficient knowledge about protecting tissue integrity as evidenced by redness and tissue damage.” 目前 PES 格式的 NANDA-I 诊断样本为"组织完整性受损，与保护组织完整性的知识不足有关，表现为发红和组织损伤"。
Outcome Identification 成果鉴定
An example of a broad goal for a patient experiencing alterations in tissue integrity is: 为组织完整性发生变化的患者制定广泛目标的一个例子是
The patient will experience tissue healing. 患者将经历组织愈合。
A sample SMART expected outcome for a patient with a wound is: 对于有伤口的病人，SMART 预期成果的示例是
The patient’s wound will decrease in size and have increased granulation tissue within two weeks. 病人的伤口会在两周内缩小，肉芽组织增多。
Planning Interventions 规划干预措施
In addition to the interventions outlined under the “Braden Scale” section to prevent and treat pressure injury, see the following box for a list interventions to prevent and treat impaired skin integrity. As always, consult a current, evidence-based nurse care planning resource for additional interventions when planning patient care. 除了 "布莱登量表 "部分概述的预防和治疗压力性损伤的干预措施外，请参阅以下方框中列出的预防和治疗皮肤完整性受损的干预措施。在制定患者护理计划时，请一如既往地参考最新的循证护士护理计划资源，以了解其他干预措施。
Selected Interventions to Prevent and Treat Impaired Skin Integrity ^(14,15,16)\stackrel{14,15,16}{ } 预防和治疗皮肤完整性受损的选定干预措施 ^(14,15,16)\stackrel{14,15,16}{ }
Assess and document the patient’s skin status routinely. (Frequency is determined based on the patient’s status.) 定期评估和记录患者的皮肤状况。(根据患者的状况确定频率）。
Use the Braden Scale to identify patients at risk for skin breakdown. Customize interventions to prevent and treat skin breakdown according to patient needs. 使用布莱登量表识别有皮肤破损风险的患者。根据患者需求定制干预措施，预防和治疗皮肤破损。
If a wound is present, evaluate the healing process at every dressing change. Note and document characteristics of the wound, including size, appearance, staging (if applicable), and drainage. Notify the provider of new signs of infection or lack of progress in healing. 如果有伤口，每次换药时都要评估伤口的愈合过程。注意并记录伤口的特征，包括大小、外观、分期（如适用）和引流情况。如果出现新的感染迹象或伤口愈合缺乏进展，请通知医疗服务提供者。
Provide wound care treatments, as prescribed by the provider or wound care specialist, and monitor the patient’s response toward expected outcomes. 按照医疗服务提供者或伤口护理专家的处方提供伤口护理治疗，并监测患者的反应，以达到预期效果。
Cleanse the wound per facility protocol or as ordered. 按照设备规程或医嘱清洁伤口。
Maintain non-touch or aseptic technique when performing wound dressing changes, as indicated. (Read more details about using aseptic technique and the non-touch method in the “Aseptic Technique” chapter of the Open RN Nursing Skills textbook.) 根据指示，在进行伤口换药时保持非接触式或无菌技术。(请阅读《开放式注册护士护理技能》教材中 "无菌技术 "一章中有关无菌技术和非接触式方法的更多详情）。
Change wound dressings as needed to keep them clean and dry and prevent bacterial reservoir. 根据需要更换伤口敷料，保持清洁干燥，防止细菌滋生。
Monitor for signs of infection in an existing wound (as indicated by redness, warmth, edema, increased pain, 监测现有伤口是否有感染迹象（如发红、发热、水肿、疼痛加剧等）、
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier. pp. 348-349, 417-419. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018)。护理干预分类（NIC）》。Elsevier.348-349, 417-419.
Ackley, B., Ladwig, G., & Makic, M. B. (2016). Nursing diagnosis handbook: An evidence-based guide to planning care (17th ed.). pp. 884-885. Elsevier. Ackley, B., Ladwig, G., & Makic, M. B. (2016).Nursing diagnosis handbook：第 17 版）。第 884-885 页。Elsevier.
Cox, J. (2019). Wound care 101. Nursing, 49(10), 32-39. https://doi.org/10.1097/01.nurse.0000580632.58318.08 Cox, J. (2019).伤口护理 101。护理学》，49（10），32-39。https://doi.org/10.1097/01.nurse.0000580632.58318.08。
reddened appearance of surrounding skin, fever, increased white blood cell count, changes in wound drainage, or sudden change in patient’s level of consciousness). 周围皮肤发红、发烧、白细胞计数增加、伤口排泄物变化或患者意识突然改变）。
Apply lotion to dry areas to prevent cracking. 在干燥部位涂抹润肤露，防止干裂。
Apply lubricant to moisten lips and oral mucosa, as needed. 根据需要使用润滑剂湿润嘴唇和口腔粘膜。
Keep skin free of excess moisture. Use moisture barrier ointments (protective skin barriers) or incontinence products in skin areas subject to increased moisture and risk of skin breakdown. 保持皮肤不过分潮湿。在容易受潮和有皮肤破损风险的皮肤部位使用防潮软膏（皮肤保护屏障）或失禁用品。
Educate the patient and/or family caregivers on caring for the wound and request return demonstrations, as appropriate. 教育患者和/或家庭护理人员如何护理伤口，并要求他们酌情进行回访演示。
Administer medications, as prescribed, and monitor for expected effects. 按照处方用药，并监测预期效果。
Consult with a wound specialist, as needed. 必要时咨询伤口专家。
Obtain specimens of wound drainage for wound culture, as indicated, and monitor results. 根据需要获取伤口引流液标本进行伤口培养，并监测结果。
Advocate for pressure-relieving devices in patients at risk for pressure injuries, such as elbow protectors, heel protectors, chair cushions, and specialized mattresses and monitor the patient’s response. 提倡为有压力损伤风险的患者提供压力减轻装置，如护肘、护足跟、椅垫和专用床垫，并监测患者的反应。
Promote adequate nutrition and hydration intake, unless contraindicated. 除非有禁忌症，否则应促进充足的营养和水分摄入。
Use a minimum of two-person assistance and a draw sheet to pull a patient up in bed to minimize shear and friction. 至少使用两人协助和拉床将病人从床上拉起，以尽量减少剪切力和摩擦力。
Reposition the patient frequently to prevent skin breakdown and to promote healing. Turn the immobilized patient at least every two hours, according to a specific schedule. 经常让病人复位，以防止皮肤破损并促进愈合。按照特定的时间表，至少每两小时为固定的病人翻身一次。
Maintain a patient’s position at 30 degrees or less, as appropriate, to prevent shear. 酌情将患者的体位保持在 30 度或更低，以防止剪切。
Keep bed linens clean, dry, and wrinkle free. 保持床单干净、干燥、无褶皱。
Implementation 实施
Before implementing interventions, it is important to assess the current status of the skin and risk factors present for skin breakdown and modify interventions based on the patient’s current status. For example, if a patient’s rash has resolved, some interventions may no longer be appropriate (such as applying topical creams). However, if a wound is showing signs of worsening or delayed healing, additional interventions may be required. As always, if the patient demonstrates new signs of localized or systemic infection, the provider should be notified. 在实施干预措施之前，重要的是要评估皮肤的现状和皮肤破损的风险因素，并根据患者的现状修改干预措施。例如，如果患者的皮疹已经消退，某些干预措施可能不再合适（如涂抹局部药膏）。但是，如果伤口有恶化或延迟愈合的迹象，则可能需要采取额外的干预措施。与往常一样，如果患者出现局部或全身感染的新迹象，应通知医疗服务提供者。
Evaluation 评估
It is important to evaluate for healing when performing wound care. Use the following expected outcomes when evaluating wound healing: 在进行伤口护理时，评估伤口愈合情况非常重要。在评估伤口愈合时，请使用以下预期结果：
Resolution of periwound redness in 1 week 1 周内消除伤口周围发红现象
50%50 \% reduction in wound dimensions in 2 weeks 50%50 \% 两周内伤口尺寸缩小
Reduction in volume of exudate 减少渗出量
25%25 \% reduction in amount of necrotic tissue/eschar in 1 week 25%25 \% 1 周内减少坏死组织/炭化物的数量
If a patient is experiencing delayed wound healing or has a chronic wound, it is helpful to advocate for a referral to a wound care nurse specialist. 如果患者出现伤口愈合延迟或慢性伤口，主张转诊给伤口护理专科护士是很有帮助的。
Read a sample nursing care plan for a patient with impaired skin integrity. 阅读针对皮肤完整性受损患者的护理计划样本。
Review the following example of applying the nursing process to a patient with a pressure injury. 请看下面将护理程序应用于压伤患者的示例。
Betty Pruitt is a 92-year-old female admitted to a skilled nursing facility after a fall at her daughter’s home while transferring the patient from her bed to a wheelchair. See Figure 10.24 for an image of Betty Pruitt. Although no injury 贝蒂-普鲁伊特是一名 92 岁的女性，她在女儿家将病人从床上转移到轮椅时不慎摔倒，随后住进了一家专业护理机构。贝蒂-普鲁伊特的图像见图 10.24。虽然没有受伤
was sustained, it became clear to the family that they could no longer provide adequate care at home. 在这种情况下，家庭显然无法再在家中提供足够的护理。
Ms. Pruitt’s past medical history includes congestive heart failure, hypertension, hypercholesterolemia, and moderate stage Alzheimer’s disease. Her cognitive ability has significantly declined over the last six months. Patient’s speech continues to be mostly clear and at times coherent but she tends to be quiet and does not express her needs adequately, even with prompting. She no longer has the ability to ambulate but can stand for short periods of time, requiring two people to transfer. She rarely changes body position without encouragement and assistance, spending most of her days in a recliner or bed. Betty is 69 inches tall and currently weighs 122 pounds, having lost 22 pounds over the last 3 months. BMI is 18 . Family reports her appetite is poor, and she eats only in small amounts at meal times with feeding assistance. She does take liquids well and shows no swallowing difficulties at this time. Betty is incontinent of urine and stool most of the time but will use the toilet if offered and given transfer help. Unknown to the family, a skin assessment revealed a Stage III pressure injury on coccyx area. Wound measures 4 cm long, 4 cm wide, 3 cm deep, with adipose tissue visible. No undermining, tunneling, bone, muscle, or tendons visible. Scant amount of yellowish purulent drainage noted. Slight foul odor, with redness, and increased heat around the wound present. 普鲁伊特女士的既往病史包括充血性心力衰竭、高血压、高胆固醇血症和中度阿尔茨海默病。在过去的六个月里，她的认知能力明显下降。患者的言语大部分仍然清晰，有时还能连贯地说话，但她往往沉默寡言，即使在提示下也不能充分表达自己的需求。她不再有行走能力，但可以短时间站立，需要两个人来转移。在没有鼓励和帮助的情况下，她很少改变身体姿势，大部分时间都是躺在躺椅或床上。贝蒂身高 69 英寸，目前体重 122 磅，在过去 3 个月中体重下降了 22 磅。体重指数为 18。家人称她的食欲很差，吃饭时只能在喂食人员的帮助下少量进食。她能很好地接受流质食物，目前没有吞咽困难。贝蒂大部分时间大小便失禁，但如果有人让她如厕并帮助她转移，她会如厕。家人不知道的是，皮肤评估显示贝蒂的尾骨部位有一处三级压伤。伤口长 4 厘米，宽 4 厘米，深 3 厘米，可见脂肪组织。未见皮下组织、隧道、骨骼、肌肉或肌腱。有少量淡黄色脓性引流物。伤口周围有轻微恶臭、发红和发热。
A Braden Scale Risk Assessment was completed and revealed a total score of 12 (High Risk) with the following category scores: Sensory Perception-3, Moisture-2, Activity-2, Mobility-2, Nutrition-2, Friction & Shear-1. 布莱登量表风险评估完成后，显示总分为 12 分（高风险），类别得分如下：感觉-3、水分-2、活动-2、移动-2、营养-2、摩擦和剪切-1。
Applying the Nursing Process 应用护理程序
Based on this information, the following nursing care plan was implemented for Ms. Pruitt. 根据这些信息，为普鲁伊特女士实施了以下护理计划。
Nursing Diagnosis: Impaired Tissue Integrity related to imbalanced nutritional state and associated with impaired mobility as evidenced by damaged tissue, redness, area hot to touch. 护理诊断：组织完整性受损，与营养失衡状态有关，并与活动能力受损有关，表现为组织受损、发红、触摸部位发热。
Overall Goal: The patient will experience wound healing demonstrated by decreased wound size and increased granulation tissue. 总体目标：患者伤口愈合，表现为伤口面积缩小，肉芽组织增加。
SMART Expected Outcome: Ms. Pruitt will have a 50%50 \% reduction in wound dimensions (from 4 cm in diameter to 2 cm ) within two weeks. SMART 预期成果：Pruitt 女士的伤口将在两周内缩小 50%50 \% （直径从 4 厘米缩小到 2 厘米）。
Planned Nursing Interventions with Rationale: See Table 10.7 for a list of planned nursing interventions with rationale. 计划的护理干预措施及理由：请参阅表 10.7，了解计划的护理干预措施及理由。
Table 10.7 Selected Interventions and Rationale for Ms. Pruitt 表 10.7 针对普鲁伊特女士的选定干预措施和理由
Interventions 干预措施
Rationale 理由
1. Assess and document wound characteristics every shift, including size (length xx width xx\times depth), stage (I-IV), location, exudate, presence of granulation tissue, and epithelization. 1.每班评估并记录伤口特征，包括大小（长度 xx 宽度 xx\times 深度）、阶段（I-IV）、位置、渗出物、肉芽组织的存在和上皮化。
Consistent and accurate documentation of wounds is important in determining the progression of wound healing and effectiveness of treatments. 一致而准确的伤口记录对于确定伤口愈合进展和治疗效果非常重要。
2. Monitor for signs of infection (color, temperature, edema, moisture, pain, and appearance of surrounding skin). 2.监测感染迹象（颜色、温度、水肿、湿度、疼痛和周围皮肤的外观）。
Frequent monitoring for possible wound infection provides the ability to intervene quickly if changes in the wound are noted. Additionally, pain medications should be offered prior to dressing changes if pain is present. 经常监测伤口是否可能感染，这样就能在发现伤口变化时迅速采取干预措施。此外，如果出现疼痛，应在换药前提供止痛药物。
3. Cleanse wound per facility protocol or as ordered. 3.按照设施规程或医嘱清洁伤口。
Removal of exudate, dirt, and slough promotes wound healing. 清除渗出物、污垢和痂皮可促进伤口愈合。
4. Cleanse the periwound area (skin around the wound) with mild soap and water. 4.用温和的肥皂和水清洗伤口周围（伤口周围的皮肤）。
Decreasing the number of microorganisms around the wound may decrease the chance of wound infection. 减少伤口周围微生物的数量可以降低伤口感染的几率。
5. Apply and change wound dressings, per facility protocol or wound orders. 5.根据设施协议或伤口医嘱进行伤口敷料的应用和更换。
Dressings that maintain moisture in the wound keep periwound skin dry, absorb drainage, and pad the wound to protect from further injury assist in healing. 敷料可保持伤口湿度，使伤口周围皮肤保持干燥，吸收排泄物，并垫起伤口以防止进一步损伤，从而帮助伤口愈合。
6. Turn/reposition the patient every 2 hours and position with pillows as needed. 6.每隔 2 小时为病人翻身/复位一次，并根据需要用枕头定位。
Frequent repositioning relieves pressure point areas from damage. Avoid positioning the patient directly on an injured area if possible. 经常调整体位可缓解压痛点部位的损伤。尽可能避免让病人直接躺在受伤部位。
7. Consider the use of a specialty mattress, bed, or chair pad. 7.考虑使用专用床垫、床或椅垫。
Specialty mattresses, beds, or pads offer added padding and support, while decreasing pressure areas. 专用床垫、床或垫子可提供更多的衬垫和支撑，同时减少受压部位。
8. Use moisture barrier ointments (protective skin barriers). 8.使用防潮软膏（皮肤保护屏障）。
Moisture barrier ointments can significantly decrease skin breakdown and pressure injury formation. 水分屏障软膏可大大减少皮肤破损和压伤的形成。
9. Check incontinence pads frequently (every 2-3 hours) and change as needed to keep dry. 9.经常（每 2-3 小时）检查失禁垫，并根据需要更换，以保持干燥。
Frequent changing of soiled pads will prevent exposure to chemicals in urine and stool that erode the skin. 经常更换弄脏的护垫可以防止接触到尿液和粪便中腐蚀皮肤的化学物质。
10. Monitor nutritional status and obtain order for dietary consult if needed. 10.监测营养状况，并在必要时获取饮食咨询订单。
Optimizing nutritional intake, including calories, protein, and vitamins, is essential to promote wound healing. 优化营养摄入（包括热量、蛋白质和维生素）对促进伤口愈合至关重要。
11. Offer nutritional supplements and water. 11.提供营养补充剂和水。
Nutritional supplements, such as protein shakes, can provide additional calories and protein without a large volume of intake needed. Water intake is essential for proper tissue hydration. 蛋白质奶昔等营养补充剂可提供额外的热量和蛋白质，而无需大量摄入。水的摄入对于适当的组织水合至关重要。
Interventions Rationale
1. Assess and document wound characteristics every shift, including size (length x width xx depth), stage (I-IV), location, exudate, presence of granulation tissue, and epithelization. Consistent and accurate documentation of wounds is important in determining the progression of wound healing and effectiveness of treatments.
2. Monitor for signs of infection (color, temperature, edema, moisture, pain, and appearance of surrounding skin). Frequent monitoring for possible wound infection provides the ability to intervene quickly if changes in the wound are noted. Additionally, pain medications should be offered prior to dressing changes if pain is present.
3. Cleanse wound per facility protocol or as ordered. Removal of exudate, dirt, and slough promotes wound healing.
4. Cleanse the periwound area (skin around the wound) with mild soap and water. Decreasing the number of microorganisms around the wound may decrease the chance of wound infection.
5. Apply and change wound dressings, per facility protocol or wound orders. Dressings that maintain moisture in the wound keep periwound skin dry, absorb drainage, and pad the wound to protect from further injury assist in healing.
6. Turn/reposition the patient every 2 hours and position with pillows as needed. Frequent repositioning relieves pressure point areas from damage. Avoid positioning the patient directly on an injured area if possible.
7. Consider the use of a specialty mattress, bed, or chair pad. Specialty mattresses, beds, or pads offer added padding and support, while decreasing pressure areas.
8. Use moisture barrier ointments (protective skin barriers). Moisture barrier ointments can significantly decrease skin breakdown and pressure injury formation.
9. Check incontinence pads frequently (every 2-3 hours) and change as needed to keep dry. Frequent changing of soiled pads will prevent exposure to chemicals in urine and stool that erode the skin.
10. Monitor nutritional status and obtain order for dietary consult if needed. Optimizing nutritional intake, including calories, protein, and vitamins, is essential to promote wound healing.
11. Offer nutritional supplements and water. Nutritional supplements, such as protein shakes, can provide additional calories and protein without a large volume of intake needed. Water intake is essential for proper tissue hydration.| Interventions | Rationale |
| :--- | :--- |
| 1. Assess and document wound characteristics every shift, including size (length $x$ width $\times$ depth), stage (I-IV), location, exudate, presence of granulation tissue, and epithelization. | Consistent and accurate documentation of wounds is important in determining the progression of wound healing and effectiveness of treatments. |
| 2. Monitor for signs of infection (color, temperature, edema, moisture, pain, and appearance of surrounding skin). | Frequent monitoring for possible wound infection provides the ability to intervene quickly if changes in the wound are noted. Additionally, pain medications should be offered prior to dressing changes if pain is present. |
| 3. Cleanse wound per facility protocol or as ordered. | Removal of exudate, dirt, and slough promotes wound healing. |
| 4. Cleanse the periwound area (skin around the wound) with mild soap and water. | Decreasing the number of microorganisms around the wound may decrease the chance of wound infection. |
| 5. Apply and change wound dressings, per facility protocol or wound orders. | Dressings that maintain moisture in the wound keep periwound skin dry, absorb drainage, and pad the wound to protect from further injury assist in healing. |
| 6. Turn/reposition the patient every 2 hours and position with pillows as needed. | Frequent repositioning relieves pressure point areas from damage. Avoid positioning the patient directly on an injured area if possible. |
| 7. Consider the use of a specialty mattress, bed, or chair pad. | Specialty mattresses, beds, or pads offer added padding and support, while decreasing pressure areas. |
| 8. Use moisture barrier ointments (protective skin barriers). | Moisture barrier ointments can significantly decrease skin breakdown and pressure injury formation. |
| 9. Check incontinence pads frequently (every 2-3 hours) and change as needed to keep dry. | Frequent changing of soiled pads will prevent exposure to chemicals in urine and stool that erode the skin. |
| 10. Monitor nutritional status and obtain order for dietary consult if needed. | Optimizing nutritional intake, including calories, protein, and vitamins, is essential to promote wound healing. |
| 11. Offer nutritional supplements and water. | Nutritional supplements, such as protein shakes, can provide additional calories and protein without a large volume of intake needed. Water intake is essential for proper tissue hydration. |
12. Keep bed linens clean, dry, and wrinkle free. 12.保持床单干净、干燥、无褶皱。
Soiled, wet, or wrinkled sheets may contribute to skin breakdown. 弄脏、弄湿或弄皱的床单可能会导致皮肤破损。
13. Use a minimum of two-person assistance and a draw sheet to pull the patient up in bed. 13.至少需要两人协助，并使用拉床将病人从床上拉起。
Carefully transferring patients avoids adverse effects of external mechanical forces (pressure, friction, and shear) from causing skin or tissue damage. 小心转运病人可避免外部机械力（压力、摩擦力和剪切力）造成皮肤或组织损伤。
12. Keep bed linens clean, dry, and wrinkle free. Soiled, wet, or wrinkled sheets may contribute to skin breakdown.
13. Use a minimum of two-person assistance and a draw sheet to pull the patient up in bed. Carefully transferring patients avoids adverse effects of external mechanical forces (pressure, friction, and shear) from causing skin or tissue damage.| 12. Keep bed linens clean, dry, and wrinkle free. | Soiled, wet, or wrinkled sheets may contribute to skin breakdown. |
| :--- | :--- |
| 13. Use a minimum of two-person assistance and a draw sheet to pull the patient up in bed. | Carefully transferring patients avoids adverse effects of external mechanical forces (pressure, friction, and shear) from causing skin or tissue damage. |
Interventions Implemented: 实施干预措施：
After the admission assessment was completed, Ms. Pruitt became settled in her new room. The wound was assessed, documented, and cleaned. A specimen for wound culture was obtained and a wound dressing applied per protocol. The health care provider was notified of the wound. Requests were made for a wound culture, referrals to a wound care nurse specialist and a dietician, and a pressure-relieving mattress for the bed. A two-hour turning schedule was implemented, and the CNA was reminded to use two-person assistance with a lift sheet when repositioning the patient. A barrier cream was applied to protect the peri-area whenever a new incontinence pad was placed. The following documentation note was entered in the patient chart. 入院评估完成后，普鲁伊特女士在新房间安顿下来。对伤口进行了评估、记录和清洁。采集了伤口培养标本，并按照规定进行了伤口包扎。已将伤口情况通知医护人员。要求进行伤口培养、转诊至伤口护理专科护士和营养师，并在床上铺设减压床垫。实施了两小时翻身计划，并提醒护理助理在调整患者体位时使用双人辅助抬起床单。每当放置新的失禁垫时，都会涂上隔离霜以保护周围区域。患者病历中记录了以下文件说明。
Documentation: 文件：
On admission, a Stage III pressure injury was discovered on the patient’s coccyx area. The wound measured 4 cm long, 4 cm wide, 3 cm deep, with adipose tissue visible. No undermining, tunneling, bone, muscle, or tendons visible. A small amount of yellow purulent drainage noted. Slight foul odor, with redness, and increased heat around the wound present. Wound was cleaned with normal saline and packed with moist gauze and covered with hydrogel dressing. Patient tolerated the procedure well and gave no evidence of pain. A pressure-relieving mattress was placed on the patient’s bed and a two-hour turning schedule was implemented. Patient voided xx1\times 1 and the pad was changed. Barrier cream was applied to the perineal area. Patient encouraged to rest until lunchtime and is resting. 入院时，发现患者尾骨部位有一处 III 期压伤。伤口长 4 厘米，宽 4 厘米，深 3 厘米，可见脂肪组织。未见皮下组织、隧道、骨骼、肌肉或肌腱。发现少量黄色脓性引流物。伤口周围有轻微恶臭、发红和发热。用生理盐水清洗伤口，用湿润的纱布包扎，并覆盖水凝胶敷料。患者对手术的耐受性良好，没有疼痛感。在患者床上铺上了减压床垫，并实施了两小时翻身计划。患者排空 xx1\times 1 后更换了尿垫。在会阴部位涂抹隔离霜。鼓励病人休息至午餐时间，病人正在休息。
Evaluation: After two weeks, the measurements of the wound were compared to those on admission and the wound decreased in size to less than 2 cm . The expected outcome was “met.” A new expected outcome was 评估：两周后，伤口的测量结果与入院时的测量结果进行了比较，伤口缩小到了 2 厘米以下。达到了预期效果。新的预期结果是
established, “Mrs. Pruitt’s wound will resolve within the next 2 weeks.” The same planned interventions were continued to be implemented. 确定 "普鲁伊特夫人的伤口将在未来两周内愈合"。同样的计划干预措施继续得到实施。
Learning Activities 学习活动
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
You are a nurse working in a long-term care facility. You have been assigned to care for Mr. Johns, a 74-year-old client recently diagnosed with a urinary tract infection, resulting in frequent incontinence. Mr. Johns suffered a CVA (stroke) six months ago and has difficulties ambulating and attending to his own needs because of weakness on his right side. Mr. Johns is alert and oriented to person, place, and time, but has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a wheelchair due to his difficulty with ambulation. He eats about 50% of his meals. While assessing Mr. Johns, you note that he is thin for his height, incontinent of foul-smelling urine, and has a deepened reddened area on his sacrum. 您是一名在长期护理机构工作的护士。约翰斯先生是一位 74 岁的客户，最近被诊断出患有尿路感染，导致经常大小便失禁。约翰斯先生六个月前曾患过一次 CVA（中风），由于右侧肢体无力，他在行走和自理方面都有困难。约翰斯先生对人、地点和时间都很警觉，但整个右侧感觉减退。由于行动不便，他大部分时间都躺在床上或坐在床边的轮椅上。他大约有 50% 的饭量是自己吃的。在对约翰斯先生进行评估时，您注意到他身高偏瘦、小便失禁且有恶臭，骶骨上有一块加深发红的区域。
What additional information, including lab work, would you like to gather to further assess Mr. Johns’ potential for pressure injury development? 为了进一步评估约翰斯先生受压伤的可能性，您还需要收集哪些信息（包括实验室检查）？
What factors make him particularly vulnerable to the development of pressure injuries? 哪些因素使他特别容易发生压伤？
Angiogenesis: The process of wound healing when new capillaries begin to develop within the wound 24 hours after injury to bring in more oxygen and nutrients for healing. 血管生成：伤口愈合过程：受伤 24 小时后，伤口内开始出现新的毛细血管，为伤口愈合带来更多氧气和养分。
Approximated edges: The well-closed edges of a wound healing by primary intention. 近似边缘：通过原意愈合的伤口边缘闭合良好。
Arterial insufficiency: A condition caused by lack of adequately oxygenated blood supply to specific tissues. 动脉供血不足：特定组织缺乏充足的含氧血液供应而导致的病症。
Braden Scale: A standardized assessment tool used to assess and document a patient’s risk factors for developing pressure injuries. 布莱登量表：布莱登量表：一种标准化的评估工具，用于评估和记录病人发生压伤的风险因素。
Deep tissue pressure injuries: Persistent; non-blanchable; deep red, maroon, or purple discoloration of intact or nonintact skin revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. 深层组织压力伤：持续性；不可灼伤；完好或非完好皮肤出现深红色、褐红色或紫色褪色，显示深色伤口床或充血水泡。疼痛和体温变化往往先于皮肤颜色变化。色素沉着的皮肤可能会出现不同程度的变色。
Dehiscence: The separation of a surgical incision. 开裂：手术切口分离。
Dermis: The layer of skin underneath under the epidermis, containing hair follicles, sebaceous glands, blood vessels, endocrine sweat glands, and nerve endings. 真皮层：表皮下的皮肤层，包含毛囊、皮脂腺、血管、内分泌汗腺和神经末梢。
Epidermis: The very thin, top layer of the skin that contains openings of the sweat gland ducts and the visible part of hair known as the hair shaft. 表皮层：非常薄的皮肤表层，包含汗腺导管开口和被称为毛干的头发可见部分。
Epithelialization: The development of new epidermis and granulation tissue in a healing wound. 上皮化：伤口愈合过程中新表皮和肉芽组织的形成。
Eschar: Dark brown/black, dry, thick, and leathery dead tissue in wounds. 炭化：暗褐色/黑色、干燥、厚实、革质的伤口坏死组织。
Excoriation: Redness and removal of the surface of the topmost layer of skin, often due to maceration or itching. 剥脱：最表层皮肤发红和脱落，通常是由于浸渍或瘙痒引起的。
Friction: The rubbing of skin against a hard object, such as the bed or the arm 摩擦：皮肤与床或手臂等硬物的摩擦
of a wheelchair. This rubbing causes heat that can remove the top layer of skin and often results in skin damage. 轮椅的摩擦。这种摩擦会产生热量，使表层皮肤脱落，往往会造成皮肤损伤。
Granulation tissue: New connective tissue in a healing wound with new, fragile, thin-walled capillaries. 肉芽组织：愈合伤口中的新结缔组织，带有新的、脆弱的薄壁毛细血管。
Hemostasis phase of wound healing: The first stage of wound healing when clotting factors are released to form clots to stop the bleeding. 伤口愈合的止血阶段：伤口愈合的第一阶段，此时会释放凝血因子，形成血块来止血。
Hypodermis: The bottom layer of skin, also referred to as the subcutaneous layer, consisting mainly of adipose tissue or fat, along with some blood vessels and nerve endings. Beneath this layer lies muscles, tendons, ligaments, and bones. 真皮下层：皮肤的底层，也称为皮下层，主要由脂肪组织或脂肪以及一些血管和神经末梢组成。这一层下面是肌肉、肌腱、韧带和骨骼。
Impaired skin integrity: Altered epidermis and/or dermis. 皮肤完整性受损：表皮和/或真皮发生变化。
Impaired tissue integrity: Damage to deeper layers of the skin or other integumentary structures. The NANDA-I definition of impaired tissue integrity is, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.” 组织完整性受损：皮肤深层或其他皮肤结构受损。NANDA-I 对组织完整性受损的定义是："粘膜、角膜、皮肤系统、肌肉筋膜、肌肉、肌腱、骨骼、软骨、关节囊和/或韧带受损"。
Inflammatory phase of wound healing: The second stage of healing when vasodilation occurs to move white blood cells into the wound to start cleaning the wound bed. 伤口愈合的炎症阶段：伤口愈合的第二阶段，此时血管扩张，白细胞进入伤口开始清洁伤口床。
Maceration: A condition that occurs when skin has been exposed to moisture for too long causing it to appear soggy, wrinkled, or whiter than usual. 浸渍：皮肤长时间暴露在潮湿环境中，会出现潮湿、起皱或变白的情况。
Maturation phase: The final stage of wound healing when collagen continues to be created to strengthen the wound and prevent it from reopening. 成熟阶段：伤口愈合的最后阶段，此时胶原蛋白不断生成，以巩固伤口并防止其再次裂开。
Necrosis: Tissue death. 坏死：组织坏死
Necrotic: Dead tissue that is black. 坏死：黑色的坏死组织
Nonblanchable erythema: Skin redness that does not turn white when pressed. 非焯性红斑：按压后不会变白的皮肤红斑。
Osteomyelitis: Bone infection. 骨髓炎骨感染。
Pressure injuries: Localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear. 压力伤：皮肤或下层软组织的局部损伤，通常发生在骨突部位，是由于长时间的强压和剪切造成的。
Primary intention: A type of wound that is sutured, stapled, glued, or otherwise closed so the wound heals beneath the closure. 原发性伤口：缝合、订书、粘合或以其他方式闭合伤口，使伤口在闭合处愈合。
Proliferative phase of wound healing: The third stage of wound healing that begins a few days after injury and includes four processes: epithelialization, angiogenesis, collagen formation, and contraction. 伤口愈合的增殖期：伤口愈合的第三阶段，从受伤后几天开始，包括四个过程：上皮化、血管生成、胶原蛋白形成和收缩。
Purulent: Drainage that is thick; opaque; tan, yellow, green, or brown in color. New purulent drainage should always be reported to the health care provider. 化脓性：脓性：引流液粘稠，不透明，呈棕褐色、黄色、绿色或褐色。新的化脓性引流物应随时报告给医护人员。
Sanguineous: Drainage from a wound that is fresh bleeding. 淤血：从新出血的伤口流出。
Secondary intention: A type of healing that occurs when the edges of a wound cannot be brought together, so the wound fills in from the bottom up by the production of granulation tissue. An example of a wound healing by secondary intention is a pressure ulcer. 继发意向：当伤口边缘无法合拢时，伤口就会通过肉芽组织的生成从下往上填平，这就是伤口愈合的一种类型。压疮就是伤口二次愈合的一个例子。
Serosanguinous: Serous drainage with small amounts of blood present. 血清性： 含少量血液的血清性引流。
Serous: Drainage from a wound that is clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage. 血清：从伤口排出的清澈、稀薄的水样血浆。这在伤口愈合的炎症阶段是正常的，少量被认为是正常的伤口引流。
Shear: Damage that occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. 剪切力：剪切：当组织层相互移动，导致血管在穿过皮下组织时拉伸和断裂而造成的损伤。
Slough: Inflammatory exudate in wounds that is usually light yellow, soft, and moist. 蜕皮：伤口中的炎性渗出物，通常呈淡黄色，柔软湿润。
Stage 1 pressure injuries: Intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred. 第一阶段压力伤害：皮肤完好，局部出现非灼伤性红斑，且长时间受压。
Stage 2 pressure injuries: Partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear like an intact or ruptured blister. 第二阶段压力伤：皮肤部分厚度脱落，真皮外露。伤口床可以存活，看起来像一个完整或破裂的水泡。
Stage 3 pressure injuries: Full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. The depth of tissue damage varies by anatomical location. Undermining and tunneling may be present. If slough or eschar obscures the wound so that tissue loss cannot be assessed, the pressure injury is referred to as unstageable. 第三阶段压力伤害：全厚度组织缺损，可见脂肪，但软骨、肌腱、韧带、肌肉和骨骼没有暴露。组织损伤的深度因解剖位置而异。可能会出现破坏和隧道现象。如果痂皮或粘液掩盖了伤口，导致无法评估组织损失，这种压力性损伤就被称为不稳定型损伤。
Stage 4 pressure injuries: Full-thickness tissue loss like Stage 3 pressure injuries but also have exposed cartilage, tendon, ligament, muscle, or bone. 第 4 阶段压力伤害：与第 3 阶段压力伤一样，全厚度组织缺损，但也有软骨、肌腱、韧带、肌肉或骨骼外露。
Tertiary intention: The healing of a wound that has had to remain open or has been reopened, often due to severe infection. 第三意向：伤口愈合：通常由于严重感染而不得不保持开放或重新开放的伤口的愈合。
Tunneling: Passageways underneath the surface of the skin that extend from a wound and can take twists and turns. 隧道：皮肤表面下的通道：从伤口延伸出来的通道，可蜿蜒曲折。
Undermining: A condition that occurs in wounds when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge. 破坏：伤口边缘下的组织被侵蚀，导致伤口边缘的皮肤下出现一个口袋。
Unstageable pressure injuries: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. 无法分期的压力性损伤：全层皮肤和组织缺损，由于溃疡内的组织损伤程度被痂皮或粘液遮盖而无法确认。
Venous insufficiency: A condition that occurs when the cardiovascular system cannot adequately return blood and fluid from the extremities to the heart. 静脉功能不全：当心血管系统无法将血液和液体从四肢充分回流到心脏时，就会出现这种情况。
COMFORT 舒适
Learning Objectives 学习目标
Assess patients for subjective and objective manifestations of alterations in comfort 评估患者舒适度改变的主观和客观表现
Identify factors related to comfort across the life span 确定与整个生命周期的舒适度有关的因素
Adhere to standards of care for the patient experiencing pain 遵守疼痛患者的护理标准
Identify nonpharmacologic measures to minimize pain and discomfort 确定将疼痛和不适降至最低的非药物措施
Outline the plan for monitoring the patient response to the interventions for pain and discomfort 概述监测病人对疼痛和不适干预措施反应的计划
Identify evidence-based practices related to assessing pain and providing comfort 确定与评估疼痛和提供安慰有关的循证实践
Pain is a universal sensation that everyone experiences, and acute pain is a common reason why patients seek medical care. Nurses work with the interdisciplinary team to assess and manage pain in a multidimensional approach to provide comfort and prevent suffering. This chapter will review best practices and standards of care for the assessment and management of pain. 疼痛是每个人都会经历的一种普遍感觉，急性疼痛是病人就医的常见原因。护士与跨学科团队合作，以多维方式评估和管理疼痛，为患者提供安慰并防止痛苦。本章将回顾疼痛评估和管理的最佳实践和护理标准。
11.2 Comfort Basic Concepts 11.2 舒适的基本概念
Definitions of Pain 疼痛的定义
Pain has been defined as, “Whatever the patient says it is, experienced whenever they say they are experiencing it.” In 2020 the International Association for the Study of Pain (IASP) released a revised definition of pain as, “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” along with these additional notes: 疼痛被定义为："无论患者说疼痛是什么，只要他们说正在经历疼痛，就会出现疼痛"。2020 年，国际疼痛研究协会（IASP）发布了修订后的疼痛定义，即 "与实际或潜在组织损伤相关或类似的不愉快的感觉和情绪体验"，并附有以下补充说明：
Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors. 疼痛始终是一种个人体验，在不同程度上受到生理、心理和社会因素的影响。
Individuals learn the concept of pain throughout all stages of their life. 人在一生的各个阶段都会学习到疼痛的概念。
A person’s report of an experience as pain should be respected. 应尊重一个人对疼痛经历的报告。
Although pain usually serves an adaptive role, it can have adverse effects on function, socialization, and psychological well-being. 虽然疼痛通常具有适应作用，但它也会对功能、社交和心理健康产生不利影响。
Verbal description is only one of several behaviors that express pain. The inability to communicate does not negate the possibility that a person is experiencing pain. ^(2){ }^{2} 语言描述只是表达疼痛的几种行为之一。无法交流并不能否定一个人正在经历疼痛的可能性。 ^(2){ }^{2}
Pain motivates the individual to withdraw from dangerous stimuli, to protect a damaged body part while it heals, and to avoid similar experiences in the future. Most pain resolves after the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body. Additionally, pain can occur in the absence of any detectable stimulus, damage, or disease. ^(3){ }^{3} 疼痛会促使个体远离危险刺激，在身体受损部位痊愈时保护它，并避免今后再有类似经历。大多数疼痛会在疼痛刺激消失、身体痊愈后消失，但有时尽管刺激消失、身体明显痊愈，疼痛仍然存在。此外，疼痛也可能在没有任何可察觉的刺激、损伤或疾病的情况下发生。 ^(3){ }^{3}
Physiology of Pain 疼痛生理学
Let’s begin by reviewing the physiological processes of pain. A nociceptor is a type of sensory receptor that responds to potentially damaging stimuli by sending nerve signals to the spinal cord and brain in a process called nociception. There are several types and functions of nociceptors: 首先让我们回顾一下疼痛的生理过程。痛觉感受器是一种感觉受体，它通过向脊髓和大脑发送神经信号对潜在的破坏性刺激做出反应，这一过程被称为痛觉。痛觉感受器有多种类型和功能：
Thermal nociceptors are activated by noxious heat or cold, such as a hot pan. 热敏感受器会被热锅等有害的热或冷激活。
Mechanical nociceptors are activated by excess pressure or mechanical deformation, such as a finger getting caught in a car door. They also respond to incisions that break the skin surface. 过大的压力或机械变形（如手指被车门夹住）会激活机械痛觉感受器。它们也会对破坏皮肤表面的切口做出反应。
Chemical nociceptors are activated by a wide variety of spices commonly used in cooking. For example, capsaicin is a compound in chili peppers that causes a burning sensation of the mucus membranes. It is also used in common over-the-counter creams for pain relief because when it is applied to the skin, it blocks the transmission of pain impulses. ^(4){ }^{4} 烹饪中常用的各种香料会激活化学痛觉感受器。例如，辣椒素是辣椒中的一种化合物，会引起粘膜灼烧感。它也被用于常见的非处方止痛膏中，因为当它涂抹在皮肤上时，会阻断痛觉冲动的传递。 ^(4){ }^{4}
Noxious stimuli are detected by nociceptors and transduced into electrical energy. An action potential is created and transmitted along nociceptor fibers. There are two types of nociceptor fibers, A-Delta and C. A-Delta fibers are fast-conducting fibers and associated with the initial sharp, stinging, or pricking pain sensation. C fibers are slower-conducting fibers and are associated with the secondary sensation of diffuse, dull, burning, and aching pain. The pain impulse is transmitted along these nociceptor fibers to the dorsal horn in the spinal cord and then from the spinal cord to the thalamus, where pain messages are relayed to the cerebral cortex. In the cerebral cortex, pain impulses are perceived and the conscious awareness of pain occurs. ^(5,6){ }^{5,6} 痛觉感受器能检测到有害刺激，并将其转化为电能。动作电位产生并沿着痛觉感受器纤维传递。A-Delta 纤维是快速传导纤维，与最初的尖锐、刺痛或刺痛感有关。C 纤维是传导速度较慢的纤维，与弥漫性、钝痛、灼痛和隐痛等继发性感觉有关。痛觉冲动沿着这些痛觉感受器纤维传递到脊髓背角，然后从脊髓传递到丘脑，在丘脑中痛觉信息被传递到大脑皮层。在大脑皮层，疼痛冲动被感知，疼痛的意识也随之产生。 ^(5,6){ }^{5,6}
See Figure 11.1^(7)11.1^{7} for an illustration of how the pain signal is transmitted from the nociceptors to the spinal cord and then to the brain. 疼痛信号如何从痛觉感受器传递到脊髓，然后再传递到大脑，见图 11.1^(7)11.1^{7} 。
Figure 11.1 Pain Transmission 图 11.1 疼痛的传播
View supplementary videos on pain: 观看有关疼痛的补充视频：
Karen D. Davis: How does your brain respond to pain? ITED Talk Karen D. Davis：您的大脑如何应对疼痛？ITED 讲座
A one-minute review of how pain receptors work: Feeling Pain 一分钟回顾痛觉感受器的工作原理：感受疼痛
Types of Pain 疼痛类型
Pain can be divided into visceral, deep somatic, superficial, and neuropathic pain. 疼痛可分为内脏痛、深部躯体痛、浅表痛和神经性疼痛。
Visceral structures are highly sensitive to stretch, ischemia, and inflammation. Visceral pain is diffuse, difficult to locate, and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull. ^(8){ }^{8} 内脏结构对拉伸、缺血和炎症高度敏感。内脏疼痛是弥漫性的，难以定位，通常是指远处的，通常是浅表的结构。疼痛可能伴有恶心和呕吐，可描述为恶心、深部、挤压和钝痛。 ^(8){ }^{8}
Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia, and muscles and is a dull, aching, poorly localized pain. Examples include sprains and broken bones. ^(9){ }^{9} 深层躯体痛是由韧带、肌腱、骨骼、血管、筋膜和肌肉中的痛觉感受器受到刺激而引发的，是一种钝痛、隐痛和局部疼痛。例如扭伤和骨折。 ^(9){ }^{9}
Superficial pain is initiated by the activation of nociceptors in the skin or other superficial tissue and is sharp, well-defined, and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first-degree) burns. ^(10){ }^{10} 肤浅疼痛是由皮肤或其他表层组织中的痛觉感受器激活引起的，疼痛尖锐、清晰、定位明确。产生浅表躯体疼痛的伤害包括轻微伤口和轻微（一级）烧伤。 ^(10){ }^{10}
Neuropathic pain is defined by the International Association for the Study of Pain (IASP) as pain caused by a lesion or disease of the somatosensory nervous system. It is typically described by patients as “burning” or “like pins and needles.” Neuropathic pain can be caused by 国际疼痛研究协会（IASP）将神经性疼痛定义为由躯体感觉神经系统病变或疾病引起的疼痛。患者通常将其描述为 "烧灼感 "或 "像针刺一样"。神经性疼痛可由以下原因引起
This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 本作品是 Boundless 的《解剖学与生理学》的衍生作品，采用 CC BY-SA 4.0 许可。
This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 本作品是 Boundless 的《解剖学与生理学》的衍生作品，采用 CC BY-SA 4.0 许可。
This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 本作品是 Boundless 的《解剖学与生理学》的衍生作品，采用 CC BY-SA 4.0 许可。
several disease processes, such as diabetes mellitus, strokes, and HIV, and is generally undertreated because it typically does not respond to analgesics. Medications such as tricyclic antidepressants and gabapentin are typically used to manage this type of pain." 由于这种疼痛通常对镇痛药无反应，因此通常治疗不足。三环类抗抑郁药和加巴喷丁等药物通常用于控制这类疼痛"。
Pain can radiate from one area to another. For example, back pain caused by a herniated disk can cause pain to radiate down an individual’s leg. Referred pain is different from radiating pain because it is perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder. See Figure 11.2^(12)11.2^{12} for an illustration of common sites of referred pain. 疼痛会从一个部位放射到另一个部位。例如，腰椎间盘突出引起的背痛会导致疼痛向腿部放射。牵涉痛不同于辐射痛，因为它是在疼痛刺激部位以外的其他部位感知到的。例如，结肠中潴留的气体会导致肩部疼痛。请参阅图 11.2^(12)11.2^{12} ，了解转发痛的常见部位。
Figure 17.2 Referred Pain 图 17.2 转诊疼痛
Factors Affecting the Pain Experience 影响疼痛体验的因素
There are many biological, psychological, and social factors that affect the perception of pain, making it a unique, individual experience. See Table 11.2a for a list of these factors. ^(13){ }^{13} Nurses must consider these factors while assessing and providing holistic nursing care for patients experiencing pain. 有许多生物、心理和社会因素会影响对疼痛的感知，从而使疼痛成为一种独特的个体体验。有关这些因素的列表，请参见表 11.2a。 ^(13){ }^{13} 护士在评估疼痛患者并为其提供整体护理时必须考虑这些因素。
Table 11.2a Biological, Psychological, and Social Factors Affecting Pain 表 11.2a 影响疼痛的生物、心理和社会因素
Biological Factors 生物因素
Psychological Factors 心理因素
Social Factors 社会因素
- Nociception - 痛觉
- Mood/affect - 情绪/影响
- Culture - 文化
- Brain function - 大脑功能
- Fatigue - 疲劳
- Values - 价值观
- Source of pain - 疼痛的根源
- Stress - 压力
- Economic - 经济
- Illness - 疾病
- Coping - 应对
- Environment - 环境
- Medical diagnosis - 医疗诊断
- Trauma - 创伤
- Social support - 社会支持
- Age - 年龄
- Sleep - 睡眠
- Coping mechanisms - 应对机制
- Injury, past or present - 过去或现在受伤
- Fear - 恐惧
- Spirituality - 灵性
- Genetic sensitivity - 遗传敏感性
- Anxiety - 焦虑
- Ethnicity - 种族
- Hormones - 荷尔蒙
- Developmental stage - 发展阶段
- Education - 教育
- Inflammation - 炎症
- Meaning of pain - 疼痛的含义
- Obesity - 肥胖症
- Memory - 内存
- Cognitive function - 认知功能
- Attitude - 态度
- Beliefs - 信念
Biological Factors Psychological Factors Social Factors
- Nociception - Mood/affect - Culture
- Brain function - Fatigue - Values
- Source of pain - Stress - Economic
- Illness - Coping - Environment
- Medical diagnosis - Trauma - Social support
- Age - Sleep - Coping mechanisms
- Injury, past or present - Fear - Spirituality
- Genetic sensitivity - Anxiety - Ethnicity
- Hormones - Developmental stage - Education
- Inflammation - Meaning of pain
- Obesity - Memory
- Cognitive function - Attitude
- Beliefs | Biological Factors | Psychological Factors | Social Factors |
| :--- | :--- | :--- |
| - Nociception | - Mood/affect | - Culture |
| - Brain function | - Fatigue | - Values |
| - Source of pain | - Stress | - Economic |
| - Illness | - Coping | - Environment |
| - Medical diagnosis | - Trauma | - Social support |
| - Age | - Sleep | - Coping mechanisms |
| - Injury, past or present | - Fear | - Spirituality |
| - Genetic sensitivity | - Anxiety | - Ethnicity |
| - Hormones | - Developmental stage | - Education |
| - Inflammation | - Meaning of pain | |
| - Obesity | - Memory | |
| - Cognitive function | - Attitude | |
| | - Beliefs | |
Acute vs. Chronic Pain 急性疼痛与慢性疼痛
Pain is differentiated between acute pain and chronic pain. Acute pain has limited duration and is associated with a specific cause. It usually causes a physiological response resulting in increased pulse, respirations, and blood pressure. Diaphoresis (sweating, especially to an unusual degree) may also occur. Examples of acute pain include postoperative pain; burns; acute musculoskeletal conditions like strains, sprains, and fractures; labor and delivery; and traumatic injury. 疼痛有急性疼痛和慢性疼痛之分。急性疼痛持续时间有限，且与特定原因有关。它通常会引起生理反应，导致脉搏、呼吸和血压加快。此外，还可能出现出汗（尤其是异常程度的出汗）。急性疼痛的例子包括术后疼痛；烧伤；急性肌肉骨骼疾病，如拉伤、扭伤和骨折；分娩；以及外伤。
Chronic pain is ongoing and persistent for longer than six months. It typically does not cause a change in vital signs or diaphoresis. It may be diffuse and not confined to a specific area of the body. Chronic pain often affects an individual’s psychological, social, and behavioral responses that can influence daily functioning. Chronic medical problems, such as osteoarthritis, spinal conditions, fibromyalgia, and peripheral neuropathy, are common causes of chronic pain. Chronic pain can continue even after the original injury or illness 慢性疼痛是一种持续性疼痛，持续时间超过六个月。它通常不会引起生命体征的变化或舒张。它可能是弥漫性的，并不局限于身体的某个特定部位。慢性疼痛通常会影响个人的心理、社交和行为反应，从而影响日常功能。骨关节炎、脊柱疾病、纤维肌痛和周围神经病变等慢性疾病是慢性疼痛的常见原因。慢性疼痛甚至会在最初的伤害或疾病之后继续存在
that caused it has healed or resolved. Some people suffer chronic pain even when there is no past injury or apparent body damage. 导致疼痛的因素已经痊愈或消除。有些人即使过去没有受过伤或明显的身体损伤，也会遭受慢性疼痛的折磨。
People who have chronic pain often have physical effects that are stressful on the body. These effects include tense muscles, limited ability to move around, lack of energy, and appetite changes. Emotional effects of chronic pain include depression, anger, anxiety, and fear of reinjury. These effects can limit a person’s ability to return to their regular work or leisure activities. ^(14){ }^{14} It is estimated that chronic pain affects 50 million U.S. adults, and 19.6 million of those adults experience high-impact chronic pain that interferes with daily life or work activities. ^(15){ }^{15} See Figure 11.3^(16)11.3^{16} for an illustration of low back pain, an example of both acute and chronic pain that often affects daily functioning. 患有慢性疼痛的人常常会对身体造成压力。这些影响包括肌肉紧张、活动能力受限、精力不足和食欲改变。慢性疼痛对情绪的影响包括抑郁、愤怒、焦虑和害怕再次受伤。这些影响会限制患者恢复正常工作或休闲活动的能力。 ^(14){ }^{14} 据估计，慢性疼痛影响着 5000 万美国成年人，其中有 1960 万成年人经历过影响日常生活或工作活动的高影响慢性疼痛。 ^(15){ }^{15} 请参阅图 11.3^(16)11.3^{16} ，以了解腰背痛的情况，腰背痛是急性和慢性疼痛的一个例子，经常影响日常功能。
14. Cleveland Clinic. (2020, December 8). Acute v. chronic pain. https://my.clevelandclinic.org/health/articles/ 12051-acute-vs-chronic-pain 14.克利夫兰诊所。(2020 年 12 月 8 日）。https://my.clevelandclinic.org/health/articles/ 12051-acute-vs-chronic-pain.
15. Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 15.疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
16. “Lower_back_pain.jpg” by Injurymap is licensed under CC BY 4.0 16."Lower_back_pain.jpg" by Injurymap 采用 CC BY 4.0 许可。
Figure 11.3 Back Pain 图 11.3 背痛
Read additional information about pain using the following hyperlinks: 使用以下超链接阅读有关疼痛的更多信息：
Overview of Pain - Brain, Spinal Cord, and Nerve Disorders 疼痛概述--大脑、脊髓和神经疾病
Pain 疼痛
Assessing and Managing Acute Pain: A Call to Action 评估和管理急性疼痛：行动呼吁书
Quick Facts: Chronic Pain 快讯：慢性疼痛
Life Span and Cultural Considerations 生命周期和文化因素
The pain experience varies across the life span. Newborns and infants can feel pain but are unable to verbalize it. Repetitive and prolonged pain may be associated with altered pain sensitivity and pain processing later in life. Toddlers and preschoolers often have difficulty describing, identifying, and locating pain. Instead, pain may be demonstrated behaviorally with crying, anger, physical resistance, or withdrawal. School-age children and adolescents may try to be “brave” and rationalize the pain; they are more responsive to explanations about pain. 不同年龄段的人对疼痛的体验各不相同。新生儿和婴儿能感觉到疼痛，但无法用语言表达。重复和长时间的疼痛可能与日后疼痛敏感性和疼痛处理能力的改变有关。幼儿和学龄前儿童通常很难描述、识别和定位疼痛。相反，疼痛可能会通过哭泣、愤怒、身体抵抗或退缩等行为表现出来。学龄儿童和青少年可能会尝试 "勇敢"，并将疼痛合理化；他们更容易接受有关疼痛的解释。
Older adults are at increased risk for undertreatment of pain. It is estimated that up to 70%70 \% of older adults in the community and up to 85%85 \% living in longterm care centers have significant pain due to chronic conditions such as osteoarthritis and peripheral neuropathy. Pain is often underassessed in older adults because they are less likely to report it and also because it can present atypically with confusion and agitation.’ 老年人疼痛治疗不足的风险增加。据估计，多达 70%70 \% 的社区老年人和多达 85%85 \% 居住在长期护理中心的老年人由于骨关节炎和周围神经病变等慢性疾病而有明显的疼痛。老年人对疼痛的评估往往不足，因为他们不太可能报告疼痛，还因为疼痛可能不典型地表现为精神错乱和躁动。
Other special populations who are at increased risk for the undertreatment of pain include the following: 疼痛治疗不当风险增加的其他特殊人群包括：
Patients with a history of addictive disease 有成瘾病史的患者
Nonverbal, cognitively impaired, or unconscious patients 无语言能力、认知障碍或失去知觉的患者
Patients who endure pain without complaining due to cultural or religious beliefs 因文化或宗教信仰而忍痛不诉的患者
Non-English speaking patients where communicating is a barrier 沟通有障碍的非英语病人
Uninsured or underinsured patients where cost of medications is a barrier ^(18){ }^{18} 无保险或保险额度不足的患者，药费成为他们的障碍 ^(18){ }^{18} .
Nurses must be especially vigilant of nonverbal signs of pain in these at-risk groups and implement appropriate assessment tools and interventions. Read an example of a patient with untreated pain in the following box. 护士必须对这些高危人群的非言语疼痛迹象保持特别警惕，并实施适当的评估工具和干预措施。请阅读下框中一个疼痛未得到治疗的病人的例子。
A True Story of Undertreated Pain 一个关于未得到充分治疗的疼痛的真实故事
A teenage boy from the Amish community was admitted to the hospital after he sustained several fractures when his buggy was hit by a motor vehicle. His parents stayed at his bedside throughout his hospital stay. The nurses noticed that although he denied pain, he grimaced and guarded the body parts that were injured. He moaned when repositioned and declined to get out of bed to begin physical therapy when it was prescribed for rehabilitation. However, despite these nonverbal indicators of pain, he continued to deny the existence of pain and refused all pain medication. One day, when his parents left the room briefly to get coffee, the nurse said to the patient, “Most people in your situation experience severe pain. I can see that you are hurting by your expressions when you move. Can you help me to understand why you don’t want any pain medication?” A tear began to fall down the boy’s cheek. He explained that his community does not believe in complaining about pain and to be a man, he must learn how to tolerate suffering. The nurse explained, “It is important for you to attend physical therapy so that you can heal and go home. Can we bring you pain pills every 一名来自阿米什社区的十几岁男孩在他的越野车被一辆机动车撞倒后多处骨折，被送进了医院。住院期间，他的父母一直守在床边。护士们注意到，虽然他否认疼痛，但却面无表情，紧紧护住受伤的身体部位。他在调整体位时发出呻吟声，并拒绝下床开始理疗，而理疗是康复治疗的处方。然而，尽管有这些非语言的疼痛迹象，他仍然否认疼痛的存在，并拒绝所有止痛药物。一天，当他的父母短暂离开病房去喝咖啡时，护士对病人说："大多数人在你这种情况下都会感到剧烈疼痛。我可以从你活动时的表情看出你很痛苦。你能帮我理解一下你为什么不想吃止痛药吗？一滴眼泪开始从男孩的脸颊滑落。他解释说，他所在的社区不相信抱怨疼痛，要想成为男子汉，就必须学会如何忍受痛苦。护士解释说："你必须参加物理治疗，这样才能痊愈回家。我们能不能每次都给你带止痛药？
day before physical therapy so that you can participate in the exercises, recover quickly, and go home?” The boy agreed to this plan. The nurse documented her findings and made notes in the care plan to administer the prescribed PRN pain medications one hour before physical therapy was scheduled. She also communicated her findings during the nurse handoff report. The boy was able to satisfactorily complete the prescribed physical therapy and was discharged home the following week. 在物理治疗前一天，这样你就可以参加锻炼，尽快恢复，然后回家？"男孩同意了这一计划。护士将她的发现记录在案，并在护理计划中注明在安排物理治疗前一小时服用处方止痛药。她还在护士交接报告中传达了她的发现。男孩圆满完成了规定的物理治疗，并于下周出院回家。
" Use the following hyperlinks to read more information about treating pain: "使用以下超链接阅读更多有关治疗疼痛的信息：
Treating pain in Special Populations 治疗特殊人群的疼痛
The National Institute on Aging provides a wide range of information for older adults: Pain: You Can Get Help. 美国国家老龄化研究所为老年人提供了广泛的信息：疼痛：您可以获得帮助。
Health in Aging offers additional information on pain management at Pain Management | Aging & Health AZ | American Geriatrics Society. Health in Aging 在疼痛管理 | Aging & Health AZ | American Geriatrics Society 提供有关疼痛管理的更多信息。
Trends in Pain Management, Substance Abuse, and Addiction 疼痛管理、药物滥用和成瘾的趋势
Several well-known agencies have recently published materials focused on the importance of optimal pain management. For example, in 2017 The Joint Commission published new and revised standards of pain assessment and pain management that apply to all Joint Commission-accredited hospitals. ^(19){ }^{19} 一些知名机构最近发布了一些材料，重点强调最佳疼痛管理的重要性。例如，2017 年，联合委员会发布了新修订的疼痛评估和疼痛管理标准，适用于所有通过联合委员会认证的医院。 ^(19){ }^{19}
The American Nurses Association published a position statement in 2018 on the ethical responsibility of nurses to properly manage pain. ^(20){ }^{20} In 2019 the U.S. Department of Health and Human Services published Pain Management Best Practices. ^(21){ }^{21} Why is there continued emphasis on optimal pain management? Let’s review some trends related to pain management over the past few decades. 美国护士协会于 2018 年发表了一份立场声明，阐述了护士正确处理疼痛的道德责任。 ^(20){ }^{20} 2019 年，美国卫生与公众服务部发布了《疼痛管理最佳实践》。 ^(21){ }^{21} 为什么持续强调最佳疼痛管理？让我们回顾一下过去几十年与疼痛管理有关的一些趋势。
Pain assessment and pain management began to undergo significant changes in the 1990s when pain experts recognized that inadequate assessment and treatment of pain had become a public health issue. Recommendations for improving the quality of pain care were followed by initiatives that recognized patients’ reported pain as “the 5th vital sign.” Hospital administrators and regulators began to focus on pain scores, encouraging and incentivizing providers to aggressively treat pain to lower pain scores. These trends led to liberal prescribing of opioid pain medications for both acute and chronic pain. 20 世纪 90 年代，疼痛专家认识到疼痛评估和治疗不足已成为一个公共卫生问题，疼痛评估和疼痛管理开始发生重大变化。在提出提高疼痛治疗质量的建议之后，又提出了将病人报告的疼痛视为 "第五生命体征 "的倡议。医院管理者和监管者开始关注疼痛评分，鼓励和激励医疗服务提供者积极治疗疼痛以降低疼痛评分。这些趋势导致了对急性和慢性疼痛开具阿片类止痛药的自由化。
Unfortunately, this increase in prescription of opioid pain medication led to an associated rise in the number of deaths from overdose. Organizations began to urge caution about the use of opioids for pain, including guidelines published in 2016 by the Centers for Disease Control (CDC) on prescribing opioids for pain. ^(22){ }^{22} The 2016 CDC guideline led to limited prescriptions of opioids and unintended consequences, such as forced tapering of medications for established patients requiring chronic pain control and the transition of some patients desperate for pain control to using illicit drugs, such as heroin. 不幸的是，阿片类止痛药处方的增加导致因用药过量而死亡的人数也随之增加。一些组织开始呼吁谨慎使用阿片类止痛药，包括美国疾病控制中心（CDC）于 2016 年发布的阿片类止痛药处方指南。 ^(22){ }^{22} 2016 年疾病控制中心的指导方针导致阿片类药物的处方受到限制，并产生了意想不到的后果，如需要控制慢性疼痛的既往患者被迫减量用药，以及一些急需控制疼痛的患者转而使用海洛因等非法药物。
r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936 C 1
20. ANA Center for Ethics and Human Rights. (2018). Position statement: The ethical responsibility to manage pain and the suffering it causes. American Nurses Association. https://www.nursingworld.org/~495e9b/ globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf 20.ANA Center for Ethics and Human Rights.(2018).立场声明：管理疼痛及其造成的痛苦的伦理责任。https://www.nursingworld.org/~495e9b/ globalassets/docs/ana/ethics/theethicalresponsibilitytomanagepainandthesufferingitcauses2018.pdf
21. Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 21.疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
22. Cleveland Clinic. (2020, December 8). Acute v. chronic pain. https://my.clevelandclinic.org/health/articles/ 12051-acute-vs-chronic-pain 22.克利夫兰诊所。(2020 年 12 月 8 日）。急性疼痛与慢性疼痛。https://my.clevelandclinic.org/health/articles/ 12051-acute-vs-chronic-pain
In this manner, pain management and the opioid crisis have influenced one another as each continues to evolve. It is imperative for nurses to ensure that patients with painful conditions can work with their health care providers to develop pain treatment plans that balance pain control, optimize function, and enhance quality of life while also minimizing risks for opioid misuse and harm. ^(23){ }^{23} 因此，疼痛管理和阿片类药物危机在不断发展的同时也相互影响。护士必须确保疼痛患者能够与医疗服务提供者合作，制定疼痛治疗计划，在控制疼痛、优化功能和提高生活质量之间取得平衡，同时最大限度地降低阿片类药物滥用和伤害的风险。 ^(23){ }^{23}
Associated Definitions 相关定义
When discussing the use and abuse of drugs used to treat pain, it is important to distinguish between tolerance, physical dependence, misuse, substance abuse disorder, and addiction. 在讨论用于治疗疼痛的药物的使用和滥用时，必须区分耐受性、身体依赖性、滥用、药物滥用障碍和成瘾。
Tolerance is a reduced response to pain medication when the same dose of a drug has been given repeatedly, requiring a higher dose of the drug to achieve the same level of response. ^(24){ }^{24} For example, when a patient receives morphine for palliative care, the dosage often needs to be increased over time because the patient develops a tolerance to the effects of the medication. 耐受性是指反复服用相同剂量的药物后，对止痛药物的反应减弱，需要加大药物剂量才能达到相同的反应水平。 ^(24){ }^{24} 例如，当病人接受吗啡进行姑息治疗时，由于病人对药物的作用产生了耐受性，往往需要随着时间的推移而增加剂量。
Physical dependence refers to withdrawal symptoms that occur when a chronic pain medication is suddenly reduced or stopped because of physiological adaptations that occur to chronic exposure to the medication. ^(25){ }^{25} For example, if a patient who receives hydromorphone daily suddenly has their prescription stopped, they will likely experience symptoms of withdrawal, such as sweating, goose bumps, vomiting, anxiety, insomnia, and muscle pain. 生理依赖性是指当慢性止痛药物突然减少或停止时，由于长期接触药物而产生的生理适应而出现的戒断症状。 ^(25){ }^{25} 例如，如果每天服用氢吗啡酮的患者突然停药，很可能会出现戒断症状，如出汗、起鸡皮疙瘩、呕吐、焦虑、失眠和肌肉疼痛。
Misuse refers to a person taking prescription pain medications in a 滥用指的是患者在服用处方止痛药时出现以下情况
Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf/ 疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf/
Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high). ^(26){ }^{26} ^(26){ }^{26} 不按处方的方式或剂量用药；服用别人的处方药，即使是用于治疗疼痛等病症；或服用药物以获得兴奋感（即 "嗨 "起来）。 ^(26){ }^{26}
Substance abuse disorder is a significant impairment or distress from a pattern of substance use (i.e., alcohol, drugs, or prescription medication) with at least two of the symptoms listed below in a given year: 药物滥用障碍是指在某一特定年份内，因使用药物（即酒精、毒品或处方药）的模式而造成的严重损害或困扰，并至少出现以下所列的两种症状：
The use of more of a substance than planned or using a substance for a longer interval than desired 使用某种物质的次数超过计划次数，或使用某种物质的时间间隔超过预期时间
The inability to cut down despite desire to do so 尽管有削减的愿望，却无法削减
Spending a substantial amount of the day obtaining, using, or recovering from substance use 每天花大量时间获取、使用药物或从使用药物中恢复过来
Cravings or intense urge to use a substance 渴望或强烈要求使用某种药物
Repeated usage causing an inability to meet important social or professional obligations 反复使用导致无法履行重要的社会或职业义务
Persistent usage despite user’s knowledge that it is causing frequent problems at work, school, or home 尽管用户知道它经常给工作、学习或家庭带来麻烦，但仍坚持使用
Giving up or cutting back on important social, professional, or leisure activities because of use 因为吸毒而放弃或减少重要的社交、职业或休闲活动
Usage in physically hazardous situations, such as driving, or usage despite it causing physical or mental harm 在驾驶等对身体有害的情况下使用，或在造成身体或精神伤害的情况下使用
Persistent use despite the user’s awareness that the substance is causing, or at least worsening, a physical or mental problem ^(27){ }^{27} 尽管使用者意识到该物质正在导致或至少恶化身体或精神问题，但仍持续使用 ^(27){ }^{27} .
Addiction is a chronic disease of the brain’s reward, motivation, memory, and related circuitry reflected in an individual pathologically pursuing reward and/or relief by substance use. Addiction is characterized by several symptoms, such as the inability to consistently abstain from a substance, impaired behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic 成瘾是大脑奖赏、动机、记忆和相关回路的一种慢性疾病，反映为个人病态地通过使用药物来追求奖赏和/或解脱。成瘾有多种症状，如无法持续戒除某种物质、行为控制能力受损、渴求、对自身行为和人际关系中存在的重大问题认识不足，以及情绪反应失调。与其他慢性
Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books. 9780890425596 《美国精神病学协会。(2013).精神障碍诊断与统计手册》（第 5 版）。https://doi.org/10.1176/appi.books。9780890425596
diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. ^(2.){ }^{2 .} 吸毒成瘾是一种慢性疾病，通常会出现复发和缓解的循环。如果不进行治疗或参与康复活动，成瘾会逐渐发展，并可能导致残疾或过早死亡。 ^(2.){ }^{2 .}
Substance Abuse Among Nurses and Nursing Students 护士和护理专业学生中的药物滥用问题
Substance abuse and addiction can occur in anyone, including nurses and nursing students. The American Nursing Association released the following statements in 2016: 滥用药物和药物成瘾可能发生在任何人身上，包括护士和护理专业学生。美国护理协会在 2016 年发布了以下声明：
Health care facilities should provide education to nurses and other employees regarding alcohol and other drug use and establish policies, procedures, and practices to promote safe, supportive, drug-free workplaces. 医疗机构应向护士和其他员工提供有关酒精和其他药物使用的教育，并制定政策、程序和做法，以促进安全、支持性和无毒品的工作场所。
Health care facilities and schools of nursing should adopt alternative-todiscipline approaches to treating nurses and nursing students with substance use disorders, with stated goals of retention, rehabilitation, and reentry into safe, professional practice. 医疗机构和护理学校应采用替代性学科方法来治疗有药物使用障碍的护士和护理专业学生，并明确提出留用、康复和重返安全专业实践的目标。
Drug diversion, in the context of personal use, is viewed primarily as a symptom of a serious and treatable disease, and not exclusively as a crime. 在个人使用的情况下，药物转用主要被视为一种可治疗的严重疾病的症状，而不完全是一种犯罪。
Nurses and nursing students are aware of the risks associated with substance use, impaired practice, and drug diversion and have the responsibility and means to report suspected or actual concerns. 护士和护理专业学生了解与药物使用、实践能力受损和药物转用相关的风险，并有责任和手段报告可疑或实际的问题。
Read the American Nurses Association (ANA) statement on Substance Use Among Nurses and Nursing Students. 阅读美国护士协会 (ANA) 关于护士和护理专业学生使用药物的声明。
Read the NCSBN brochure on Substance Use Disorder in Nursing. Many states offer assistance to nurses 阅读 NCSBN 的《护理工作中的药物使用障碍》手册。许多州为护士提供帮助
28. Pain Management Best Practices Inter-Agency Task Force. (2019, May 9). Pain management best practices. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf 28.疼痛管理最佳实践机构间工作组。(2019 年 5 月 9 日）。疼痛管理最佳实践。美国卫生与公众服务部。https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf。
29. American Nurses Association. (2016, October). Substance use among nurses and nursing students. https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/substance-use-among-nurses-and-nursing-students 29.美国护士协会。(2016 年 10 月）。护士和护理专业学生中的药物使用情况。https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/substance-use-among-nurses-and-nursing-students。
with substance use disorders to maintain their nursing license and employment status. See Wisconsin’s Professional Assistance Procedure (PAP) or New York’s Statewide Peer Assistance for Nurses program. Read more details about substance abuse disorder in the “Legal/Ethical” chapter in Open RN Nursing Pharmacology. 请参阅威斯康星州的专业援助程序 (PAP) 或纽约州的护士同伴援助计划。请参阅威斯康星州的专业援助程序 (PAP) 或纽约州的全州护士同伴援助计划。请阅读《开放式注册护士护理药理学》中 "法律/伦理 "一章中有关药物滥用障碍的更多详情。
Standards of Care 护理标准
Pain assessment and management standards were recently revised and published in 2018 by The Joint Commission. The revised standards require hospitals to identify pain assessment and pain management, including safe opioid prescribing, as an organizational priority. Nurses are expected to implement these best practices. See Table 11.2b for a summary of associated requirements that must be incorporated into nursing care. ^(30){ }^{30} If these components are not included when providing nursing care, the hospital may be cited by The Joint Commission and potentially lose Medicare funding. 疼痛评估和管理标准最近进行了修订，并于 2018 年由联合委员会发布。修订后的标准要求医院将疼痛评估和疼痛管理（包括阿片类药物的安全处方）确定为组织优先事项。护士应实施这些最佳实践。请参见表 11.2b，了解必须纳入护理工作的相关要求。 ^(30){ }^{30} 如果在提供护理服务时没有包含这些内容，医院可能会被联合委员会通报批评，并有可能失去医疗保险的资助。
Table 11.2b. The Joint Commission’s Pain Assessment and Management Requirements ^(31){ }^{31} 表 11.2b.联合委员会的疼痛评估和管理要求 ^(31){ }^{31} .
30. The Joint Commission. (2017, August 29). R3 report / Requirements, rationale, reference. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/ r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936 C1 30.联合委员会。(2017, August 29).https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/ r3_report_issue_11_pain_assessment_8_25_17_final.pdf?db=web&hash=938C24A464A5B8B5646C8E297C8936 C1
31. The Joint Commission. (2017, August 29). R3 report | Requirements, rationale, reference. 31.联合委员会。(2017, August 29).R3 report | Requirements, rationale, reference.
Requirement 要求
Rationale 理由
Patients are screened for pain during emergency department visits and at the time of admission. 在急诊室就诊时和入院时对患者进行疼痛筛查。
The misidentification and undertreatment of pain continues to occur in hospitals.
When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment.
The misidentification and undertreatment of pain continues to occur in hospitals.
When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment.| The misidentification and undertreatment of pain continues to occur in hospitals. |
| :--- |
| When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment. |
Criteria to screen, assess, and reassess pain are used that are consistent with the patient's age, condition, and ability to understand. 筛查、评估和重新评估疼痛的标准应符合患者的年龄、病情和理解能力。
An accurate screening and assessment are required for satisfactory pain management, and the hospital is responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately. 准确的筛查和评估是令人满意的疼痛管理所必需的，医院有责任确保适当的筛查和评估工具随时可用并得到合理使用。
Requirement Rationale
Patients are screened for pain during emergency department visits and at the time of admission. "The misidentification and undertreatment of pain continues to occur in hospitals.
When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment."
Criteria to screen, assess, and reassess pain are used that are consistent with the patient's age, condition, and ability to understand. An accurate screening and assessment are required for satisfactory pain management, and the hospital is responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately.| Requirement | Rationale |
| :--- | :--- |
| Patients are screened for pain during emergency department visits and at the time of admission. | The misidentification and undertreatment of pain continues to occur in hospitals. <br> When a patient presents to the hospital for other medical issues, pain may be overlooked or missed. Screening patients for pain or the risk of pain at the time of admission and while taking vital signs helps to improve pain identification and treatment. |
| Criteria to screen, assess, and reassess pain are used that are consistent with the patient's age, condition, and ability to understand. | An accurate screening and assessment are required for satisfactory pain management, and the hospital is responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately. |
Patients are involved in the pain management treatment planning process by:
- Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain
- Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function)
- Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed
Patients are involved in the pain management treatment planning process by:
- Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain
- Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function)
- Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed| Patients are involved in the pain management treatment planning process by: |
| :--- |
| - Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain |
| - Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) |
| - Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed |
Patient involvement in planning pain management involves information sharing and collaboration between the patient and provider to arrive at realistic expectations and clear goals. Numerous patient factors may cause undertreatment or overtreatment of pain, such as pain expectations, knowledge of pain and its treatment, and underreporting of pain. Patient involvement in the pain management planning process allows the provider to clarify the objectives of the process and guides patients in a manner that increases the likelihood of treatment adherence. 患者参与疼痛治疗计划涉及患者与医疗服务提供者之间的信息共享与合作，以达成现实的期望和明确的目标。许多患者因素可能导致疼痛治疗不足或过度治疗，如疼痛预期、对疼痛及其治疗的了解以及对疼痛的报告不足。患者参与疼痛管理规划过程可以使医疗服务提供者明确该过程的目标，并以一种增加患者坚持治疗可能性的方式对患者进行指导。
"Patients are involved in the pain management treatment planning process by:
- Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain
- Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function)
- Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed" Patient involvement in planning pain management involves information sharing and collaboration between the patient and provider to arrive at realistic expectations and clear goals. Numerous patient factors may cause undertreatment or overtreatment of pain, such as pain expectations, knowledge of pain and its treatment, and underreporting of pain. Patient involvement in the pain management planning process allows the provider to clarify the objectives of the process and guides patients in a manner that increases the likelihood of treatment adherence.| Patients are involved in the pain management treatment planning process by: <br> - Collaboratively developing realistic expectations and measurable goals for the degree, duration, and reduction of pain <br> - Discussing the criteria used to evaluate treatment progress (for example, relief of pain and improved physical and psychosocial function) <br> - Receiving education on pain management, treatment options, and safe use of opioid and nonopioid medications when they are prescribed | Patient involvement in planning pain management involves information sharing and collaboration between the patient and provider to arrive at realistic expectations and clear goals. Numerous patient factors may cause undertreatment or overtreatment of pain, such as pain expectations, knowledge of pain and its treatment, and underreporting of pain. Patient involvement in the pain management planning process allows the provider to clarify the objectives of the process and guides patients in a manner that increases the likelihood of treatment adherence. |
| :--- | :--- |
对病人的疼痛进行治疗或转诊治疗。疼痛治疗策略可能包括非药物治疗、药物治疗或多种方法的结合。
Patient's pain is treated or they are referred for treatment.
Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches.
Patient's pain is treated or they are referred for treatment.
Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches.| Patient's pain is treated or they are referred for treatment. |
| :--- |
| Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches. |
Referrals may be required for patients who present with complex pain management needs, such as the opioid-addicted patient, the patient who is at high risk for adverse events but requires treatment with opioids, or a patient whose pain management needs exceed the expertise of the patient's provider. 有复杂疼痛治疗需求的患者可能需要转诊，如阿片类药物成瘾患者、不良事件高风险但需要阿片类药物治疗的患者，或疼痛治疗需求超出了患者医疗服务提供者专业能力的患者。
Nonpharmacologic pain treatment modalities are promoted. 推广非药物疼痛治疗模式。
Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided.
Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.
Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided.
Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.| Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided. |
| :--- |
| Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy. |
Patients identified as being high risk for adverse outcomes related to opioid treatment are monitored. 对确定为与阿片类药物治疗相关的不良后果高风险患者进行监测。
The most dangerous adverse effect of opioid analgesics is respiratory depression.
Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen).
The most dangerous adverse effect of opioid analgesics is respiratory depression.
Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen).| The most dangerous adverse effect of opioid analgesics is respiratory depression. |
| :--- |
| Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen). |
Patients experiencing opioid substance abuse are referred to opioid treatment programs. 滥用阿片类药物的患者会被转介到阿片类药物治疗计划。
When clinicians encounter patients who are addicted to opioids, the patients should be referred for treatment. The U.S. Substance Abuse and Mental Health Services Administration provides a directory of opioid treatment programs. 当临床医生遇到对阿片类药物上瘾的患者时，应将其转介接受治疗。美国药物滥用和精神健康服务管理局提供了一份阿片类药物治疗计划目录。
The hospital facilitates access to the Prescription Drug Monitoring Program databases. 医院为访问处方药监控计划数据库提供便利。
Prescription Drug Monitoring Programs (PDMP) aggregate prescribing and dispensing data submitted by pharmacies and health care providers. They are an effective tool for reducing prescription drug abuse and diversion. Read more about PDMP in the "Legal/Ethical" chapter of the Open RN Nursing Pharmacology textbook. 处方药监控计划 (PDMP) 汇集了药房和医疗服务提供者提交的处方和配药数据。它们是减少处方药滥用和转移的有效工具。请在《开放式注册护士药理学》教科书的 "法律/伦理 "章节中阅读有关 PDMP 的更多信息。
"Patient's pain is treated or they are referred for treatment.
Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches." Referrals may be required for patients who present with complex pain management needs, such as the opioid-addicted patient, the patient who is at high risk for adverse events but requires treatment with opioids, or a patient whose pain management needs exceed the expertise of the patient's provider.
Nonpharmacologic pain treatment modalities are promoted. "Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided.
Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy."
Patients identified as being high risk for adverse outcomes related to opioid treatment are monitored. "The most dangerous adverse effect of opioid analgesics is respiratory depression.
Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen)."
Patients experiencing opioid substance abuse are referred to opioid treatment programs. When clinicians encounter patients who are addicted to opioids, the patients should be referred for treatment. The U.S. Substance Abuse and Mental Health Services Administration provides a directory of opioid treatment programs.
The hospital facilitates access to the Prescription Drug Monitoring Program databases. Prescription Drug Monitoring Programs (PDMP) aggregate prescribing and dispensing data submitted by pharmacies and health care providers. They are an effective tool for reducing prescription drug abuse and diversion. Read more about PDMP in the "Legal/Ethical" chapter of the Open RN Nursing Pharmacology textbook.| Patient's pain is treated or they are referred for treatment. <br> Treatment strategies for pain may include nonpharmacologic, pharmacologic, or a combination of approaches. | Referrals may be required for patients who present with complex pain management needs, such as the opioid-addicted patient, the patient who is at high risk for adverse events but requires treatment with opioids, or a patient whose pain management needs exceed the expertise of the patient's provider. |
| :--- | :--- |
| Nonpharmacologic pain treatment modalities are promoted. | Nonpharmacologic modalities should be promoted by ensuring that patient preferences are discussed and some nonpharmacologic treatment options provided. <br> Nonpharmacologic strategies include, but are not limited to, physical modalities (e.g., acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy. |
| Patients identified as being high risk for adverse outcomes related to opioid treatment are monitored. | The most dangerous adverse effect of opioid analgesics is respiratory depression. <br> Equipment must be available to monitor patients deemed highest risk (e.g., patients with sleep apnea, those receiving continuous intravenous opioids, or those on supplemental oxygen). |
| Patients experiencing opioid substance abuse are referred to opioid treatment programs. | When clinicians encounter patients who are addicted to opioids, the patients should be referred for treatment. The U.S. Substance Abuse and Mental Health Services Administration provides a directory of opioid treatment programs. |
| The hospital facilitates access to the Prescription Drug Monitoring Program databases. | Prescription Drug Monitoring Programs (PDMP) aggregate prescribing and dispensing data submitted by pharmacies and health care providers. They are an effective tool for reducing prescription drug abuse and diversion. Read more about PDMP in the "Legal/Ethical" chapter of the Open RN Nursing Pharmacology textbook. |
Patient's pain is reassessed and responded to through the following:
Evaluation and documentation of:
- Response to pain intervention(s)
- Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control)
- Side effects of treatment
Patient's pain is reassessed and responded to through the following:
Evaluation and documentation of:
- Response to pain intervention(s)
- Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control)
- Side effects of treatment| Patient's pain is reassessed and responded to through the following: |
| :--- |
| Evaluation and documentation of: |
| - Response to pain intervention(s) |
| - Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control) |
| - Side effects of treatment |
Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients' pain is inadequate.
The Joint Commission's technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient's ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain.
Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients' pain is inadequate.
The Joint Commission's technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient's ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain.| Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients' pain is inadequate. |
| :--- |
| The Joint Commission's technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient's ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain. |
"Patient's pain is reassessed and responded to through the following:
Evaluation and documentation of:
- Response to pain intervention(s)
- Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control)
- Side effects of treatment" "Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients' pain is inadequate.
The Joint Commission's technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient's ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain."| Patient's pain is reassessed and responded to through the following: <br> Evaluation and documentation of: <br> - Response to pain intervention(s) <br> - Progress toward pain management goals including functional ability (for example, the ability to take a deep breath, turn in bed, walk with improved pain control) <br> - Side effects of treatment | Reassessment should be completed in a timely manner to determine if the intervention is working or if the patient is experiencing adverse effects. Only using numerical pain scales to monitor patients' pain is inadequate. <br> The Joint Commission's technical advisory panel stressed the importance of assessing how pain affects function and the ability to make progress towards treatment goals. For example, immediately after major abdominal surgery, the goal of pain control may be the patient's ability to take a breath without excessive pain. Over the next few days, the goal of pain control may be the ability to sit up in bed or walk to the bathroom without limitation due to pain. |
| :--- | :--- |
Patients and their family members are educated on discharge plans related to pain management including the following: 向患者及其家属讲解与疼痛治疗相关的出院计划，包括以下内容：
Pain 疼痛
management plan of care 护理管理计划
Side effects of pain management treatment 疼痛控制治疗的副作用
Activities of daily living, including the home environment that might exacerbate pain or reduce effectiveness of the pain management plan of care, as well as strategies to address these issues 日常生活活动，包括可能加剧疼痛或降低疼痛治疗计划有效性的家庭环境，以及解决这些问题的策略
Safe use, storage, and disposal of opioids when prescribed 安全使用、储存和处置处方中的阿片类药物
During the discharge process, patients and families need education on the importance of how to manage the patient’s pain at home. Unmanaged pain may cause a patient to regress in their recovery process or have uncontrolled pain at home leading to a readmission to the hospital. It is necessary to have a discussion with patients and their families regarding their home environment and activities of daily living that may increase the need for pain management. When a patient is being discharged with an opioid medication, education on safe use, including when and how much medication to take, should be included in the discharge plan. Opioid disposal education is also critical to both reduce diversion and decrease the risk of accidental exposure to someone other than the person for whom the opioid was prescribed. 在出院过程中，患者和家属需要了解如何在家中控制患者疼痛的重要性。未经管理的疼痛可能会导致患者在康复过程中出现倒退，或在家中疼痛得不到控制，从而导致再次入院。有必要与患者及其家属讨论他们的家庭环境和日常生活活动，因为这些可能会增加疼痛管理的需求。当患者带着阿片类药物出院时，出院计划中应包括安全用药教育，包括用药时间和用药量。阿片类药物处置教育对于减少药物转用和降低非阿片类药物处方对象意外接触阿片类药物的风险也至关重要。
Read The Joint Commission’s Pain Assessment and Management Standards for Hospitals. 阅读联合委员会的《医院疼痛评估和管理标准》。
Read Pain Management Best Practices from the United States Department of Health & Human Services. 阅读美国卫生与公众服务部提供的疼痛管理最佳实践。
Asking a patient to rate the severity of their pain on a scale from 0 to 10 , with " 0 " being no pain and " 10 " being the worst pain imaginable is a common question used to screen patients for pain. However, according to The Joint Commission requirements described earlier, this question can be used to initially screen a patient for pain, but a thorough pain assessment is required. Additionally, the patient’s comfort-function goal must be assessed. The comfort-function goal provides the basis for the patient’s individualized pain treatment plan and is used to evaluate the effectiveness of interventions. 让病人用 0 到 10 分来评价自己疼痛的严重程度，"0 "代表没有疼痛，"10 "代表最严重的疼痛，这是筛选病人疼痛的一个常用问题。不过，根据联合委员会的要求，这个问题可以用来初步筛查病人的疼痛，但需要进行彻底的疼痛评估。此外，还必须评估患者的舒适功能目标。舒适功能目标为患者的个性化疼痛治疗计划提供了依据，并用于评估干预措施的有效性。
PQRSTU, OLDCARTES, and COLDSPA PQRSTU、OLDCARTES 和 COLDSPA
The “PQRSTU,” “OLDCARTES,” or “COLDSPA” mnemonics are helpful in remembering a standardized set of questions used to gather additional data about a patient’s pain. See Figure 11.4^(')11.4^{\prime} for the questions associated with a “PQRSTU” assessment framework. While interviewing a patient about pain, use open-ended questions to allow the patient to elaborate on information that further improves your understanding of their concerns. If their answers do not seem to align, continue to ask focused questions to clarify information. For example, if a patient states that “the pain is tolerable” but also rates the pain as a “7” on a 0-10 pain scale, these answers do not align, and the nurse should continue to use follow-up questions using the PQRSTU framework. Upon further questioning the patient explains they rate the pain as a " 7 " in their knee when participating in physical therapy exercises, but currently feels the pain is tolerable while resting in bed. This additional information assists the nurse to customize interventions for effective treatment with reduced potential for overmedication with associated side effects. PQRSTU"、"OLDCARTES "或 "COLDSPA "助记词有助于记住用于收集患者疼痛额外数据的标准化问题集。与 "PQRSTU "评估框架相关的问题见图 11.4^(')11.4^{\prime} 。在就疼痛问题与患者面谈时，应使用开放式问题，让患者详细说明可进一步增进您对其关切问题的理解的信息。如果他们的回答似乎不一致，则继续提出重点问题以澄清信息。例如，如果患者说 "疼痛可以忍受"，但同时在 0-10 级疼痛量表中将疼痛评为 "7 "级，那么这些答案并不一致，护士应继续使用 PQRSTU 框架进行追问。进一步询问后，患者解释说他们在参加理疗锻炼时将膝关节疼痛评为 "7 "级，但目前在床上休息时感觉疼痛可以忍受。这些额外信息有助于护士为有效治疗定制干预措施，同时降低过度用药并产生相关副作用的可能性。
Figure 11.4 PQRSTU Assessment 图 11.4 PQRSTU 评估
Sample questions when using the PQRSTU assessment are included in Table 11.3a. 表 11.3a 列出了使用 PQRSTU 评估时的问题样本。
What makes your pain worse?
What makes your pain feel better?| What makes your pain worse? |
| :--- |
| What makes your pain feel better? |
Quality 质量
疼痛的感觉是什么？注意：您可以就疼痛特征提出建议，如 "隐隐作痛"、"刺痛 "或 "灼痛"。
What does the pain feel like?
Note: You can provide suggestions for pain characteristics such as "aching," "stabbing," or "burning."
What does the pain feel like?
Note: You can provide suggestions for pain characteristics such as "aching," "stabbing," or "burning."| What does the pain feel like? |
| :--- |
| Note: You can provide suggestions for pain characteristics such as "aching," "stabbing," or "burning." |
Region 地区
您究竟在哪里感到疼痛？疼痛是否四处移动或向其他地方放射？注意：指导患者指出疼痛位置。
Where exactly do you feel the pain? Does it move around or radiate elsewhere?
Note: Instruct the patient to point to the pain location.
Where exactly do you feel the pain? Does it move around or radiate elsewhere?
Note: Instruct the patient to point to the pain location.| Where exactly do you feel the pain? Does it move around or radiate elsewhere? |
| :--- |
| Note: Instruct the patient to point to the pain location. |
Severity 严重性
How would you rate your pain on a scale of 0 to 10, with "0" being no pain and " 10 " being the worst pain you've ever experienced? 如果用 0 到 10 来表示您的疼痛，"0 "代表没有疼痛，"10 "代表最严重的疼痛，您会如何给自己打分？
When did the pain start?
What were you doing when the pain started?
Is the pain constant or does it come and go?
If the pain is intermittent, when does it occur?
How long does the pain last?
Have you taken anything to help relieve the pain?| When did the pain start? |
| :--- |
| What were you doing when the pain started? |
| Is the pain constant or does it come and go? |
| If the pain is intermittent, when does it occur? |
| How long does the pain last? |
| Have you taken anything to help relieve the pain? |
Understanding 理解
What do you think is causing the pain? 您认为是什么导致了疼痛？
PQRSTU Questions Related to Pain
Provocation/Palliation "What makes your pain worse?
What makes your pain feel better?"
Quality "What does the pain feel like?
Note: You can provide suggestions for pain characteristics such as "aching," "stabbing," or "burning.""
Region "Where exactly do you feel the pain? Does it move around or radiate elsewhere?
Note: Instruct the patient to point to the pain location."
Severity How would you rate your pain on a scale of 0 to 10, with "0" being no pain and " 10 " being the worst pain you've ever experienced?
Timing/Treatment "When did the pain start?
What were you doing when the pain started?
Is the pain constant or does it come and go?
If the pain is intermittent, when does it occur?
How long does the pain last?
Have you taken anything to help relieve the pain?"
Understanding What do you think is causing the pain?| PQRSTU | Questions Related to Pain |
| :--- | :--- |
| Provocation/Palliation | What makes your pain worse? <br> What makes your pain feel better? |
| Quality | What does the pain feel like? <br> Note: You can provide suggestions for pain characteristics such as "aching," "stabbing," or "burning." |
| Region | Where exactly do you feel the pain? Does it move around or radiate elsewhere? <br> Note: Instruct the patient to point to the pain location. |
| Severity | How would you rate your pain on a scale of 0 to 10, with "0" being no pain and " 10 " being the worst pain you've ever experienced? |
| Timing/Treatment | When did the pain start? <br> What were you doing when the pain started? <br> Is the pain constant or does it come and go? <br> If the pain is intermittent, when does it occur? <br> How long does the pain last? <br> Have you taken anything to help relieve the pain? |
| Understanding | What do you think is causing the pain? |
An alternative mnemonic to use when assessing pain is “OLDCARTES.” 评估疼痛时的另一个记忆法是 "OLDCARTES"。
Onset: When did the pain start? How long does it last? 发病：疼痛从何时开始？持续多久？
Location: Where is the pain? 位置：疼痛在哪里？
Duration: How long has the pain been going on? How long does an episode last? 持续时间：疼痛持续了多久？一次发作持续多久？
Characteristics: What does the pain feel like? Can the pain be described in terms such as stabbing, gnawing, sharp, dull, aching, piercing, or 特征疼痛是什么感觉？疼痛可以用刺痛、啃咬痛、尖锐痛、钝痛、隐痛、刺痛等词语来描述吗？
crushing? 粉碎？
Aggravating factors: What brings on the pain? What makes the pain worse? Are there triggers such as movement, body position, activity, eating, or the environment? 加重因素：是什么导致了疼痛？是什么让疼痛加剧？是否有运动、身体姿势、活动、饮食或环境等诱因？
Radiating: Does the pain travel to another area or the body, or does it stay in one place? 辐射：疼痛是向身体其他部位扩散，还是停留在一个地方？
Treatment: What has been done to make the pain better and has it been helpful? Examples include medication, position change, rest, and application of hot or cold. 治疗：已采取哪些措施来改善疼痛，这些措施是否有帮助？例如药物治疗、改变体位、休息、热敷或冷敷。
Effect: What is the effect of the pain on participating in your daily life activities? 影响：疼痛对您参与日常生活活动有什么影响？
Severity: Rate your pain from 0 to 10. 严重程度：从 0 到 10 为您的疼痛评分。
A third mnemonic used is “COLDSPA.” 第三个记忆法是 "COLDSPA"。
C: Character C: 字符
O: Onset O:开始
L: Location L: 地点
D: Duration D: 持续时间
S: Severity S： 严重程度
P: Pattern P: 图案
A: Associated Factors A：相关因素
No matter which mnemonic is used to guide the assessment questions, the goal is to obtain comprehensive assessment data that allows the nurse to create a customized nursing care plan that effectively addresses the patient’s need for comfort. 无论使用哪种记忆法来指导评估问题，目的都是为了获得全面的评估数据，使护士能够制定个性化的护理计划，有效满足患者对舒适的需求。
Pain Scales 疼痛量表
In addition to using the PQRSTU or OLDCARTES methods of investigating a patient’s chief complaint, there are several standardized pain rating scales used in nursing practice. 除了使用 PQRSTU 或 OLDCARTES 方法调查患者的主诉外，护理实践中还使用了几种标准化的疼痛评分量表。
FACES SCALE 面孔比例
The FACES scale is a visual tool for assessing pain with children and others who cannot quantify the severity of their pain on a scale of 0 to 10 . See Figure 11.5^(2)11.5^{2} for the FACES Pain Rating Scale. To use this scale, use the following evidence-based instructions. Explain to the patient that each face represents a person who has no pain (hurt), some pain, or a lot of pain. “Face 0 doesn’t hurt at all. Face 2 hurts just a little. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don’t have to be crying to have this worst pain.” Ask the person to choose the face that best represents the pain they are feeling. ^(3){ }^{3} FACES 量表是一种可视化工具，用于评估无法用 0 到 10 的量表量化疼痛严重程度的儿童和其他人的疼痛。有关 FACES 疼痛评分量表，请参见图 11.5^(2)11.5^{2} 。使用该量表时，请遵循以下循证指导。向患者解释每张脸代表一个人没有疼痛（受伤）、有些疼痛或非常疼痛。"脸 0 完全不痛。脸 2 只有点疼。第 4 张脸更疼一些。脸 6 更疼。第 8 张脸非常疼。第 10 张脸的疼痛程度超乎你的想象，尽管你不一定要哭才能承受这种最严重的疼痛"。请他选择最能代表他所感受到的痛苦的那张脸。 ^(3){ }^{3}
The FLACC scale (i.e., the Face, Legs, Activity, Cry, Consolability scale) is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals who are unable to verbally communicate their pain. The scale has five criteria, which are each assigned a score of 0,1,0r20,1,0 r 2. The FLACC 量表（即脸部、腿部、活动、哭泣、安慰量表）用于评估 2 个月至 7 岁儿童或无法用语言表达疼痛的人的疼痛程度。该量表有五个标准，每个标准的分值为 0,1,0r20,1,0 r 2 。疼痛量表
scale is scored in a range of 0-10 with “0” representing no pain. ^(4){ }^{4} See Table 11.3b for the FLACC scale. 量表的评分范围为 0-10，"0 "代表无痛。 ^(4){ }^{4} FLACC 量表见表 11.3b。
Occasional grimace or frown, withdrawn, or uninterested 偶尔面无表情或皱眉，孤僻或不感兴趣
Frequent to constant quivering chin; clenched jaw 下巴经常或持续颤动；下巴紧咬
Legs 腿部
Normal position or relaxed 正常姿势或放松
Uneasy, restless, or tense 不安、焦躁或紧张
Kicking or legs drawn up 踢腿或抬腿
Activity 活动
Lying quietly, normal position, and moves easily 安静地躺着，姿势正常，活动自如
Squirming, shifting, back and forth, or tense 蠕动、前后移动或紧张
Arched, rigid, or jerking 拱起、僵硬或抽搐
Cry 哭泣
No cry (awake or asleep) 不哭闹（醒着或睡着）
Moans or whimpers or occasional complaint 呻吟、呜咽或偶尔抱怨
Crying steadily, screams or sobs, or frequent complaints 持续哭泣、尖叫或啜泣，或经常抱怨
Consolability 可调和性
Content and relaxed 内容和轻松
Reassured by occasional touching, hugging, or being talked to; distractible 偶尔的触摸、拥抱或交谈会让他感到安心；容易分心
Difficult to console or comfort 难以安慰或安慰
Criteria Score 0 Score 1 Score 2
Face No particular expression or smile Occasional grimace or frown, withdrawn, or uninterested Frequent to constant quivering chin; clenched jaw
Legs Normal position or relaxed Uneasy, restless, or tense Kicking or legs drawn up
Activity Lying quietly, normal position, and moves easily Squirming, shifting, back and forth, or tense Arched, rigid, or jerking
Cry No cry (awake or asleep) Moans or whimpers or occasional complaint Crying steadily, screams or sobs, or frequent complaints
Consolability Content and relaxed Reassured by occasional touching, hugging, or being talked to; distractible Difficult to console or comfort| Criteria | Score 0 | Score 1 | Score 2 |
| :--- | :--- | :--- | :--- |
| Face | No particular expression or smile | Occasional grimace or frown, withdrawn, or uninterested | Frequent to constant quivering chin; clenched jaw |
| Legs | Normal position or relaxed | Uneasy, restless, or tense | Kicking or legs drawn up |
| Activity | Lying quietly, normal position, and moves easily | Squirming, shifting, back and forth, or tense | Arched, rigid, or jerking |
| Cry | No cry (awake or asleep) | Moans or whimpers or occasional complaint | Crying steadily, screams or sobs, or frequent complaints |
| Consolability | Content and relaxed | Reassured by occasional touching, hugging, or being talked to; distractible | Difficult to console or comfort |
COMFORT BEHAVIORAL SCALE 舒适行为量表
The COMFORT Behavioral Scale is a behavioral-observation tool validated for use in children of all ages who are receiving mechanical ventilation. Eight physiological and behavioral indicators are scored on a scale of 1 to 5 to assess pain and sedation. ^(6){ }^{6} COMFORT 行为量表是一种经过验证的行为观察工具，适用于接受机械通气的各年龄段儿童。八项生理和行为指标按 1 到 5 级评分，以评估疼痛和镇静。 ^(6){ }^{6}
4. Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3). https://pubmed.ncbi.nlm.nih.gov/9220806/ 4.Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997).FLACC：为幼儿术后疼痛评分的行为量表。儿科护理》，23（3）。https://pubmed.ncbi.nlm.nih.gov/9220806/。
5. Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3). https://pubmed.ncbi.nlm.nih.gov/9220806/ 5.Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997).FLACC：为幼儿术后疼痛评分的行为量表。儿科护理》，23（3）。https://pubmed.ncbi.nlm.nih.gov/9220806/。
6. Freund, D., & Bolick, B. (2019). CE: Assessing a Child’s Pain. American Journal of Nursing. 119(5), 34. https://journals.lww.com/ajnonline/Fulltext/2019/05000/CE_Assessing_a_Child_s_Pain.25.aspx 6.Freund, D., & Bolick, B. (2019).CE：评估儿童疼痛。美国护理学杂志》。119(5), 34. https://journals.lww.com/ajnonline/Fulltext/2019/05000/CE_Assessing_a_Child_s_Pain.25.aspx
PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) 晚期痴呆症的疼痛评估（paintad）
SCALE 规模
The Pain Assessment in Advanced Dementia (PAINAD) Scale is a simple, valid, and reliable instrument for assessing pain in noncommunicative patients with advanced dementia. See Table 11.3c for the items included on the scale. Each item is scored from 0-2, When totaled, the score can range from 0 (no pain) to 10 (severe pain). 晚期痴呆疼痛评估量表（PAINAD）是一种简单、有效且可靠的工具，用于评估非交流性晚期痴呆患者的疼痛。该量表的项目见表 11.3c。每个项目的评分范围为 0-2 分，总分从 0 分（无疼痛）到 10 分（剧烈疼痛）不等。
Distracted or reassured by voice or touch. 通过声音或触摸来分散注意力或安抚情绪。
Unable to console, distract, or reassure. 无法安慰、转移注意力或安抚。
Item 0 1 2
Breathing independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation. Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations.
Negative vocalization None Occasional moan or groan. Low-level speech with a negative or disapproving quality. Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial Expression Smiling or inexpressive Sad. Frightened. Frown. Facial grimacing.
Body language Relaxed Tense. Distressed pacing. Fidgeting. Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.
Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract, or reassure.| Item | 0 | 1 | 2 |
| :--- | :--- | :--- | :--- |
| Breathing independent of vocalization | Normal | Occasional labored breathing. Short period of hyperventilation. | Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations. |
| Negative vocalization | None | Occasional moan or groan. Low-level speech with a negative or disapproving quality. | Repeated troubled calling out. Loud moaning or groaning. Crying. |
| Facial Expression | Smiling or inexpressive | Sad. Frightened. Frown. | Facial grimacing. |
| Body language | Relaxed | Tense. Distressed pacing. Fidgeting. | Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. |
| Consolability | No need to console | Distracted or reassured by voice or touch. | Unable to console, distract, or reassure. |
Download the full PAINAD scale from the The Hartford Institute for Geriatric Nursing. ^(8){ }^{8} 从哈特福德老年护理研究所下载完整的 PAINAD 量表。 ^(8){ }^{8}
7. Warden V., Hurley A., & Volicer, L. (2003). Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4(1), 9-15. https://doi.org/10.1097/01.JAM.0000043422.31640.F7 7.Warden V., Hurley A., & Volicer, L. (2003)。晚期痴呆症（PAINAD）疼痛评估量表的开发与心理测量学评估。美国医务主任协会期刊》，4（1），9-15。 https://doi.org/10.1097/01.JAM.0000043422.31640.F7
8. The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers School of Nursing. (n.d.). Assessment tools for best practices of care for older adults. https://hign.org/consultgeri-resources/try-this-series 8.纽约大学罗里-迈尔斯护理学院哈特福德老年护理研究所。(n.d.).老年人最佳护理实践的评估工具。https://hign.org/consultgeri-resources/try-this-series。
Comfort-Function Goals 舒适-功能目标
Comfort-function goals encourage the patient to establish their level of comfort needed to achieve functional goals based on their current health status. For example, one patient may be comfortable ambulating after surgery and their pain level is 3 on a 0-to-10 pain intensity rating scale, whereas another patient desires a pain level of 0 on a 0 -to- 10 scale in order to feel comfortable ambulating. To properly establish a patient’s comfortfunction goal, nurses must first describe the essential activities of recovery and explain the link between pain control and positive outcomes. ^(9){ }^{9} 舒适功能目标鼓励患者根据自己当前的健康状况，确定实现功能目标所需的舒适程度。例如，一名患者可能在术后能够自如地行走，其疼痛程度在 0-10 级疼痛强度评分表中为 3 级，而另一名患者则希望疼痛程度在 0-10 级评分表中为 0 级，以便能够自如地行走。要正确确定患者的舒适功能目标，护士必须首先描述康复的基本活动，并解释疼痛控制与积极疗效之间的联系。 ^(9){ }^{9}
If a patient’s pain score exceeds their comfort-function goal, nurses must implement an intervention and follow up within 1 hour to ensure that the intervention was successful. Using the previous example, if a patient had established a comfort-function goal of 3 to ambulate and the current pain rating was 6 , the nurse would provide appropriate interventions, such as medication, application of cold packs, or relaxation measures. Documentation of the comfort-function goal, pain level, interventions, and follow-up are key to effective, individualized pain management. ^(10){ }^{10} 如果患者的疼痛评分超过了舒适功能目标，护士必须实施干预措施，并在 1 小时内进行随访，以确保干预措施取得成功。以前面的例子为例，如果患者设定的舒适功能目标是 3 分，可以行走，而目前的疼痛评分是 6 分，护士就会采取适当的干预措施，如药物治疗、冷敷或放松措施。记录舒适功能目标、疼痛程度、干预措施和随访是有效、个性化疼痛管理的关键。 ^(10){ }^{10}
9. Boswell, C., & Hall, M. (2017). Engaging the patient through comfort-function levels. Nursing 2017, 47 (10), 68-69. https://www.nursingcenter.com/ journalarticle?Article_ID=4345712&Journal_ID=54016&Issue_ID=4345459 9.Boswell, C., & Hall, M. (2017)。通过舒适功能水平吸引患者。Nursing 2017, 47 (10), 68-69. https://www.nursingcenter.com/ journalarticle?Article_ID=4345712&Journal_ID=54016&Issue_ID=4345459
10. Boswell, C., & Hall, M. (2017). Engaging the patient through comfort-function levels. Nursing 2017, 47 (10), 68-69. https://www.nursingcenter.com/ journalarticle?Article_ID=4345712&Journal_ID=54016&Issue_ID=4345459 10.Boswell, C., & Hall, M. (2017)。通过舒适功能水平吸引患者。Nursing 2017, 47 (10), 68-69. https://www.nursingcenter.com/ journalarticle?Article_ID=4345712&Journal_ID=54016&Issue_ID=4345459
Pain management requires collaboration with the interdisciplinary team, including nurses, health care providers, pharmacists, and sometimes pain specialists. There are many different types of pain medications (called analgesics) that can be administered by various routes. Analgesics are classified as nonopioids, opioids, or adjuvants. An adjuvant is a medication that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids. Examples of adjuvant medications include antidepressants (e.g., amitriptyline) and anti-seizure medications (e.g., gabapentin). 疼痛管理需要跨学科团队的合作，包括护士、医疗服务提供者、药剂师，有时还包括疼痛专家。有许多不同类型的止痛药物（称为镇痛剂）可以通过不同的途径给药。镇痛药分为非阿片类、阿片类或辅助药物。辅助药物是指在临床实践中发现与阿片类药物一起使用时具有独立镇痛效果或附加镇痛特性的药物。辅助药物的例子包括抗抑郁药（如阿米替林）和抗癫痫药（如加巴喷丁）。
A general rule of thumb when administering analgesics is to use the lowest dose of medication, with fewest potential side effects and the least invasive route of administration, to effectively treat the level of pain as reported by the patient. The WHO ladder was originally developed by the World Health Organization for selecting analgesics for patients with cancer pain, but it can be broadened to illustrate this rule of thumb for managing pain appropriately for all patients. See Figure 11.6^(1)11.6^{1} for an image of the WHO ladder. 在使用镇痛药时，一般的经验法则是使用最低剂量、潜在副作用最小、侵入性最小的给药途径，以有效治疗患者报告的疼痛程度。世界卫生组织的阶梯疗法最初是由世界卫生组织为癌症疼痛患者选择镇痛药而开发的，但它可以扩展到所有患者，以说明这一适当管理疼痛的经验法则。请参阅图 11.6^(1)11.6^{1} ，了解 WHO 梯形图。
For example, if a patient reports a pain level of “2,” then a nurse typically starts at the lowest rung of the WHO ladder and administers a prescribed nonopioid via the oral route. If the nonopioid is not effective, then a prescribed adjuvant medication may be administered, or the nurse may decide to step up a rung on the ladder and administer a prescribed oral opioid for mild to moderate pain. On the other hand, if a patient reports severe pain, the nurse may start at the top rung of the ladder and administer a prescribed opioid for moderate to severe pain via the intravenous route for rapid relief. 例如，如果病人报告疼痛程度为 "2"，那么护士通常会从世界卫生组织阶梯的最低一级开始，通过口服途径给病人服用处方非阿片类药物。如果非阿片类药物效果不佳，则可使用处方辅助药物，或者护士可决定将阶梯提升一级，针对轻度至中度疼痛使用处方口服阿片类药物。另一方面，如果患者报告有剧烈疼痛，护士可以从阶梯的最高一级开始，通过静脉注射的方式为中度到重度疼痛患者注射处方阿片类药物，以快速缓解疼痛。
Figure 11.6 The WHO Pain Ladder 图 11.6 世界卫生组织疼痛阶梯
Nonopioid Analgesics 非阿片类镇痛药
Nonopioid analgesics include acetaminophen and NSAIDs. 非阿片类镇痛药包括对乙酰氨基酚和非甾体抗炎药。
Acetaminophen 对乙酰氨基酚
Acetaminophen (Tylenol) is used to treat mild pain and fever but does not have anti-inflammatory properties. Acetaminophen is safe for all ages and can be administered using various routes, such as orally, rectally, and intravenously. Many over-the-counter (OTC) medications contain acetaminophen, along with other medications. See Figure 11.7^(2)11.7^{2} for an image of acetaminophen (Tylenol) and acetaminophen and diphenhydramine (Tylenol PM). 对乙酰氨基酚（泰诺）用于治疗轻微疼痛和发烧，但没有消炎作用。对乙酰氨基酚对所有年龄段的人都安全，可通过口服、直肠给药和静脉注射等多种途径给药。许多非处方药（OTC）和其他药物都含有对乙酰氨基酚。对乙酰氨基酚（泰诺）和对乙酰氨基酚和苯海拉明（泰诺 PM）的图片见图 11.7^(2)11.7^{2} 。
A potential severe side effect of acetaminophen is hepatotoxicity (severe liver damage). Severe liver damage may occur if an adult patient takes more than 4,000mg4,000 \mathrm{mg} of acetaminophen in 24 hours (or 3,200mg3,200 \mathrm{mg} for older adults or 2,000 mg for chronic alcoholics) or consumes three or more alcoholic drinks every day while using acetaminophen. 对乙酰氨基酚的一个潜在严重副作用是肝毒性（严重肝损伤）。如果成人患者在 24 小时内服用超过 4,000mg4,000 \mathrm{mg} 的对乙酰氨基酚（或老年人服用 3,200mg3,200 \mathrm{mg} 或慢性酗酒者服用 2,000 毫克），或在使用对乙酰氨基酚期间每天饮用三杯或三杯以上的酒精饮料，可能会出现严重的肝损伤。
Because some medications are combined with acetaminophen or are prescribed “as needed,” the nurse must calculate the cumulative dose of acetaminophen over the previous 24 -hour period before administering an additional dose. For example, Percocet 5/325 contains a combination of oxycodone 5 mg and acetaminophen 325 mg and may be prescribed as " 1-21-2 tablets every 4-6 hours as needed for pain." If two tablets are truly administered every four hours over a 24-hour period, this would add up to 3,900mg3,900 \mathrm{mg} of acetaminophen, exceeding the recommended guidelines for a geriatric patient, with the potential for causing liver damage. 由于有些药物与对乙酰氨基酚合用，或者是 "按需 "处方，因此护士必须计算出前 24 小时内对乙酰氨基酚的累积剂量，然后才能追加剂量。例如，Percocet 5/325 含有 5 毫克羟考酮和 325 毫克对乙酰氨基酚，处方中可能会写明" 1-21-2 根据疼痛需要每 4-6 小时服用一片"。如果真的在 24 小时内每 4 小时服用两片，那么对乙酰氨基酚的用量将达到 3,900mg3,900 \mathrm{mg} ，超过了老年病人的推荐剂量，并有可能造成肝损伤。
Figure 11.7 Acetaminophen (Tylenol) and Acetaminophen with Benadryl (Tylenol PM) 图 11.7 对乙酰氨基酚（泰诺）和对乙酰氨基酚加苯海拉明（泰诺 PM）
NSAIDs 非甾体抗炎药
Nonsteroidal anti-inflammatories (NSAIDs) provide mild to moderate pain relief and also reduce fever and inflammation by inhibiting the production of prostaglandins. They can also be used as an adjuvant with opioids for severe pain. Examples of NSAIDs include ibuprofen, naproxen, and ketorolac. All NSAIDs, except aspirin, increase the risk of heart attack, heart failure, and stroke, with the risk being higher if the patient takes more than is directed or takes it for longer than directed. Common side effects include dyspepsia, nausea, and vomiting, so it is helpful to administer this medication with food. 非甾体抗炎药（NSAIDs）可缓解轻度至中度疼痛，还能通过抑制前列腺素的分泌来退烧和消炎。非甾体抗炎药还可作为阿片类药物的辅助药物，用于缓解剧烈疼痛。非甾体抗炎药的例子包括布洛芬、萘普生和酮咯酸。除阿司匹林外，所有非甾体抗炎药都会增加心脏病发作、心力衰竭和中风的风险，如果患者服用量超过说明书规定或服用时间超过说明书规定，风险会更高。常见的副作用包括消化不良、恶心和呕吐，因此在用药时最好同时进食。
Older adults and those taking NSAIDs concurrently with other drugs, such as warfarin or corticosteroids, are at elevated risk for gastrointestinal bleeding. Renal failure can also occur with NSAIDs. 老年人和同时服用华法林或皮质类固醇等其他药物的非甾体抗炎药患者发生胃肠道出血的风险较高。服用非甾体抗炎药还可能出现肾功能衰竭。
Ibuprofen (Motrin) is safe for infants 6 months or older. It is typically prescribed every 6 to 8 hours. 布洛芬（Motrin）对 6 个月或以上的婴儿是安全的。一般每 6 至 8 小时服用一次。
Naproxen (Naprosyn) is longer-acting than ibuprofen and is typically prescribed 2 or 3 times a day with a full glass of water. 萘普生（Naprosyn）的药效比布洛芬长，一般每天用药 2 或 3 次，每次用一整杯水送服。
Ketorolac (Toradol) is commonly used to treat “breakthrough” pain that occurs during the treatment of severe acute pain already being treated with opioids. It is indicated for the short-term management (up to 5 days in adults) of moderate to severe acute pain that requires analgesia at the opioid level. Ketorolac is safe for adults, but the dosage should be reduced for patients ages 65 and over. 酮咯酸（托拉多）常用于治疗已接受阿片类药物治疗的严重急性疼痛过程中出现的 "突破性 "疼痛。它适用于需要阿片类药物镇痛的中度至重度急性疼痛的短期治疗（成人不超过 5 天）。酮咯酸对成人是安全的，但对于 65 岁及以上的患者应减少用量。
Read about nonopioid medications in the “Analgesic and Musculoskeletal” chapter in Open RN Nursing Pharmacology. 请阅读《开放式注册护士护理药理学》中 "镇痛和肌肉骨骼 "一章中有关非阿片类药物的内容。
View a supplementary video on “How Do Pain Relievers Work?” 观看补充视频 "止痛药如何发挥作用？
Opioid Analgesics 阿片类镇痛药
Opioids are used to treat moderate to severe pain and work by blocking the release of neurotransmitters involved in the processing of pain. Different opioids have different amounts of analgesia, ranging from codeine used to treat mild to moderate pain, up to morphine, used to treat severe pain and considered to be at the top of the WHO ladder. See Table 11.4a for a summary of common opioids. As always, check a drug reference for current dosage ranges before administering medications. 阿片类药物用于治疗中度至重度疼痛，通过阻断参与疼痛处理的神经递质的释放发挥作用。不同的阿片类药物有不同程度的镇痛效果，从用于治疗轻度到中度疼痛的可待因到用于治疗重度疼痛的吗啡不等，吗啡被认为是世界卫生组织镇痛阶梯的最高级药物。常见阿片类药物汇总见表 11.4a。一如既往，在用药前应查阅药物参考资料，了解当前的剂量范围。
Table 11.4a Common Opioid Analgesics 表 11.4a 常见阿片类镇痛药
5mg//300mg5 \mathrm{mg} / 300 \mathrm{mg} or 325 mg
10mg//320mg10 \mathrm{mg} / 320 \mathrm{mg} or 325 mg
5mg//500mg5 \mathrm{mg} / 500 \mathrm{mg}
5mg//300mg or 325 mg
10mg//320mg or 325 mg
5mg//500mg| $5 \mathrm{mg} / 300 \mathrm{mg}$ or 325 mg |
| :--- |
| $10 \mathrm{mg} / 320 \mathrm{mg}$ or 325 mg |
| $5 \mathrm{mg} / 500 \mathrm{mg}$ |
羟考酮（速释和缓释）或羟考酮加对乙酰氨基酚
Oxycodone (immediate release and extended release)
OR
Oxycodone with acetaminophen
Oxycodone (immediate release and extended release)
OR
Oxycodone with acetaminophen| Oxycodone (immediate release and extended release) |
| :--- |
| OR |
| Oxycodone with acetaminophen |
Duramorph, MS Contin, Oramorph SR, & Roxanol Duramorph、MS Contin、Oramorph SR 和 Roxanol
口服和直肠给药，肌注和静脉注射
PO & Rectal
SubQ, IM, & IV
PO & Rectal
SubQ, IM, & IV| PO & Rectal |
| :--- |
| SubQ, IM, & IV |
30 毫克（可增加） 4-10 毫克（可增加）
30 mg (may be increased)
4-10 mg (may be increased)
30 mg (may be increased)
4-10 mg (may be increased)| 30 mg (may be increased) |
| :--- |
| 4-10 mg (may be increased) |
Generic Name Trade Name(s) Route Adult Dosages
Codeine with acetaminophen Tylenol #3 PO 30mg//300 mg
Hydrocodone with acetaminophen Lortab, Norco, Vicodin PO "5mg//300mg or 325 mg
10mg//320mg or 325 mg
5mg//500mg"
"Oxycodone (immediate release and extended release)
OR
Oxycodone with acetaminophen" "Oxycodone IR & OxyContin (ER)
Percocet & Roxicet" "PO
PO" "5mg-10mg
5mg//325mg"
Fentanyl Duragesic, Sublimaze "Transdermal
IM
IV" "12mcg-100 mcg//hr
0.5-1mcg//kg
0.5-1mcg//kg"
Hydromorphone Dilaudid "PO
Rectal
SubQ, IM, & IV" "4-8mg
3 mg
1.5 mg (may be increased)"
Morphine Duramorph, MS Contin, Oramorph SR, & Roxanol "PO & Rectal
SubQ, IM, & IV" "30 mg (may be increased)
4-10 mg (may be increased)"| Generic Name | Trade Name(s) | Route | Adult Dosages |
| :--- | :--- | :--- | :--- |
| Codeine with acetaminophen | Tylenol #3 | PO | $30 \mathrm{mg} / 300$ mg |
| Hydrocodone with acetaminophen | Lortab, Norco, Vicodin | PO | $5 \mathrm{mg} / 300 \mathrm{mg}$ or 325 mg <br> $10 \mathrm{mg} / 320 \mathrm{mg}$ or 325 mg <br> $5 \mathrm{mg} / 500 \mathrm{mg}$ |
| Oxycodone (immediate release and extended release) <br> OR <br> Oxycodone with acetaminophen | Oxycodone IR & OxyContin (ER) <br> Percocet & Roxicet | PO <br> PO | $5 \mathrm{mg}-10 \mathrm{mg}$ <br> $5 \mathrm{mg} / 325 \mathrm{mg}$ |
| Fentanyl | Duragesic, Sublimaze | Transdermal <br> IM <br> IV | $12 \mathrm{mcg}-100$ $\mathrm{mcg} / \mathrm{hr}$ <br> $0.5-1 \mathrm{mcg} / \mathrm{kg}$ <br> $0.5-1 \mathrm{mcg} / \mathrm{kg}$ |
| Hydromorphone | Dilaudid | PO <br> Rectal <br> SubQ, IM, & IV | $4-8 \mathrm{mg}$ <br> 3 mg <br> 1.5 mg (may be increased) |
| Morphine | Duramorph, MS Contin, Oramorph SR, & Roxanol | PO & Rectal <br> SubQ, IM, & IV | 30 mg (may be increased) <br> 4-10 mg (may be increased) |
Morphine is also commonly used to treat cancer pain and end-of-life pain because there is no “ceiling effect,” meaning the higher the dose, the higher 吗啡也常用于治疗癌症疼痛和临终疼痛，因为它没有 "天花板效应"，即剂量越大，疼痛越严重。
the level of analgesia. Morphine is administered via various routes of administration, including orally, rectally, subcutaneously, intramuscularly, and intravenously. See Figure 11.8^(3)11.8^{3} for an image of a vial of morphine for injection or intravenous use. 镇痛程度。吗啡有多种给药途径，包括口服、直肠给药、皮下注射、肌肉注射和静脉注射。参见图 11.8^(3)11.8^{3} ，查看注射或静脉注射用吗啡瓶的图片。
Figure 11.8 Morphine 图 11.8 吗啡
Other types of opioids can be administered through the skin, such as the fentanyl transdermal patch. See Figure 11.9^(4)11.9^{4} for an image of a fentanyl transdermal patch. 其他类型的阿片类药物可以通过皮肤给药，例如芬太尼透皮贴片。有关芬太尼透皮贴片的图片，请参见图 11.9^(4)11.9^{4} 。
3. “Morphine_vial.JPG” by Vaprotan is licensed under CC BY-SA 3.0 3."Morphine_vial.JPG" by Vaprotan 采用 CC BY-SA 3.0 许可协议发布。
4. “Fentanyl_Transdermal_System_50_mcg_Patch.jpg” by User:Crohnie is licensed under CC BY-SA 3.0 4."Fentanyl_Transdermal_System_50_mcg_Patch.jpg" by User:Crohnie 采用 CC BY-SA 3.0 许可。
Figure 11.9 Fentanyl Patch 图 11.9 芬太尼贴片
Read more about analgesics and opioid medications in the “Analgesic and Musculoskeletal” chapter in the Open RN Nursing Pharmacology textbook. 请在《开放式注册护士护理药理学》教科书的 "镇痛和肌肉骨骼 "章节中阅读更多有关镇痛药和阿片类药物的信息。
Alternative Routes of Administration of Opioids 阿片类药物的其他给药途径
Analgesic medications can be administered via several routes, including 镇痛药物可通过多种途径给药，包括
orally, rectally, subcutaneously, and intravenously. Intramuscular routes are typically avoided. Other routes of administration include patient-controlled analgesia (PCA), intrathecally, and by epidural. 口服、直肠、皮下和静脉注射。通常避免使用肌肉注射途径。其他给药途径包括患者自控镇痛（PCA）、鞘内注射和硬膜外注射。
PATIENT CONTROLLED ANALGESIA 患者自控镇痛
Patient-controlled analgesia (PCA) is a method of pain management that allows hospitalized patients with severe pain to safely self-administer opioid medications using a programmed pump according to their level of discomfort. See Figure 11.10^(5)11.10^{5} for an image of a PCA pump. A computerized pump contains a syringe of pain medication and is connected directly to a patient’s intravenous (IV) line. Pain medication includes morphine, hydromorphone, and fentanyl. Doses of medication can be self-administered as needed by the patient by pressing a button. However, the pump is programmed to only allow administration of medication every set number of minutes with a maximum dose of medication every hour. These pump settings, and the design of the system requiring the patient to be alert enough to press the button, are safety measures to prevent overmedication that can cause sedation and respiratory depression. For this reason, no one but the patient should press the button for administration of medication (not even the nurse.) 患者自控镇痛（PCA）是一种疼痛管理方法，它允许住院的重度疼痛患者根据自己的不适程度，使用编程泵安全地自行给药阿片类药物。有关 PCA 泵的图像，请参见图 11.10^(5)11.10^{5} 。计算机化泵包含一个装有止痛药物的注射器，并直接连接到患者的静脉注射（IV）管路。止痛药物包括吗啡、氢吗啡酮和芬太尼。患者可根据需要按下按钮自行给药。不过，泵的程序设定为每设定分钟只能给药一次，每小时最多给药一次。这些泵设置以及要求病人保持足够警觉才能按下按钮的系统设计，都是防止过度用药的安全措施，过度用药会导致镇静和呼吸抑制。因此，除病人外，任何人（甚至护士）都不应按下给药按钮。
In other cases, the PCA pump delivers a small, continuous flow of pain medication intravenously with the option of the patient self-delivering additional medication as needed, according to the limits set on the pump. 在其他情况下，PCA 泵会通过静脉持续输送少量止痛药物，患者可根据泵上设置的限制根据需要自行输送更多药物。
To document the amount and frequency of pain medication the patient is receiving, as well as to prevent drug diversion, the settings on the pump are checked at the end of every shift as part of the bedside report. The incoming and outgoing nurses double-check and document the pump settings, the amount of medication administered during the previous shift, and the amount of medication left in the syringe. 为了记录病人接受止痛药物的数量和频率，并防止药物被挪作他用，在每个班次结束时都要检查泵的设置，这是床边报告的一部分。接班和下班的护士会仔细检查并记录泵的设置、上一班的用药量以及注射器中的剩余药量。
Another type of pump used to deliver pain medication is the intrathecal pump. This pump is surgically implanted under the skin and delivers small quantities of pain medication, such as morphine, directly into the spinal fluid. It is used to treat pain and muscle spasticity when other methods have not effectively treated the pain. It is typically used for patients with severe chronic pain, such as cancer pain, back pain, or nerve pain. However, the FDA urges 另一种用于输送止痛药物的泵是鞘内泵。这种泵通过手术植入皮下，将吗啡等少量止痛药物直接注入脊髓液中。当其他方法无法有效治疗疼痛时，它可用于治疗疼痛和肌肉痉挛。它通常用于治疗严重的慢性疼痛患者，如癌症疼痛、背痛或神经痛。然而，美国食品和药物管理局敦促
cautious use because it has received numerous Medical Device Reports (MDRs) describing adverse events with implanted pumps. These reports describe pump failures, dosing errors, and other potential safety issues. Patient symptoms described in these reports include pain, opioid withdrawal, fever, vomiting, muscle spasm, cognitive changes, weakness, and cardiac and respiratory distress. ^(6){ }^{6} 慎用，因为它收到了许多医疗器械报告 (MDR)，其中描述了植入泵的不良事件。这些报告描述了泵故障、剂量错误和其他潜在的安全问题。这些报告中描述的患者症状包括疼痛、阿片类药物戒断、发热、呕吐、肌肉痉挛、认知改变、虚弱以及心脏和呼吸窘迫。 ^(6){ }^{6}
EPIDURAL
A third route of alternative administration of pain medication is epidural anesthesia. See Figure 11.11^(7)11.11^{7} for an image of an epidural anesthesia. Morphine is administered into the spinal fluid via an epidural catheter for severe pain management associated with surgical procedures or during labor and delivery. It is also used to treat chronic pain that has not responded to other treatments. Epidural administration of 5mg_(8)5 \mathrm{mg}_{8} of morphine provides adequate postoperative analgesia for up to 24 hours. 硬膜外麻醉是替代镇痛药物的第三种途径。硬膜外麻醉的图像见图 11.11^(7)11.11^{7} 。通过硬膜外导管将吗啡注入脊髓液，用于治疗手术或分娩过程中的剧烈疼痛。它还用于治疗对其他疗法无效的慢性疼痛。硬膜外注射 5mg_(8)5 \mathrm{mg}_{8} 吗啡可提供长达 24 小时的充分术后镇痛。
6. U.S. Food & Drug Administration. (2018, November 14). Use caution with implanted pumps for intrathecal administration of medicines for pain management: FDA safety communication. https://www.fda.gov/ medical-devices/safety-communications/use-caution-implanted-pumps-intrathecal-administration-medicines-pain-management-fda-safety 6.美国食品和药物管理局。(2018 年 11 月 14 日）。慎用植入泵鞘内给药治疗疼痛：https://www.fda.gov/ medical-devices/safety-communications/use-caution-implanted-pumps-intrathecal-administration-medicines-pain-management-fda-safety.
7. “Epidural_Anesthesia.png” by BruceBlaus is licensed under CC BY-SA 4.0 7."Epidural_Anesthesia.png" by BruceBlaus 采用 CC BY-SA 4.0 许可。
8. This work is a derivative of StatPearls by Martinez-Velez and Singh and is licensed under CC BY 4.0 8.本作品是 Martinez-Velez 和 Singh 的 StatPearls 的衍生作品，采用 CC BY 4.0 许可。
Adverse Effects of Opioids 阿片类药物的不良影响
RESPIRATORY DEPRESSION 呼吸抑制
The most serious potential adverse effect of opioids is respiratory depression. Respiratory depression is usually preceded by sedation. The nurse must carefully monitor patients receiving opioids for oversedation, which results in decreased respiratory rate. Patients at greatest risk are those who have never received an opioid and are receiving their first dose, those receiving an increased dose of opioids, or those taking benzodiazepines or other sedatives concurrently with opioids. If a patient develops opioid-induced respiratory depression, the opioid is reversed with naloxone (Narcan) that immediately 阿片类药物最严重的潜在不良反应是呼吸抑制。呼吸抑制之前通常会出现镇静。护士必须仔细观察接受阿片类药物治疗的患者是否过度镇静，过度镇静会导致呼吸频率下降。风险最大的患者是从未服用过阿片类药物且首次服用的患者、服用阿片类药物剂量增加的患者或在服用阿片类药物的同时服用苯二氮卓类药物或其他镇静剂的患者。如果患者出现阿片类药物引起的呼吸抑制，可立即使用纳洛酮（Narcan）逆转阿片类药物。
reverses all analgesic effect. ^(9){ }^{9} See Figure 11.12^(10)11.12^{10} for an image of a naloxone rescue kit to treat respiratory depression caused by opioids. 可逆转所有镇痛效果。 ^(9){ }^{9} 用于治疗阿片类药物引起的呼吸抑制的纳洛酮抢救包图片见图 11.12^(10)11.12^{10} 。
Figure 17.12 Naloxone Rescue Kit 图 17.12 纳洛酮抢救包
Opioids can cause several other common adverse effects, such as constipation, nausea and vomiting, urinary retention, and pruritus (itching). 阿片类药物还会引起其他一些常见的不良反应，如便秘、恶心和呕吐、尿潴留和瘙痒。
CONSTIPATION 结社
Opioids slow peristalsis and cause increased reabsorption of fluid into the large intestine, resulting in slow-moving, hard stools. Nurses play an important role in preventing constipation for all patients taking opioids. A bowel management program should be initiated with the first dose and 阿片类药物会减缓肠胃蠕动，增加大肠对液体的再吸收，从而导致大便移动缓慢、坚硬。护士在预防所有服用阿片类药物的患者便秘方面发挥着重要作用。肠道管理计划应在首次用药时启动，并在用药后的第 3 个月开始实施。
continued until the opioid is discontinued. A stool softener (such as docusate) is typically prescribed initially as part of the bowel management program. If needed, a stimulant laxative, such as sennoside (Senna), bisacodyl, or Milk of Magnesia may be added to maintain a normal bowel pattern. However, stimulants should not be taken long-term because they can be addictive. Patients taking opioids should be encouraged to increase fluid and fiber intake and ambulate, as appropriate." 在停用阿片类药物之前，应继续服用。软便剂（如多库酯）作为肠道管理计划的一部分，通常是最初的处方。如有必要，还可添加番泻叶苷（番泻叶）、比沙可啶或镁乳等刺激性泻药，以维持正常的排便模式。不过，刺激性药物可能会上瘾，因此不应长期服用。应鼓励服用阿片类药物的患者增加液体和纤维的摄入量，并酌情多走动。
NAUSEA AND VOMITING 恶心和呕吐
Nausea and vomiting can occur with opioid administration due to several factors, such as the slowing of gastrointestinal mobility, constipation, or stimulation of the vestibular system. Tolerance will develop to these adverse effects within a few days. Treatment includes antiemetics, such as compazine or ondansetron. ^(12){ }^{12} 服用阿片类药物可能会出现恶心和呕吐，这是由多种因素造成的，如肠胃蠕动减慢、便秘或刺激前庭系统。几天内就会对这些不良反应产生耐受性。治疗方法包括止吐药，如康帕秦（compazine）或昂丹司琼（ondansetron）。 ^(12){ }^{12}
URINARY RETENTION 尿潴留
Urinary retention is common in opioid-naive patients or when opioids are delivered via the spinal route. Urinary catheterization may be required if the patient is unable to void. Tolerance to this effect occurs within a few days. ^(13){ }^{13} 尿潴留常见于未服用阿片类药物的患者或通过脊髓途径服用阿片类药物的患者。如果患者无法排尿，可能需要导尿。几天内就会对这种影响产生耐受性。 ^(13){ }^{13}
PRURITUS
Pruritus (itching) may occur, especially when opioids are administered via the spinal route. Antihistamines, such as diphenhydramine (Benadryl), may be used to treat pruritus, but the patient should be monitored for potential sedative effects of this medication. ^(14){ }^{14} 可能会出现瘙痒（瘙痒症），尤其是通过脊髓途径使用阿片类药物时。抗组胺药，如苯海拉明（苯海拉明），可用于治疗瘙痒症，但应注意这种药物可能产生的镇静作用。 ^(14){ }^{14}
11. American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC). https://www.aacnnursing.org/ ELNEC 11.美国护理学院协会。(n.d.).https://www.aacnnursing.org/ ELNEC.
12. American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC). https://www.aacnnursing.org/ ELNEC 12.美国护理学院协会。(n.d.).https://www.aacnnursing.org/ ELNEC.
13. American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC). https://www.aacnnursing.org/ ELNEC 13.美国护理学院协会。(n.d.).https://www.aacnnursing.org/ ELNEC.
14. American Association of Colleges of Nursing. (n.d.). End-of-Life-Care (ELNEC). https://www.aacnnursing.org/ ELNEC 14.美国护理学院协会。(n.d.).https://www.aacnnursing.org/ ELNEC.
Adjuvant Medications 辅助药物
Adjuvants are medications that are not classified as analgesics but have been found to contribute to analgesic effects, especially when used in addition to opioids. Two common examples of adjuvant medications are amitriptyline and gabapentin. 辅助药物是指不属于镇痛药但被发现有助于镇痛效果的药物，尤其是在与阿片类药物同时使用时。阿米替林和加巴喷丁就是两种常见的辅助药物。
AMITRIPTYLINE
Amitriptyline is a tricyclic antidepressant that is also believed to be effective in treating neuropathic pain, such as diabetic neuropathy, postherpetic neuralgia, or post-stroke pain. The mechanism of action of amitriptyline in the treatment of neuropathic pain remains uncertain, although it is known to inhibit both serotonin and noradrenaline reuptake. It is usually administered at bedtime in an attempt to reduce any sedative effects during the day. ^(15){ }^{15} 阿米替林是一种三环类抗抑郁药，据信也能有效治疗神经性疼痛，如糖尿病神经病变、带状疱疹后神经痛或中风后疼痛。阿米替林治疗神经性疼痛的作用机制尚不明确，但已知它能抑制血清素和去甲肾上腺素的再摄取。阿米替林通常在睡前服用，以减少白天的镇静作用。 ^(15){ }^{15}
GABAPENTIN 加巴喷丁
Gabapentin is an anticonvulsant that is also effective in treating neuropathic pain and restless leg syndrome. Patients taking gabapentin should be warned that their mental health may change in unexpected ways or they may become suicidal. Nurses should implement fall precautions for patients taking gabapentin because it can cause sleepiness, weakness, and unsteadiness. ^(16){ }^{16} 加巴喷丁是一种抗惊厥药，对治疗神经性疼痛和不安腿综合征也很有效。应提醒服用加巴喷丁的患者，他们的精神健康可能会发生意想不到的变化，或者他们可能会有自杀倾向。护士应对服用加巴喷丁的患者实施跌倒预防措施，因为它可能会导致嗜睡、虚弱和站立不稳。 ^(16){ }^{16}
Nonpharmacological Interventions 非药物干预
Nonpharmacological interventions can be used with or without pharmacologic interventions and often provide tremendous benefits to the patient. A variety of techniques can be selected by the patient that best fit their needs and goals. Nonpharmacological interventions should be 非药物干预可以与药物干预一起使用，也可以不使用药物干预，通常会给患者带来巨大的益处。患者可以选择最适合自己需要和目标的各种技术。非药物干预应
documented in the plan of care and their effectiveness evaluated in terms of their ability to meet the patient’s goals for pain relief. Table 11.4b provides examples of several types of nonpharmacological interventions. 在护理计划中记录下来，并根据其实现患者止痛目标的能力对其有效性进行评估。表 11.4b 列举了几种非药物干预措施。
Describing photos, telling jokes, and playing games 描述照片、讲笑话和玩游戏
Relaxation 放松
Rhythmic breathing, meditation, prayer, imagery, and music therapy 有节奏的呼吸、冥想、祈祷、想象和音乐疗法
Basic comfort measures 基本舒适措施
正确的体位和治疗环境 避免突然移动 减少环境中的疼痛刺激
Proper positioning and therapeutic environment
Avoiding sudden movement
Reducing pain stimuli within the environment
Proper positioning and therapeutic environment
Avoiding sudden movement
Reducing pain stimuli within the environment| Proper positioning and therapeutic environment |
| :--- |
| Avoiding sudden movement |
| Reducing pain stimuli within the environment |
Cutaneous stimulation 皮肤刺激
针灸和穴位按摩：经皮神经电刺激（TENS）装置：将专门的刺激器置于疼痛部位，3-5 分钟即可见效
Acupuncture and acupressure
Massage: 3-5 minutes offers benefits
Transcutaneous Electrical Nerve Stimulation (TENS) unit: a specialized stimulator placed over the area of pain
Acupuncture and acupressure
Massage: 3-5 minutes offers benefits
Transcutaneous Electrical Nerve Stimulation (TENS) unit: a specialized stimulator placed over the area of pain| Acupuncture and acupressure |
| :--- |
| Massage: 3-5 minutes offers benefits |
| Transcutaneous Electrical Nerve Stimulation (TENS) unit: a specialized stimulator placed over the area of pain |
Heat: vasodilation increases blood flow; duration should be 5-20 minutes based on patient tolerance
Cold: vasoconstriction reduces blood flow; cold numbs nerve sensations; duration should be no longer than 20 minutes
Cool baths and moist, cool compresses
Heat: vasodilation increases blood flow; duration should be 5-20 minutes based on patient tolerance
Cold: vasoconstriction reduces blood flow; cold numbs nerve sensations; duration should be no longer than 20 minutes
Cool baths and moist, cool compresses| Heat: vasodilation increases blood flow; duration should be 5-20 minutes based on patient tolerance |
| :--- |
| Cold: vasoconstriction reduces blood flow; cold numbs nerve sensations; duration should be no longer than 20 minutes |
| Cool baths and moist, cool compresses |
Mind-body therapies 身心疗法
生物反馈 冥想和正念
Biofeedback
Meditation and mindfulness
Biofeedback
Meditation and mindfulness| Biofeedback |
| :--- |
| Meditation and mindfulness |
Aromatherapy 芳香疗法
乳液和保湿霜 避免强烈气味
Lotions and moisturizing cream
Avoiding strong smells
Lotions and moisturizing cream
Avoiding strong smells| Lotions and moisturizing cream |
| :--- |
| Avoiding strong smells |
Exercise 运动
体育活动 太极拳 瑜伽
Physical activity
Tai chi
Yoga
Physical activity
Tai chi
Yoga| Physical activity |
| :--- |
| Tai chi |
| Yoga |
Patients may also consider using complementary health approaches to manage chronic pain. Complementary approaches include acupuncture, massage therapy, meditation, relaxation techniques, spinal manipulation, Tai 患者还可以考虑使用辅助保健方法来控制慢性疼痛。辅助方法包括针灸、按摩疗法、冥想、放松技巧、脊柱手法、太极拳、穴位按摩等。
17. “Massage-hand-4.jpg” by Lubyanka is licensed under CC BY-SA 3.0, “Biofeedback_training_program_for_posttraumatic_stress_symptoms.jpg” by Army Medicine is licensed under CC BY 2.0, “Tai_Chi1.jpg” by Craig Nagy is licensed under CC BY-SA 2.0, “Musicoterapia_Imidiman_flickr.jpg” by Midiman is licensed under CC BY 2.0, “Cold_Hot_Pack.jpg” by Mamun2a is licensed under_CC BY-SA 4.0, “pexels-photo-1188511.jpeg” by Mareefe is licensed under CCO, “STOTT-PILATES-reformer-class.jpg” by MHandF is licensed under CC BY-SA 3.0, “prayer-2544994_960_720.jpg” by Himsan is licensed under CCO, “gaming-2259191_960_720.jpg” by JESHOOTS-com is licensed under CCO 17."Massage-hand-4.jpg" by Lubyanka 采用 CC BY-SA 3.0 许可协议授权，"Biofeedback_training_program_for_posttraumatic_stress_symptoms.jpg" by Army Medicine 采用 CC BY 2.0 许可协议授权，"Tai_Chi1.jpg" by Craig Nagy 采用 CC BY-SA 2.0 许可协议授权，"Musicoterapia_Imidiman_flickr.jpg" by Midiman 采用 CC BY 2.0 许可协议授权，"Cold_Hot_Pack.jpg" by Mamun2a is licensed under_CC BY-SA 4.0, "pexels-photo-1188511.jpeg" by Mareefe is licensed under CCO, "STOTT-PILATES-reformer-class.jpg" by MHandF is licensed under CC BY-SA 3.0, "prayer-2544994_960_720.jpg" by Himsan is licensed under CCO, "gaming-2259191_960_720.jpg" by JESHOOTS-com is licensed under CCO
Chi, yoga, and dietary supplements. Read more about complementary approaches using the hyperlink provided in the following box. 气、瑜伽和膳食补充剂。请使用下框中提供的超链接阅读更多有关辅助方法的信息。
Read The Joint Commission document on “Non-pharmacologic and non-opioid solutions for pain management.” 阅读联合委员会关于 "疼痛管理的非药物和非阿片类药物解决方案 "的文件。
Read more about complementary approaches to treat pain from the National Center for Complementary and Integrative Health. 请阅读美国国家补充与整合健康中心提供的有关治疗疼痛的补充方法的更多信息。
Read about pain management for older adults from the University of Iowa. 阅读爱荷华大学关于老年人疼痛管理的文章。
Assessment 评估
Nurses play an essential role in performing comprehensive pain assessment. Assessments include asking questions about the presence of pain, as well as observing for nonverbal indicators of pain, such as grimacing, moaning, and touching the painful area. It is especially important to observe for nonverbal indicators of pain in patients unable to self-report their pain, such as infants, children, patients who have a cognitive disorder, patients at end of life, nonEnglish speaking patients, or patients who tend to be stoic due to cultural beliefs. See Figure 17.14^(1)17.14^{1} for an image of a patient who is expressing pain nonverbally. 护士在进行全面疼痛评估方面发挥着重要作用。评估包括询问是否存在疼痛，以及观察非语言性疼痛指标，如龇牙咧嘴、呻吟和触摸疼痛部位。对于无法自我报告疼痛的患者，如婴儿、儿童、有认知障碍的患者、临终患者、不会说英语的患者或因文化信仰而倾向于委曲求全的患者，观察他们是否有非语言的疼痛指标尤为重要。请参阅图 17.14^(1)17.14^{1} ，了解病人以非口头方式表达疼痛的图像。
Figure 17.14 Nonverbal Expression of Pain 图 17.14 疼痛的非语言表达
Recall that pain is defined as whatever the person experiencing it says it is. Subjective assessment includes asking questions regarding the severity rating, as well as obtaining comprehensive information by using the “PQRSTU” or “OLDCARTES” methods for assessing a chief complaint. For some patients who are unable to quantify the severity of their pain, a visual scale like the FACES scale is the best way to perform subjective assessment regarding the severity of pain. 回想一下，疼痛的定义就是体验者所说的疼痛。主观评估包括询问有关严重程度分级的问题，以及通过使用 "PQRSTU "或 "OLDCARTES "方法评估主诉来获取全面信息。对于一些无法量化疼痛严重程度的患者，像 FACES 量表这样的视觉量表是对疼痛严重程度进行主观评估的最佳方法。
Objective data includes observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. For patients who cannot verbalize their pain, using a 客观数据包括对疼痛的非语言迹象的观察，如坐立不安、面部狰狞和畏缩、呻吟、摩擦或警惕疼痛部位。对于无法用语言表达疼痛的患者，可以使用
scale like the FLACC, COMFORT, or PAINAD is helpful to standardize observations across different staff members. Keep in mind that patients experiencing acute pain will also likely have vital signs changes, such as increased blood pressure, increased heart rate, and increased respiratory rate. 像 FLACC、COMFORT 或 PAINAD 这样的量表有助于标准化不同工作人员的观察结果。请记住，经历急性疼痛的患者也可能会出现生命体征变化，如血压升高、心率加快和呼吸频率加快。
It is important to assess the impact of pain on a patient’s daily functioning. This can be accomplished by asking what effect the pain has on their ability to bathe, dress, prepare food, eat, walk, and complete other daily activities. Assessing the impact of pain on daily functioning is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the patient’s situation. For example, for some patients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other patients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal. ^(2){ }^{2} 评估疼痛对患者日常功能的影响非常重要。这可以通过询问疼痛对患者洗澡、穿衣、准备食物、进食、行走和完成其他日常活动的能力有何影响来实现。评估疼痛对日常功能的影响是一项新的护理标准，有助于跨学科团队根据患者的具体情况制定治疗目标和干预措施。例如，对某些病人来说，慢性疼痛会影响他们的就业能力，因此有效的疼痛管理对他们重返工作岗位至关重要。对于其他接受姑息治疗的患者来说，能够坐起来和亲人一起吃饭而不感到疼痛是一个重要的目标。 ^(2){ }^{2}
When performing a patient assessment, any new complaints of pain or pain that is unresponsive to the current treatment plan should be reported to the health care provider. Instances of sudden, severe pain or chest pain require immediate notification or contact of emergency services. 在对患者进行评估时，任何新的疼痛主诉或对当前治疗方案无反应的疼痛都应报告给医护人员。突发的剧烈疼痛或胸痛需要立即通知或联系急救服务。
Diagnoses 诊断
Commonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than 3 months) and Chronic Pain. See Table 11.5 for more information regarding these diagnoses. ^(3){ }^{3} For more information about defining characteristics and related factors for other NANDA-I nursing diagnoses, refer to a current nursing diagnosis resource. 常用的 NANDA-I 疼痛护理诊断包括急性疼痛（持续时间少于 3 个月）和慢性疼痛。有关这些诊断的更多信息，请参见表 11.5。 ^(3){ }^{3} 有关其他 NANDA-I 护理诊断的定义特征和相关因素的更多信息，请参阅当前的护理诊断资源。
Unpleasant sensory and emotional experience associated with acute or potential tissue damage, or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months. 与急性或潜在的组织损伤有关的或以这种损伤来描述的令人不快的感觉和情绪体验；突然或缓慢发生，强度从轻微到严重不等，有预期或可预测的结束，持续时间少于 3 个月。
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Hopelessness
- Narrowed focus
- Protective behavior
- Proxy report of pain behavior/activity changes
- Pupil dilation
- Restlessness
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument
- Alteration in sleep pattern
- Appetite change
- Change in physiological parameters (i.e., blood pressure, heart rate, respiratory rate)
- Diaphoresis
- Distraction behavior
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Hopelessness
- Narrowed focus
- Protective behavior
- Proxy report of pain behavior/activity changes
- Pupil dilation
- Restlessness
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument| - Alteration in sleep pattern |
| :--- |
| - Appetite change |
| - Change in physiological parameters (i.e., blood pressure, heart rate, respiratory rate) |
| - Diaphoresis |
| - Distraction behavior |
| - Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally |
| - Expressive behavior |
| - Facial expression of pain |
| - Guarding behavior |
| - Hopelessness |
| - Narrowed focus |
| - Protective behavior |
| - Proxy report of pain behavior/activity changes |
| - Pupil dilation |
| - Restlessness |
| - Self-focused |
| - Self-report of intensity using standardized pain scale |
| - Self-report of pain characteristics using standardized pain instrument |
NANDA-I Diagnosis Definition Defining Characteristics
Acute Pain Unpleasant sensory and emotional experience associated with acute or potential tissue damage, or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months. "- Alteration in sleep pattern
- Appetite change
- Change in physiological parameters (i.e., blood pressure, heart rate, respiratory rate)
- Diaphoresis
- Distraction behavior
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Expressive behavior
- Facial expression of pain
- Guarding behavior
- Hopelessness
- Narrowed focus
- Protective behavior
- Proxy report of pain behavior/activity changes
- Pupil dilation
- Restlessness
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument"| NANDA-I Diagnosis | Definition | Defining Characteristics |
| :--- | :--- | :--- |
| Acute Pain | Unpleasant sensory and emotional experience associated with acute or potential tissue damage, or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end, and with a duration of less than 3 months. | - Alteration in sleep pattern <br> - Appetite change <br> - Change in physiological parameters (i.e., blood pressure, heart rate, respiratory rate) <br> - Diaphoresis <br> - Distraction behavior <br> - Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally <br> - Expressive behavior <br> - Facial expression of pain <br> - Guarding behavior <br> - Hopelessness <br> - Narrowed focus <br> - Protective behavior <br> - Proxy report of pain behavior/activity changes <br> - Pupil dilation <br> - Restlessness <br> - Self-focused <br> - Self-report of intensity using standardized pain scale <br> - Self-report of pain characteristics using standardized pain instrument |
Chronic Pain 慢性疼痛
Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without anticipated or predictable end, and with a duration of greater than 3 months. 与实际或潜在的组织损伤有关，或以这种损伤来描述的令人不快的感觉和情绪体验（国际疼痛研究协会）；突然或缓慢发生，强度从轻微到严重不等，持续或反复出现，没有预期或可预测的结局，持续时间超过 3 个月。
- Alteration in ability to continue previous activities
- Alteration in sleep pattern
- Anorexia
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Facial expression of pain
- Proxy report of pain behavior/activity changes
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument
- Alteration in ability to continue previous activities
- Alteration in sleep pattern
- Anorexia
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Facial expression of pain
- Proxy report of pain behavior/activity changes
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument| - Alteration in ability to continue previous activities |
| :--- |
| - Alteration in sleep pattern |
| - Anorexia |
| - Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally |
| - Facial expression of pain |
| - Proxy report of pain behavior/activity changes |
| - Self-focused |
| - Self-report of intensity using standardized pain scale |
| - Self-report of pain characteristics using standardized pain instrument |
Chronic Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without anticipated or predictable end, and with a duration of greater than 3 months. "- Alteration in ability to continue previous activities
- Alteration in sleep pattern
- Anorexia
- Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally
- Facial expression of pain
- Proxy report of pain behavior/activity changes
- Self-focused
- Self-report of intensity using standardized pain scale
- Self-report of pain characteristics using standardized pain instrument"| Chronic Pain | Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without anticipated or predictable end, and with a duration of greater than 3 months. | - Alteration in ability to continue previous activities <br> - Alteration in sleep pattern <br> - Anorexia <br> - Evidence of pain using standardized pain behavior checklist for those unable to communicate verbally <br> - Facial expression of pain <br> - Proxy report of pain behavior/activity changes <br> - Self-focused <br> - Self-report of intensity using standardized pain scale <br> - Self-report of pain characteristics using standardized pain instrument |
| :--- | :--- | :--- |
Outcome Identification 成果鉴定
An overall goal when providing pain management is, “The patient will report that the pain management treatment plan achieves their comfort-function goals.” ^(5){ }^{5} 提供疼痛管理的总体目标是："患者将报告疼痛管理治疗计划实现了他们的舒适功能目标"。 ^(5){ }^{5}
SMART outcomes are customized to the patient’s unique situation. An example of a SMART goal is, “The patient will notify the nurse promptly for pain intensity level that is greater than their comfort-function goal throughout shift.” ^(6){ }^{6} SMART 结果是根据病人的独特情况定制的。SMART 目标的一个例子是："在整个轮班期间，如果疼痛强度超过舒适功能目标，患者将及时通知护士。 ^(6){ }^{6}
5. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 676-691. 5.Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020).Nursing diagnosis handbook：基于证据的护理计划指南》（第 12 版）。Elsevier, pp.
6. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier, pp. 676-691. 6.Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020).Nursing diagnosis handbook：基于证据的护理计划指南》（第 12 版）。Elsevier, pp.
Planning Interventions 规划干预措施
Several pharmacological and nonpharmacological interventions have been described throughout this chapter. See the following box for a summarized list of interventions for acute pain management. 本章介绍了几种药物和非药物干预措施。有关急性疼痛治疗干预措施的汇总清单，请参阅下框。
Identify pain intensity during required recovery activities (e.g., coughing and deep breathing, ambulation, transfers to chair, etc.) 确定所需恢复活动（如咳嗽和深呼吸、行走、转移到椅子上等）中的疼痛强度
Explore patient’s knowledge and beliefs about pain, including cultural influences 探索患者对疼痛的认识和信念，包括文化影响
Question patient regarding the level of pain that allows a state of comfort and desired function and attempt to keep pain at or lower than identified level 询问患者疼痛的程度，使其达到舒适状态和期望的功能，并尝试将疼痛控制在或低于确定的程度
Ensure that the patient receives prompt analgesic care before the pain becomes severe or before pain-inducing activities 确保患者在疼痛变得严重之前或在进行引起疼痛的活动之前及时接受镇痛治疗
Administer analgesics around-the-clock as needed the first 24 to 48 hours after surgery, trauma, or injury except if sedation or respiratory status indicates otherwise 在手术、创伤或受伤后的 24 至 48 小时内，根据需要全天候使用镇痛剂，除非镇静或呼吸状况另有指示。
Monitor sedation and respiratory status before administering opioids and at regular intervals when opioids are administered 在使用阿片类药物前以及在使用阿片类药物后定期监测镇静和呼吸状态
Follow agency protocols in selecting analgesia and dosage 在选择镇痛剂和剂量时遵循机构协议
Use a combination of prescribed medications (e.g., opioids, nonopioids, and adjuvants), if pain level is severe 如果疼痛程度严重，可结合使用处方药物（如阿片类药物、非阿片类药物和辅助药物）。
Select and implement interventions tailored to the 选择并实施适合以下情况的干预措施
patient’s risks, benefits, and preferences (e.g., pharmacological and nonpharmacological) to facilitate pain relief 病人的风险、益处和偏好（如药物和非药物），以促进疼痛缓解
Cautiously use analgesics that may have adverse effects in older adults 慎用可能对老年人产生不良影响的镇痛药
Administer analgesics using the least invasive route available, avoiding the intramuscular route 使用侵入性最小的途径给予镇痛剂，避免使用肌肉注射途径
Advocate PCA, intrathecal, and epidural routes of administration when appropriate 在适当情况下，提倡使用 PCA、鞘内注射和硬膜外给药途径
Modify pain control measures on the basis of the patient’s response to treatment 根据病人对治疗的反应修改疼痛控制措施
Prevent and/or manage medication side effects 预防和/或控制药物副作用
Notify prescribing provider if pain control measures are unsuccessful 如果止痛措施不成功，通知处方提供者
Provide accurate information to family members or caregivers about the patient’s pain experience with the patient’s permission 在病人允许的情况下，向其家人或护理人员提供有关病人疼痛经历的准确信息
See the following box for a summarized list of interventions for chronic pain management. 有关慢性疼痛治疗干预措施的汇总清单，请参见下框。
Explore the patient’s knowledge and beliefs about pain, including cultural influences 探索病人对疼痛的认识和信念，包括文化影响
Determine the pain experience on quality of life (e.g., sleep, 确定疼痛对生活质量（如睡眠）的影响、
appetite, activity, cognition, mood, relationships, job performance, and role responsibilities) 食欲、活动、认知、情绪、人际关系、工作表现和角色责任)
Evaluate the effectiveness of past pain control measures with the patient 与患者一起评估以往疼痛控制措施的效果
Question the patient regarding the level of pain that allows a state of comfort and appropriate functioning and attempt to keep pain at or lower than identified level 询问患者疼痛的程度，使其处于舒适和适当的功能状态，并试图将疼痛控制在或低于所确定的程度
Control environmental factors that may influence the patient’s pain experience 控制可能影响患者疼痛体验的环境因素
Ensure that the patient receives prompt analgesic care before the pain becomes severe or before activities that are anticipated to be pain-inducing 确保患者在疼痛剧烈前或在进行预计会引起疼痛的活动前及时接受镇痛治疗
Select and implement intervention options tailored to the patient’s risks, benefits, and preferences (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate 根据患者的风险、益处和偏好（如药物治疗、非药物治疗、人际交往）选择并实施干预方案，以酌情促进疼痛缓解
Instruct the patient and family about principles of pain management 指导病人和家属了解疼痛管理原则
Encourage the patient to monitor own pain and to use selfmanagement approaches 鼓励患者监测自己的疼痛并使用自我管理方法
Encourage appropriate use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy, acupressure, heat and cold application, and massage) and pharmacological options as pain control measures 鼓励适当使用非药物疗法（如生物反馈、TENS、催眠、放松、引导想象、音乐疗法、分散注意力、游戏疗法、活动疗法、穴位按摩、冷热敷和按摩）和药物疗法作为疼痛控制措施
Avoid use of analgesics that may have adverse effects on older adults 避免使用可能对老年人产生不良影响的镇痛剂
Collaborate with the patient, family, and other health professionals to select and implement pain control measures 与患者、家属和其他医疗专业人员合作，选择并实施疼痛控制措施
Prevent or manage side effects 预防或控制副作用
Evaluate the effectiveness of pain control measures through ongoing monitoring of the pain experience 通过持续监测疼痛体验，评估疼痛控制措施的有效性
Watch for signs of depression (e.g., sleeplessness, not eating, flat affect, statements of depression, or suicidal ideation) 注意抑郁症的征兆（如失眠、不吃饭、情绪低落、抑郁陈述或自杀念头等）
Watch for signs of anxiety or fear (e.g., irritability, tension, worry, or fear of movement) 注意焦虑或恐惧的迹象（例如，易怒、紧张、担心或害怕移动）
Modify pain control measures on the basis of the patient’s response to treatment 根据病人对治疗的反应修改疼痛控制措施
Incorporate the family in the pain relief modality, when possible 在可能的情况下，让家人参与缓解疼痛的方式
Utilize a multidisciplinary approach to pain management, when appropriate 酌情采用多学科方法进行疼痛管理
Consider referrals for the patient and family to support groups and other resources, as appropriate 酌情考虑将病人和家属转介到支持小组和其他资源机构
Evaluate patient satisfaction with pain management at specified intervals 在规定时间间隔内评估患者对疼痛治疗的满意度
Evaluate barriers to adherence with past pain management care plans 评估遵守以往疼痛管理护理计划的障碍
Implementing Pharmacological Interventions 实施药物干预
Patients should be involved and engaged in their plan of care to treat pain. By demonstrating empathy and collaborating with patients and the interdisciplinary team, it is more likely the treatment plan will be effective based on the patient’s goals. 患者应参与治疗疼痛的护理计划。通过与患者和跨学科团队表现出同理心和合作精神，更有可能根据患者的目标制定出有效的治疗计划。
When administering analgesic medication, holistic nursing care is important. Begin by considering the patient’s goals for pain relief and ask if they have been met effectively by previously administered medications. If they have not been met, it may be necessary to advocate for additional or alternative 在使用镇痛药物时，整体护理非常重要。首先要考虑患者的止痛目标，并询问之前使用的药物是否有效地满足了这些目标。如果没有达到这些目标，则可能有必要提倡使用额外的或替代性的镇痛药物。
medication with the health care provider. It is also important to consider if the patient is experiencing any side effects that may impact the patient’s desire to take additional pain medication. 与医疗服务提供者一起用药。同样重要的是，要考虑患者是否有任何副作用，这些副作用可能会影响患者服用额外止痛药的意愿。
When administering medications that have been ordered on an “as-needed” basis, it is vital for the nurse to verify the amount of medication the patient received in the past 24 hours and if any dosage limits have been met to ensure patient safety. 在使用 "按需 "开具的药物时，护士必须核实病人在过去 24 小时内的用药量，以及是否达到了用药剂量限制，以确保病人的安全。
Prior to administration, consider the best route of administration for this patient at this particular time. For example, if the patient is nauseated and vomiting, then an oral route may not be effective. On the other hand, if a patient’s pain has improved when receiving intravenous medications during the recovery process, it may be possible for the patient to begin taking oral pain medications in preparation for discharge home. Keep the WHO ladder in mind when selecting medications to reach patient goals while also avoiding potential adverse effects when possible. 在给药前，应考虑病人此时的最佳给药途径。例如，如果病人恶心呕吐，那么口服途径可能无效。另一方面，如果患者在恢复过程中接受静脉给药后疼痛有所改善，则可以开始口服止痛药，为出院回家做准备。在选择药物时，请牢记世界卫生组织的阶梯疗法，以达到患者的目标，同时尽可能避免潜在的不良反应。
When preparing opioid medications, it is important to remember that these medications are controlled substances with special regulations regarding storage, count auditing, and disposal/wasting of medication. Follow agency policy regarding these issues. It is also important to assess the patient’s level of sedation and respiratory status before administering additional doses of opioids and withhold the medication if the patient is oversedated or their respiratory rate is less than 12/minute. However, when providing pain management during end-of-life care, these parameters no longer apply because the emphasis is on providing comfort according to the patient’s preferences. Read more about end-of-life care in the “Grief and Loss” chapter. 在配制阿片类药物时，必须牢记这些药物属于管制药物，在储存、计数审核和药物处置/浪费方面有特殊规定。请遵守机构有关这些问题的政策。同样重要的是，在使用额外剂量的阿片类药物之前，要评估患者的镇静程度和呼吸状态，如果患者过度镇静或呼吸频率低于 12/分钟，则应暂停用药。然而，在临终关怀期间提供疼痛管理时，这些参数不再适用，因为重点是根据患者的偏好提供舒适。请在 "悲伤与丧失 "章节中阅读更多有关临终关怀的内容。
Evaluation 评估
It is vital for the nurse to regularly evaluate if the established interventions are effectively meeting the pain management and function goals established collaboratively with the patient. Additionally, when administering analgesics, the patient should be reassessed in an hour (or other time frame based on the onset and peak of the medication) to determine if the medication was 护士必须定期评估既定的干预措施是否有效地达到了与患者共同制定的疼痛控制和功能目标。此外，在使用镇痛药时，应在一小时后（或根据药物的起效时间和峰值确定的其他时间段）对患者进行重新评估，以确定药物是否
effective. If interventions are not effective, then follow-up interventions are required, which may include contacting the health care provider. 有效。如果干预无效，则需要采取后续干预措施，其中可能包括联系医疗服务提供者。
For patients living with chronic pain, it can be helpful for them or their caregiver to maintain a pain journal. In the journal they can document activities that precipitated pain, medications taken to manage the pain, and whether these medications were effective in helping them to meet their functional goals. This journal is shared with the health care provider during follow-up visits to enhance the treatment plan. ^(9){ }^{9} 对于患有慢性疼痛的患者来说，他们或其护理人员坚持写疼痛日志可能会有所帮助。他们可以在日志中记录引起疼痛的活动、控制疼痛的药物以及这些药物是否有效帮助他们实现功能目标。在复诊时，可与医疗服务提供者分享该日志，以改进治疗计划。 ^(9){ }^{9}
The nurse must continually monitor for potential adverse effects of pain medications. For example, if a patient is receiving acetaminophen daily for chronic osteoarthritis pain, signs of liver dysfunction, such as jaundice and elevated liver function bloodwork, should be monitored. For older adults receiving NSAIDs, it is important to watch for early signs of gastrointestinal bleeding, such as melena. Patients receiving opioids should be continually monitored for oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus. Side effects should be reported to the health care provider and orders received for treatment. 护士必须持续监测止痛药物的潜在不良反应。例如，如果患者每天服用对乙酰氨基酚治疗慢性骨关节炎疼痛，则应监测肝功能异常的迹象，如黄疸和肝功能血检升高。对于服用非甾体抗炎药的老年人，必须注意消化道出血的早期症状，如血色素沉着。接受阿片类药物治疗的患者应持续监测过度镇静、呼吸抑制、便秘、恶心呕吐、尿潴留和瘙痒等症状。应向医护人员报告副作用，并接受治疗指令。
11.6 Putting It All Together 11.6 将所有内容整合在一起
Patient Scenario 患者情景
Mrs. Jamison is a 34 -year-old woman admitted through the emergency department with kidney stones. As you reposition her in bed, she is visibly grimacing and audibly moaning. She rates her pain at an " 8 out of 10 " although she reports her pain has “improved” since admission with the IV morphine delivered via PCA pump. You recheck her vital signs and her blood pressure is elevated at 150/90 and her heart rate is 120. 杰米森女士是一名 34 岁的女性，因肾结石经急诊科入院。当您将她重新安置在床上时，她明显面无表情，并发出呻吟声。虽然她说入院后通过 PCA 泵静脉注射吗啡后疼痛 "有所改善"，但她对自己的疼痛评分为 "8 分（满分 10 分）"。您重新检查了她的生命体征，她的血压升高至 150/90，心率为 120。
Applying the Nursing Process 应用护理程序
Assessment: The nurse notes that Mrs. Jamison demonstrates signs of discomfort with visible grimacing, audible moaning, and elevated blood pressure and heart rate. She rates her pain at " 8 out of 10 ." 评估：护士注意到杰米森女士表现出明显的龇牙咧嘴、呻吟声、血压和心率升高等不适症状。她给自己的疼痛评分为 "8 分（满分 10 分）"。
Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Jamison. 根据收集到的评估信息，为杰米森女士制定了以下护理计划。
Nursing Diagnosis: Acute Pain related to physical injury agent as evidenced by change in physiological parameters and self-report of pain rated as “8 out of 10 .” 护理诊断：急性疼痛与身体损伤剂有关，表现为生理参数发生变化，自述疼痛为 "10 分中的 8 分"。
Overall Goal: The patient will report that the pain management treatment plan achieves her comfort-function goal. 总体目标：患者将报告疼痛控制治疗计划实现了其舒适-功能目标。
SMART Expected Outcomes: SMART 预期成果：
Mrs. Jamison will verbalize pain reduction to a self-reported tolerable level of " 4 " or less on a 0-10 scale by the end of the shift. 杰米森女士将在轮班结束时，口头陈述疼痛已减轻到自我报告的可忍受程度，即 0-10 级中的 "4 "级或以下。
Mrs. Jamison’s blood pressure and heart rate will return to baseline levels by the end of the shift. 贾米森太太的血压和心率将在下班前恢复到基准水平。
Planning and Implementing Nursing Interventions: 规划和实施护理干预：
The nurse will perform a comprehensive pain assessment and identify the 护士将进行全面的疼痛评估，并确定
patient’s expectation regarding pain management. The nurse will encourage the patient to use breathing techniques and relaxation methods to facilitate pain management. The nurse will notify the provider of unrelieved pain and request additional prescriptions for medication as needed. 病人对疼痛控制的期望。护士会鼓励病人使用呼吸技巧和放松方法来缓解疼痛。护士会将疼痛未缓解的情况通知医疗服务提供者，并根据需要申请额外的药物处方。
Sample Documentation: 文件样本：
Mrs. Jamison was admitted with acute pain related to kidney stones and is receiving Morphine via PCA pump. At 1400, her blood pressure was elevated at 150/90 and her heart rate elevated at 120. She reported pain as an “8 out of 10.” She was visibly grimacing and audibly moaning when repositioned in bed. Dr. Smith was notified at 1400 and a new prescription received. Ketorolac 30 mg IV was administered at 1415. At 1515, the patient stated her pain had decreased to a "3 out of 10 " level and this level was “satisfactory.” Her blood pressure also decreased to 135/76 and her heart rate decreased to 88. 杰米森女士因肾结石引起的急性疼痛入院，目前正通过 PCA 泵接受吗啡治疗。14:00 时，她的血压升至 150/90，心率升至 120。她称疼痛为 "10 分中的 8 分"。重新躺在床上时，她明显面无表情，并发出呻吟声。14:00 时通知了史密斯医生，并收到了新的处方。14 时 15 分给她静脉注射了 30 毫克酮咯酸。15 时 15 分，病人说她的疼痛已经减轻到 "3 分（满分 10 分）"的水平，而且这个水平 "令人满意"。她的血压也降至 135/76，心率降至 88。
Evaluation: 评估：
Within one hour of administration of Ketorolac, Mrs. Jamison verbalized pain reduction to her reported satisfactory level of “3,” and her blood pressure and heart rate decreased to her baseline levels. SMART outcomes were “met.” 在服用酮咯酸后一小时内，杰米森女士口头表示疼痛减轻到了她所报告的 "3 "级满意水平，血压和心率也降至基线水平。SMART 结果 "达标"。
Learning Activities 学习活动
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
Apply the concepts you learned from this chapter to the following patient scenario. 将本章所学的概念应用于以下患者情景。
Figure 17.15 Simulated Patient 图 17.15 模拟病人
Joe is a 68-year-old male who was recently diagnosed for colon cancer last week and underwent a colon resection three days ago. See Figure 11.15 for an image of Joe. ^(2){ }^{2} In the change of shift report, you hear that he is receiving morphine by PCA pump for pain, but he is not using it very often. Staff reports he “needs much encouragement” to get out of bed and participate in self-cares. He has crackles in his lung bases and his oxygen saturation is 88%88 \% on room air. 乔是一名 68 岁的男性，上周刚被诊断出患有结肠癌，三天前接受了结肠切除手术。乔的图像见图 11.15。 ^(2){ }^{2} 在交班报告中，您听说他正在使用 PCA 泵接受吗啡止痛，但使用频率不高。工作人员报告说，他 "需要很多鼓励 "才能下床参与自我护理。他的肺部有裂纹，室内空气中的血氧饱和度为 88%88 \% 。
What additional assessments (subjective and objective) will you perform on Joe? 您还将对乔进行哪些评估（主观和客观评估）？
List the top three priority nursing diagnoses for Joe. 列出乔的三大优先护理诊断。
Joe states, “I don’t want to use morphine. I am afraid I will become addicted to it like my friend did after he came home from the war.” How will you respond to therapeutically address his concerns, yet also teach Joe about good pain management? 乔说："我不想使用吗啡。我担心自己会像我的朋友一样，在战争结束回家后对吗啡上瘾。你将如何应对，既能从治疗上解决他的顾虑，又能向乔传授良好的疼痛管理知识？
What are common side effects of opioids and how will you plan to manage these side effects for Joe? 阿片类药物有哪些常见的副作用，您打算如何为乔控制这些副作用？
Emotional issues could also be affecting Joe’s perception of pain. What will you further physically assess and therapeutically address? 情绪问题也可能影响乔对疼痛的感知。您将对哪些问题进行进一步的身体评估和治疗？
After providing patient education about morphine and the PCA pump, you check on Joe later in the day and notice he has had five self-doses every hour with 15 attempts in the past hour. The pump is set for a maximum of 6 doses per hour. What further assessments will you perform? 在对病人进行了吗啡和 PCA 泵的相关教育后，您在当天晚些时候查看了乔的情况，发现他每小时自行给药五次，在过去一小时内尝试了 15 次。泵的设置为每小时最多 6 次给药。您还需要进行哪些评估？
Acute pain: Pain that is limited in duration and is associated with a specific cause. 急性疼痛：持续时间有限且与特定原因相关的疼痛。
Addiction: A chronic disease of the brain’s reward, motivation, memory, and related circuitry reflected in an individual pathologically pursuing reward and/ or relief by substance use and other behaviors. Addiction is characterized by several symptoms, such as the inability to consistently abstain from a substance, impaired behavioral control, cravings, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. 成瘾：一种大脑奖赏、动机、记忆和相关回路的慢性疾病，反映在个人通过使用药物和其他行为病态地追求奖赏和/或解脱。瘾症有多种症状，如无法持续戒除某种物质、行为控制能力受损、渴望、对自身行为和人际关系中存在的重大问题认识不足，以及情绪反应失调。
Adjuvant: Medication that is not classified as an analgesic but has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids. 辅助剂：不属于镇痛药，但在临床实践中发现与阿片类药物一起使用时具有独立镇痛效果或附加镇痛特性的药物。
Analgesics: Medications used to relieve pain. 镇痛药：止痛药：用于缓解疼痛的药物。
Chronic pain: Pain that is ongoing and persistent for longer than six months. 慢性疼痛：持续性疼痛：持续时间超过六个月。
Misuse: Taking prescription pain medications in a manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high). 滥用：以处方以外的方式或剂量服用处方止痛药；服用别人的处方药，即使是用于治疗疼痛等病症；或服用药物以获得兴奋感（即兴奋）。
Neuropathic pain: Pain caused by a lesion or disease of the somatosensory nervous system that is typically described by patients as “burning” or “like pins and needles.” 神经性疼痛：由躯体感觉神经系统的病变或疾病引起的疼痛，患者通常描述为 "烧灼感 "或 "像针刺一样"。
Nociceptor: A sensory receptor for painful stimuli. 痛觉感受器：疼痛刺激的感觉受体。
Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. 疼痛：一种不愉快的感觉和情绪体验，与实际或潜在的组织损伤相关或相似。
Patient-Controlled Analgesia (PCA): A method of pain management that allows hospitalized patients with severe pain to safely self-administer opioid 患者自控镇痛（PCA）：一种疼痛管理方法，可让住院的重度疼痛患者安全地自行使用阿片类药物。
medications using a programmed pump according to their level of discomfort. 根据他们的不适程度，使用程序泵进行药物治疗。
Physical dependence: Withdrawal symptoms that occur when chronic pain medication is suddenly reduced or stopped because of physiological adaptations that occur from chronic exposure to the medication. 生理依赖：戒断症状：由于长期接触药物而产生的生理适应，在突然减少或停用慢性止痛药时出现的症状。
Referred pain: Pain perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder. 转移性疼痛：在疼痛刺激部位以外的其他部位感觉到的疼痛。例如，结肠中潴留的气体会导致肩部疼痛。
Substance abuse disorder: Significant impairment or distress from a pattern of substance use (i.e., alcohol, drugs or misuse of prescription medications). 药物滥用障碍：药物滥用模式（即酗酒、吸毒或滥用处方药）造成的严重损害或困扰。
Tolerance: A reduced response to pain medication when the same dose of a drug has been given repeatedly, requiring a higher dose of the drug to achieve the same level of response. 耐受性：反复服用相同剂量的药物后，对止痛药物的反应减弱，需要服用更大剂量的药物才能达到相同程度的反应。
SLEEP AND REST 睡眠与休息
Learning Objectives 学习目标
Assess factors that put patients at risk for problems with sleep 评估使患者面临睡眠问题风险的因素
Identify factors related to sleep/rest across the life span 识别一生中与睡眠/休息有关的因素
Recognize characteristics of sleep deprivation 认识睡眠不足的特征
Consider the use of nonpharmacological measures to promote sleep and rest 考虑使用非药物措施来促进睡眠和休息
Identify evidence-based practices 确定循证实践
Maslow’s hierarchy of needs indicates sleep as one of our physiological requirements. Getting enough quality sleep at the right times according to our circadian rhythms can protect mental and physical health, safety, and quality of life. Conversely, chronic sleep deficiency increases the risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke, as well as weakening the immune system. This chapter will review the physiology of sleep and common sleep disorders, as well as interventions to promote good sleep. 马斯洛的需求层次理论指出，睡眠是我们的生理需求之一。根据我们的昼夜节律，在适当的时间获得足够的高质量睡眠，可以保护身心健康、安全和生活质量。相反，长期睡眠不足会增加患心脏病、肾病、高血压、糖尿病和中风的风险，并削弱免疫系统。本章将回顾睡眠生理学和常见睡眠障碍，以及促进良好睡眠的干预措施。
12.2 Basic Concepts 12.2 基本概念
What Causes Sleep? 睡眠的原因是什么？
There are two internal biological mechanisms that work together to regulate wakefulness and sleep referred to as circadian rhythms and sleep-wake homeostasis. 有两种内部生物机制共同调节觉醒和睡眠，即昼夜节律和睡眠-觉醒平衡。
Circadian rhythms direct a wide variety of body functions including wakefulness, core temperature, metabolism, and the release of hormones. They control the timing of sleep, causing a person to feel sleepy at night and creating a tendency to wake in the morning without an alarm. See Figure 12.1^(1)12.1^{1} for an illustration of circadian rhythms. Circadian rhythms are based roughly on a 24 -hour clock and use environmental cues, such as light and temperature to determine the time of day. ^(2){ }^{2} 昼夜节律引导着人体的各种功能，包括觉醒、核心体温、新陈代谢和荷尔蒙的释放。昼夜节律控制着睡眠的时间，使人在晚上感到困倦，并在早上醒来时没有闹钟。昼夜节律的示意图见图 12.1^(1)12.1^{1} 。昼夜节律大致以 24 小时时钟为基础，利用光线和温度等环境线索来确定一天中的时间。 ^(2){ }^{2}
Sleep-wake homeostasis keeps track of a person’s need for sleep. A pressure to sleep builds with every hour that a person is awake, reaching a peak in the evening when most people fall asleep. The homeostatic sleep drive also regulates sleep intensity, causing a person to sleep longer and more deeply after a period of sleep deprivation. ^(3){ }^{3} Adenosine is linked to this drive for sleep. While awake, the level of adenosine in the brain continues to rise, with increased levels signaling a shift toward sleep. While sleeping, the body breaks down adenosine. When it gets dark, the body also releases a hormone called melatonin. Melatonin signals the body that it’s time to prepare for sleep and creates a feeling of drowsiness. The amount of melatonin in the bloodstream peaks as the evening wears on. A third hormone, cortisol, is 睡眠-觉醒平衡系统记录着一个人对睡眠的需求。人每清醒一小时，睡眠压力就会增加一小时，到傍晚大多数人入睡时达到顶峰。平衡睡眠驱动力还能调节睡眠强度，使人在睡眠不足后睡得更长、更深。 ^(3){ }^{3} 腺苷与这种睡眠驱动力有关。在清醒状态下，大脑中的腺苷水平会持续上升，而腺苷水平的升高则预示着人们将进入睡眠状态。睡眠时，身体会分解腺苷。天黑时，人体还会释放一种叫做褪黑激素的荷尔蒙。褪黑激素会向身体发出信号，告诉它该准备睡觉了，并产生一种昏昏欲睡的感觉。随着夜幕降临，血液中的褪黑激素含量会达到峰值。第三种激素是皮质醇。
released in the early morning hours and naturally prepares the body to wake up. ^(4){ }^{4} 在清晨释放，自然而然地让身体做好觉醒的准备。 ^(4){ }^{4}
Factors that influence a person’s sleep and wakefulness include medical conditions, medications, stress, sleep environment, and foods and fluids consumed, but the greatest influence is exposure to light. Specialized cells in the retina process light and provide messages to the brain to align the body clock with periods of day or night. Exposure to bright artificial light in the late evening can disrupt this process, making it hard to fall asleep. Examples of bright artificial light include the light from a TV screen, computer, or smartphone. Exposure to light can also make it difficult to return to sleep after being awakened. ^(5){ }^{5} 影响人的睡眠和觉醒的因素包括医疗条件、药物、压力、睡眠环境以及摄入的食物和液体，但最大的影响因素是光照。视网膜上的专门细胞会处理光线，并向大脑提供信息，使人体时钟与白天或黑夜的时段保持一致。深夜暴露在明亮的人造光线下会扰乱这一过程，使人难以入睡。人造强光的例子包括电视屏幕、电脑或智能手机发出的光线。在被唤醒后，暴露在光线下也会使人难以入睡。 ^(5){ }^{5}
Night shift workers often have trouble falling asleep when they go to bed and may have trouble staying awake at work because their natural circadian rhythm and sleep-wake cycle are disrupted. Jet lag also disrupts circadian 夜班工人在上床睡觉时往往难以入睡，在工作时也可能难以保持清醒，因为他们的自然昼夜节律和睡眠-觉醒周期被打乱了。时差也会扰乱昼夜节律。
rhythms. When flying to a different time zone, a mismatch is created between a person’s internal clock and the actual time of day. ^(6){ }^{6} 节律。当飞往不同的时区时，人的内部时钟和一天中的实际时间就会不匹配。 ^(6){ }^{6}
The rhythm and timing of the body clock change with age. For example, teenagers fall asleep later at night than younger children and adults because melatonin is released and peaks later in the 24-hour cycle for teens. As a result, it’s natural for many teens to prefer later bedtimes at night and sleep later in the morning than adults. ^(7){ }^{7} 人体时钟的节奏和时间会随着年龄的变化而改变。例如，青少年晚上入睡的时间要晚于年幼的儿童和成人，这是因为青少年的褪黑激素在 24 小时周期中释放和达到峰值的时间较晚。因此，与成年人相比，许多青少年喜欢晚上晚点睡觉，早上晚点入睡，这是很自然的。 ^(7){ }^{7}
Individuals also need more sleep early in life, when they’re growing and developing. For example, newborns may sleep more than 16 hours a day, and preschool-aged children need to take naps. Young children tend to sleep more in the early evening whereas older adults tend to go to bed earlier and wake up earlier. 人在生命早期的生长发育阶段也需要更多的睡眠。例如，新生儿每天的睡眠时间可能超过 16 小时，学龄前儿童需要午睡。幼儿往往在傍晚睡得更多，而老年人则往往睡得更早，醒得更早。
Sleep Phases and Stages 睡眠阶段和阶段
When sleeping, individuals cycle through two phases of sleep: rapid eye movement (REM) and non-REM sleep. A full sleep cycle takes 80 to 100 minutes to complete, and most people typically cycle through four to six cycles per night. It is common to wake up briefly between cycles. ^(9){ }^{9} 人在睡眠时会经历两个睡眠阶段：快速眼动睡眠（REM）和非快速眼动睡眠。一个完整的睡眠周期需要 80 到 100 分钟，大多数人每晚通常要经历四到六个睡眠周期。在睡眠周期之间短暂醒来是很常见的现象。 ^(9){ }^{9}
Restoration takes place mostly during slow-wave non-REM sleep, during which the body’s temperature, heart rate, and brain oxygen consumption decrease. Brain activity decreases, so this stage is also referred to as slowwave sleep and is observed during sleep studies. Non-REM sleep has these three stages: 恢复主要发生在慢波非快速眼动睡眠期间，在此期间，人体的体温、心率和大脑耗氧量都会降低。大脑活动减少，因此这一阶段也被称为慢波睡眠，并在睡眠研究中被观察到。非快速眼动睡眠有以下三个阶段：
6. National Institute of Neurological Disorders and Stroke. (2019, August 13). Understanding sleep. U.S. Department of Health & Human Services. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/ Understanding-Sleep 6.国家神经疾病和中风研究所。(2019 年 8 月 13 日）。了解睡眠。https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/ Understanding-Sleep.
7. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 7.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
8. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 8.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
9. National Heart, Lung, and Blood Institute. (n.d). How sleep works. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/how-sleep-works 9.国家心肺血液研究所。(n.d).How sleep works.美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/how-sleep-works
Stage 1: The transition between wakefulness and sleep. 第一阶段：清醒与睡眠之间的过渡阶段。
Stage 2: The initiation of the sleep phase. 第 2 阶段：进入睡眠阶段。
Stage 3: The deep sleep or slow-wave sleep stage based on a pattern that appears during measurements of brain activity. Individuals spend the most amount of sleep time in this stage during the early part of the night. (Note that the previously considered 4th stage of non-REM sleep is now included within Stage 3). 第 3 阶段：深度睡眠或慢波睡眠阶段，以测量大脑活动时出现的模式为基础。人在这一阶段的睡眠时间最长，在夜间的早些时候。(请注意，之前被认为是第四阶段的非快速眼动睡眠现在也包含在第三阶段中）。
During REM sleep, a person’s heart rate and respiratory rate increase. Eyes twitch as they rapidly move back and forth and the brain is active. Brain activity measured during REM sleep is similar to activity during waking hours. Dreaming occurs during REM sleep, and muscles normally become limp to prevent acting out one’s dreams. People typically experience more REM sleep as the night progresses. However, hot and cold environments can affect a person’s REM sleep because the body does not regulate temperature well during REM sleep. ^(11){ }^{11} See Figure 12.2^(12)12.2^{12} for an image illustrating stages of sleep with increased REM sleep through the night indicated in solid red lines. 在快速动眼期睡眠中，人的心率和呼吸频率会加快。眼睛在快速来回移动时会抽搐，大脑处于活跃状态。在快速动眼期睡眠中测得的大脑活动与清醒时的活动相似。快速动眼期睡眠时会做梦，肌肉通常会变得松弛，以防止做梦。一般来说，随着时间的推移，人的快速动眼期睡眠会越来越多。然而，冷热环境会影响人的快速动眼期睡眠，因为人体在快速动眼期睡眠时不能很好地调节温度。 ^(11){ }^{11} 请参阅图 12.2^(12)12.2^{12} ，该图展示了睡眠的各个阶段，红色实线表示快速眼动睡眠在夜间的增加。
10. National Heart, Lung, and Blood Institute. (n.d). How sleep works. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/how-sleep-works 10.国家心肺血液研究所。(n.d).How sleep works.美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/how-sleep-works
11. National Heart, Lung, and Blood Institute. (n.d). How sleep works. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/how-sleep-works 11.国家心肺血液研究所。(n.d).How sleep works.美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/how-sleep-works
12. “The_master_circadian_clock_in_the_human_brain.jpg” by Ian B. Hickie, Sharon L. Naismith, Rébecca Robillard, Elizabeth M. Scott, and Daniel F. Hermens is licensed under CC BY 3.0 12."The_master_circadian_clockin_the_human_brain.jpg" 由 Ian B. Hickie、Sharon L. Naismith、Rébecca Robillard、Elizabeth M. Scott 和 Daniel F. Hermens 采用 CC BY 3.0 许可。
Figure 12.2 Stages of Sleep 图 12.2 睡眠阶段
The patterns and types of sleep change as people mature. For example, newborns spend more time in REM sleep. The amount of slow-wave sleep peaks in early childhood and then drops sharply in the teenage years. Slowwave sleep continues to decrease through adulthood, and older people may not have any slow-wave sleep at all. ^(13){ }^{13} 睡眠的模式和类型会随着人的成熟而改变。例如，新生儿的快速眼动睡眠时间较长。慢波睡眠的时间在幼儿期达到高峰，然后在青少年期急剧下降。慢波睡眠在成年后继续减少，老年人可能根本没有慢波睡眠。 ^(13){ }^{13}
Why Is Sleep Important? 睡眠为何重要？
Sleep plays a vital role in good health and well-being. Getting enough quality sleep at the right times protects mental health and physical health. Lack of sleep affects daytime performance, quality of life, and safety. The way a person feels while awake depends on what happens while they are sleeping. During sleep, the body is working to support healthy brain function and 睡眠对身心健康起着至关重要的作用。在适当的时间获得足够的高质量睡眠可以保护心理健康和身体健康。睡眠不足会影响白天的工作表现、生活质量和安全。一个人清醒时的感觉取决于睡眠时发生的事情。在睡眠中，身体正在努力支持健康的大脑功能，并且
maintain physical health. In children and teens, sleep also helps support growth and development. ^(14){ }^{14} 保持身体健康。对于儿童和青少年来说，睡眠还有助于生长和发育。 ^(14){ }^{14}
Healthy Brain Function and Emotional Well-Being 健康的大脑功能和良好的情绪
Sleep helps the brain work properly. While sleeping, the brain is forming new pathways to help a person learn and remember information. Studies show that a good night’s sleep improves learning and problem-solving skills. Sleep also helps a person pay attention, make decisions, and be creative. Conversely, sleep deficiency alters activity in some parts of the brain, causing difficulty in making decisions, solving problems, controlling emotions and behavior, and coping with change. Sleep deficiency has also been linked to depression, suicide, and risk-taking behavior. ^(15){ }^{15} 睡眠有助于大脑正常工作。睡眠时，大脑正在形成新的通路，帮助人们学习和记忆信息。研究表明，良好的睡眠能提高学习和解决问题的能力。睡眠还有助于一个人集中注意力、做出决定和发挥创造力。相反，睡眠不足会改变大脑某些部分的活动，导致难以做出决定、解决问题、控制情绪和行为以及应对变化。睡眠不足还与抑郁、自杀和冒险行为有关。 ^(15){ }^{15}
Physical Health 身体健康
Sleep also plays an important role in physical health. For example, sleep is involved in healing and repairing the heart and blood vessels. Ongoing sleep deficiency is linked to an increased risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke. Sleep helps maintain a healthy balance of the hormones that cause hunger (ghrelin) or a feeling of fullness (leptin). When a person doesn’t get enough sleep, the level of ghrelin increases and the level of leptin decreases, causing a person to feel hungry when sleep deprived. The way the body responds to insulin is also affected, causing increased blood sugar. 睡眠对身体健康也有重要作用。例如，睡眠参与心脏和血管的愈合和修复。长期睡眠不足会增加患心脏病、肾病、高血压、糖尿病和中风的风险。睡眠有助于维持引起饥饿（胃泌素）或饱腹感（瘦素）的荷尔蒙的健康平衡。睡眠不足时，胃泌素水平会升高，瘦素水平会降低，从而导致睡眠不足的人感到饥饿。身体对胰岛素的反应方式也会受到影响，导致血糖升高。
Sleep supports healthy growth and development. Deep sleep triggers the body to release hormones that promote normal growth in children and teens. 睡眠有助于健康成长和发展。深度睡眠会促使身体释放荷尔蒙，促进儿童和青少年的正常生长。
14. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 14.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
15. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 15.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
16. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 16.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
See Figure 12.3. ^(17){ }^{17} of a sleeping child. These hormones also boost muscle mass and help repair cells and tissues. ^(18){ }^{18} 参见图 12.3。 ^(17){ }^{17} 一个熟睡的孩子。这些激素还能增强肌肉质量，帮助修复细胞和组织。 ^(18){ }^{18}
Figure 12.3 Sleeping Child 图 12.3 熟睡中的儿童
Daytime Performance 日间演出
Getting enough quality sleep at the right times also enhances functioning throughout the day. People who are sleep deficient are less productive at work and school. They take longer to finish tasks, have a slower reaction time, and make more mistakes. After several nights of losing sleep, even a loss of 在适当的时间获得足够的高质量睡眠还能提高全天的工作效率。睡眠不足的人工作和学习效率较低。他们完成任务的时间更长，反应速度更慢，犯的错误也更多。经过几个晚上的失眠后，即使失去了
17. “6041578611_f2c9e4d164_k.jpg” by rachel CALAMUSA is licensed under CC BY-SA 2.0 17."6041578611_f2c9e4d164_k.jpg" by rachel CALAMUSA is licensed under CC BY-SA 2.0
18. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 18.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
just 1 or 2 hours per night, the ability to function declines. ^(19){ }^{19} See Figure 12.4^(20)12.4^{20} for an image of a student demonstrating sleep deficiency while studying. 如果每晚只睡 1 或 2 个小时，身体机能就会下降。 ^(19){ }^{19} 见图 12.4^(20)12.4^{20} ，图中的学生在学习时表现出睡眠不足。
19. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 19.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
20. “Study_sleep.jpg” by Nic Ashman, Chippewa Valley Technical College is licensed under CC BY 4.0 20."Study_sleep.jpg" 由奇佩瓦山谷技术学院的 Nic Ashman 创作，采用 CC BY 4.0 许可。
Figure 12.4 Sleep Deficiency 图 12.4 睡眠不足
Lack of sleep can lead to microsleep. Microsleep refers to brief moments of sleep that occur when one is normally awake. You can’t control microsleep, and you might not be aware of it. For example, have you ever driven somewhere and then not remembered part of the trip? If so, you may have 睡眠不足会导致微睡眠。微睡眠是指人在正常清醒时出现的短暂睡眠。你无法控制微睡眠，也可能意识不到它的存在。例如，您是否曾经开车到过某个地方，但却不记得行程的一部分？如果有，您可能
experienced microsleep. Even if you’re not driving, microsleep can affect how you function. If you’re listening to a lecture, for example, you might miss some of the information or feel as if you don’t understand the point. In reality, you may have slept through part of the lecture and not been aware of experiencing microsleep. ^(21){ }^{21} 经历微睡眠。即使您没有开车，微睡眠也会影响您的工作。例如，如果您在听讲座，您可能会错过一些信息，或者感觉自己没有理解重点。实际上，您可能睡过了讲座的部分内容，并没有意识到自己正在经历微睡眠。 ^(21){ }^{21}
Effects of Sleep Deficiency 睡眠不足的影响
The damage from sleep deficiency can occur in an instant. For example, drowsy drivers may feel capable of driving. Yet, studies show that sleep deficiency harms one’s driving ability as much as, or more than, being drunk. It is estimated that driver sleepiness is a factor in about 100,000 car accidents each year, resulting in about 1,500 deaths. ^(22){ }^{22} 睡眠不足造成的伤害可能在瞬间发生。例如，昏昏欲睡的司机可能会觉得自己有能力开车。然而，研究表明，睡眠不足对驾驶能力的损害不亚于醉酒，甚至有过之而无不及。据估计，每年约有 100,000 起车祸是由于司机嗜睡造成的，造成约 1,500 人死亡。 ^(22){ }^{22}
Drivers aren’t the only ones affected by sleep deficiency. It can affect people in all lines of work, including health care workers, pilots, students, mechanics, and assembly line workers. As a result, sleep deficiency is harmful not only on a personal level, but also can cause large-scale damage. For example, sleep deficiency has played a role in human errors linked to tragic accidents, such as nuclear reactor meltdowns, grounding of large ships, and aviation accidents. ^(23){ }^{23} 受睡眠不足影响的不仅仅是司机。各行各业的人都可能受到睡眠不足的影响，包括医护人员、飞行员、学生、机械师和流水线工人。因此，睡眠不足不仅对个人有害，还可能造成大规模损害。例如，在核反应堆熔毁、大型船舶搁浅和航空事故等悲剧性事故中，睡眠不足都与人为失误有关。 ^(23){ }^{23}
Sleep deficiency can also cause long-term harm. It increases the risk of obesity. For example, one study of teenagers showed that with each hour of sleep lost, the odds of becoming obese went up. Sleep deficiency increases the risk of obesity in other age groups as well. Sleep also affects how your body reacts to insulin, the hormone that controls your blood glucose (sugar) level. Sleep deficiency results in a higher than normal blood sugar level, which 睡眠不足也会造成长期危害。它会增加肥胖的风险。例如，一项针对青少年的研究表明，睡眠时间每减少一小时，肥胖的几率就会增加。睡眠不足也会增加其他年龄组的肥胖风险。睡眠也会影响身体对胰岛素的反应，胰岛素是控制血糖水平的激素。睡眠不足会导致血糖水平高于正常值，从而
21. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 21.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
22. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 22.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
23. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 23.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
may increase your risk for diabetes. ^(24){ }^{24} Ongoing sleep deficiency can also change the way in which your immune system responds. For example, if you’re sleep deficient, you may have trouble fighting common infections. ^(25){ }^{25} In addition, children and teens who are sleep deficient may have problems getting along with others. They may feel angry and impulsive, have mood swings, feel sad or depressed, or lack motivation. They also may have problems paying attention, and they may get lower grades and feel stressed. ^(26){ }^{26} 可能会增加您患糖尿病的风险。 ^(24){ }^{24} 持续睡眠不足也会改变免疫系统的反应方式。例如，如果你睡眠不足，你可能难以抵抗常见的感染。 ^(25){ }^{25} 此外，睡眠不足的儿童和青少年在与他人相处时可能会出现问题。他们可能会感到愤怒和冲动，情绪不稳定，感到悲伤或沮丧，或缺乏动力。他们还可能注意力不集中，成绩下降，感到压力。 ^(26){ }^{26}
If a person routinely loses sleep or chooses to sleep less than needed, the sleep loss adds up. The total sleep lost is called sleep debt. For example, if you lose 2 hours of sleep each night, you’ll have a sleep debt of 14 hours after a week. ^(27){ }^{27} See Figure 12.5^(28)12.5^{28} of an individual feeling the effects of sleep debt on awakening. 如果一个人经常失眠或选择睡得比需要的少，睡眠损失就会增加。损失的总睡眠时间称为睡眠负债。例如，如果你每晚失眠 2 小时，一周后你就会欠下 14 小时的睡眠债。 ^(27){ }^{27} 请看图 12.5^(28)12.5^{28} ，图中的人在醒来时会感受到睡眠负债的影响。
24. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 24.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
25. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 25.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
26. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 26.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
27. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 27.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
28. “8609141689_ff923d2934_k.jpg” by Navy_NADAP is licensed under CC BY-NC-ND 2.0 28."8609141689_ff923d2934_k.jpg" by Navy_NADAP 采用 CC BY-NC-ND 2.0 许可协议发布。
Figure 12.5 Sleep Debt 图 12.5 睡眠债务
Some people nap as a way to deal with sleepiness. Naps can provide a shortterm boost in alertness and performance. However, napping doesn’t provide restorative sleep. Some people sleep more on their days off than on work days. They also may go to bed later and get up later on days off. Although extra sleep on days off might help a person feel better, it can upset the body’s sleep-wake rhythm. ^(29){ }^{29} See Figure 12.6^(30)12.6^{30} of an adult napping during the day. 有些人把小睡作为解决困倦的一种方法。午睡可以在短期内提高警觉性和工作效率。然而，午睡并不能提供恢复性睡眠。有些人在休息日比工作日睡得更多。他们也可能在休息日晚睡晚起。虽然在休息日多睡会让人感觉更好，但这会扰乱身体的睡眠-觉醒节奏。 ^(29){ }^{29} 见图 12.6^(30)12.6^{30} ，一个成年人在白天打盹。
29. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 29.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency。
30. “Sleeping_man_J2.jpg” by Jamain is licensed under CC BY-SA 3.0 30."Sleeping_man_J2.jpg" by Jamain 采用 CC BY-SA 3.0 许可。
Figure 12.6 Napping 图 12.6 小睡
Sleep deficiency can affect people even when they sleep the total number of hours recommended for their age group. For example, people whose sleep is out of sync with their body clocks (such as shift workers) or whose sleep is routinely interrupted (such as caregivers or emergency responders) often need to pay special attention to their sleep needs. ^(31){ }^{31} Individuals should also talk to a health care provider if they sleep more than eight hours a night, but don’t feel well-rested. This can indicate a sleep disorder or other health problem. ^(32){ }^{32} 即使睡眠时间达到了同年龄组建议的总时数，睡眠不足也会对人造成影响。例如，睡眠与身体时钟不同步的人（如轮班工作者）或睡眠经常被打断的人（如护理人员或应急人员）往往需要特别注意自己的睡眠需求。 ^(31){ }^{31} 如果个人每晚睡眠时间超过八小时，但感觉没有休息好，也应该向医疗保健提供者咨询。这可能预示着睡眠障碍或其他健康问题。 ^(32){ }^{32}
31. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 31.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
32. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 32.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
Sleep Disorders 睡眠障碍
There are several sleep disorders that can cause sleep deficiency, such as insomnia, sleep apnea, and narcolepsy. 有几种睡眠障碍会导致睡眠不足，如失眠、睡眠呼吸暂停和嗜睡症。
Insomnia 失眠
Insomnia is a common sleep disorder that causes trouble falling asleep, staying asleep, or getting good quality sleep. Insomnia interferes with daily activities and causes the person to feel unrested or sleepy during the day. Short-term insomnia may be caused by stress or changes in one’s schedule or environment. It can last for a few days or weeks. Chronic insomnia occurs three or more nights a week, lasts more than three months, and cannot be fully explained by another health problem or a medication. Chronic insomnia raises the risk of high blood pressure, coronary heart disease, diabetes, and cancer. ^(34){ }^{34} 失眠是一种常见的睡眠障碍，会导致难以入睡、难以保持睡眠状态或难以获得高质量的睡眠。失眠会影响日常活动，使人在白天感到精神不振或昏昏欲睡。短期失眠可能是由于压力或个人作息时间或环境的改变造成的。它可能持续几天或几周。慢性失眠每周出现三个或三个以上的夜晚，持续时间超过三个月，并且无法用其他健康问题或药物完全解释。长期失眠会增加患高血压、冠心病、糖尿病和癌症的风险。 ^(34){ }^{34}
Symptoms of insomnia include the following: 失眠的症状包括以下几种：
Lying awake for a long time before falling asleep. This is more common in younger adults. 入睡前长时间醒着。这种情况在年轻人中更为常见。
Sleeping for only short periods due to waking up often during the night or being awake for most of the night. This is the most common symptom and typically affects older adults. 由于夜间经常醒来或大半夜都醒着，只能睡一小会儿。这是最常见的症状，通常影响老年人。
Waking up too early in the morning and not being able to get back to sleep. 早上起得太早，无法继续入睡。
Having poor-quality of sleep that causes one to wake up feeling unrested. The person often feels sleepy during the day and has difficulty focusing on tasks. Insomnia can also cause irritability, anxiousness, and depression. ^(35){ }^{35} 睡眠质量差，使人醒来后感到精神不振。白天经常感到困倦，难以集中精力做事情。失眠还会导致烦躁、焦虑和抑郁。 ^(35){ }^{35}
See Figure 12.7^(36)12.7^{36} for an illustration of insomnia. 有关失眠的说明，请参见图 12.7^(36)12.7^{36} 。
Figure 12.7 Insomnia 图 12.7 失眠
To diagnose insomnia, the health care provider asks about a person’s sleep habits and may request the person to keep a sleep diary for 1-2 weeks. A sleep diary records the time a person goes to sleep, wakes up, and takes naps each day. Timing of activities such as exercising and drinking caffeine or alcohol are also recorded, as well as feelings of sleepiness throughout the day. ^(37){ }^{37} A sleep study may be ordered to look for other sleep problems, such as circadian rhythm disorders, sleep apnea, and narcolepsy. 要诊断失眠症，医疗服务提供者会询问患者的睡眠习惯，并可能要求患者记录 1-2 周的睡眠日记。睡眠日记记录一个人每天睡觉、起床和小睡的时间。运动、饮用咖啡因或酒精等活动的时间以及全天的困倦感也会被记录下来。 ^(37){ }^{37} 可能需要进行睡眠检查，以发现其他睡眠问题，如昼夜节律紊乱、睡眠呼吸暂停和嗜睡症。 https://www.nhlbi.nih.gov/health-topics/insomnia
36. “Depiction_of_a_person_suffering_from_Insomnia_(sleeplessness).png” by https://www.myupchar.com/en is licensed under CC BY-SA 4.0 36.https://www.myupchar.com/en 制作的 "Depiction_of_a_person_suffering_from_Insomnia_(sleeplessness).png "采用 CC BY-SA 4.0 许可。
37. National Heart, Lung, and Blood Institute. (n.d). Insomnia. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/insomnia 37.国家心肺血液研究所。(n.d).失眠。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/insomnia。
TREATMENT 治疗
Lifestyle changes often help improve short-term insomnia. The patient should be educated about healthy sleep habits, such as the following: 改变生活方式通常有助于改善短期失眠。应教育患者养成健康的睡眠习惯，如以下几点：
Make your bedroom sleep-friendly. Sleep in a cool, quiet place. Avoid artificial light from the TV or electronic devices, as this can disrupt your sleep-wake cycle. 让卧室适合睡眠。在凉爽、安静的地方睡觉。避免电视或电子设备的人造光，因为这会扰乱您的睡眠-觉醒周期。
Go to sleep and wake up around the same times each day, even on the weekends. If you can, avoid night shifts, irregular schedules, or other things that may disrupt your sleep schedule. 每天在相同的时间睡觉和起床，即使在周末也是如此。如果可以，避免上夜班、作息不规律或其他可能扰乱睡眠时间的事情。
Avoid caffeine, nicotine, and alcohol before bedtime. Although alcohol can make it easier to fall asleep, it triggers sleep that tends to be lighter than normal. This makes it more likely that you will wake up during the night. The effect of caffeine can last as long as eight hours. 睡前避免摄入咖啡因、尼古丁和酒精。虽然酒精能让人更容易入睡，但它引发的睡眠往往比正常睡眠更浅。这使您更有可能在夜间醒来。咖啡因的作用可持续长达八个小时。
Get regular physical activity during the daytime (at least 5 to 6 hours before going to bed). Exercising close to bedtime can make it harder to fall asleep. 在白天（至少在睡前 5 到 6 个小时）进行有规律的体育锻炼。临睡前运动会使人更难入睡。
Avoid daytime naps, especially in the afternoon. This may help you sleep longer at night. 避免白天小睡，尤其是下午。这可能有助于你晚上睡得更长。
Eat meals on a regular schedule and avoid late-night dinners to maintain a regular sleep-wake cycle. 按时进餐，避免吃夜宵，以保持正常的睡眠-觉醒周期。
Limit how much fluid you drink close to bedtime. This may help you sleep longer without having to use the bathroom. 限制临睡前的饮水量。这可能会帮助您睡得更久而无需上厕所。
Learn new ways to manage stress. Follow a routine that helps you wind down and relax before bed. For example, read a book, listen to soothing music, or take a hot bath. Your doctor may also recommend massage therapy, meditation, or yoga to help you relax. Acupuncture may also help improve insomnia, especially in older adults. 学习管理压力的新方法。睡前按部就班，帮助自己放松身心。例如，读一本书、听舒缓的音乐或洗个热水澡。医生可能还会建议您进行按摩疗法、冥想或瑜伽来帮助您放松。针灸也有助于改善失眠，尤其是老年人。
Avoid certain over-the-counter and prescription medicines that can disrupt sleep (for example, some cold and allergy medicines). ^(38){ }^{38} 避免服用某些会干扰睡眠的非处方药和处方药（例如某些感冒药和过敏药）。 ^(38){ }^{38}
A type of counseling called cognitive behavioral therapy for insomnia is 一种名为认知行为疗法的失眠症咨询是
usually the first treatment recommended for chronic insomnia. Several prescription medications may also be prescribed to treat insomnia. Some are meant for short-term use while others are meant for long-term use. Some insomnia medications can be habit-forming, and they all can cause dizziness, drowsiness, or worsening of depression or suicidal thoughts. ^(39){ }^{39} Common medications prescribed to treat insomnia are as follows: 通常是治疗慢性失眠的首选方法。治疗失眠症的处方药也有几种。有些是短期用药，有些则是长期用药。有些失眠药物可能会形成习惯，它们都可能导致头晕、嗜睡、抑郁加重或产生自杀念头。 ^(39){ }^{39} 治疗失眠的常见药物如下：
Benzodiazepines, such as lorazepam (Ativan). Benzodiazepines can be habit-forming and should be taken for only a few weeks. They can interfere with REM sleep. 苯二氮卓类药物，如劳拉西泮（Ativan）。苯二氮卓类药物会形成习惯，只能服用几周。它们会干扰快速动眼期睡眠。
Benzodiazepine-receptor agonists, such as zolpidem (Ambien). Side effects may include anxiety. Rare side effects may include a severe allergic reaction or unintentionally doing activities while asleep such as walking, eating, or driving. 苯二氮卓受体激动剂，如唑吡坦（安眠酮）。副作用可能包括焦虑。罕见的副作用可能包括严重过敏反应或在睡眠中无意中进行行走、进食或驾驶等活动。
Melatonin-receptor agonists, such as ramelteon (Rozerem). Rare side effects may include doing activities while asleep, such as walking, eating, or driving, or a severe allergic reaction. 褪黑素受体激动剂，如雷美替尼（Rozerem）。罕见的副作用可能包括在睡眠状态下进行行走、进食或驾驶等活动，或出现严重的过敏反应。
Orexin-receptor antagonists, such as suvorexant (Belsomra). This medicine is not recommended for people who have narcolepsy. Rare side effects may include doing activities while asleep, such as walking, eating, or driving, or not being able to move or speak for several minutes while going to sleep or waking up. ^(40){ }^{40} 促肾上腺皮质激素受体拮抗剂，如 suvorexant（Belsomra）。不建议嗜睡症患者服用这种药物。罕见的副作用可能包括在睡觉时进行活动，如行走、进食或开车，或在入睡或醒来后几分钟内无法动弹或说话。 ^(40){ }^{40}
Some patients use over-the-counter (OTC) products as sleep aids. Many contain antihistamines that cause sleepiness. However, they can be unsafe for some people and may not be the best treatment for insomnia. Melatonin supplements are lab-made versions of the sleep hormone melatonin. Many people take melatonin supplements to improve their sleep. However, research has not proven that melatonin is an effective treatment for insomnia. Side effects of melatonin may include daytime sleepiness, headaches, upset 有些患者使用非处方（OTC）产品作为助眠剂。许多产品含有抗组胺剂，会引起嗜睡。然而，这些产品对某些人来说可能不安全，而且可能不是治疗失眠的最佳方法。褪黑素补充剂是实验室制造的睡眠荷尔蒙褪黑素。许多人服用褪黑素补充剂来改善睡眠。然而，研究并未证明褪黑素是治疗失眠的有效方法。
stomach, and worsening depression. It can also affect the body’s control of blood pressure, causing high or low blood pressure. ^(41){ }^{41} 胃部不适，抑郁加重。它还会影响人体对血压的控制，导致高血压或低血压。 ^(41){ }^{41}
Sleep Apnea 睡眠呼吸暂停
Sleep apnea is a common sleep condition that occurs when the upper airway becomes repeatedly blocked during sleep, reducing or completely stopping airflow. If the brain does not send the signals needed to breathe, the condition may be called central sleep apnea. 睡眠呼吸暂停是一种常见的睡眠疾病，是指上气道在睡眠过程中反复受阻，气流减少或完全停止。如果大脑没有发出呼吸所需的信号，这种情况可能被称为中枢性睡眠呼吸暂停。
Sleep apnea can be caused by a person’s physical structure or other medical conditions. Risk factors include obesity (causing fat deposits in the neck), large tonsils (that narrow the airway), thyroid disorders, neuromuscular disorders, heart or kidney failure (causing fluid buildup in the neck that narrows the airway), genetic syndromes (such as cleft lip or Down’s syndrome), and premature birth (before 37 weeks gestation). ^(43){ }^{43} 睡眠呼吸暂停可能是由人的身体结构或其他疾病引起的。危险因素包括肥胖（导致颈部脂肪沉积）、扁桃体过大（使气道变窄）、甲状腺疾病、神经肌肉疾病、心脏或肾功能衰竭（导致颈部积液，使气道变窄）、遗传综合征（如唇裂或唐氏综合征）和早产（妊娠 37 周前）。 ^(43){ }^{43}
Common signs and symptoms of sleep apnea include the following: 睡眠呼吸暂停的常见体征和症状包括以下几种：
Reduced or absent breathing, known as apnea events 呼吸减弱或消失，称为呼吸暂停事件
Frequent loud snoring 经常打鼾
Gasping for air during sleep 睡眠时大口喘气
Excessive daytime sleepiness and fatigue 白天过度嗜睡和疲劳
Decreases in attention, vigilance, concentration, motor skills, and verbal and visuospatial memory 注意力、警觉性、集中力、运动技能以及言语和视觉空间记忆力下降
Dry mouth or headaches when waking 醒来时口干或头痛
Sexual dysfunction or decreased libido 性功能障碍或性欲减退
Waking up often during the night to urinate ^(44){ }^{44} 夜里经常醒来小便 ^(44){ }^{44}
National Heart, Lung, and Blood Institute. (n.d). Insomnia. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/insomnia 国家心肺血液研究所。(n.d).失眠。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/insomnia
National Heart, Lung, and Blood Institute. (n.d). Sleep apnea. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-apnea 国家心肺血液研究所。(n.d).睡眠呼吸暂停。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-apnea
National Heart, Lung, and Blood Institute. (n.d). Sleep apnea. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-apnea 国家心肺血液研究所。(n.d).睡眠呼吸暂停。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-apnea
National Heart, Lung, and Blood Institute. (n.d). Sleep apnea. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-apnea 国家心肺血液研究所。(n.d).睡眠呼吸暂停。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-apnea
Sleep apnea is diagnosed by a health care provider based on the person’s medical history, a physical exam, and results from a sleep study. During sleep studies, the number of episodes of slowed or stopped breathing events are recorded, along with documentation of oxygen levels in the blood during these events. 睡眠呼吸暂停是由医护人员根据患者的病史、体格检查和睡眠研究结果诊断出来的。在睡眠研究中，会记录呼吸减慢或停止的次数，以及在这些情况下血液中的含氧量。
TREATMENT 治疗
A breathing device, such as a CPAP machine, is the most commonly recommended treatment for patients with sleep apnea. CPAP stands for continuous positive airway pressure therapy. It uses mild air pressure to keep the airways open. See Figure 12.8^(46)12.8^{46} for an illustration of a CPAP. 呼吸设备，如 CPAP 机器，是睡眠呼吸暂停患者最常推荐的治疗方法。CPAP 是持续气道正压疗法的缩写。它使用温和的气压保持呼吸道通畅。请参阅图 12.8^(46)12.8^{46} ，了解 CPAP 的示意图。
Read more about CPAP devices in the “Oxygen Therapy” chapter in Open RN Nursing Skills. 请阅读《开放式注册护士护理技能》中 "氧气疗法 "一章中有关 CPAP 设备的更多内容。
A mouthpiece may be prescribed for patients with mild sleep apnea or if the apnea occurs only when lying on their back. Mouthpieces, or oral appliances, are custom-fit devices that are worn while sleeping. See Figure 12.9^(47)12.9^{47} for examples of mouthpieces used to treat sleep apnea. Mouthpieces are custom-fit by a dentist or an orthodontist to the patient’s mouth and jaw. There are two types of mouthpieces that work differently to open the upper airway. Mandibular repositioning mouthpieces are devices that cover the upper and lower teeth and hold the jaw in a position that prevents it from blocking the upper airway. Tongue-retaining devices are mouthpieces that 对于轻度睡眠呼吸暂停患者或仅在仰卧时出现呼吸暂停的患者，可以为其开具口罩。吹嘴或口腔矫治器是睡眠时佩戴的定制装置。请参阅图 12.9^(47)12.9^{47} ，了解用于治疗睡眠呼吸暂停的吹嘴示例。口塞由牙医或正畸医生根据患者的口腔和下颌定制安装。有两种类型的吹嘴以不同的方式打开上气道。下颌复位口塞是一种覆盖上下牙齿的装置，可将下颌固定在一定位置，防止其阻塞上气道。舌头固定器是一种可以
47. “Orthoapnea_,_oral_appliance.jpg” by Orthoapnea is licensed under CC BY-SA 3.0 and “3D_printed_mouthpeace.jpg” by unknown author is licensed under CC BY 3.0 47.Orthoapnea 的作品 "Orthoapnea_,_oral_appliance.jpg "采用 CC BY-SA 3.0 许可协议进行许可，未知作者的作品 "3D_printed_mouthpeace.jpg "采用 CC BY 3.0 许可协议进行许可。
hold the tongue in a forward position to prevent it from blocking the upper airway. 保持舌头向前，防止舌头堵塞上呼吸道。
Figure 12.9 Mouthpieces Used to Treat Sleep Apnea 图 12.9 用于治疗睡眠呼吸暂停的吹嘴
Narcolepsy 嗜睡症
Narcolepsy is an uncommon sleep disorder that causes periods of extreme daytime sleepiness and sudden, brief episodes of deep sleep during the day. Signs and symptoms of narcolepsy include extreme daytime sleepiness; falling asleep without warning, called sleep attacks; difficulty focusing or staying awake; and waking frequently at night. Individuals may experience hallucinations while falling asleep or waking up or sleep paralysis, a feeling of being awake but being unable to move for several minutes. Narcolepsy is diagnosed based on medical history, family history, a physical exam, and a sleep study. The sleep study looks at daytime naps to identify disturbed sleep or a quick onset of rapid eye movement (REM) sleep. Treatment for narcolepsy combines medications and behavior changes. Medications used to treat narcolepsy include stimulants, modafinil, and sodium oxybate to treat daytime sleepiness, and sedatives to improve nighttime sleep. Daytime 嗜睡症是一种不常见的睡眠障碍，会导致白天极度嗜睡和白天突然短暂的深度睡眠。嗜睡症的体征和症状包括白天极度嗜睡；毫无征兆地入睡，称为睡眠发作；难以集中注意力或保持清醒；夜间频繁醒来。患者在入睡或醒来时可能会出现幻觉，或出现睡眠麻痹，即感觉自己醒着，但在几分钟内无法动弹。嗜睡症的诊断依据是病史、家族史、体格检查和睡眠检查。睡眠检查通过观察白天的小睡来确定睡眠是否紊乱或快速眼动（REM）睡眠是否快速开始。嗜睡症的治疗结合了药物和行为改变。用于治疗嗜睡症的药物包括治疗白天嗜睡的兴奋剂、莫达非尼和羟苯酸钠，以及改善夜间睡眠的镇静剂。白天
sleepiness is often improved by promoting good quality sleep at night with scheduled naps during the day. 嗜睡通常可以通过促进夜间高质量睡眠和白天定时小睡来改善。
49. National Heart, Lung, and Blood Institute. (n.d). Narcolepsy. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/narcolepsy 49.国家心肺血液研究所。(n.d).嗜睡症。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/narcolepsy。
Assessment 评估
Begin a focused assessment on a patient’s sleep patterns by asking an openended question such as, “Do you feel rested upon awakening?” From there, five key sleep characteristics should be assessed: sleep duration, sleep quality, sleep timing, daytime alertness, and the presence of a sleep disorder. Examples of focused interview questions are included in Table 12.3a. These questions have been selected from sleep health questionnaires from the National Sleep Foundation’s Sleep Health Index and the National Healthy Sleep Awareness Project.’ 在开始对患者的睡眠模式进行重点评估时，首先要问一个开放式的问题，如 "您醒来时感觉休息好吗？然后，应评估五个关键的睡眠特征：睡眠时间、睡眠质量、睡眠时间、白天警觉性和是否存在睡眠障碍。表 12.3a 列出了重点访谈问题的示例。这些问题选自全美睡眠基金会的睡眠健康指数和全美健康睡眠意识项目的睡眠健康问卷。
How many hours do you sleep on an average night? 您平均每晚睡几个小时？
7-8 hours for adults (See Table 12.3b for recommended sleep by age range.) 成人为 7-8 小时（各年龄段的建议睡眠时间见表 12.3b）。
During the past month, how would you rate your sleep quality overall? 在过去一个月中，您如何评价自己的总体睡眠质量？
Very good or fairly good 非常好或相当好
Do you go to bed and wake up at the same time every day, even on weekends? 您每天都在同一时间睡觉和起床吗，即使是周末？
Yes, maintain a consistent sleep schedule in general 是的，总体上保持一致的睡眠时间
How likely is it for you to fall asleep during the daytime without intending to struggle to stay awake while you are doing things? 您在白天无意中睡着的可能性有多大？
Unlikely 不太可能
How often do you have trouble going to sleep or staying asleep? 您经常难以入睡或无法入睡吗？
Never, rarely, or sometimes 从不、很少或有时
在过去两周中，您有多少天打鼾声音很大？注意：向患者的睡眠伴侣询问这个问题会有所帮助。
During the past 2 weeks, how many days did you have loud snoring?
Note: It is helpful to ask the patient's sleep partner this question.
During the past 2 weeks, how many days did you have loud snoring?
Note: It is helpful to ask the patient's sleep partner this question.| During the past 2 weeks, how many days did you have loud snoring? |
| :--- |
| Note: It is helpful to ask the patient's sleep partner this question. |
Never 从不
Questions Desired Answers
How many hours do you sleep on an average night? 7-8 hours for adults (See Table 12.3b for recommended sleep by age range.)
During the past month, how would you rate your sleep quality overall? Very good or fairly good
Do you go to bed and wake up at the same time every day, even on weekends? Yes, maintain a consistent sleep schedule in general
How likely is it for you to fall asleep during the daytime without intending to struggle to stay awake while you are doing things? Unlikely
How often do you have trouble going to sleep or staying asleep? Never, rarely, or sometimes
"During the past 2 weeks, how many days did you have loud snoring?
Note: It is helpful to ask the patient's sleep partner this question." Never| Questions | Desired Answers |
| :--- | :--- |
| How many hours do you sleep on an average night? | 7-8 hours for adults (See Table 12.3b for recommended sleep by age range.) |
| During the past month, how would you rate your sleep quality overall? | Very good or fairly good |
| Do you go to bed and wake up at the same time every day, even on weekends? | Yes, maintain a consistent sleep schedule in general |
| How likely is it for you to fall asleep during the daytime without intending to struggle to stay awake while you are doing things? | Unlikely |
| How often do you have trouble going to sleep or staying asleep? | Never, rarely, or sometimes |
| During the past 2 weeks, how many days did you have loud snoring? <br> Note: It is helpful to ask the patient's sleep partner this question. | Never |
It is also helpful to determine the effects of caffeine intake and medications on a patient’s sleep pattern. If a patient provides information causing a concern for impaired sleep patterns or a sleep disorder, it is helpful to encourage them to create a sleep diary to share with a health care provider. Use the following hyperlink to view a sample sleep diary. 确定咖啡因摄入量和药物对患者睡眠模式的影响也很有帮助。如果患者提供的信息引起了对睡眠模式受损或睡眠障碍的担忧，鼓励他们制作睡眠日记与医疗服务提供者分享是很有帮助的。使用以下超链接查看睡眠日记样本。
Download a Sleep Diary from the National Heart, Lung, and Blood Institute. 从美国国家心肺血液研究所下载睡眠日记。
Additional subjective assessment questions can be used to gather information about a patient’s typical sleep routine so that it can be mirrored during inpatient care, when feasible. 还可以使用其他主观评估问题来收集有关患者典型睡眠习惯的信息，以便在可行的情况下，在住院治疗期间将其反映出来。
Nurses also perform objective assessments of a patient’s sleep patterns during inpatient care. The number of hours slept, wakefulness during the 在住院治疗期间，护士还会对病人的睡眠模式进行客观评估。睡眠时长、睡眠期间的觉醒情况、睡眠时间和睡眠质量。
night, and episodes of loud snoring or apnea should be documented. Note physical (e.g., sleep apnea, pain, and urinary frequency) or psychological (e.g., fear or anxiety) circumstances that interrupt sleep, as well as sleepiness and napping during the day., ^(3){ }^{3} 应记录打鼾或呼吸暂停的情况。注意干扰睡眠的生理（如睡眠呼吸暂停、疼痛和尿频）或心理（如恐惧或焦虑）情况，以及白天嗜睡和打盹的情况。
Concerns about signs of sleep disorders should be communicated to the health care provider for follow-up. 应将对睡眠障碍迹象的担忧告知医疗服务提供者，以便采取后续行动。
Life Span Considerations 寿命考虑因素
The amount of sleep needed changes over the course of a person’s lifetime. Although sleep needs vary from person to person, Table 12.3b shows general recommendations for different age groups based on recommendations from the American Academy of Sleep Medicine (AASM) and the American Academy of Pediatrics (AAP). ^(5){ }^{5} 人一生中所需的睡眠时间会发生变化。虽然睡眠需求因人而异，但表 12.3b 列出了根据美国睡眠医学学会（AASM）和美国儿科学会（AAP）的建议，针对不同年龄段人群的一般建议。 ^(5){ }^{5}
Table 12.3b Recommended Amounts of Sleep by Age Group ^(6){ }^{6} 表 12.3b 按年龄组分列的建议睡眠时间 ^(6){ }^{6}
Age 年龄
Recommended Amount of Sleep 建议睡眠时间
Infants aged 4-12 months 4-12 个月大的婴儿
12-16 hours a day (including naps) 每天 12-16 小时（包括小睡时间）
Children aged 1-2 years 1-2 岁儿童
11-14 hours a day (including naps) 每天 11-14 小时（包括小睡时间）
Children aged 3-5 years 3-5 岁儿童
10-13 hours a day (including naps) 每天 10-13 小时（包括小睡时间）
Children aged 6-12 years 6-12 岁儿童
9-12 hours a day 每天 9-12 小时
Teens aged 13-18 years 13-18 岁青少年
8-10 hours a day 每天 8-10 小时
Adults aged 18 years or older 18 岁或以上的成年人
7-8 hours a day 每天 7-8 小时
Age Recommended Amount of Sleep
Infants aged 4-12 months 12-16 hours a day (including naps)
Children aged 1-2 years 11-14 hours a day (including naps)
Children aged 3-5 years 10-13 hours a day (including naps)
Children aged 6-12 years 9-12 hours a day
Teens aged 13-18 years 8-10 hours a day
Adults aged 18 years or older 7-8 hours a day| Age | Recommended Amount of Sleep |
| :--- | :--- |
| Infants aged 4-12 months | 12-16 hours a day (including naps) |
| Children aged 1-2 years | 11-14 hours a day (including naps) |
| Children aged 3-5 years | 10-13 hours a day (including naps) |
| Children aged 6-12 years | 9-12 hours a day |
| Teens aged 13-18 years | 8-10 hours a day |
| Adults aged 18 years or older | 7-8 hours a day |
If an older adult has Alzheimer’s disease, it often changes their sleeping 如果老年人患有老年痴呆症，他们的睡眠通常会发生以下变化
3. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 349-350. 3.Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018)。护理干预分类（NIC）》。Elsevier，第 349-350 页。
4. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. 4.Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020).Nursing diagnosis handbook：基于证据的护理计划指南》（第 12 版）。第 843-846 页。
5. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 5.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
6. National Heart, Lung, and Blood Institute. (n.d). Sleep deprivation and deficiency. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency 6.国家心肺血液研究所。(n.d).睡眠不足和缺乏。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/sleep-deprivation-and-deficiency
habits. Some people with Alzheimer’s disease sleep too much; others don’t sleep enough. Some people wake up many times during the night; others wander or yell at night. The person with Alzheimer’s disease isn’t the only one who loses sleep. Caregivers may have sleepless nights, leaving them tired for the challenges they face. Educate caregivers about these steps to promote safety for their loved one, and help them and the patient sleep better at night: 习惯。有些阿尔茨海默病患者睡得太多，有些则睡得不够。有些人会在夜间醒来很多次；有些人则会在夜间徘徊或大喊大叫。失眠的不仅仅是阿尔茨海默病患者。护理人员也可能彻夜难眠，疲于应对所面临的挑战。让护理人员了解这些促进亲人安全的步骤，帮助他们和病人晚上睡得更好：
Make sure the floor is clear of objects. 确保地板上没有物体。
Lock up any medications. 锁好所有药品。
Attach grab bars in the bathroom. 在浴室安装扶手。
Place a gate across the stairs. ^(7){ }^{7} 在楼梯对面设置一道门。 ^(7){ }^{7}
DIAGNOSTIC TESTS 诊断测试
A sleep study may be ordered for a patient suspected of having a sleep disorder. A sleep study monitors and records data during a patient’s full night of sleep. A sleep study may be performed at a sleep center or at home with a portable diagnostic device. If done at a sleep center, the patient will sleep in a bed at the sleep center for the duration of the study. Removable sensors are placed on the person’s scalp, face, eyelids, chest, limbs, and a finger to record brain waves, heart rate, breathing effort and rate, oxygen levels, and muscle movements before, during, and after sleep. There is a small risk of irritation from the sensors, but this will resolve after they are removed. ^(8){ }^{8} See Figure 12.10^(9)12.10^{9} of an image of a patient with sensors in place for a sleep study. 对于怀疑患有睡眠障碍的病人，可以要求进行睡眠检查。睡眠检查可监测和记录患者整晚睡眠的数据。睡眠检查可以在睡眠中心进行，也可以在家中使用便携式诊断设备进行。如果在睡眠中心进行，患者将在研究期间睡在睡眠中心的床上。在患者的头皮、面部、眼睑、胸部、四肢和手指上放置可拆卸的传感器，以记录睡眠前、睡眠中和睡眠后的脑电波、心率、呼吸力度和频率、血氧水平和肌肉运动。传感器会有轻微的刺激风险，但取出后就会消失。 ^(8){ }^{8} 请参见图 12.10^(9)12.10^{9} ，图中的患者在睡眠研究中安装了传感器。
7. National Institute on Aging. (2016, May 1). A good night’s sleep. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/good-nights-sleep#safe 7.National Institute on Aging.(2016 年 5 月 1 日）。良好的睡眠。美国卫生与公众服务部。https://www.nia.nih.gov/health/good-nights-sleep#safe
8. National Heart, Lung, and Blood Institute. (n.d). Insomnia. U.S. Department of Health & Human Services. https://www.nhlbi.nih.gov/health-topics/insomnia 8.国家心肺血液研究所。(n.d).失眠。美国卫生与公众服务部。https://www.nhlbi.nih.gov/health-topics/insomnia。
9. “Wired_up_for_a_sleep_study_02A.jpg” by Joe Mabel is licensed under CC BY-SA 3.0 9."Wired_up_for_a_sleep_study_02A.jpg" by Joe Mabel 采用 CC BY-SA 3.0 许可。
DIAGNOSES
NANDA-I nursing diagnoses related to sleep include Disturbed Sleep Pattern, Insomnia, Readiness for Enhanced Sleep, and Sleep Deprivation. ^(10){ }^{10} When creating a nursing care plan for a patient, review a nursing care planning source for current NANDA-I approved nursing diagnoses and interventions related to sleep. See Table 12.3c for the definition and selected defining characteristics of Sleep Deprivation." 与睡眠相关的 NANDA-I 护理诊断包括睡眠模式紊乱、失眠、准备加强睡眠和睡眠不足。 ^(10){ }^{10} 在为患者制定护理计划时，请查看护理计划资料，了解当前 NANDA-I 批准的与睡眠相关的护理诊断和干预措施。有关睡眠不足的定义和选定的定义特征，请参见表 12.3c"。
Table 12.3c Sample NANDA-I Nursing Diagnosis Related to Sleep Deprivation ^(12){ }^{12} 表 12.3c 与睡眠不足有关的 NANDA-I 护理诊断样本 ^(12){ }^{12}
10. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 214-216. 10.Herdman, T. H., & Kamitsuru, S. (Eds.).(2018).护理诊断：Definitions and classification, 2018-2020.Thieme Publishers New York, pp.
11. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 214-216. 11.Herdman, T. H., & Kamitsuru, S. (Eds.).(2018).护理诊断：Definitions and classification, 2018-2020.Thieme Publishers New York, pp.
12. Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification, 2018-2020. Thieme Publishers New York, pp. 214-216. 12.Herdman, T. H., & Kamitsuru, S. (Eds.).(2018).护理诊断：Definitions and classification, 2018-2020.Thieme Publishers New York, pp.
NANDA-I Diagnosis NANDA-I 诊断
Definition 定义
Selected Defining Characteristics 选定的定义特征
Sleep Deprivation 睡眠不足
Prolonged periods of time without sustained natural, periodic suspension of relative consciousness that provides rest. 长时间没有持续的自然、周期性的相对意识暂停，以提供休息。
Agitation
Alteration in concentration
Anxiety
Apathy
Combativeness
Decrease in functional ability
Decrease in reaction time
Drowsiness
Fatigue
Hallucinations
Heightened sensitivity to pain
Irritability
Restlessness| Agitation |
| :--- |
| Alteration in concentration |
| Anxiety |
| Apathy |
| Combativeness |
| Decrease in functional ability |
| Decrease in reaction time |
| Drowsiness |
| Fatigue |
| Hallucinations |
| Heightened sensitivity to pain |
| Irritability |
| Restlessness |
NANDA-I Diagnosis Definition Selected Defining Characteristics
Sleep Deprivation Prolonged periods of time without sustained natural, periodic suspension of relative consciousness that provides rest. "Agitation
Alteration in concentration
Anxiety
Apathy
Combativeness
Decrease in functional ability
Decrease in reaction time
Drowsiness
Fatigue
Hallucinations
Heightened sensitivity to pain
Irritability
Restlessness"| NANDA-I Diagnosis | Definition | Selected Defining Characteristics |
| :--- | :--- | :--- |
| Sleep Deprivation | Prolonged periods of time without sustained natural, periodic suspension of relative consciousness that provides rest. | Agitation <br> Alteration in concentration <br> Anxiety <br> Apathy <br> Combativeness <br> Decrease in functional ability <br> Decrease in reaction time <br> Drowsiness <br> Fatigue <br> Hallucinations <br> Heightened sensitivity to pain <br> Irritability <br> Restlessness |
A sample PES statement is, “Sleep Deprivation related to an overstimulating environment as evidenced by irritability, difficulty concentrating, and drowsiness.” 一个 PES 陈述样本是："睡眠不足与过度刺激的环境有关，表现为易怒、难以集中精力和嗜睡"。
Outcome Identification 成果鉴定
An overall goal related to sleep is, “The patient will awaken refreshed once adequate time is spent sleeping.” ^(13){ }^{13} 与睡眠有关的一个总体目标是："一旦有足够的睡眠时间，病人就会神清气爽地醒来"。 ^(13){ }^{13}
A sample SMART outcome is, “The patient will identify preferred actions to ensure adequate sleep by discharge.” ^(14){ }^{14} SMART 结果的示例是："患者将确定首选行动，以确保在出院前获得充足睡眠"。 ^(14){ }^{14}
Planning Interventions 规划干预措施
Since the days of Florence Nightingale, sleep has been recognized as beneficial to health and of great importance during nursing care due to its restorative function. It is common for sleep disturbances and changes in sleep pattern to occur in connection with hospitalization, especially among surgical patients. Patients in medical and surgical units often report disrupted sleep, not feeling refreshed by sleep, wakeful periods during the night, and increased sleepiness during the day. Illness and the stress of being hospitalized are causative factors, but other reasons for insufficient sleep in hospitals may be due to an uncomfortable bed, being too warm or too cold, environmental noise such as IV pump alarms, disturbance from health care personnel and other patients, and pain. The presence of intravenous catheters, a urinary catheter, and drainage tubes can also impair sleep. Increased daytime sleepiness, a consequence of poor quality sleep at night, can cause decreased mobility and slower recovery from surgery. Research indicates that postoperative sleep disturbances can last for months. Therefore, it is important to provide effective nursing interventions to promote sleep. ^(15){ }^{15} 自弗洛伦斯-南丁格尔（Florence Nightingale）时代起，人们就认识到睡眠有益于健康，并且由于其恢复功能，在护理过程中具有重要意义。住院期间，尤其是手术病人，睡眠紊乱和睡眠模式改变是很常见的现象。内科和外科病房的病人经常反映睡眠中断、睡后感觉不精神、夜间易醒、白天嗜睡。疾病和住院的压力是致病因素，但在医院睡眠不足的其他原因可能是床铺不舒服、太冷或太热、环境噪音（如静脉输液泵警报）、医护人员和其他病人的干扰以及疼痛。静脉导管、导尿管和引流管的存在也会影响睡眠。夜间睡眠质量差导致的白天嗜睡现象增加，会导致活动能力下降，术后恢复速度减慢。研究表明，术后睡眠障碍可持续数月。因此，提供有效的护理干预以促进睡眠非常重要。 ^(15){ }^{15}
A literature review found evidence for effective nursing interventions including massage, acupuncture, and music or natural sounds. Because massage requires trained personnel and can be somewhat time-consuming, it might only be feasible in particular environments. However, as a promoter of sleep, massage is effective in severely ill patients. ^(16){ }^{16} 文献综述发现，有证据表明有效的护理干预措施包括按摩、针灸、音乐或自然声音。由于按摩需要训练有素的人员，而且可能有些耗时，因此可能只有在特定环境下才可行。不过，作为一种促进睡眠的方法，按摩对重症患者是有效的。 ^(16){ }^{16}
14. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. 14.Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020).Nursing diagnosis handbook：基于证据的护理计划指南》（第 12 版）。第 843-846 页。
15. Hellström, A., Fagerström, C., & Willman, A. (2011). Promoting sleep by nursing interventions in health care settings: A systematic review. Worldviews on Evidence-Based Nursing, 8(3), 128-142. https://doi.org/10.1111// j.1741-6787.2010.00203.x 15.Hellström, A., Fagerström, C., & Willman, A. (2011)。在医疗机构中通过护理干预促进睡眠：系统综述。https://doi.org/10.1111// j.1741-6787.2010.00203.x
16. Hellström, A., Fagerström, C., & Willman, A. (2011). Promoting sleep by nursing interventions in health care settings: A systematic review. Worldviews on Evidence-Based Nursing, 8(3), 128-142. https://doi.org/10.1711/ j.1741-6787.2010.00203.x 16.Hellström, A., Fagerström, C., & Willman, A. (2011)。在医疗机构中通过护理干预促进睡眠：系统综述。https://doi.org/10.1711/ j.1741-6787.2010.00203.x
Nurses nationwide have been looking at innovative and common sense ways to transform hospitals into more restful environments. As reported in the American Nurse, strategies include using red lights at night, reducing environmental noise, bundling care, offering sleep aids, and providing patient education. ^(17){ }^{17} 全国的护士们一直在寻找创新和常识性的方法，将医院改造成更适合休息的环境。据《美国护士》杂志报道，这些策略包括在夜间使用红灯、减少环境噪声、捆绑护理、提供助眠剂以及提供患者教育。 ^(17){ }^{17}
One strategy included reducing patients’ light exposure by switching to red lights during the night while using Actiwatches to measure specific light color exposure, sleep, and activity. Both adult and pediatric patients were found to sleep better with reduced white lights, and the red light met the visual needs of nurses while providing care at night. ^(18){ }^{18} 其中一项策略包括在夜间改用红灯减少病人的光照，同时使用 Actiwatches 测量特定的光色照射、睡眠和活动。结果发现，白光减少后，成人和儿童患者的睡眠质量都有所提高，而红光则满足了护士在夜间提供护理时的视觉需求。 ^(18){ }^{18}
In addition to reducing light, nurses also sought to reduce environmental noise. Patients were surveyed regarding factors that affected their ability to sleep, and results indicated bed noises, alarms, squeaking equipment, and sounds from other patients. The nurses’ efforts led to a number of changes, including replacing the wheels on the trash cans and squeaky wheels on chairs, repairing malfunctioning motors on beds, switching automatic paper towel machines in the hallways with manual ones, and altering the times floors were buffed. Nursing staff also developed visitor rules, such as no overnight stays in semiprivate rooms. Overnight visitors in private rooms were asked to honor the quiet environment by not using their cell phones, turning on TVs, or using bright lights at night. ^(19){ }^{19} 除了减少光线，护士们还设法减少环境噪音。对病人进行了关于影响其睡眠能力的因素的调查，结果显示有床声、警报声、设备的吱吱声和其他病人的声音。在护士们的努力下，医院做出了一系列改变，包括更换垃圾桶上的轮子和椅子上吱吱作响的轮子，修理床铺上出现故障的电机，将走廊上的自动纸巾机换成手动纸巾机，以及改变地板抛光的时间。护理人员还制定了访客规则，如不得在半私密房间过夜。私密病房的过夜访客被要求在夜间不使用手机、不开电视、不使用强光灯，以保持安静的环境。 ^(19){ }^{19}
In addition to addressing light and noise, nurses also reinforced the importance of bundling care by interdisciplinary team members to reduce sleep interruptions. One interdisciplinary effort is called “Quiet Time” that occurs from 2 p.m. to 4 p.m. and from midnight to 5 a.m. Quiet Time includes dimming lights, closing patient room doors, and talking in lower voices. To bolster this intervention, project team members used a staff intervention 除了解决光线和噪音问题，护士们还强调了跨学科团队成员捆绑护理的重要性，以减少睡眠中断。其中一项跨学科工作被称为 "安静时间"，时间为下午 2 点至 4 点以及午夜至凌晨 5 点。"安静时间 "包括调暗灯光、关闭病房门以及小声交谈。为了加强这一干预措施，项目组成员使用了一项员工干预措施
17. Trossman, S. (2018, November 7). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ 17.Trossman, S. （2018 年，11 月 7 日）。护士提供促进患者休息和睡眠的策略。https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/
18. Trossman, S. (2018, November 7). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ 18.Trossman, S. （2018 年，11 月 7 日）。护士提供促进患者休息和睡眠的策略。https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/
19. Trossman, S. (2018, November 7). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ 19.Trossman, S. （2018 年，11 月 7 日）。护士提供促进患者休息和睡眠的策略。https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/
called “Hushpuppies.” The aim of the intervention was to build staff awareness and accountability around noise they generate during these Quiet Times, often without realizing it. At the beginning of the shift, everyone, including physicians, is given a clothespin. If someone hears one of their peers talking too loudly, for example, they take away that person’s clothespin. Whoever has the most clothespins at the end of the shift receives a gift card for coffee. The project team felt that Hushpuppies worked well because it allowed staff to address loud conversations and other noise and hold each other accountable in a nonconfrontational way. 称为 "Hushpuppies"。这项干预措施的目的是培养员工对自己在 "安静时间 "产生的噪音（往往是在不知不觉中产生的）的意识和责任感。轮班开始时，包括医生在内的每个人都会得到一个衣夹。例如，如果有人听到同伴说话太大声，他们就会拿走那个人的衣夹。轮班结束时，谁的衣夹最多，谁就能得到一张咖啡礼品卡。项目小组认为，Hushpuppies 的效果很好，因为它允许员工处理大声交谈和其他噪音，并以一种非对抗性的方式相互问责。
Other pro-sleep strategies included asking patients about what aids they use at home to help them sleep, such as extra pillows or listening to music. On admission, patients were given small hospitality kits that included ear plugs and eye masks, along with the offer to use a white noise machine. After dinnertime, warm washcloths were offered to patients. Patients and families were also provided with printed materials on the benefits of sleep and rest, such as decreased length of stay, the prevention of delirium, and the ability of patients to participate in more educational activities and cardiac rehabilitation. ^(21){ }^{21} 其他有利于睡眠的策略包括询问病人在家中使用什么辅助工具帮助睡眠，如额外的枕头或听音乐。病人入院时，会收到包括耳塞和眼罩在内的小型招待包，并提供使用白噪声机的机会。晚餐后，还为病人提供温热的毛巾。此外，还向患者和家属提供了有关睡眠和休息益处的印刷材料，如缩短住院时间、预防谵妄、使患者能够参加更多的教育活动和心脏康复等。 ^(21){ }^{21}
See a summary of other evidence-based nursing interventions used to promote sleep in the following box. 请参阅下框中用于促进睡眠的其他循证护理干预措施摘要。
Trossman, S. (2018, November 7). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ 特罗斯曼，S.（2018 年 11 月 7 日）。护士提供促进患者休息和睡眠的策略。https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/
Trossman, S. (2018, November 7). Nurses offer strategies to promote patients’ rest and sleep. American Nurse. https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/ 特罗斯曼，S.（2018 年 11 月 7 日）。护士提供促进患者休息和睡眠的策略。https://www.myamericannurse.com/strategies-promote-patients-rest-sleep/
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 349-350. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018)。护理干预分类（NIC）》。Elsevier，第 349-350 页。
Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. pp. 843-846. Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020).护理诊断手册：基于证据的护理计划指南》（第 12 版）。第 843-846 页。
Adjust the environment (e.g., light, noise, temperature, mattress, and bed) to promote sleep 调整环境（如光线、噪音、温度、床垫和床）以促进睡眠
Encourage the patient to establish a bedtime routine to facilitate wakefulness to sleep 鼓励患者建立睡前常规，以促进从清醒到入睡的转变
Facilitate maintenance of the patient’s usual bedtime routines during inpatient care 在住院治疗期间，帮助病人保持通常的就寝习惯
Encourage elimination of stressful situations before bedtime 鼓励在睡前消除紧张情绪
Instruct the patient to avoid bedtime foods and beverages that interfere with sleep 指导患者避免食用影响睡眠的睡前食物和饮料
Encourage the patient to limit daytime sleep and participate in activity, as appropriate 鼓励患者限制白天睡眠时间，并酌情参加活动
Bundle care activities to minimize the number of awakenings by staff to allow for sleep cycles of at least 90 minutes 捆绑护理活动，尽量减少工作人员醒来的次数，使睡眠周期至少达到 90 分钟
Consider sleep apnea as a possible cause and notify the provider for a possible referral for a sleep study when daytime drowsiness occurs despite adequate periods of undisturbed night sleep 在夜间睡眠充足且不受干扰的情况下仍出现白天嗜睡时，考虑睡眠呼吸暂停的可能原因，并通知医疗服务提供者转诊进行睡眠研究
Educate the patient regarding sleep-enhancing techniques 向患者传授促进睡眠的技巧
Pharmacological Interventions 药物干预
See specific information about medications used to facilitate sleep in the previous “Sleep Disorders” section of this chapter. 有关用于促进睡眠的药物的具体信息，请参阅本章前面的 "睡眠障碍 "部分。
Implementing Interventions 实施干预措施
When implementing interventions to promote sleep, it is important to customize them according to the specific patient’s needs and concerns. If medications are administered to promote sleep, fall precautions should be 在实施促进睡眠的干预措施时，重要的是要根据患者的具体需求和关注点进行定制。如果使用药物来促进睡眠，应注意以下事项
implemented, and the nurse should monitor for potential side effects, such as dizziness, drowsiness, worsening of depression or suicidal thoughts, or unintentionally walking or eating while asleep. 护士应监测潜在的副作用，如头晕、嗜睡、抑郁或自杀念头加重，或睡眠时无意中行走或进食。
Evaluation 评估
When evaluating the effectiveness of interventions, start by asking the patient how rested they feel upon awakening. Determine the effectiveness of interventions based on the established SMART outcomes customized for each patient situation. 在评估干预措施的效果时，首先询问患者醒来后的休息情况。根据针对不同患者情况定制的 SMART 成果，确定干预措施的有效性。
12.4 Putting It All Together 12.4 将所有内容整合在一起
Patient Scenario 患者情景
Mrs. Salvo is a 65-year-old woman admitted to the hospital for a gastrointestinal (GI) bleed. She has been hospitalized for three days on the medical surgical floor. During this time, she has received four units of PRBCs, has undergone a colonoscopy, upper GI series, and had hemoglobin levels drawn every four hours. The nurse reports to the patient’s room to conduct an assessment prior to beginning the 11 p.m. -7 a.m. shift. 萨尔沃夫人是一位 65 岁的妇女，因消化道（GI）出血入院。她已在内外科住院三天。在此期间，她接受了四个单位的 PRBCs，进行了结肠镜检查和上消化道系列检查，并每四小时抽血一次。护士在晚上 11 点到早上 7 点的轮班开始之前，到病人的病房进行评估。
Although Mrs. Salvo’s hemoglobin has stabilized for the last 24 hours, Mrs. Salvo appears fatigued with bags under her eyes. In conversation with her, she yawns frequently and wanders off in her train of thought. She reports, “You can’t get any rest in here. I am poked and prodded at least once an hour.” 虽然萨尔沃夫人的血红蛋白在过去 24 小时内已经稳定，但她仍显得疲惫不堪，眼袋很深。在与她交谈时，她经常打哈欠，思绪飘忽不定。她说："在这里根本无法休息。我每小时至少要被戳戳戳"。
Applying the Nursing Process 应用护理程序
Assessment: The nurse notes that Mrs. Salvo has bags under her eyes, is yawning frequently, reports difficulty achieving rest, and seems to have difficulty following the conversation. 评估：护士注意到萨尔沃夫人有眼袋，经常打哈欠，说很难得到休息，而且似乎很难跟上谈话内容。
Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Salvo: 根据收集到的评估信息，为萨尔沃女士制定了以下护理计划：
Nursing Diagnosis: Disturbed Sleep Pattern related to interruptions for therapeutic monitoring. 护理诊断：睡眠模式紊乱与治疗监测中断有关。
Overall Goal: The patient will demonstrate improvement in sleeping pattern. 总体目标：患者的睡眠模式将得到改善。
SMART Expected Outcome: Mrs. Salvo will report feeling more rested on awakening within 24 hours. SMART 预期成果：萨尔沃女士将在 24 小时内表示，醒来后感觉休息得更好了。
Planning and Implementing Nursing Interventions: 规划和实施护理干预：
The nurse will assess the patient’s sleep pattern and therapeutic monitoring disturbances. The nurse will group lab draws, vital signs, assessments, and 护士将评估病人的睡眠模式和治疗监测干扰。护士将分组进行实验室抽血、生命体征、评估和
other care tasks to decrease sleep disruption. The nurse will ensure the patient’s door is closed and lighting is turned down to create a restful environment. The nurse will complete as many tasks as possible when Mrs. Salvo is awake and advocate with the interprofessional team for uninterrupted periods of rest during the night. 其他护理工作，以减少对睡眠的干扰。护士将确保病人的房门紧闭，灯光调暗，以创造一个舒适的环境。护士将在萨尔沃夫人清醒时完成尽可能多的任务，并与跨专业团队一起倡导夜间不间断休息。
Sample Documentation: 文件样本：
Mrs. Salvo has a disturbed sleep pattern due to frequent therapeutic monitoring. Mrs. Salvo reports difficulty achieving rest, and despite stabilization in hemoglobin level, continues to demonstrate signs of fatigue. Interventions have been implemented to group therapeutic care to minimize disruption to the patient’s sleep. 由于经常接受治疗监测，萨尔沃夫人的睡眠模式受到干扰。萨尔沃夫人表示很难得到休息，尽管血红蛋白水平趋于稳定，但仍有疲劳迹象。为了尽量减少对病人睡眠的干扰，我们已经采取了干预措施，对病人进行分组治疗护理。
Evaluation: 评估：
The following morning, Mrs. Salvo reports improved feeling more rested with fewer awakenings throughout the night. SMART outcome “met.” 第二天早上，萨尔沃夫人报告说，她感觉休息得更好了，整夜醒来的次数也减少了。SMART 结果 "达到"。
Learning Activities 学习活动
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
Scenario A 方案 A
A nurse is caring for a patient who has been hospitalized after undergoing hip-replacement surgery. The patient complains of not sleeping well and feels very drowsy during the day. 一名护士正在护理一名接受髋关节置换手术后住院的病人。病人抱怨睡眠不好，白天昏昏欲睡。
What factors are affecting the patient’s sleep pattern? 影响患者睡眠模式的因素有哪些？
What assessments should the nurse perform? 护士应进行哪些评估？
What SMART outcome can be established for this patient? 可以为该患者确定哪些 SMART 结果？
Outline interventions the nurse can implement to enhance sleep for this patient. 概述护士可以采取哪些干预措施来改善该患者的睡眠。
How will the nurse evaluate if the interventions are effective? 护士如何评估干预措施是否有效？
Scenario B 方案 B
A nurse is assigned to work rotating shifts and develops difficulty sleeping. 一名护士被分配轮班工作，并出现睡眠困难。
Why do rotating shifts affect a person’s sleep pattern? 为什么轮班会影响人的睡眠模式？
What are the symptoms of insomnia? 失眠有哪些症状？
Describe healthy sleep habits the nurse can adopt for more restful sleep. 描述护士可以养成的健康睡眠习惯，以获得更安稳的睡眠。
Circadian rhythms: Body rhythms that direct a wide variety of functions, including wakefulness, body temperature, metabolism, and the release of hormones. They control the timing of sleep, causing individuals to feel sleepy at night and creating a tendency to wake in the morning without an alarm. 昼夜节律昼夜节律：人体节律可引导多种功能，包括觉醒、体温、新陈代谢和荷尔蒙的释放。昼夜节律控制着睡眠的时间，使人在晚上感到困倦，并在早上醒来时没有闹钟。
Insomnia: A common sleep disorder that causes trouble falling asleep, staying asleep, or getting good quality sleep. Insomnia interferes with daily activities and causes the person to feel unrested or sleepy during the day. Short-term insomnia may be caused by stress or changes in one’s schedule or environment, lasting a few days or weeks. Chronic insomnia occurs three or more nights a week, lasts more than three months, and cannot be fully explained by another health problem or a medicine. Chronic insomnia raises the risk of high blood pressure, coronary heart disease, diabetes, and cancer. 失眠：失眠：一种常见的睡眠障碍，会导致入睡困难、无法保持睡眠状态或无法获得高质量的睡眠。失眠会影响日常活动，使人在白天感到精神不振或昏昏欲睡。短期失眠可能是由压力或个人日程或环境的改变引起的，持续几天或几周。慢性失眠每周出现三个或三个以上的夜晚，持续时间超过三个月，并且无法用其他健康问题或药物完全解释。长期失眠会增加罹患高血压、冠心病、糖尿病和癌症的风险。
Microsleep: Brief moments of sleep that occur when a person is awake. A person can’t control microsleep and might not be aware of it. 微睡眠人在清醒时出现的短暂睡眠。人无法控制微睡眠，也可能意识不到微睡眠。
Narcolepsy: An uncommon sleep disorder that causes periods of extreme daytime sleepiness and sudden, brief episodes of deep sleep during the day. 嗜睡症嗜睡症：一种不常见的睡眠障碍，会导致白天极度嗜睡，并在白天突然出现短暂的深度睡眠。
Non-REM sleep: Slow-wave sleep when restoration takes place and the body’s temperature, heart rate, and oxygen consumption decrease. 非快速眼动睡眠：慢波睡眠：当身体得到恢复，体温、心率和耗氧量下降时。
REM sleep: Rapid eye movement (REM) sleep when heart rate and respiratory rate increase, eyes twitch, and brain activity increases. Dreaming occurs during REM sleep, and muscles become limp to prevent acting out one’s dreams. 快速眼动睡眠快速眼动（REM）睡眠时，心跳和呼吸频率加快，眼睛抽搐，大脑活动增加。快速眼动睡眠时会做梦，肌肉会变得瘫软，以防止做梦。
Sleep apnea: A common sleep condition that occurs when the upper airway becomes repeatedly blocked during sleep, reducing or completely stopping airflow. If the brain does not send the signals needed to breathe, the condition may be called central sleep apnea. 睡眠呼吸暂停：睡眠呼吸暂停：一种常见的睡眠疾病，是指上气道在睡眠过程中反复受阻，气流减少或完全停止。如果大脑没有发出呼吸所需的信号，这种情况可称为中枢性睡眠呼吸暂停。
Sleep diary: A record of the time a person goes to sleep, wakes up, and takes 睡眠日记：记录一个人入睡、醒来和休息的时间。
naps each day for 1-2 weeks. Timing of activities such as exercising and drinking caffeine or alcohol are also recorded, as well as feelings of sleepiness throughout the day. 每天小睡 1-2 周。运动、饮用咖啡因或酒精等活动的时间以及全天的困倦感也会被记录下来。
Sleep study: A diagnostic test that monitors and records data during a patient’s full night of sleep. A sleep study may be performed at a sleep center or at home with a portable diagnostic device. 睡眠研究：一种诊断测试，用于监测和记录患者整晚睡眠的数据。睡眠检查可在睡眠中心进行，也可在家中使用便携式诊断设备进行。
Sleep-wake homeostasis: The homeostatic sleep drive keeps track of the need for sleep, reminds the body to sleep after a certain time, and regulates sleep intensity. This sleep drive gets stronger every hour a person is awake and causes individuals to sleep longer and more deeply after a period of sleep deprivation. 睡眠-觉醒平衡：睡眠-觉醒平衡：睡眠-觉醒平衡是一种睡眠驱动力，它能跟踪睡眠需求，提醒身体在一定时间后入睡，并调节睡眠强度。人每清醒一小时，这种睡眠驱动力就会变得更强，并使人在睡眠不足一段时间后睡得更长、更深。
MOBILITY 机动性
13.1 Mobility Introduction 13.1 流动简介
Learning Objectives 学习目标
Assess factors that put patients at risk for problems with mobility 评估使患者面临行动不便风险的因素
Identify factors related to mobility across the life span 识别与终生流动有关的因素
Assess the effects of immobility on body systems 评估不动对身体系统的影响
Detail the nursing measures to prevent complications of immobility 详细介绍预防行动不便并发症的护理措施
Promote the use of effective techniques of body mechanics among caregivers, patients, and significant others 在护理人员、患者和重要他人中推广使用有效的身体力学技术
Identify evidence-based practices 确定循证实践
Sit on a sturdy chair with your legs and arms stretched out in front of you, and then try to stand. This basic mobility task can be impaired during recovery from major surgery or for patients with chronic musculoskeletal conditions. Mobility, which includes moving one’s extremities, changing positions, sitting, standing, and walking, helps avoid degradation of many body systems and prevents complications associated with immobility. Nurses assist patients to be as mobile as possible, based on their individual circumstances, to achieve their highest level of independence, prevent complications, and promote a feeling of well-being. This chapter will discuss nursing assessments and interventions related to promoting mobility. 坐在一把结实的椅子上，双腿和双臂伸向前方，然后尝试站立。在大手术后的恢复期或患有慢性肌肉骨骼疾病的患者，这项基本的活动能力任务可能会受到影响。活动能力包括移动四肢、改变体位、坐、站和行走，有助于避免许多身体系统的退化，并预防因活动不便而引起的并发症。护士应根据患者的具体情况，帮助他们尽可能活动自如，以实现最高程度的自立，预防并发症，并提升患者的幸福感。本章将讨论与促进行动能力相关的护理评估和干预措施。
Musculoskeletal Anatomy, Physiology, and Assessment 肌肉骨骼解剖学、生理学与评估
Before discussing the concept of mobility, it is important to understand the anatomy of the musculoskeletal system, common musculoskeletal conditions, and the components of a musculoskeletal system assessment. Read more about these topics in the “Musculoskeletal Assessment” chapter in Open RN Nursing Skills. 在讨论移动能力的概念之前，了解肌肉骨骼系统的解剖结构、常见的肌肉骨骼状况以及肌肉骨骼系统评估的组成部分是非常重要的。在《开放式注册护士护理技能》中的 "肌肉骨骼评估 "章节中阅读有关这些主题的更多内容。
Mobility and Immobility 流动性和不流动性
Mobility is the ability of a patient to change and control their body position. Physical mobility requires sufficient muscle strength and energy, along with adequate skeletal stability, joint function, and neuromuscular synchronization. Anything that disrupts this integrated process can lead to impaired mobility or immobility. ^("² "){ }^{\text {² }} Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to being completely immobile (i.e., the patient is unable to make even slight changes in body or extremity position without assistance). See Figure 13.1^(2)13.1^{2} for an image of a patient with impaired physical mobility requiring assistance with a wheelchair. 活动能力是指患者改变和控制身体位置的能力。身体移动能力需要足够的肌肉力量和能量，以及足够的骨骼稳定性、关节功能和神经肌肉同步性。任何破坏这一综合过程的因素都会导致活动能力受损或无法移动。 ^("² "){ }^{\text {² }} 活动能力存在于一个连续统一体中，从无障碍（即患者可以在没有帮助的情况下频繁地改变体位）到完全无法移动（即患者在没有帮助的情况下甚至无法轻微地改变身体或四肢的位置）。请参阅图 13.1^(2)13.1^{2} ，了解需要轮椅辅助的身体活动能力受损患者的图像。
Functional mobility is the ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing, and moving around in bed. The three main areas of functional mobility are the following: 功能性移动能力是指一个人在其所处环境中的移动能力，包括行走、从椅子上站起、从站立到坐下以及在床上走动。功能性移动能力主要包括以下三个方面：
Bed Mobility: The ability of a patient to move around in bed, including moving from lying to sitting and sitting to lying. 床上活动能力：病人在床上走动的能力，包括从躺到坐和从坐到躺的移动。
Transferring: The action of a patient moving from one surface to another. This includes moving from a bed into a chair or moving from one chair to another. 转移：病人从一个表面移动到另一个表面的动作。这包括从床上搬到椅子上或从一把椅子搬到另一把椅子上。
Ambulation: The ability to walk. This includes assistance from another person or an assistive device, such as a cane, walker, or crutches. 行走：行走能力：行走的能力。这包括他人或辅助设备的帮助，如手杖、助行器或拐杖。
Immobility can be caused by several physical and psychological factors, including acute and chronic diseases, traumatic injuries, and chronic pain. 行动不便可由多种生理和心理因素造成，包括急性和慢性疾病、外伤和慢性疼痛。
Several neurological and musculoskeletal disorders can adversely affect mobility, including osteoarthritis, rheumatoid arthritis, muscular dystrophy, cerebral palsy, multiple sclerosis, and Parkinson’s disease. Traumatic injuries, such as skeletal fractures, head injuries, or spinal injuries, also impair mobility. Diseases that cause fatigue, such as heart failure, chronic obstructive pulmonary disease, and depression, or conditions that cause pain also affect the patient’s desire to move. 一些神经和肌肉骨骼疾病会对行动能力产生不利影响，包括骨关节炎、类风湿性关节炎、肌肉萎缩症、脑瘫、多发性硬化症和帕金森病。骨骼骨折、头部受伤或脊柱受伤等外伤也会影响行动能力。导致疲劳的疾病，如心力衰竭、慢性阻塞性肺病和抑郁症，或导致疼痛的疾病，也会影响病人的活动欲望。
Effects of Immobility 不流动的影响
Patients who spend an extended period of time in bed as they recover from surgery, injury, or illness can develop a variety of complications due to loss of muscle strength (estimated at a rate of 20%20 \% per week of immobility). Regardless of the cause, immobility can cause degradation of cardiovascular, respiratory, gastrointestinal, and musculoskeletal functioning. Promoting mobility can prevent these complications from occurring. Findings from a literature review demonstrated several benefits of mobilization, including less delirium, pain, urinary discomfort, urinary tract infection, fatigue, deep vein thrombosis (DVT), and pneumonia, as well as an improved ability to void. Mobilization also decreased depression, anxiety, and symptom distress, while enhancing comfort, satisfaction, quality of life, and independence. ^(3){ }^{3} See Table 13.2a for a summary of the effects of immobility on these body systems. ^(4.5,6){ }^{4.5,6} Decreased mobility is also a major risk factor for skin breakdown, as indicated on the Braden Scale. See Figure 13.2^(7)13.2^{7} for an image of a patient with impaired mobility who developed a DVT. 病人在手术、受伤或疾病后的康复过程中，如果长时间卧床不起，就会因肌肉力量的丧失而引发各种并发症（估计每周的活动量为 20%20 \% ）。无论原因如何，不活动都会导致心血管、呼吸、肠胃和肌肉骨骼功能退化。促进活动能力可以预防这些并发症的发生。文献综述的研究结果表明了移动的几大益处，包括减少谵妄、疼痛、排尿不适、尿路感染、疲劳、深静脉血栓（DVT）和肺炎，以及提高排尿能力。移动还能减少抑郁、焦虑和症状困扰，同时提高舒适度、满意度、生活质量和独立性。 ^(3){ }^{3} 关于不移动对这些身体系统的影响，请参见表 13.2a。 ^(4.5,6){ }^{4.5,6} 正如布莱登量表（Braden Scale）所示，活动能力下降也是皮肤破损的一个主要风险因素。请参阅图 13.2^(7)13.2^{7} ，了解一名活动能力受损并发生深静脉血栓的患者的图像。
3. Kalisch, B., Lee, S., & Dabney, B. (2013). Outcomes of inpatient mobilisation: A literature review. Journal of Clinical Nursing, 23(11-12), 1486-1501. https://doi.org/10.1171/jocn. 12315 3.Kalisch, B., Lee, S., & Dabney, B. (2013)。住院病人动员的结果：文献综述。临床护理学杂志》，23（11-12），1486-1501。https://doi.org/10.1171/jocn。12315
4. This work is a derivative of StatPearls by Javed & Davis and is licensed under CC BY 4.0 4.本作品是 Javed & Davis 的 StatPearls 的衍生作品，采用 CC BY 4.0 许可。
5. American Nurses Association. (2014). Current topics in safe patient handling and mobility. American Nurse Today (supplement). https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf 5.美国护士协会。(2014).安全搬运和移动患者的当前主题。今日美国护士》（增刊）。https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf。
6. Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://doi.org/10.1016/ j.pmr.2012.06.009 6.Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防与管理》。https://doi.org/10.1016/ j.pmr.2012.06.009
7. “Deep_vein_thrombosis_of_the_right_leg.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0 7.医学博士 James Heilman 的作品 "Deep_vein_thrombosis_of_the_right_leg.jpg "采用 CC BY-SA 3.0 许可。
Figure 13.2 Deep Vein Thrombosis (DVT) 图 13.2 深静脉血栓（DVT）
Table 13.2a Effects of Immobility on Body Systems ^(8){ }^{8} 表 13.2a 不动对身体系统的影响 ^(8){ }^{8}
Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://doi.org/10.1016/ j.pmr.2012.06.009 Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防与管理》。https://doi.org/10.1016/ j.pmr.2012.06.009
Decreased delivery of oxygen and nutrients to tissues
Tissue ischemia
Inflammation over bony prominences
Friction and shear
Decreased delivery of oxygen and nutrients to tissues
Tissue ischemia
Inflammation over bony prominences
Friction and shear| Decreased delivery of oxygen and nutrients to tissues |
| :--- |
| Tissue ischemia |
| Inflammation over bony prominences |
| Friction and shear |
Read additional information pertaining to the content in Table 13.2a using the hyperlinks in the following box. 使用下框中的超链接阅读与表 13.2a 中内容有关的更多信息。
Read additional details about assessing the cardiovascular system and assessing for deep vein thrombosis (DVT) in the “Cardiovascular Assessment” chapter in Open RN Nursing Skills. 请阅读《开放式注册护士护理技能》中 "心血管评估 "一章中有关评估心血管系统和评估深静脉血栓形成（DVT）的更多详情。
Read additional details about performing a “Respiratory Assessment” in Open RN Nursing Skills. 阅读 Open RN Nursing Skills 中有关执行 "呼吸评估 "的更多详情。
Read more about treating hypoxia in the “Oxygenation” chapter of this textbook. 请阅读本教科书 "氧合 "一章中有关治疗缺氧的更多内容。
Read about preventing pressure injuries in the “Integumentary” chapter of this textbook. 请阅读本教科书 "Integumentary"（整体器官）一章中有关预防压力伤害的内容。
Read details about performing a “Musculoskeletal Assessment” in Open RN Nursing Skills. 阅读 "开放式注册护士护理技能 "中有关执行 "肌肉骨骼评估 "的详细信息。
Read more about constipation, impaction, ileus, urinary retention, and urinary tract infection in the “Elimination” chapter of this textbook. 请阅读本教科书 "排泄 "一章中有关便秘、肠梗阻、回肠炎、尿潴留和尿路感染的更多内容。
Review how to perform an “Abdominal Assessment” in Open RN Nursing Skills. 复习如何在 "开放式注册护士护理技能 "中进行 "腹部评估"。
Strategies to promote patient mobility can be divided into two categories: those used when the patient is in bed and those used when the patient is able to get out of bed. In-bed interventions to enhance mobility include performing repositioning activities, completing range of motion exercises, and assisting the patient to dangle on the edge of a bed. Out-of-bed interventions to enhance mobility include transferring the patient from bed to chair and assisting with ambulation. ^(9){ }^{9} Unfortunately, ambulation of patients has been identified as the most frequently missed element of inpatient 促进病人移动能力的策略可分为两类：一类是病人躺在床上时使用的策略，另一类是病人能够下床时使用的策略。在床上进行的增强行动能力的干预措施包括：进行重新定位活动、完成一定范围的运动练习以及协助病人在床边悬垂。增强行动能力的床外干预措施包括将患者从床上转移到椅子上，以及协助患者行走。 ^(9){ }^{9} 遗憾的是，病人的下床活动被认为是住院病人护理中最常被忽略的因素。
nursing care with rates as high as 76-88%76-88 \% of the time. Before discussing these interventions to promote mobility, let’s review the assessments that a nurse must perform prior to safely implementing mobilization interventions. 的比例高达 76-88%76-88 \% 。在讨论这些促进移动的干预措施之前，让我们回顾一下护士在安全实施移动干预措施之前必须进行的评估。
Assessing Mobility Status and the Need for Assistance 评估行动状况和援助需求
A patient’s mobility status and their need for assistance affect nursing care decisions, such as handling and transferring procedures, ambulation, and implementation of fall precautions. Initial mobility assessments are typically performed on admission to a facility by a physical therapist (PT). See Table 13.2b for an example of common types of assistance required. 患者的行动能力状况及其对协助的需求会影响护理决策，例如搬运和转移程序、步行以及跌倒预防措施的实施。最初的行动能力评估通常在患者入院时由理疗师（PT）进行。请参见表 13.2b，了解所需的常见协助类型。
Table 13.2b Common Types of Assistance Required" 表 13.2b "所需援助的常见类型
Type of Assistance Required 所需援助类型
Description 说明
Dependent 受抚养人
The patient is unable to help at all. A mechanical lift and assistance by other personnel are required to perform tasks. 病人根本无法提供帮助。需要机械移位机和其他人员的协助才能完成任务。
Maximum Assistance 最高援助额
The patient can perform 25% of the mobility task while the caregiver assists with 75%. 患者可以完成 25% 的移动任务，而护理人员则协助完成 75%。
Moderate Assistance 适度援助
The patient can perform 50% of the mobility task while the caregiver assists with 50%50 \%. 患者可以完成 50%的移动任务，而护理人则协助完成 50%50 \% 。
Minimal Assistance 最低限度的援助
The patient can perform 75% of the mobility task while the caregiver assists with 25%25 \%. 患者可以完成 75% 的移动任务，而护理人则协助完成 25%25 \% 。
Contact Guard Assist 联系 Guard Assist
The caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task. 护理人将一只或两只手放在患者的身体上帮助其保持平衡，但不提供执行功能性移动任务所需的其他帮助。
Stand By Assist 待命辅助
The caregiver does not touch the patient or provide assistance, but remains close to the patient for safety in case they lose their balance or need help to maintain safety during the task being performed. 护理人员不接触病人，也不提供帮助，但为了安全起见，会一直靠近病人，以防他们在执行任务时失去平衡或需要帮助以保持安全。
Independent 独立
The patient can safely perform the functional task with no assistance on their own. 病人可以在没有任何帮助的情况下安全地独立完成功能性任务。
Type of Assistance Required Description
Dependent The patient is unable to help at all. A mechanical lift and assistance by other personnel are required to perform tasks.
Maximum Assistance The patient can perform 25% of the mobility task while the caregiver assists with 75%.
Moderate Assistance The patient can perform 50% of the mobility task while the caregiver assists with 50%.
Minimal Assistance The patient can perform 75% of the mobility task while the caregiver assists with 25%.
Contact Guard Assist The caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task.
Stand By Assist The caregiver does not touch the patient or provide assistance, but remains close to the patient for safety in case they lose their balance or need help to maintain safety during the task being performed.
Independent The patient can safely perform the functional task with no assistance on their own.| Type of Assistance Required | Description |
| :--- | :--- |
| Dependent | The patient is unable to help at all. A mechanical lift and assistance by other personnel are required to perform tasks. |
| Maximum Assistance | The patient can perform 25% of the mobility task while the caregiver assists with 75%. |
| Moderate Assistance | The patient can perform 50% of the mobility task while the caregiver assists with $50 \%$. |
| Minimal Assistance | The patient can perform 75% of the mobility task while the caregiver assists with $25 \%$. |
| Contact Guard Assist | The caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task. |
| Stand By Assist | The caregiver does not touch the patient or provide assistance, but remains close to the patient for safety in case they lose their balance or need help to maintain safety during the task being performed. |
| Independent | The patient can safely perform the functional task with no assistance on their own. |
Kalisch, B., Lee, S., & Dabney, B. (2013). Outcomes of inpatient mobilisation: A literature review. Journal of Clinical Nursing 23(11-12), 1486-1501. https://doi.org/10.1111/jocn. 12315 Kalisch, B., Lee, S., & Dabney, B. (2013)。住院病人动员的结果：文献综述。临床护理学杂志》23（11-12），1486-1501。https://doi.org/10.1111/jocn。12315
Miller, B. (n.d.). Functional mobility and physical therapy. Capital Area Physical Therapy and Wellness. https://www.capitalareapt.com/functional-mobility-and-physical-therapy/ Miller, B. (n.d.).功能移动与物理治疗。首都地区物理治疗与保健。https://www.capitalareapt.com/functional-mobility-and-physical-therapy/
In addition to the amount of assistance required, physical therapists may determine a patient’s weight-bearing status. For example, patients with lower extremity fractures or those recovering from knee or hip replacement often progress through stages of weight-bearing activity. See Table 13.2c for common weight-bearing prescriptions. 除了所需的辅助量，理疗师还可以确定患者的负重状态。例如，下肢骨折患者或膝关节或髋关节置换术后恢复期患者通常会经历不同阶段的负重活动。有关常见的负重处方，请参见表 13.2c。
The leg must not touch the floor and is not permitted to support any weight at all. Crutches or other devices are used for mobility. 腿部不得触地，也不得支撑任何重量。行动时使用拐杖或其他装置。
Toe-touch weight-bearing (TTWB) 脚趾触地负重（TTWB）
The foot or toes may touch the floor to maintain balance, but no weight should be placed on the affected leg. 脚或脚趾可以触地以保持平衡，但不应将重量放在患腿上。
Partial weight-bearing 部分负重
A small amount of weight may be supported on the affected leg. Weight may be gradually increased to 50%50 \% of body weight, which permits the person to stand with body weight evenly supported by both feet (but not walking). 患肢可承受少量重量。体重可逐渐增加到 50%50 \% 体重的 50%50 \% ，这样患者就可以在双脚均匀支撑体重的情况下站立（但不能行走）。
Weight-bearing as tolerated 在可以承受的情况下负重
The patient can support 50%50 \% to 100%100 \% of weight on the affected leg and can independently choose the weight supported by the extremity based on their tolerance and the circumstances. 患者的患肢可承受 50%50 \% 至 100%100 \% 的重量，并可根据自己的承受能力和具体情况自主选择肢体可承受的重量。
Full weight-bearing 完全负重
The leg can support 100% of a person's body weight, which permits walking. 腿部可以支撑人 100%的体重，从而可以行走。
Type of Weight-Bearing Description
Nonweight-bearing (NWB) The leg must not touch the floor and is not permitted to support any weight at all. Crutches or other devices are used for mobility.
Toe-touch weight-bearing (TTWB) The foot or toes may touch the floor to maintain balance, but no weight should be placed on the affected leg.
Partial weight-bearing A small amount of weight may be supported on the affected leg. Weight may be gradually increased to 50% of body weight, which permits the person to stand with body weight evenly supported by both feet (but not walking).
Weight-bearing as tolerated The patient can support 50% to 100% of weight on the affected leg and can independently choose the weight supported by the extremity based on their tolerance and the circumstances.
Full weight-bearing The leg can support 100% of a person's body weight, which permits walking.| Type of Weight-Bearing | Description |
| :--- | :--- |
| Nonweight-bearing (NWB) | The leg must not touch the floor and is not permitted to support any weight at all. Crutches or other devices are used for mobility. |
| Toe-touch weight-bearing (TTWB) | The foot or toes may touch the floor to maintain balance, but no weight should be placed on the affected leg. |
| Partial weight-bearing | A small amount of weight may be supported on the affected leg. Weight may be gradually increased to $50 \%$ of body weight, which permits the person to stand with body weight evenly supported by both feet (but not walking). |
| Weight-bearing as tolerated | The patient can support $50 \%$ to $100 \%$ of weight on the affected leg and can independently choose the weight supported by the extremity based on their tolerance and the circumstances. |
| Full weight-bearing | The leg can support 100% of a person's body weight, which permits walking. |
In addition to reviewing orders regarding weight-bearing and assistance required, all staff should assess patient mobility before and during interventions, such as transferring from surface to surface or during ambulation. Staff may frequently rely on the patient’s or a family member’s report on the patient’s ability to stand, transfer, and ambulate, but this information can be unreliable. For example, the patient may have unrecognized physical deconditioning from the disease or injury that necessitated hospitalization, or they may have developed new cognitive impairments related to the admitting diagnosis or their current medications. 除了查看有关负重和所需协助的医嘱外，所有员工都应在干预措施之前和期间评估患者的活动能力，例如从地面到地面的转移或行走期间。医护人员可能会经常依赖患者或家属关于患者站立、转移和行走能力的报告，但这些信息可能并不可靠。例如，患者可能因为疾病或受伤而导致身体机能下降，但这一情况并未得到认可，因此才需要住院治疗；或者患者可能因为入院诊断或目前的药物治疗而出现了新的认知障碍。
Several objective screening tests, such as the Timed Get Up and Go Test, have traditionally been used by nurses to assess a patient’s mobility status. The Timed Get Up and Go Test begins by having the patient stand up from an armchair, walk three yards, turn around, walk back to the chair, and sit down. As the patient performs these maneuvers, their posture, body alignment, balance, and gait are analyzed. However, this test and other tests do not provide guidance on what the nurse should do if the patient can’t maintain seated balance, bear weight, or stand and walk. The Banner Mobility Assessment Tool (BMAT) was developed to provide guidance regarding safe patient handling and mobility (SPHM). It is used as a nurse-driven bedside assessment of patient mobility and walks the patient through a four-step functional task list and identifies the mobility level the patient can achieve. It then provides guidance regarding the SPHM technology needed to safely lift, transfer, and mobilize the patient. ^(13){ }^{13} Read additional information about the Banner Mobility Assessment Tool (BMAT) using the following hyperlink. 传统上，护士会使用几种客观的筛选测试来评估患者的行动能力状况，例如定时起立行走测试（Timed Get Up and Go Test）。定时起立行走测试的第一步是让患者从扶手椅上站起来，步行三码，转身，走回椅子，然后坐下。在病人做这些动作时，会对他们的姿势、身体排列、平衡和步态进行分析。但是，这项测试和其他测试并不能指导护士在病人无法保持坐姿平衡、承受体重或站立行走时应该采取什么措施。班纳移动能力评估工具（Banner Mobility Assessment Tool，BMAT）的开发旨在为患者的安全操作和移动能力（SPHM）提供指导。该工具由护士在床边对患者的移动能力进行评估，引导患者完成四步功能任务清单，并确定患者可以达到的移动能力水平。然后，它就安全移位、转移和移动病人所需的 SPHM 技术提供指导。 ^(13){ }^{13} 请使用以下超链接阅读有关班纳移动能力评估工具（BMAT）的更多信息。
View the Banner Mobility Assessment Tool for Nurses. ^(14){ }^{14} 查看 Banner 护士移动能力评估工具。 ^(14){ }^{14}
See the following box for an example of a nurse using the BMAT. 护士使用 BMAT 的示例见下框。
Example of Banner Mobility Assessment Tool In Action ^(15){ }^{15} 横幅移动性评估工具使用示例 ^(15){ }^{15}
A 65-year-old male was admitted to the hospital late in the 一名 65 岁的男性在深夜入院。
Today (supplement). https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf 《今日》（增刊）。https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf
13. American Nurses Association. (2014). Current topics in safe patient handling and mobility. American Nurse Today (supplement). https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf 13.美国护士协会。(2014).安全搬运和移动患者的当前主题。今日美国护士》（增刊）。https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf。
14. Boynton, T., Kelly, L., Perez, A., Miller, M., An, Y., & Trudgen, C. (2014). Banner mobility assessment tool for nurses: Instrument validation. American Journal of Safe Patient Handling & Movement, 4(3). https://www.safety.duke.edu/sites/default/files/BMAT for Nurses.pdf 14.Boynton, T., Kelly, L., Perez, A., Miller, M., An, Y., & Trudgen, C. (2014)。护士横幅移动性评估工具：工具验证。美国病人安全搬运与移动期刊》，4（3）。https://www.safety.duke.edu/sites/default/files/BMAT for Nurses.pdf
15. American Nurses Association. (2014). Current topics in safe patient handling and mobility. American Nurse Today (supplement). https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf 15.美国护士协会。(2014).安全搬运和移动患者的当前主题。今日美国护士》（增刊）。https://www.myamericannurse.com/wp-content/uploads/2014/07/ant9-Patient-Handling-Supplement-821a_LOW.pdf。
evening. He is 6^(')2^('')6^{\prime} 2^{\prime \prime} tall and weighs 350 lbs . ( 158 kg ). He needed to have a bowel movement but didn’t want to use a bedpan. The nurse wasn’t comfortable getting him up to use the bathroom because he hadn’t yet been evaluated by physical therapy, and a physical therapist wasn’t available until the following morning. Per agency policy, the nurse used the BMAT and determined the patient was currently at Mobility Level 3. He was transferred to the toilet using a nonpowered stand aid. Both the patient and nurse were relieved and satisfied with the outcome. 晚上。他身高 6^(')2^('')6^{\prime} 2^{\prime \prime} ，体重 350 磅（158 千克）。他需要排便，但不想使用便盆。护士不放心让他起来上厕所，因为他还没有接受理疗评估，而理疗师要到第二天早上才能到。根据护理机构的政策，护士使用了 BMAT，确定病人目前的移动能力为三级。他被转移到了使用无动力站立辅助工具的卫生间。病人和护士都松了一口气，并对结果感到满意。
Safe Patient Handling 安全处理病人
Assisting patients with decreased immobility poses an increased risk of injury to health care workers. A focus on safe patient handling and mobility (SPHM) in acute and long-term care over the past decade has resulted in decreased staff lifting injuries for the first time in 30 years. Nonetheless, nurses still suffer more musculoskeletal disorders from lifting than other employees in the manufacturing and construction industries. Many employers and nurses previously believed that lifting injuries could be prevented by using proper body mechanics, but evidence contradicts this assumption. Body mechanics involves the coordinated effort of muscles, bones, and one’s nervous system to maintain balance, posture, and alignment when moving, transferring, and positioning patients. ^(16){ }^{16} The National Institute of Occupational Safety and Health (NIOSH) calculates maximum loads for lifting, pushing, pulling, and carrying for all types of employees. For example, a maximum load for employees lifting a box with handles is 50 pounds ( 23 kg ), but this weight is decreased when the lifter has to reach, lift from near the floor, or assume a twisted or awkward position. Because patients don’t come in simple shapes and may sit or lie in awkward positions, move unexpectedly, or have wounds 协助行动不便的患者会增加医护人员受伤的风险。在过去的十年中，急诊和长期护理领域对安全搬运和移动病人（SPHM）的重视使得员工的移位伤害在 30 年来首次出现下降。尽管如此，与制造业和建筑业的其他员工相比，护士因举重造成的肌肉骨骼损伤仍然更多。许多雇主和护士以前都认为，通过使用正确的身体力学可以预防移位伤害，但证据与这一假设相矛盾。身体力学涉及肌肉、骨骼和神经系统的协调努力，以便在移动、转移和安置病人时保持平衡、姿势和对齐。 ^(16){ }^{16} 美国国家职业安全与健康研究所（NIOSH）为各类员工计算了举起、推、拉和搬运的最大负荷。例如，员工举起一个带手柄的箱子时的最大负荷是 50 磅（23 千克），但当举起者需要伸手、从接近地面的地方举起或采取扭曲或笨拙的姿势时，这一重量就会减少。因为病人的体形并不简单，他们可能会以尴尬的姿势坐着、躺着、意外移动或有伤口。
or devices that interfere with lifting, the safe lifting load for patients is less than this maximum 50 pound load. Although using proper body mechanics and good lifting techniques are important, they don’t prevent lifting injuries in these patient circumstances ^(17,18,9)\stackrel{17,18,9}{ } Factors that increase risk for lifting injuries in nurses are exertion, frequency, posture, and duration of exposure. Combinations of these factors, such as high exertion while in an awkward posture (for example, holding a patient’s leg while bent over and twisted), unpredictable patient movements, and extended reaching, intensify the risk. ^(20){ }^{20} 或设备会影响移位，因此病人的安全移位负荷要小于 50 磅的最大负荷。虽然使用正确的身体力学和良好的移位技术非常重要，但它们并不能防止在这些病人情况下发生移位伤害 ^(17,18,9)\stackrel{17,18,9}{ } 增加护士移位伤害风险的因素包括用力、频率、姿势和接触时间。这些因素的组合，如在姿势笨拙的情况下高度用力（例如，在弯腰和扭曲的情况下抱住病人的腿）、不可预测的病人移动和长时间伸手，都会增加风险。 ^(20){ }^{20}
In 2013 the American Nurses Association (ANA) published Safe Patient Handling and Mobility (SPHM) standards. See the standards in the following box. Learn more about safe patient handling using the following hyperlinks. 2013 年，美国护士协会 (ANA) 发布了《病人安全搬运和移动 (SPHM) 标准》。请参见下框中的标准。使用以下超链接了解有关安全搬运患者的更多信息。
View ANA videos on safe patient handling: Preventing Nurse Injuries and ANA Presents Safe Patient Handling and Mobility. 观看 ANA 有关安全搬运病人的视频：防止护士受伤》和《ANA 介绍病人安全搬运和移动》。
" Read an ANA article on Safe Patient Handling - The Journey Continues. 阅读全美护士协会关于 "安全处理病人--旅程仍在继续 "的文章。
ANA Standards for Safe Patient Handling and Mobility ^(21){ }^{21} ANA 安全搬运和移动病人标准 ^(21){ }^{21}
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
National Institute for Occupational Safety and Health. (2013, August 2). Safe patient handling and mobility (SPHM). Centers for Disease Control and Prevention. https://www.cdc.gov/niosh/topics/safepatient/ default.html 国家职业安全与健康研究所。(2013 年 8 月 2 日）。安全搬运和移动病人（SPHM）。美国疾病控制和预防中心。https://www.cdc.gov/niosh/topics/safepatient/ default.html
Francis, R., & Dawson, M. (2016) Safe patient handling and mobility: The journey continues. American Nurse Today, 71(5)71(5). https://www.myamericannurse.com/wp-content/uploads/2016/05/Patient-Handling-Safety-426b.pdf Francis, R., & Dawson, M. (2016)《安全的患者搬运和移动》：旅程仍在继续。今日美国护士》， 71(5)71(5) . https://www.myamericannurse.com/wp-content/uploads/2016/05/Patient-Handling-Safety-426b.pdf
American Nurses Association. (2014). Current topics in safe patient handling and mobility. American Nurse 美国护士协会。(2014).安全搬运和移动患者的当前主题。美国护士
Standard 1: Establish a culture of safety. This standard calls for the employer to establish a commitment to a culture of safety. This means prioritizing safety over competing goals in a blamefree environment where individuals can report errors or incidents without fear. The employer is compelled to evaluate systemic issues that contribute to incidents or accidents. The standard also calls for safe staffing levels and improved communication and collaboration. Every organization should have a procedure for nurses to report safety concerns or refuse an assignment due to concern about patients’ or their own safety. 标准 1：建立安全文化。该标准要求雇主对安全文化做出承诺。这意味着在一个个人可以毫无顾忌地报告错误或事故的无责环境中，安全优先于其他竞争目标。雇主必须评估导致事故或意外的系统性问题。该标准还要求达到安全的人员配备水平，并加强沟通与协作。每个组织都应制定护士报告安全问题或因担心病人或自身安全而拒绝执行任务的程序。
Standard 2: Implement and sustain an SPHM program. This standard outlines SPHM program components, including patient assessment and written guidelines for safe patient handling by staff. 标准 2：实施并维持 SPHM 计划。该标准概述了 SPHM 计划的组成部分，包括患者评估和员工安全处理患者的书面指南。
Standard 3: Incorporate ergonomic design principles to provide a safe care environment. This standard is based on the concept of prevention of injuries through ergonomic design that considers the physical layout, work-process flow, and use of technology to reduce exposure to injury or illness. 标准 3：结合人体工程学设计原则，提供安全的护理环境。该标准基于通过人体工程学设计预防伤害的概念，考虑了物理布局、工作流程和技术的使用，以减少受伤或患病的风险。
Standard 4: Select, install, and maintain SPHM technology. This standard provides guidance in selecting, installing, and maintaining SPHM technology. 标准 4：选择、安装和维护 SPHM 技术。该标准为选择、安装和维护 SPHM 技术提供指导。
Standard 5: Establish a system for education, training, and maintaining competence. This standard outlines SPHM training for employees, including the demonstration of competency before using SPHM technology with patients. 标准 5：建立教育、培训和能力保持系统。该标准概述了对员工的 SPHM 培训，包括在对患者使用 SPHM 技术前的能力展示。
Standard 6: Integrate patient-centered SPHM assessment, plan of care, and use of SPHM technology. This standard focuses on the patient’s needs by establishing assessment guidelines and developing an individual plan of care. It outlines the importance of using SPHM technology in a therapeutic manner with the goal of promoting patients’ independence. For example, a patient may need full-body lift technology immediately after surgery, then progress to a sit-to-stand lift for transfers, and then progress to a technology that supports ambulation. 标准 6：整合以患者为中心的 SPHM 评估、护理计划和 SPHM 技术的使用。该标准通过建立评估准则和制定个人护理计划，重点关注患者的需求。它概述了以治疗方式使用 SPHM 技术的重要性，目的是促进患者的独立性。例如，病人在手术后可能需要立即使用全身移位机技术，然后再使用坐立移位机进行转移，最后再使用支持步行的技术。
Standard 7: Include SPHM in reasonable accommodation and post-injury return to work. This standard promotes an employee’s return to work after an injury. 标准 7：将 SPHM 纳入合理便利和受伤后重返工作岗位。该标准有助于员工在受伤后重返工作岗位。
Standard 8: Establish a comprehensive evaluation system. The final standard calls for evaluation of outcomes related to an agency’s implementation of a SPHM program with remediation of deficiencies. 标准 8：建立综合评估系统。最终标准要求对机构实施 SPHM 计划的相关成果进行评估，并对不足之处进行补救。
Assistive Devices 辅助设备
There are several types of assistive devices that a nurse may incorporate during safe patient handling and mobility. An assistive device is an object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift. ^(22){ }^{22} Assistive devices include other items described below. 护士在安全搬运和移动病人时可以使用几种类型的辅助设备。辅助设备是一种旨在帮助患者进行日常生活活动的物体或设备，例如助行器、手杖、步态带或机械移位机。 ^(22){ }^{22} 辅助设备包括以下描述的其他物品。
Gait Belts 步态带
Gait belts should be used to ensure stability when assisting patients to stand, 在协助病人站立时，应使用步态带以确保稳定性、
ambulate, or transfer from bed to chair. A gait belt is a 2-inch-wide ( 5 mm ) belt, with or without handles, that is placed around a patient’s waist and fastened with a buckle. The gait belt should be applied on top of clothing or a gown to protect the patient’s skin. See Figure 13.3^(23)13.3^{23} for an image of a gait belt. 或从床上转移到椅子上。步态腰带是一条 2 英寸宽（5 毫米）的腰带，可带手柄或不带手柄，系在病人腰部并用带扣固定。步态带应套在衣服或外袍上，以保护病人的皮肤。步态带图片见图 13.3^(23)13.3^{23} 。
Figure 13.3 Gait Belt 图 13.3 步态带
Slider Boards 滑动板
A slider board (also called a transfer board) is used to transfer an immobile patient from one surface to another while the patient is lying supine (e.g., from a stretcher to hospital bed)…^(24)^{24} See Figure 13.4^(25)13.4^{25} for an image of a patient being transferred by logrolling off a slider board with several assistants. 滑动板（也称为转移板）用于将仰卧的不动病人从一个表面转移到另一个表面（例如，从担架转移到病床）...... ^(24)^{24} 请参阅图 13.4^(25)13.4^{25} ，其中显示了一名病人在几名助手的协助下从滑动板上滚动转移的图像。
23. “GaitBelt.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-2-body-mechanics/ 23."GaitBelt.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-2-body-mechanics/
24. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 24.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
25. “SliderBoard2-1.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-7-transfers-and-ambulation/ 25."SliderBoard2-1.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-7-transfers-and-ambulation/
Figure 13.4 Slider Board 图 13.4 滑动板
Sit to Stand Lifts 坐立移位机
Sit to Stand Lifts (also referred to as Sara Lifts, Lift Ups, Stand Assist, or Stand Up Lifts) are mobility devices that assist weight-bearing patients who are unable to transition from a sitting position to a standing position using their own strength. They are used to safely transfer patients who have some muscular strength but not enough strength to safely change positions by themselves. Some sit to stand lifts use a mechanized lift whereas others are nonmechanized. See Figure 13.5^(26)13.5^{26} for an image of a nurse assisting a patient to stand with a sit to stand lift. Use. 坐立移位机（也称为萨拉移位机、上举移位机、站立辅助移位机或站立移位机）是一种移位设备，用于帮助无法通过自身力量从坐姿过渡到站立姿势的负重病人。它们用于安全地转移有一定肌肉力量但没有足够力量自己安全地改变体位的病人。一些坐立移位机使用机械化移位机，而另一些则使用非机械化移位机。请参阅图 13.5^(26)13.5^{26} ，了解护士使用坐立移位机协助病人站立的图像。使用。
Figure 13.5 Sit to Stand Lift 图 13.5 坐立移位机
Mechanical Lifts 机械升降机
A mechanical lift is a hydraulic lift with a sling used to move patients who cannot bear weight or have a medical condition that does not allow them to stand or assist with moving. It can be a portable device or permanently attached to the ceiling. See Figure 13.6^(27)13.6^{27} for an image of a mechanical lift. 机械移位机是一种带有吊衣的液压移位机，用于移动无法承受体重或因疾病而无法站立或协助移动的病人。它可以是便携式设备，也可以永久固定在天花板上。有关机械移位机的图像，请参阅图 13.6^(27)13.6^{27} 。
27. “molift_air_200_rgosling_mb_env_585707.jpg” by unknown author, courtesy of etac. This image is included on the basis of Fair Use. 27."molift_air_200_rgosling_mb_env_585707.jpg" 作者不明，由 etac 提供。本图片基于 "合理使用 "原则收录。
Most clinical agencies do not allow nursing students to operate mechanical lifts independently without the supervision of agency staff. Review agency policy and obtain assistance as indicated, even if you have experience using mechanical lifts as an employee at another agency. 大多数临床机构不允许护理学生在没有机构员工监督的情况下独立操作机械移位机。即使您作为其他机构的员工拥有使用机械升降机的经验，也要查看机构政策并在必要时寻求帮助。
Figure 13.6 Mechanical Lift 图 13.6 机械升降机
Early Mobility Protocols 早期流动协议
Many hospitals use nurse-driven mobility protocols to encourage early mobility of patients in intensive care units and after surgery. The purpose of early mobility protocols is to maintain the patient’s baseline mobility and 许多医院使用护士主导的移动方案来鼓励重症监护病房和手术后患者的早期移动。早期移动方案的目的是保持病人的基线移动能力，并在病人术后和术后护理中发挥重要作用。
functional capacity, decrease the incidence of delirium, and decrease hospital length of stay. Protocols include a coordinated approach by the multidisciplinary team and may include respiratory therapists, physical therapists, pharmacists, occupational therapists, and the health care provider who focus on getting the patient out of bed faster. ^(28){ }^{28} 这些方案包括多学科团队的协调方法，其中可能包括呼吸治疗师、物理治疗师、药剂师、职业治疗师和医疗服务提供者，他们的工作重点是让病人离开医院。协议包括多学科团队的协调方法，其中可能包括呼吸治疗师、理疗师、药剂师、职业治疗师和医疗服务提供者，他们的工作重点是让患者更快下床活动。 ^(28){ }^{28}
When early mobility protocols are in place, nurses use a screening tool to determine whether a patient is clinically ready to attempt the protocol. This algorithm begins by reviewing the patient’s neurological criteria, such as, does the patient open his or her eyes in response to verbal stimulation? If the patient meets neurological criteria, they are assessed against additional criteria for respiratory, circulatory, neurological, and other considerations. If the patient clears these criteria, a registered nurse may carefully initiate an early mobilization protocol in collaboration with a physical therapist. See Figure 13.7^(29)13.7^{29} for an example of an early mobilization protocol used for patients in an ICU. ^(30){ }^{30} 在实施早期移动方案时，护士会使用一种筛选工具来确定患者在临床上是否已准备好尝试该方案。这种算法首先要审查患者的神经系统标准，例如，患者是否会在语言刺激下睁开眼睛？如果患者符合神经系统标准，则根据呼吸系统、循环系统、神经系统和其他考虑因素的附加标准对其进行评估。如果患者符合这些标准，注册护士可以与理疗师合作，仔细启动早期移动方案。请参阅图 13.7^(29)13.7^{29} ，了解用于重症监护病房患者的早期移动方案示例。 ^(30){ }^{30}
28. Agency for Healthcare Research and Quality. (2017, January). Nurse-driven early mobility protocols: Facilitator guide. https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html 28.医疗保健研究与质量机构。(2017, January).护士驱动的早期移动协议：https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
29. This work is derived from Nurse-Driven Early Mobility Protocols: Facilitator Guide. Content last reviewed January 2017. Agency for Healthcare Research and Quality, Rockville, MD. Access for free at https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html 29.这项工作源自《护士驱动的早期移动协议》：促进者指南》。内容最后审核日期：2017 年 1 月。医疗保健研究与质量机构，马里兰州罗克维尔。免费访问：https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
30. Agency for Healthcare Research and Quality. (2017, January). Nurse-driven early mobility protocols: Facilitator guide. https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html 30.医疗保健研究与质量机构。(2017, January).护士驱动的早期移动协议：https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
AHRQ Safety Program for Mechanically Ventilated Patients AHRQ 机械通气患者安全计划
Figure 13.7 Early Mobilization Protocol for ICU Patients 图 13.7 重症监护病房患者早期动员规程
See the following box for an example of a mobilization protocol in an intermediate care unit. 请参阅下面的方框，了解中级护理病房动员协议的示例。
Example of Early Mobilization Protocol ^(31){ }^{31} 早期动员规程示例 ^(31){ }^{31}
Here is an example of using an early mobilization protocol in an intermediate care unit with patient care technicians (PCT). Three PCTs collaborate with nurses from 7 a.m. to 7 p.m. Each PCT has eight patients and is responsible for mobilizing patients during each 12-hour shift. Each patient care technician discusses each 下面是一个在中级护理病房与病人护理技师（PCT）一起使用早期动员方案的例子。每名患者护理技师有 8 名患者，负责在每个 12 小时的轮班中对患者进行动员。每位病人护理技师都要与护士讨论每位病人的病情。
31. Agency for Healthcare Research and Quality. (2017, January). Nurse-driven early mobility protocols: Facilitator guide. https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html 31.医疗保健研究与质量机构。(2017, January).护士驱动的早期移动协议：促进者指南。https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html
patient’s level of activity with the RN at the beginning of the shift and determines how many times each patient will be mobilized throughout the day. Any concerns that arise during mobilization are shared with the nurse for appropriate follow-up. 在轮班开始时，护士会与护士长一起评估病人的活动水平，并确定每位病人全天的移动次数。移动过程中出现的任何问题都会告知护士，以便采取适当的后续行动。
Range of Motion Exercises 伸展运动
When patients are unable to ambulate or have injury to specific extremities, range of motion (ROM) exercises are often prescribed. ROM exercises facilitate movement of specific joints and promote mobility of the extremities. Because changes in joints can occur after three days of immobility, ROM exercises should be started as soon as possible. There are three types of ROM exercises: passive, active, and active assist. Passive range of motion is movement applied to a joint solely by another person or by a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part while they are lying in bed. For example, patients who undergo knee replacement surgery may be prescribed a passive motion machine that continuously flexes and extends the patient’s knee while lying in bed. See Figure 13.8^(32)13.8^{32} for an image of a passive motion machine. Active range of motion is movement of a joint by the individual performing the exercise with no outside force aiding in the movement. Active assist range of motion is joint movement with partial assistance from an outside force. For example, during the recovery period after shoulder surgery, a patient attends physical therapy and receives 50% assistance in moving the arm with the help of a physical therapy assistant. 当患者无法行走或特定肢体受伤时，医生通常会开出运动范围（ROM）练习处方。ROM 运动有助于特定关节的活动，并促进四肢的灵活性。由于关节在三天不能活动后就会发生变化，因此应尽快开始进行 ROM 运动。ROM 运动有三种类型：被动、主动和主动辅助。被动运动范围是指仅由他人或被动运动器械对关节进行运动。在进行被动运动范围锻炼时，接受锻炼的人的关节是完全放松的，当他们躺在床上时，外力会移动身体部位。例如，接受膝关节置换手术的患者可能会被要求使用被动运动机，在躺在床上时持续弯曲和伸展患者的膝关节。被动运动机的图片见图 13.8^(32)13.8^{32} 。主动运动范围是指个人在没有外力辅助的情况下进行的关节运动。主动辅助运动范围是指在外力的部分辅助下进行的关节运动。例如，在肩部手术后的恢复期，病人接受物理治疗，并在物理治疗助理的帮助下活动手臂，活动幅度为 50%。
Figure 13.8 Passive Motion Machine 图 13.8 被动运动机
View an infographic demonstrating range of motion exercises. 查看演示运动范围练习的信息图表。
Patients may receive temporary ROM exercises due to injury, surgery, or other temporary conditions. These patients are expected to make a full recovery and over time will no longer need ROM to ensure the proper functioning of their joint. Other patients require long-term ROM exercises to prevent contractures that can occur in conditions such as spinal cord injury, stroke, neuromuscular diseases, or traumatic brain injury. A contracture is the lack of full passive range of motion due to joint, muscle, or soft tissue limitations. 患者可能会因为受伤、手术或其他暂时性情况而接受临时的 ROM 锻炼。预计这些患者会完全康复，随着时间的推移，他们将不再需要进行 ROM 运动来确保关节的正常功能。其他患者则需要长期的关节活动度锻炼，以防止脊髓损伤、中风、神经肌肉疾病或脑外伤等情况下可能出现的挛缩。挛缩是指由于关节、肌肉或软组织的限制而无法完全被动地活动。
33. Skalsky, A. J., & McDonald, C. M. (2012). Prevention management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://dx.doi.org/ 10.1016%2Fj.pmr.2012.06.009 33.Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防管理》。https://dx.doi.org/ 10.1016%2Fj.pmr.2012.06.009
See Figure 13.9^(34)13.9^{34} for an image of a severe leg contracture in a patient with a terminal neurological condition. 请参阅图 13.9^(34)13.9^{34} ，这是一位神经系统疾病晚期患者严重腿部挛缩的图像。
34. “Muscle_contractures_of_young_man.jpg” by Maria Sieglinda von Nudeldorf is licensed under CC BY-SA 4.0 34.Maria Sieglinda von Nudeldorf 的作品 "Muscle_contractures_of_young_man.jpg "采用 CC BY-SA 4.0 许可。
Figure 13.9 Contracture 图 13.9 挛缩
Range of motion exercises are prescribed by a physical therapist and can be performed by physical therapy assistants, nursing assistants, patient technicians, and nurses based on agency policy. Guidelines for performing range of motion exercises include the following: 运动幅度练习由理疗师开出处方，可根据机构政策由理疗助理、护理助理、病人技师和护士进行。运动幅度练习的指导原则如下：
A program of passive stretching should be started as early as possible in the course of neuromuscular disease to prevent contractures and become part of a regular morning and evening routine. 在神经肌肉疾病的病程中，应尽早开始被动拉伸计划，以防止挛缩，并将其作为早晚例行活动的一部分。
Proper technique is essential for passive stretching to be effective. With each stretch, the position should be held for a count of 15 , and each exercise should be repeated 10 to 15 times during a session (or as prescribed). Stretching should be performed slowly and gently. An overly strenuous stretch may cause discomfort and reduce cooperation. 正确的技巧对于被动拉伸的效果至关重要。每次拉伸时，姿势应保持 15 秒，每次练习应重复 10 至 15 次（或按医嘱）。拉伸动作应缓慢轻柔。过于剧烈的拉伸可能会引起不适并降低合作性。
Written instructional materials should be provided to the patient and family as a supplement to verbal instructions and demonstrations by the physical therapist. 应向患者和家属提供书面指导材料，作为物理治疗师口头指导和示范的补充。
Watch a YouTube video demonstration of passive motion ^(35){ }^{35} exercises. 观看 YouTube 视频演示被动运动 ^(35){ }^{35} 练习。
Limb positioning with assistive devices can also be used to prevent contracture formation. The limb should be placed in a resting position that opposes or minimizes flexion. ^(36){ }^{36} Positioning aids include pillows, foot boots, handrolls, hand-wrist splints, heel or elbow protectors, abduction pillows, or a 使用辅助设备进行肢体定位也可用于防止挛缩的形成。应将肢体置于反对或尽量减少屈曲的静止位置。 ^(36){ }^{36} 定位辅助工具包括枕头、足靴、手卷、手腕夹板、足跟或肘部保护器、外展枕或腕部夹板。
trapeze bar. See Figure 13.10^(37)13.10^{37} for an image of a brace used to prevent foot drop in a patient with multiple sclerosis. Foot drop is a complication of immobility that results in plantar flexion of the foot, interfering with the ability to complete weight bearing activities. 梯杠。请参阅图 13.10^(37)13.10^{37} ，了解用于防止多发性硬化症患者足下垂的支架。足下垂是行动不便的一种并发症，会导致足跖屈，影响完成负重活动的能力。
Figure 13.10 Brace to Prevent Foot Drop 图 13.10 防止足下垂的支架
Read additional information about range of motion exercises, preventing contractures, and physical therapy using the following hyperlinks. 请使用以下超链接阅读有关运动范围练习、预防挛缩和物理治疗的更多信息。
Review how to perform Active Range of Motion Exercises. 复习如何进行主动活动范围练习。
Read how to Prevent and Manage Contractures. 阅读如何预防和管理挛缩。
Read more details about Physical Therapy. 了解有关物理治疗的更多详情。
Repositioning Patients 重新安置病人
Repositioning a bedridden patient maintains body alignment and prevents pressure injuries, foot drop, and contractures. Proper positioning also provides comfort for patients who have decreased mobility related to a medical condition or treatment. When repositioning a patient in bed, supportive devices such as pillows, rolls, and blankets can aid in providing comfort and safety. There are several potential positions that are determined based on the patient’s medical condition, preferences, or treatment related to an illness. ^(38){ }^{38} It is important to reposition patients appropriately to prevent neurological injury that can occur if a patient is inadvertently placed on their arm. 调整卧床病人的体位可以保持身体的直线，防止压伤、足下垂和挛缩。适当的体位还能为因疾病或治疗而行动不便的病人提供舒适感。在调整卧床病人的体位时，枕头、滚轮和毯子等支撑设备可以帮助提供舒适和安全。有几种可能的体位是根据病人的病情、喜好或与疾病相关的治疗来决定的。 ^(38){ }^{38} 重要的是要适当地调整病人的体位，以防止不慎将病人的手臂放在自己的手臂上而造成神经损伤。
Supine Position 仰卧姿势
In supine positioning, the patient lies flat on their back. Pillows or other devices may be used to prevent foot drop. Additional supportive devices, such 仰卧位时，病人平躺在床上。可以使用枕头或其他装置来防止足下垂。其他支撑装置，如
as pillows under the arms, may be added for comfort. See Figure 13.17^(39)13.17^{39} for an image of a patient in the supine position. 为了舒适起见，还可以在腋下添加枕头。患者仰卧位的图像见图 13.17^(39)13.17^{39} 。
Figure 13.11 Supine Position 图 13.11 仰卧位
Prone Position 俯卧姿势
In prone positioning, the patient lies on their stomach with their head turned to the side. ^(4.){ }^{4 .} Pillows may be placed under the lower legs to align the feet. See Figure 13.12^(42)13.12^{42} for an image of a patient in the prone position. Placing patients in the prone position may improve their oxygenation status in certain types of medical disorders, such as COVID-19. ^(43){ }^{43} 俯卧位时，病人俯卧，头转向一侧。 ^(4.){ }^{4 .} 可在小腿下放置枕头，使双脚对齐。患者俯卧位的图片见图 13.12^(42)13.12^{42} 。在某些类型的内科疾病（如 COVID-19）中，让患者采取俯卧位可能会改善他们的氧合状态。 ^(43){ }^{43}
39. “supine.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ 39."supine.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/
40. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 40.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
47. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 47.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
42. “prone.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ 42."prone.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/
43. Shelhamer, M., Wesson, P., Solari, I. L., Jensen, D. L., Steele, W. A., Dimitrov, V. G., Kelly, J. D., Aziz, S., Gutierrez, V. P., Vittinghoff, E., Chung, K. K., Menon, V. P., Ambris, H. A., & Baxi, S. M.(2021). Prone positioning in moderate to severe acute respiratory distress syndrome due to COVID-19: A cohort study and analysis of physiology. Journal of Intensive Care Medicine, 36(2), 241-252. https://doi.org/10.1177%2F0885066620980399 43.Shelhamer, M., Wesson, P., Solari, I. L., Jensen, D. L., Steele, W. A., Dimitrov, V. G., Kelly, J. D., Aziz, S., Gutierrez, V. P., Vittinghoff, E., Chung, K. K., Menon, V. P., Ambris, H. A., & Baxi, S. M. (2021)。由 COVID-19 引起的中重度急性呼吸窘迫综合征的俯卧位：一项队列研究和生理学分析。重症监护医学杂志》，36（2），241-252。https://doi.org/10.1177%2F0885066620980399。
Figure 13.12 Prone Position 图 13.12 俯卧位
Lateral Position 侧面位置
In lateral positioning, the patient lies on one side of their body with the top leg flexed over the bottom leg. This position helps relieve pressure on the coccyx. ^(44){ }^{44} A pillow may be placed under the top arm for comfort. See Figure 13.13^(45)13.13^{45} for an image of a patient in the lateral position. The lateral position is often used for pregnant women to prevent inferior vena cava compression and enhance blood flow to the fetus. 在侧卧位时，病人侧卧在身体一侧，上肢屈曲放在下肢上。这种姿势有助于减轻尾骨受到的压力。 ^(44){ }^{44} 可在上臂下放一个枕头，以增加舒适度。患者侧卧位的图片见图 13.13^(45)13.13^{45} 。侧卧位常用于孕妇，以防止下腔静脉受压，增强胎儿的血流量。
Figure 13.13 Lateral Position 图 13.13 侧向位置
44. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 44.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
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Sims Position Sims 职位
In Sims positioning, the patient is positioned halfway between the supine and prone positions with their legs flexed. A pillow is placed under the top leg. Their arms should be comfortably placed beside them, not underneath. ^(46){ }^{46} See Figure 13.14^(47)13.14^{47} for an image of a patient in Sims position. The Sims position is used during some procedures, such as the administration of an enema. 在 Sims 体位法中，病人的位置介于仰卧位和俯卧位之间，双腿弯曲。上肢下放一个枕头。双臂应舒适地放在旁边，而不是下面。 ^(46){ }^{46} 请参阅图 13.14^(47)13.14^{47} ，了解病人采用 Sims 体位的图像。在某些操作过程中会使用 Sims 体位，例如灌肠。
Figure 13.14 Sims Position 图 13.14 模拟位置
Fowler's Position 福勒的立场
In Fowler’s positioning, the head of bed is placed at a 45- to 90-degree angle. The bed can be positioned to slightly flex the hips to help prevent the patient from migrating downwards in bed. ^(48){ }^{48} See Figure 13.15^(49)13.15^{49} for an image of a patient in Fowler’s position. High Fowler’s position refers to the bed being at a 90-degree angle. The Fowler’s position is used to promote lung expansion and improve a patient’s oxygenation. It is also used to prevent aspiration in patients while eating or receiving tube feeding. 在 Fowler's 定位法中，床头呈 45 至 90 度角。床的位置可以稍微弯曲臀部，以帮助防止病人在床上向下移动。 ^(48){ }^{48} 请参阅图 13.15^(49)13.15^{49} ，了解病人采用 Fowler 体位的图像。高位 Fowler 体位是指床呈 90 度角。福勒体位用于促进肺扩张和改善患者的氧合。它还用于防止病人在进食或接受管喂时误吸。
46. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 46.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
47. “sims.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ 47."sims.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/
48. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 48.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
49. “degreeLow.jpg” by unknown author is licensed under CC BY 4.0. Access for free at https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/ 49."degreeLow.jpg" 作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/ clinicalskills/chapter/3-4-positioning-a-patient-in-bed/
Flgure 13.15 Fowler’s Position 图 13.15 福勒的位置
Semi-Fowler's Position 半福勒位置
In Semi-Fowler’s positioning, the head of bed is placed at a 30- to 45-degree angle. The patient’s hips may or may not be flexed. See Figure 13.16^(50)13.16^{50} for an image of a patient in Semi-Fowler’s position. Semi-Fowler’s position is used for the same purposes as Fowler’s position but is generally better tolerated over long periods of time. 在半福勒式体位法中，床头呈 30 至 45 度角。病人的臀部可以弯曲，也可以不弯曲。请参阅图 13.16^(50)13.16^{50} ，了解病人采用半福勒式体位的图像。半福勒体位的使用目的与福勒体位相同，但通常更适合长期使用。
Figure 13.16 Semi-Fowler’s Position 图 13.16 半福勒位
Trendelenburg Position 仰卧位
In Trendelenburg positioning, the head of the bed is placed lower than the 在 Trendelenburg 体位法中，床头低于床尾。
patient’s feet. This position may be used in certain situations to promote venous return to the head and heart, such as during severe hypotension and medical emergencies. ^(51){ }^{51} See Figure 13.17^(52)13.17^{52} for an image of Trendelenburg position. 病人的双脚。这种体位在某些情况下可用于促进头部和心脏的静脉回流，例如在严重低血压和医疗紧急情况下。 ^(51){ }^{51} 图 13.17^(52)13.17^{52} 为 Trendelenburg 体位的图像。
Figure 13.17 Trendelenburg Position 图 13.17 俯卧位
Tripod Position 三脚架位置
Patients who are feeling short of breath often naturally assume the tripod position. In the tripod position, the patient leans forward while sitting with their elbows on their knees or resting on a table. Patients experiencing 感到气短的患者通常会自然而然地采取三脚架姿势。在三脚架姿势中，患者坐着时身体前倾，手肘放在膝盖上或靠在桌子上。患者会感到
breathing difficulties can be placed in this position to enhance lung expansion and air exchange. See Figure 13.18^(53)13.18^{53} for images of an individual demonstrating breathing difficulty who has assumed the tripod position. 呼吸困难的患者可以采取这种体位，以增强肺部扩张和空气交换。请参阅图 13.18^(53)13.18^{53} ，了解采用三脚架姿势的呼吸困难患者的图像。
Figure 13.18 Tripod Position 图 13.18 三脚架位置
Moving a Patient Up in Bed 在床上移动病人
When moving a patient up in bed, first determine the level of assistance needed to provide optimal patient care. It is vital to prevent friction and shear when moving a patient up in bed to prevent pressure injuries. If a patient is 在床上移动病人时，首先要确定提供最佳病人护理所需的辅助程度。在床上移动病人时，必须防止摩擦和剪切，以防压伤。如果病人
unable to assist with repositioning in bed, follow agency policy regarding using lifting devices and mechanical lifts. If the patient is able to assist with repositioning and minimal lifting by staff is required, use the following guidelines with assistance from another health care professional to help with the move and prevent injury. ^(54){ }^{54} See Figure 13.19^(55)13.19^{55} for an image of moving a patient up in bed. 如果病人无法协助在床上重新定位，则应遵循机构有关使用移位设备和机械移位机的政策。如果病人能够协助调整体位，并且只需要医护人员进行少量移位，则应在其他医护人员的协助下使用以下指导原则来帮助移动病人，并防止受伤。 ^(54){ }^{54} 请参阅图 13.19^(55)13.19^{55} ，了解将患者从床上移起的图像。
Explain to the patient what will happen and how the patient can help. 向患者解释将会发生什么，以及患者可以如何提供帮助。
Raise the bed to a safe working height and ensure that the brakes are applied. 将床升至安全工作高度，并确保已踩下制动器。
Position the patient in the supine position with the bed flat. Place a pillow at the head of the bed and against the headboard to prevent accidentally bumping the patient’s head on the headboard. 让病人保持仰卧姿势，将床放平。在床头和床头板上放一个枕头，以防病人的头部不小心撞到床头板。
Two health care professionals should stand with feet shoulder width apart between the shoulders and hips of the patient at the bedside. This keeps the heaviest part of the patient closest to the center of gravity of the health care providers. Weight will be shifted from back foot to front foot. 两名医护人员应站在床边，双脚分开与肩同宽，站在患者的肩膀和臀部之间。这样可以使病人最重的部分最靠近医护人员的重心。重量将从后脚转移到前脚。
Fan-fold the draw sheet toward the patient with palms facing up. This provides a strong grip to move the patient up with the draw sheet. 手掌朝上，将牵引单朝病人方向扇形折叠。这样可以提供有力的抓地力，使病人能随牵引单向上移动。
Ask the patient to tilt their head toward their chest, fold arms across their chest, and bend their knees to assist with the movement. Let the patient know when the move will happen. This step prevents injury from occurring to the patient and prepares them for the move. 要求患者将头偏向胸部，双臂交叉叠放在胸前，并弯曲膝盖以协助动作。让病人知道何时进行移动。这一步骤可以防止患者受伤，并让他们为移动做好准备。
Tighten your gluteal and abdominal muscles, bend your knees, and keep your back straight and neutral. Face the direction of movement. Proper body mechanics can help prevent back injury when used in appropriate patient care situations. 收紧臀部和腹部肌肉，弯曲膝盖，保持背部挺直和中立。面向运动方向。在适当的病人护理情况下，正确的身体力学有助于预防背部受伤。
On the count of three by the lead person, gently slide (not lift) the patient up the bed, shifting your weight from the back foot to the front, keeping your back straight and knees slightly bent. 带头人数到三时，轻轻地将病人滑到（而不是抬起）床上，将重心从后脚移到前脚，保持背部挺直，膝盖微屈。
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
Replace the pillow under the patient’s head, reposition the patient in the bed, and cover them with a sheet or blanket to provide comfort. 更换病人头下的枕头，调整病人在床上的位置，给他们盖上床单或毯子以提供舒适。
Lower the bed, raise the side rails as indicated, and ensure the call light is within reach. Perform hand hygiene. 放下床，按指示升起侧扶手，并确保呼叫灯在触手可及的地方。进行手部卫生。
Figure 13.19 Moving a Patient Up in Bed 图 13.19 在床上移动病人
Assisting Patients to Seated Position 协助病人取坐姿
Prior to ambulating, repositioning, or transferring a patient from one surface to another (e.g., a bed to a wheelchair), it often necessary to move the patient to the side of the bed to avoid straining or excessive reaching by the health care professional. Positioning the patient to the side of the bed also allows the 在移动、调整体位或将病人从一个表面转移到另一个表面（如从床到轮椅）之前，通常需要将病人移到床的一侧，以避免医护人员劳累或过度伸手。将病人安置在床的一侧还可以让医护人员
health care provider to have the patient as close as possible to their center of gravity for optimal balance during patient handling. ^(5){ }^{5} 医护人员在搬运病人时，应让病人尽可能靠近自己的重心，以达到最佳平衡。 ^(5){ }^{5}
Patients who have been lying in bed may experience vertigo, a sensation of dizziness as if the room is spinning, or orthostatic hypotension, low blood pressure that occurs when a patient changes position from lying to sitting or sitting to standing and causes the patient to feel dizzy, faint, or light-headed. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop of diastolic blood pressure of 10 mm Hg or more within 3 minutes of sitting or standing. For this reason, always begin a transfer or ambulation process by sitting the patient on the side of the bed for a few minutes with their legs dangling. 一直躺在床上的患者可能会出现眩晕，即头晕的感觉，就像房间在旋转一样；或正性低血压，即当患者从躺着到坐着或从坐着到站着改变体位时出现低血压，导致患者感到头晕、虚弱或头重脚轻。直立性低血压的定义是，坐或站 3 分钟内收缩压下降 20 毫米汞柱或以上，或舒张压下降 10 毫米汞柱或以上。因此，在开始转运或移动过程时，一定要让病人坐在床边几分钟，双腿悬空。
Begin by explaining to the patient what will happen and how they can help. Determine if additional assistance or a mechanical lift is needed. ^(59){ }^{59} Ensure the bed is in a low and locked position, and then use the following guidelines to assist a patient to the seated position on the edge of the bed. ^(60){ }^{60} See Figure 13.20^(61)13.20^{61} for images of a nurse assisting a patient to a seated position. 首先向病人解释将会发生什么以及他们可以如何提供帮助。确定是否需要额外的帮助或机械移位机。 ^(59){ }^{59} 确保床处于低位和锁定位置，然后使用以下指导原则帮助病人在床边就坐。 ^(60){ }^{60} 请参阅图 13.20^(61)13.20^{61} ，了解护士协助病人就坐的图像。
Stand facing the head of the bed at a 45-degree angle with your feet apart, with one foot in front of the other. Stand next to the waist of the patient. 面对床头站立，双脚分开 45 度角，一只脚在另一只脚的前面。站在病人腰部旁边。
Ask the patient to turn onto their side, facing you, as they move closer to the edge of the bed. 要求病人侧身，面向你，同时靠近床边。
Place one hand behind the patient’s shoulders, supporting the neck and vertebrae. 将一只手放在患者肩后，支撑颈部和脊椎骨。
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
“Book-pictures-2015-5851.jpg,” “Book-pictures-2015-587.jpg,” and “Book-pictures-2015-588.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/ 3-5-positioning-a-patient-on-the-side-of-a-bed/ 由未知作者创作的 "Book-pictures-2015-5851.jpg"、"Book-pictures-2015-587.jpg "和 "Book-pictures-2015-588.jpg "采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/clinicalskills/chapter/ 3-5-positioning-a-patient-on-the-side-of-a-bed/
On the count of three, instruct the patient to use their elbows to push up against the bed and then grasp the side rail as you support their shoulders as they sit. Shift your weight from the front foot to the back foot as you assist them to sit. Do not allow the patient to place their arms around your shoulders because this can lead to serious back injuries. 数到三时，指导病人用肘部顶住床，然后抓住侧栏，在他们坐下时支撑他们的肩膀。在协助他们坐下时，将重心从前脚转移到后脚。不要让病人将手臂搭在你的肩膀上，因为这会导致严重的背部损伤。
As you shift your weight, gently grasp the patient’s outer thighs with your other hand and help them slide their feet off the bed to dangle or touch the floor. This step helps the patient sit and move their legs off the bed at the same time. As you perform this action, bend your knees and keep your back straight and neutral. 在转移重心的同时，用另一只手轻轻抓住病人的大腿外侧，帮助他们将双脚滑离床面，使其悬空或接触地面。这个步骤可以帮助病人坐下，同时将腿从床上移开。在做这个动作时，弯曲膝盖，保持背部挺直和中立。
Assess the patient for symptoms of orthostatic hypotension or vertigo. If they are experiencing any dizziness, request them to sit and dangle on the edge of the bed and determine if the symptoms resolve before transferring or ambulating. 评估患者是否有正性低血压或眩晕症状。如果出现任何头晕症状，请让他们坐在床边，并在转移或移动之前确定症状是否缓解。
Figure 13.20 Assisting a Patient to a Seated Position 图 13.20 协助病人取坐位
Ambulating a Patient 移动病人
Ambulation is the ability of a patient to safely walk independently, with assistance from another person, or with an assistive device, such as a cane, 下地行走是指病人能够独立、在他人协助下或借助拐杖等辅助设备安全地行走、
walker, or crutches. After a patient has been assessed and determined safe to ambulate, determine if assistive devices or the assistance of a second staff member is required. Assist the patient to sit on the side of the bed and assess for symptoms of vertigo or orthostatic hypotension before proceeding. Ensure the patient is wearing proper footwear, such as shoes or nonslip socks. Apply a gait belt snugly over their clothing and around their waist if any type of assistance is required. See Figure 13.27^(63)13.27^{63} for an image of applying a gait belt. The patient should be cooperative, able to bear weight on their own, have good trunk control, and be able to transition to a standing position on their own. If these criteria are not met, then mechanical devices, such as a sit to stand lift, should be used to assist a weight-bearing patient from a sitting position to a standing position. If a patient uses a walker or cane, these assistive devices should be placed near the bed before beginning this procedure. 助行器或拐杖。在对病人进行评估并确定可以安全行走后，确定是否需要辅助设备或第二名工作人员的协助。协助病人坐在床边，评估是否有眩晕或正性低血压症状后再继续。确保患者穿着合适的鞋袜，如鞋子或防滑袜。如果需要任何类型的帮助，可在患者的衣服外面和腰部系上步态带。请参阅图 13.27^(63)13.27^{63} ，了解系步态带的图像。患者应该合作，能够自己承受体重，对躯干有良好的控制能力，并且能够自己过渡到站立姿势。如果不符合这些标准，则应使用坐立移位机等机械装置来帮助负重患者从坐姿转为站姿。如果病人使用助行器或拐杖，则应在开始此过程之前将这些辅助设备放在床边。
Figure 13.21 Application of a Gait Belt 图 13.21 步态带的应用
Stand in front of the patient, with your legs on the outside of their legs. Grasp each side of the gait belt, while keeping your back straight and knees bent, and then rock your weight backwards while gently steadying the patient into a standing position. After the patient is standing and feels stable, move to 站在患者面前，双腿放在患者双腿外侧。抓住步态带的两侧，同时保持背部挺直、膝盖弯曲，然后向后摇动身体重心，同时轻轻地将患者稳住，使其站立。在病人站立并感觉稳定后，移动到
their unaffected side and grasp the gait belt in the middle of their back. ^(64){ }^{64} If needed for stability, place one arm under the patient’s arm, gently grasp their forearm, and lock your arm firmly under the patient’s axilla. In this position, if the patient starts to fall, you can provide support at the patient’s shoulder. ^(65){ }^{65} If the patient uses a walker or cane, ensure the patient is using this device before beginning ambulation. See Figure 13.22^(66)13.22^{66} for an image of a nurse assisting the patient to stand. ^(64){ }^{64} 如果需要保持稳定，可将一只手放在患者的手臂下，轻轻抓住其前臂，并将手臂紧紧锁在患者的腋窝下。 ^(64){ }^{64} 如果需要保持稳定，可将一只手臂放在患者的手臂下方，轻轻抓住他们的前臂，并将手臂牢牢锁在患者的腋窝下。在这种姿势下，如果患者开始跌倒，您可以在患者肩部提供支撑。 ^(65){ }^{65} 如果患者使用助行器或手杖，请确保患者在开始行走前使用了该装置。请参阅图 13.22^(66)13.22^{66} ，了解护士协助患者站立的图片。
Figure 13.22 Assisting a Patient to Stand 图 13.22 协助病人站立
Before stepping away from the bed, ask the patient if they feel dizzy or lightheaded. If they do, sit the patient back down on the bed until the symptoms resolve. If the patient feels stable, begin walking by matching your steps to the patient’s. Instruct the patient to look ahead and lift each foot off the ground. Walk only as far as the patient can tolerate without feeling dizzy or 在离开病床之前，询问病人是否感到头晕或头昏。如果有，让病人坐回床上，直到症状消失。如果病人感觉稳定，就开始行走，步调要与病人一致。指导病人目视前方，抬起每只脚离开地面。步行距离以患者能够忍受而不会感到头晕或眩晕为限。
64. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 64.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
65. Moroz, A. (2017, June). Physical therapy (PT). Merck Manual Professional Version. https://www.merckmanuals.com/professional/special-subjects/rehabilitation/physical-therapy-pt 65.Moroz, A.（2017 年 6 月）。物理治疗（PT）》。默克手册专业版》。https://www.merckmanuals.com/professional/special-subjects/rehabilitation/physical-therapy-pt
66. “Sept-22-2015-122-e1443986200821.jpg,” “Sept-22-2015-124.jpg,” and “Sept-22-2015-128.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-5-positioning-a-patient-on-the-side-of-a-bed/ 66."Sept-22-2015-122-e1443986200821.jpg"、"Sept-22-2015-124.jpg "和 "Sept-22-2015-128.jpg "由作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/clinicalskills/chapter/3-5-positioning-a-patient-on-the-side-of-a-bed/
weak. Periodically ask them how they are feeling to check for dizziness or weakness. ^(67){ }^{67} In some situations of early ambulation, it is helpful for a second staff member to follow behind the patient with a wheeled walker or wheelchair in case the patient needs to sit while walking. 虚弱。定期询问他们的感觉，检查是否有头晕或虚弱的情况。 ^(67){ }^{67} 在某些早期行走的情况下，如果病人在行走时需要坐着，那么第二名工作人员用轮式助行器或轮椅跟在病人身后会很有帮助。
To assist the patient back into the bed or a chair, have them stand with the back of their knees touching the bed or chair. Grasp the gait belt and assist them as they lower into a sitting position, keeping your back straight and knees bent. Remove the gait belt. If the patient is returning to bed, place the bed in the lowest position, raise the side rails as indicated, and ensure the call light is within reach. Cover the patient with a sheet or blanket to provide comfort. Document the length of ambulation and the patient’s tolerance of ambulation. 协助病人回到床上或椅子上时，让他们站立，膝盖后部接触床或椅子。握住步态带，协助他们降低到坐姿，保持背部挺直，膝盖弯曲。取下步态带。如果病人要回到床上，将床放到最低位置，按指示升起侧扶手，并确保呼叫灯在触手可及的地方。给患者盖上床单或毯子，以提供舒适感。记录患者行走的时间长度和患者对行走的耐受程度。
Transfer From Bed to Chair or Wheelchair 从床上转移到椅子或轮椅上
Patients often require assistance when moving from a bed to a chair or wheelchair. A patient must be cooperative and predictable, able to bear weight on both legs, and able to take small steps and pivot to safely transfer with a one-person assist. If any of these criteria are not met, a two-person transfer or mechanical lift is recommended. Always complete a mobility assessment and check the provider’s or physical therapist’s orders prior to transferring patients. ^(68){ }^{68} 病人从床上转移到椅子或轮椅上时通常需要帮助。病人必须具有合作精神和可预测性，双腿能够承受体重，能够迈出小步和转动，以便在单人协助下安全转移。如果不符合其中任何一项标准，建议采用双人转运或机械移位机。在转运病人之前，一定要完成移动能力评估，并检查医护人员或理疗师的医嘱。 ^(68){ }^{68}
Begin by explaining to the patient what will happen during the transfer and how they can help. Be sure proper footwear is in place. Lower the bed; set it at a 45-degree angle. Place the wheelchair next to the bed and apply the wheelchair brakes. If the patient has weakness on one side, place the wheelchair on their strong side. ^(69){ }^{69} 首先要向病人解释转运过程中会发生什么以及他们可以如何提供帮助。确保穿上合适的鞋。放低床；将床摆成 45 度角。将轮椅放在床边，并踩下轮椅制动器。如果患者一侧无力，则将轮椅放在其强壮的一侧。 ^(69){ }^{69}
Assist the patient to a seated position on the side of the bed with their feet on the floor. (See the previous section on how to assist a patient to a seated position.) Apply the gait belt snugly around their waist. Place your legs on the outside of their legs. Ask them to place their hands on your waist as they raise themselves into a standing position. Do not lift the patient. If additional assistance is required, obtain a mechanical lift, such as a sit to stand device. Do not allow them to put their arms around your neck because this can cause back injury. Stay close to the patient during the transfer to keep the patient’s weight close to your center of gravity. Once standing, ask the patient to pivot and then take a few steps back until they can feel the wheelchair on the back of their legs. Have the patient grasp the arm of the wheelchair and lean forward slightly. Assist the patient to lower themselves, while shifting your weight from your back leg to the front leg with your knees bent, trunk straight, and elbows slightly bent. Allow the patient to slowly lower themselves into the wheelchair using the armrests for support. 将步态带紧紧套在患者腰部。将你的腿放在他们腿的外侧。要求他们将双手放在你的腰部，同时将自己抬起成站立姿势。不要抬起病人。如果需要额外的帮助，请使用机械移位机，如从坐到站装置。不要让他们用手臂搂住您的脖子，因为这可能会导致背部受伤。在转运过程中紧贴病人，使病人的体重靠近您的重心。站立后，请病人转过身，然后后退几步，直到他们能感觉到轮椅在他们的腿后部。让患者抓住轮椅的扶手，身体略微前倾。协助病人放低身体，同时将重心从后腿转移到前腿，膝盖弯曲，躯干伸直，肘部微屈。让病人利用扶手的支撑慢慢将自己放进轮椅。
See Figure 13.23^(70)13.23^{70} for an image of a staff member assisting a patient to a wheelchair. 请参见图 13.23^(70)13.23^{70} ，其中显示了一名工作人员协助病人坐轮椅的画面。
Reflective Question: What could be improved during this transfer? 反思问题：在这次转移过程中，有哪些地方可以改进？
Figure 13.23 Assisting a Patient to a Wheelchair 图 13.23 协助病人坐轮椅
View a video on Assisting a Patient from Bed to Chair with a Gait Belt or Transfer Belt. ^(71){ }^{71} 观看关于使用步态带或转移带协助病人从床上转移到椅子上的视频。 ^(71){ }^{71}
Lowering A Patient to the Floor 将病人移至地面
A patient may begin to fall while ambulating or while being transferred from one surface to another. If a patient begins to fall from a standing position, do 病人可能会在行走或从一个地面转移到另一个地面时开始跌倒。如果病人开始从站立姿势摔倒，请执行以下操作
not attempt to stop the fall or catch the patient because this can cause back injury. Instead, try to control their fall by lowering them to the floor." 不要试图阻止跌倒或抓住病人，因为这可能会导致背部受伤。相反，应试着将病人放倒在地，以控制其坠落"。
If a patient starts to fall and you are close by, move behind the patient and take one step back. Support the patient around the waist or hip area or grab the gait belt. Bend one leg and place it between the patient’s legs. Slowly slide the patient down your leg, lowering yourself to the floor at the same time. Always protect their head first. Once the patient is on the floor, assess the patient for injuries prior to moving them. Assess the patient’s need for assistance to get off the floor. If the patient is unable to get up off the floor, use a mechanical lift. Complete an incident report and follow up according to the patient’s condition and agency policy. See Figure 13.24^(73)13.24^{73} for images of lowering a patient to the floor. 如果病人开始跌倒，而您就在附近，请移动到病人身后并后退一步。支撑病人的腰部或臀部，或抓住步态带。弯曲一条腿，放在病人两腿之间。慢慢地将病人从你的腿上滑下，同时将自己降至地面。始终先保护他们的头部。一旦病人躺在地板上，在移动他们之前要评估病人是否受伤。评估病人是否需要帮助才能离开地面。如果患者无法从地板上站起来，则使用机械移位机。完成事故报告，并根据患者的病情和机构政策采取后续行动。请参见图 13.24^(73)13.24^{73} ，了解将病人放至地面的图像。
Figure 13.24 Lowering a Patient to the Floor 图 13.24 将病人放至地面
72. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 72.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
73. “Sept-22-2015-132-001.jpg” and “Sept-22-2015-133.jpg” by unknown authors are licensed under CC BY 4.0. Access for free at https://opentextbc.ca/clinicalskills/chapter/3-7-fall-prevention/ 73."Sept-22-2015-132-001.jpg "和 "Sept-22-2015-133.jpg "作者未知，采用 CC BY 4.0 许可。免费访问：https://opentextbc.ca/clinicalskills/chapter/3-7-fall-prevention/
Preventing Falls 预防跌倒
Falls are a major safety concern in health care. Nurses are responsible for identifying, managing, and eliminating potential fall hazards for patients. All patient-handling activities (positioning, transfers, and ambulation) pose a risk to both patients and health care professionals. Older adults are often at increased risk for falls due to impaired mental status, decreased strength, impaired balance and mobility, and decreased sensory perception. Patients may also be at risk for falls due to gait problems, cognitive ability, visual problems, urinary frequency, generalized weakness, cognitive impairments, or medications that may cause hypotension or drowsiness. ^(74){ }^{74} Falls can cause head injuries, fractures, lacerations, and other injuries. 跌倒是医疗安全的一大隐患。护士有责任识别、管理和消除患者潜在的跌倒危险。所有处理病人的活动（定位、转移和移动）都会给病人和医护人员带来风险。老年人由于精神状态受损、体力下降、平衡能力和活动能力受损以及感官知觉减退，通常会增加跌倒的风险。患者还可能因步态问题、认知能力、视力问题、尿频、全身无力、认知障碍或可能导致低血压或嗜睡的药物而有跌倒的风险。 ^(74){ }^{74} 跌倒可能导致头部受伤、骨折、撕裂伤和其他伤害。
Fall prevention is key. If a patient begins to feel dizzy while ambulating or transferring, assist them to sit on a chair or on the floor to avoid a fall. The head is the most important part of the body, so protect it as much as possible. In the event of a fall, seek help and stay with the patient until assistance arrives. Follow agency policy for reporting, assessing, and documenting. After a fall, always assess a patient for injuries prior to moving them. If the patient remains weak or dizzy, do not attempt to ambulate them, but instead, ask for assistance to transfer them to a chair or bed. ^(75){ }^{75} 预防跌倒是关键。如果病人在行走或转移时开始感到头晕，应协助他们坐在椅子上或地板上，以避免跌倒。头部是身体最重要的部位，因此要尽可能保护好头部。一旦发生跌倒，应寻求帮助并陪伴在病人身边，直到救援人员到来。遵循机构的报告、评估和记录政策。跌倒后，在移动病人之前，一定要评估他们是否受伤。如果病人仍然虚弱或头晕，不要试图移动他们，而是请求帮助将他们转移到椅子或床上。 ^(75){ }^{75}
All patients should be assessed for risk factors for falls and necessary fall precautions implemented per agency policy. Read more information about preventing falls in the “Safety” chapter. 应对所有患者进行跌倒风险因素评估，并根据机构政策实施必要的跌倒预防措施。请阅读 "安全 "一章中有关预防跌倒的更多信息。
74. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 74.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
75. This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 75.本作品是不列颠哥伦比亚理工学院《更安全的病人护理临床程序》的衍生作品，采用 CC BY 4.0 许可。
13.3 Applying the Nursing Process 13.3 应用护理程序
OPEN RESOURCES FOR NURSING (OPEN RN) 开放式护理资源（open rn）
Assessment 评估
Because mobility issues are directly related to musculoskeletal disorders, perform a thorough assessment of the musculoskeletal system and its effect on the patient’s mobility status. Assess muscle strength and coordination, and then assess mobility skills in the following order: mobility in bed, dangling on the bed with supported and unsupported sitting, weight-bearing while transferring from sitting to standing or to a chair, standing and walking with assistance, and walking independently. 由于行动能力问题与肌肉骨骼疾病直接相关，因此要对肌肉骨骼系统及其对患者行动能力状况的影响进行全面评估。首先评估患者的肌肉力量和协调性，然后按照以下顺序评估患者的行动能力：在床上的行动能力、在床上悬空、有支撑和无支撑的坐姿、从坐姿转移到站姿或转移到椅子时的负重能力、在他人协助下的站立和行走能力以及独立行走能力。
Read more details about performing a “Musculoskeletal Assessment” in Open RN Nursing Skills. 请在《开放式注册护士护理技能》中阅读有关执行 "肌肉骨骼评估 "的更多详情。
Because immobility can negatively affect several body systems, perform a thorough assessment for patients with impaired mobility. Assess the cardiovascular system, including blood pressure, heart sounds, apical and peripheral pulses, and capillary refill time. Assess for the presence of lower extremity edema and for signs of a potential deep vein thrombosis (DVT). 由于行动不便会对多个身体系统产生负面影响，因此要对行动不便的患者进行全面评估。评估心血管系统，包括血压、心音、心尖和外周搏动以及毛细血管再充盈时间。评估是否存在下肢水肿以及潜在深静脉血栓 (DVT) 的迹象。
Assess the respiratory system, including respiratory rate, oxygen saturation, lung sounds, chest wall movement and symmetry, and depth and effort of respirations. Assess for potential signs of atelectasis and pneumonia. 评估呼吸系统，包括呼吸频率、血氧饱和度、肺鸣音、胸壁运动和对称性、呼吸深度和力度。评估是否有肺不张和肺炎的潜在迹象。
Assess the gastrointestinal system by inspecting for distension, auscultating bowel sounds, and palpating the abdomen for tenderness. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. If constipation is suspected, palpate the patient’s left lower quadrant for signs of stool presence. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. 通过检查腹胀、听诊肠鸣音和触诊腹部是否有压痛来评估胃肠道系统。询问患者上次排便的日期，观察粪便形态和粪便特征。如果怀疑有便秘，则触诊患者左下腹是否有粪便存在的迹象。评估是否存在与行动不便有关的泌尿道异常，如耻骨上胀痛或尿潴留引起的触痛。监测 24 小时的出入量趋势以及排尿困难、尿急或尿频症状。
Note if urinary incontinence is occurring due to the inability of the patient to reach the restroom in time.’ 注意患者是否因无法及时到达洗手间而导致尿失禁。
Life Span Considerations 寿命考虑因素
At each stage of growth and development, the nurse assesses a patient’s mobility and provides appropriate education. For example, infants move their limbs, hold their head up, roll, sit, crawl, stand, and then eventually walk. Parents are educated about these developmental milestones during wellchild visits. When working with school-age children, nurses provide education to prevent injury that can occur with activity, such as using helmets and knee pads to prevent injury while bicycling and skateboarding. As teenagers become adults, the nurse provides education about the effects of alcohol and other drugs on balance and safety while driving. Older adults are at increased risk for immobility. Conditions such as osteoarthritis, orthostatic hypotension, inner ear dysfunction, osteoporosis resulting in hip fractures, stroke, and Parkinson’s disease are among the most common causes of immobility in old age. 在生长发育的每个阶段，护士都要对病人的活动能力进行评估，并提供适当的教育。例如，婴儿会移动四肢、抬头、打滚、坐、爬、站，最终会走路。在进行儿童健康检查时，护士会向家长讲解这些发育里程碑。在为学龄儿童提供服务时，护士会提供预防活动伤害的教育，例如使用头盔和护膝来预防骑自行车和玩滑板时受伤。当青少年长大成人后，护士会提供有关酒精和其他药物对平衡和驾驶安全影响的教育。老年人行动不便的风险增加。骨关节炎、正性低血压、内耳功能障碍、导致髋部骨折的骨质疏松症、中风和帕金森病等疾病都是导致老年人行动不便的最常见原因。
Hospitalization poses a risk for altered functional status of older adults due to acute illness, decreased mobility, and the negative effects of bedrest. The American Academy of Nursing issued a recommendation in 2014 stating, “Don’t let older adults lie in bed or only get up to a chair during their hospital stay.” This recommendation highlights the importance of implementing evidence-based measures to promote activity during hospitalization to prevent functional decline in older adults. ^(2){ }^{2} 由于急性病、活动能力下降以及卧床的负面影响，住院会给老年人的功能状态带来改变的风险。美国护理学会在 2014 年发布了一项建议，指出 "不要让老年人在住院期间躺在床上或只能起身坐在椅子上"。该建议强调了在住院期间实施循证措施促进活动以防止老年人功能衰退的重要性。 ^(2){ }^{2}
View evidence-based strategies to reduce functional decline in hospitalized older adults provided by The Hartford Institute for Geriatric Nursing. ^(3){ }^{3} 查看哈特福德老年护理研究所提供的减少住院老年人功能衰退的循证策略。 ^(3){ }^{3}
Diagnoses 诊断
There are several nursing diagnoses related to mobility. Review a nursing care planning source for current NANDA-I approved nursing diagnoses and interventions. A commonly used NANDA-I nursing diagnosis is Impaired Physical Mobility. ^(4){ }^{4} See Table 13.3 for the definition and selected defining characteristics of this diagnosis. ^(5){ }^{5} 有几种护理诊断与移动性有关。查看护理计划资料，了解当前 NANDA-I 批准的护理诊断和干预措施。常用的 NANDA-I 护理诊断是身体移动能力受损。 ^(4){ }^{4} 有关该诊断的定义和选定的定义特征，请参见表 13.3。 ^(5){ }^{5}
Alteration in gait
Decrease in fine motor skills
Decrease in gross motor skills
Decrease in range of motion
Decrease in reaction time
Difficulty turning
Exertional dyspnea
Postural instability
Uncoordinated or slow movement| Alteration in gait |
| :--- |
| Decrease in fine motor skills |
| Decrease in gross motor skills |
| Decrease in range of motion |
| Decrease in reaction time |
| Difficulty turning |
| Exertional dyspnea |
| Postural instability |
| Uncoordinated or slow movement |
NANDA-I Diagnosis Definition Selected Defining Characteristics
Impaired Physical Mobility Limitation in independent, purposeful movement of the body or of one or more extremities "Alteration in gait
Decrease in fine motor skills
Decrease in gross motor skills
Decrease in range of motion
Decrease in reaction time
Difficulty turning
Exertional dyspnea
Postural instability
Uncoordinated or slow movement"| NANDA-I Diagnosis | Definition | Selected Defining Characteristics |
| :--- | :--- | :--- |
| Impaired Physical Mobility | Limitation in independent, purposeful movement of the body or of one or more extremities | Alteration in gait <br> Decrease in fine motor skills <br> Decrease in gross motor skills <br> Decrease in range of motion <br> Decrease in reaction time <br> Difficulty turning <br> Exertional dyspnea <br> Postural instability <br> Uncoordinated or slow movement |
A sample nursing diagnosis in PES format is, “Impaired Physical Mobility related to decrease in muscle strength as evidenced by slow movement and alteration in gait.” PES 格式的护理诊断样本是："身体活动能力受损，与肌肉力量下降有关，表现为行动缓慢和步态改变"。
Outcome Identification 成果鉴定
A sample overall goal for a patient with Impaired Physical Mobility is, “The patient will participate in activities of daily living to the fullest extent possible for their condition.” 肢体活动能力受损患者的总体目标样本是："患者将根据自身情况尽可能充分地参与日常生活活动"。
A sample SMART outcome is, “The patient will demonstrate appropriate use of adaptive equipment (e.g., a walker) for safe ambulation by the end of the shift.” SMART 结果的示例是："病人将在轮班结束前展示适当使用适应性设备（如助行器）以安全行走的能力"。
Planning Interventions 规划干预措施
Nursing interventions promote a patient’s mobility and prevent effects of immobility. To avoid or minimize complications of immobility, mobilize the patient as soon as possible and to the fullest extent possible. Mobilization efforts, ranging from dangling on the edge of the bed, sitting up in a chair, and assisting with early ambulation, depend on the patient’s unique circumstances, such as their medical condition and surgery performed. For example, a patient undergoing a cardiac catheterization may be mobilized within a few hours following the procedure, whereas a patient undergoing total knee arthroplasty may begin mobilizing 24 hours following the surgery. ^(7){ }^{7} See details about early mobilization protocols earlier in this chapter. 护理干预可以促进患者的活动能力，并预防不活动所带来的影响。为了避免或最大限度地减少行动不便的并发症，应尽快并尽可能充分地移动患者。移动的范围从悬挂在床边、在椅子上坐起来到协助早期移动，这取决于病人的特殊情况，如他们的医疗状况和所做的手术。例如，接受心导管检查的病人可能在手术后几小时内就能活动，而接受全膝关节置换术的病人可能在手术后 24 小时就开始活动。 ^(7){ }^{7} 请参阅本章前面关于早期康复方案的详细内容。
Encourage the patient to perform activities of daily living (ADLs) as independently as possible and participate in prescribed physical therapy. Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Be aware that pain and fear of falling can be major deterrents to a patient’s willingness to ambulate or perform physical therapy. Monitor the patient’s level of pain by using a valid pain intensity rating scale. Administer medications if warranted and consider nonpharmacologic measures such as repositioning, splinting, and heat/cold application to reduce musculoskeletal discomfort. Encourage rest between activities. Educate the patient about appropriately using assistive devices and other fall precautions., ^(8,9){ }^{8,9} 鼓励患者尽可能独立地进行日常生活活动（ADL），并参与规定的物理治疗。按照理疗师的处方鼓励或进行主动或被动的活动范围练习。要知道，疼痛和对跌倒的恐惧可能会严重影响患者行走或进行物理治疗的意愿。使用有效的疼痛强度评分表监测患者的疼痛程度。必要时使用药物，并考虑采取非药物措施，如调整体位、夹板固定和热敷/冷敷等，以减轻肌肉骨骼的不适感。鼓励患者在两次活动之间休息。教育患者正确使用辅助设备和其他防跌倒措施。
For patients at risk for developing pneumonia due to immobility, encourage adequate fluid intake to liquefy pulmonary secretions, and teach deep breathing and coughing exercises to prevent atelectasis. Monitor oxygenation 对于因行动不便而有可能患肺炎的患者，应鼓励其摄入足够的液体以液化肺部分泌物，并指导其进行深呼吸和咳嗽练习，以防止出现肺不张。监测氧合
levels and provide supplemental oxygen as prescribed to maintain adequate oxygenation, especially during ambulation. 水平，并遵医嘱补充氧气，以保持足够的氧合，尤其是在行走过程中。
For bed-bound patients, elevate the head of the bed to 30 to 45 degrees, unless medically contraindicated, and turn and reposition the patient every two hours. Perform hourly rounding to check on the patient’s needs and prevent falls. Protect the skin as needed to minimize the potential for breakdown, and advocate for devices to prevent contractures, as needed.".12 对于卧床病人，除非医学上有禁忌，否则应将床头抬高至 30 至 45 度，并每两小时为病人翻身和调整体位。每小时查房一次，了解病人的需求，防止跌倒。根据需要保护皮肤，将皮肤破损的可能性降到最低，并提倡根据需要使用防止挛缩的设备"。
Implementing Interventions 实施干预措施
When implementing interventions to promote mobility, in addition to reviewing the current orders regarding assistance and weight-bearing, assess the patient’s current status. For example, use the Banner Mobility Assessment Tool to determine the patient’s current mobility status and needs for safe patient handling. 在实施促进移动能力的干预措施时，除了查看当前有关协助和负重的医嘱外，还要评估患者的当前状况。例如，使用班纳移动能力评估工具（Banner Mobility Assessment Tool）来确定患者当前的移动能力状况以及安全搬运患者的需求。
Monitor for signs of vertigo and orthostatic hypotension and assist the patient to a sitting or lying position if they occur. Monitor vital signs before, during, and after physical activity and institute appropriate fall prevention strategies as indicated. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mmHg or more or in diastolic blood pressure of 10 mm Hg or more within three minutes of standing. If orthostatic hypotension is suspected, measure the patient’s vital signs while he or she is supine, sitting, and standing before encouraging ambulation. Monitor and document the 监测是否有眩晕和正性低血压的迹象，如果有，则协助病人取坐位或卧位。在体力活动之前、期间和之后监测生命体征，并根据情况采取适当的预防跌倒策略。直立性低血压的定义是站立三分钟内收缩压下降 20 毫米汞柱或以上，或舒张压下降 10 毫米汞柱或以上。如果怀疑存在直立性低血压，应在鼓励患者走动之前测量其仰卧、坐位和站立时的生命体征。监测并记录
10. Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://doi.org/10.1016/ j.pmr.2012.06.009 10.Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防与管理》。https://doi.org/10.1016/ j.pmr.2012.06.009
11. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 281-282. 11.Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018)。护理干预分类（NIC）》。Elsevier，第 281-282 页。
12. Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://doi.org/10.1016/ j.pmr.2012.06.009 12.Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防与管理》。https://doi.org/10.1016/ j.pmr.2012.06.009
patient’s response to activity, such as heart rate, blood pressure, dyspnea, and skin color. ^(13,14){ }^{13,14} 病人对活动的反应，如心率、血压、呼吸困难和皮肤颜色。 ^(13,14){ }^{13,14}
Evaluation 评估
Determine the patient’s progress towards their specific SMART outcomes. Encourage their participation in the setting of realistic goals for mobility and modify these goals as needed for safety. 确定患者在实现特定 SMART 结果方面的进展。鼓励患者参与制定切实可行的移动目标，并根据安全需要修改这些目标。
13. Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing Interventions Classification (NIC). Elsevier, pp. 281-282. 13.Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018)。护理干预分类（NIC）》。Elsevier，第 281-282 页。
14. Skalsky, A. J., & McDonald, C. M. (2012). Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine and Rehabilitation Clinics of North America, 23(3), 675-687. https://doi.org/10.1016/ j.pmr.2012.06.009 14.Skalsky, A. J., & McDonald, C. M. (2012)。神经肌肉疾病肢体挛缩的预防与管理》。https://doi.org/10.1016/ j.pmr.2012.06.009
13.4 Putting It All Together 13.4 将所有内容整合在一起
Patient Scenario 患者情景
Mrs. Howard is a 73-year-old woman who was recently admitted to the medical surgical floor with pneumonia. She has an underlying history of emphysema and has experienced a recent exacerbation in dyspnea during activity. This morning when being assisted to the bathroom, she reports, “I have to stop and catch my breath when walking.” Vital signs this morning indicated oxygen saturation 91%91 \% and respiratory rate 18 on room air at rest. During report it was communicated that Mrs. Howard is able to ambulate with the assistance of one but only moves short distances around the room before she needs to stop and rest. 霍华德夫人是一名 73 岁的妇女，最近因肺炎住进了内外科病房。她有肺气肿病史，最近活动时呼吸困难加重。今天早上，当有人搀扶着她去卫生间时，她说 "走路时我必须停下来喘气"。今天上午的生命体征显示，她的血氧饱和度为 91%91 \% ，呼吸频率为 18，休息时呼吸室内空气。报告显示，霍华德夫人能够在一个人的协助下行走，但只能在房间内走一小段距离就需要停下来休息。
Applying the Nursing Process 应用护理程序
Assessment: The nurse identifies a relevant cue that the patient, diagnosed with pneumonia and a previous history of emphysema, is experiencing increased dyspnea when walking around the room that requires her to stop and rest. Vital signs at 0700 were reviewed, and it was noted that the patient’s respiratory rate was 24 with oxygen saturation level 91%91 \% on room air at rest. The nurse gathers additional assessment data while the patient is walking and discovers her respiratory rate increases to 30 and her oxygen saturation level decreases to 85%85 \% after walking for 2 minutes. Additionally, the patient stops and catches her breath after walking approximately 10 feet, causing her to limit her mobility. 评估：护士发现了一条相关线索，即患者被诊断患有肺炎并曾有肺气肿病史，她在房间里走动时呼吸困难加剧，需要停下来休息。护士查看了患者 0700 时的生命体征，发现患者的呼吸频率为 24，休息时室内空气中的血氧饱和度为 91%91 \% 。护士在患者行走时收集其他评估数据，发现她在行走 2 分钟后呼吸频率上升到 30，血氧饱和度下降到 85%85 \% 。此外，患者在行走大约 10 英尺后就会停下来喘气，导致她的活动能力受到限制。
The nurse reviews the patient’s chart and finds an order for “Oxygen via nasal cannula up to 5L//min5 \mathrm{~L} / \mathrm{min} PRN to maintain oxygen saturation at 90%.” The nurse also notes a referral for physical therapy assessment and strengthening exercises. 护士查看了患者的病历，发现了一张 "通过鼻插管吸氧至 5L//min5 \mathrm{~L} / \mathrm{min} PRN 以维持血氧饱和度在 90% 以下 "的医嘱。护士还注意到转介病人进行理疗评估和强化训练。
Based on the assessment information gathered, the following nursing care plan is created for Mrs. Howard: 根据收集到的评估信息，为霍华德夫人制定了以下护理计划：
Nursing Diagnosis: Impaired Physical Mobility r/t activity intolerance as 护理诊断：肢体活动能力受损/活动不耐受，因为
manifested by decreased oxygen saturation, increased respirations, and patient report of “I have to stop and catch my breath while walking.” 表现为血氧饱和度下降、呼吸次数增加，以及病人说 "走路时我必须停下来喘气"。
Overall Goal: The patient will demonstrate improvement in mobility. 总体目标：患者的活动能力将得到改善。
SMART Expected Outcomes: SMART 预期成果：
Mrs. Howard will ambulate 50 feet in the hallway within 24 hours. 霍华德夫人将在 24 小时内在走廊上行走 50 英尺。
Mrs. Howard will maintain an oxygen saturation level of 90% or higher while walking within 24 hours. 霍华德夫人在 24 小时内行走时的血氧饱和度将保持在 90% 或以上。
Planning and Implementing Nursing Interventions: 规划和实施护理干预：
The nurse plans to administer oxygen to the patient via nasal cannula as needed to maintain an oxygen saturation level of 90%90 \% or higher. The nurse will teach the patient about the importance of balancing periods of activity with periods of rest and reinforce the use of pursed-lip breathing. The nurse will encourage patient ambulation and her active participation in completing ADLs. The nurse will collaborate with physical therapy to educate the patient regarding strengthening exercises and reinforce principles of progressive exercise. The nurse plans to further assess the patient’s smoking history and promote smoking cessation. 护士计划根据需要通过鼻插管为患者供氧，以维持 90%90 \% 或更高的血氧饱和度。护士将教导病人平衡活动和休息时间的重要性，并加强抿唇呼吸法的使用。护士将鼓励患者下床活动并积极参与完成日常活动。护士将与理疗师合作，向患者传授有关加强锻炼的知识，并强化循序渐进的锻炼原则。护士计划进一步评估患者的吸烟史并促进戒烟。
Sample Documentation 文件样本
At 0800 when assisting the patient to the bathroom, the patient reported, “I have to stop and catch my breath when walking.” Vital signs at 0700 were respiratory rate 24 and oxygen saturation level 97% on room air at rest. At 0830, vital signs were reassessed while the patient was walking. Her respiratory rate increased to 30 and her oxygen saturation level decreased to 85%85 \% after 2 minutes of walking. The patient stopped to catch her breath after walking approximately 10 feet. Oxygen via nasal cannula at 7L//min7 \mathrm{~L} / \mathrm{min} was applied to the patient before ambulating in the hallway at 1000. The patient’s oxygen saturation level dropped to 88%88 \% after one minute of walking and the oxygen was increased to 2L//min2 \mathrm{~L} / \mathrm{min}. The patient’s oxygen saturation then remained at 90% for the remainder of the walk, and she was able to 8:00 时，在搀扶病人去卫生间时，病人说："我走着走着就得停下来喘气。7:00 时的生命体征为呼吸频率 24，静息时室内空气中的血氧饱和度为 97%。8 时 30 分，在患者行走时重新评估了生命体征。步行 2 分钟后，她的呼吸频率上升到 30，血氧饱和度下降到 85%85 \% 。患者走了大约 10 英尺后停下来喘气。通过鼻插管为患者输入 7L//min7 \mathrm{~L} / \mathrm{min} 氧气后，患者于 1000 时在走廊中行走。步行一分钟后，患者的血氧饱和度降至 88%88 \% ，氧气被增至 2L//min2 \mathrm{~L} / \mathrm{min} 。随后，患者的血氧饱和度在剩余的步行过程中一直保持在 90%，并且她能够
ambulate 50 feet. Pursed-lip breathing was demonstrated and reinforced during the walk. Physical therapy was contacted and an assessment scheduled for later this morning. The patient reports a smoking history of a pack per day for 50 years. She is interested in stopping smoking. A smoking cessation brochure was provided and discussed. Dr. Smith was notified of these events at 1030. 行走 50 英尺。在行走过程中演示并加强了噘嘴呼吸。已联系物理治疗师，并安排在今天上午晚些时候进行评估。患者称其吸烟史长达 50 年，每天一包。她对戒烟很感兴趣。我们向她提供了戒烟手册，并进行了讨论。史密斯医生于 10:30 获知这些情况。
Evaluation 评估
Within 24 hours, Mrs. Howard successfully ambulated 50 feet in the hallway while maintaining oxygen saturation level of 90%90 \%. SMART outcomes were “met.” Planned interventions will continue. SMART outcome is revised to, “Mrs. Howard will ambulate 100 feet in the hallway within 24 hours.” 在 24 小时内，Howard 女士成功地在走廊上行走了 50 英尺，同时保持了 90%90 \% 的血氧饱和度水平。SMART 结果 "达到"。计划的干预措施将继续进行。SMART 结果修改为："霍华德夫人将在 24 小时内在走廊上行走 100 英尺"。
Learning Activities 学习活动
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.) (学习活动 "的答案可在书末的 "答案集 "中找到。互动活动元素的答案将作为即时反馈在元素中提供）。
Ms. Curtis is a 67-year-old patient admitted for a left total knee replacement. She is post-op Day 2 and is currently receiving care on the medical surgical unit. Ms. Curtis has been complaining of pain and refused her previous two physical therapy appointments. She agrees to sitting up in the chair, but declines walking. 柯蒂斯女士是一名 67 岁的患者，因左膝关节全置换术入院。术后第 2 天，她正在内科手术室接受治疗。柯蒂斯女士一直抱怨疼痛，并拒绝了前两次理疗预约。她同意在椅子上坐起来，但拒绝行走。
What focused assessments should the nurse perform and why? 护士应进行哪些重点评估，为什么？
What complications could occur related to Ms. Curtis’ immobility? 柯蒂斯女士行动不便会引发哪些并发症？
What SMART outcomes should the nurse plan in collaboration with Ms. Curtis? 护士应该与柯蒂斯女士合作规划哪些 SMART 成果？
List interventions the nurse should plan for Ms. Curtis and their rationale. 列出护士应为柯蒂斯女士计划的干预措施及其理由。
How will the nurse evaluate if the interventions are successful? 护士如何评估干预措施是否成功？
Mobility Case Study by Susan Jepsen for Lansing Community 苏珊-杰普森（Susan Jepsen）为兰辛社区撰写的流动性案例研究
College are licensed under CC BY 4.0 学院采用 CC BY 4.0 许可协议。
Active assist range of motion exercise: A patient’s joint receiving partial assistance in movement from an outside force. 主动辅助活动范围练习：患者的关节在运动时接受外力的部分辅助。
Active range of motion: Movement of a joint by the individual performing the exercise. 主动运动范围：个人在进行锻炼时的关节活动。
Ambulation: The ability of a patient to safely walk independently, with assistance from another person, or with an assistive device, such as a cane, walker, or crutches. 行走能力：患者独立、在他人协助下或在手杖、助行器或拐杖等辅助设备的帮助下安全行走的能力。
Assistive device: An object or piece of equipment designed to help a patient with activities of daily living, such as a walker, cane, gait belt, or mechanical lift. 辅助设备：旨在帮助病人进行日常生活活动的物体或设备，如助行器、手杖、步态带或机械移位机。
Bed mobility: The ability of a patient to move around in bed, including moving from lying to sitting and sitting to lying. 床上活动能力：病人在床上走动的能力，包括从躺到坐和从坐到躺的移动。
Body mechanics: The coordinated effort of muscles, bones, and the nervous system to maintain balance, posture, and alignment during moving, transferring, and repositioning patients. 身体力学：在移动、转移和重新安置病人的过程中，肌肉、骨骼和神经系统协调努力，以保持平衡、姿势和对齐。
Fowler’s position: A position where the patient is supine with the head of bed placed at a 45- to 90-degree angle. The bed can be used to slightly flex the hips to help prevent the patient from migrating downwards in bed. 福勒体位：患者仰卧位，床头呈 45 至 90 度角。床可以用来稍微弯曲臀部，以帮助防止病人在床上向下移动。
Functional mobility: The ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing, and moving around in bed. 功能性移动能力一个人在周围环境中移动的能力，包括行走、从椅子上站起、从站立到坐下，以及在床上移动。
Gait belt: A 2-inch-wide ( 5 mm ) belt, with or without handles, that is fastened around a patient’s waist used to ensure stability when assisting patients to stand, ambulate, or to transfer from bed to chair. 步态带：步态腰带：一种 2 英寸宽（5 毫米）的腰带，有把手或无把手，系在病人腰部，用于协助病人站立、行走或从床上转移到椅子上时确保其稳定性。
Lateral positioning: A position where the patient lies on one side of the body 侧卧位病人躺在身体一侧的体位
with the top leg over the bottom leg. This position helps relieve pressure on the coccyx. 上肢放在下肢上。这种姿势有助于减轻尾骨受到的压力。
Mechanical lift: A hydraulic lift with a sling used to move patients who cannot bear weight or have a medical condition that does not allow them to stand or assist with moving. It can be a portable device or permanently attached to the ceiling. 机械移位机：带吊衣的液压移位机，用于移动无法承受体重或因疾病而无法站立或协助移动的病人。它可以是一个便携式设备，也可以永久性地固定在天花板上。
Mobility: The ability of a patient to change and control body position. Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to being completely immobile (i.e., the patient is unable to make even slight changes in body or extremity position without assistance). 活动能力患者改变和控制身体姿势的能力。移动能力是一个连续统一体，从无障碍（即病人可以在没有帮助的情况下频繁地改变体位）到完全无法移动（即病人在没有帮助的情况下甚至无法轻微地改变身体或四肢的位置）。
Orthostatic hypotension: Low blood pressure that occurs when a patient changes position from lying to sitting or sitting to standing that causes symptoms of dizziness or light-headedness. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop of diastolic blood pressure of 10 mm Hg or more within three minutes of sitting or standing. 直立性低血压：患者从躺到坐或从坐到站改变体位时出现的低血压，会引起头晕或头重脚轻的症状。躯体静力性低血压的定义是：坐或站三分钟内收缩压下降 20 毫米汞柱或以上，或舒张压下降 10 毫米汞柱或以上。
Passive range of motion exercises: Movement applied to a joint solely by another person or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part. 被动运动范围练习：仅由他人或被动运动器械对关节进行的运动。在进行被动运动时，接受锻炼的人的关节完全放松，而外力则使身体部位运动。
Prone positioning: A position where the patient lies on their stomach with their head turned to the side. 俯卧位：俯卧位：病人俯卧，头转向一侧。
Range of motion (ROM) exercises: Activities aimed to facilitate movement of specific joints and promote mobility of extremities. 运动范围（ROM）练习：旨在促进特定关节运动和提高四肢灵活性的活动。
Semi-Fowler’s position: A position where the head of the bed is placed at a 30- to 45-degree angle. The patient’s hips may or may not be flexed. 半福勒式体位：床头呈 30 至 45 度角的体位。病人的臀部可以弯曲，也可以不弯曲。
Sims positioning: A position where the patient is positioned halfway between the supine and prone positions with their legs flexed. Sims 体位法：将患者置于仰卧位和俯卧位之间，双腿弯曲。
Sit to stand lifts: Mobility devices that assist weight-bearing patients who are unable to transition from a sitting position to a standing position by using their own strength. They are used to safely transfer patients who have some muscular strength, but not enough strength to safely change positions by themselves. Some sit to stand lifts use a mechanized lift whereas others are nonmechanized. 坐立移位机：坐立移位机：用于帮助无法通过自身力量从坐姿过渡到站姿的负重病人的移位设备。坐立移位机用于安全地转移有一定肌肉力量但没有足够力量自己安全地改变体位的病人。一些坐立移位机使用机械化移位机，而另一些则使用非机械化移位机。
Slider board: A board (also called a transfer board) used to transfer an immobile patient from one surface to another while the patient is lying supine (e.g., from a stretcher to hospital bed). 滑板：用于将仰卧的不动病人从一个表面转移到另一个表面（如从担架转移到病床）的板（也称为转移板）。
Supine positioning: A position where the patient lies flat on their back. 仰卧位：患者平躺的姿势。
Timed Get Up and Go Test: A mobility assessment by nurses that begins by having the patient stand up from an armchair, walk three yards, turn, walk back to the chair, and sit down. As the patient performs these maneuvers, their posture, alignment, balance, and gait are analyzed as the patient’s mobility status is assessed. 定时起立行走测试：这是一种由护士进行的行动能力评估，首先让患者从扶手椅上站起来，步行三码，转身，走回椅子，然后坐下。当病人完成这些动作时，护士会对他们的姿势、对齐、平衡和步态进行分析，从而评估病人的行动能力状况。
Transferring: The action of a patient moving from one surface to another. This includes moving from a bed into a chair or moving from one chair to another. 转移：病人从一个表面移动到另一个表面的动作。这包括从床上搬到椅子上或从一把椅子搬到另一把椅子上。
Trendelenburg position: A position where the head of the bed is placed lower than the patient’s feet. This position is used in situations such as hypotension and medical emergencies because it helps promote venous return to major organs such as the brain and heart. Trendelenburg 体位：床头低于患者双脚的体位。这种体位适用于低血压和医疗紧急情况等情况，因为它有助于促进脑部和心脏等主要器官的静脉回流。
Tripod position: A position where the patient sits in a chair with their elbows on their knees or at the side of the bed with their arms resting on an overbed table. This position is often naturally assumed by patients with breathing difficulties. 三脚架体位：三脚架体位：病人坐在椅子上，手肘放在膝盖上，或坐在床边，手臂放在床头柜上。呼吸困难的病人通常会自然采取这种姿势。
Vertigo: A sensation of dizziness as if the room is spinning. 眩晕症：一种眩晕感，仿佛房间在旋转。
NUTRITION 营养
Learning Objectives 学习目标
Describe variables that influence nutrition 描述影响营养的各种变量
Identify factors related to nutrition across the life span 确定与整个生命周期的营养有关的因素
Assess a patient’s nutritional status 评估病人的营养状况
Outline specific nursing interventions to promote nutrition 概述促进营养的具体护理干预措施
Base your decisions on the action of nutrients, signs of excess and deficiency, and specific foods associated with each nutrient 根据营养素的作用、过量和缺乏的迹象以及与每种营养素相关的特定食物做出决定
Base your decisions on the interpretation of diagnostic tests and lab values indicative of a disturbance in nutrition 根据显示营养紊乱的诊断测试和实验室数值的解释做出决定
Give examples of appropriate vitamin use across the life span 举例说明在人的一生中如何合理使用维生素
Identify evidence-based practices related to nutrition 确定与营养有关的循证实践
Nurses promote healthy nutrition to prevent disease, assist patients to recover from illness and surgery, and teach patients how to optimally manage chronic illness with healthy food choices. Healthy nutrition helps to prevent obesity and chronic diseases, such as diabetes mellitus and cardiovascular disease. By proactively encouraging healthy eating habits, nurses provide the tools for patients to maintain their health, knowing it is easier to stay healthy than to become healthy after disease sets in. When patients are recovering from illness or surgery, nurses use strategies to promote good nutrition even when a patient has a poor appetite or nausea. If a patient develops chronic disease, the nurse provides education about prescribed diets that can help manage the disease, such as a low carbohydrate diet for patients with diabetes or a low fat, low salt, low cholesterol diet for patients with cardiovascular disease. 护士提倡健康营养以预防疾病，帮助病人从疾病和手术中恢复，并教导病人如何通过选择健康的食物来最佳地控制慢性疾病。健康营养有助于预防肥胖和慢性疾病，如糖尿病和心血管疾病。护士通过积极鼓励患者养成健康的饮食习惯，为他们提供保持健康的工具，因为他们知道保持健康比疾病袭来时变得健康要容易得多。当病人从疾病或手术中恢复过来时，即使病人食欲不振或恶心，护士也会采取策略促进良好的营养。如果病人患上慢性疾病，护士会向病人介绍有助于控制疾病的规定饮食，如糖尿病病人的低碳水化合物饮食或心血管疾病病人的低脂、低盐、低胆固醇饮食。
Nurses also advocate for patients with conditions that can cause nutritional deficits. For example, a nurse may be the first to notice that a patient is having difficulty swallowing at mealtime and advocates for a swallow study to prevent aspiration. A nurse may also notice other psychosocial risk factors that place a patient at risk for poor nutrition in their home environment and make appropriate referrals to enhance their nutritional status. Nurses also administer alternative forms of nutrition, such as enteral (tube) feedings or parenteral (intravenous) feedings. 护士还为患有可能导致营养不良的疾病的病人提供帮助。例如，护士可能是第一个注意到病人在进餐时吞咽困难的人，并主张进行吞咽检查以防止误吸。护士还可能会注意到病人在家庭环境中存在营养不良风险的其他社会心理风险因素，并作出适当的转介，以改善他们的营养状况。护士还可提供其他形式的营养，如肠内（管式）喂养或肠外（静脉）喂养。
This chapter will review basic information about the digestive system, essential nutrients, nutritional guidelines, and then discuss the application of the nursing process to addressing patients’ nutritional status. 本章将回顾有关消化系统、必需营养素、营养指南的基本信息，然后讨论护理程序在解决病人营养状况方面的应用。
14.2 Nutrition Basic Concepts 14.2 营养基本概念
Before discussing assessments and interventions related to promoting good nutrition, let’s review the structure and function of the digestive system, essential nutrients, and nutritional guidelines. 在讨论与促进良好营养有关的评估和干预措施之前，让我们先回顾一下消化系统的结构和功能、必需营养素和营养指南。
Digestive System 消化系统
The digestive system breaks down food and then absorbs nutrients into the bloodstream via the small intestine and large intestine. Because good health depends on good nutrition, any disorder affecting the functioning of the digestive system can significantly impact overall health and well-being and increase the risk of chronic health conditions. 消化系统分解食物，然后通过小肠和大肠将营养物质吸收到血液中。由于健康取决于良好的营养，任何影响消化系统功能的疾病都会严重影响整体健康和福祉，并增加患慢性疾病的风险。
Structure and Function 结构与功能
The gastrointestinal system (also referred to as the digestive system) is responsible for several functions, including digestion, absorption, and immune response. Digestion begins in the upper gastrointestinal tract at the mouth, where chewing of food occurs, called mastication. Mastication results in mechanical digestion when food is broken down into small chunks and swallowed. Masticated food is formed into a bolus as it moves toward the pharynx in the back of the throat and then into the esophagus. Coordinated muscle movements in the esophagus called peristalsis move the food bolus into the stomach where it is mixed with acidic gastric juices and further broken down into chyme through a chemical digestion process. As chyme is moved out of the stomach and into the duodenum of the small intestine, it is mixed with bile from the gallbladder and pancreatic enzymes from the pancreas for further digestion.’ 胃肠道系统（也称为消化系统）负责多种功能，包括消化、吸收和免疫反应。消化从上消化道的口腔开始，在这里咀嚼食物，称为咀嚼。当食物被分解成小块并吞咽下去时，咀嚼会导致机械性消化。咀嚼后的食物在向喉咙后部的咽部移动过程中形成栓状，然后进入食道。食道中协调的肌肉运动称为蠕动，它将食物团移动到胃中，在胃中与酸性胃液混合，并通过化学消化过程进一步分解成食糜。当食糜从胃中移出并进入小肠十二指肠时，会与胆囊中的胆汁和胰腺中的胰酶混合，以便进一步消化。
Absorption is a second gastrointestinal function. After chyme enters the small intestine, it comes into contact with tiny fingerlike projections along the 吸收是胃肠道的第二项功能。食糜进入小肠后，会接触到小肠壁上细小的指状突起。
inside of the intestine called villi. Villi increase the surface area of the small intestine and allow nutrients, such as protein, carbohydrates, fat, vitamins, and minerals, to absorb through the intestinal wall and into the bloodstream. Absorption of nutrients is essential for metabolism to occur because nutrients fuel bodily functions and create energy. Peristalsis moves leftover liquid from the small intestine into the large intestine, where additional water and minerals are absorbed. Waste products are condensed into feces and excreted from the body through the anus. See Figure 14.1^(3)14.1^{3} for labeled parts of the gastrointestinal system. 小肠内部的绒毛被称为 "绒毛"。绒毛增加了小肠的表面积，使蛋白质、碳水化合物、脂肪、维生素和矿物质等营养物质能够通过肠壁吸收并进入血液。营养物质的吸收对于新陈代谢的进行至关重要，因为营养物质能为身体机能提供燃料并产生能量。蠕动将小肠中残留的液体转移到大肠，在大肠中吸收更多的水分和矿物质。废物凝结成粪便，通过肛门排出体外。胃肠道系统的标注部分见图 14.1^(3)14.1^{3} 。
In addition to digestion and absorption, the gastrointestinal system is also involved in immune function. Good bacteria in the stomach create a person’s gut biome. Gut biome contributes to a person’s immune response through antibody production in response to foreign materials, chemicals, bacteria, and other substances. ^(4){ }^{4} For example, patients may develop Clostridium difficile (Cdiff) after taking antibiotics that kill these beneficial bacteria in the gut. Read additional details about our microbiome and immune response in the “Infection” chapter of this book. 除了消化和吸收，肠胃系统还参与免疫功能。胃中的好细菌创造了人的肠道生物群。肠道生物群通过对外来物质、化学物质、细菌和其他物质产生抗体来促进人的免疫反应。 ^(4){ }^{4} 例如，服用抗生素杀死肠道中的有益细菌后，患者可能会患上艰难梭菌病（Cdiff）。请阅读本书 "感染 "一章中有关微生物群和免疫反应的更多详情。
2. This work is a derivative of Anatomy and Physiology by Boundless and is licensed under CC BY-SA 4.0 2.本作品是 Boundless 的《解剖学与生理学》的衍生作品，采用 CC BY-SA 4.0 许可。
3. “Digestive-41529_1280.png” by Sarahguess5 is licensed under CCO 3."Digestive-41529_1280.png" by Sarahguess5 采用 CCO 许可协议授权。
4. Human digestive system. (2019). In Britannica. Gastrointestinal tract as an organ of immunity. https://www.britannica.com/science/human-digestive-system/The-gastrointestinal-tract-as-an-organ-ofimmunity 4.人体消化系统。(2019).In Britannica.作为免疫器官的胃肠道。https://www.britannica.com/science/human-digestive-system/The-gastrointestinal-tract-as-an-organ-ofimmunity。
Figure 14.1 The Gastrointestinal System 图 14.1 胃肠系统
Essential Nutrients 必需营养素
Nutrients from food and fluids are used by the body for growth, energy, and bodily processes. Essential nutrients refer to nutrients that are necessary for bodily functions but must come from dietary intake because the body is unable to synthesize them. Essential nutrients include vitamins, minerals, 食物和液体中的营养物质被人体用于生长、提供能量和身体运作。必需营养素是指人体功能所必需的营养素，但由于人体无法合成这些营养素，因此必须从食物中摄取。必需营养素包括维生素和矿物质、
some amino acids, and some fatty acids. ^(5){ }^{5} Essential nutrients can be further divided into macronutrients and micronutrients. 一些氨基酸和一些脂肪酸。 ^(5){ }^{5} 必需营养素可进一步分为宏量营养素和微量营养素。
Macronutrients 宏量营养素
Macronutrients make up most of a person’s diet and provide energy, as well as essential nutrient intake. Macronutrients include carbohydrates, proteins, and fats. However, too many macronutrients without associated physical activity cause excess nutrition that can lead to obesity, cardiovascular disease, diabetes mellitus, kidney disease, and other chronic diseases. Too few macronutrients result in undernutrition, which contributes to nutrient deficiencies and malnourishment. ^(6){ }^{6} 宏量营养素占人膳食的大部分，提供能量和必需的营养摄入。宏量营养素包括碳水化合物、蛋白质和脂肪。然而，如果摄入过多的宏量营养素而又没有相应的体育锻炼，就会造成营养过剩，导致肥胖、心血管疾病、糖尿病、肾病和其他慢性疾病。常量营养素过少会导致营养不足，造成营养缺乏和营养不良。 ^(6){ }^{6}
CARBOHYDRATES 碳水化合物
Carbohydrates are sugars and starches and are an important energy source that provides 4kcal//g4 \mathrm{kcal} / \mathrm{g} of energy. Simple carbohydrates are small molecules (called monosaccharides or disaccharides) and break down quickly. As a result, simple carbohydrates are easily digested and absorbed into the bloodstream, so they raise blood glucose levels quickly. Examples of simple carbohydrates include table sugar, syrup, soda, and fruit juice. Complex carbohydrates are larger molecules (called polysaccharides) that break down more slowly, which causes slower release into the bloodstream and a slower increase in blood sugar over a longer period of time. Examples of complex carbohydrates include whole grains, beans, and vegetables. ^(7){ }^{7} 碳水化合物是糖和淀粉，是提供 4kcal//g4 \mathrm{kcal} / \mathrm{g} 能量的重要能源。简单碳水化合物是小分子（称为单糖或双糖），分解迅速。因此，简单碳水化合物很容易被消化和吸收到血液中，从而使血糖水平迅速升高。简单碳水化合物的例子包括食糖、糖浆、苏打水和果汁。复合碳水化合物的分子较大（称为多糖），分解速度较慢，因此释放到血液中的速度较慢，血糖升高的时间也较长。复合碳水化合物的例子包括全谷物、豆类和蔬菜。 ^(7){ }^{7}
Foods can also be categorized according to their glycemic index, a measure 食物还可根据血糖生成指数进行分类。
5. Youdim, A. (2019, May). Overview of nutrition. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition 5.Youdim, A. (2019, May).营养概述。默克手册专业版。https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition
6. Youdim, A. (2019, May). Overview of nutrition. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition 6.Youdim, A. (2019, May).营养概述。默克手册专业版。https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition
7. Youdim, A. (2019, May). Overview of nutrition. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition 7.Youdim, A. (2019, May).营养概述。默克手册专业版。https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition
of how quickly glucose levels increase in the bloodstream after carbohydrates are consumed. The glycemic index was initially introduced as a way for people with diabetes mellitus to control their blood glucose levels. For example, processed foods, white bread, white rice, and white potatoes have a high glycemic index. They quickly raise blood glucose levels after being consumed and also cause the release of insulin, which can result in more hunger and overeating. However, foods such as fruit, green leafy vegetables, raw carrots, kidney beans, chickpeas, lentils, and bran breakfast cereals have a low glycemic index. These foods minimize blood sugar spikes and insulin release after eating, which leads to less hunger and overeating. Eating a diet of low glycemic foods has been linked to a decreased risk of obesity and diabetes mellitus. ^(8){ }^{8} See Figure 14.2^(9)14.2^{9} for an image of the glycemic index of various foods. 血糖生成指数是指摄入碳水化合物后，血液中葡萄糖水平上升的速度。血糖生成指数最初是作为糖尿病患者控制血糖水平的一种方法。例如，加工食品、白面包、白米饭和白土豆的血糖生成指数都很高。它们食用后会迅速升高血糖水平，还会导致胰岛素释放，从而引起饥饿和暴饮暴食。然而，水果、绿叶蔬菜、生胡萝卜、菜豆、鹰嘴豆、扁豆和麦麸早餐谷物等食物的血糖生成指数较低。这些食物能最大限度地降低进食后的血糖峰值和胰岛素释放，从而减少饥饿感和暴饮暴食。食用低血糖生成指数食物与降低肥胖和糖尿病风险有关。 ^(8){ }^{8} 各种食物的血糖生成指数见图 14.2^(9)14.2^{9} 。
Figure 14.2 Glycemic Index 图 14.2 血糖生成指数
8. Youdim, A. (2019, May). Overview of nutrition. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition 8.Youdim, A. (2019, May).营养概述。默克手册专业版。https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition
9. “Eat-Foods-Low-on-the-Glycemic-Index-Step-1-Version-2.jpg” by unknown is licensed under CC BY-NC-SA 3.0. Access for free at https://www.wikihow.com/Eat-Foods-Low-on-the-Glycemic-Index#aiinfo 9."Eat-Foods-Low-on-the-Glycemic-Index-Step-1-Version-2.jpg" 作者未知，采用 CC BY-NC-SA 3.0 许可。免费访问 https://www.wikihow.com/Eat-Foods-Low-on-the-Glycemic-Index#aiinfo
PROTEINS 蛋白质
Proteins are peptides and amino acids that provide 4kcal//g4 \mathrm{kcal} / \mathrm{g} of energy. Proteins are necessary for tissue repair and function, growth, energy, fluid balance, clotting, and the production of white blood cells. Protein status is also referred to as nitrogen balance. Nitrogen is consumed in dietary intake and excreted in the urine and feces. If the body excretes more nitrogen than it takes in through the diet, this is referred to as a negative nitrogen balance. Negative nitrogen balance is seen in patients with starvation or severe infection. Conversely, if the body takes in more nitrogen through the diet than what is excreted, this is referred to as a positive nitrogen balance. ^(10){ }^{10} During positive nitrogen balance, excess protein is converted to fat tissue for storage. 蛋白质是提供 4kcal//g4 \mathrm{kcal} / \mathrm{g} 能量的肽和氨基酸。蛋白质是组织修复和功能、生长、能量、体液平衡、凝血和制造白细胞所必需的。蛋白质状态也称为氮平衡。氮从饮食中摄入，通过尿液和粪便排出体外。如果人体排出的氮多于从饮食中摄入的氮，则称为负氮平衡。负氮平衡常见于饥饿或严重感染的患者。相反，如果人体通过饮食摄入的氮多于排出的氮，则称为正氮平衡。 ^(10){ }^{10} 正氮平衡时，多余的蛋白质会转化为脂肪组织储存起来。
Proteins are classified as complete, incomplete, or partially complete. Complete proteins must be ingested in the diet. They have enough amino acids to perform necessary bodily functions, such as growth and tissue maintenance. Examples of foods containing complete proteins are soy, quinoa, eggs, fish, meat, and dairy products. Incomplete proteins do not contain enough amino acids to sustain life. Examples of incomplete proteins include most plants, such as beans, peanut butter, seeds, grains, and grain products. Incomplete proteins must be combined with other types of proteins to add to amino acids and form complete protein combinations." For example, vegetarians must be careful to eat complementary proteins, such as grains and legumes, or nuts and seeds and legumes, to create complete protein combinations during their daily food intake. Partially complete proteins have enough amino acids to sustain life, but not enough for tissue growth and maintenance. Because of the similarities, most sources consider partially complete proteins to be in the same category as incomplete proteins. See Figure 14.3^(12)14.3^{12} for an image of protein-rich foods. 蛋白质分为完全蛋白质、不完全蛋白质和部分完全蛋白质。完全蛋白质必须从饮食中摄取。它们含有足够的氨基酸来执行必要的身体功能，如生长和组织维护。含有完全蛋白质的食物有大豆、藜麦、鸡蛋、鱼、肉和乳制品。不完全蛋白质不含足够的氨基酸来维持生命。不完全蛋白质的例子包括大多数植物，如豆类、花生酱、种子、谷物和谷物制品。不完全蛋白质必须与其他类型的蛋白质结合，以增加氨基酸，形成完全蛋白质组合"。例如，素食者在日常食物摄入中必须注意摄入互补蛋白质，如谷物和豆类，或坚果、种子和豆类，以形成完整的蛋白质组合。部分完全蛋白质含有足够的氨基酸来维持生命，但不足以促进组织的生长和维持。由于两者的相似性，大多数资料来源认为部分完全蛋白质与不完全蛋白质属于同一类别。富含蛋白质的食物图片见图 14.3^(12)14.3^{12} 。
Figure 14.3 Protein-Rich Foods 图 14.3 富含蛋白质的食物
FATS
Fats consist of fatty acids and glycerol and are essential for tissue growth, insulation, energy, energy storage, and hormone production. Fats provide 9 kcal//g\mathrm{kcal} / \mathrm{g} of energy. ^(13){ }^{13} While some fat intake is necessary for energy and uptake of fat-soluble vitamins, excess fat intake contributes to heart disease and obesity. Due to its high-energy content, a little fat goes a long way. 脂肪由脂肪酸和甘油组成，是组织生长、保温、能量、能量储存和激素分泌所必需的物质。脂肪可提供 9 kcal//g\mathrm{kcal} / \mathrm{g} 种能量。 ^(13){ }^{13} 虽然摄入一些脂肪对提供能量和吸收脂溶性维生素是必要的，但过量摄入脂肪会导致心脏病和肥胖症。由于脂肪含有高能量，少量脂肪就能提供大量能量。
Fats are classified as saturated, unsaturated, and trans fatty acids. Saturated 脂肪分为饱和脂肪酸、不饱和脂肪酸和反式脂肪酸。饱和脂肪酸
13. Youdim, A. (2019, May). Overview of nutrition. Merck Manual Professional Version. 13.Youdim, A.（2019 年 5 月）。营养学概述。Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ overview-of-nutrition https://www.merckmanuals.com/professional/nutritional-disorders/nutrition-general-considerations/ 营养概述
fats come from animal products, such as butter and red meat (e.g., steak). Saturated fats are solid at room temperature. Recommended intake of saturated fats is less than 10%10 \% of daily calories because saturated fat raises cholesterol and contributes to heart disease. ^(14){ }^{14} 饱和脂肪来自动物产品，如黄油和红肉（如牛排）。饱和脂肪在室温下呈固态。饱和脂肪的建议摄入量低于 10%10 \% 每日热量的 10%10 \% ，因为饱和脂肪会使胆固醇升高，导致心脏病。 ^(14){ }^{14}
Unsaturated fats come from oils and plants, although chicken and fish also contain some unsaturated fats. Unsaturated fats are healthier than saturated fats. Examples of unsaturated fats include olive oil, canola oil, avocados, almonds, and pumpkin seeds. Fats containing omega-3 fatty acids are considered polyunsaturated fats and help lower LDL cholesterol levels. Fish and other seafood are excellent sources of omega-3 fatty acids. 不饱和脂肪来自油和植物，不过鸡肉和鱼肉中也含有一些不饱和脂肪。不饱和脂肪比饱和脂肪更健康。不饱和脂肪的例子包括橄榄油、菜籽油、鳄梨、杏仁和南瓜籽。含有欧米伽-3 脂肪酸的脂肪被认为是多不饱和脂肪，有助于降低低密度脂蛋白胆固醇水平。鱼类和其他海产品是欧米伽-3 脂肪酸的绝佳来源。
Trans fats are fats that have been altered through a hydrogenation process, so they are not in their natural state. During the hydrogenated process, fat is changed to make it harder at room temperature and have a longer shelf life. Trans fats are found in processed foods, such as chips, crackers, and cookies, as well as in some margarines and salad dressings. Minimal trans fat intake is recommended because it increases cholesterol and contributes to heart disease. ^(15){ }^{15} 反式脂肪是经过氢化过程改变的脂肪，因此不是天然状态。在氢化过程中，脂肪会发生变化，使其在室温下更硬，保质期更长。反式脂肪存在于薯片、饼干和曲奇等加工食品以及一些人造黄油和沙拉酱中。建议尽量少摄入反式脂肪，因为它会增加胆固醇并导致心脏病。 ^(15){ }^{15}
Micronutrients 微量营养素
Micronutrients include vitamins and minerals. 微量营养素包括维生素和矿物质。
VITAMINS 维生素
Vitamins are necessary for many bodily functions, including growth, development, healing, vision, and reproduction. Most vitamins are considered essential because they are not manufactured by the body and must be 人体的许多功能都需要维生素，包括生长、发育、愈合、视力和生殖。大多数维生素都被认为是人体必需的，因为它们不能由人体制造，必须通过以下途径获得
ingested in the diet. Vitamin D is also manufactured through exposure to sunlight. ^(16){ }^{16} 从饮食中摄取。维生素 D 也可以通过日光照射制造。 ^(16){ }^{16}
Vitamin toxicity can be caused by overconsumption of certain vitamins, such as vitamins A, D, C, B6, and niacin. Conversely, vitamin deficiencies can be caused by various factors including poor food intake due to poverty, malabsorption problems with the gastrointestinal tract, drug and alcohol abuse, proton pump inhibitors, and prolonged parenteral nutrition. Deficiencies can take years to develop, so it is usually a long-term problem for patients. ^(17){ }^{17} 过量摄入某些维生素（如维生素 A、D、C、B6 和烟酸）会导致维生素中毒。反之，维生素缺乏症可由多种因素引起，包括因贫穷导致食物摄入量不足、胃肠道吸收不良、滥用药物和酒精、质子泵抑制剂以及长期肠外营养等。缺乏症的形成需要数年时间，因此对患者来说通常是一个长期问题。 ^(17){ }^{17}
Vitamins are classified as water soluble or fat soluble. Water-soluble vitamins are not stored in the body and include vitamin C and B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), B12 (cyanocobalamin), and B9 (folic acid). Additional water-soluble vitamins include biotin and pantothenic acid. Excess amounts of these vitamins are excreted through the kidneys in urine, so toxicity is rarely an issue, though excess intake of vitamin 维生素分为水溶性和脂溶性。水溶性维生素不会储存在体内，包括维生素 C 和复合维生素 B：B1（硫胺素）、B2（核黄素）、B3（烟酸）、B6（吡哆醇）、B12（氰钴胺）和 B9（叶酸）。其他水溶性维生素包括生物素和泛酸。过量的这些维生素会通过肾脏随尿液排出体外，因此很少会出现中毒问题。
16. Johnson, L. E. (2020, November). Overview of vitamins. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/overview-of-vitamins? redirectid=43#v2089966 16.Johnson, L. E. (2020, November).维他命概述。Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/overview-of-vitamins? redirectid=43#v2089966
17. Johnson, L. E. (2020, November). Overview of vitamins. Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/overview-of-vitamins? redirectid=43#v2089966 17.Johnson, L. E. (2020, November).维他命概述。Merck Manual Professional Version. https://www.merckmanuals.com/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/overview-of-vitamins? redirectid=43#v2089966
18 B6, C, or niacin can result in toxicity. See Table 14.2a for a list of selected water-soluble vitamins, their sources, and their function. 18 B6、C 或烟酸会导致中毒。表 14.2a 列出了部分水溶性维生素、其来源和功能。 19202122,23,24,25,26,2719202122,23,24,25,26,27
Infection prevention, wound healing, collagen formation, iron absorption, amino acid metabolism, antioxidant, and bone growth in children. 预防儿童感染、伤口愈合、胶原蛋白形成、铁吸收、氨基酸代谢、抗氧化和骨骼生长。
Early Signs: weakness, weight loss, myalgias, and irritability. Late Signs: scurvy; swollen, spongy gums; loose teeth; bleeding gums and skin; poor wound healing; edema; leg pain; anorexia; irritability; and poor growth in children. 早期症状：虚弱、体重减轻、肌痛和易怒。晚期症状：坏血病；牙龈肿胀，呈海绵状；牙齿松动；牙龈和皮肤出血；伤口愈合不良；水肿；腿痛；厌食；易怒；儿童发育不良。
B1 (Thiamine) B1（硫胺素）
Nuts, liver, whole grains, pork, and legumes 坚果、肝脏、全谷物、猪肉和豆类
Nerve function; metabolism of carbohydrates, fat, amino acids, glucose, and alcohol; appetite and digestion. 神经功能；碳水化合物、脂肪、氨基酸、葡萄糖和酒精的新陈代谢；食欲和消化。
Fatigue, memory deficits, insomnia, chest pain, abdominal pain, anorexia, numbness of extremities, muscle wasting, heart failure, and shock in severe cases. 疲劳、记忆力减退、失眠、胸痛、腹痛、厌食、四肢麻木、肌肉萎缩、心力衰竭，严重时还会休克。
B2 (Riboflavin) B2（核黄素）
Eggs, liver, leafy greens, milk, and whole grains 鸡蛋、肝脏、绿叶蔬菜、牛奶和全谷物
Protein and carbohydrate metabolism, healthy skin, and normal vision. 蛋白质和碳水化合物的新陈代谢、健康的皮肤和正常的视力。
Pallor, lip fissures, and seborrheic dermatitis. 面色苍白、唇裂和脂溢性皮炎。
B3 (Niacin) B3（烟酸）
Fish, chicken, eggs, dairy, mushrooms, peanut butter, whole grains, and red meat 鱼、鸡肉、鸡蛋、奶制品、蘑菇、花生酱、全谷物和红肉
Pellagra characterized by skin lesions at pressure points/sun exposed skin, glossitis (swollen tongue), constipation progressing to bloody diarrhea, abdominal pain, abdominal distention, nausea, psychosis, and encephalopathy. 糙皮病的特征是受压点/暴露在阳光下的皮肤出现皮损、舌炎（舌头肿胀）、便秘发展为血性腹泻、腹痛、腹胀、恶心、精神错乱和脑病。
B6 (Pyridoxine) B6（吡哆醇）
Organ meats, fish, and various fruits and vegetables 内脏、鱼类、各种水果和蔬菜
Protein metabolism and red blood cell formation. 蛋白质代谢和红细胞形成。
Rare due to presence in most foods. Peripheral neuropathy, seizures refractory to antiseizure medications, anemia, glossitis (swollen tongue), seborrheic dermatitis, depression, and confusion. 由于存在于大多数食物中，因此很少见。周围神经病变、抗癫痫药物难治性癫痫发作、贫血、舌炎（舌头肿胀）、脂溢性皮炎、抑郁和精神错乱。
Water-Soluble Vitamin Sources Functions Deficiency
C (Ascorbic Acid) Citrus fruits, broccoli, greens, sweet peppers, tomatoes, lettuce, potatoes, tropical fruits, and strawberries Infection prevention, wound healing, collagen formation, iron absorption, amino acid metabolism, antioxidant, and bone growth in children. Early Signs: weakness, weight loss, myalgias, and irritability. Late Signs: scurvy; swollen, spongy gums; loose teeth; bleeding gums and skin; poor wound healing; edema; leg pain; anorexia; irritability; and poor growth in children.
B1 (Thiamine) Nuts, liver, whole grains, pork, and legumes Nerve function; metabolism of carbohydrates, fat, amino acids, glucose, and alcohol; appetite and digestion. Fatigue, memory deficits, insomnia, chest pain, abdominal pain, anorexia, numbness of extremities, muscle wasting, heart failure, and shock in severe cases.
B2 (Riboflavin) Eggs, liver, leafy greens, milk, and whole grains Protein and carbohydrate metabolism, healthy skin, and normal vision. Pallor, lip fissures, and seborrheic dermatitis.
B3 (Niacin) Fish, chicken, eggs, dairy, mushrooms, peanut butter, whole grains, and red meat Glycogen metabolism, cell metabolism, tissue regeneration, fat synthesis, nerve function, digestion, and skin health. Pellagra characterized by skin lesions at pressure points/sun exposed skin, glossitis (swollen tongue), constipation progressing to bloody diarrhea, abdominal pain, abdominal distention, nausea, psychosis, and encephalopathy.
B6 (Pyridoxine) Organ meats, fish, and various fruits and vegetables Protein metabolism and red blood cell formation. Rare due to presence in most foods. Peripheral neuropathy, seizures refractory to antiseizure medications, anemia, glossitis (swollen tongue), seborrheic dermatitis, depression, and confusion.| Water-Soluble Vitamin | Sources | Functions | Deficiency |
| :--- | :--- | :--- | :--- |
| C (Ascorbic Acid) | Citrus fruits, broccoli, greens, sweet peppers, tomatoes, lettuce, potatoes, tropical fruits, and strawberries | Infection prevention, wound healing, collagen formation, iron absorption, amino acid metabolism, antioxidant, and bone growth in children. | Early Signs: weakness, weight loss, myalgias, and irritability. Late Signs: scurvy; swollen, spongy gums; loose teeth; bleeding gums and skin; poor wound healing; edema; leg pain; anorexia; irritability; and poor growth in children. |
| B1 (Thiamine) | Nuts, liver, whole grains, pork, and legumes | Nerve function; metabolism of carbohydrates, fat, amino acids, glucose, and alcohol; appetite and digestion. | Fatigue, memory deficits, insomnia, chest pain, abdominal pain, anorexia, numbness of extremities, muscle wasting, heart failure, and shock in severe cases. |
| B2 (Riboflavin) | Eggs, liver, leafy greens, milk, and whole grains | Protein and carbohydrate metabolism, healthy skin, and normal vision. | Pallor, lip fissures, and seborrheic dermatitis. |
| B3 (Niacin) | Fish, chicken, eggs, dairy, mushrooms, peanut butter, whole grains, and red meat | Glycogen metabolism, cell metabolism, tissue regeneration, fat synthesis, nerve function, digestion, and skin health. | Pellagra characterized by skin lesions at pressure points/sun exposed skin, glossitis (swollen tongue), constipation progressing to bloody diarrhea, abdominal pain, abdominal distention, nausea, psychosis, and encephalopathy. |
| B6 (Pyridoxine) | Organ meats, fish, and various fruits and vegetables | Protein metabolism and red blood cell formation. | Rare due to presence in most foods. Peripheral neuropathy, seizures refractory to antiseizure medications, anemia, glossitis (swollen tongue), seborrheic dermatitis, depression, and confusion. |
Coenzyme in protein metabolism and cell growth, red blood cell formation, and prevention of fetal neural tube defects in utero. 辅酶参与蛋白质代谢和细胞生长、红细胞形成，以及预防胎儿宫内神经管畸形。
Meat, organ meat, dairy, seafood, poultry, and eggs 肉类、内脏、奶制品、海鲜、家禽和蛋类
Mature red blood cell formation, DNA/RNA synthesis, new cell formation, and nerve function. 成熟红细胞的形成、DNA/RNA 的合成、新细胞的形成以及神经功能。
Pernicious anemia from lack of intrinsic factor in intestines. Early Signs: weight loss, abdominal pain, peripheral neuropathy, weakness, hyporeflexia, and ataxia. Late Signs: irritability, depression, paranoia, and confusion. 因肠道缺乏固有因子而导致恶性贫血。早期症状：体重减轻、腹痛、周围神经病变、虚弱、反射减弱和共济失调。晚期症状：易怒、抑郁、妄想症和精神错乱。
B9 (Folic Acid) Liver, legumes, leafy greens, seeds, orange juice, and enriched refined grains Coenzyme in protein metabolism and cell growth, red blood cell formation, and prevention of fetal neural tube defects in utero. Glossitis (swollen tongue), confusion, depression, diarrhea, anemia, and fetal neural tube defects.
B12 (Cyanocobalamin) Meat, organ meat, dairy, seafood, poultry, and eggs Mature red blood cell formation, DNA/RNA synthesis, new cell formation, and nerve function. Pernicious anemia from lack of intrinsic factor in intestines. Early Signs: weight loss, abdominal pain, peripheral neuropathy, weakness, hyporeflexia, and ataxia. Late Signs: irritability, depression, paranoia, and confusion.| B9 (Folic Acid) | Liver, legumes, leafy greens, seeds, orange juice, and enriched refined grains | Coenzyme in protein metabolism and cell growth, red blood cell formation, and prevention of fetal neural tube defects in utero. | Glossitis (swollen tongue), confusion, depression, diarrhea, anemia, and fetal neural tube defects. |
| :--- | :--- | :--- | :--- |
| B12 (Cyanocobalamin) | Meat, organ meat, dairy, seafood, poultry, and eggs | Mature red blood cell formation, DNA/RNA synthesis, new cell formation, and nerve function. | Pernicious anemia from lack of intrinsic factor in intestines. Early Signs: weight loss, abdominal pain, peripheral neuropathy, weakness, hyporeflexia, and ataxia. Late Signs: irritability, depression, paranoia, and confusion. |
Fat-soluble vitamins are absorbed with fats in the diet and include vitamins A, D, E, and K. They are stored in fat tissue and can build up in the liver. They are not excreted easily by the kidneys due to storage in fatty tissue and the liver, so overconsumption can cause toxicity, especially with vitamins A and 脂溶性维生素与饮食中的脂肪一起被吸收，包括维生素 A、D、E 和 K。由于储存在脂肪组织和肝脏中，它们不容易被肾脏排出体外，因此过量摄入会导致中毒，尤其是维生素 A 和维生素 D。
D. ^(28){ }^{28} See Table 14.2 b for a list of selected fat-soluble vitamins, their sources, their function, and manifestations of deficiencies and toxicities. ^(29),30,31,3,33,34,35,36,37{ }^{29}, 30,31,3,33,34,35,36,37 D. ^(28){ }^{28} 部分脂溶性维生素、其来源、功能以及缺乏和中毒的表现见表 14.2 b。 ^(29),30,31,3,33,34,35,36,37{ }^{29}, 30,31,3,33,34,35,36,37
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www.uofmhealth.org/health-library/ta3868 Healthwise.(2020 年 12 月 17 日）。维生素：它们的功能和来源。密歇根大学密歇根医学院。https://www.uofmhealth.org/health-library/ta3868
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www.uofmhealth.org/health-library/ta3868 Healthwise.(2020 年 12 月 17 日）。维生素：它们的功能和来源。密歇根大学密歇根医学院。https://www.uofmhealth.org/health-library/ta3868
Healthwise. (2020, December 17). Vitamins: Their functions and sources. Michigan Medicine at University of Michigan. https://www.uofmhealth.org/health-library/ta3868 Healthwise.(2020 年 12 月 17 日）。维生素：它们的功能和来源。密歇根大学密歇根医学院。https://www.uofmhealth.org/health-library/ta3868
Retinol: fortified milk and dairy, egg yolks, and fish liver oil
Beta
carotene: green leafy vegetables, and dark orange fruits and vegetables
Retinol: fortified milk and dairy, egg yolks, and fish liver oil
Beta
carotene: green leafy vegetables, and dark orange fruits and vegetables| Retinol: fortified milk and dairy, egg yolks, and fish liver oil |
| :--- |
| Beta |
| carotene: green leafy vegetables, and dark orange fruits and vegetables |
Eyesight, epithelial, bone and tooth development, normal cellular proliferation, and immunity. 视力、上皮、骨骼和牙齿的发育、正常的细胞增殖以及免疫力。
Night blindness, rough scaly skin, dry eyes, and poor tooth/ bone development. Causes poor growth and infections common with mortality > 50%>50 \%. 夜盲症、皮肤粗糙、眼睛干涩、牙齿/骨骼发育不良。导致生长不良和常见的感染，并造成死亡 > 50%>50 \% 。
Milk, dairy, sun exposure, egg yolks, fatty fish, and liver 牛奶、乳制品、阳光照射、蛋黄、肥鱼和肝脏
Changed to active form with sun exposure. Needed for calcium/ phosphorus absorption, immunity, and bone strength. 在阳光照射下转变为活性形式。钙/磷的吸收、免疫力和骨骼强度都需要它。
Rickets, poor dentition, tetany, osteomalacia, muscle aches and weakness, bone pain, poor calcium absorption leading to hypocalcemia and subsequent hyperparathyroidism and tetany. 佝偻病、牙齿不整齐、四肢抽搐、骨软化症、肌肉酸痛和无力、骨痛、钙吸收不良导致低钙血症，继而引起甲状旁腺功能亢进和四肢抽搐。
Hypercalcemia resulting in nausea, vomiting, anorexia, renal failure, weakness, pruritus, and polyuria. 高钙血症导致恶心、呕吐、厌食、肾功能衰竭、虚弱、瘙痒和多尿。
E
Green leafy vegetables, whole grains, liver, egg yolks, nuts, and plant oils 绿叶蔬菜、全谷物、肝脏、蛋黄、坚果和植物油
Anticoagulant, antioxidant, and cellular protection. 抗凝血、抗氧化和保护细胞。
Red blood cell breakdown leading to anemia, neuron degeneration, neuropathy, and retinopathy. 红细胞破裂导致贫血、神经元变性、神经病变和视网膜病变。
Rare. Occasionally muscle weakness, fatigue, Gl upset with diarrhea, and hemorrhagic stroke. 罕见。偶尔会出现肌无力、疲劳、腹泻引起的胃肠不适和出血性中风。
Fat-Soluble Vitamin Source Function Deficiency Toxicity
A (Retinol) "Retinol: fortified milk and dairy, egg yolks, and fish liver oil
Beta
carotene: green leafy vegetables, and dark orange fruits and vegetables" Eyesight, epithelial, bone and tooth development, normal cellular proliferation, and immunity. Night blindness, rough scaly skin, dry eyes, and poor tooth/ bone development. Causes poor growth and infections common with mortality > 50%. Dry, itchy skin; headache; nausea; blurred vision; and yellowing skin (carotenosis).
D Milk, dairy, sun exposure, egg yolks, fatty fish, and liver Changed to active form with sun exposure. Needed for calcium/ phosphorus absorption, immunity, and bone strength. Rickets, poor dentition, tetany, osteomalacia, muscle aches and weakness, bone pain, poor calcium absorption leading to hypocalcemia and subsequent hyperparathyroidism and tetany. Hypercalcemia resulting in nausea, vomiting, anorexia, renal failure, weakness, pruritus, and polyuria.
E Green leafy vegetables, whole grains, liver, egg yolks, nuts, and plant oils Anticoagulant, antioxidant, and cellular protection. Red blood cell breakdown leading to anemia, neuron degeneration, neuropathy, and retinopathy. Rare. Occasionally muscle weakness, fatigue, Gl upset with diarrhea, and hemorrhagic stroke.| Fat-Soluble Vitamin | Source | Function | Deficiency | Toxicity |
| :--- | :--- | :--- | :--- | :--- |
| A (Retinol) | Retinol: fortified milk and dairy, egg yolks, and fish liver oil <br> Beta <br> carotene: green leafy vegetables, and dark orange fruits and vegetables | Eyesight, epithelial, bone and tooth development, normal cellular proliferation, and immunity. | Night blindness, rough scaly skin, dry eyes, and poor tooth/ bone development. Causes poor growth and infections common with mortality $>50 \%$. | Dry, itchy skin; headache; nausea; blurred vision; and yellowing skin (carotenosis). |
| D | Milk, dairy, sun exposure, egg yolks, fatty fish, and liver | Changed to active form with sun exposure. Needed for calcium/ phosphorus absorption, immunity, and bone strength. | Rickets, poor dentition, tetany, osteomalacia, muscle aches and weakness, bone pain, poor calcium absorption leading to hypocalcemia and subsequent hyperparathyroidism and tetany. | Hypercalcemia resulting in nausea, vomiting, anorexia, renal failure, weakness, pruritus, and polyuria. |
| E | Green leafy vegetables, whole grains, liver, egg yolks, nuts, and plant oils | Anticoagulant, antioxidant, and cellular protection. | Red blood cell breakdown leading to anemia, neuron degeneration, neuropathy, and retinopathy. | Rare. Occasionally muscle weakness, fatigue, Gl upset with diarrhea, and hemorrhagic stroke. |
K
绿叶蔬菜和绿色蔬菜 *由肠道细菌产生
Green leafy vegetables and green vegetables
*produced by bacteria in intestines
Green leafy vegetables and green vegetables
*produced by bacteria in intestines| Green leafy vegetables and green vegetables |
| :--- |
| *produced by bacteria in intestines |
Needed for producing clotting factors in the liver. 需要在肝脏中产生凝血因子。
Rare in adults. Prolonged clotting times, hemorrhaging (especially in newborns causing morbidity & mortality), and jaundice. 成人罕见。凝血时间延长、出血（尤其是新生儿，会导致发病和死亡）和黄疸。
Rare, but can interfere with effectiveness of certain anticoagulant medications (Warfarin). 罕见，但会干扰某些抗凝药物（华法林）的疗效。
K "Green leafy vegetables and green vegetables
*produced by bacteria in intestines" Needed for producing clotting factors in the liver. Rare in adults. Prolonged clotting times, hemorrhaging (especially in newborns causing morbidity & mortality), and jaundice. Rare, but can interfere with effectiveness of certain anticoagulant medications (Warfarin).| K | Green leafy vegetables and green vegetables <br> *produced by bacteria in intestines | Needed for producing clotting factors in the liver. | Rare in adults. Prolonged clotting times, hemorrhaging (especially in newborns causing morbidity & mortality), and jaundice. | Rare, but can interfere with effectiveness of certain anticoagulant medications (Warfarin). |
| :--- | :--- | :--- | :--- | :--- |
MINERALS 矿物
Minerals are inorganic materials essential for hormone and enzyme production, as well as for bone, muscle, neurological, and cardiac function. Minerals are needed in varying amounts and are obtained from a wellrounded diet. In some cases of deficiencies, mineral supplements may be prescribed by a health care provider. Deficiencies can be caused by malnutrition, malabsorption, or certain medications, such as diuretics. 矿物质是产生激素和酶以及骨骼、肌肉、神经和心脏功能所必需的无机物。矿物质的需要量各不相同，可从全面的饮食中获取。在某些缺乏矿物质的情况下，医疗服务提供者可能会开出矿物质补充剂的处方。营养不良、吸收不良或某些药物（如利尿剂）都可能导致矿物质缺乏。
Minerals are classified as either macrominerals or trace minerals. 矿物质分为宏量矿物质和微量矿物质。
Macrominerals are needed in larger amounts and are typically measured in milligrams, grams, or milliequivalents. Macrominerals include sodium, potassium, calcium, magnesium, chloride, and phosphorus. Macrominerals are discussed in further detail in the “Electrolytes” section of the “Fluids and Electrolytes” chapter of this book. 宏量矿物质的需要量较大，通常以毫克、克或毫当量为单位。宏量矿物质包括钠、钾、钙、镁、氯和磷。本书 "液体和电解质 "一章中的 "电解质 "部分将进一步详细讨论宏量矿物质。
Trace minerals are needed in tiny amounts. Trace minerals include zinc, iron, chromium, copper, fluorine, iodine, manganese, molybdenum, and 微量元素的需要量极少。微量元素包括锌、铁、铬、铜、氟、碘、锰、钼和硒。
selenium. ^(38){ }^{38} See Table 14.2c for a list of selected macrominerals and Table 14.2d for a list of trace minerals. 39,40,41,4239,40,41,42 硒。 ^(38){ }^{38} 选定的宏量矿物质清单见表 14.2c，微量矿物质清单见表 14.2d。 39,40,41,4239,40,41,42
Table 14.2c Macrominerals 表 14.2c 宏观矿物
Macromineral 大矿物
Source 资料来源
Function 功能
Sodium 钠
Table salt, spinach, and milk 食盐、菠菜和牛奶
Water balance 水平衡
Potassium 钾
Legumes, potatoes, bananas, and whole grains 豆类、马铃薯、香蕉和全谷物
Muscle contraction, cardiac muscle function, and nerve function 肌肉收缩、心肌功能和神经功能
Calcium 钙
Dairy, eggs, and green leafy vegetables 奶制品、鸡蛋和绿叶蔬菜
Bone and teeth development, nerve function, muscle contraction, immunity, and blood clotting 骨骼和牙齿发育、神经功能、肌肉收缩、免疫力和凝血功能
Magnesium 镁
Raw nuts, spinach (cooked has higher magnesium content), tomatoes, and beans 生坚果、菠菜（煮熟后镁含量更高）、西红柿和豆类
Cell energy, muscle function, cardiac function, and glucose metabolism 细胞能量、肌肉功能、心脏功能和葡萄糖代谢
Chloride 氯化物
Table salt 食盐
Fluid and electrolyte balance and digestion 体液和电解质平衡与消化
Phosphorus 磷
Red meat, poultry, rice, oats, dairy, and fish 红肉、家禽、大米、燕麦、奶制品和鱼类
Bone strength and cellular function 骨骼强度和细胞功能
Macromineral Source Function
Sodium Table salt, spinach, and milk Water balance
Potassium Legumes, potatoes, bananas, and whole grains Muscle contraction, cardiac muscle function, and nerve function
Calcium Dairy, eggs, and green leafy vegetables Bone and teeth development, nerve function, muscle contraction, immunity, and blood clotting
Magnesium Raw nuts, spinach (cooked has higher magnesium content), tomatoes, and beans Cell energy, muscle function, cardiac function, and glucose metabolism
Chloride Table salt Fluid and electrolyte balance and digestion
Phosphorus Red meat, poultry, rice, oats, dairy, and fish Bone strength and cellular function| Macromineral | Source | Function |
| :--- | :--- | :--- |
| Sodium | Table salt, spinach, and milk | Water balance |
| Potassium | Legumes, potatoes, bananas, and whole grains | Muscle contraction, cardiac muscle function, and nerve function |
| Calcium | Dairy, eggs, and green leafy vegetables | Bone and teeth development, nerve function, muscle contraction, immunity, and blood clotting |
| Magnesium | Raw nuts, spinach (cooked has higher magnesium content), tomatoes, and beans | Cell energy, muscle function, cardiac function, and glucose metabolism |
| Chloride | Table salt | Fluid and electrolyte balance and digestion |
| Phosphorus | Red meat, poultry, rice, oats, dairy, and fish | Bone strength and cellular function |
Table 14.2d Trace Minerals 表 14.2d 微量矿物质
MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Oct 19]. Minerals; [reviewed 2015, Apr 2; cited 2021, Mar 5]. https://medlineplus.gov/minerals.html MedlinePlus [Internet].贝塞斯达（马里兰州）：美国国家医学图书馆；[2020 年 10 月 19 日更新]。Minerals; [reviewed 2015, Apr 2; cited 2021, Mar 5].https://medlineplus.gov/minerals.html。
Eggs, spinach, yogurt, whole grains, fish, and brewer's yeast 鸡蛋、菠菜、酸奶、全谷物、鱼和啤酒酵母
Immune function, healing, and vision 免疫功能、愈合和视力
Iron 铁
Red meat, organ meats, spinach, shrimp, tuna, salmon, kidney beans, peas, and lentils (nonanimal forms are harder to absorb, so need more!) 红肉、内脏、菠菜、虾、金枪鱼、鲑鱼、菜豆、豌豆和扁豆（非动物性食物更难吸收，所以需要更多！）。
Hemoglobin production and collagen production 生成血红蛋白和胶原蛋白
Chromium 铬
Whole grains, meat, and brewer's yeast 全谷物、肉类和啤酒酵母
Glucose metabolism 葡萄糖代谢
Copper 铜
Shellfish, fruits, nuts, and organ meats 贝类、水果、坚果和内脏肉类
Hemoglobin production, collagen, elastin, neurotransmitter production, and melanin production 血红蛋白生成、胶原蛋白、弹性蛋白、神经递质生成和黑色素生成
Flourine 面粉
Fluoridated water and toothpaste 含氟水和牙膏
Retention of calcium in bones and teeth 保持骨骼和牙齿中的钙质
Iodine 碘
lodized salt and seafood 腌制盐和海鲜
Energy production and thyroid function 能量生产和甲状腺功能
Manganese 锰
Whole grain and nuts 全谷物和坚果
Not fully understood 不完全了解
Molybdenum 钼
Organ meats, green leafy vegetables, legumes, whole grains, and dairy 内脏、绿叶蔬菜、豆类、全谷物和奶制品
Not fully understood; detoxification 尚未完全了解；解毒
Selenium 硒
Broccoli, cabbage, garlic, whole grains, brewer's yeast, celery, onions, and organ meats 西兰花、卷心菜、大蒜、全谷物、啤酒酵母、芹菜、洋葱和内脏肉类
Not fully understood 不完全了解
Trace Mineral Source Function
Zinc Eggs, spinach, yogurt, whole grains, fish, and brewer's yeast Immune function, healing, and vision
Iron Red meat, organ meats, spinach, shrimp, tuna, salmon, kidney beans, peas, and lentils (nonanimal forms are harder to absorb, so need more!) Hemoglobin production and collagen production
Chromium Whole grains, meat, and brewer's yeast Glucose metabolism
Copper Shellfish, fruits, nuts, and organ meats Hemoglobin production, collagen, elastin, neurotransmitter production, and melanin production
Flourine Fluoridated water and toothpaste Retention of calcium in bones and teeth
Iodine lodized salt and seafood Energy production and thyroid function
Manganese Whole grain and nuts Not fully understood
Molybdenum Organ meats, green leafy vegetables, legumes, whole grains, and dairy Not fully understood; detoxification
Selenium Broccoli, cabbage, garlic, whole grains, brewer's yeast, celery, onions, and organ meats Not fully understood| Trace Mineral | Source | Function |
| :--- | :--- | :--- |
| Zinc | Eggs, spinach, yogurt, whole grains, fish, and brewer's yeast | Immune function, healing, and vision |
| Iron | Red meat, organ meats, spinach, shrimp, tuna, salmon, kidney beans, peas, and lentils (nonanimal forms are harder to absorb, so need more!) | Hemoglobin production and collagen production |
| Chromium | Whole grains, meat, and brewer's yeast | Glucose metabolism |
| Copper | Shellfish, fruits, nuts, and organ meats | Hemoglobin production, collagen, elastin, neurotransmitter production, and melanin production |
| Flourine | Fluoridated water and toothpaste | Retention of calcium in bones and teeth |
| Iodine | lodized salt and seafood | Energy production and thyroid function |
| Manganese | Whole grain and nuts | Not fully understood |
| Molybdenum | Organ meats, green leafy vegetables, legumes, whole grains, and dairy | Not fully understood; detoxification |
| Selenium | Broccoli, cabbage, garlic, whole grains, brewer's yeast, celery, onions, and organ meats | Not fully understood |
Nutritional Guidelines 营养指南
Nutritional guidelines are developed by governmental agencies to provide guidance to the population on how to best meet nutritional needs. These guidelines may vary by country. The National Academies of Sciences, Engineering, and Medicine set the Dietary Reference Intakes (DRIs) for the United States and Canada. Dietary Reference Intakes (DRIs) are a set of reference values used to plan and assess nutrient intakes of healthy people, including proteins, carbohydrates, fats, vitamins, minerals, and fiber. Nutrients 营养指南是由政府机构制定的，旨在指导人们如何最好地满足营养需求。这些指南可能因国家而异。美国国家科学、工程和医学院为美国和加拿大制定了膳食营养素参考摄入量（DRIs）。膳食营养素参考摄入量 (DRI) 是一套参考值，用于规划和评估健康人群的营养素摄入量，包括蛋白质、碳水化合物、脂肪、维生素、矿物质和纤维。营养素
included in the DRIs are obtained through a typical diet, although some foods may be fortified with certain nutrients that are commonly deficient in diets. 虽然某些食品可能强化了膳食中普遍缺乏的某些营养素，但 DRIs 所包含的营养素是通过一般膳食获得的。
Choose MyPlate Food Guide 选择 MyPlate 食物指南
The U.S. Department of Agriculture (USDA) issues dietary guidelines for appropriate serving sizes of each food group and number of servings recommended each day. The “Choose MyPlate” food guide is an easy-tounderstand visual representation of how a healthy plate of food should be divided based on food groups. See Figure 14.4^(44)14.4^{44} for a Choose MyPlate image. A little more than half of the plate should be grains and vegetables, with a focus on whole grains and a variety of vegetables. About one quarter of the plate should be fruits, with an emphasis on whole fruits. About one quarter of the plate should be protein, with an emphasis on consuming a variety of low-fat protein sources. All of these groups combined should make up no more than 85%85 \% of daily caloric intake based on a 2,000 calorie diet. Fats, oils, and added sugars are not included, but should make up no more than 15%15 \% of daily caloric intake. Foods should be selected that are as nutrient-dense as possible. 美国农业部（USDA）发布了膳食指南，规定了每个食物类别的适当份量以及建议的每日份量。选择我的餐盘"（Choose MyPlate）食物指南以通俗易懂的直观方式介绍了健康餐盘中的食物应如何根据食物类别进行划分。请参阅图 14.4^(44)14.4^{44} ，了解 "选择我的餐盘 "图片。盘子里一半多一点的食物应该是谷物和蔬菜，重点是全谷物和各种蔬菜。大约四分之一的餐盘应该是水果，重点是全水果。约四分之一的餐盘应该是蛋白质，重点是摄入各种低脂蛋白质。以 2,000 卡路里的饮食为基础，所有这些食物的总和不应超过每日热量摄入的 85%85 \% 。脂肪、油和添加糖不包括在内，但在每日热量摄入量中所占比例不应超过 15%15 \% 。应尽可能选择营养丰富的食物。
Nutrient-dense means there is a high proportion of nutritional value relative to calories contained in the food, such as fruits and vegetables. Conversely, calorie-dense foods should be minimized because they have a large amount of calories with few nutrients. For example, candy and soda are calorie-dense with few nutrients and should be minimized. ^(45,46){ }^{45,46} See the following hyperlink to the MyPlate web site for further information on USDA dietary guidelines and patient educational materials 营养密集型是指食物（如水果和蔬菜）所含营养价值相对于热量的比例较高。相反，热量高的食物热量高，营养素少，应尽量少吃。例如，糖果和苏打水热量高，营养成分少，应尽量少吃。 ^(45,46){ }^{45,46} 有关美国农业部膳食指南和患者教育材料的更多信息，请参阅以下 MyPlate 网站的超链接
Read more about USDA dietary guidelines at https://www.myplate.gov/. 有关美国农业部膳食指南的更多信息，请访问 https://www.myplate.gov/。
MyPlate information and images are also available in several other languages so that education can be tailored to the patient’s preferred language. For example, Figure 14.5^(48)14.5^{48} shows MyPlate in Vietnamese. This image would be accompanied with written information about food groups that include the patient’s typical dietary choices. MyPlate 的信息和图像还有其他几种语言版本，这样就可以根据患者喜欢的语言进行教育。例如，图 14.5^(48)14.5^{48} 显示了 MyPlate 的越南语版本。该图片附有关于食物类别的书面信息，其中包括患者的典型饮食选择。
Figure 14.5 MyPlate in Vietnamese 图 14.5 "我的餐盘 "越南语版
VEGETABLE GROUP 蔬菜组
For a well-rounded diet, a variety of vegetables should be consumed, including vegetables from all five vegetable groups: dark green leafy vegetables; red and orange vegetables; beans, peas, and lentils (formerly called the legumes group); starchy vegetables; and other vegetables. Vegetables can be fresh, frozen, canned, or dried. Dark green leafy vegetables include kale, Swiss chard, spinach, broccoli, and salad greens. Red and orange vegetables include carrots, bell peppers, sweet potatoes, tomatoes, tomato juice, and squash. The beans, peas, and lentils group includes dried beans, black beans, chickpeas, kidney beans, split peas, and black-eyed peas. (Note that this group does not include green beans or green peas.) This vegetable group also supplies some protein and can be included in the protein group as well. Starchy vegetables include root vegetables, such as potatoes, as well as corn. The “other vegetables” category includes any vegetable that doesn’t fit in the other four categories, such as asparagus, avocados, brussels sprouts, cabbage, cucumbers, snow peas, and mushrooms, and a variety of others. 要想饮食全面，就应摄入各种蔬菜，包括所有五个蔬菜类别中的蔬菜：深绿色叶菜类；红色和橙色蔬菜；豆类、豌豆和扁豆（以前称为豆类）；淀粉类蔬菜；以及其他蔬菜。蔬菜可以是新鲜的、冷冻的、罐装的或干的。深绿色叶菜包括羽衣甘蓝、瑞士甜菜、菠菜、西兰花和沙拉蔬菜。红色和橙色蔬菜包括胡萝卜、甜椒、红薯、番茄、番茄汁和南瓜。豆类、豌豆和扁豆类包括干豆、黑豆、鹰嘴豆、菜豆、豌豆和黑眼豌豆（注意这一组不包括青豆或绿豌豆）。 这一组蔬菜也提供一些蛋白质，因此也可列入蛋白质组。淀粉类蔬菜包括根茎类蔬菜，如土豆和玉米。其他蔬菜 "类包括任何不属于其他四类的蔬菜，如芦笋、鳄梨、球芽甘蓝、卷心菜、黄瓜、雪豌豆和蘑菇，以及其他各种蔬菜。
Daily serving suggestions of vegetables for individuals with a 2,000 calorie diet are 21//221 / 2 cup equivalents of vegetables per day. For example, a “one cup equivalent” equals 1 cup raw or cooked vegetables, one cup 100% vegetable juice, 1//21 / 2 cup of dried vegetables, or 2 cups of leafy green vegetables. 对于饮食热量为 2,000 卡路里的人，每日蔬菜食用量建议为 21//221 / 2 杯等量蔬菜。例如，"一杯当量 "等于 1 杯生或熟蔬菜、1 杯 100% 蔬菜汁、 1//21 / 2 杯干蔬菜或 2 杯绿叶蔬菜。
Approximately 90% of Americans do not meet the recommended daily intake of vegetables. ^(49){ }^{49} See Figure 14.6^(50)14.6^{50} for an image of vegetables. 大约 90% 的美国人没有达到建议的每日蔬菜摄入量。 ^(49){ }^{49} 蔬菜图片见图 14.6^(50)14.6^{50} 。
Figure 14.6 Vegetables 图 14.6 蔬菜
GRAIN GROUP 谷物组
Grains are classified as whole grains or refined grains. Whole grains include the entire grain kernel and supply more fiber than refined grains. Examples of whole grains include amaranth, whole barley, popcorn, oats, whole grain cornmeal, brown or wild rice, and whole grain cereal or crackers. Refined grains have been processed to remove parts of the grain kernel and supply 谷物分为全谷物和精制谷物。全谷物包括整个谷粒，比精制谷物提供更多的纤维。全谷物的例子包括苋菜、全大麦、爆米花、燕麦、全谷物玉米粉、糙米或野生大米以及全谷物麦片或饼干。精制谷物经过加工，去除了部分谷物颗粒，提供的纤维素更多。
49. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 49.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
50. “Food-healthy-vegetables-potatoes_(23958160949).jpg” by www.Pixel.la Free Stock Photos is licensed under CCO 50."Food-healthy-vegetables-potatoes_(23958160949).jpg "由 www.Pixel.la Free Stock Photos 根据 CCO 许可发布。
little fiber. As a result, they quickly increase blood glucose levels. Examples of refined grains include white bread, white rice, Cream of Wheat, pearled barley, white pasta, and refined-grain cereals or crackers. Some grains are fortified to ensure adequate intake of folic acid. See Figure 14.7^(51)14.7^{51} for an image of whole grain whole wheat bread. 纤维很少。因此，它们会迅速增加血糖水平。精制谷物的例子包括白面包、白米饭、奶油小麦、珍珠大麦、白意大利面以及精制谷物麦片或饼干。有些谷物经过强化，以确保摄入足够的叶酸。全谷物全麦面包的图片见图 14.7^(51)14.7^{51} 。
The daily serving suggestions of grains for an individual with a 2,000 calorie diet are six ounce equivalents per day, split equally between whole and refined grains. For example, a “one ounce equivalent” of grains equals 1//21 / 2 cup of cooked rice, pasta, or cereal or 1 cup of flaked cereal. Most Americans consume adequate amounts of total grains, although roughly 98%98 \% are deficient in recommended whole grain amounts, and 74%74 \% consume more than the recommended refined grain amounts. ^(52){ }^{52} 对于饮食热量为 2,000 卡路里的人，建议每天摄入六盎司等量的谷物，其中全谷物和精制谷物各占一半。例如，"一盎司等量 "的谷物相当于 1//21 / 2 杯煮熟的米饭、面食或谷物，或 1 杯谷物片。大多数美国人摄入足量的谷物总量，但大约 98%98 \% 的人缺乏推荐的全谷物量， 74%74 \% 的人摄入的精制谷物量超过推荐量。 ^(52){ }^{52}
Figure 14.7 Whole Grain, Whole Wheat Bread 图 14.7 全谷物、全麦面包
51. “front_en.3.400.jpg” by openfoodfacts-contributors is licensed under CC BY-SA 3.0 51."front_en.3.400.jpg" by openfoodfacts-contributors 采用 CC BY-SA 3.0 许可协议发布。
52. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 52.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
FRUIT GROUP 水果组
Fruits can be frozen, canned, or dried, in addition to 100% fruit juice. A few examples of fruits include apples, oranges, bananas, melons, peaches, apricots, pineapples, and rhubarb. Daily serving suggestions of fruits for an individual with a 2,000 calorie diet are 2 cup equivalents per day. For example, “one cup equivalent” equals 1 cup of raw or cooked fruit, 8 ounces of 100%100 \% fruit juice, or 1//21 / 2 cup of dried fruit. Approximately 80%80 \% of Americans do not consume the recommended daily intake of fruits. ^(53){ }^{53} See Figure 14.8^(54)14.8^{54} for an image of fruits. 除了 100% 果汁外，水果还可以是冷冻的、罐装的或干的。水果的几个例子包括苹果、橙子、香蕉、甜瓜、桃子、杏、菠萝和大黄。对于饮食热量为 2,000 卡路里的人，建议每天食用 2 杯等量的水果。例如，"一杯当量 "等于 1 杯生或熟水果、8 盎司 100%100 \% 果汁或 1//21 / 2 杯干果。大约 80%80 \% 的美国人没有摄入建议的每日水果摄入量。 ^(53){ }^{53} 水果图片见图 14.8^(54)14.8^{54} 。
53. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 53.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
54. “Culinary_fruits_cropped_top_view.jpg” by Bill Ebbesen is licensed under CC BY 3.0 54.Bill Ebbesen 制作的 "Culinary_fruits_cropped_top_view.jpg "采用 CC BY 3.0 许可。
DAIRY GROUP 乳制品集团
Dairy products can be liquid, dried, semi-solid, or solid depending on the type of product. Dairy products include milk, lactose-free milk, fortified soy milk, buttermilk, cheese, yogurt, and kefir. Sour cream and cream cheese are not considered dairy items in terms of nutritional benefits. Daily serving suggestions of dairy products for an individual with a 2,000 calorie diet are 3 cup equivalents per day. For example, “one cup equivalent” equals 1 cup of milk, soy milk, or yogurt; 11//211 / 2 ounces of natural cheese, or 2 ounces of processed cheese. Approximately 90% of Americans consume less than the recommended daily intake of dairy products. ^(55){ }^{55} See Figure 14.9^(56)14.9^{56} for an image of dairy products. 根据产品种类的不同，乳制品可以是液态、干的、半固态或固态。乳制品包括牛奶、无乳糖牛奶、强化豆奶、酪乳、奶酪、酸奶和酸乳酒。就营养价值而言，酸奶油和奶油奶酪不属于乳制品。对于饮食热量为 2,000 卡路里的人来说，奶制品的每日食用量建议为 3 杯等量。例如，"一杯当量 "等于 1 杯牛奶、豆奶或酸奶； 11//211 / 2 盎司天然奶酪或 2 盎司加工奶酪。大约 90% 的美国人每天摄入的乳制品少于建议摄入量。 ^(55){ }^{55} 乳制品图片见图 14.9^(56)14.9^{56} 。
55. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 55.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
56. “Good_Dairy_Sources.png” by Brookepinsent is licensed under CC BY-SA 4.0 56."Good_Dairy_Sources.png" by Brookepinsent 采用 CC BY-SA 4.0 许可。
Figure 14.9 Dairy Products 图 14.9 乳制品
PROTEIN GROUP 蛋白质组
Proteins are categorized by the type of protein source. The meats, poultry, and eggs category consists of any type of animal or poultry meat, organ meat, or poultry egg. Lean meats should be selected to minimize fat and calorie intake from high-fat meats. 蛋白质按蛋白质来源类型分类。肉类、家禽和蛋类包括任何类型的动物或家禽肉、内脏肉或禽蛋。应选择瘦肉，以尽量减少高脂肪肉类的脂肪和热量摄入。
The seafood category includes any type of fish, clams, crab, lobster, oyster, 海鲜类包括任何种类的鱼、蛤、蟹、龙虾和牡蛎、
and scallops. It is important to choose fish with low mercury levels to prevent negative effects of a buildup of mercury in the body. In general, large, fatty ocean fish, such as tuna, have higher levels of mercury due to their diet and storage of mercury in their fatty tissues. 和扇贝。选择汞含量低的鱼类很重要，可防止汞在体内积聚产生负面影响。一般来说，金枪鱼等体型大、脂肪多的海鱼，由于其饮食习惯和脂肪组织中的汞储存，汞含量较高。
The nuts, seeds, and soy products category includes tree nuts, peanuts, nut butters, seeds, or seed butters. Soy products include tofu and any other products made from soy. Unsalted nuts should be selected to avoid excess salt intake. 坚果、种子和豆制品类别包括树坚果、花生、坚果奶油、种子或种子奶油。豆制品包括豆腐和其他任何由大豆制成的产品。应选择无盐坚果，以避免摄入过多盐分。
Protein is also contained in other food groups, such as dairy or the vegetable category of peas, beans, and lentils. Daily serving suggestions of proteins for individuals with a 2,000 calorie diet are 51//251 / 2 ounce equivalents per day. Servings should total up to 26 ounce equivalents per week of meats, eggs, and poultry; 8 ounce equivalents per week of seafood; and 5 ounce equivalents per week of nuts, seeds, or soy products. A “one ounce equivalent” of protein equals 1 ounce of lean meat, one egg, 1//41 / 4 cup cooked beans, or 1 tablespoon of peanut butter. Most Americans consume adequate amounts of protein, but many consume proteins high in saturated fat and sodium that contribute to diseases such as coronary artery disease. ^(57){ }^{57} 其他食物类别中也含有蛋白质，如乳制品或蔬菜类中的豌豆、豆类和扁豆。对于饮食热量为 2,000 卡路里的人，蛋白质的每日食用量建议为 51//251 / 2 盎司当量。每周肉类、蛋类和家禽类的摄入量应达到 26 盎司等量；每周海鲜类的摄入量应达到 8 盎司等量；每周坚果、种子或豆制品的摄入量应达到 5 盎司等量。一盎司等量 "蛋白质等于 1 盎司瘦肉、1 个鸡蛋、 1//41 / 4 杯煮熟的豆子或 1 汤匙花生酱。大多数美国人摄入足量的蛋白质，但许多人摄入的蛋白质饱和脂肪和钠含量较高，会导致冠心病等疾病。 ^(57){ }^{57}
OIL/FAT GROUP 油脂组
Examples of oils are vegetable oil, canola oil, olive oil, butter, lard, and coconut oil. Daily serving suggestions of fats or oils for individuals with a 2,000 calorie diet are 27 grams per day. While it is important to limit oils and fats due to their calorie-dense nature, some fat and oil intake is essential for nutrient absorption and overall health. It is best to select healthy unsaturated fats, such as avocados, nuts, or olive oil. ^(58){ }^{58} 油的例子有植物油、菜籽油、橄榄油、黄油、猪油和椰子油。建议饮食热量为 2,000 卡路里的人每天摄入 27 克脂肪或油。由于油脂热量高，限制油脂摄入量非常重要，但摄入一定量的油脂对营养吸收和整体健康至关重要。最好选择健康的不饱和脂肪，如鳄梨、坚果或橄榄油。 ^(58){ }^{58}
57. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 57.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
58. U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary guidelines for Americans, 2020-2025 (9th ed.). https://www.dietaryguidelines.gov/ 58.美国农业部和美国卫生与公众服务部。(2020).2020-2025 年美国人膳食指南》（第 9 版）。https://www.dietaryguidelines.gov/。
Gender 性别
A person’s gender affects their calorie and nutrient requirements. Males typically have higher calorie and protein needs related to increased muscle mass. Females typically require fewer calories to maintain their body weight due to a higher proportion of adipose (fat tissue) than muscle. Menstruating females also have higher iron requirements to offset losses that occur during menstruation. 一个人的性别会影响其热量和营养需求。男性通常需要更多的卡路里和蛋白质，这与肌肉量增加有关。女性由于脂肪组织的比例高于肌肉组织，通常需要较少的卡路里来维持体重。月经期女性对铁的需求也较高，以抵消月经期间的铁流失。
Read Nutrition and Food Safety Information and Resources for Healthcare Professionals from the U.S. Food and Drug Administration. 阅读美国食品和药物管理局为医疗保健专业人员提供的营养与食品安全信息和资源。
"View the infographic “What’s MyPlate All About?” from the USDA. "查看来自美国农业部的信息图表 "MyPlate 是什么？
Factors Affecting Nutritional Status 影响营养状况的因素
Now that we have discussed basic nutritional concepts and dietary guidelines, let’s discuss factors that can affect a person’s nutritional status. Many things that can cause altered nutrition, such as physiological factors, cultural and religious beliefs, economic resources, drug and nutrient disorders, surgery, altered metabolic states, alcohol and drug abuse, and psychological states. 在讨论了基本营养概念和膳食指南之后，我们来讨论一下可能影响个人营养状况的因素。导致营养状况改变的因素有很多，如生理因素、文化和宗教信仰、经济来源、药物和营养失调、手术、代谢状态改变、酗酒和吸毒以及心理状态等。
Physiological Factors 生理因素
Nutritional intake is affected by several physiological factors. Appetite is controlled by the hypothalamus, a tiny gland deep within the brain that triggers feelings of hunger or fullness depending on hormone and neural 营养摄入受多种生理因素影响。食欲是由下丘脑控制的，下丘脑是大脑深处的一个小腺体，它能根据激素和神经元的作用引发饥饿或饱腹感。
signals being sent and received. See Figure 14.10^(59)14.10^{59} for an image of the hypothalamus indicated by the red arrow. Hunger causes a feeling of emptiness in the abdomen and is often accompanied by audible noises coming from the abdomen as the stomach contracts due to emptiness. Hunger can cause feelings of discomfort, nausea, and tiredness. Satiety is a feeling of fullness that often comes after eating, although it can also be caused by impairments of the hypothalamus. Electrolyte imbalances and fluid volume imbalances can also trigger hunger and thirst by sending signals to the hypothalamus. 信号的发送和接收。红色箭头所示的下丘脑图像见图 14.10^(59)14.10^{59} 。饥饿会让人感到腹部空虚，由于腹部空虚，胃部收缩时往往会伴有从腹部发出的声音。饥饿会引起不适、恶心和疲倦感。饱腹感通常是指进食后产生的饱腹感，但也可能是下丘脑功能受损所致。电解质失衡和液体容量失衡也会通过向下丘脑发送信号来引发饥饿和口渴。
Figure 14.10 Hypothalamus 图 14.10 下丘脑
59. “Hypothalamus.jpg” by Methoxyroxy~commonswiki is in the Public Domain 59."下丘脑.jpg" by Methoxyroxy~commonswiki 已进入公共领域
60. Human Nutrition by University of Hawai’i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 60.夏威夷大学马诺阿分校食品科学与人类营养计划的《人类营养学》以 CC BY 4.0 许可发布。
The five senses play an important role in food intake. For example, food with a pleasing aroma may induce mouth watering and hunger, whereas food or environments with displeasing aromas often suppress the appetite. Texture and taste of foods also play a role in stimulation of appetite. 五感在食物摄入中起着重要作用。例如，香气怡人的食物会让人垂涎欲滴，产生饥饿感，而香气令人不快的食物或环境往往会抑制食欲。食物的质地和味道也会刺激食欲。
Poor dentition or poor oral care has a negative effect on appetite, so adequate oral care is crucial for patients prior to eating. ^(61){ }^{61} Additionally, the condition of a patient’s teeth and gums, the fit of dentures, and gastrointestinal function also play an important role in nutrition. Loose teeth, swollen gums, or poorfitting dentures can make eating difficult. 牙列不齐或口腔护理不当会对食欲产生负面影响，因此在进食前对患者进行充分的口腔护理至关重要。 ^(61){ }^{61} 此外，患者的牙齿和牙龈状况、假牙是否合适以及胃肠功能也对营养起着重要作用。牙齿松动、牙龈肿胀或假牙不合适都会给进食带来困难。
Difficulty swallowing, called dysphagia, can make it dangerous for the patient to swallow food because it can result in pneumonia from aspiration of food into the lungs. Special soft diets or enteral or parenteral nutrition are typically prescribed for patients with dysphagia. Nurses collaborate with speech therapists when assessing and managing dysphagia. 吞咽困难被称为吞咽困难，患者吞咽食物时可能会因食物吸入肺部而导致肺炎，因此吞咽困难会给患者带来危险。吞咽困难患者通常会被处方特殊的软质饮食或肠内或肠外营养。护士在评估和处理吞咽困难时要与语言治疗师合作。
A poorly functioning gastrointestinal tract makes nutrient absorption difficult and can result in malnourishment. Diseases that cause inflammation of the gastrointestinal tract impair absorption of nutrients. Examples of these conditions include esophagitis, gastritis, inflammatory bowel disease, and cholecystitis. Patients with these disorders should select nutrient-dense foods and may require prescribed supplements to increase nutrient intake. 胃肠道功能不良会导致营养吸收困难，并可能造成营养不良。导致胃肠道炎症的疾病会影响营养的吸收。这些疾病包括食管炎、胃炎、炎症性肠病和胆囊炎。患有这些疾病的患者应选择营养丰富的食物，并可能需要处方补充剂来增加营养摄入。
Cultural and Religious Beliefs 文化和宗教信仰
Cultural and religious beliefs often influence food selection and food intake. It is important for nurses to conduct a thorough patient assessment, including food preferences, to ensure adequate nutritional intake during hospitalization. The nurse should not assume a particular diet based on a patient’s culture or religion, but instead should determine their individual preferences through the assessment interview. 文化和宗教信仰往往会影响食物的选择和摄入。护士必须对病人进行全面评估，包括食物偏好，以确保病人在住院期间摄入充足的营养。护士不应根据患者的文化或宗教信仰来假定其特定的饮食习惯，而应通过评估访谈来确定其个人偏好。
61. Human Nutrition by University of Hawai’i at Mānoa Food Science and Human Nutrition Program is licensed under CC BY 4.0 61.夏威夷大学马诺阿分校食品科学与人类营养学项目的《人类营养学》以 CC BY 4.0 许可发布。
Cultural beliefs affect types of food eaten and when they are eaten. Some foods may be restricted due to beliefs or religious rituals, whereas other foods may be viewed as part of the healing process. For example, some cultures do not eat pork because it is considered unclean, and others eat “kosher” food that prescribes how food is prepared. Some religions fast during religious holidays from sunrise to sunset, where others avoid eating meat during the time of Lent. ^(62,63){ }^{62,63} 文化信仰会影响食物的种类和食用时间。有些食物可能因信仰或宗教仪式而受到限制，而其他食物则可能被视为治疗过程的一部分。例如，有些文化不吃猪肉，因为猪肉被视为不洁之物，而另一些文化则吃 "犹太 "食物，因为 "犹太 "食物规定了食物的制作方法。有些宗教在宗教节日期间从日出到日落禁食，而有些宗教则在大斋期避免吃肉。 ^(62,63){ }^{62,63}
Read more about the impact of religious and cultural beliefs on food intake in the “Spirituality” chapter of this book. 如需了解宗教和文化信仰对食物摄入量的影响，请参阅本书 "精神 "一章。
Economic Resources 经济资源
If a patient has inadequate financial resources, food security and food choices are often greatly impacted. Healthy, nutrient-dense, fresh foods typically cost more than prepackaged, heavily processed foods. Poor economic status is correlated with the consumption of calorie-dense, nutrient-poor food choices, putting these individuals at risk for inadequate nutrition and obesity. ^(64){ }^{64} Social programs such as Meals on Wheels, free or reduced-cost school breakfast and lunch programs, and government subsidies based on income help reduce 如果病人的经济来源不足，食品安全和食品选择往往会受到很大影响。健康、营养丰富的新鲜食品通常要比预先包装、经过大量加工的食品昂贵。经济状况不佳与选择热量高、营养低的食物有关，使这些人面临营养不足和肥胖的风险。 ^(64){ }^{64} 社会计划，如 "车轮上的膳食"、免费或减价的学校早餐和午餐计划，以及基于收入的政府补贴，都有助于减少肥胖。
62. Dindyal, S., & Dindyal, S. (n.d.). How personal factors, including culture and ethnicity, affect the choices and selection of food we make. Internet Scientific Publications, 7(3). https://ispub.com/IJTWM/1/2/11779 62.Dindyal, S., & Dindyal, S. (n.d.).包括文化和种族在内的个人因素如何影响我们对食物的选择。互联网科学出版物，7(3). https://ispub.com/IJTWM/1/2/11779
63. Stewardship. (n.d.). What is Lent? When does Lent start? What to do during Lent? https://40acts.org.uk/ about/what-is- 63.管理。(n.d.).什么是四旬斋？大斋期何时开始？四旬斋期间做什么？https://40acts.org.uk/ about/what-is-
lent/?cf_chl_jschl_tk=ef2ed5d0d147e0ea2b579938aca20e0e943f1c75-1614133089-0-AWdOUzF-oUz7XgHuq9pRLnxaEUF5qIJeJYQwB4UPNFLdq498NOvOE_PhRZ_-2Fnlf-j-arlifd4YLDpre2QBuuMI6KI_tI7wGUp8Cil7_K28S-
RBVgOp_30ChPVHXqS1_FCgntbnR8yj7TPb8LszliTpbD5KCZVxOJeTw_f03LYD_DB7gZNOTbsv-r4EQKXEP_ Bvgf3rX_uyNNxXfEUvXiZ88bluD4Dh3ltPLjc9ZxmBCkQS36pkRU7ilu4eRVTfbRON5zBGmxuiriWsRqM5I9aP_yN AkL-OSZhbMtAJOR34IHilovA68VFHPP6au-681TyrxjIJd1IISzsH1nf7TfU RBVgOp_30ChPVHXqS1_FCgntbnR8yj7TPb8LsliTpbD5KCZVxOJeTw_f03LYD_DB7gZNOTbsv-r4EQKXEP_ Bvgf3rX_uyNNxXfEUvXiZ88bluD4Dh3ltPLjc9ZxmBCkQS36pkRU7ilu4eRVTfbRON5zBGmxuiriWsRqM5I9aP_yN AkL-OSZhbMtAJOR34IHilovA68VFHPP6au-681TyrxjIJd1IISzsH1nf7TfU
64. Alkerwi, A., Vernier, C., Sauvageot, N., Crichton, G., & Elias, M. (2015). Demographic and socioeconomic disparity in nutrition: Application of a novel correlated component regression approach. BMJ Open, 5(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431064/ 64.Alkerwi, A., Vernier, C., Sauvageot, N., Crichton, G., & Elias, M. (2015)。营养方面的人口和社会经济差异：新型相关成分回归方法的应用。BMJ Open, 5(5). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431064/
food insecurity and promote the consumption of healthy, nutrient-dense foods. Nurses refer at-risk patients to social workers and case managers for assistance in applying for these social programs. 护士将高危病人转介给社会工作者和个案经理，帮助他们申请这些社会计划。护士会将有风险的病人转介给社会工作者和个案经理，以帮助他们申请这些社会计划。
Drug and Nutrient Interactions 药物与营养素的相互作用
Some prescription drugs affect nutrient absorption. For example, some medications such as proton pump inhibitors (omeprazole) alter the pH of stomach acid, resulting in poor absorption of nutrients. Other medications, such as opioids, often decrease a person’s appetite or cause nausea, resulting in decreased calorie and nutrient intake. 有些处方药会影响营养的吸收。例如，质子泵抑制剂（奥美拉唑）等药物会改变胃酸的酸碱度，导致营养吸收不良。其他药物，如阿片类药物，通常会降低人的食欲或引起恶心，导致热量和营养摄入减少。
Surgery 外科手术
Surgery can affect a patient’s nutritional status due to several factors. Food and drink are typically withheld for a period of time prior to surgery to prevent aspiration of fluid into the lungs during anesthesia. Anesthesia and pain medication used during surgery slow peristalsis, and it often takes time to return to normal. Slow peristalsis can cause nausea, vomiting, and constipation. Until the patient is able to pass gas and bowel sounds return, the patient is typically ordered to have nothing by mouth (NPO). If a patient experiences prolonged NPO status, such as after significant abdominal surgery, intravenous fluids and nutrition may be required. 由于多种因素，手术会影响病人的营养状况。手术前通常要禁食禁饮一段时间，以防止麻醉期间液体吸入肺部。手术中使用的麻醉药和止痛药会减缓肠胃蠕动，通常需要一段时间才能恢复正常。蠕动缓慢会导致恶心、呕吐和便秘。在患者能够排出气体和肠鸣音恢复之前，通常会要求患者口服任何药物（NPO）。如果患者长期处于 NPO 状态，例如在重大腹部手术后，可能需要静脉输液和补充营养。
Surgery also stimulates the physiological stress response and increases metabolic demands, causing the need for increased calories. The stress response can also cause elevated blood glucose levels due to the release of corticosteroids, even if the patient has not been previously diagnosed with diabetes mellitus. For this reason, nurses often monitor post-op patients’ bedside blood glucose levels carefully. 手术还会刺激生理应激反应，增加新陈代谢需求，导致热量需求增加。由于皮质类固醇的释放，应激反应也会导致血糖水平升高，即使患者以前未被诊断出患有糖尿病。因此，护士通常会仔细监测术后病人的床边血糖水平。
Bowel resection surgery in particular has a negative impact on nutrient absorption. Because all or parts of the intestine are removed, there is decreased absorption of nutrients, which can result in nutrient deficiencies. 肠切除手术尤其会对营养吸收产生负面影响。由于全部或部分肠道被切除，营养吸收减少，可能导致营养缺乏。
Many patients who have experienced bowel resection require nutrient supplementation. 许多经历过肠道切除术的病人需要补充营养。
Bariatric surgery is used to treat obesity and reduce obesity-related cardiovascular risk factors. Bariatric procedures alter the anatomy and physiology of the gastrointestinal tract, which makes patients susceptible to nutritional deficiencies. ^(65){ }^{65} Read more about bariatric surgery and long-term nutritional issues using the hyperlink in the following box. 减肥手术用于治疗肥胖症和减少与肥胖相关的心血管风险因素。减肥手术改变了胃肠道的解剖和生理结构，使患者容易出现营养缺乏。 ^(65){ }^{65} 请使用下框中的超链接阅读有关减肥手术和长期营养问题的更多信息。
Read more about bariatric surgery and long-term nutritional issues. 了解更多有关减肥手术和长期营养问题的信息。
Altered Metabolic States 代谢状态的改变
Metabolic demands impact nutrient intake. In conditions where metabolic demands are increased, such as during growth spurts in childhood or adolescence, nutritional intake should be increased. Disease states, such as cancer, hyperthyroidism, and AIDS, can increase metabolism and require an increased amount of nutrients. However, cancer treatment, such as radiation and chemotherapy, often causes nausea, vomiting, and decreased appetite, making it difficult for patients to obtain adequate nutrients at a time when they are needed in high amounts due to increased metabolic demand. 代谢需求会影响营养摄入量。在新陈代谢需求增加的情况下，如儿童或青少年生长高峰期，应增加营养摄入量。癌症、甲状腺功能亢进和艾滋病等疾病状态会增加新陈代谢，需要更多的营养素。然而，癌症治疗（如放疗和化疗）通常会引起恶心、呕吐和食欲下降，使患者在新陈代谢需求增加而需要大量营养时难以获得足够的营养。
Other diseases like diabetes mellitus cause complications with nutrient absorption due to insulin. Insulin is necessary for the metabolism of fats, proteins, and carbohydrates, but in patients with diabetes mellitus, insulin production is insufficient or their body is not able to effectively use circulating insulin. This lack of insulin can result in impaired nutrient metabolism. 由于胰岛素的作用，糖尿病等其他疾病也会导致营养吸收方面的并发症。胰岛素是脂肪、蛋白质和碳水化合物新陈代谢所必需的，但对于糖尿病患者来说，胰岛素分泌不足或身体无法有效利用循环中的胰岛素。胰岛素的缺乏会导致营养代谢受损。
65. Lupoli, R., Lembo, E., et al. (2017) Bariatric surgery and long-term nutritional issues. World Journal of Diabetes, 8(11), 464-474. DOI: 10.4239/wjd.v8.i11. 464 65.Lupoli, R., Lembo, E., et al. (2017) 减肥手术与长期营养问题。世界糖尿病杂志》，8（11），464-474。DOI: 10.4239/wjd.v8.i11.464
66. Lupoli, R., Lembo, E., et al. (2017) Bariatric surgery and long-term nutritional issues. World Journal of Diabetes, 8(11), 464-474. DOI: 10.4239/wjd.v8.i17. 464 66.Lupoli, R., Lembo, E., et al. (2017) 减肥手术与长期营养问题。世界糖尿病杂志》，8（11），464-474。DOI: 10.4239/wjd.v8.i17.464
Alcohol and Drug Abuse 酗酒与吸毒
Alcohol and drug abuse can affect nutritional status. Alcohol is calorie-dense and nutrient-poor. With alcohol use, the consumption of water, food, and other nutrients often decreases as patients “drink their calories.” This may result in decreased protein intake and body protein deficiency. Nutrient digestion and absorption can also decrease with alcohol consumption if the stomach lining becomes eroded or scarred. This can cause hemoglobin, hematocrit, albumin, folate, thiamine, vitamin B12, and vitamin C deficiencies, as well as decreased calcium, magnesium, and phosphorus levels. ^(67){ }^{67} 酗酒和吸毒会影响营养状况。酒精热量高，营养成分少。在酗酒的情况下，由于患者 "喝掉了卡路里"，水、食物和其他营养物质的摄入量往往会减少。这可能会导致蛋白质摄入减少和体内蛋白质缺乏。如果胃黏膜受到侵蚀或出现疤痕，营养物质的消化和吸收也会随着饮酒而减少。这会导致血红蛋白、血细胞比容、白蛋白、叶酸、硫胺素、维生素 B12 和维生素 C 缺乏，以及钙、镁和磷水平下降。 ^(67){ }^{67}
Drug abuse of stimulants, such as methamphetamine and cocaine abuse, causes an increased metabolic rate and decreased appetite and contributes to weight loss and malnourishment. 滥用兴奋剂，如滥用甲基苯丙胺和可卡因，会导致新陈代谢率上升，食欲下降，造成体重下降和营养不良。
Psychological State 心理状态
Various psychological states have a direct effect on appetite and a patient’s desire to eat. Acute and chronic stress stimulates the hypothalamus and increases production of glucocorticoids and glucose. This can increase the person’s appetite, causing increased calorie intake, fat storage, and subsequent weight gain. When a person feels stressed, their food choices are often nutrient-poor and calorie-dense, which further increases weight gain and nutrient deficiencies. In other individuals, the stress response causes loss of appetite, weight loss, and nutrient deficiencies. ^(68){ }^{68} 各种心理状态会直接影响患者的食欲和进食欲望。急性和慢性压力会刺激下丘脑，增加糖皮质激素和葡萄糖的分泌。这会增加患者的食欲，导致热量摄入增加、脂肪储存和体重增加。当一个人感到压力大时，他所选择的食物往往缺乏营养，热量过高，这进一步增加了体重增加和营养缺乏。在另一些人中，压力反应会导致食欲不振、体重下降和营养缺乏。 ^(68){ }^{68}
Depression can cause loss of appetite or overeating. Many people eat calorie- 抑郁会导致食欲不振或暴饮暴食。许多人吃热量
67. Gramlich, L., Tandon, P., & Rahman, A. (2019). Nutritional status in patients with sustained heavy alcohol use. UpToDate. Retrieved February 21, 2021, from https://www.uptodate.com/contents/nutritional-status-in-patients-with-sustained-heavy-alcohol-use?csi=5c4a69dc-6adc-4ae0-a572-4be3ef0e325f&source=contentShare 67.Gramlich, L., Tandon, P., & Rahman, A. (2019)。持续大量饮酒患者的营养状况。UpToDate。2021 年 2 月 21 日，从 https://www.uptodate.com/contents/nutritional-status-in-patients-with-sustained-heavy-alcohol-use?csi=5c4a69dc-6adc-4ae0-a572-4be3ef0e325f&source=contentShare 检索。
68. Ulrich-Lai, Y. M., Fulton, S., Wilson, M., Petrovich, G., & Rinaman, L. (2015). Stress exposure, food intake and emotional state. Stress (Amsterdam, Netherlands), 18(4), 381-399. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4843770/ 68.Ulrich-Lai, Y. M., Fulton, S., Wilson, M., Petrovich, G., & Rinaman, L. (2015)。压力暴露、食物摄入和情绪状态。Stress (Amsterdam, Netherlands), 18(4), 381-399. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4843770/
dense “comfort foods” as a coping mechanism. Additionally, many antidepressants can cause weight gain as a side effect. 高密度的 "安慰性食物 "作为一种应对机制。此外，许多抗抑郁药的副作用还可能导致体重增加。
14.3 Applying the Nursing Process 14.3 应用护理程序
OPEN RESOURCES FOR NURSING (OPEN RN) 开放式护理资源（open rn）
Now that we have discussed basic nutritional concepts, dietary guidelines, and factors affecting nutritional status, let’s apply the nursing process to this information when caring for patients. 既然我们已经讨论了基本的营养概念、饮食指南和影响营养状况的因素，那么让我们在护理病人时将这些信息应用到护理过程中。
Assessment 评估
A thorough nutritional assessment provides information about an individual’s nutritional status, as well as risk factors for nutritional imbalances. 全面的营养评估可提供有关个人营养状况以及营养失衡风险因素的信息。
Assessment starts with reviewing the patient’s medical record and initiating a patient interview, followed by a physical exam and review of lab and diagnostic test results. 评估工作首先要查看患者的病历，并对患者进行访谈，然后进行体格检查，并查看化验和诊断测试结果。
Subjective Assessment 主观评估
Subjective assessments include questions regarding normal eating patterns and risk factor identification. Subjective assessment data is obtained by interviewing the patient as a primary source or a family member or caregiver as a secondary source. While a wealth of subjective information can be obtained through a chart review, it is important to verify this information with either the patient or family member because details may be recorded inaccurately or may have changed over time. Subjective information to obtain when completing a nutritional assessment includes age, sex, history of illness or chronic disease, surgeries, dietary intake including a 24-hour diet recall or food diary, food preferences, cultural practices related to diet, normal snack and meal timings, food allergies, special diets, and food shopping or preparation activities. 主观评估包括有关正常饮食模式和风险因素识别的问题。主观评估数据主要通过询问患者获得，或通过询问家庭成员或护理人员获得。虽然可以通过查看病历获得大量主观信息，但重要的是要与患者或家属核实这些信息，因为细节记录可能不准确，或可能随着时间的推移而发生变化。在完成营养评估时需要获取的主观信息包括年龄、性别、病史或慢性病史、手术史、饮食摄入量（包括 24 小时饮食回忆或饮食日记）、饮食偏好、与饮食相关的文化习俗、正常的零食和进餐时间、食物过敏、特殊饮食以及食物购物或准备活动。
A detailed nutritional assessment can also provide important clues for identification of risk factors for nutritional deficits or excesses. For example, a history of anorexia or bulimia will put the patient at risk for vitamin, mineral, and electrolyte disturbances, as well as potential body image disturbances. Swallowing impairments place the patient at risk for decreased intake that may be insufficient to meet metabolic demands. Use of recreational drugs or 详细的营养评估还能为识别营养缺乏或营养过剩的风险因素提供重要线索。例如，厌食症或暴食症病史会使患者面临维生素、矿物质和电解质紊乱的风险，以及潜在的身体形象障碍。吞咽障碍会使患者面临摄入量减少的风险，摄入量可能不足以满足新陈代谢的需求。使用娱乐性药物或
alcohol places the patient at risk for insufficient nutrient intake and impaired nutrient absorption. Use of nutritional supplements places the patient at risk for excess nutrient absorption and potential toxicity. Recognizing and identifying risks to nutritional status help the nurse anticipate problems that may arise and identify complications as they occur. Ideally, the nurse will recognize subtle cues of impending or actual dysfunction and prevent bigger problems from happening. 酒精会使病人面临营养摄入不足和营养吸收受损的风险。使用营养补充剂会使患者面临营养吸收过量和潜在中毒的风险。认识和识别营养状况的风险有助于护士预测可能出现的问题，并在并发症发生时及时发现。理想情况下，护士能够识别即将发生或实际发生功能障碍的微妙线索，防止更大的问题发生。
Objective Assessment 客观评估
Objective assessment data is information derived from direct observation by the nurse and is obtained through inspection, auscultation, and palpation. The nurse should consider nutritional status while performing a physical examination. 客观评估数据是护士通过直接观察和检查、听诊和触诊获得的信息。护士在进行体格检查时应考虑营养状况。
The nurse begins the physical examination by making general observations about the patient’s status. A well-nourished patient has normal skin color and hair texture for their ethnicity, healthy nails, a BMI within normal range according to their height, and appears energetic. 体格检查开始时，护士要对病人的状况进行一般观察。营养状况良好的患者肤色和发质与他们的种族相符，指甲健康，体重指数（BMI）与身高相符，在正常范围内，并且看起来精力充沛。
Height and weight should be accurately measured and documented. Height and weight in infants and children are plotted on a growth chart to give a percentile ranking across the United States. The infant or child should show a trend of consistent height and weight increase. 应准确测量并记录身高和体重。将婴儿和儿童的身高和体重绘制在生长曲线图上，以得出全美百分位数排名。婴儿或儿童的身高和体重应呈现持续增长的趋势。
Height and weight in adults are often compared to a Body Mass Index (BMI) graph. BMI can also be calculated using the following formulas: 成人的身高和体重通常与身体质量指数（BMI）图表进行比较。BMI 也可以用以下公式计算：
To calculate BMI using a BMI table, the patient’s height is plotted on the horizontal axis and their weight is plotted on the perpendicular axis. The BMI 使用体重指数表计算体重指数时，病人的身高绘制在横轴上，体重绘制在纵轴上。BMI
is measured where the lines intersect. See Figure 14.11^(7)14.11^{7} for an image of a BMI table. BMI is interpreted using the following ranges: 是在两条线相交的地方测量的。有关 BMI 表的图像，请参见图 14.11^(7)14.11^{7} 。BMI 使用以下范围进行解释：
Less than 18.5: Underweight 小于 18.5：体重不足
18.5-24.9: Desirable range 18.5-24.9: 理想范围
25-29.9: Overweight 25-29.9: 超重
Equal or greater than 30: Obese ^(2){ }^{2} 等于或大于 30：肥胖 ^(2){ }^{2}
Figure 14.11 BMI Table 图 14.11 BMI 表
After completing the subjective and objective assessment, the data should be analyzed for expected and unexpected findings. See Table 14.3a for a 在完成主观和客观评估后，应对数据进行分析，以确定预期和意外结果。参见表 14.3a。
“Bmi-chart_colored.gif” by Cbizzy2313 is licensed under CC BY-SA 4.0 Cbizzy2313 制作的 "Bmi-chart_colored.gif "采用 CC BY-SA 4.0 许可。
Hood, W. A. (2020, September 25). Nutritional status assessment in adults technique. Medscape. https://emedicine.medscape.com/article/2141861-technique Hood, W. A. (2020, September 25).成人营养状况评估技术。https://emedicine.medscape.com/article/2141861-technique
comparison of expected versus unexpected assessment findings related to nutritional status on assessment, including those that require notification of the health care provider in bold font. 比较与营养状况有关的预期和意外评估结果，包括需要用粗体字通知医疗服务提供者的评估结果。
Table 14.3a Expected Versus Unexpected Findings During Nutritional Assessment ^(3){ }^{3} 表 14.3a 营养评估过程中的预期结果与意外结果 ^(3){ }^{3}
3. Hood, W. A. (2020, September 25). Nutritional status assessment in adults technique. Medscape. 3.Hood, W. A. (2020, September 25).成人营养状况评估技术。Medscape.
Assessment 评估
Expected Findings 预期结果
意外发现 *粗体字为危急情况，需要立即通知医疗服务提供者。
Unexpected Findings
*Bolded items are critical conditions that require immediate health care provider notification.
Unexpected Findings
*Bolded items are critical conditions that require immediate health care provider notification.| Unexpected Findings |
| :--- |
| *Bolded items are critical conditions that require immediate health care provider notification. |
General appearance 总体外观
Energetic; normal skin, hair, and nails; and normal weight related to height 精力充沛；皮肤、头发和指甲正常；身高体重正常
Lethargic, skin ulcerations, rashes, bruising, thinning or loss of hair, spooning of nails, obese, or underweight 嗜睡、皮肤溃疡、皮疹、瘀伤、毛发稀疏或脱落、指甲稀疏、肥胖或体重不足
Dry/sticky mucous membranes, oral ulcerations, glossitis (swollen tongue), coughing while swallowing or inability to swallow, or swollen throat 粘膜干燥/粘稠、口腔溃疡、舌炎（舌头肿胀）、吞咽时咳嗽或无法吞咽，或喉咙肿胀
Extremities/ Integumentary 四肢/器官
Normal skin, nontenting (good skin turgor) and supple texture 皮肤正常，不紧绷（皮肤张力良好），质地柔软
Clear lung sounds throughout, normal respiratory rate, and no shortness of breath 整个肺部听诊清晰，呼吸频率正常，无呼吸急促感
Crackles in lung fields, pink frothy sputum, shortness of breath, or respiratory distress 肺部出现噼啪声、粉红色泡沫痰、呼吸急促或呼吸困难
Gastrointestinal 胃肠道
Normal stool quality and frequency for patient, bowel sounds present xx4\times 4 quadrants, and absence of nausea/vomiting 患者大便质量和次数正常， xx4\times 4 象限出现肠鸣音，无恶心/呕吐症状
Constipation, diarrhea, nausea, or vomiting 便秘、腹泻、恶心或呕吐
Urinary 泌尿系统
Clear urine, normal urine specific gravity, and urine output >30 mL/hr 尿液清澈，尿比重正常，尿量大于 30 毫升/小时
Assessment Expected Findings "Unexpected Findings
*Bolded items are critical conditions that require immediate health care provider notification."
General appearance Energetic; normal skin, hair, and nails; and normal weight related to height Lethargic, skin ulcerations, rashes, bruising, thinning or loss of hair, spooning of nails, obese, or underweight
Eyes Normal vision and normal eye moisture Impaired night vision or dry eyes
Mouth Moist mucous membranes, intact oral mucosa, and intact smooth tongue Dry/sticky mucous membranes, oral ulcerations, glossitis (swollen tongue), coughing while swallowing or inability to swallow, or swollen throat
Extremities/ Integumentary Normal skin, nontenting (good skin turgor) and supple texture Tenting (poor skin turgor), dry skin, edema, or shiny skin
Neurological Normal sensation and normal cognition Numbness or tingling, tetany, dementia, or acute confusion
Cardiac Normal heart tones, capillary refill < 3 seconds, normal pulses, and normal EKG tracing Bounding pulses, S3 heart tone, jugular venous distention, abnormal EKG tracing, or cardiac arrhythmias
Respiratory Clear lung sounds throughout, normal respiratory rate, and no shortness of breath Crackles in lung fields, pink frothy sputum, shortness of breath, or respiratory distress
Gastrointestinal Normal stool quality and frequency for patient, bowel sounds present xx4 quadrants, and absence of nausea/vomiting Constipation, diarrhea, nausea, or vomiting
Urinary Clear urine, normal urine specific gravity, and urine output >30 mL/hr Decreased urine output <30 mL/ hr or < 0.5mL//kg//hr, concentrated urine, or burning with urination| Assessment | Expected Findings | Unexpected Findings <br> *Bolded items are critical conditions that require immediate health care provider notification. |
| :--- | :--- | :--- |
| General appearance | Energetic; normal skin, hair, and nails; and normal weight related to height | Lethargic, skin ulcerations, rashes, bruising, thinning or loss of hair, spooning of nails, obese, or underweight |
| Eyes | Normal vision and normal eye moisture | Impaired night vision or dry eyes |
| Mouth | Moist mucous membranes, intact oral mucosa, and intact smooth tongue | Dry/sticky mucous membranes, oral ulcerations, glossitis (swollen tongue), coughing while swallowing or inability to swallow, or swollen throat |
| Extremities/ Integumentary | Normal skin, nontenting (good skin turgor) and supple texture | Tenting (poor skin turgor), dry skin, edema, or shiny skin |
| Neurological | Normal sensation and normal cognition | Numbness or tingling, tetany, dementia, or acute confusion |
| Cardiac | Normal heart tones, capillary refill < 3 seconds, normal pulses, and normal EKG tracing | Bounding pulses, S3 heart tone, jugular venous distention, abnormal EKG tracing, or cardiac arrhythmias |
| Respiratory | Clear lung sounds throughout, normal respiratory rate, and no shortness of breath | Crackles in lung fields, pink frothy sputum, shortness of breath, or respiratory distress |
| Gastrointestinal | Normal stool quality and frequency for patient, bowel sounds present $\times 4$ quadrants, and absence of nausea/vomiting | Constipation, diarrhea, nausea, or vomiting |
| Urinary | Clear urine, normal urine specific gravity, and urine output >30 mL/hr | Decreased urine output <30 mL/ hr or $<0.5 \mathrm{~mL} / \mathrm{kg} / \mathrm{hr}$, concentrated urine, or burning with urination |
Normal BMI of 18.5-24.9,
weight loss or gain of 0.5 to 1
pound per week is realistic,
and < 5% weight loss over 6
months| Normal BMI of 18.5-24.9, |
| :--- |
| weight loss or gain of 0.5 to 1 |
| pound per week is realistic, |
| and $<5 \%$ weight loss over 6 |
| months |
BMI < 18.5 or > 25, weight gain or
loss of > 1kg over 24 hrs, or
severe weight loss of > 10% over 6
months| BMI $<18.5$ or $>25$, weight gain or |
| :--- |
| loss of $>1 \mathrm{~kg}$ over 24 hrs, or |
| severe weight loss of $>10 \%$ over 6 |
| months |
Weight "Normal BMI of 18.5-24.9,
weight loss or gain of 0.5 to 1
pound per week is realistic,
and < 5% weight loss over 6
months" "BMI < 18.5 or > 25, weight gain or
loss of > 1kg over 24 hrs, or
severe weight loss of > 10% over 6
months"| Weight | Normal BMI of 18.5-24.9, <br> weight loss or gain of 0.5 to 1 <br> pound per week is realistic, <br> and $<5 \%$ weight loss over 6 <br> months | BMI $<18.5$ or $>25$, weight gain or <br> loss of $>1 \mathrm{~kg}$ over 24 hrs, or <br> severe weight loss of $>10 \%$ over 6 <br> months |
| :--- | :--- | :--- |
Review how to perform a physical examination on the body systems listed in Table 14.3a in Open RN Nursing Skills. 复习如何对《开放式注册护士护理技能》中表 14.3a 所列的身体系统进行体格检查。
DIAGNOSTIC AND LAB WORK 诊断和实验室工作
Diagnostic and lab work results can provide important clues about a patient’s overall nutritional status and should be used in conjunction with a thorough subjective and objective assessment to provide an accurate picture of the patient’s overall health status. Common lab tests include hemoglobin (hgb), hematocrit (HCT), white blood cells (WBC), albumin, prealbumin, and transferrin. 诊断和实验室检查结果可提供有关患者整体营养状况的重要线索，应与全面的主观和客观评估结合使用，以准确反映患者的整体健康状况。常见的实验室检查包括血红蛋白 (hgb)、血细胞比容 (HCT)、白细胞 (WBC)、白蛋白、前白蛋白和转铁蛋白。
Anemia is a medical condition diagnosed by low hemoglobin levels. Hemoglobin is important for oxygen transport throughout the body. Anemia can be caused acutely by hemorrhage, but it is often the result of chronic iron deficiency, vitamin B12 deficiency, or folate deficiency. Iron supplements, B12 injections, folate supplements, and increased iron or folate intake in the diet can help increase hemoglobin levels.
