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⚠️ 风险降低 · 第5课，共6课 · 6 min

DVT预防与绝不能漏诊的肺栓塞

DVT Prevention and the Pulmonary Embolism You Must Not Miss

🫁 一名髋关节置换术后正在恢复的患者坐着聊天，然后突然抓住胸口，喘着气说她觉得自己快要死了。她的血氧饱和度是84%。接下来的60秒就是一道考试题。

🫁 A client recovering from a hip replacement is sitting up chatting, then suddenly grabs her chest, gasps and says she feels like she is going to die. Her saturation is 84%. The next 60 seconds are an exam question.

💡 核心要点

通过活动、加压和抗凝剂来预防。DVT表现为一条腿肿胀发热，不要按摩。PE表现为突发呼吸困难和胸痛：坐起、吸氧、呼叫快速反应团队、使用heparin。

Prevent with movement, compression and anticoagulants. DVT: one swollen warm leg, do not massage. PE: sudden dyspnea and chest pain: sit up, oxygen, rapid response, heparin.

🧠 为什么重要

VIRCHOW'S TRIAD（Virchow三联征）解释了血栓风险：静脉淤滞、血管损伤和高凝状态，因此制动、手术、癌症、妊娠、estrogen和脱水都会增加风险。通过尽早下床活动、腿部锻炼、按医嘱使用间歇性加压装置或抗栓袜、补水和预防性抗凝剂来预防深静脉血栓形成。DVT的征象包括单侧腿部肿胀、温热感、发红和压痛；测量小腿围并比较两侧；不要按摩腿部；Homans征不可靠，已不再推荐。治疗包括抗凝，并常按医嘱继续下床活动。肺栓塞表现为突发呼吸困难、胸膜炎性胸痛、心动过速、呼吸急促、低氧血症、咳嗽、焦虑和濒死感，有时伴咯血。立即采取的行动包括抬高床头、给予吸氧、陪伴患者、呼叫快速反应团队、建立IV通路，并预期进行抗凝治疗（heparin）、CT肺动脉造影以及可能使用溶栓药。教导服用抗凝剂的出院患者注意出血预防措施和新血栓形成的征象。

VIRCHOW'S TRIAD explains clot risk: venous stasis, vessel injury and hypercoagulability, so immobility, surgery, cancer, pregnancy, estrogen and dehydration raise the risk. PREVENT deep vein thrombosis with early ambulation, leg exercises, intermittent compression devices or antiembolism stockings as ordered, hydration and prophylactic anticoagulants. DVT signs: unilateral leg swelling, warmth, redness and tenderness; measure calf circumference and compare sides; do not massage the leg; Homans' sign is unreliable and no longer recommended. Treat with anticoagulation and, often, continued ambulation per order. PULMONARY EMBOLISM: sudden dyspnea, pleuritic chest pain, tachycardia, tachypnea, hypoxemia, cough, anxiety and a feeling of doom, sometimes hemoptysis. Immediate actions: raise the head of the bed, apply oxygen, stay with the client, call the rapid response team, obtain IV access, and anticipate anticoagulation (heparin), CT pulmonary angiography and possibly thrombolytics. Teach discharge clients on anticoagulants about bleeding precautions and the signs of a new clot.

🏥 真实场景

⚡ 护士抬高床头，给喘息的患者戴上非重复呼吸面罩，并呼叫快速反应团队，同时她的同事建立第二条IV通路。她没有离开房间去找医疗服务提供者。CT证实了肺栓塞，并开始输注heparin。考试的正确顺序是让护士留在床边并保持氧气持续供给的那个顺序。

⚡ The nurse raises the head of the bed, puts a non-rebreather on the gasping client, and calls the rapid response team while her colleague places a second IV. She does not leave the room to find the provider. A CT confirms a pulmonary embolism and a heparin infusion begins. The exam's correct sequence is the one that keeps the nurse at the bedside and the oxygen flowing.

📌 要点总结

  • 淤滞、血管损伤、高凝状态：风险三联征Stasis, vessel injury, hypercoagulability: the risk triad
  • DVT：单侧肿胀、温热感、压痛；切勿按摩DVT: unilateral swelling, warmth, tenderness; never massage
  • PE：突发呼吸困难和胸膜炎性疼痛：坐起、吸氧、呼叫快速反应团队、抗凝PE: sudden dyspnea and pleuritic pain: upright, oxygen, rapid response, anticoagulate

📖 本课术语

肺栓塞 (Pulmonary embolism): 血栓阻塞在肺部，引起突发呼吸困难、胸膜炎性胸痛、心动过速和低氧血症。

D-dimer: 一种血栓分解片段，正常低于约0.5 mcg/mL（500 ng/mL）；正常值有助于排除DVT和肺栓塞，而高值不特异，在DIC、手术、妊娠和感染时都会升高。

✅ 自我测试

一名术后患者突然出现呼吸困难、胸痛，血氧饱和度为85%。护士首先应该怎么做？A post-operative client suddenly develops dyspnea, chest pain and an oxygen saturation of 85%. What should the nurse do first?
  1. 离开去通知医疗服务提供者Leave to notify the provider
  2. 让患者坐起并给予吸氧Sit the client up and apply oxygen
  3. 让患者下床活动以改善循环Ambulate the client to improve circulation
  4. 给予预定的口服抗凝剂Administer the scheduled oral anticoagulant

答案: B · 让患者坐起并给予吸氧

这些是肺栓塞的征象。在召唤帮助的同时稳定气道和氧合；不要离开患者。

These are signs of pulmonary embolism. Stabilize the airway and oxygenation while summoning help; do not leave the client.

哪项发现提示左腿有深静脉血栓形成？Which finding suggests a deep vein thrombosis in the left leg?
  1. 左小腿肿胀、温热感和压痛Left calf swelling, warmth and tenderness
  2. 双脚麻木Numbness in both feet
  3. 一天结束时双侧踝部水肿Bilateral ankle edema at the end of the day
  4. 左脚凉、苍白且脉搏消失Cool, pale left foot with absent pulses

答案: A · 左小腿肿胀、温热感和压痛

单侧肿胀、温热感和压痛指向静脉血栓形成；肢体凉、苍白、无脉提示动脉闭塞。

Unilateral swelling, warmth and tenderness point to venous thrombosis; cool pale pulseless limbs suggest arterial occlusion.

对于制动的术后患者，哪项干预适合预防DVT？Which intervention is appropriate to prevent DVT in an immobile post-operative client?
  1. 用枕头垫在膝下保持膝部屈曲Keeping the knees flexed with pillows under them
  2. 使用气压加压装置Applying pneumatic compression devices
  3. 限制口服液体以减少腿部肿胀Restricting oral fluids to reduce leg swelling
  4. 每4小时按摩小腿以促进静脉回流Massaging the calves every 4 hours to promote venous return

答案: B · 使用气压加压装置

加压装置可改善静脉回流。按摩可能使血栓脱落，膝下垫枕头会导致淤滞，脱水会使血液变稠。

Compression devices improve venous return. Massage can dislodge clots, pillows under the knees cause stasis, and dehydration thickens the blood.

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