内外科护理：速成包

公式表、每个专题的关键方法步骤和 16 道练习题，完整解答附在最后。

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1公式与方法

内外科护理：心血管与呼吸

方法

  1. 说出问题所在：泵衰竭、动脉阻塞、节律、血栓、气道狭窄、感染或设备问题。
  2. 先检查危险征象：低氧、低血压、胸痛、新出现的意识模糊、冰冷无脉搏的肢体。
  3. 让氧疗与患者相匹配：大多数人为 94–98%，有 CO₂ 潴留风险者为 88–92%。
  4. 把每种药物与其检测和风险联系起来：华法林与 INR，肝素与 aPTT 和血小板，利尿剂与血钾。
  5. 选择安全的第一步措施，然后升级处理并重新评估。

内外科护理：神经、内分泌与肾脏

方法

  1. 对每位新出现意识模糊、乏力或癫痫发作的患者都检查血糖。
  2. 把意识水平作为脑部问题最早的警示；瞳孔变化和库欣三联征出现得较晚。
  3. 对于糖尿病急症，要区分 DKA（酮体、酸中毒）和 HHS（渗透压很高、脱水）；先补液。
  4. 对于钠和水，要判断是 ADH 过多（SIADH）还是缺乏（尿崩症），并缓慢纠正慢性变化。
  5. 对于肾脏问题，把原因分为肾前性、肾性或肾后性，并监测血钾和液体。

内外科护理：消化、围手术期与肿瘤

方法

  1. 想一想可能隐藏着什么：内出血、无发热的感染、SpO₂ 正常背后的通气不足。
  2. 利用术后的时间来缩小并发症的范围：出血在数小时内，胸部问题在数天内，伤口和吻合口漏出现得更晚。
  3. 对于疼痛，要评估、用多模式镇痛治疗、重新评估，并且在每次使用阿片类药物时监测镇静程度。
  4. 对于癌症患者，把低谷期的任何疾病都当作中性粒细胞减少性脓毒症处理，并了解肿瘤急症。
  5. 对于烧伤，只计算浅二度/深二度和三度的面积，从烧伤的时刻开始计算 Parkland 时间，并根据尿量调整。

实验室检查值与电解质

方法

  1. 把数值与本实验室自己的参考范围比较，再与患者的基线和趋势比较。
  2. 检查标本：溶血、延迟，或在静脉输液附近采血都可能得出错误结果。
  3. 把数值与其典型体征以及引起它的药物和疾病联系起来。
  4. 注意相互作用：低钾或低镁会增加地高辛中毒的风险；脱水会使锂浓度升高。
  5. 对患者采取行动：评估，血药浓度不安全时暂停用药，复述危急值并通知开医嘱的医生。

动脉血气分析解读

正常范围
pH 7.35–7.45, PaCO₂ 35–45 mmHg (4.7–6.0 kPa), HCO₃⁻ 22–26 mmol/L
ROME
呼吸性：PaCO₂ 与 pH 相反； 代谢性：HCO₃⁻ 与 pH 同向
温特公式
PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2
代谢性碱中毒
PaCO₂ ≈ 0.7·HCO₃⁻ + 21
阴离子间隙
AG = Na⁺ − (Cl⁻ + HCO₃⁻) ≈ 8–12
白蛋白校正阴离子间隙
AG + 2.5·(4.0 − alb g/dL) = AG + 0.25·(40 − alb g/L)
Δ 比值
(AG − 12)/(24 − HCO₃⁻)
P/F 比值
PaO₂/FiO₂
肺泡气方程
PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8
血清渗透压
2·Na⁺ + glucose + urea (2·Na⁺ + glucose/18 + BUN/2.8)

方法

  1. 先看 pH：低于 7.35 为酸中毒，高于 7.45 为碱中毒。
  2. 找出能解释它的指标：PaCO₂ 与 pH 反向变化为呼吸性，HCO₃⁻ 与 pH 同向变化为代谢性。
  3. 再看另一个指标：正常表示未代偿，沿代偿方向异常表示部分代偿，pH 正常而两项指标都异常表示完全代偿。
  4. 对于代谢性酸中毒，用温特公式 1.5·HCO₃⁻ + 8 ± 2 与 PaCO₂ 比较，并计算阴离子间隙 Na⁺ − (Cl⁻ + HCO₃⁻)。
  5. 阴离子间隙升高时，用 Δ 比值检查；白蛋白偏低时，再用校正后的间隙检查。

心电图节律条带解读

纸速（25 mm/s，10 mm/mV）
1 个小格 = 0.04 s， 1 个大格 = 0.20 s， 10 mm = 1 mV
心率，节律规则
300 ÷ 大格数 = 1500 ÷ 小格数 = 60 ÷ RR (s)
心率，节律不规则
6 s 内的 QRS 波群数 × 10
正常 PR 间期
0.12–0.20 s
正常 QRS 时限
< 0.12 s
QTc（Bazett）
QT/√RR
QTc（Fridericia）
QT/∛RR
QTc（Framingham）
QT + 154·(1 − RR)
窦性心率
心动过缓 < 60， 正常 60–100， 心动过速 > 100 次/分
逸搏心率
交界性 40–60， 室性 20–40 次/分
快速性心律
SVT 150–250 /min（窄）， VT > 100 /min（宽）

方法

  1. 心率：节律规则时，用 300 除以两个 R 波之间的大格数，或用 1500 除以小格数；节律不规则时，数 6 秒内的 QRS 波群数并乘以 10。
  2. 节律：比较 R–R 间期。相等为规则；有重复规律为规律性不规则；完全没有规律为绝对不规则。
  3. P 波：II 导联中每个 QRS 之前是否都有直立的 P 波，且形态一致？注意寻找颤动波或锯齿状波、倒置的 P 波以及后面没有 QRS 的 P 波。
  4. PR 间期：从 P 波起点到 QRS 起点，正常为 0.12–0.20 s 且恒定。注意它是逐渐延长、在脱漏搏动之前保持固定，还是随机变化。
  5. QRS 时限：低于 0.12 s 为窄；0.12 s 或以上为宽。然后命名节律，QT 用 QTc = QT/√RR（Bazett），时间以秒计。

优先排序与委派

方法

  1. 问自己：如果什么都不做，什么会最快伤害患者。
  2. 应用 ABC（心脏骤停时为 C-A-B），然后是 Maslow 需求层次：生理需要先于安全，安全先于心理需要。
  3. 比较各选项：急性先于慢性，不稳定先于稳定，意外先于预期，全身性先于局部，并将每项发现与患者的基线对照。
  4. 除非是紧急情况，否则先评估再行动；然后选择其他步骤所依赖的那一步。
  5. 委派时核对五项正确：任务、情境、人员、指示和监督。评估、宣教和评价仍由注册护士负责。

2练习题

1.内外科护理：心血管与呼吸中等

Suspected pulmonary TB is being investigated. How are sputum samples usually collected?

  1. AA single sample after the first week of treatment
  2. BSeveral samples, ideally including early-morning sputum
  3. CA swab from the nose only
  4. DOne sample of saliva collected at any time of the day
2.内外科护理：心血管与呼吸困难

A 70-year-old man has a small abdominal aortic aneurysm found on screening and is placed under surveillance. Which advice is most important?

  1. AHave the aneurysm repaired immediately, whatever its size or growth rate
  2. BStop all blood pressure medicines to avoid low pressure
  3. CAvoid all exercise and lifting for the rest of his life to protect the aorta
  4. DStop smoking, control BP and seek help at once for sudden back pain
3.内外科护理：神经、内分泌与肾脏中等

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

  1. AThrough the nose (nasogastric)
  2. BThrough a fine-bore nasal tube
  3. CThrough the nose with a guidewire
  4. DThrough the mouth (orogastric)
4.内外科护理：神经、内分泌与肾脏困难

The nurse has four neurology patients. Which one needs to be seen first?

  1. AA patient with Guillain–Barré syndrome whose vital capacity is falling
  2. BA patient with Parkinson's disease whose next dose is due in one hour
  3. CA patient with a headache after a lumbar puncture this morning
  4. DA patient with multiple sclerosis who is tired after physiotherapy
5.内外科护理：消化、围手术期与肿瘤中等

Which task for a stable patient with an established ileostomy can usually be delegated to a trained healthcare assistant (nursing assistant)?

  1. ADeciding whether IV fluids are needed
  2. BTeaching the patient about high-output risks
  3. CAssessing the stoma for signs of necrosis
  4. DEmptying the pouch and measuring the output
6.内外科护理：消化、围手术期与肿瘤困难

Which history should most alert the nurse to a possible latex allergy before surgery?

  1. AA rash after taking amoxicillin as a child, with a family history of asthma
  2. BHay fever every spring since childhood
  3. CItching with bananas, avocado and kiwi, and many operations
  4. DFeeling sick after eating shellfish once
7.临床护理中等

Which side effects are common after high doses of salbutamol (albuterol)?

  1. AConstipation and urinary retention
  2. BBradycardia and drowsiness
  3. CHair loss and weight gain
  4. DTremor and a fast heart rate
8.临床护理困难

A nurse is teaching a patient who is starting warfarin. Which statement shows a need for further teaching?

  1. A"I will tell my dentist that I take warfarin."
  2. B"I will report black stools or unusual bruising."
  3. C"I will keep my INR blood test appointments."
  4. D"I can take aspirin if I get a headache."
9.实验室检查值与电解质中等

How should a patient collect a clean-catch midstream urine sample?

  1. ACollect urine from the toilet bowl after voiding into the toilet
  2. BCollect the very first urine of the stream directly in the sterile cup
  3. CFill the cup completely, then add tap water if there is not enough
  4. DClean the area, start voiding into the toilet, then catch the middle part
10.实验室检查值与电解质困难

A patient with heavy alcohol use and a poor diet has a hemoglobin of 10.1 g/dL (101 g/L), an MCV of 110 fL and a low red cell folate. Which explanation fits best?

  1. AFolate deficiency, made worse by a direct alcohol effect
  2. BAnemia caused by long-standing chronic kidney disease
  3. CIron deficiency from slow, chronic bleeding in the gut
  4. DThalassemia trait inherited from one of the parents
11.动脉血气分析解读中等

练习数值：Na⁺ 145 mmol/L，葡萄糖 28.3 mmol/L，尿素 2.9 mmol/L。计算血清渗透压 Osm = 2·Na⁺ + 葡萄糖 + 尿素，取最接近的整数。

Na⁺ 145 mmol/L葡萄糖 28.3 mmol/L尿素 2.9 mmol/L
Osm = mOsm/kg
12.动脉血气分析解读困难

练习数值：Na⁺ 143，Cl⁻ 113，HCO₃⁻ 11 mmol/L，白蛋白 36 g/L。求经白蛋白校正的阴离子间隙 AGc = AG + 0.25·(40 − 白蛋白)。

Na⁺ 143 mmol/LCl⁻ 113 mmol/LHCO₃⁻ 11 mmol/L白蛋白 36 g/L
AGc = mmol/L
13.心电图节律条带解读中等
II25 mm/s · 10 mm/mV窦性心动过速正常窦性心律一度房室传导阻滞窦性心动过缓

解读这条 II 导联心律条带。这是什么节律？点击你的答案。

II 导联，25 mm/s，10 mm/mV1 个小格 = 0.04 s，1 个大格 = 0.20 s条带长度 6 s
  1. 1窦性心动过速
  2. 2正常窦性心律
  3. 3一度房室传导阻滞
  4. 4窦性心动过缓
14.心电图节律条带解读困难
II25 mm/s · 10 mm/mV

这条 II 导联心电图显示二度房室传导阻滞 I 型（文氏现象）。共有多少个每组的 P 波数，包括未下传的那一个（n:(n − 1) 阻滞中的 n）？

II 导联，25 mm/s，10 mm/mV1 个小格 = 0.04 s，1 个大格 = 0.20 s条带长度 6 s
每组的 P 波数 =
15.优先排序与委派中等

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

  1. A“I will use my reliever inhaler and get emergency help straight away.”
  2. B“I will stop all my inhalers until the reading is back up.”
  3. C“I will wait until tomorrow morning to see if the reading gets better on its own.”
  4. D“I will go for a short run to open up my lungs.”
16.优先排序与委派困难

A patient takes lithium. Which statement shows a need for further teaching?

  1. A“I will drink enough fluid every day.”
  2. B“I will keep my daily salt intake about the same as usual.”
  3. C“I will take ibuprofen every day for my headaches.”
  4. D“I will go for my blood tests as planned.”

3溶液

1.内外科护理：心血管与呼吸

答案: B · Several samples, ideally including early-morning sputum

为什么是这个答案

Usually three sputum samples, including an early-morning sample, are sent for smear microscopy, culture and molecular testing. Deep coughed sputum, not saliva, is needed. Samples are collected before treatment where possible and in a way that limits exposure to others.

答案

B · Several samples, ideally including early-morning sputum
2.内外科护理：心血管与呼吸

答案: D · Stop smoking, control BP and seek help at once for sudden back pain

为什么是这个答案

Small aneurysms are usually monitored with regular ultrasound, with repair considered when they reach a threshold size or grow fast. Stopping smoking slows growth, and BP and cardiovascular risk are managed. Sudden abdominal or back pain may mean rupture and needs emergency care.

答案

D · Stop smoking, control BP and seek help at once for sudden back pain
3.内外科护理：神经、内分泌与肾脏

答案: D · Through the mouth (orogastric)

为什么是这个答案

A tube passed through the nose could enter the cranial vault through the fractured skull base. An orogastric route avoids this. Nasal suction and nose blowing are also avoided.

答案

D · Through the mouth (orogastric)
4.内外科护理：神经、内分泌与肾脏

答案: A · A patient with Guillain–Barré syndrome whose vital capacity is falling

为什么是这个答案

A falling vital capacity and weak cough in Guillain–Barré syndrome warn of respiratory failure, which may need ventilation. The other patients have expected or less urgent problems.

答案

A · A patient with Guillain–Barré syndrome whose vital capacity is falling
5.内外科护理：消化、围手术期与肿瘤

答案: D · Emptying the pouch and measuring the output

为什么是这个答案

Emptying and measuring output is a routine task. Assessment of the stoma, teaching and decisions about treatment remain with the registered nurse, who reviews the recorded output.

答案

D · Emptying the pouch and measuring the output
6.内外科护理：消化、围手术期与肿瘤

答案: C · Itching with bananas, avocado and kiwi, and many operations

为什么是这个答案

Latex–fruit syndrome links latex allergy with foods such as banana, avocado, kiwi and chestnut. Repeated exposure, for example through many operations or catheters, also increases risk.

答案

C · Itching with bananas, avocado and kiwi, and many operations
7.临床护理

答案: D · Tremor and a fast heart rate

为什么是这个答案

Salbutamol is a beta2-agonist and can cause tremor, tachycardia and palpitations. High doses can also lower serum potassium.

答案

D · Tremor and a fast heart rate
8.临床护理

答案: D · "I can take aspirin if I get a headache."

为什么是这个答案

Aspirin and other NSAIDs increase the bleeding risk with warfarin, so patients should ask before taking any new medicine. Paracetamol (acetaminophen) is usually the safer choice for simple pain.

答案

D · "I can take aspirin if I get a headache."
9.实验室检查值与电解质

答案: D · Clean the area, start voiding into the toilet, then catch the middle part

为什么是这个答案

Cleaning the urethral area and discarding the first part of the stream reduce contamination from skin and urethral bacteria. The inside of the sterile container must not be touched, and the sample should reach the laboratory promptly.核对依据: Clean catch urine sample · MedlinePlus (NIH) (2024)

答案

D · Clean the area, start voiding into the toilet, then catch the middle part
10.实验室检查值与电解质

答案: A · Folate deficiency, made worse by a direct alcohol effect

为什么是这个答案

Poor diet and alcohol reduce folate intake and absorption, causing macrocytic anemia, and alcohol itself also raises the MCV. Iron deficiency and thalassemia cause small cells. Folate is replaced after B12 deficiency is excluded, and thiamine is also commonly given.核对依据: Folate-deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2026)

答案

A · Folate deficiency, made worse by a direct alcohol effect
11.动脉血气分析解读

答案: Osm = 321 mOsm/kg

衍生数值：计算所得的血清渗透压为 2·Na⁺ + 葡萄糖 + 尿素，各值均以 mmol/L 计（葡萄糖和 BUN 以 mg/dL 计时为 2·Na⁺ + 葡萄糖/18 + BUN/2.8）；正常约为 275–295 mOsm/kg。P/F 比值是 PaO₂ 除以以小数表示的 FiO₂。海平面的肺泡氧分压为 PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg，A–a 梯度为 PAO₂ − PaO₂。

计算所得的渗透压

Osm = 2·145 + 28.3 + 2.9 = 321.2 ≈ 321 mOsm/kg

答案

Osm = 321 mOsm/kg
12.动脉血气分析解读

答案: AGc = 20 mmol/L

预期代偿：代谢性酸中毒时，温特公式预测 PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg；实测值高于该范围提示合并呼吸性酸中毒，低于该范围提示合并呼吸性碱中毒。阴离子间隙 AG = Na⁺ − (Cl⁻ + HCO₃⁻)，正常约为 8–12 mmol/L，用于区分高阴离子间隙与正常阴离子间隙代谢性酸中毒；低白蛋白会掩盖升高的间隙（白蛋白低于 4.0 的部分，每 g/dL 加 2.5）。Δ 比值 (AG − 12)/(24 − HCO₃⁻) 约在 0.8 到 2 之间符合单纯高间隙酸中毒（有些教材用 1 代替 0.8），低于此范围提示合并正常间隙酸中毒，高于 2 提示合并代谢性碱中毒。

阴离子间隙

AG = 143 − (113 + 11) = 19

白蛋白校正

19 + 0.25·(40 − 36) = 20 mmol/L

答案

AGc = 20 mmol/L

校正后高于约 12：阴离子间隙升高。

13.心电图节律条带解读

答案: 一度房室传导阻滞

节律标准（II 导联）：窦性心律每个 QRS 之前都有直立的 P 波，PR 恒定为 0.12–0.20 s，QRS 狭窄：60–100 次/分为正常窦性心律，低于 60 为窦性心动过缓，高于 100 为窦性心动过速。心房颤动：无 P 波，基线呈颤动，R–R 绝对不规则。心房扑动：约 250–350 次/分的锯齿状扑动波，伴固定的传导比例，如 2:1 或 4:1。一度房室传导阻滞：窦性心律，PR 恒定且大于 0.20 s。交界性心律：窄 QRS，40–60 次/分，P 波缺失或倒置（PR 低于 0.12 s，或 P 波在 QRS 之后）。室性早搏（PVC）是提前出现的宽大（0.12 s 或以上）、形态怪异的 QRS，没有 P 波，T 波方向相反，通常有完全性代偿间歇；二联律是指每隔一个搏动就有一个室性早搏。

五个步骤

1. 心率：R–R = 19 个小格，1500 ÷ 19 ≈ 79 次/分。
2. 节律：规则，每个 R–R 均为 0.76 s。
3. P 波：直立，每个 QRS 之前各有一个，形态一致。
4. PR 间期：0.24 s，恒定，长于 0.20 s。
5. QRS：0.08 s，狭窄（低于 0.12 s）。

解读

一度房室传导阻滞

答案

一度房室传导阻滞
14.心电图节律条带解读

答案: 每组的 P 波数 = 3

房室传导阻滞：逐个标出 P 波，检查哪些 P 波后面跟着 QRS。一度：每个 P 波都下传，PR 恒定且大于 0.20 s。二度 I 型（Mobitz I，文氏现象）：PR 逐搏延长，直到一个 P 波未下传，然后周期重新开始（成组搏动）。二度 II 型（Mobitz II）：下传搏动的 PR 保持恒定，P 波突然不下传；QRS 常增宽。三度（完全性）阻滞：P 波和 QRS 波群各自规则但互相独立，PR 随机变化，心房率快于逸搏率（交界性逸搏 40–60 次/分，QRS 窄；室性逸搏 20–40 次/分，QRS 宽）。2:1 阻滞仅凭一份条带无法判断是 I 型还是 II 型。

逐个标出 P 波

P–P = 0.88 s，规则；每 3 个 P 波中有一个未下传

每组中的 PR

PR₁ = 0.16 s, PR₂ = 0.30 s

答案

每组的 P 波数 = 3

3:2 文氏阻滞。

15.优先排序与委派

答案: A · “I will use my reliever inhaler and get emergency help straight away.”

为什么是这个答案

A red-zone reading means a severe flare. The patient uses their quick-relief inhaler as in their action plan and seeks emergency care at once.

答案

A · “I will use my reliever inhaler and get emergency help straight away.”
16.优先排序与委派

答案: C · “I will take ibuprofen every day for my headaches.”

为什么是这个答案

NSAIDs such as ibuprofen can raise lithium levels and cause toxicity. Steady fluid and salt intake and regular blood tests help keep levels safe.

答案

C · “I will take ibuprofen every day for my headaches.”

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