肾积水护理查房课件

护理查房 肾积水 第十病区 Nursing Rounds Hydronephrosis Ward Ten 病史摘要 患儿,女,11月,于2009年03月03日因B超发 现左肾积水二月余而入院。患儿近日来无 发热,大便正常, 肾脏动态显象及GFR测定示 ：肾小球滤过率功能正常，左肾中度积水 因左输尿管上段狭窄所致。入院后完善 相关检查,予2009年3月05日在全麻下行左 肾盂输尿管成形术,术后生命体征平稳,于03 -07拔除导尿管，当日能自行解小便，无疼 痛。03-10拔除后腹膜负压吸引管，03-15 拔除输尿管支架管，现肾造瘘引流管固定 良好，引流通畅。 Brief history Children, female, 10 months old, was found left hydronephrosis by B ultrasonic and was hospitalized on March 3th, 2009 by B-February. Children has no fever, defecate is normal in recent days ,the Kidney dynamic manifestations and GFR determination display: the glomerular filtration rate is normal, renal water moderate because of the left upper segment ureter was narrow. After admission perfect relevant inspection,angioplasty of left renal pelvis and ureter on under general anesthesia March 5, 2009, with stable vital signs after surgery, catheter was removed on 03-07, it could urinate by itself with no pain, peritoneal suction tube was removed on 03-10, ureteral stent was removed on 03-15, nephrostomy drainage tube is fixed well, drainage is unobstructed. 护理评估 术前评估 (1)身体评估 (2)心理和社会支持状况 术后评估 (1)康复状况 (2)心理认知状况 (3)预后判断 Nursing assessment Preoperative Assessment (1) physical assessment (2) psychological and social support Postoperative evaluation (1) rehabilitation condition (2) Psychological Cognition (3) prognosis 护理诊断 1. 知识缺乏(家属):缺乏术前准备知识,注意事 项 2. 有感染的危险:与术后抵抗力下降，留置引 流管有关 3. 躯体移动障碍：与置引流管有关 4. 有皮肤完整性受损的危险：与长期卧床， 活动受限有关。 5.有体液不足的危险：与呕吐有关 6. 焦虑(家属):担心术后预后不良 Nursing Diagnosis 1. lack of knowledge (family): lack of preoperative preparation knowledge Notes 2. the risk of infection: related to postoperative decreased resistance, indwelling drainage tube 3. physical mobility barriers: related to the drainage tube 4. the risk of impaired skin integrity: related to long-term bed rest, limited mobility. 5. the risk of inadequate fluid: related to vomiting 6. anxiety (family): fear of poor prognosis after surgery 预期目标 1.术前家属掌握相关注意事项 2.患儿留置导尿期间无感染发生 3.患儿能适当进行活动 4.患儿皮肤完整性得到保护，不发生破 损。 5.患儿体液保持平衡，生命体征平 稳 6.患儿家属术后能够掌握有关配合治疗 护理的方法 Expected Outcomes 1. Family members have relevant preoperative precautions 2. Children with no infection occurred during the catheterization 3. Children can properly conduct activities 4. Children skin integrity protected, with no damaged. 5. Children humoral balance, vital signs smoothly 6. Childrens family can master relevant cooperate cure nursing methods postoperative 护理措施 Nursing measures 知识缺乏的护理措施 1. 评估家属的文化程度,接受能力 2. 患儿排尿或排便后,指导家属及 时清洗会阴部,保持会阴部清洁 3. 指导家属给患儿多饮水 4. 指导家属为患儿注意保暖,避免 呼吸道感染,以免延误手术 Nursing measures of lack of knowledge 1.To estimate family education, reception 2.To guide the family clean the genitalia in time to keep the perineum clean after childrens urination or defecation 3. To guide the family members to give children with drinking water more 4. to guide family members to keep warm, avoid respiratory infections for children, so as not to delay surgery 预防感染的护理措施 1. 观察患儿体温变化，每日测体温二次 2. 保持伤口敷料干燥清洁,避免污染 3. 妥善固定各根引流导管,防止扭曲折叠,保持引流通 畅。集尿袋每日更换,严格执行无菌操作。 4. 遵医嘱予呋喃西林液，聚维酮碘清洗消毒会阴。 5. 遵医嘱使用抗生素静脉滴注。 6. 指导家属合理喂养，加强营养。 7. 遵医嘱予静脉滴注抗生素 8. 给予患儿多喝水,起到自净作用 9. 病室空气负离子消毒，预防交叉感染。 Nursing measures to prevent infection 1.Observe children temperature changes, measure temperature twice daily 2 .Keep the wound clean and dry dressing to avoid contamination 3. To properly fix the root catheter, to prevent distortion of folding, maintaining unobstructed drainage. Urine collection bags change daily, implement the sterile operation strictly. 4. As physician directed use nitrofurazone solution, povidone-iodine perineal cleaning and disinfection. 5. As physician directed use Antibiotics intravenous drip. 6.To guide famliy rational feeding, strengthen nutrition. 7. As physician directed use intravenous antibiotics 8. To give children with drinking water more, in order to self- purification 9. Patients negative ion disinfection of room air to prevent cross- infection 躯体移动障碍的护理措施 1. 患儿活动时固定好输液管道，和穿刺 部位。 2. 指导家长协助患儿床上翻身及活动。 3. 妥善固定肾造瘘管,输尿支架管，导尿 管，后腹膜负压吸引管，各个导管标签 清楚。 4. 勿牵拉勿压迫,保持各根导管通畅,勿 折叠勿扭曲。 Nursing measures of body moving barrier 1. infusion in children with activities, fixed piping, and the puncture site. 2. To guide parents to help children with bed turn over and activities. 3. Properly fixed nephrostomy, urinary output frame tubes, ureters, retroperitoneal suction tubes, each tube label clearly. 4. Do not pull pressure to maintain patency of the catheters, do not distort the fold. 预防皮肤完整性受损的护理 1. 保持床铺干燥平整，会阴部垫尿布或 一次性横单。 2. 每班观察评估有无皮肤受损征兆如： 潮红，压痕。 3. 告知家属每日给患儿温水擦身，更换 清洁衣裤。 4. 会阴部妥善护理，防止大小便污染。 5. 告知家属经常给患儿翻身的重要性。 每2-4小时翻身一次。 Nursing of preventing skin integrity damaged 1. Keep bed drying level off, the perineum mat diapers or one-time horizontal list. 2. Observe whether skin damage assessment sign every shift such as: flush and creasing. 3. Notify family to brush with warm water, replace the clean pajamas. 4. perineum properly nursing, preventing urine pollution. 5. Notify family the importance for rolling over children often. rolling over it every 2-4 hours. 预防体液不足的护理 1. 遵医嘱按时完成输液，注意输液 速度，量，输液部位皮肤。 2. 观察患儿皮肤粘膜有无脱水表现 。 3. 准确记录24小时尿量。 4. 观察记录呕吐次数及呕吐物量。 5. 教会家属正确给患儿口服ORS 液。 Nursing of preventing humoral deficiency 1. As physician directed finish infusion, pay attention to infusion speed, quantity, infusion parts skin. 2. Observation children skin mucosa whether dehydrated 3. Accurately record 24-hour urine volume. 4. Observation records vomiting and frequency vomit a quantity. 5. Teach family to give children with oral ORS fluid. 家属焦虑的护理措施 1. 评估家属的焦虑原因及程度 2. 经常与家属沟通,介绍有关手术 效果及预后情况,取得家属信任 3. 教会家属观察尿液颜色及性状。 4. 教会家属准确计算尿量并记录。 5. 建议穿质地柔软的内衣裤，用棉 质尿不湿。 Nursing of families anxiety measures 1. Assess familys anxiety reasons and degree. 2. communication with the family often, to introduce the operation effect and prognosis, obtains the family trust. 3. To