胸外科护理查房最终版.ppt

SpontaneousPneumothorax,Thoracicsurgerynursingwardround,Thespeaker:WuhanPolytechnicUniversity,自发性气胸,Groupdivisionoflabor,Case-甄媛媛Etiologyandclassification-于广平马莹Clinicalmanifestations-蒋娟Auxiliaryexaminationand-桓秀山刘严逸夫TherapeuticprinciplesNursingmeasures-毛雅琴潘娟王辉Healtheducation-李飘飘赵娟,CASE,PatientYuWeichengmale17yearsWithpainatleftchestanddifficultybreathing,chestdistress10days.Pastmedicalhistory:Alwaysbodyhealth,denyhistoryofotherseriousdiseasesanddrugallergy.Historyofpresentdisease:Withoutanyobviouscause,hefeltpainattheleftchestanddifficultybreathing,chestdistress10daysago.Nofever,lowhead,cough,haemoptysis,lackofpower,nightsweatandsoon.Atfirstdidnotpayattentiontothese,butsymptomsfornoease.Achestradiographyshowedthattheleftlungtissuecompressionby85%.Physicalexamination:T37.3,P96/min,R20/min,BP140/80mmHgIntelligenceclear,trachealatthecenterofneck.Theleftbreathsoundsalittleweak.Diagnosticexamination:WBC11.4109,N8.05,L18.1Admissiondiagnosis:SpontaneousPneumothorax,病例,患者：余炜成，男，17岁左侧胸痛、胸闷伴呼吸困难10天。既往史：既往体健，否认其他重大疾病病史及药物过敏史。现病史：患者于10天前无明显诱因，自感左侧胸痛、胸闷，偶有呼吸困难，无发热、咳嗽、咳痰、咯血、心慌、乏力、盗汗、声嘶等不适。起初未予注意，症状持续无明显缓解，胸片检查，提示：左侧肺组织压缩85%左右。体格检查：T37.3,P96次/分,R20次/分,BP140/83mmHg,神智清楚，皮肤巩膜无黄染，气管居中，左侧呼吸音稍弱，未明显干湿罗音。辅助检查：WBC11.4109,N8.05,L18.1入院诊断：左侧自发性气胸,Etiologyandclassification,病因及分类,THESPEAKER:于广平,Thecauseofspontaneouspneumothorax,ClassificationofoneSpontaneouspneumothoraxTraumapneumothoraxArtificialpneumothoraxClassificationoftwoClosedpneumothoraxOpenpneumothoraxTensionpneumothorax,Thecauseofspontaneouspneumothorax,Whenatriggercausesalveolarpressurerisesharply,lesionsofthelungandpleuralruptureoccurs,thepleuralcavityiscommunicatedwiththeair,airflowwillflowintothethoraxleadtotheformationofspontaneouspneumothorax.,Clinicalmanifestations,临床表现与体征蒋娟,Clmicalmanifestations（临床表现）：,Suddenchestpain（突然发生胸痛），difficultyinbreathing（呼吸困难），chesttightness(胸闷)，inseverecasesirritability、profusely、cyanosis（严重者烦躁不安、大汗、紫绀）acceleratedrespiration（呼吸加快），pulsebreakdownandevendeath（脉搏细数甚至死亡）。,Signs（体征）：,Frachealshifttothecontralateral（气管向健侧移位）。Ipsilateralchestfull（患侧胸部饱满）weakeningordisappearanceofresiratorymotion（呼吸运动减弱或消失）。Percussiondrumsound（叩诊呈鼓音），fremitusanddecreasedbreathsound（语颤呼吸音减弱）。,11,Auxiliaryexamination,辅助检查,THESPEAKER:桓秀山,12,Auxiliaryexamination,1.X-ray2.CT3.Pleuralcavityangiography4.Thoracoscopic,13,Auxiliaryexamination,1.X-rayexaminationisthemostreliablemethodofdiagnosisofpneumothoraTypicalpneumothoraxX-rayfindingsofthepneumothoraxpartthroughthebrightnessincrease,nomarkings,thepulmonaryhilaratrophy,higherdensity,andtheedgeofthevisiblehairline-likevisceralpleurashadow;Contralaterallungcompensatoryemphysema,lungmarkings;TracheawithConcurrentpleuralfluidorblood,fluidlevelscanbeseen.mediastinalshifttothecontralateral;,X线检查是诊断气胸最可靠的方法。典型的气胸X线表现为气胸部分透亮度增加，无肺纹理，肺向肺门萎缩，密度增高，其边缘可见发线样脏层胸膜阴影；健侧肺可有代偿性肺气肿，肺纹理增粗；气管与纵隔可向健侧移位；并发胸水或血液时，可见到液平面。,14,Auxiliaryexamination,2.CTIsmoresensitivetothediagnosisofasmallamountofgasinthepleuralcavityClearlyshowsasmallamountofpneumothoraxandlungtissueoverlappingpartsofthepneumothorax;Location,extentdeterminethepleuralproductgas;Mayfoundemphysemablister;Easytoidentifythelimitationsofpneumothoraxandlungbullae.,2.CT对胸腔内少量气体的诊断较为敏感可清晰地显示少量气胸和与肺组织重叠部位的气胸；确定胸腔积气的位置、程度；有可能发现肺气肿疱；易于鉴别局限性气胸和肺大疱。,15,3.Pleuralcavityangiography,Thismethodcanclearthepleuralsurface,easytoclearthecauseofpneumothorax.Whenthelungcompressionareain30%40%whenthecontrastisappropriate,bullaislobeprofilewithinasingleormultiplecysticlowdensityshadow;abubblesprayperformanceforpleuralphenomenon,especiallywhenpatientswithcough,duetointrapulmonarypressureincreases,thisphenomenonismoreobvious.,此方法可以明了胸膜表面的情况，易于明确气胸的病因。当肺压缩面积在30%40%时行造影为宜，肺大泡表现为肺叶轮廓之内单个或多个囊状低密度影；胸膜裂口表现为冒泡喷雾现象，特别是当患者咳嗽时，由于肺内压增高，此征象更为明显。,16,4.Thoracoscopic,Thoracoscopycaneasilydetectpneumothoraxetiology,flexibleoperation,canreachtheinterlobarfissure,apex,hilar,almostnoblindspots,observethevisceralpleurawithnorips,pleurawithoutbullaeoflungandchestcavitywithnoadhesivejoint.,胸腔镜可以较容易地发现气胸的病因，操作灵活，可达叶间裂、肺尖、肺门，几乎没有盲区，观察脏层胸膜有无裂口、胸膜下有无肺大泡及胸腔内有无粘连带。,17,Principlesoftreatment,治疗原则,18,Principlesoftreatment,1.Conservativetreatment2.Exhausttreatment3.Operationtreatment,19,1.Conservativetreatment,MainlyapplicabletothestabilityofasmallamountofclosedpneumothoraxSpecificmethods:strictbedresanalgesicdrugs.t,oxygen,bronchodilator.bronchospasm,grantingthesedativeand,主要适用稳定型小量闭合性气胸具体方法：严格卧床休息、给氧，支气管痉挛者使用支气管扩张剂，酌情给予镇静镇痛等药物。,20,2.Exhausttreatment,1.张力性气胸病情危急可行紧急排气2.胸腔穿刺抽气适用小量气胸，呼困较轻，心肺功能尚好的闭合性气胸。3.胸腔闭式引流适用不稳定气胸，呼困明显，交货张气胸，反复发生气胸的病人,Tensionpneumothoraxincriticalconditionfeasibleemergencyexhaust2pleuralpunctureexhaustapplyasmallamountofpneumothorax,respiratorydifficultieslighter,theclosedpneumothoraxheartandlungfunctionisstillgood.Closedthoracicdrainageunstablepneumothoraxapplicablecalltrappedobvious,deliveryZhangpneumothorax,recurrentpneumothoraxpatients,21,Operationtreatment,ThoracoscopicandThoracotomy,22,胸腔镜通过二至三个“钥匙孔”，在电视影像监视辅助下完成过去由传统开胸进行的操作手术。其本质是用“腔镜”做手术，相对于传统的开刀手术具有创伤小、恢复快、住院时间短等技术特点,ThoracoscopicCompleteoperatingtraditionalthoracotomysurgeryinthepasttwotothreekeyholeintheTVimagemonitoringaid.Byitsverynatureislaparoscopicsurgery,relativetotraditionalopensurgerywithlesstrauma,recoveryfaster,shorterhospitalstayandothertechnicalfeatures,23,外科手术治疗手术的目的是结扎或切除肺大疱、或胸膜修补、或对壁层胸膜切除或摩擦促使其与脏层胸膜粘连，防止气胸复发。,SurgicaltreatmentThepurposeofsurgicalligationorresectionofbullae,orpleuralrepairorresectionorfrictionparietalpleuraprocureitsvisceralpleuraladhesions,andtopreventtherecurrenceofpneumothorax.,24,Nursingdiagnosisandmeasures,THESPEAKER:王辉、毛雅琴、潘娟,护理诊断,Nursingdiagnosis,painatchest),Theriskofinfection,Activitieswithoutendurance,nutritionaltered,knowledgedeficit,护理措施,Nursingmeasures,1.ImpairedGasexchange,Measures：a.ObservepatientsTemperature，breathing，pulse，bloodpressureb.Observepatientsbonythoraxmovementandtherangoftherespiratorynotion,andauscultationpatientsbreathingsoundc.Keepthethoraciccloseddrainagesystemfixed,beclosedtightlyandbeunobstructed.(保持闭式引流装置固定、密闭等）d.Observethefluctuationofthewatercolumn,colore.Tochangethethoracicregularity,andpreventretyogradeinfection,1.Positivepressurecontinuousexhaustmethod.,2.Continuesthenegativepressureexhaustmethod.,Drainagebottle,Theriskofinfection,1.Tokeeprespiratorytractunobstructedpromptlyeliminatesputum2.Dooralcare,preventsecondaryinfection3.Keepcloseddrainagesystemsterile,Activitieswithoutendurance,a.Completebedrest,takehalf-clinostatism.b.Askthepatienttoavoidtoholdhisbreathandtocoughintensity.c.Givinglowflowoxygen.,Malnutrition,1.Givehighprotein2.Highvitamin3.Lighteasytodigestfood,Nursinganalysis,problems,Nursingkeypoints,Thoraciccloseddrainageofnursing（胸腔闭式引流的护理）,purpose：1.Thedischargepneumatosis,effusion,hemorrhage2.Promotelungcomplexzhang3.KeepmediastinalnormalpositionThelocationofthecatheter:1.Thegaswithsidesecondintercostalclaviclemiddle2.Liquidwithside7,8ribclearanceofaxillarylineandaxillarylineplaceafter3.ThepusbymeansofxlineinthevomicalowestplaceNursingkeypoints,胸腔闭式引流的护理,38,HealthEducation,THEPEAKER:李飘飘、赵娟,39,1.Thecause,typeandcureofPneumothorax2.Thepurposeofthoraciccloseddrainageandattention3.thepurposeofstartingexerciseearly4.Lungfunctionwereexercisepurposeandmethod5.dietfordiscovery6.Convalescencerehabilitationactivitiesofthemethodandthemattersneedingattention7.dischargeguidance,40,Earlyactivitiesofthemethodsandsignificance,promotethewholebodyfunctionrecoveryPromotethebloodcirculationPromotegastrointestinalperistalsisPromoteurinationfunctionrecovery,41,Methods:,1.deepbreath,sputum,assistkeelover,takeback,andsmoothbloodpressureaftertakehalfdecubitus;2.Thenextdayhelpedbythesidesofthebed,onthebedcanbeactivitiesduringtheupperlimbs,andflexionandexercise;3.4dayslatergraduallyoffthebedactivities,firstinbedsidestand,andgraduallyintheindoorwalkslowly,anddiscretionarygooutforawalk4.seriouslyillweakandcomplicationsandactivityrestrictionpatientscantgetupearly,butstillneedtoadheretothebedactivities.,Lungfunctionwereexercisepurposeandmethod,1).lungfunctionexercisetoletthelunglobefullexpansion,toincreasealveolarsurfacetension,increasethevitalcapacity,improvelungfunction2).coughtrainingpreven