04-29胆囊结石英语查房(项娅妮).doc

Liu nurse: Welcome warmly the nursing department leadership nurses, nursing sisters to guide the work of our department. The contents is patients care of Gallbladder stones with diabetes. As limited, please give us help, thank you! here is the responsibility of nurse Xiang Yani to describe the condition:刘护士长：热烈欢迎护理部领导、各位护士长、护士姐妹们来我科指导工作，我们查房的内容是胆囊结石合并糖尿病的护理，由于水平有限，准备时间不充分，不足之处，请给以帮助指导。下面请护士项娅妮介绍病情:Xiang Yani: Good afternoon,Teachers, I am a level one nurse Xiang Yani,I was the day of the duty nurse, here I introduce the patients condition.项娅妮：各位老师，大家下午好，我是NI级护士项娅妮，同时也是患者的责任护士，下面我为大家介绍病人情况。Nursing roundThe Nursing of the Gallbladder stones with diabetes护理查房胆 囊 结 石 合 并 糖 尿 病 的 护 理 Introduction: Patients with Sun Zhimings disease, male, 57 years old, the number of hospitalized patients: 601498 in March 30, 2015 11:20 entered the ward, with epigastric fullness discomfort over January. Patient with gallbladder stone and cholecystitis income my division. Go to already healthy patients. There are a total of more than 30 years history of smoking and drinking, no drug allergy and other allergic history. More than 40 years ago measles caused by hypertension is blind in the left eye, more than three years, regularly taking metoprolol, ale, Feiluodiping Huanshi Pian, aspirin, aspirin has been disabled for eight days. More than one year for diabetes, insulin, acarbose, pre hospital outpatient B ultrasound tip of gallbladder stones.病情简介：患者孙志明，男，57岁，住院号：601498。患者于2015年3月30 日11:20步入病房，主诉“上腹饱胀不适一月余”。门诊以胆囊结石并胆囊炎收入我科,患者有吸烟饮酒史30余年，已戒烟酒一年。无药物过敏及其他过敏史。40余年前因“麻疹”致左眼失明，右眼视力正常。高血压病史三年余，能遵医嘱按时服用倍他乐克、阿乐、非洛地平缓释片、阿司匹林等药物，阿司匹林已停用八天。糖尿病一年余，曾在内分泌科治疗，能自行注射甘精胰岛素，口服阿卡波糖，入院前门诊B超提示胆囊结石。 T36.2, P72 times / min, BP110/70mmHg. The spirit of good, normal appetite, physical strength is normal, normal sleep, urine normal, no significant changes in body weight, abdominal palpation: abdomen soft, no muscle tension, without apparent tenderness and rebound tenderness, did not touch bag piece, the lower bound of untouched liver, spleen was not palpable. Limb muscle strength is normal, no sensory disability, ADL score of 85 points, scoring 30 points of skin. Fall / bed fall risk factor score of 10 points, For nutrition score 14 points.Were treated with anti infection, protecting stomach, blood glucose control therapy (0.9% sodium chloride 100ml+ ceftazidime intravenous infusion of 2G for two times a day,0.9% sodium chloride 100ml+pantoprazole 80mg intravenous drip once a day. Subcutaneous injection of insulin before breakfast and dinner 4U and 9U) .laboratory examination, fasting blood glucose 7.26 tendency for L, prescribed to detect blood sugar, March 30, heart colour to exceed tip: left ventricular diastolic function to reduce, please heart medicine consultation Suggestions: blood pressure is normal, no special treatment; On March 31, CT tip: right lung bronchiectasis with infection, respiratory medicine consultation, please advice: after anti-infection treatment; On April 4, please endocrinology consultation Suggestions: in diabetes diet, hypoglycemic therapy, monitoring of blood sugar.April 5 fingers on an empty stomach blood sugar control in tendency for 7.2 / L, two hours after meals tendency for 11.0 / L respectively, and the tendency for 8.7 / L, the tendency for 8.5 L. April 6, fasting blood sugar tendency for 6.7 / L finger, two hours after meals were 11.7 tendency L12.9 tendency L9.3 tendency/L. Is surgery on April 7, preoperative preparation, on April 7, finger blood sugar on an empty stomach tendency for 7.9 L.查体：T36.2，P72次/分，R19次/分，BP110/70mmHg。精神食欲可，大小便正常，体重75KG，无明显增减，腹部触诊：腹软，无明显压痛、反跳痛、肌紧张，莫非氏征阴性。四肢肌力正常，无感觉障碍，ADL评分100分，皮肤评分30分。跌倒/坠床危险因子评分10分，营养评分为14分。入院后给予抗感染、护胃、控制血糖等治疗。完善术前相关检查，肺功能、胸片、心电图均正常，实验室检查基本正常，空腹血糖为7.26mmol/L,遵医嘱检测手指血糖。3月30日心脏彩超提示：左室舒张功能减低，请心内科会诊建议：血压正常，暂无特殊处理；于3月31日CT提示：右肺支气管扩张伴感染，请呼吸内科会诊后建议：行抗感染治疗；4月4日请内分泌科会诊建议：进糖尿病饮食，降糖治疗，监测血糖。4月5日空腹手指血糖控制在7.2mmol/L，三餐后两小时分别为11.0mmol/L，8.7mmol/L，8.5mmol/L。4月6日空腹手指血糖6.7mmol/L，三餐后两小时分别为11.7mmol/L，12.9mmol/L，9.3mmol/L。拟于4月7日手术行术前准备，4月7日空腹手指血糖为7.9mmol/L. On April 7th 08:00 under general anesthesia downlink laparoscopic gallbladder excision (LC), finish operation in, and get back to the room, postoperative ecg monitoring, oxygen inhalation, the diet, anti-infection, protecting stomach, protect liver, nutrition support treatment, such as for postoperative ADL score 20 points, catheter slippage risk factor score for 1 minute, fall/drop of bed risk factor score of 12 points, nutrition score of 12 points, pain score is 6 points, 28 points for skin pressure sores score. Stop on April 8, ecg monitoring and oxygen for ADL score 85 points, fall/drop bed risk factor score of 10 points, pain score of 3 points, catheter slippage risk factor score of 0. On April 9 semi-liquid diet is administered after the anus exhaust, for nutrition score 14 points, ADL score of 100 points, to cure the hospital on April 13, 2015.于4月7日08:00在全麻下行腹腔镜下胆囊摘除术(LC术），于10:20术毕回房，麻醉清醒，切口敷料清洁干燥。术后给予心电监护，氧气吸入，禁饮食，抗感染，护胃，护肝，营养支持等治疗，术后ADL评分为20分，导管滑脱危险因子评分为1分，跌倒/坠床危险因子评分为12分,营养评分为12分,疼痛评分为6分,皮肤压疮评分为26分.于4月8日生命体征平稳，停止心电监护及氧气,ADL评分为85分，跌倒/坠床危险因子评分为10分，疼痛评分为3分，皮肤压疮评分为28分，导管滑脱危险因子评分为0分。于4月9肛门排气后给予半流质饮食，营养评分为14分，ADL评分为100分,于2015年4月13日治愈出院。Wang Qing: Good afternoon, Teachers, I am a level one nurse Wang Qing, I am here to brief you on the Etiology and pathology of Gallbladder stones .王青：各位老师，下午好，我是N1级护士王青，现在由我为各位介绍胆囊结石的病因病理。Etiology and pathology: Gallstone by the composition of the stones into cholesterol gallstones, bile pigment calculus, mixed stones. Gallbladder stones are cholesterol stones or mixed stones to cholesterol dominated. The etiology of gallbladder stone is very complex, is the result of comprehensive factors. At present considered abnormal biliary infection and metabolic composition of bile and changed the physicochemical properties, leading to bile cholesterol is satiety, easy precipitation and crystallization and the formation of stones. In addition, there may be a contributing factor in patients with gallstone nuclear in bile formation, which produce large amounts of mucus glycoprotein promote nucleation and stones. Gallbladder contraction function decreased, formed in the gallbladder cholestasis also conducive to stone.病因病理：胆石按结石的成分分为胆固醇结石、胆色素结石、混合结石。胆囊结石多是胆固醇结石或者是以胆固醇成分为主的混合性结石。胆囊结石的病因十分复杂，是综合性因素所致。目前认为是胆道感染和代谢异常因素使胆汁的成分和理化性质发生了改变，导致胆汁中的胆固醇呈过饱状态，易于沉淀析出和结晶而形成结石。另外，胆囊结石病人的胆汁中可能存在一种促成核因子，可分泌大量的黏液糖蛋白促使成核和结石的形成。胆囊收缩功能降低，胆囊内胆汁淤积也利于结石的形成。Feng Li: Good afternoon, Teachers,I am a level one nurse Feng Li, I am here to brief you on the Clinical manifestation of Gallbladder stones.冯丽：各位老师，下午好，我是N1级护士冯丽，现在由我为各位介绍胆囊结石的临床表现。Clinical manifestation: 60% patients without obvious clinical manifestations, to check the body or line other abdominal operation was found. Also can behave for biliary colic or acute, chronic cholecystitis. The symptoms occur or not and the size, parts of stones, whether complicated with infection, obstruction and gallbladder function. The main clinical manifestations of symptomatic gallbladder stone with:1.Indigestion and other gastrointestinal symptoms: most of the patients only after eating especially after eating greasy food, presented with epigastric or right upper abdominal pain, fullness, belching, hiccup, is often misdiagnosed as stomach.2.Biliary colic is the typical performance: when the meal, after eating greasy food gallbladder contraction or sleep posture change, shift and calculus incarcerated in the gallbladder ampulla or neck of gallbladder emptying of gallbladder, bile is blocked, pressure within the gallbladder contraction and the occurrence of angina pectoris, strength. Pain in the upper abdomen or right upper quadrant, paroxysmal, may apply to the scapular and the back radiation, accompanied with nausea, vomiting.3.Gallbladder hydrops of gallbladder stones: long-term incarceration but not merge infection of bile in the gallbladder mucosa of bile pigment is absorbed, and secrete mucus substances caused hydrops of gallbladder. Gallbladder accumulated liquid is colorless, known as the white bile.4.Mirizzi syndrome: continued incarceration and oppression of Hartmanns gallbladder and neck a large stone, can cause stricture of common bile duct or gallbladder bile duct fistula, and repeated attacks of cholecystitis.5.Other: (1) small stones by bile duct enter and stay in the common bile duct to form secondary biliary calculi. (2) into the common bile duct calculi can damage or incarcerated in the ampulla cause pancreatitis by sphincter of oddi. (3) because of the stone compression can cause cholecystoduodenal fistula stones can also through cystic platoon to the small intestine caused by intestinal obstruction. (4) repeated stimulation of stone and inflammation can induce临床表现：60的病人无明显临床表现，在体检或行上腹部其它手术而被发现。也可表现为胆绞痛或急、慢性胆囊炎。症状出现与否和结石的大小、部位，是否合并感染、梗阻及胆囊的功能有关。有症状的胆囊结石主要临床表现有：1、 消化不良等胃肠道症状：大多数病人仅在进食后特别是进食油腻食物后，出现 上腹部或右上腹部隐痛不适、饱胀、伴嗳气，呃逆等，常被误诊为“胃病”。2、 胆绞痛是其典型表现：当饱餐、进食油腻食物后胆囊收缩，或睡眠体位改变，结石移位并嵌顿于胆囊壶腹部或颈部，胆囊排空胆汁受阻，胆囊内压升高，胆囊强力收缩而发生绞痛。疼痛位于上腹部或右上腹，呈阵发性，可向肩胛部和背部放射，多伴恶心、呕吐。3、 胆囊积液：胆囊结石长期嵌顿但未合并感染时胆汁中的胆色素被胆囊黏膜吸收，并分泌黏液性物质而致胆囊积液。胆囊积存的液体呈透明无色，称为“白胆汁”。4、 Mirizzi综合征：持续嵌顿和压迫胆囊壶腹部和颈部较大的石头，可引起胆总管狭窄或胆囊胆管瘘，以及反复发作的胆囊炎、胆管炎及梗阻性黄疸。5、 其他：（1）小的结石可通过胆管进入并停留于胆总管内形成继发性胆管结石。（2）进入胆总管的结石可通过oddi括约肌损伤或嵌顿于壶腹部引起胰腺炎。（3）因结石压迫可致胆囊十二指肠瘘，结石还可以经胆囊排至小肠引起肠梗阻。（4）结石及炎症的反复刺激可诱发胆囊癌变。Shao Yanfu: Good afternoon, Teachers,I am a level one nurse Shao Yanfu, I am here to brief you on the Differential diagnosis.邵彦复：各位老师，下午好，我是N1级护士邵彦复，现在由我为各位介绍疾病的鉴别诊断。Differential diagnosis1.Chronic gastritis: the main symptoms of epigastric bulging pain, belching, loss of appetite and indigestion history. Fiberoptic endoscopic examination in diagnosis of chronic gastritis and important, can be found in gastric mucosal edema, hyperemia, mucous membrane color into yellow white or pale yellow.2.Peptic ulcer: a history of peptic ulcer, upper abdominal pain and diet related chronic cholecystitis and gallbladder stones, and is often increased pain after eating, especially the consumption of high fat foods. Ulcer disease, often in the spring and autumn acute, chronic cholecystitis and gallstone incidence at night. Barium meal examination and gastroscopy fiber has obvious diagnostic value.3.Chronic pancreatitis: often acute pancreatitis sequela, the upper abdominal pain to the left shoulder and back radiation, X-ray sometimes visible pancreatic calcification or pancreatic lithiasis. Conclusions Duodenoendoscopy and retrograde cholangiopancreatography has some value in the diagnosis of chronic pancreatitis.4.Gallbladder cancer: a short history of illness development is rapid, more persistent jaundice,right upper quadrant abdominal pain is persistent, symptoms of most patients in the right costal margin hard lumps, B ultrasound examination can help the diagnosis of CT.5.Hepatocellular carcinoma: primary liver cancer such as right upper quadrant or upper abdominal pain has been late, at this time often can touch swollen and nodular liver. B ultrasound examination and CT examination can discover the liver tumor, positive alpha fetoprotein.鉴别诊断1、慢性胃炎：主要症状为上腹闷胀疼痛，嗳气，食欲减退及消化不良史。纤维胃镜检查对慢性胃炎的诊断极为重要，可发现胃粘膜水肿、充血、粘膜色泽变为黄白或灰黄色。2、消化性溃疡：有溃疡病史，上腹痛与饮食规律有关，而胆囊结石及慢性胆囊炎往往是进食后疼痛加重，特别是进食高脂肪食物。溃疡病常在春秋季节急性发作，而胆石性慢性胆囊炎多在夜间发病。钡餐检查及纤维胃镜检查有明显的诊断价值。3、慢性胰腺炎：常为急性胰腺炎的后遗症，其上腹痛向左肩背部放射，线片有时可见胰腺钙化影或胰腺结石。纤维十二指肠镜检查及逆行胆胰管造影对诊断慢性胰腺炎有一定价值。4、胆囊癌症：病史短病情发展快，多出现持续性黄疸，右上腹痛为持续性，症状明显时多数病人于右上腹肋缘下可触及硬性肿块，超检查可帮助诊断。5、肝癌：原发性肝癌如出现右上腹或上腹痛多已较晚，此时常可触及肿大并有结节的肝脏。超检查及检查可发现肝脏有肿瘤，甲胎蛋白阳性。Xiao Ting: Good afternoon, Teachers,I am a level one nurse Xiao Ting, I am here to brief you on the Auxiliary examination.肖婷：各位老师，下午好，我是N1级护士肖婷，现在由我为各位介绍疾病的辅助检查。Auxiliary examination: preferred B ultrasound,CT, MRI.Imaging examination is the main means of diagnosis of resistant to gallstone disease, ultrasonography is often the first-line examination means, can be found in gallbladder stones, gallbladder wall thickening of gallbladder contraction, the lack of accurate and reliable, the results are often. Check the other methods are often based on ultrasound examination results and determine whether or not a further. CT and MRI examination can show the stone, but the price is expensive, not as a routine clinical.辅助检查：B超（首选），CT 、MRI。影像学检查是当前耐以确诊胆囊结石病的主要手段，超声常是第一线的检查手段，可以发现胆囊内结石、胆囊壁增厚、胆囊缺乏收缩，结果常是准确可靠的。其他的检查方法则往往根据超声检查结果而确定是否采用进一步。CT及MRI检查亦能显示结石，但其价格昂贵，临床不作为常规检查。Tan Ting: Good afternoon, Teachers,I am a level one nurse Tan Ting, I am here to brief you on the Treatment principle.谈婷：各位老师，下午好，我是N1级护士谈婷，现在由我为各位介绍疾病的治疗原则。Therapeutic principles：1.Non-surgical treatment: fasting, gastrointestinal decompression, keeping water electrolyte and acid-base metabolism imbalance. Spasmolysis acetanilide, use of antibiotics, dissolve the stone or stone therapy.2.The surgical treatment： cholecystectomy is the treatment of choice for gallbladder stone. Operation methods are commonly used in resection and LC and open cholecystectomy. LC is monitoring using the TV screen, through 3-4 small abdominal poke a hole, laparoscopic will with the optical fiber and the necessary operation instrument is inserted into the abdominal cavity of cholecystec to my, is a minimally invasive operation. With less trauma, less pain, the patients with systemic and intraperitoneal local little disturbance, rapid postoperative recovery, shorter hospitalization time and has the advantages of small scar. 治疗原则： 1.非手术治疗：禁食，胃肠减压，纠正水电解质及酸碱代谢失衡。解痉止痛，应用抗生素，溶石或排石疗法。 2.手术治疗：胆囊切除是治疗胆囊结石的首选方法。常用的手术方式有开腹胆囊切除术和LC术。LC术是利用电视荧屏的监控下，通过个腹壁小戳孔，将带有光导纤维的腹腔镜及与之配套的手术器械插入腹腔进行胆囊切除术，是一种微创性手术。具有创伤小，痛苦轻，对病人全身及腹腔局部的干扰少，术后恢复快，住院时间短和遗留瘢痕较小等优点。Tian Fang: Good afternoon, Teachers,I am a level one nurse Tian Fang, I am here to brief you on the Indications of LC.田芳：各位老师，下午好，我是N1级护士田芳，现在由我为各位介绍LC术的适应症。Indications: 1. Gallbladder stones, recurrent clinical symptoms.2.Stone incarcerationin thegallbladder neckor bile duct,acuteepisodes can cause.3.Cholecystitis orgallbladdergangrene perforationof gallbladderof gallbladderstones,full,no function.4.Acute cholecystitisafter treatmentto alleviate the symptoms ofthe patients with operation indications.5.Theoperationwas well tolerated.适应症：1、胆囊结石反复发作，有临床症状。 2、结石嵌顿在胆囊颈部或胆管处，可致急性发作。 3、胆囊炎或胆囊坏疽穿孔，结石充满胆囊，胆囊无功能。 4、急性胆囊炎经过治疗后症状缓解有手术指征者。 5、对手术耐受良好者。Li Li: Good afternoon, Teachers,I am a level one nurse Li Li, I am here to brief you on the Indications of LC.李莉：各位老师，下午好，我是N1级护士李莉，现在由我为各位介绍LC术的禁忌症。Contraindication: 1. Suspected of gallbladder cancer. 2. Combined primary bile duct stone and bile duct stenosis. 3. Serious intra-abdominal infection and peritonitis. 4. Suspected intraperitoneal extensive adhesion. 5. Combined pregnancy. 6. Had a tendency to bleeding and coagulation dysfunction. 7. Have serious heart and lung function of important organs disorder unbearable general anesthesia, and provided withcardic pacemakre.禁忌症：1、 疑有胆囊癌变者。2、 合并原发性胆管结石及胆管狭窄者。3、 腹腔内严重感染及腹膜炎。4、 疑有腹腔广泛黏连者。5、 合并妊娠。6、 有出血倾向和凝血功能障碍者。7、 有严重心肺功能重要器官障碍而难以忍受全身麻醉者，以及安有心脏起搏器者。Yang Yuang: Good afternoon, Teachers,I am a level one nurse Yang Yuang,I am here to brief you on the complications.杨媛：各位老师，下午好，我是N1级护士杨媛，现在由我为各位介绍疾病的并发症。complications1.Gallbladder perforationoccurred inacutecholecystitis:onsetwithin 72 hours,moreorlessin thefirstepisodesof patients,such asabdominal pain,increasedduring the course ofgallbladderwas significantly increased,high feverand elevated white blood cell count,is highly suggestive ofperforation.2.Internal gallbladder fistula:the most commongallbladderduodenum fistula.In theprocess ofacute cholecystitis,gallbladderinflammationadhesion withadjacent organs,gallbladdergangrene,penetrating anditsvascular embolizationandulcerationand intestinaladhesion,resulting inthe gallbladderand intestinalcavityfistula formation.3.Others:acute pancreatitis,cancausechronic cholecystitis acute attackof subphrenic abscess,liver abscess,suppurativepylephlebitis,gangrene of gallbladder,cholangitisandsepticemia,hemoperitoneum.并发症一、胆囊穿孔：多发生在急性胆囊炎起病72小时内，多见多见于初次或发作次数较少的患者，如病程中腹痛加重、胆囊显著增大、高热和血白细胞计数增高，高度提示穿孔。二、胆囊内瘘：最常见的为胆囊-十二指肠瘘。在急性胆囊炎过程中，胆囊与邻近脏器发生炎症粘连，胆囊壁发生坏疽、穿透并使其与粘着的肠壁发生血管栓塞而破溃，导致胆囊与肠腔相通形成内瘘。三、其他：慢性胆囊炎急性发作尚可引起急性胰腺炎、膈下脓肿、肝脓肿、化脓性门静脉炎、胆囊坏疽、胆管炎、腹腔积血及败血症等。Xiang Yani: Teachers, according to the patients condition on admission raised the following nursing problems.项娅妮：各位老师，根据患者入院时的情况提出了以下的护理问题：护理问题及措施（Problems and measures for nursing）术前（Preoperative）P1:Potential adverse events: fall/drop of bed.（30/3 10:20项娅妮）I: 1, The head of a bed hangs warning labels for easy happening area were carefully slip falls carefully drop bed logo.2, Easy to put items in patients taking place, keep the ward clean and dry ground, clear wards and aisle obstruction by the bed, extra bed guardrail.3, The appropriate to the size of the shoes and clothing, and activity in patients with someone to accompany.4, Dont suddenly up, avoid causing orthostatic hypotension; Avoid long crouch down suddenly stand up or down.O: Patients master fall prevention/pendant measures bed, bed fall/drop during hospitalization did not happen. Item (13/4 08:30李晓霞)P1.潜在不良事件：跌倒/坠床。（30/3 10:20 项娅妮）I:1、床头挂警示标识，对易发生跌倒的区域放置“小心滑倒”“小心坠床”等标识。2、将物品置于患者易取处、保持病房地面清洁干燥、清除病房及床旁走道障碍物，加床护栏。3、着大小合适的鞋及衣裤、患者活动时有人陪伴。4、不要猛然起来，避免引起体位性低血压；避免长时间下蹲或蹲下突然站起。O：患者掌握预防跌倒/坠床措施，住院期间未发生跌倒/坠床情况。（13/4 08:30 李晓霞)P2: anxiety, worry and arrange the date of operation and hospitalization expenses to worry about the prognosis of the disease and the effect of operation.（30/3 11:30项娅妮）I:1. Actively communicating with the patient to understand their psychological status, the reasons of anxiety. 2.Explain the i