骨科二区胸椎内固定术术后护理查房

PPT模板下载：/moban/ 行业PPT模板：/hangye/ 节日PPT模板：/jieri/ PPT素材下载：/sucai/PPT背景图片：/beijing/ PPT图表下载：/tubiao/ 优秀PPT下载：/xiazai/ PPT教程： /powerpoint/ Word教程： /word/ Excel教程：/excel/ 资料下载：/ziliao/ PPT课件下载：/kejian/ 范文下载：/fanwen/ 试卷下载：/shiti/ 教案下载：/jiaoan/,A case of thoracic vertebral internal fixation surgery patients after nursing care rounds一例胸椎内固定术术后患者的护理查房,Speaker & Physical examination & PPT production：石彩兰Advisor：王莉2017.04.07,Guangzhou medical university,General information（一般资料）,2017/11/9,Name: Huang lixuan（黄李轩）Age: 53-year-old Sex: male bed number: GK2017 Date of admission: March 23th, 2017Chief complaint（主诉）: Low back pain three months, increased with numbness of both lower limbs a month.（腰痛三月，加重伴双下肢麻木一月）Diagnosis : Thoracic tumor(胸椎肿瘤),Patients condition（病情汇报）,2017/11/9,Admission: T 37.0 C, P 70 times / min, R 20 times / min, BP 120/60 mmHg. Surgery: 2017-03-24, general anesthesia with thoracic spine tumor resection (全麻下胸椎肿瘤切除)+ thoracic internal fixation（胸椎内固定术）,Auxiliary check（辅助检查）：,2017/11/9,（2017-02-15，广州市番禺区第二人民医院）腰部CT提示：L3/4、L4/5椎间盘膨出，L5/S1椎间盘突出，腰椎退行性病变，胸12椎体骨质破坏。,（2017-03-21，解放军第四五八医院）腰椎MR提示：1、胸9、12椎体及椎旁异常信号影，考虑肿瘤，骨髓瘤可能性大；胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；2、腰2、4椎体占位性病变；3、腰3/4、4/5椎间盘膨出；4、腰椎退行性病变,Auxiliary check（辅助检查）：,（2017-03-24，我院）全身骨显像：第10胸椎骨代谢异常局灶性增高活跃。结合病史，考虑肿瘤性病变与椎体压缩性骨折相鉴别。,2017/11/9,（2017-03-24，我院）胸部正侧位：1、双肺及心膈未见异常。2、T9椎体压缩性改变胸,Auxiliary check（辅助检查）：,2017/11/9,Auxiliary check（辅助检查）：,2017/11/9,项目名,Basic treatment & medication（基本治疗&用药）：,2017/11/9,PO：多烯磷脂酰胆碱胶囊（易善复）、丁二磺酸腺苷蛋氨酸肠溶片（喜美欣）；IV：注射用帕瑞昔布钠（特耐）；IM：鼠神经生长因子注射剂（恩经复）；Ivgtt：五水头孢唑林注射剂（新泰林）、醒脑静、注射用丹参多酚酸盐、地塞米松磷酸钠注射液&甘露醇注射液、小牛皮提取物注射液（斯普林）、骨肽注射液（鼓键）、甲泼尼龙琥珀酸钠针（甲强龙）、（申捷）单唾液酸四己糖神经节苷脂钠注射液、头孢曲松他唑巴坦针（优他能）。,Limb brake（制动）, analgesic（止痛），nutritional support（营养支持） and other symptomatic treatment,床边体查,2017/11/9,Results of physical examination (体查结果),Current condition: patients with thoracic internal fixation on the 15th day after surgery, lower limb numbness(下肢麻木无力), postoperative（术后） wound dressing clean, no bleeding exudate,（渗液） no waist pain, dizziness（头晕） and other symptoms , and consciousness is clear，appetite(食欲) is well and have a good spirit .His sleep is well now, and defecate and urinate is normal.,2017/11/9,T、P、H、R、Bp,Specialty（专科情况）:Double lower limbs tactile（双下肢） feel normal. The strength of lower limbs level。The operative wound dressings is dry and clean, no bleeding, drainage(渗液).,Nursing diagnosis（护理诊断）,1、Risk of falls: associated with long bedside lower limb muscle weakness（下肢肌无力）,2017/11/9,3、Lack of knowledge: related to lack of disease-related knowledge,2、decline of self-care ability: related to long bed rest,Risk of falls: associated with long bedside lower limb muscle weakness（下肢肌无力）,Nursing measures:1, Tell the patient and family members to stay with patient all the time , and if need help ring that call nurses.2, change the position should obey with the three steps, that is lying 30 seconds, sit up 30 seconds, and stand 30 seconds before the walk in order to avoid orthostatic hypotension(体位性低血压), especially at night.3, When walking dizziness, lower limb weakness, and gait instability and can not move, immediately sit down in situ(原地), and call help.4, wear anti-skid slippers（拖鞋） and the appropriate（合适的） clothes in order to avoid tripping, and take bed bar when sleep at bed.,2017/11/9,Nursing target: the patient did not fall,Nursing evaluation: patients did not fall during hospitalization.,2、decline of self-care ability: related to long bed rest,2017/11/9,Nursing objectives: patients can adapt to the state of decline of self-care ability , and Life needs can be satisfied during hospitalization.,Nursing measures:(1) explain the importance of cleaning-care to the patient.(2) do morning care in order to increase the comfort of patient: wash face, wash hands, oral care, warm water wipe（擦） back, etc.(3) keep warm while operation, and avoid exposure to the patient too long to prevent colds.(4) Keep the bed clean and dry.(5) help patient eating, dressing, into the toilet and other life care.,Nursing evaluation: patients adapt to the state, andThe decline of self-care ability during hospitalization has improved .,2017/11/9,3、Lack of knowledge: related to lack of disease-related knowledge,Nursing Objective: The patient can describe the disease-related knowledge,Nursing measures:(1) confirm the patients concerns about the disease and future lifestyle by talking, and explain or guide the patients concerns.(2) use easy to understand language to the patient to introduce the course and treatment.(3) Distribute health education prescription regularly . Provide the necessary learning materials for the patient.(4) encourage patients to ask questions, and answer to patient patiently .,Nursing Rating: Patients can describe disease-related knowledge during hospitalization,health education（健康教育）,2017/11/9,1, functional exercise: Teach patient turn the body like axis turn(轴线翻身), raising straight leg exercise（直腿抬高运动）, quadriceps femoris isotonic contraction exercise（股四头机等长收缩运动）and the correct way to get up and lie down.,2, prevent lung infection: change the position constantly, and encourage patients to do an effective cough action, turn back to shoot（翻身拍背） regular, promote lung secretions（分泌物） and accumulation of sputum（积痰） discharge.,3 early exercise: to prevent soft tissue adhesions（粘连） and spine joint（脊柱关节） activity decreased, and affecting the spine movement, which resulting in chronic pain in the waist(腰) and low back muscle atrophy（腰背肌废用性萎缩）.,4, the prevention of pressure sores: In order to prevent the formation of pressure sores, it need to do a good job on mission work, and teach patients and their families to master the turning skills . And do not plug when use the potty(便盆),in order to avoid to damage the skin.,Discharge instruction（出院指导）：,2017/11/9,4, regular outpatient review,