骨科二区胸椎内固定术术后护理查房

1、会计学1骨科二区胸椎内固定术术后护理查房骨科二区胸椎内固定术术后护理查房第1页/共19页2022-7-2Name: Name: Huang lixuanHuang lixuan（黄李轩）（黄李轩）Age: Age: 53-year-old Sex: male 53-year-old Sex: male bed number: bed number: GK2017 GK2017 Date of admission: Date of admission: March 23th, 2017March 23th, 2017Chief complaintChief complaint（主诉）（主诉）:

2、: Low back pain three Low back pain three months, increased with numbness of both months, increased with numbness of both lower limbs a month.lower limbs a month.（腰痛三月，加重伴双下（腰痛三月，加重伴双下肢麻木一月）肢麻木一月）Diagnosis : Diagnosis : Thoracic tumor(Thoracic tumor(胸椎肿瘤胸椎肿瘤) )第2页/共19页2022-7-2Admission:Admission: T

3、37.0 T 37.0 C, P 70 times / C, P 70 times / min, R 20 times / min, BP 120/60 min, R 20 times / min, BP 120/60 mmHg.mmHg. Surgery: 2017-03-24, general Surgery: 2017-03-24, general anesthesia with thoracic spine tumor anesthesia with thoracic spine tumor resection (resection (全麻下胸椎肿瘤切除全麻下胸椎肿瘤切除)+ thor

4、acic )+ thoracic internal fixationinternal fixation（胸椎内固定术）（胸椎内固定术）第3页/共19页2022-7-2（2017-02-152017-02-15，广州市番禺区第二人民医院）腰部，广州市番禺区第二人民医院）腰部CTCT提示：提示：L3/4L3/4、L4/5L4/5椎间盘膨出，椎间盘膨出，L5/S1L5/S1椎间盘突出，椎间盘突出，腰椎退行性病变，胸腰椎退行性病变，胸1212椎体骨质破坏。椎体骨质破坏。（2017-03-21，解放军第四五八医院）腰椎，解放军第四五八医院）腰椎MR提示：提示：1、胸胸9、12椎体及椎旁异常信号影，考虑肿

5、瘤，骨髓瘤可能椎体及椎旁异常信号影，考虑肿瘤，骨髓瘤可能性大；胸性大；胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；椎体异常信号影，脂肪沉积与血管瘤鉴别；2、腰、腰2、4椎体占位性病变；椎体占位性病变；3、腰、腰3/4、4/5椎间盘膨出；椎间盘膨出；4、腰椎退行性病变、腰椎退行性病变第4页/共19页2022-7-2（2017-03-24，我院）胸部正侧位：，我院）胸部正侧位：1、双肺及心、双肺及心膈未见异常。膈未见异常。2、T9椎体压缩性改变胸椎体压缩性改变胸第5页/共19页2022-7-2项目名称项目名称结果结果参考范围参考范围单位单位提示提示癌胚抗原癌胚抗原5.715.710-50-5ug

6、ug/L/L细胞角蛋白细胞角蛋白1919片段片段3.363.360-3.30-3.3ugug/L/L白细胞计数白细胞计数22.722.73.59.53.59.5101099/L/L血红蛋白血红蛋白158158130175130175g/Lg/L正常正常总蛋白总蛋白63.163.165856585g/Lg/L尿素尿素/ /肌酐肌酐30.7130.7115241524RatioRatio补体单体补体单体0.140.140.160.380.160.38g/Lg/L白蛋白白蛋白35.335.340554055g/Lg/L总胆汁酸总胆汁酸17.117.109.6709.67umolumol/L/L第6页

7、/共19页2022-7-2项目名项目名项目名称项目名称结果结果参考范围参考范围单位单位提示提示丙氨酸氨基转移酶丙氨酸氨基转移酶205205950950U/LU/L-羟丁酸脱氢酶羟丁酸脱氢酶2052057218272182U/LU/L天门冬氨酸氨基转移酶天门冬氨酸氨基转移酶696915401540U/LU/L乳酸脱氢酶乳酸脱氢酶294294120250120250U/LU/L-谷氨酰基转移酶谷氨酰基转移酶747410601060U/LU/L肌酸激酶同工酶肌酸激酶同工酶 MBMB活性活性2626025025U/LU/L总胆固醇总胆固醇5.855.853.005.183.005.18mmolmmol

8、/L/L高密度脂蛋白胆固醇高密度脂蛋白胆固醇2.092.091.161.421.161.42mmolmmol/L/L第7页/共19页2022-7-2POPO：多烯磷脂酰胆碱胶囊（易善复）、丁二磺酸腺苷蛋氨酸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）；肠溶片（喜美欣）；IVIV：注射用帕瑞昔布钠（特耐）；注射用帕瑞昔布钠（特耐）；IMIM：鼠神经生长因子注射剂（恩经复）；鼠神经生长因子注射剂（恩经复）；IvgttIvgtt：五水头孢唑林注射剂（新泰林）、醒脑静、注射用丹：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参多酚酸盐、地塞米松磷酸钠

9、注射液& &甘露醇注射液、小牛皮甘露醇注射液、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）。注射液、头孢曲松他唑巴坦针（优他能）。Limb brakeLimb brake（制动）（制动）, analgesic, analgesic（止痛），（止痛），nutritional nutritional supportsupport（营养支持）（营养支持） and other symptom

10、atic and other symptomatic treatmenttreatment第8页/共19页2022-7-2第9页/共19页2022-7-2T、P、H、R、BpSpecialty（专科情况）（专科情况）:Doublelowerlimbstactile（双下肢）（双下肢）feelnormal.Thestrengthoflowerlimbslevel。Theoperativewounddressingsisdryandclean,nobleeding,drainage(渗液渗液).第10页/共19页2022-7-23、Lackofknowledge:relatedtolackofdi

11、sease-relatedknowledge2、declineofself-careability:relatedtolongbedrest第11页/共19页2022-7-2Nursing target: the patient did not fallNursingevaluation:patientsdidnotfallduringhospitalization.第12页/共19页2022-7-2Nursing objectives: patients can adapt to the state of decline of self-care ability , and Life nee

12、ds 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

13、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 .第13页/共19页2022-7-2Nursing Objective: Th

14、e patient can describe the disease-related knowledgeNursing 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

15、 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第14页/共19页2022-7-21,functionalexercise:Te

16、achpatientturnthebodylikeaxisturn(轴线翻身轴线翻身),raisingstraightlegexercise（直腿抬高运动）（直腿抬高运动）,quadricepsfemorisisotoniccontractionexercise（股四头机等长收缩运动）（股四头机等长收缩运动）andthecorrectwaytogetupandliedown.2,preventlunginfection:changethepositionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktosho

17、ot（翻身拍背）（翻身拍背）regular,promotelungsecretions（分泌物）（分泌物）andaccumulationofsputum（积痰）（积痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘连）（粘连）andspinejoint（脊柱关节）（脊柱关节）activitydecreased,andaffectingthespinemovement,whichresultinginchronicpaininthewaist(腰腰)andlowbackmuscleatrophy（腰背肌废用性萎缩）（腰背肌废用性萎缩

18、）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆便盆),inordertoavoidtodamagetheskin.第15页/共19页2022-7-24, regular outpatient review, if the lower back disco

19、mfort or lower limb numbness timely treatment1, Tell patient to exercise insistently after discharge , but should avoid fatigue(劳累), and prevent trauma（外伤）.2, Tell patient to strengthen nutrition intake, and enhance physical fitness(增强体质), to guide the high protein intake, high vitamin diet.3, Expla

20、in the importance of the time to activities in detail , in order to ensure the stability of the internal fixation(内固定), and get out of the ground to activities must wear brace(支具) , and standing walking time should not be too long. Practice the exercise of bending bent flexion(弯腰前屈) after 3 months ，and sleep at a hard bed.第16页/共19页17第17页/共19页2022-7-2Name: Name: Huang lixuanHuang lixuan（黄李轩）（黄李轩）Age: Age: 53-year-old Sex: male 53-year-old Sex: male bed number: bed number: GK2017 GK2017 Date of admission: Date of admission: March 23th,