结肠癌术后造瘘口并发症护理

结肠癌术后造瘘口并发症护理第一页，共29页。Contents1.病例简介2.治理方法3.护理评估4.护理计划5.健康教育LogoLogoLogo第二页，共29页。病历简介一般资料姓名：李秀英性别：女年龄：73岁民族：汉职业：退休婚姻：已婚籍贯：陕西汉中文化程度：高中入院途径：门诊入院方式：步行入院日期：2011-12-29

入院诊断：直肠癌前切除术后并吻合口及阴道瘘入院原因：发现瘘口半月余LogoLogoLogo第三页，共29页。入院查体一般资料姓名：李秀英性别：女年龄：73岁民族：汉职业：退休婚姻：已婚籍贯：陕西汉中文化程度：高中入院途径：门诊入院方式：步行入院日期：2011-12-29

入院诊断：直肠癌前切除术后并吻合口及阴道瘘入院原因：发现瘘口半月余LogoLogoLogo第四页，共29页。主诉：便血2月现病史：

患者2月无明显原因及诱因出现便血，大便后少量鲜血，次数正常，下腹部伴有隐痛，与当地医院以“痔疮”。

既往史：否认高血压、冠心病、糖尿病病史，否认其他传染病史，否认食物、药物过敏史，否认手术外伤史。个人史：否认经常外出就餐，否认输血及血制品运用史，否认传染病患者密切接触史，预防接种史不详。过敏史：否认食物、药物过敏史。LogoLogoLogo第五页，共29页。现病史：

患者26年前体检发现HBsAg（+），当时肝功能正常，无明显不适症状，间断服用药物治疗。8月前体检考虑为肝癌可能性大，肝硬化、食管下段-胃底静脉曲张、少量腹水。于4月1日在我院行肝动脉化疗栓塞治疗，肿瘤大小为72*67mm，此次为进一步治疗入院。

入院后核磁检查提示：建议行介入术治疗，并于7.22日在局麻下行介入治疗。

既往史：否认高血压、冠心病、糖尿病病史，否认其他传染病史，否认食物、药物过敏史，否认手术外伤史。个人史：否认经常外出就餐，否认输血及血制品运用史，否认传染病患者密切接触史，预防接种史不详。过敏史：否认食物、药物过敏史。LogoLogoLogo第六页，共29页。睡眠：正常排泄：正常自理程度：生活可自理对疾病的认识：部分了解生命体征：

T36.5℃，P80次/分，R18次/分，BP130/80mmHg体格检查：一般状况良好，肝掌阳性，皮肤黏膜无黄染，双下肢不肿，胸腹部情况良好，无带入管路，无牵引。LogoLogoLogo第七页，共29页。辅助检查日期项目检查结果2011-7-13心电图窦性心律正常ECG2011-7-15核磁肿瘤强化建议行介入术治疗2011-7-13

超声

肝内实性占位，肝右叶可及大小约80*67mm的不均回声，边界尚清，其内可及动脉样血流信号LogoLogoLogo第八页，共29页。实验室检查

7-127-18

总胆红素12.77.5

丙氨酸氨基转移酶37.465

门冬氨酸氨基转移酶34.442

白细胞4.53.95

钾离子3.513.41

LogoLogoLogo第九页，共29页。护理诊断

1.潜在并发症：上消化道出血

2.潜在并发症：有肝癌破裂出血的危险

3.有感染的危险

4.潜在并发症：有出血的危险:与介入术后有关

5.有皮肤完整性受损的危险：与介入术后需长时间卧床有关

6.营养失调：低于机体需要量

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