骨科二区胸椎内固定术术后护理查房课件

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Acaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎内固定术术后患者的护理查房Speaker&Physicalexamination&PPTproduction：石彩兰Advisor：王莉2017.04.07GuangzhoumedicaluniversityGeneralinformation（一般资料）Name:Huanglixuan（黄李轩）Age:53-year-oldSex:malebednumber:GK2017Dateofadmission:March23th,2017Chiefcomplaint（主诉）:Lowbackpainthreemonths,increasedwithnumbnessofbothlowerlimbsamonth.（腰痛三月，加重伴双下肢麻木一月）Diagnosis:Thoracictumor(胸椎肿瘤)

Patient‘scondition（病情汇报）

Admission:

T37.0°C,P70times/min,R20times/min,BP120/60mmHg.Surgery:2017-03-24,generalanesthesiawiththoracicspinetumorresection(全麻下胸椎肿瘤切除)+thoracicinternalfixation（胸椎内固定术）Auxiliarycheck（辅助检查）：（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Auxiliarycheck（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。（2017-03-24，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Auxiliarycheck（辅助检查）：项目名称结果参考范围单位提示癌胚抗原5.710-5ug/L↑细胞角蛋白19片段3.360-3.3ug/L↑白细胞计数22.73.5~9.510^9/L

↑血红蛋白158130~175g/L正常总蛋白63.165~85g/L↓尿素/肌酐30.7115~24Ratio↑补体单体0.140.16~0.38g/L↓白蛋白35.340~55g/L↓总胆汁酸17.10~9.67umol/L↑Auxiliarycheck（辅助检查）：项目名项目名称结果参考范围单位提示丙氨酸氨基转移酶2059~50U/L↑α-羟丁酸脱氢酶20572~182U/L↑天门冬氨酸氨基转移酶6915~40U/L↑乳酸脱氢酶294120~250U/L↑γ-谷氨酰基转移酶7410~60U/L↑肌酸激酶同工酶MB活性260~25U/L↑总胆固醇5.853.00~5.18mmol/L↑高密度脂蛋白胆固醇2.091.16~1.42mmol/L↑Basictreatment&medication

（基本治疗&用药）：

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）。Limbbrake（制动）,analgesic（止痛），nutritionalsupport（营养支持）andothersymptomatictreatment床边体查

Resultsofphysicalexamination(体查结果)Currentcondition:patientswiththoracicinternalfixationonthe15thdayaftersurgery,lowerlimbnumbness(下肢麻木无力),postoperative（术后）wounddressingclean,nobleedingexudate,（渗液）nowaistpain,dizziness（头晕）andothersymptoms,andconsciousnessisclear，appetite(食欲)iswellandhaveagoodspirit.Hissleepiswellnow,anddefecateandurinateisnormal.T、P、H、R、BpSpecialty（专科情况）:Doublelowerlimbstactile（双下肢）feelnormal.ThestrengthoflowerlimbsⅣlevel。Theoperativewounddressingsisdryandclean,nobleeding,drainage(渗液).Nursingdiagnosis（护理诊断）1、Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌无力）3、Lackofknowledge:relatedtolackofdisease-relatedknowledge2、declineofself-careability:relatedtolongbedrestRiskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌无力）Nursingmeasures:1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(体位性低血压),especiallyatnight.3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.4,wearanti-skidslippers（拖鞋）

andtheappropriate（合适的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.

Nursingtarget:thepatientdidnotfallNursingevaluation:patientsdidnotfallduringhospitalization.2、declineofself-careability:relatedtolongbedrest

Nursingobjectives:patientscanadapttothestateofdeclineofself-careability,andLifeneedscanbesatisfiedduringhospitalization.Nursingmeasures:(1)explaintheimportanceofcleaning-caretothepatient.(2)domorningcareinordertoincreasethecomfortofpatient:washface,washhands,oralcare,warmwaterwipe（擦）back,etc..(3)keepwarmwhileoperation,andavoidexposuretothepatienttoolongtopreventcolds.(4)Keepthebedcleananddry.(5)helppatienteating,dressing,intothetoiletandotherlifecare.Nursingevaluation:patientsadapttothestate,andThedeclineofself-careabilityduringhospitalizationhasimproved.3、Lackofknowledge:relatedtolackofdisease-relatedknowledge

NursingObjective:Thepatientcandescribethedisease-relatedknowledgeNursingmeasures:(1)confirmthepatient'sconcernsaboutthediseaseandfuturelifestylebytalking,andexplainorguidethepatient'sconcerns.(2)useeasytounderstandlanguagetothepatienttointroducethecourseandtreatment.(3)Distributehealtheducationprescriptionregularly.Providethenecessarylearningmaterialsforthepatient.(4)encouragepatientstoaskquestions,andanswertopatientpatiently.NursingRating:Patientscandescribedisease-relatedknowledgeduringhospitalizationhealtheducation（健康教育）1,functionalexercise:Teachpatientturnthebodylikeaxisturn(轴线翻身),raisingstraightlegexercise（直腿抬高运动）,quadricepsfemorisisotoniccontractionexercise（股四头机等长收缩运动）andthecorrectwaytogetupandliedown.2,preventlunginfection:changethepositionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktoshoot（翻身拍背）regular,promotelungsecretions（分泌物）andaccumulationofsputum（积痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘连）andspinejoint（脊柱关节）activitydecreased,andaffectingthespinemovement,whichresultinginchronicpaininthewaist(腰)andlowbackmuscleatrophy（腰背肌废用性萎缩）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆),inordertoavoidtodamagetheskin.Dischargeinstruction（出院指导）：4,regularoutpatientreview,ifthelowerbackdiscomfortorlowerlimbnumbnesstimelytreatment1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(劳累),andpreventtrauma（外伤）.2,Tellpatienttostreng