骨科二區(qū)胸椎內(nèi)固定術(shù)術(shù)后護(hù)理查房

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3、 試卷下載：www.1ppt.com/shiti/ 教案下載：www.1ppt.com/jiaoan/,,,A case of thoracic vertebral internal fixation surgery patients after nursing care rounds一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房,,Speaker & Physical examination & PPT

4、 production：石彩蘭Advisor：王莉2017.04.07,,Guangzhou medical university,,,General information（一般資料）,2024/2/8,Name: Huang lixuan（黃李軒）Age: 53-year-old Sex: male bed number: GK2017 Date of admission: March 23th,

5、2017Chief complaint（主訴）: Low back pain three months, increased with numbness of both lower limbs a month.（腰痛三月，加重伴雙下肢麻木一月）Diagnosis : Thoracic tumor(胸椎腫瘤),,,,Patient‘s condition（病情匯報(bào)）,2024/2/8,,,,Admission: T 37.0 

6、6;C, P 70 times / min, R 20 times / min, BP 120/60 mmHg. Surgery: 2017-03-24, general anesthesia with thoracic spine tumor resection (全麻下胸椎腫瘤切除)+ thoracic internal fixation（胸椎內(nèi)固定術(shù)）,,,,Auxiliary check（輔助檢查）：,2024/2/8,（20

7、17-02-15，廣州市番禺區(qū)第二人民醫(yī)院）腰部CT提示：L3/4、L4/5椎間盤膨出，L5/S1椎間盤突出，腰椎退行性病變，胸12椎體骨質(zhì)破壞。,,（2017-03-21，解放軍第四五八醫(yī)院）腰椎MR提示：1、胸9、12椎體及椎旁異常信號(hào)影，考慮腫瘤，骨髓瘤可能性大；胸3、8椎體異常信號(hào)影，脂肪沉積與血管瘤鑒別；2、腰2、4椎體占位性病變；3、腰3/4、4/5椎間盤膨出；4、腰椎退行性病變,,,,Auxiliary check（輔助檢

8、查）：,（2017-03-24，我院）全身骨顯像：第10胸椎骨代謝異常局灶性增高活躍。結(jié)合病史，考慮腫瘤性病變與椎體壓縮性骨折相鑒別。,2024/2/8,,,（2017-03-24，我院）胸部正側(cè)位：1、雙肺及心膈未見異常。2、T9椎體壓縮性改變胸,Auxiliary check（輔助檢查）：,2024/2/8,Auxiliary check（輔助檢查）：,2024/2/8,項(xiàng)目名,,,,Basic treatment & me

9、dication（基本治療&用藥）：,2024/2/8,,PO：多烯磷脂酰膽堿膠囊（易善復(fù)）、丁二磺酸腺苷蛋氨酸腸溶片（喜美欣）；IV：注射用帕瑞昔布鈉（特耐）；IM：鼠神經(jīng)生長因子注射劑（恩經(jīng)復(fù)）；Ivgtt：五水頭孢唑林注射劑（新泰林）、醒腦靜、注射用丹參多酚酸鹽、地塞米松磷酸鈉注射液&甘露醇注射液、小牛皮提取物注射液（斯普林）、骨肽注射液（鼓鍵）、甲潑尼龍琥珀酸鈉針（甲強(qiáng)龍）、（申捷）單唾液酸四己糖神經(jīng)節(jié)苷

10、脂鈉注射液、頭孢曲松他唑巴坦針（優(yōu)他能）。,Limb brake（制動(dòng)）, analgesic（止痛），nutritional support（營養(yǎng)支持） and other symptomatic treatment,,床邊體查,2024/2/8,,,,,,,Results of physical examination (體查結(jié)果),Current condition: patients with thoracic inte

11、rnal fixation on the 15th day after surgery, lower limb numbness(下肢麻木無力), postoperative（術(shù)后） wound dressing clean, no bleeding exudate,（滲液） no waist pain, dizziness（頭暈） and other symptoms , and consciousness is clear，appe

12、tite(食欲) is well and have a good spirit .His sleep is well now, and defecate and urinate is normal.,2024/2/8,T、P、H、R、Bp,Specialty（?？魄闆r）:Double lower limbs tactile（雙下肢） feel normal. The strength of lower limbs Ⅳ level。Th

13、e operative wound dressings is dry and clean, no bleeding, drainage(滲液).,,,,,Nursing diagnosis（護(hù)理診斷）,1、Risk of falls: associated with long bedside lower limb muscle weakness（下肢肌無力）,2024/2/8,,3、Lack of knowledge: related

14、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（下肢肌無力）,Nursing measures:1, Tell the patient and fam

15、ily 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 seco

16、nds before the walk in order to avoid orthostatic hypotension(體位性低血壓), 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 cal

17、l help.4, wear anti-skid slippers（拖鞋） and the appropriate（合適的） clothes in order to avoid tripping, and take bed bar when sleep at bed.,2024/2/8,,Nursing target: the patient did not fall,,Nursing evaluation: patients did

18、 not fall during hospitalization.,,,,,2、decline of self-care ability: related to long bed rest,2024/2/8,,Nursing objectives: patients can adapt to the state of decline of self-care ability , and Life needs can be satisfi

19、ed 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（

20、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

21、evaluation: patients adapt to the state, andThe decline of self-care ability during hospitalization has improved .,,2024/2/8,3、Lack of knowledge: related to lack of disease-related knowledge,,,,,Nursing Objective: The p

22、atient can describe the disease-related knowledge,Nursing measures:(1) confirm the patient's concerns about the disease and future lifestyle by talking, and explain or guide the patient's concerns.(2) use easy

23、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 as

24、k questions, and answer to patient patiently .,Nursing Rating: Patients can describe disease-related knowledge during hospitalization,,health education（健康教育）,2024/2/8,,,,,,1, functional exercise: Teach patient turn the

25、body like axis turn(軸線翻身), raising straight leg exercise（直腿抬高運(yùn)動(dòng)）, quadriceps femoris isotonic contraction exercise（股四頭機(jī)等長收縮運(yùn)動(dòng)）and the correct way to get up and lie down.,2, prevent lung infection: change the position con

26、stantly, 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（積痰） discharge.,3 early exercise: to prevent soft tissue adhesions

27、（粘連） and spine joint（脊柱關(guān)節(jié)） activity decreased, and affecting the spine movement, which resulting in chronic pain in the waist(腰) and low back muscle atrophy（腰背肌廢用性萎縮）.,4, the prevention of pressure sores: In order to pre

28、vent 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

29、skin.,,,Discharge instruction（出院指導(dǎo)）：,2024/2/8,,,,,,4, regular outpatient review, if the lower back discomfort or lower limb numbness timely treatment,1, Tell patient to exercise insistently after discharge , but should a

30、void fatigue(勞累), and prevent trauma（外傷）.,2, Tell patient to strengthen nutrition intake, and enhance physical fitness(增強(qiáng)體質(zhì)), to guide the high protein intake, high vitamin diet.,3, Explain the importance of the time to

31、activities in detail , in order to ensure the stability of the internal fixation(內(nèi)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