消化系统疾病患者的精品文稿.ppt

消化系统疾病患者的第1页，本讲稿共49页学习目标1.熟悉肠胃系统的正常功能2.认识肠胃系统的异常表现3.掌握肠胃系统的评估要点4.熟悉肠胃系统评估技巧分辨不同年纪、性别、疾病谱在消化系统的表现 第2页，本讲稿共49页GI System Assessment 消化系统评估健康史:1.生活背景Biographical and demographic data2.目前健康状况 Current Health3.过去健康病史 Past Health history4.家族史 Family Health5.心理社会因素 Psychosocial Factors6.系统回顾 Review of system 第3页，本讲稿共49页Demographic Data背景资料评估 GenderAgeMarital StatusWorking condition Women(calcium),elderly(inadequate food intake,gastric ulcer,colon cancer),teenagers(Duodenal ulcers,gastric cancers)may have different health problem and nutritional needs.第4页，本讲稿共49页Current Health Assessment 目前健康评估评估主诉是否出现：恶心、呕吐吞咽困难：梗阻与疼痛不消化：反酸或嗳气腹痛呕血、便血腹泻、便秘腹水黄疸体重及食欲改变.第5页，本讲稿共49页Past Health History 过去病史1.Bleeding-iron deficiency anemia2.Liver Disease:protein malnutrition 3.Peptic Ulcer With bleeding4.Jaundice5.Gallbladder sisease6.Pancreatitis7.Cancer8.Change of bowel habits9.Tarry stools 10.Unexplained weight loss or gain 第6页，本讲稿共49页Health History of The GI SystemHealth Perception-health management patternNutritional-metabolic patternElimination patternActivity-exercise patternSleep-Rest PatternCongitive-preception patternSelf-Perception,self-concept patternRole-relationship patternSexuality-reproductive patternCoping-stress tolerance patternValue-belief pattern Lewis,2004,p.955第7页，本讲稿共49页Assess for Medications药物评估Use of Aspirin,NAISD(Nonsteroidal anti-inflammatory drugs)gastritis/bleeding是否使用阿斯匹林，非激素类止痛药，胃出血Antacids:type and frequency 制酸剂，种类、频率Laxatives or stool softeners?软便剂Dietary Supplement:vitamins,minerals,herbs,amino acids 食品补充，维生素、草药、蛋白质第8页，本讲稿共49页Assessment for Allergies 评估过敏史Food allergies:hives or dyspnea Food intolerance:GI abdominal cramping,flatulence,or diarrhea(lactose intolerance)Comment food allergies items:nuts,shellfish,cows milk,food additives 第9页，本讲稿共49页Assessment for Family HistoryGI problem may associate with family history and environment factors.Ulcerative colitis 溃疡性结肠炎Crohns Disease 克罗恩病Alcoholism 酗酒Liver diseases 肝脏疾病Family history of DM,anemia,jaundice,hepatitis,Pancreatitis,obesity,irritable bowel syndrome.糖尿病家族史、贫血、黄疸、肝炎、胰脏炎、肥胖、小肠激惹症候群第10页，本讲稿共49页Psychosocial History 心理社会病史Occupation:environmental toxins(lead,mercury,carbon tetrachloride)Travel:Pathogens(protozoa,parasites),eating raw shellfish,swimming in polluted water Diet habits change 第11页，本讲稿共49页Assessment of GI SystemAbdomen Inspection 视诊视诊1.skin intact,smooth 皮肤完整、平滑2.Contour:flat,rounded,no distention or irregular contour 形状，腹胀、不规则形状3.Rashes,discoloration,scares,petechiae,striate,dilated veins 红疹、变色、疤痕、青紫、横纹、扩张静脉4.Peristaltic movement if pt has obstruction of the bowel 小肠阻塞可见肠蠕动运动5.Abdominal pulsation 腹部可见脉动第12页，本讲稿共49页Review of System系统回顾Mouth:oral lesions,excessive salivation,mouth dryness,oral ulcer Dental cavity:floss usageWater supply with fluoridate?Dentist for teeth cleaningPeriodontal diseaseTrouble tasting,chewing or swallowing?第13页，本讲稿共49页Assessment of the GI systemMouth Lips:symmetry,color,hydration,lesions,nodules,position of teeth(malocclusion),dental caries,color of mucosa and gums,swelling or lesions,leukoplakis lesion（白斑）Tonsils:redness,swelling,lesions,ulcers,Tongue:color,moisture,atrophy,abnormal coating,swelling,lesions,symmetry movement,difficulty to swallow(Dysphagia 吞咽困难)第14页，本讲稿共49页Assessment for Oral Disorders Stomatitis:1.Aphthous ulcer(unknown),口腔溃疡2.Herpes Simplex(HSV infection),疱疹3.Oral candidiasis-Thrush(Candida Albicans fungus infection)念珠球菌感染Assess for immunosuppression,prolonged antibiotic use,pain,tenderness,bleeding,oral intake/nutrition（免疫低下者，长期使用抗生素者、疼痛、压痛、出血、营养进食情况）第15页，本讲稿共49页Assessment of Oral DisorderPremalignant tumor：恶性肿瘤前期 Leukoplasia 白斑Erythroplakia 红斑Tumor of the oral cavity:Basal cell or Squamous cell carcinoma Risk factor:tobacco and long term alcohol consumption,Very Hot beverages,槟榔第16页，本讲稿共49页评估吞咽困难（Dysphagia）口腔疾病：吞咽时梗阻与疼痛，感觉吞咽时间延长，口腔溃疡扁桃体炎咽炎咽壁浓肿、肿瘤急性喉咽喉头水肿喉癌第17页，本讲稿共49页Assessment of the Salivary Glands 唾液腺Sings of inflammationInactivity of the gland caused by medication or prolonged NG tube,NPODry mouth Bad breath order from bacteria accumulated in the mouth due to insufficient salivary.第18页，本讲稿共49页Assessment of Esophagus食管评估Dysphagia 吞咽困难Regurgitation 反流:reflux can affect respiratory tractPain 疼痛Heartburn or pyrosis 烧灼感第19页，本讲稿共49页评估吞咽困难（Dysphagia）食管疾病食管炎食管溃疡食管狭窄食管异常或先天性异常食管裂孔疝喷门口失驰缓症食管癌第20页，本讲稿共49页Assessment of GI SystemAbdomenAuscultation:Air and fluid move through the GI tract,soft clicks and gurgles q5-15 sec.1.Normal bowel sound:irregular 4-5/min2.Hyperactivity:Loud,high-pitch sound of the GI tract,10/min-GI bleeding,acute gastroenteritis3.Hypoactivity:few bowel sound(listen for 5 minutes or 1 minute each quadrant(absence of bowel sounds does not mean absence of bowel peristalsis)第21页，本讲稿共49页Assessment of GI SystemAbdomenPercussion/Palpation 1.疼痛部位、性质（钝、绞痛）腹肌柔软度、是否出现压痛或反跳痛、剧烈绞痛拌有高肠鸣音（肠梗），腹部包块、液波震颤如门脉高压腹水、腹胀、阵痛、是否反射至右肩（胆结石），或后背及中上腹（胰腺炎），右下腹反跳痛（阑尾）2.炎症刺激，腹壁是否紧张痉挛，如穿孔可导致腹肌高度紧张（abdominal rigidity）、强直“板样腹”第22页，本讲稿共49页腹部疼痛的病因与特征 1腹部脏器扭转或阻塞（Organ obstruction or twisting）:1.intermittent collicky pain,间断性绞痛2.under umbilicus associate with small bowel在脐部位与小肠有关.3.distended abdomen with no flatus or bowel movement,腹胀，缺乏排气或肠蠕动4.bowel sound may change from high pitch to absent 肠鸣音由高音到消失第23页，本讲稿共49页腹部疼痛的病因与特征2腹部脏器炎症：Peritoneal inflammation(Perforated ulcer,ruptured spleen,ruptured appendix)1.Steady aching pain over area of inflammation,在炎症部位疼痛2.pain increased with motion,活动时疼痛增加3.may associate with shock if pain is severe 过度疼痛时可能与休克有关第24页，本讲稿共49页腹部疼痛的病因与特征3腹部脏器血管狭窄或梗阻 Vascular Catastrophe(Aortic aneurysm or mesenteric infarction)1.2-3 days mild tomoderate pain and hyperperistalsis followed by severe abdominal pain 中等度疼痛，肠蠕动增加，腹部疼痛厉害2.Back and flank pain are common with aortic aneurysms.主动脉瘤常见后背或腰部疼痛第25页，本讲稿共49页Assessment for Regurgitation评估反流（反酸）Regurgitation 是指酸性胃液反流到口腔的现象。导因：炎症、溃疡、肿瘤使喷门扩约肌松弛，胃逆蠕动增加，使胃酸容易反流入口腔，侵蚀食管，容易引起酸性胃液反流入口，胸骨后烧灼感第26页，本讲稿共49页Assessment of Vomiting 患者的呕吐物需要仔细评估量、色、性质、频率、反射性呕吐？诱发因素？是否带血样？是否呈咖啡色样液体，呕吐后生理变化患者有哪些过去病史、现在疾病导致呕吐或呕血？食管、胃、十二指肠、粘膜、溃疡、癌症、胰胆疾病等因素需要评估第27页，本讲稿共49页评估腹水Assessment of Ascites 腹腔内过多液体积聚，分为浆液性、血性、浓性、乳糜性，依照腹水中的蛋白含量、比重、细胞量而区分。引起腹水原因包括：肝硬化、重度肝炎、腹膜炎、癌症、心衰竭等。评估腹水影响：呼吸、皮肤完整性、血清蛋白缺失、体重变化、行动、活动度，舒适程度第28页，本讲稿共49页评估黄胆Assessment of Jaundice 胆红素代谢障碍使血中胆红素浓度升高，渗入组织、皮肤、巩膜、粘膜，呈黄色。正常血清总胆红素 8.55-17.1 umol/L(0.5-1mg/dl,升高到34.2umol/L(2mg/dl),临床可见黄胆。评估：皮肤干燥、骚痒、外观影响，小便颜色深茶色第29页，本讲稿共49页Assessment of the Liver and Spleen Hepatomegaly 肝脏肿大:enlargement of liver,liver edge 1-2cm below costal margin(possible Hepatitis 肝炎,venous congestion 静脉充血,metastatic carcinoma肿瘤转移)Splenomegaly脾脏肿大:Enlargement of spleen(possible portal hypertension 门静脉高压,infection感染)第30页，本讲稿共49页下胃肠道系统症状评估分析：1.时间：出现时间及持续，突发？是否与进食有关2.性质与量：叙述疼痛性质，深、闷痛、弥散性疼痛，腹泻与血便性质3.部位：反射其它部位，涉及肝脏、脾脏、阑尾区、直肠？4.诱因：压力、食物、药物5.相关表现：生活影响、食物不耐受、黄疸、腹水、腹部绞痛等第31页，本讲稿共49页下胃肠道健康评估腹部评估：腹胀、肿块、对等性、明显的肠蠕动、脐或腹股沟疝气、肠鸣音、腹水、腹痛区是否反射性疼痛、反跳性疼痛（Rebound tenderness)肛门与直肠：痔疮、脱肛、皮肤完整性、红疹、溃疡、肛裂（Anal Fissure）、瘘管（Anal Fistula）、脓肿（Anorectal abscess）第32页，本讲稿共49页Assessment of the Bowel Elimination 年龄与性别：Colorectal cancer 常见于年纪长者、男性溃疡性结肠炎 Ulcerative colitis 常发生于中年白种人，犹太人Diverticular disease 常见于已开发国家精制食物摄取较多第33页，本讲稿共49页Assessment for Bowel EliminationAscites 腹水 Diarrhea 腹泻Constipation 便秘Melena 便血Pain in Rectal or Abdominal:腹部疼痛或肛门疼痛第34页，本讲稿共49页Assessment of Diarrhea and Constipation Diarrhea:acute or chronic(2 months of diarrhea评估腹泻后生理变化：渗透压升高、消化不完全、肠蠕动过快、肠内容物水份高、消化不完全急性腹泻：与细菌感染有关、与进食感染源有关，包括菌痢第35页，本讲稿共49页评估腹泻 Diarrhea腹泻性质、频率、量。是否腹痛及里急后重感？是否有肠粘膜破坏？浓样血便？水样便？饮食不洁？细菌感染？常见的致病菌为：大肠杆菌、沙门菌、轮状病毒、肠病毒、血吸虫等。可依可能的感染途径评估致病因素。第36页，本讲稿共49页评估便血消化道出血，由肛门排出，颜色与出血量、时间、部位有关。1.下消化道出血，近直肠肛门部位，停留时间短：鲜红2.上消化道出血，通过肠道，Hb 与肠道硫化物结合，形成黑色便（Tarry Stool）3.鉴别：肠道细菌感染或炎症，肠道肿瘤、息肉、痔疮、克罗恩病、肠套叠等。第37页，本讲稿共49页评估便秘Constipation结肠性便秘：结肠内的机械梗阻，结肠蠕动减少、结肠痉挛直肠性便秘：直肠肛周病变所致，生活习惯改变，排便习惯不正确，常服用泻药或灌肠，导致直肠粘膜感受器的敏感性降低，常发生于老年人及长期卧床休息者。第38页，本讲稿共49页Physical Assessment Annus and Rectum Assess for:1.Tenderness,压痛2.Masses,肿块3.hemorrhoids,痔疮4.Prolapsed,脱垂5.Rectal mucosa smooth,直肠粘膜平滑6.Stool negative for blood 便血阴性第39页，本讲稿共49页 Aging Patient GI Assessment 年长者肠胃系统评估Mouth:1.Loss of teeth2.Decreased taste buds,decreased sense of smell 胃蕾减少，嗅觉下降3.Decreased volume of saliva 唾液减少4.Atrophy of gingival tissue 牙龈萎缩第40页，本讲稿共49页Aging Patient GI Assessment 年长者肠胃系统评估Esophagus 食管1.Decreased tone and motility 降低张力及动力第41页，本讲稿共49页Aging Patient GI Assessment 年长者肠胃系统评估Abdominal Wall1.Thiner and less taut 2.Decrese in number and sensitivity of sensory receptors 3.More visible peristalsisStomach:Decreased acid secretion,atrophy of gastric mucosa 降低胃酸分泌，胃粘膜萎缩第42页，本讲稿共49页Aging Patient GI Assessment 年长者肠胃系统评估Small Intestines:小肠1.Decreased secretion of most digestive enzymes,消化液分泌减少2.Decreased moltility-complain of indigestion 动力降低，主述“不消化”Liver:肝脏1.Decreased size and lowered in position 降低尺寸及位置第43页，本讲稿共49页Aging Patient GI Assessment 年长者肠胃系统评估Large intestine,anus,rectum:大肠、肛门、直肠1.Decreased anal sphincter tone and nerve to rectal area-fecal incontinence 肛门扩约肌张力及神经传导下降，失禁2.Decreased muscular tone,decreased motility-Flatulence,abdominal distension constipation,fecal impaction 肌肉张力下降，活动力降低，腹胀、便秘、粪便嵌塞第44页，本讲稿共49页营养与消化系统评估的重要性The importance of nutritional health and digestive assessmentNutritional health requires a functional gut to receive,transport,absorb,and metabolize nutrients.Interdependence assessment of the gastrointestinal tract and nutritional status第45页，本讲稿共49页进行营养评估Nutritional Health AssessmentDietary Intake食物摄取量：列出过去24小时所有的饮食摄取(Dietary intake recall)参考食物建议摄取量（Recommended Daily Allowance）计算健康者每日所需要的热量及蛋白质：1.3050 Calories/Kg2.0.8-1.2 g of protein/Kg第46页，本讲稿共49页Malnutrition 营养不良Micronutrient Malnutrition 常见于慢性胰脏炎（Chronic Pancreatitis),小肠短小症（shortbowel syndrome),Pressure ulcer 胃溃疡,Cancer 癌症,AIDS 艾滋病,Prior to gastric surgery第47页，本讲稿共49页营养评估收集病史，了解过去资料健康现况现性健康历史家族史社会心理支持第48页，本讲稿共49页总结：肠胃系统评估包括口腔、食管、胃肠道、肝脾腹部器官、大肠、直肠、肛门等器官消化系统的健康与营养的摄取息息相关。评估消化系统需要以整体观点来评估患者，了解正常的肠胃系功能有利于教学。第49页，本讲稿共49页