结肠癌术后造瘘口并发症的护.ppt

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1、LOGO结肠癌术后造瘘口结肠癌术后造瘘口结肠癌术后造瘘口结肠癌术后造瘘口并发症的护理并发症的护理并发症的护理并发症的护理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Company LogoLogo病历简介病历简介vv一般资料一般资料一般资料一般资料v姓名：李秀英性别：女v年龄：73岁民族：汉v职业：退休婚姻：已婚v籍贯：陕西汉中文化程度：高中v入院途径：门诊入院方式：步行v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：发现瘘口半月余入院原因：发现瘘口半月余 Company Logo

2、Logo入院查体入院查体vv一般资料一般资料一般资料一般资料v姓名：李秀英性别：女v年龄：73岁民族：汉v职业：退休婚姻：已婚v籍贯：陕西汉中文化程度：高中v入院途径：门诊入院方式：步行v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：发现瘘口半月余入院原因：发现瘘口半月余 Company LogoLogovv主诉：便血主诉：便血主诉：便血主诉：便血2 2月月月月vv现病史现病史现病史现病史：患者患者2 2月月无明显原因及诱因出现便血，大便后少量鲜血，次数正常，无明显原因及诱因出现便血，大便后少量鲜血，次数正常，下

3、腹部伴有隐痛，与当地医院以下腹部伴有隐痛，与当地医院以“痔疮痔疮”。vv既往史既往史既往史既往史：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、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。药物过敏史，否认手术外伤史。vv个人史：个人史：个人史：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。接触史，预防接种史不详。vv过敏史：过敏史：过敏史：过敏史：否认食物、药物过敏史。否认食物、药物过敏史。Company LogoLogovv现病史

4、现病史现病史现病史：患者患者2626年前体检发现年前体检发现HBsAgHBsAg（+），当时肝功能正常，无明显不适症），当时肝功能正常，无明显不适症状，间断服用药物治疗。状，间断服用药物治疗。8 8月前体检考虑为肝癌可能性大，肝硬化、食管下段月前体检考虑为肝癌可能性大，肝硬化、食管下段-胃胃底静脉曲张、少量腹水。于底静脉曲张、少量腹水。于4 4月月1 1日在我院行肝动脉化疗栓塞治疗，肿瘤大小为日在我院行肝动脉化疗栓塞治疗，肿瘤大小为72*67mm72*67mm，此次为进一步治疗入院。，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，入院后核磁检查提示：建议行介入术治疗，并于并于7.

5、227.22日在局麻下行介入治疗。日在局麻下行介入治疗。vv既往史既往史既往史既往史：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、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。药物过敏史，否认手术外伤史。vv个人史：个人史：个人史：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。接触史，预防接种史不详。vv过敏史：过敏史：过敏史：过敏史：否认食物、药物过敏史。否认食物、药物过敏史。Company LogoLogo睡眠：睡眠：正常正常排

6、泄：排泄：排泄：排泄：正常正常自理程度：自理程度：自理程度：自理程度：生活可自理生活可自理对疾病的认识：对疾病的认识：对疾病的认识：对疾病的认识：部分了解部分了解生命体征：生命体征：生命体征：生命体征：T36.5T36.5，P80P80次次/分，分，R18R18次次/分，分，BP130/80mmHgBP130/80mmHg体格检查：体格检查：体格检查：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，无牵引肿，胸腹部情况良好，无带入管路，无牵引 。Company LogoLogo辅助检查辅助检查辅助检查辅助

7、检查v日期日期项目项目检查结果检查结果v2011-7-13心电图心电图窦性心律窦性心律正常正常ECGv2011-7-15核核磁磁肿肿瘤瘤强强化化建建议议行行介介入入术术治治疗疗v2011-7-13超超声声肝肝内内实实性性占占位位，肝肝右右叶叶可可及及大大小小约约80*67mm的的不不均均回回声声，边边界界尚尚清清，其内可及动脉样血流信号其内可及动脉样血流信号Company LogoLogo实验室检查实验室检查实验室检查实验室检查v7-127-18总胆红素总胆红素12.77.5丙氨酸氨基转移酶丙氨酸氨基转移酶37.465门冬氨酸氨基转移酶门冬氨酸氨基转移酶34.442白细胞白细胞4.53.95钾

8、离子钾离子3.513.41vvCompany LogoLogo护理诊断护理诊断护理诊断护理诊断v1.潜在并发症：上消化道出血上消化道出血v2.潜在并发症：有肝癌破裂出血的危险有肝癌破裂出血的危险v3.有感染的危险有感染的危险v4.潜在并发症：有出血的危险:与介入术后有关v5.有皮肤完整性受损的危险有皮肤完整性受损的危险：与介入术 后需长时间卧床有关v6.营养失调营养失调：低于机体需要量Company LogoLogoHot TipvHowdoIincorporatemylogotoaslidethatwillapplytoalltheotherslides?OntheViewmenu,poin

9、ttoMaster,andthenclickSlideMasterorNotesMaster.Changeimagestotheoneyoulike,thenitwillapplytoalltheotherslides.Imageinformationinproduct-TitleImagewww.ilikeclick.co.kr-CD:medicalperspectives(Eyewire)-Notetocustomers:ThisimagehasbeenlicensedtobeusedwithinthisPowerPointtemplateonly.Youmaynotextractthei

10、mageforanyotheruse.Company LogoLogoDiagramThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.TitleAddyourtextThemeGalleryisaDesignDigitalContent&ContentsmalldevelopedbyGuildDesignInc.Company LogoLogo Cycle DiagramTextTextTextTextTextCyclenameAdd Your TextCompany LogoLogoDiagra

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