骨科二區(qū)胸椎內(nèi)固定術術后護理查房

1、會計學1骨科二區(qū)胸椎內(nèi)固定術術后護理查房骨科二區(qū)胸椎內(nèi)固定術術后護理查房第1頁/共19頁2022-7-2Name: Name: Huang lixuanHuang lixuan（黃李軒）（黃李軒）Age: Age: 53-year-old Sex: male 53-year-old Sex: male bed number: bed number: GK2017 GK2017 Date of admission: Date of admission: March 23th, 2017March 23th, 2017Chief complaintChief complaint（主訴）（主訴）:

2、: Low back pain three Low back pain three months, increased with numbness of both months, increased with numbness of both lower limbs a month.lower limbs a month.（腰痛三月，加重伴雙下（腰痛三月，加重伴雙下肢麻木一月）肢麻木一月）Diagnosis : Diagnosis : Thoracic tumor(Thoracic tumor(胸椎腫瘤胸椎腫瘤) )第2頁/共19頁2022-7-2Admission:Admission: T

3、37.0 T 37.0 C, P 70 times / C, P 70 times / min, R 20 times / min, BP 120/60 min, R 20 times / min, BP 120/60 mmHg.mmHg. Surgery: 2017-03-24, general Surgery: 2017-03-24, general anesthesia with thoracic spine tumor anesthesia with thoracic spine tumor resection (resection (全麻下胸椎腫瘤切除全麻下胸椎腫瘤切除)+ thor

4、acic )+ thoracic internal fixationinternal fixation（胸椎內(nèi)固定術）（胸椎內(nèi)固定術）第3頁/共19頁2022-7-2（2017-02-152017-02-15，廣州市番禺區(qū)第二人民醫(yī)院）腰部，廣州市番禺區(qū)第二人民醫(yī)院）腰部CTCT提示：提示：L3/4L3/4、L4/5L4/5椎間盤膨出，椎間盤膨出，L5/S1L5/S1椎間盤突出，椎間盤突出，腰椎退行性病變，胸腰椎退行性病變，胸1212椎體骨質(zhì)破壞。椎體骨質(zhì)破壞。（2017-03-21，解放軍第四五八醫(yī)院）腰椎，解放軍第四五八醫(yī)院）腰椎MR提示：提示：1、胸胸9、12椎體及椎旁異常信號影，考慮腫

5、瘤，骨髓瘤可能椎體及椎旁異常信號影，考慮腫瘤，骨髓瘤可能性大；胸性大；胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；椎體異常信號影，脂肪沉積與血管瘤鑒別；2、腰、腰2、4椎體占位性病變；椎體占位性病變；3、腰、腰3/4、4/5椎間盤膨出；椎間盤膨出；4、腰椎退行性病變、腰椎退行性病變第4頁/共19頁2022-7-2（2017-03-24，我院）胸部正側位：，我院）胸部正側位：1、雙肺及心、雙肺及心膈未見異常。膈未見異常。2、T9椎體壓縮性改變胸椎體壓縮性改變胸第5頁/共19頁2022-7-2項目名稱項目名稱結果結果參考范圍參考范圍單位單位提示提示癌胚抗原癌胚抗原5.715.710-50-5ug

6、ug/L/L細胞角蛋白細胞角蛋白1919片段片段3.363.360-3.30-3.3ugug/L/L白細胞計數(shù)白細胞計數(shù)22.722.73.59.53.59.5101099/L/L血紅蛋白血紅蛋白158158130175130175g/Lg/L正常正?？偟鞍卓偟鞍?3.163.165856585g/Lg/L尿素尿素/ /肌酐肌酐30.7130.7115241524RatioRatio補體單體補體單體0.140.140.160.380.160.38g/Lg/L白蛋白白蛋白35.335.340554055g/Lg/L總膽汁酸總膽汁酸17.117.109.6709.67umolumol/L/L第6頁

7、/共19頁2022-7-2項目名項目名項目名稱項目名稱結果結果參考范圍參考范圍單位單位提示提示丙氨酸氨基轉移酶丙氨酸氨基轉移酶205205950950U/LU/L-羥丁酸脫氫酶羥丁酸脫氫酶2052057218272182U/LU/L天門冬氨酸氨基轉移酶天門冬氨酸氨基轉移酶696915401540U/LU/L乳酸脫氫酶乳酸脫氫酶294294120250120250U/LU/L-谷氨酰基轉移酶谷氨?；D移酶747410601060U/LU/L肌酸激酶同工酶肌酸激酶同工酶 MBMB活性活性2626025025U/LU/L總膽固醇總膽固醇5.855.853.005.183.005.18mmolmmol

8、/L/L高密度脂蛋白膽固醇高密度脂蛋白膽固醇2.092.091.161.421.161.42mmolmmol/L/L第7頁/共19頁2022-7-2POPO：多烯磷脂酰膽堿膠囊（易善復）、丁二磺酸腺苷蛋氨酸多烯磷脂酰膽堿膠囊（易善復）、丁二磺酸腺苷蛋氨酸腸溶片（喜美欣）；腸溶片（喜美欣）；IVIV：注射用帕瑞昔布鈉（特耐）；注射用帕瑞昔布鈉（特耐）；IMIM：鼠神經(jīng)生長因子注射劑（恩經(jīng)復）；鼠神經(jīng)生長因子注射劑（恩經(jīng)復）；IvgttIvgtt：五水頭孢唑林注射劑（新泰林）、醒腦靜、注射用丹：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參多酚酸鹽、地塞米松磷酸鈉

9、注射液& &甘露醇注射液、小牛皮甘露醇注射液、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（甲強龍）、（申捷）單唾液酸四己糖神經(jīng)節(jié)苷脂鈉珀酸鈉針（甲強龍）、（申捷）單唾液酸四己糖神經(jīng)節(jié)苷脂鈉注射液、頭孢曲松他唑巴坦針（優(yōu)他能）。注射液、頭孢曲松他唑巴坦針（優(yōu)他能）。Limb brakeLimb brake（制動）（制動）, analgesic, analgesic（止痛），（止痛），nutritional nutritional supportsupport（營養(yǎng)支持）（營養(yǎng)支持） and other symptom

10、atic and other symptomatic treatmenttreatment第8頁/共19頁2022-7-2第9頁/共19頁2022-7-2T、P、H、R、BpSpecialty（?？魄闆r）（?？魄闆r）:Doublelowerlimbstactile（雙下肢）（雙下肢）feelnormal.Thestrengthoflowerlimbslevel。Theoperativewounddressingsisdryandclean,nobleeding,drainage(滲液滲液).第10頁/共19頁2022-7-23、Lackofknowledge:relatedtolackofdi

11、sease-relatedknowledge2、declineofself-careability:relatedtolongbedrest第11頁/共19頁2022-7-2Nursing target: the patient did not fallNursingevaluation:patientsdidnotfallduringhospitalization.第12頁/共19頁2022-7-2Nursing objectives: patients can adapt to the state of decline of self-care ability , and Life nee

12、ds can be satisfied 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（擦） back, etc.(3) keep warm while operation, and avoid exposure to

13、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 evaluation: patients adapt to the state, andThe decline of self-care ability during hospitalization has improved .第13頁/共19頁2022-7-2Nursing Objective: Th

14、e patient can describe the disease-related knowledgeNursing measures:(1) confirm the patients concerns about the disease and future lifestyle by talking, and explain or guide the patients concerns.(2) use easy to understand language to the patient to introduce the course and treatment.(3) Distribute

15、 health education prescription regularly . Provide the necessary learning materials for the patient.(4) encourage patients to ask questions, and answer to patient patiently .Nursing Rating: Patients can describe disease-related knowledge during hospitalization第14頁/共19頁2022-7-21,functionalexercise:Te

16、achpatientturnthebodylikeaxisturn(軸線翻身軸線翻身),raisingstraightlegexercise（直腿抬高運動）（直腿抬高運動）,quadricepsfemorisisotoniccontractionexercise（股四頭機等長收縮運動）（股四頭機等長收縮運動）andthecorrectwaytogetupandliedown.2,preventlunginfection:changethepositionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktosho

17、ot（翻身拍背）（翻身拍背）regular,promotelungsecretions（分泌物）（分泌物）andaccumulationofsputum（積痰）（積痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘連）（粘連）andspinejoint（脊柱關節(jié)）（脊柱關節(jié)）activitydecreased,andaffectingthespinemovement,whichresultinginchronicpaininthewaist(腰腰)andlowbackmuscleatrophy（腰背肌廢用性萎縮）（腰背肌廢用性萎縮

18、）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆便盆),inordertoavoidtodamagetheskin.第15頁/共19頁2022-7-24, regular outpatient review, if the lower back disco

19、mfort or lower limb numbness timely treatment1, Tell patient to exercise insistently after discharge , but should avoid fatigue(勞累), and prevent trauma（外傷）.2, Tell patient to strengthen nutrition intake, and enhance physical fitness(增強體質(zhì)), to guide the high protein intake, high vitamin diet.3, Expla

20、in the importance of the time to 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 of bending bent flexion(彎腰前屈) after 3 months ，and sleep at a hard bed.第16頁/共19頁17第17頁/共19頁2022-7-2Name: Name: Huang lixuanHuang lixuan（黃李軒）（黃李軒）Age: Age: 53-year-old Sex: male 53-year-old Sex: male bed number: bed number: GK2017 GK2017 Date of admission: Date of admission: March 23th,