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

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Acaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房Speaker&Physicalexamination&PPTproduction：石彩蘭Advisor：王莉GuangzhoumedicaluniversityPPT模板下載：行業(yè)PPT模板：Acaseofthor1Generalinformation（一般資料）2022/12/15Name:Huanglixuan（黃李軒）Age:53-year-oldSex:malebednumber:GK2017Dateofadmission:March23th,2017Chiefcomplaint（主訴）:Lowbackpainthreemonths,increasedwithnumbnessofbothlowerlimbsamonth.（腰痛三月，加重伴雙下肢麻木一月）Diagnosis:Thoracictumor(胸椎腫瘤)Generalinformation（一般資料）2022/2

Patient‘scondition（病情匯報）

2022/12/15Admission:

T37.0°C,P70times/min,R20times/min,BP120/60mmHg.Surgery:2017-03-24,generalanesthesiawiththoracicspinetumorresection(全麻下胸椎腫瘤切除)+thoracicinternalfixation（胸椎內(nèi)固定術(shù)）

Patient‘scondition（病情匯報）

203Auxiliarycheck（輔助檢查）：2022/12/15（2017-02-15，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影，考慮腫瘤，骨髓瘤可能性大；胸3、8椎體異常信號影，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Auxiliarycheck（輔助檢查）：2022/12/4Auxiliarycheck（輔助檢查）：（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。2022/12/15（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Auxiliarycheck（輔助檢查）：（2017-035Auxiliarycheck（輔助檢查）：2022/12/15項目名稱結(jié)果參考范圍單位提示癌胚抗原5.710-5ug/L↑細(xì)胞角蛋白19片段3.360-3.3ug/L↑白細(xì)胞計數(shù)22.73.5~9.510^9/L

↑血紅蛋白158130~175g/L正?？偟鞍?3.165~85g/L↓尿素/肌酐30.7115~24Ratio↑補體單體0.140.16~0.38g/L↓白蛋白35.340~55g/L↓總膽汁酸17.10~9.67umol/L↑Auxiliarycheck（輔助檢查）：2022/12/6Auxiliarycheck（輔助檢查）：2022/12/15項目名項目名稱結(jié)果參考范圍單位提示丙氨酸氨基轉(zhuǎn)移酶2059~50U/L↑α-羥丁酸脫氫酶20572~182U/L↑天門冬氨酸氨基轉(zhuǎn)移酶6915~40U/L↑乳酸脫氫酶294120~250U/L↑γ-谷氨酰基轉(zhuǎn)移酶7410~60U/L↑肌酸激酶同工酶MB活性260~25U/L↑總膽固醇5.853.00~5.18mmol/L↑高密度脂蛋白膽固醇2.091.16~1.42mmol/L↑Auxiliarycheck（輔助檢查）：2022/12/7Diagnosis:Thoracictumor(胸椎腫瘤)4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.Nursingevaluation:patientsdidnotfallduringhospitalization.3、Lackofknowledge:relatedtolackofdisease-relatedknowledgePPT模板下載：行業(yè)PPT模板：3、腰3/4、4/5椎間盤膨出；1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Speaker&Physicalexamination1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Thedeclineofself-careabilityduringhospitalizationhasimproved.3、腰3/4、4/5椎間盤膨出；Surgery:2017-03-24,generalanesthesiawiththoracicspinetumorresection(全麻下胸椎腫瘤切除)+thoracicinternalfixation（胸椎內(nèi)固定術(shù)）Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatmentNursingevaluation:patientsdidnotfallduringhospitalization.胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；Dischargeinstruction（出院指導(dǎo)）：Acaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房3、Lackofknowledge:relatedtolackofdisease-relatedknowledge(3)Distributehealtheducationprescriptionregularly.3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.Basictreatment&medication

（基本治療&用藥）：

2022/12/15PO：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）。Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatmentDiagnosis:Thoracictumor(胸椎腫8床邊體查2022/12/15床邊體查2022/12/159

Resultsofphysicalexamination(體查結(jié)果)Currentcondition:patientswiththoracicinternalfixationonthe15thdayaftersurgery,lowerlimbnumbness(下肢麻木無力),postoperative（術(shù)后）wounddressingclean,nobleedingexudate,（滲液）nowaistpain,dizziness（頭暈）andothersymptoms,andconsciousnessisclear，appetite(食欲)iswellandhaveagoodspirit.Hissleepiswellnow,anddefecateandurinateisnormal.2022/12/15T、P、H、R、BpSpecialty（?？魄闆r）:Doublelowerlimbstactile（雙下肢）feelnormal.ThestrengthoflowerlimbsⅣlevel。Theoperativewounddressingsisdryandclean,nobleeding,drainage(滲液).Resultsofphysicalexaminat10Nursingdiagnosis（護(hù)理診斷）1、Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）2022/12/153、Lackofknowledge:relatedtolackofdisease-relatedknowledge2、declineofself-careability:relatedtolongbedrestNursingdiagnosis（護(hù)理診斷）1、Risk11Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）Nursingmeasures:1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(體位性低血壓),especiallyatnight.3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.

2022/12/15Nursingtarget:thepatientdidnotfallNursingevaluation:patientsdidnotfallduringhospitalization.Riskoffalls:associatedwith122、declineofself-careability:relatedtolongbedrest

2022/12/15Nursingobjectives: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.2、declineofself-careability132022/12/153、Lackofknowledge:relatedtolackofdisease-relatedknowledge

NursingObjective:Thepatientcandescribethedisease-relatedknowledgeNursingmeasures:(1)confirmthepatient'sconcernsaboutthediseaseandfuturelifestylebytalking,andexplainorguidethepatient'sconcerns.(2)useeasytounderstandlanguagetothepatienttointroducethecourseandtreatment.(3)Distributehealtheducationprescriptionregularly.Providethenecessarylearningmaterialsforthepatient.(4)encouragepatientstoaskquestions,andanswertopatientpatiently.NursingRating:Patientscandescribedisease-relatedknowledgeduringhospitalization2022/12/153、Lackofknowledge:14healtheducation（健康教育）2022/12/151,functionalexercise:Teachpatientturnthebodylikeaxisturn(軸線翻身),raisingstraightlegexercise（直腿抬高運動）,quadricepsfemorisisotoniccontractionexercise（股四頭機等長收縮運動）andthecorrectwaytogetupandliedown.2,preventlunginfection:changethepositionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktoshoot（翻身拍背）regular,promotelungsecretions（分泌物）andaccumulationofsputum（積痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘連）andspinejoint（脊柱關(guān)節(jié)）activitydecreased,andaffectingthespinemovement,whichresultinginchronicpaininthewaist(腰)andlowbackmuscleatrophy（腰背肌廢用性萎縮）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆),inordertoavoidtodamagetheskin.healtheducation（健康教育）2022/12/15Dischargeinstruction（出院指導(dǎo)）：2022/12/154,regularoutpatientreview,ifthelowerbackdiscomfortorlowerlimbnumbnesstimelytreatment1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.2,Tellpatienttostrengthennutritionintake,andenhancephysicalfitness(增強體質(zhì)),toguidethehighproteinintake,highvitamindiet.3,Explaintheimportanceofthetimetoactivitiesindetail,inordertoensurethestabilityoftheinternalfixation(內(nèi)固定),andgetoutofthegroundtoactivitiesmustwearbrace(支具),andstandingwalkingtimeshouldnotbetoolong.Practicetheexerciseofbendingbentflexion(彎腰前屈)after3months，andsleepatahardbed.Dischargeinstruction（出院指導(dǎo)）：2016(3)keepwarmwhileoperation,andavoidexposuretothepatienttoolongtopreventcolds.Generalinformation（一般資料）2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(體位性低血壓),especiallyatnight.Currentcondition:(2)domorningcareinordertoincreasethecomfortofpatient:washface,washhands,oralcare,warmwaterwipe（擦）back,etc.PPT模板下載：行業(yè)PPT模板：4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.&PPTproduction：石彩蘭Diagnosis:Thoracictumor(胸椎腫瘤)(1)explaintheimportanceofcleaning-caretothepatient.2、T9椎體壓縮性改變胸Providethenecessarylearningmaterialsforthepatient.Practicetheexerciseofbendingbentflexion(彎腰前屈)after3months，andsleepatahardbed.Dateofadmission:March23th,2017結(jié)合病史，考慮腫瘤性病變與椎體壓縮性骨折相鑒別。Name:Huanglixuan（黃李軒）1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；Age:53-year-oldSex:male（2017-02-15，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。Thedeclineofself-careabilityduringhospitalizationhasimproved.Auxiliarycheck（輔助檢查）：4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；3、腰3/4、4/5椎間盤膨出；4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.(1)explaintheimportanceofcleaning-caretothepatient.1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Nursingevaluation:patientsdidnotfallduringhospitalization.Nursingobjectives:patientscanadapttothestateofdeclineofself-careability,andLifeneedscanbesatisfiedduringhospitalization.1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.肌酸激酶同工酶MB活性4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Diagnosis:Thoracictumor(胸椎腫瘤)Auxiliarycheck（輔助檢查）：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）。胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；(1)explaintheimportanceofcleaning-caretothepatient.(1)confirmthepatient'sconcernsaboutthediseaseandfuturelifestylebytalking,andexplainorguidethepatient'sconcerns.(2)domorningcareinordertoincreasethecomfortofpatient:washface,washhands,oralcare,warmwaterwipe（擦）back,etc.(3)Distributehealtheducationprescriptionregularly.Speaker&Physicalexamination4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.PPT模板下載：行業(yè)PPT模板：4,regularoutpatientreview,ifthelowerbackdiscomfortorlowerlimbnumbnesstimelytreatment（2017-02-15，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。3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）Nursingtarget:thepatientdidnotfallProvidethenecessarylearningmaterialsforthepatient.3,Explaintheimportanceofthetimetoactivitiesindetail,inordertoensurethestabilityoftheinternalfixation(內(nèi)固定),andgetoutofthegroundtoactivitiesmustwearbrace(支具),andstandingwalkingtimeshouldnotbetoolong.2、T9椎體壓縮性改變胸Diagnosis:Thoracictumor(胸椎腫瘤)IV：注射用帕瑞昔布鈉（特耐）；Doublelowerlimbstactile（雙下肢）feelnormal.3、Lackofknowledge:relatedtolackofdisease-relatedknowledgeProvidethenecessarylearningmaterialsforthepatient.(1)confirmthepatient'sconcernsaboutthediseaseandfuturelifestylebytalking,andexplainorguidethepatient'sconcerns.（2017-03-24，我院）胸部正側(cè)位：1、雙肺及心膈未見異常。IM：鼠神經(jīng)生長因子注射劑（恩經(jīng)復(fù)）；4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.Thedeclineofself-careabilityduringhospitalizationhasimproved.節(jié)日PPT模板：素材下載：3、Lackofknowledge:relatedtolackofdisease-relatedknowledge（2017-02-15，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。Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）Nursingevaluation:patientsdidnotfallduringhospitalization.（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。Nursingtarget:thepatientdidnotfallAcaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房healtheducation（健康教育）2、T9椎體壓縮性改變胸2、declineofself-careability:relatedtolongbedrestWord教程：教程：胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）2,Tellpatienttostrengthennutritionintake,andenhancephysicalfitness(增強體質(zhì)),toguidethehighproteinintake,highvitamindiet.Auxiliarycheck（輔助檢查）：Doublelowerlimbstactile（雙下肢）feelnormal.(3)keepwarmwhileoperation,andavoidexposuretothepatienttoolongtopreventcolds.Nursingevaluation:patientsdidnotfallduringhospitalization.Nursingtarget:thepatientdidnotfallThedeclineofself-careabilityduringhospitalizationhasimproved.1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.Nursingdiagnosis（護(hù)理診斷）Diagnosis:Thoracictumor(胸椎腫瘤)PPT背景圖片：圖表下載：Auxiliarycheck（輔助檢查）：Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatmentDateofadmission:March23th,20173、腰3/4、4/5椎間盤膨出；2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(體位性低血壓),especiallyatnight.2,Tellpatienttostrengthennutritionintake,andenhancephysicalfitness(增強體質(zhì)),toguidethehighproteinintake,highvitamindiet.Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatment17Thankyou！(3)keepwarmwhileoperation,17PPT模板下載：行業(yè)PPT模板：節(jié)日PPT模板：素材下載：PPT背景圖片：圖表下載：優(yōu)秀PPT下載：教程：Word教程：教程：資料下載：課件下載：范文下載：試卷下載：教案下載：

Acaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房Speaker&Physicalexamination&PPTproduction：石彩蘭Advisor：王莉GuangzhoumedicaluniversityPPT模板下載：行業(yè)PPT模板：Acaseofthor18Generalinformation（一般資料）2022/12/15Name:Huanglixuan（黃李軒）Age:53-year-oldSex:malebednumber:GK2017Dateofadmission:March23th,2017Chiefcomplaint（主訴）:Lowbackpainthreemonths,increasedwithnumbnessofbothlowerlimbsamonth.（腰痛三月，加重伴雙下肢麻木一月）Diagnosis:Thoracictumor(胸椎腫瘤)Generalinformation（一般資料）2022/19

Patient‘scondition（病情匯報）

2022/12/15Admission:

T37.0°C,P70times/min,R20times/min,BP120/60mmHg.Surgery:2017-03-24,generalanesthesiawiththoracicspinetumorresection(全麻下胸椎腫瘤切除)+thoracicinternalfixation（胸椎內(nèi)固定術(shù)）

Patient‘scondition（病情匯報）

2020Auxiliarycheck（輔助檢查）：2022/12/15（2017-02-15，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影，考慮腫瘤，骨髓瘤可能性大；胸3、8椎體異常信號影，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Auxiliarycheck（輔助檢查）：2022/12/21Auxiliarycheck（輔助檢查）：（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。2022/12/15（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Auxiliarycheck（輔助檢查）：（2017-0322Auxiliarycheck（輔助檢查）：2022/12/15項目名稱結(jié)果參考范圍單位提示癌胚抗原5.710-5ug/L↑細(xì)胞角蛋白19片段3.360-3.3ug/L↑白細(xì)胞計數(shù)22.73.5~9.510^9/L

↑血紅蛋白158130~175g/L正?？偟鞍?3.165~85g/L↓尿素/肌酐30.7115~24Ratio↑補體單體0.140.16~0.38g/L↓白蛋白35.340~55g/L↓總膽汁酸17.10~9.67umol/L↑Auxiliarycheck（輔助檢查）：2022/12/23Auxiliarycheck（輔助檢查）：2022/12/15項目名項目名稱結(jié)果參考范圍單位提示丙氨酸氨基轉(zhuǎn)移酶2059~50U/L↑α-羥丁酸脫氫酶20572~182U/L↑天門冬氨酸氨基轉(zhuǎn)移酶6915~40U/L↑乳酸脫氫酶294120~250U/L↑γ-谷氨?；D(zhuǎn)移酶7410~60U/L↑肌酸激酶同工酶MB活性260~25U/L↑總膽固醇5.853.00~5.18mmol/L↑高密度脂蛋白膽固醇2.091.16~1.42mmol/L↑Auxiliarycheck（輔助檢查）：2022/12/24Diagnosis:Thoracictumor(胸椎腫瘤)4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.Nursingevaluation:patientsdidnotfallduringhospitalization.3、Lackofknowledge:relatedtolackofdisease-relatedknowledgePPT模板下載：行業(yè)PPT模板：3、腰3/4、4/5椎間盤膨出；1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Speaker&Physicalexamination1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.Thedeclineofself-careabilityduringhospitalizationhasimproved.3、腰3/4、4/5椎間盤膨出；Surgery:2017-03-24,generalanesthesiawiththoracicspinetumorresection(全麻下胸椎腫瘤切除)+thoracicinternalfixation（胸椎內(nèi)固定術(shù)）Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatmentNursingevaluation:patientsdidnotfallduringhospitalization.胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；Dischargeinstruction（出院指導(dǎo)）：Acaseofthoracicvertebralinternalfixationsurgerypatientsafternursingcarerounds

一例胸椎內(nèi)固定術(shù)術(shù)后患者的護(hù)理查房3、Lackofknowledge:relatedtolackofdisease-relatedknowledge(3)Distributehealtheducationprescriptionregularly.3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.Basictreatment&medication

（基本治療&用藥）：

2022/12/15PO：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）。Limbbrake（制動）,analgesic（止痛），nutritionalsupport（營養(yǎng)支持）andothersymptomatictreatmentDiagnosis:Thoracictumor(胸椎腫25床邊體查2022/12/15床邊體查2022/12/1526

Resultsofphysicalexamination(體查結(jié)果)Currentcondition:patientswiththoracicinternalfixationonthe15thdayaftersurgery,lowerlimbnumbness(下肢麻木無力),postoperative（術(shù)后）wounddressingclean,nobleedingexudate,（滲液）nowaistpain,dizziness（頭暈）andothersymptoms,andconsciousnessisclear，appetite(食欲)iswellandhaveagoodspirit.Hissleepiswellnow,anddefecateandurinateisnormal.2022/12/15T、P、H、R、BpSpecialty（專科情況）:Doublelowerlimbstactile（雙下肢）feelnormal.ThestrengthoflowerlimbsⅣlevel。Theoperativewounddressingsisdryandclean,nobleeding,drainage(滲液).Resultsofphysicalexaminat27Nursingdiagnosis（護(hù)理診斷）1、Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）2022/12/153、Lackofknowledge:relatedtolackofdisease-relatedknowledge2、declineofself-careability:relatedtolongbedrestNursingdiagnosis（護(hù)理診斷）1、Risk28Riskoffalls:associatedwithlongbedsidelowerlimbmuscleweakness（下肢肌無力）Nursingmeasures:1,Tellthepatientandfamilymemberstostaywithpatientallthetime,andifneedhelpringthatcallnurses.2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(體位性低血壓),especiallyatnight.3,Whenwalkingdizziness,lowerlimbweakness,andgaitinstabilityandcannotmove,immediatelysitdowninsitu(原地),andcallhelp.4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.

2022/12/15Nursingtarget:thepatientdidnotfallNursingevaluation:patientsdidnotfallduringhospitalization.Riskoffalls:associatedwith292、declineofself-careability:relatedtolongbedrest

2022/12/15Nursingobjectives: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.2、declineofself-careability302022/12/153、Lackofknowledge:relatedtolackofdisease-relatedknowledge

NursingObjective:Thepatientcandescribethedisease-relatedknowledgeNursingmeasures:(1)confirmthepatient'sconcernsaboutthediseaseandfuturelifestylebytalking,andexplainorguidethepatient'sconcerns.(2)useeasytounderstandlanguagetothepatienttointroducethecourseandtreatment.(3)Distributehealtheducationprescriptionregularly.Providethenecessarylearningmaterialsforthepatient.(4)encouragepatientstoaskquestions,andanswertopatientpatiently.NursingRating:Patientscandescribedisease-relatedknowledgeduringhospitalization2022/12/153、Lackofknowledge:31healtheducation（健康教育）2022/12/151,functionalexercise:Teachpatientturnthebodylikeaxisturn(軸線翻身),raisingstraightlegexercise（直腿抬高運動）,quadricepsfemorisisotoniccontractionexercise（股四頭機等長收縮運動）andthecorrectwaytogetupandliedown.2,preventlunginfection:changethepositionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktoshoot（翻身拍背）regular,promotelungsecretions（分泌物）andaccumulationofsputum（積痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘連）andspinejoint（脊柱關(guān)節(jié)）activitydecreased,andaffectingthespinemovement,whichresultinginchronicpaininthewaist(腰)andlowbackmuscleatrophy（腰背肌廢用性萎縮）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆),inordertoavoidtodamagetheskin.healtheducation（健康教育）2022/12/32Dischargeinstruction（出院指導(dǎo)）：2022/12/154,regularoutpatientreview,ifthelowerbackdiscomfortorlowerlimbnumbnesstimelytreatment1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.2,Tellpatienttostrengthennutritionintake,andenhancephysicalfitness(增強體質(zhì)),toguidethehighproteinintake,highvitamindiet.3,Explaintheimportanceofthetimetoactivitiesindetail,inordertoensurethestabilityoftheinternalfixation(內(nèi)固定),andgetoutofthegroundtoactivitiesmustwearbrace(支具),andstandingwalkingtimeshouldnotbetoolong.Practicetheexerciseofbendingbentflexion(彎腰前屈)after3months，andsleepatahardbed.Dischargeinstruction（出院指導(dǎo)）：2033(3)keepwarmwhileoperation,andavoidexposuretothepatienttoolongtopreventcolds.Generalinformation（一般資料）2,changethepositionshouldobeywiththe"threesteps",thatislying30seconds,situp30seconds,andstand30secondsbeforethewalkinordertoavoidorthostatichypotension(體位性低血壓),especiallyatnight.Currentcondition:(2)domorningcareinordertoincreasethecomfortofpatient:washface,washhands,oralcare,warmwaterwipe（擦）back,etc.PPT模板下載：行業(yè)PPT模板：4,wearanti-skidslippers（拖鞋）andtheappropriate（合適的）clothesinordertoavoidtripping,andtakebedbarwhensleepatbed.&PPTproduction：石彩蘭Diagnosis:Thoracictumor(胸椎腫瘤)(1)explaintheimportanceofcleaning-caretothepatient.2、T9椎體壓縮性改變胸Providethenecessarylearningmaterialsforthepatient.Practicetheexerciseofbendingbentflexion(彎腰前屈)after3months，andsleepatahardbed.Dateofadmission:March23th,2017結(jié)合病史，考慮腫瘤性病變與椎體壓縮性骨折相鑒別。Name:Huanglixuan（黃李軒）1,Tellpatienttoexerciseinsistentlyafterdischarge,butshouldavoidfatigue(勞累),andpreventtrauma（外傷）.胸3、8椎體異常信號影，脂肪沉積與血管瘤鑒別；Age:53-year-oldSex:male（2017-02-15，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。Thedeclineofself-careabilityduringhospitalizationhasimproved.Auxiliarycheck（輔助檢查）：4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneed