胸外科護理查房最終版

SpontaneousPneumothoraxThoracicsurgerynursingwardroundThespeaker:WuhanPolytechnicUniversity自發(fā)性氣胸GroupdivisionoflaborCase-------------------------------------甄媛媛Etiologyandclassification-----于廣平馬瑩Clinicalmanifestations----------蔣娟Auxiliaryexaminationand--------桓秀山劉嚴逸夫TherapeuticprinciplesNursingmeasures----------------毛雅琴潘娟王輝Healtheducation-----------------李飄飄趙娟

CASE

PatientYuWeichengmale17years Withpainatleftchestanddifficultybreathing,chestdistress10days.Pastmedicalhistory: Alwaysbodyhealth,denyhistoryofotherseriousdiseasesanddrugallergy.Historyofpresentdisease: Withoutanyobviouscause,hefeltpainattheleftchestanddifficultybreathing,chestdistress10daysago.Nofever,lowhead,cough,haemoptysis,lackofpower,nightsweatandsoon.Atfirstdidnotpayattentiontothese,butsymptomsfornoease.Achestradiographyshowedthattheleftlungtissuecompressionby85%.Physicalexamination:T37.3,P96/min,R20/min,BP140/80mmHgIntelligenceclear,trachealatthecenterofneck.Theleftbreathsoundsalittleweak.Diagnosticexamination:WBC11.410^9,N8.05,L18.1Admissiondiagnosis:SpontaneousPneumothorax

病例患者：

余煒成，男，17歲

左側(cè)胸痛、胸悶伴呼吸困難10天。既往史：既往體健，否認其他重大疾病病史及藥物過敏史?，F(xiàn)病史：患者于10天前無明顯誘因，自感左側(cè)胸痛、胸悶，偶有呼吸困難，無發(fā)熱、咳嗽、咳痰、咯血、心慌、乏力、盜汗、聲嘶等不適。起初未予注意，癥狀持續(xù)無明顯緩解，胸片檢查，提示：左側(cè)肺組織壓縮85%左右。體格檢查：T37.3,P96次/分,

R20次/分,BP140/83mmHg,神智清楚，皮膚鞏膜無黃染，氣管居中，左側(cè)呼吸音稍弱，未明顯干濕羅音。輔助檢查：WBC11.410^9,N8.05,L18.1入院診斷：左側(cè)自發(fā)性氣胸Etiologyandclassification病因及分類THESPEAKER:于廣平ThecauseofspontaneouspneumothoraxClassificationofoneSpontaneouspneumothoraxTraumapneumothoraxArtificialpneumothoraxClassificationoftwoClosedpneumothoraxOpenpneumothoraxTensionpneumothoraxThecauseofspontaneouspneumothoraxWhenatriggercausesalveolarpressurerisesharply,lesionsofthelungandpleuralruptureoccurs,thepleuralcavityiscommunicatedwiththeair,airflowwillflowintothethoraxleadtotheformationofspontaneouspneumothorax.Clinicalmanifestations臨床表現(xiàn)與體征——蔣娟Clmicalmanifestations

（臨床表現(xiàn)）：

Suddenchestpain（突然發(fā)生胸痛），difficultyinbreathing（呼吸困難），chesttightness(胸悶)，inseverecasesirritability、profusely、cyanosis（嚴重者煩躁不安、大汗、紫紺）acceleratedrespiration（呼吸加快），pulsebreakdownandevendeath（脈搏細數(shù)甚至死亡）。Signs（體征）：

Frachealshifttothecontralateral（氣管向健側(cè)移位）。Ipsilateralchestfull（患側(cè)胸部飽滿）weakeningordisappearanceofresiratorymotion（呼吸運動減弱或消失）。Percussiondrumsound（叩診呈鼓音），fremitusanddecreasedbreathsound（語顫呼吸音減弱）。Auxiliaryexamination

輔助檢查THESPEAKER:桓秀山11

Auxiliaryexamination1.X-ray

2.CT3.Pleuralcavityangiography4.Thoracoscopic12Auxiliaryexamination1.X-rayexaminationisthemostreliablemethodofdiagnosisofpneumothoraTypicalpneumothoraxX-rayfindingsofthepneumothoraxpartthroughthebrightnessincrease,nomarkings,thepulmonaryhilaratrophy,higherdensity,andtheedgeofthevisiblehairline-likevisceralpleurashadow;Contralaterallungcompensatoryemphysema,lungmarkings;TracheawithConcurrentpleuralfluidorblood,fluidlevelscanbeseen.mediastinalshifttothecontralateral;X線檢查是診斷氣胸最可靠的方法。典型的氣胸X線表現(xiàn)為氣胸部分透亮度增加，無肺紋理，肺向肺門萎縮，密度增高，其邊緣可見發(fā)線樣臟層胸膜陰影；健側(cè)肺可有代償性肺氣腫，肺紋理增粗；氣管與縱隔可向健側(cè)移位；并發(fā)胸水或血液時，可見到液平面。

13Auxiliaryexamination2.CTIsmoresensitivetothediagnosisofasmallamountofgasinthepleuralcavityClearlyshowsasmallamountofpneumothoraxandlungtissueoverlappingpartsofthepneumothorax;Location,extentdeterminethepleuralproductgas;Mayfoundemphysemablister;Easytoidentifythelimitationsofpneumothoraxandlungbullae.2.CT對胸腔內(nèi)少量氣體的診斷較為敏感可清晰地顯示少量氣胸和與肺組織重疊部位的氣胸；確定胸腔積氣的位置、程度；有可能發(fā)現(xiàn)肺氣腫皰；易于鑒別局限性氣胸和肺大皰。143.PleuralcavityangiographyThismethodcanclearthepleuralsurface,easytoclearthecauseofpneumothorax.Whenthelungcompressionareain30%～40%whenthecontrastisappropriate,bullaislobeprofilewithinasingleormultiplecysticlowdensityshadow;abubblesprayperformanceforpleuralphenomenon,especiallywhenpatientswithcough,duetointrapulmonarypressureincreases,thisphenomenonismoreobvious.此方法可以明了胸膜表面的情況，易于明確氣胸的病因。當肺壓縮面積在30%～40%時行造影為宜，肺大泡表現(xiàn)為肺葉輪廓之內(nèi)單個或多個囊狀低密度影；胸膜裂口表現(xiàn)為冒泡噴霧現(xiàn)象，特別是當患者咳嗽時，由于肺內(nèi)壓增高，此征象更為明顯。154.ThoracoscopicThoracoscopycaneasilydetectpneumothoraxetiology,flexibleoperation,canreachtheinterlobarfissure,apex,hilar,almostnoblindspots,observethevisceralpleurawithnorips,pleurawithoutbullaeoflungandchestcavitywithnoadhesivejoint.胸腔鏡可以較容易地發(fā)現(xiàn)氣胸的病因，操作靈活，可達葉間裂、肺尖、肺門，幾乎沒有盲區(qū)，觀察臟層胸膜有無裂口、胸膜下有無肺大泡及胸腔內(nèi)有無粘連帶。16

Principlesoftreatment

治療原則17Principlesoftreatment1.Conservativetreatment2.Exhausttreatment3.Operationtreatment18

1.ConservativetreatmentMainlyapplicabletothestabilityofasmallamountofclosedpneumothorax

Specificmethods:strictbedresanalgesicdrugs.t,oxygen,bronchodilator.bronchospasm,grantingthesedativeand主要適用穩(wěn)定型小量閉合性氣胸具體方法：嚴格臥床休息、給氧，支氣管痙攣者使用支氣管擴張劑，酌情給予鎮(zhèn)靜鎮(zhèn)痛等藥物。192.Exhausttreatment1.張力性氣胸病情危急可行緊急排氣2.胸腔穿刺抽氣適用小量氣胸，呼困較輕，心肺功能尚好的閉合性氣胸。3.胸腔閉式引流適用不穩(wěn)定氣胸，呼困明顯，交貨張氣胸，反復發(fā)生氣胸的病人Tensionpneumothoraxincriticalconditionfeasibleemergencyexhaust2pleuralpunctureexhaustapplyasmallamountofpneumothorax,respiratorydifficultieslighter,theclosedpneumothoraxheartandlungfunctionisstillgood.Closedthoracicdrainageunstablepneumothoraxapplicablecalltrappedobvious,deliveryZhangpneumothorax,recurrentpneumothoraxpatients20Operationtreatment

ThoracoscopicandThoracotomy21胸腔鏡通過二至三個“鑰匙孔”，在電視影像監(jiān)視輔助下完成過去由傳統(tǒng)開胸進行的操作手術(shù)。其本質(zhì)是用“腔鏡”做手術(shù)，相對于傳統(tǒng)的開刀手術(shù)具有創(chuàng)傷小、恢復快、住院時間短等技術(shù)特點

Thoracoscopic

Completeoperatingtraditionalthoracotomysurgeryinthepasttwotothree"keyhole"intheTVimage

monitoringaid.Byitsverynatureis

laparoscopic"surgery,relativeto

traditionalopensurgerywithlesstrauma,recoveryfaster,shorterhospitalstayandothertechnicalfeatures22

外科手術(shù)治療

手術(shù)的目的是結(jié)扎或切除肺大皰、或胸膜修補、或?qū)Ρ趯有啬で谐蚰Σ链偈蛊渑c臟層胸膜粘連，防止氣胸復發(fā)。Surgicaltreatment

Thepurposeofsurgicalligationorresectionofbullae,orpleuralrepairorresectionorfrictionparietalpleuraprocureitsvisceralpleuraladhesions,andtopreventtherecurrenceofpneumothorax.23Nursing

diagnosisandmeasuresTHESPEAKER:王輝、毛雅琴、潘娟24護理診斷Nursing

diagnosisimpairedGasexchangepain(1234painatchest)Theriskofinfection56Activitieswithoutendurancenutritionalteredknowledgedeficit護理措施Nursingmeasures1.ImpairedGasexchangeMeasures：a.Observepatient'sTemperature，breathing，pulse，bloodpressureb.Observepatient'sbonythoraxmovementandtherangoftherespiratorynotion,andauscultationpatient'sbreathingsoundc.Keepthethoraciccloseddrainagesystemfixed,beclosedtightlyandbeunobstructed.(保持閉式引流裝置固定、密閉等）d.Observethefluctuationofthewatercolumn,colore.Tochangethethoracicregularity,andpreventretyogradeinfectionCloseddrainageofthoraciccavity1.Positivepressurecontinuousexhaustmethod.2.Continuesthenegativepressureexhaustmethod.DrainagebottlepositionpsychologicalnutritionenvironmentmedicinepainTheriskofinfection1.Tokeeprespiratorytractunobstructedpromptlyeliminatesputum2.Dooralcare,preventsecondaryinfection3.KeepcloseddrainagesystemsterileActivitieswithoutendurance

a.Completebedrest,takehalf-clinostatism.b.Askthepatienttoavoidtoholdhisbreathandtocoughintensity.c.Givinglowflowoxygen.

Malnutrition1.Givehighprotein2.Highvitamin3.LighteasytodigestfoodLackofknowledgea.Avoidpressureshockb.Keepwarmc.keepbowelsopen