外科護(hù)理學(xué)腸梗阻

張某，男性，48歲陣發(fā)性腹痛、惡心、嘔吐、停止排便、排氣三天。

2年前曾行闌尾切除術(shù)。入院檢查：T37.8℃P110次/分BP16/11Kpa呈急性病容，神志清Casestudy整理ppt腹部膨隆見腸型及蠕動(dòng)波，腸鳴音亢進(jìn)有氣過水聲，腹部壓痛明顯，以右側(cè)腹為重，有輕度腹肌緊張及反跳痛，叩診為鼓音。X線：腸脹氣，腸管增粗并有液平面。血液檢查：WBC13×109/LN92%Na+120mmol/LK+3.0mmol/L血糖10.5mmol/LCasestudy整理ppt腸梗阻Intestinalobstraction泰山醫(yī)學(xué)院張愛華整理ppt

Whenevergastrointestinalluminalcontentispathologicallypreventedfrompassingdistally

Conception任何原因引起的腸內(nèi)容物不能正常運(yùn)行，順利通過腸道時(shí)，稱為腸梗阻〔intestinalobstruction)。整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.Theextentofobstruction5.ProgressionofobstructionClassification整理ppt１.AccordingtoitsBasiccauses機(jī)械性腸梗阻〔mechanicalobstruction〕動(dòng)力性腸梗阻〔dynamicobstruction〕血運(yùn)性腸梗阻〔obstructionofvascularsupplyorigin〕Classification整理pptClassificationmechanicalobstruction〔verycommon)A.腸腔堵塞B.腸管受壓粘連帶壓迫ascaridhernia整理pptmechanicalobstructionC.腸壁病變inflammatoryneoplasticClassification整理ppt

DynamicobstructionCauses:

NervalreflexortoxinstimulationClassification麻痹性腸梗阻〔Paralyticileus〕：acutediffuseperitonitis,abdominaloperation,retroperitonealhematomaandinfection痙攣性腸梗阻〔Spasticobstruction〕

Classification整理pptObstructionofvascularsupplyoriginthrombosisorembolism,thenintestinalparalysisClassification整理ppt1.按梗阻發(fā)生的原因2.按腸壁有無血運(yùn)障礙單純性腸梗阻

(Simpleobstruction)絞窄性腸梗阻

(Strangulationobstruction)IntussceptionVolvulusClassification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.按梗阻發(fā)生的部位高位腸梗阻(highobstruction)低位腸梗阻(lowobstruction)Classification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.按梗阻發(fā)生的程度完全性腸梗阻(completeobstruction)不完全性腸梗阻(Incompleteobstruction)Classification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.Theextentofobstruction5.按梗阻發(fā)生的速度急性腸梗阻(Acuteobstruction)慢性腸梗阻(chronicobstruction)Classification整理pptPathophysiology

整理pptSimplemechanicalobstruction梗阻以上腸蠕動(dòng)增多(contractsvigorously)梗阻以上腸管膨脹(distention)梗阻以下腸管癟陷膨脹和癟陷交界處為梗阻所在腸管局部變化Pathophysiology整理pptAcutecompleteobstruction

腸腔壓力↑→靜脈回流受阻→腸壁水腫、增厚、呈暗紅色→動(dòng)脈血運(yùn)受阻→腸管變成紫黑色→壞死、穿孔。Pathophysiology腸管局部變化整理pptChronicincompleteobstruction

梗阻以上腸腔擴(kuò)張、腸壁代償性肥厚腹壁視診?？梢姅U(kuò)大的腸型和腸蠕動(dòng)坡。Pathophysiology腸管局部變化整理ppt全身性病理生理改變主要由于體液喪失、腸膨脹、毒素的吸收和感染所致Pathophysiology整理ppt體液喪失(loseofbodyfluid)引起水、電解質(zhì)紊亂與酸堿失衡全身性感染和毒血癥腹膜炎和中毒(peritonitisandpoisoning)shockrespirationandcirculationdisorder)Pathophysiology全身性病理改變整理pptClinicalManifestations整理ppt痛吐脹閉

張某，男性，48歲陣發(fā)性腹痛、惡心、嘔吐出大量草綠色液體，1天后出現(xiàn)腹脹、3天來無排便。

2年前曾行闌尾切除術(shù)

ClinicalManifestations整理pptClinicalManifestationsPain（痛）Vomitting（吐）Distension（脹）Constipation（閉）整理ppt痛吐脹閉特點(diǎn)

脹痛持續(xù)性疼痛,陣發(fā)性加劇陣發(fā)性絞痛持續(xù)性絞痛StrangulationClinicalManifestationsParalyticileusmechanicalobstructionobstructionofvascularsupplyorigin整理ppt痛吐脹閉特點(diǎn)

出現(xiàn)早且頻繁出現(xiàn)晚、次數(shù)少且量多次數(shù)多且量多次數(shù)少且量少暗紅或血性液體high/StrangulationLowobstructionCompletelyincompletelyStrangulationClinicalManifestations整理ppt痛吐脹閉腹部膨隆腸腔擴(kuò)張ClinicalManifestations整理pptHowtoobservedistention？

腹部膨隆腹壁緊張、皮膚發(fā)亮呼吸困難、不能平臥

X線檢查血?dú)馔赐旅涢]ClinicalObservations整理ppt機(jī)理痛吐脹閉

腸管失去蠕動(dòng)功能腸蠕動(dòng)不能正常推進(jìn)ClinicalManifestations整理ppt痛吐脹閉特點(diǎn)完全停止排便、排氣屢次少量排便、排氣早期有少量排便、排氣粘液樣血便CompletelyincompletelyhighStrangulationClinicalManifestations整理ppt

ClinicalManifestationsR↑、HR↑、BP↑痛吐脹閉脫水、電解質(zhì)紊亂、酸堿失衡腸壁缺血壞死、穿孔毒素吸收→毒血癥shock整理ppt

Abruptonsetwithcontinousacuteabdominalpain.earlyvomittingshockManifestationofperitonitis。T↑P↑

。Asymmetricaldistention,localbulge,ormasswithtenderness。Characteristicofstrangulationintestinalobstruction〔1〕整理pptHemicvomitus,drainageConservativetreatmentinvainandnoimprovementinsymptomsandsignsX線檢查符合絞窄性腸梗阻特點(diǎn)Characteristicofstrangulationintestinalobstruction〔2〕整理ppt魚骨刺狀脹大腸袢Characteristicofstrangulationintestinalobstruction整理pptaccessoryexamination整理ppt1.化驗(yàn)檢查血紅蛋白值↑血細(xì)胞比容↑尿化重↑白細(xì)胞、中性粒細(xì)胞↑糞便、血?dú)夥治鲅娊赓|(zhì)、尿素氮肌酐Accessoryexamination整理ppt2.X檢查

立位或側(cè)臥位透視或拍片。可見多數(shù)液平面及氣脹腸袢。Accessoryexamination氣液平面整理pptDiagnosis

整理pptCaseReviewT37.8℃P96次/分BP126/78mmHg腹部膨隆，見腸型及胃腸蠕動(dòng)波腸鳴音亢進(jìn)，有氣過水聲叩診呈鼓音右側(cè)腹部壓痛明顯X線提示有氣液平整理pptmustmakeclearthefollowingquestionsWhetherintestinalobstructionexists?Whethertheobstructionismechanicalordynamic?Whethertheobstructionissimpleorstrangulationobstruction?Whethertheobstructionishighorlow?Whethertheobstructioniscompleteorincomplete?

Diagnosis整理pptTreatment&NursingCare整理ppt

預(yù)防和糾正水、電解質(zhì)、酸堿平衡紊亂解除梗阻治療原那么Treatment&NursingCare整理ppt為什么要求患者禁食？如何指導(dǎo)患者禁食？禁食胃腸減壓解痙止痛補(bǔ)液電解質(zhì)抗感染

Treatment&NursingCare整理ppt目的：排液、排氣，減輕腹脹，病情觀察護(hù)理要點(diǎn)：有效引流關(guān)注引流液的量、顏色、性質(zhì)及其變化禁食胃腸減壓解痙止痛補(bǔ)液電解質(zhì)抗感染Treatment&NursingCare整理ppt未明確診斷之前：如何執(zhí)行四禁嚴(yán)密觀察下應(yīng)用解痙止痛劑

禁用嗎啡類止痛劑

禁食胃腸減壓解痙止痛補(bǔ)液電解質(zhì)抗感染Treatment&NursingCare整理ppt提供補(bǔ)液的可靠依據(jù)〔記錄出入量〕補(bǔ)液量補(bǔ)充電解質(zhì)配合糾正酸中毒禁食胃腸減壓解痙止痛補(bǔ)液電解質(zhì)抗感染Treatment&NursingCare整理ppt合理應(yīng)用抗生素抗生素的配伍應(yīng)用的時(shí)間觀察療效、觀察副作用實(shí)施營養(yǎng)支持禁食胃腸減壓解痙止痛補(bǔ)液電解質(zhì)抗感染Treatment&NursingCare整理ppt解除梗阻手術(shù)治療適用于各種類型的絞窄性腸梗阻、腫瘤及先天性腸道畸形引起的腸梗阻，以及非手術(shù)治療無效的病人。Treatment&NursingCare整理ppt原那么和目的在最短手術(shù)時(shí)間內(nèi)，以最簡單的方法解除梗阻或恢復(fù)腸腔的通暢。Treatment&NursingCare整理pptoperation

A.解除梗阻原因的術(shù)式

如粘連松解術(shù)整理pptB.腸切除腸吻合術(shù)C.短路手術(shù)整理pptD.腸造口和腸外置術(shù)整理ppt如腸切開取異物，腸扭轉(zhuǎn)復(fù)位術(shù)。整理pptSpecialintestinalobstruction整理ppt較為常見，發(fā)生率20-40%Causes：手術(shù)：最多炎癥：腸粘連腸梗阻條件：①腸腔縮窄②粘連牽扯成角③粘連帶壓迫④腸袢套入粘連環(huán)⑤腸袢在粘連處扭轉(zhuǎn)一定條件粘連性腸梗阻整理pptTreatment非手術(shù)療法較好①口服生植物油②解痙劑③經(jīng)胃管緩慢注入氧氣，驅(qū)蟲每周歲80—100ml，最大不超過1500ml整理ppt性質(zhì)：閉袢性腸梗阻絞窄性腸梗阻扭轉(zhuǎn)方向：順時(shí)針旋轉(zhuǎn)多見程度：輕：3600以下重：2—3轉(zhuǎn)部位：小腸、乙狀結(jié)腸腸扭轉(zhuǎn)〔volvulus)整理ppt1.小腸扭轉(zhuǎn)多見于青壯年誘因：飽食后劇烈活動(dòng)病癥特點(diǎn)：①腹痛發(fā)作急驟②牽涉腰背部③喜胸膝位或蜷曲側(cè)臥位④嘔吐頻繁、腹脹不顯⑤易休克整理ppt2.乙狀結(jié)腸扭轉(zhuǎn)多見于老年人，常有便秘習(xí)慣，除腹部絞痛外，有明顯腹脹，而嘔吐一般不明顯。低壓灌腸：量常少于500mlX線平片：馬蹄狀雙腔充氣腸袢鋇灌：尖端呈“鳥嘴〞形整理ppt整理ppt治療

死亡率15—40%

原因：就診過晚治療延誤

方法：及時(shí)手術(shù)

方式：①扭轉(zhuǎn)復(fù)位術(shù)②腸切除術(shù)整理pptsummary整理pptConceptionWhenevergastrointestinalluminalcontentispathologicallypreventedfrompassingdistally整理pptClassificationmechanicalobstructiondynamicobstructionobstructionofvascularsupplyoriginSimpleandstrangulationobstructionHighandlow