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护理学院内科护理学教研室 王艳玲运动运动状态状态观察观察Observation of Exercise Status/FunctionLOGO课堂目标课堂目标v说出骨骼肌肉系统的结构与功能v描述运动状态观察的主要内容v说出如何通过问诊进行运动状态异常症状观察v识别运动状态的正常与异常体征v判断引起运动状态体征改变的各种因素v讨论运动状态异常的主要护理问题LOGO病例病例v 患者,男性,65岁,双膝乏力、疼痛,下蹲受限8年,加重伴行动困难6月。v 查体:双膝关节畸形,压痛,左膝屈曲70,外旋5,右膝屈曲80,外旋10,下蹲明显受限。LOGO一、肌肉骨骼的结构与功能一、肌肉骨骼的结构与功能vStructure Bones-Flat,Short,Long,Irregular Muscles visceral,cardiac,skeletal Joints slight moveable or freely,synovial fluid Cartilage,Ligaments,Tendons,Fascia,BursaevFunctionLOGO(一)(一)S&F of SkeletalS&F of SkeletalLOGO(一)(一)S&F of SkeletalS&F of Skeletal支持保护造血贮存运动骨骼的功能LOGO(二)(二)S&F of MuscleS&F of Musclev Smooth Muscle Involuntaryv Cardiac Muscle-Involuntary v Skeletal Muscle-Voluntary LOGO(三)(三)S&F of JointsS&F of JointsvNonsynovial Immovable Slightly movablevSynovial Cartilage LigamentLOGO(三)(三)S&F of JointsS&F of JointsLOGOJoints MovementsJoints Movementsv Flexion(屈)v Extension(伸)v Abduction(外展)v Adduction(内收)v Eversion(外翻)v Inversion(内翻)v Protraction(前伸)v Retraction(回缩)v Pronation(旋前)v Supination(旋后)v Rotation(旋转)v Circumduction(环转)v Elevation(提)v Depression(缩)LOGO1.Limbs1.Limbsv Shoulderv Elbowv Wrist and Carpalsv Hipv Kneev Ankle and footLOGO2.Spine2.SpineLOGO脊柱的标志与定位脊柱的标志与定位C2:第一个棘突C7:隆突Between T7&T8:肩胛下角连线L3:最长横突L4:双侧髂嵴最高点连线LOGO二、主观资料二、主观资料1.Joints2.Muscles3.Bones4.Functional assessment(ADL)5.Self-Care behaviorsLOGO病例病例v 患者,男性,65岁,双膝乏力、疼痛,下蹲受限8年,加重伴行动困难6月。v 查体:双膝关节畸形,压痛,左膝屈曲70,外旋5,右膝屈曲80,外旋10,下蹲明显受限。LOGO二、主观资料二、主观资料1.Joints Pain Stiffness(僵硬)Swelling,Heat,redness Limitation of movement LOGO二、主观资料二、主观资料2.Muscles Pain(Cramps)Weakness Atrophy3.Bones Pain Deformity(畸形)Trauma Fractures Sprains(扭伤)DislocationsLOGOCOLDSPA ExampleCOLDSPA Examplev Character:Describe the sign or symptoms.v Onset:When did it begin?v Location:Where is it?Radiate?v Duration:How longv Severity:How bad is it?v Pattern:What makes it better or worse?v Associated factors/How it Affects the clientCapital Medical University School of NursingLOGO二、主观资料二、主观资料vFunctional assessment activities of daily living(ADLs)Bathing,toileting,dressing,grooming,eating,mobility,communicatingvSelf-Care behaviors Exercise program,Weight gain Medication Affected:family,friends,yourselfLOGO病例病例v 患者,男性,65岁,双膝乏力、疼痛,下蹲受限8年,加重伴行动困难6月。v 查体:双膝关节畸形,压痛,左膝屈曲70,外旋5,右膝屈曲80,外旋10,下蹲明显受限。LOGO三、客观资料三、客观资料Capital Medical University School of Nursing动量触视LOGO三、客观资料三、客观资料vInspection:size and contourvPalpation:temperature,muscles,bony articulations,area of joints capsulevRange of Motion(ROM)vMuscle Testing:strengthCapital Medical University School of NursingLOGO(一)(一)SpineSpine1.Curve Convex thoracic curve/KyphosisConcave lumbar curve/Lordosis2.Motion and Expected Range3.Palpate the spinousLOGO1.1.CurveCurve(1)脊柱后凸:驼背,多发生于胸段佝偻病;脊柱结核;强直性脊柱炎;老年人;发育期姿势不良、外伤压缩性骨折、脊椎骨软骨炎(2)脊柱前凸:多发生于腰椎妊娠晚期、大量腹水、腹腔巨大肿瘤、髋关节结核及先天性髋关节后脱位LOGO1.Curve1.CurveKyphosisLOGO1.Curve1.CurveLOGO1.1.CurveCurve(3)脊柱侧凸(scoliosis):胸、腰段或胸、腰段联合发生1)姿势性侧凸:无结构的异常,平卧或向前弯腰时可使侧凸消失。2)颈段脊柱侧凸3)胸段脊柱侧凸4)腰段脊柱侧凸LOGO1.Curve1.CurveLOGO1.Curve1.CurveLOGO。2.Motion and Expected Range2.Motion and Expected Range(1)Cervical Spine Flexion&Extension Lateral bending Rotation(2)Lumbar Spine Lateral bending Hyperextension Rotation(bilaterally)LOGO3.Palpate the spinous3.Palpate the spinous(1)脊柱压痛:提示压痛部位的脊柱或肌肉可能有病变或损伤(2)脊柱叩击痛:提示该处有病变,如脊柱结核、脊椎骨折、脊椎肿瘤、椎间盘突出LOGO(二)四肢(二)四肢1.形态异常v匙状甲(koilonychia)LOGO(二)四肢(二)四肢1.形态异常v杵状指(clubbing)LOGO(二)四肢(二)四肢v1.形态异常v指关节变形 (1)梭形关节:类风湿关节炎(2)爪形手:进行性肌萎缩、脊髓空洞症,尺神经损伤(3)其他:老年性骨关节炎LOGO(二)四肢(二)四肢1.形态异常v腕关节变形(1)滑膜炎:类风湿关节炎(2)腱鞘囊肿:肌腱过度活动(3)其他:如腱鞘纤维脂肪瘤、软组织炎症、外伤与骨折LOGO(二)四肢(二)四肢1.形态异常v肩关节变形 正常呈弧形 方肩:肩关节脱位或三角肌萎缩LOGO (二)四肢(二)四肢1.形态异常v膝关节变形“O”形腿、“X”形腿 关节炎 关节积液LOGO(二)四肢(二)四肢1.形态异常v骨折与关节脱位LOGO(二)四肢的异常体征(二)四肢的异常体征LOGO(二)四肢(二)四肢2.活动异常(ROM)关节各方向的主动运动;被动运动观察其活动范围及有无疼痛LOGO病例病例v 患者,男性,65岁,双膝乏力、疼痛,下蹲受限8年,加重伴行动困难6月。v 查体:双膝关节畸形,压痛,左膝屈曲70,外旋5,右膝屈曲80,外旋10,下蹲明显受限。LOGO四、护理问题四、护理问题v躯体移动障碍v自理缺陷v废用综合征v疼痛v损伤的危险v活动无耐力v自我形象紊乱v皮肤完整性受损Capital Medical University School of Nursing
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