食管癌根治术护理查房ppt课件

食管癌根治术护理查房1食管癌根治术食管癌根治术护理查房1概述概述手术要点手术要点重点重点组织学分类组织学分类解剖解剖护理问题护理问题临床表现临床表现诊断诊断治疗治疗主要手术步骤主要手术步骤洗手护士配合要点洗手护士配合要点巡回护士配合要点巡回护士配合要点护理措施护理措施食管癌根治术护理查房2主讲内容概述手术要点重点组织学分类解剖护理问题临床表现诊断治解剖解剖前后扁窄的肌性管道上端：C6下缘续咽；下端：T11左侧与胃连 接；食管癌根治术护理查房3解剖前后扁窄的肌性管道食管癌根治术护理查房3生理狭窄生理狭窄食管入口处食管入口处气管分叉处气管分叉处膈肌裂孔处膈肌裂孔处食管癌根治术护理查房4生理狭窄食管入口处气管分叉处膈肌裂孔处食管癌根治术护理查房颈段颈段（5cm 5cm）食管入口食管入口-胸骨切迹胸骨切迹胸段胸段（18cm18cm）胸骨切迹胸骨切迹-膈裂孔处膈裂孔处上胸段上胸段：胸骨切迹：胸骨切迹-主动主动脉弓上缘脉弓上缘中胸段中胸段：主动脉上缘：主动脉上缘-肺肺下静脉下静脉下胸段下胸段：肺下静脉：肺下静脉-膈裂膈裂孔孔腹段腹段（2cm2cm）膈裂孔膈裂孔-贲门贲门 食管分段食管分段食管癌根治术护理查房5颈段（5cm）食管分段食管癌根治术护理查房5上段上段食管入口食管入口-主动脉弓上缘主动脉弓上缘 中段中段 主动脉弓上缘主动脉弓上缘-肺下静脉肺下静脉 下段下段 肺下静脉肺下静脉-贲门贲门临床分段临床分段食管癌根治术护理查房6上段临床分段食管癌根治术护理查房6食管癌根治术护理查房7食管癌根治术护理查房7发生于食管粘膜上皮的消发生于食管粘膜上皮的消化道恶性肿瘤化道恶性肿瘤男性多于女性男性多于女性我国食道癌发病率居世界我国食道癌发病率居世界之首，占各部位死亡率的之首，占各部位死亡率的第二位第二位5070岁最多见岁最多见食管癌食管癌食管癌根治术护理查房8发生于食管粘膜上皮的消化道恶性肿瘤食管癌食管癌根治术护理查化学性病因：亚硝胺化学性病因：亚硝胺生物性病因：真菌生物性病因：真菌微量元素缺乏：钼、铁、锌、氟、硒微量元素缺乏：钼、铁、锌、氟、硒缺缺乏乏维维生生素素：A A、B B2 2、C C及及动动物物蛋蛋白白、新新鲜鲜蔬蔬菜菜、水水果果摄摄入不入不 足足遗传易感性遗传易感性食食管管癌癌前前病病变变：食食管管慢慢性性炎炎症症、上上皮皮不不典典型型增增生生、贲贲门门失弛缓症、疤痕狭窄等失弛缓症、疤痕狭窄等不不良良的的嗜嗜好好及及饮饮食食习习惯惯：酒酒、烟烟、茶茶，粗粗、热热、硬硬、快快及蹲食等习惯及蹲食等习惯粘膜上皮损伤粘膜上皮损伤修复修复损伤损伤细胞增生活跃细胞增生活跃癌变癌变食管癌根治术护理查房9发病原因化学性病因：亚硝胺食管癌根治术护理查房9病理分型病理分型鳞状细胞癌鳞状细胞癌腺癌腺癌腺角化癌腺角化癌小细胞未分化癌小细胞未分化癌食管癌根治术护理查房10病理分型鳞状细胞癌食管癌根治术护理查房10临床分型临床分型食管癌根治术护理查房11临床分型食管癌根治术护理查房11髓质型髓质型蕈伞型蕈伞型溃疡型溃疡型缩窄型缩窄型临床分型临床分型食管癌根治术护理查房12髓质型蕈伞型溃疡型缩窄型临床分型食管癌根治术护理查房12临床病理分期临床病理分期食管癌根治术护理查房13临床病理分期食管癌根治术护理查房13TXTX：原发肿瘤不能测定：原发肿瘤不能测定T1T1：肿瘤侵及粘膜固有：肿瘤侵及粘膜固有层或粘膜下层层或粘膜下层 T2T2：肿瘤侵及肌层：肿瘤侵及肌层 T3T3：肿瘤侵及食管纤维：肿瘤侵及食管纤维膜膜 T4T4：肿瘤侵及邻近器官：肿瘤侵及邻近器官 食管癌TNM分期Nx:Nx:区域内淋巴结不区域内淋巴结不 能测定能测定 N0N0：无远处转移：无远处转移 N1N1：区域淋巴结转移：区域淋巴结转移 Mx:Mx:远处转移不能测定远处转移不能测定 M0M0：无远处转移：无远处转移 M1M1：有远处转移：有远处转移 食管癌根治术护理查房14TX：原发肿瘤不能测定食管癌TNM分期Nx:区域内淋巴结不颈部、锁骨上颈部、锁骨上颈部、锁骨上颈部、锁骨上 气管旁气管旁气管旁气管旁 隆突下隆突下隆突下隆突下 肺门肺门肺门肺门 肺下韧带肺下韧带肺下韧带肺下韧带 主动脉旁主动脉旁主动脉旁主动脉旁 食管旁食管旁食管旁食管旁 贲门贲门贲门贲门 胃左血管旁胃左血管旁胃左血管旁胃左血管旁食管癌根治术护理查房15贲门、食管淋巴结示意图颈部、锁骨上 食管癌根治术护理查房15临床表现临床表现早期：早期：早期：早期：1.1.1.1.梗噎感梗噎感梗噎感梗噎感 2.2.2.2.胸骨后烧灼感胸骨后烧灼感胸骨后烧灼感胸骨后烧灼感 3.3.3.3.异物感异物感异物感异物感 4.4.4.4.可无症状可无症状可无症状可无症状进展期：进展期：进展期：进展期：1.1.1.1.进行性吞咽困难（典型症状）进行性吞咽困难（典型症状）进行性吞咽困难（典型症状）进行性吞咽困难（典型症状）2.2.2.2.呕吐呕吐呕吐呕吐 3.3.3.3.胸背疼痛胸背疼痛胸背疼痛胸背疼痛 4.4.4.4.体重下降体重下降体重下降体重下降 晚期：晚期：晚期：晚期：1.1.侵犯穿孔：疼痛、呛咳、呕血侵犯穿孔：疼痛、呛咳、呕血 2.2.神经受累：声音嘶哑神经受累：声音嘶哑 3.3.恶病质：消瘦、贫血、低蛋白恶病质：消瘦、贫血、低蛋白 4.4.远处转移：锁骨上淋巴结、肝脏远处转移：锁骨上淋巴结、肝脏食管癌根治术护理查房16临床表现早期：1.梗噎感食管癌根治术护理查房16诊断诊断病史：进行性吞咽困难病史：进行性吞咽困难X X线食管钡餐检查线食管钡餐检查食管镜检查食管镜检查食管脱落细胞拉网检查食管脱落细胞拉网检查CTCT检查检查超声内镜检查超声内镜检查食管癌根治术护理查房17诊断病史：进行性吞咽困难食管癌根治术护理查房17治疗治疗手术治疗手术治疗 -根治性手术根治性手术 -姑息性手术姑息性手术内镜下治疗内镜下治疗 -食管扩张，食管支架食管扩张，食管支架 -内镜下电灼切除、内镜下电灼切除、光动力疗法等光动力疗法等化疗：化疗：5-Fu5-Fu和顺铂为主和顺铂为主放疗：外放射为主放疗：外放射为主以手术为主的综合治疗以手术为主的综合治疗食管癌根治术护理查房18治疗手术治疗食管癌根治术护理查房18早期食管癌早期食管癌中期（中期（）颈段颈段3cm3cm胸上段胸上段4cm4cm胸下段胸下段5cm5cm全身情况好者全身情况好者中期（中期（）病变在病变在5cm5cm以上以上无明显远处转移无明显远处转移术前放化疗与手术综合术前放化疗与手术综合放射复发，无远处转移，全身情况良好者放射复发，无远处转移，全身情况良好者 食管癌根治术护理查房19手术适应证早期食管癌食管癌根治术护理查房19病变侵犯范围大病变侵犯范围大有远处转移有远处转移 全身情况差，呈恶病质全身情况差，呈恶病质食管癌根治术护理查房20手术禁忌证病变侵犯范围大食管癌根治术护理查房20手术疗法手术疗法左进胸左进胸右进胸：管状胃右进胸：管状胃三切口三切口食管癌根治术护理查房21手术疗法左进胸食管癌根治术护理查房21手术疗法手术疗法食管癌根治术护理查房22手术疗法食管癌根治术护理查房22PowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMorePowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn 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MoreMoreMoreMore食管癌根治术护理查房ppt课件PowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMore食管癌根治术护理查房ppt课件PowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMore食管癌根治术护理查房ppt课件PowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMore食管癌根治术护理查房ppt课件PowerPoinPowerPoinPowerPoinPowerPoint t t t Slide Slide Slide Slide ShowShowShowShowConvert PowerPoint to flash for web sharing.Post your slide show on Myspace and blog.Convert PowerPoint to video or burn to DVD.Present your slide show on TV to share with family.Add flash-based quizzes and demos to slide show to interact with your audience.Learn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMoreLearn Learn Learn Learn MoreMoreMoreMore食管癌根治术护理查房ppt课件1 1、肿瘤切除率：对奇静脉和主动脉弓水平有外侵的肿瘤，、肿瘤切除率：对奇静脉和主动脉弓水平有外侵的肿瘤，右进胸切除机率较高右进胸切除机率较高2 2、手术创伤：右进胸增加了腹部切口但有利于对腹腔淋巴结、手术创伤：右进胸增加了腹部切口但有利于对腹腔淋巴结 的清扫；左进胸不需加腹部切口，但切开膈肌的清扫；左进胸不需加腹部切口，但切开膈肌 对呼吸功能有一定损害，亦不利于对腹腔淋巴对呼吸功能有一定损害，亦不利于对腹腔淋巴 结的清扫结的清扫3 3、淋巴清扫：右进胸对胸段食管显露好，便于食管旁淋巴结、淋巴清扫：右进胸对胸段食管显露好，便于食管旁淋巴结 的清扫的清扫左、右进胸比较左、右进胸比较食管癌根治术护理查房471、肿瘤切除率：对奇静脉和主动脉弓水平有外侵的肿瘤，左、右全胃全胃管状胃管状胃食管癌根治术护理查房48全胃与管状胃全胃管状胃食管癌根治术护理查房48胃短动脉胃短动脉胃左动脉胃左动脉胃右动脉胃右动脉胃网膜右动脉胃网膜右动脉淋巴结淋巴结食管癌根治术护理查房49胃的动脉血供胃短动脉胃左动脉胃右动脉胃网膜右动脉淋巴结食管癌胃左动脉胃左动脉胃右动脉胃右动脉胃短动脉胃短动脉胃网膜左动胃网膜左动脉脉胃网膜右动胃网膜右动脉脉食管癌根治术护理查房50胃的血管网胃左动脉胃右动脉胃短动脉胃网膜左动脉胃网膜右动脉食管状胃管状胃：以胃底最高点处小弯侧管状胃：以胃底最高点处小弯侧1-2cm1-2cm作为起点，于胃右动脉作为起点，于胃右动脉近幽门侧近幽门侧2-3cm2-3cm分支处切断胃右动静脉及所属小网膜所有组织，分支处切断胃右动静脉及所属小网膜所有组织，以该点作为以该点作为“管状胃管状胃”裁制的终点，以直线切割缝合器切除裁制的终点，以直线切割缝合器切除至少至少1/31/3的胃组织，仅保留胃大弯部制成的胃组织，仅保留胃大弯部制成“管状胃管状胃”，管状胃，管状胃外径约外径约4-6cm4-6cm为宜为宜食管癌根治术护理查房51管状胃管状胃：以胃底最高点处小弯侧1-2cm作为起点，于胃右1 1、可以有效延长胃的长度，消除吻合、可以有效延长胃的长度，消除吻合后吻合口张力后吻合口张力2 2、管状胃上窄下宽，形态上更接近原、管状胃上窄下宽，形态上更接近原食管及胃食管及胃3 3、管状胃易置于食管床，其扩张程度、管状胃易置于食管床，其扩张程度较小，对心肺压迫较轻较小，对心肺压迫较轻4 4、管状胃在胃血供不变的情况下切除、管状胃在胃血供不变的情况下切除胃小弯侧和贲门，使原来供应该区域的胃小弯侧和贲门，使原来供应该区域的血液重新分配，使残胃血供更为丰富，血液重新分配，使残胃血供更为丰富，有利于吻合口愈合有利于吻合口愈合5 5、减少胃泌酸组织，使胃泌素水平下、减少胃泌酸组织，使胃泌素水平下降，术后反流少，反流性食管炎发生率降，术后反流少，反流性食管炎发生率降低，应激性溃疡发生率低降低，应激性溃疡发生率低6 6、管状胃切除贲门、胃小弯及所属淋、管状胃切除贲门、胃小弯及所属淋巴结，可减少术后癌肿复发率巴结，可减少术后癌肿复发率成本高成本高食管癌根治术护理查房52管状胃优点1、可以有效延长胃的长度，消除吻合后吻合口张力成本1、平卧位：腹部胃游离、淋巴结清扫及管状胃成形2、左侧卧位：食管游离、淋巴结清扫剑突水平与腋中线交界处1cm小切口：观察镜腋前线第4肋间或第5肋间3cm小切口：主操作孔腋后线第6肋间1cm切口：次孔3、吻合：于主操作孔内吻合 颈段：左胸锁乳突肌前缘切口分离拿出食管近断端，将管状胃经右胸食管床拉至颈部行胃-食管吻合食管癌根治术护理查房53手术步骤1、平卧位：腹部胃游离、淋巴结清扫及管状胃成形食管癌术前访视术前访视器械器械准备齐全准备齐全超声刀的正确安装、使超声刀的正确安装、使用用术中无菌操作术中无菌操作熟练配合，节省手术时熟练配合，节省手术时间，减少并发症的发生间，减少并发症的发生食管癌根治术护理查房54洗手护士配合要点术前访视食管癌根治术护理查房54术前访视术前访视器械性能的检查、准备器械性能的检查、准备配合麻醉师实施麻醉配合麻醉师实施麻醉正确安放手术体位正确安放手术体位正确连接腔镜器械，调正确连接腔镜器械，调节参数节参数术中加强观察术中加强观察患者的保温患者的保温标本的正确处理标本的正确处理妥善固定引流管妥善固定引流管食管癌根治术护理查房55巡回护士配合要点术前访视食管癌根治术护理查房55恐惧、焦虑：与环境改变，对手术的担忧有关恐惧、焦虑：与环境改变，对手术的担忧有关有皮肤完整性受损的危险：与手术时间长及有皮肤完整性受损的危险：与手术时间长及 体位摆放有关体位摆放有关疼痛：与手术切口有关疼痛：与手术切口有关有灼伤的危险：与电外科仪器的使用有关有灼伤的危险：与电外科仪器的使用有关有低体温的危险：与手术暴露有关有低体温的危险：与手术暴露有关食管癌根治术护理查房56可能出现的护理问题及措施恐惧、焦虑：与环境改变，对手术的担忧有体液不足的危险：与切口暴露与输液不足有体液不足的危险：与切口暴露与输液不足 有关有关有感染的危险：与手术切口、抵抗力下降、有感染的危险：与手术切口、抵抗力下降、留置导尿有关留置导尿有关潜在并发症：出血；肿瘤细胞种植转移；乳糜胸；吻合口潜在并发症：出血；肿瘤细胞种植转移；乳糜胸；吻合口瘘瘘食管癌根治术护理查房57可能出现的护理问题及措施有体液不足的危险：与切口暴露与输液不术前访视，介绍手术室环境，耐心解答病人提出的问题术前访视，介绍手术室环境，耐心解答病人提出的问题介绍医生资质，介绍成功病例介绍医生资质，介绍成功病例病人进入手术室后热情接待病人，多与病人交流，尽量满病人进入手术室后热情接待病人，多与病人交流，尽量满足病人的要求足病人的要求食管癌根治术护理查房58恐惧、焦虑：与环境改变，对手术的担忧有关术前访视，介绍手术正确安置体位，骨突处安置软垫正确安置体位，骨突处安置软垫术中加强观察术中加强观察避免皮肤接触潮湿、金属物品避免皮肤接触潮湿、金属物品食管癌根治术护理查房59有皮肤完整性受损的危险：与手术时间长有关正确安置体位，骨突术前做好解释安慰工作，告诉病人疼痛与精神心理因素的术前做好解释安慰工作，告诉病人疼痛与精神心理因素的关系关系协助麻醉师实施麻醉协助麻醉师实施麻醉教会病人转移疼痛的方法教会病人转移疼痛的方法术后连接好镇痛泵，并教会其正确使用术后连接好镇痛泵，并教会其正确使用导尿管、引流管固定好，防止牵拉引起的疼痛导尿管、引流管固定好，防止牵拉引起的疼痛注意切口敷料干燥，避免感染加重疼痛注意切口敷料干燥，避免感染加重疼痛食管癌根治术护理查房60疼痛：与手术切口有关术前做好解释安慰工作，告诉病人疼痛与精神术前检查仪器的性能，保证术前检查仪器的性能，保证其完好其完好正确安放负极板，保证电流正确安放负极板，保证电流回路的通畅回路的通畅避免病人肢体接触金属避免病人肢体接触金属术中加强巡视术中加强巡视不盲目加大电刀功率不盲目加大电刀功率手术结束后，检查病人皮肤，手术结束后，检查病人皮肤，做出正确评估做出正确评估食管癌根治术护理查房61有灼伤的危险：与电外科仪器的使用有关术前检查仪器的性能，保证术前安放好手术体位后，注意病人术前安放好手术体位后，注意病人保暖保暖术中熟练配合，尽量减少手术时间术中熟练配合，尽量减少手术时间冲洗液温度控制于冲洗液温度控制于4040 4242输液适当加温输液适当加温术中加强观察和监测术中加强观察和监测适当使用加温装置，如变温毯等适当使用加温装置，如变温毯等食管癌根治术护理查房62有低体温的危险：与手术暴露与大量冲洗液的应用有关术前安放好手熟练配合，减少手术时间熟练配合，减少手术时间术中加强观察，评估尿量，及时补液术中加强观察，评估尿量，及时补液正确的输血与输液正确的输血与输液配合止血配合止血食管癌根治术护理查房63有体液不足的危险：与手术暴露与输液不足有关熟练配合，减少手术术前术前30min30min应用抗生素，超过应用抗生素，超过3h3h加用抗生素加用抗生素术中严格控制参观人数术中严格控制参观人数术中严格各项无菌操作术中严格各项无菌操作固定好导尿管和引流管，防止逆流固定好导尿管和引流管，防止逆流保持引流通畅保持引流通畅保持敷料干燥，防止感染保持敷料干燥，防止感染食管癌根治术护理查房64有感染的危险：与手术切口、抵抗力下降、留置导尿有关术前30m正确配合，及时止血正确配合，及时止血及时输血、输液及时输血、输液加强无瘤操作加强无瘤操作食管癌根治术护理查房65潜在并发症：出血；肿瘤细胞种植转移正确配合，及时止血食管癌根预预防防开展卫生宣教开展卫生宣教开展普查普治开展普查普治早期诊断及处理早期诊断及处理严密随访高危人群严密随访高危人群食管癌根治术护理查房66小结预开展卫生宣教开展普查普治早期诊断及处理严密随访高危人群食管癌根治术护理查房67Thank You!食管癌根治术护理查房67