临床常用诊疗技术课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式文本样式文本,样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,临床常用诊疗技术,临床常用诊疗技术,1,穿刺术,胸膜腔穿刺术,腹膜腔穿刺术,骨髓穿刺术,腰椎穿刺术,注意事项,方法,目的,操作过程：,1、常规消毒皮肤，戴无菌手套，,铺消毒洞巾,2、2%利多卡因局部浸润麻醉,3、进针，抽液,4、拔出穿刺针，覆盖无菌洞巾，,稍用力压迫片刻,穿刺术胸膜腔穿刺术注意事项操作过程：,2,一、胸膜腔穿刺术,1、目的：,2、方法：,明确积液的性质,抽液减轻压迫症状,穿刺给药,1.体位,患者多取,坐位,。面向椅背，两手交叉抱臂，置于椅背，头枕臂上，使肋间隙增宽；不能坐起者，可采取,半卧位,，举起患侧上臂,2、穿刺部位：,胸部叩诊实音最明显的部位，,多取肩胛线或腋后线第7-8肋间,腋中线第6-7肋间,腋前线第5肋间,一、胸膜腔穿刺术1、目的：明确积液的性质1.体位,3,3、注意事项：,操作前向病人说明穿刺目的，消除顾虑。,操作中密切观察病人反应。,一次抽液不可过多、过快。,严格无菌操作，防止空气进入胸腔。,病情危重、有出血倾向或严重肺气肿者，更应慎重。,1、,胸膜反应,：头晕、面苍、出汗、心悸、胸部压迫感或剧痛、昏厥等。,2、出现连续性咳嗽、气短、咯泡沫痰。,3、,处理,：立即停止抽液，并皮下注射0.1%肾上腺素0.3-0.5ml,1、诊断性抽液：50-100ml,2、减压抽液：,600ml（首次）,1000ml（以后）,3、脓胸者：尽量抽净,4、检查瘤细胞：至少100ml,3、注意事项：1、胸膜反应：头晕、面苍、出汗、心悸、胸部压迫,4,二、腹膜腔穿刺术,1、目的：同胸膜腔穿刺术,2、方法：,穿刺前须排空尿液,体位：坐位（坐在靠背椅上）、半卧位、平卧位或侧卧位,穿刺点,：,左下腹部,脐与髂前上棘连线的中外1/3交界点；,侧位,脐的水平线与腋前线或腋中线交叉处，常用于诊断性穿刺；,坐位,可取脐与耻骨联合连线中点上方1.0cm、稍偏左或偏右1-1.5cm处；,积液量少或有包裹分隔时,，须经B超定位。,二、腹膜腔穿刺术1、目的：同胸膜腔穿刺术穿刺前须排空尿液,5,3、注意事项,放液前后测量腹围、P、BP，检查腹部体征,术中密切观察病人R、P、面色。,术后平卧，使穿刺孔位于上方。,少量腹水行诊断性穿刺前，病人侧卧于拟穿刺侧,5min,放液不可过多、过快：,3000ml/次,禁忌证,：有肝性脑病先兆、包虫病、结腹腹腔内广泛粘连、巨大卵巢囊肿者,3、注意事项放液前后测量腹围、P、BP，检查腹部体征,6,三、骨髓穿刺术（髂穿）,1、目的：,细胞形态学检查,病原微生物学检查,细胞遗传学分析,造血干细胞培养,三、骨髓穿刺术（髂穿）1、目的：,7,2、方法：,穿刺部位：,髂前上棘穿刺点（仰卧位）：髂前上棘后1-2cm,髂后上棘穿刺点（侧卧位）：,骶椎两侧，臀部上方突出部位,胸骨穿刺点（仰卧位）：,胸骨柄或胸骨体相当于1、2肋间隙处,腰椎穿刺点（坐或侧卧位）：腰椎棘突突出处,2、方法：穿刺部位：,8,3、注意事项：,术前做BT、CT检查，,出血倾向者慎重，,血友病病人禁做,注射器与穿刺针必须干燥，以免溶血,髂骨穿刺深度约1.5cm，胸骨约1.0cm,抽液量:,细胞形态学检查0.2ml，细菌培养1-2ml,骨髓液取出后立即涂片,3、注意事项：,9,四、腰椎穿刺术,1、目的：,2、方法：,检查脑脊液性质,测定颅内压力，了解蛛网膜下腔是否阻塞,鞘内注射给药,侧卧于硬板床，背部与床板垂直，头向前胸屈曲，双手抱膝使其紧贴腹部，使躯干呈弓形。,穿刺点：髂后上棘连线与后正中线交汇处（约为,第3-4腰椎棘突间隙,）最适宜（或上或下一椎间隙）,进针深度：成人约4-6cm，儿童约2-4cm,动力试验（或称梗阻试验）,术后去枕平卧4-6小时,四、腰椎穿刺术1、目的：检查脑脊液性质侧卧于硬板床，背部与,10,临床常用诊疗技术课件,11,梗阻试验,1、正常脑脊液压力：,0.69-1.76kpa(70-180mmHg）或40-50滴/分钟,2、方法：测定初压后，压迫一侧颈静脉约10s,脑脊液压力立即上升1倍左右，解除压力后10-20s又迅,速降至原来水平，称为该侧,动力试验（+）,蛛网膜下腔通畅,。,蛛网膜下腔完全梗阻,：,压迫颈静脉后，CSF压力不上升。,动力试验（-）,蛛网膜下腔不完全梗阻,：,压迫颈静脉后，CSF压力缓慢上升，放松后又缓慢下降。,动力试验（-）,梗阻试验1、正常脑脊液压力：,12,3、注意事项：,禁忌证,：颅内明显高压；,休克，衰竭或濒危状态的患者；,穿刺部位或附近有感染者。,对疑有颅内压增高者必须做眼底检查，,如有明显视乳头水肿或有脑疝先兆者应禁忌穿刺。,针头刺入皮下组织后进针要缓慢，,以免用力过猛时刺伤马尾神经或血管，,产生下肢疼痛或使脑脊液混入血液影响结果的判断。,鞘内给药时，应先放出等量脑脊液，后注入药物。,3、注意事项：,13,mnemonics讲解,mnemonics讲解,14,rote learning,机械学习,Rote,learning,is a memorization technique based on repetition.,Spontaneous,自发的;自然的;天然产生的;无意识的,bordering on an identity crisis,rote learning,15,postcard/p9ustk3d/n.明信片,fascinate/f2sineit/vt.使着迷,enthralling/inFr8liM/adj.迷人的,auditorium/,5dit5ri9m/n.会堂；礼堂,applaud/9pl5d/v.拍手喝彩,fright/frait/n.受惊；惊骇,dedication/,dedikeiH9n/n.贡献,奉献,get over 克服,turn up 出现,ply/plai/vt.不断劝人吃喝,unorthodox/7n5F9d4ks/adj.非正统的；异端的,rote/r9ut/n.死记硬背,spontaneous/sp4nteinj9s/adj.自然产生的,decent/d1snt/adj.正派的；端庄的,break the ice 打破沉默,warm up 热身,border on 濒临,postcard/p9ustk3d/n.明信片,16,Ive heard a saying that went something like,if you stay in a country for three weeks you can write a book,three months a postcard,and three years nothing!I am now faced with this problem.Having lived in China for about five years,I am totally used to daily life here.That shouldnt be something to complain about,right?Adapting to a different society and culture is something to be satisfied with,is it not?Usually it would be.However,it makes writing a column about my impressions of China a lot more difficult.,In the West,student life is a combination of study and socializing with a heavy emphasis placed on the socializing part!I was genuinely impressed by the dedication and motivation of Chinese students.When I was a student I would rarely give up my spare time to any activity connected with study.Unless exams were approaching,my weekends were devoted to having fun or perhaps a part-time job.My Chinese students,on the other hand,seemed to spend their entire waking hours studying.I understand that competition in Chinese universities is extremely intense.Nonetheless,their energy and drive put me to shame.,Ive heard a saying that went,17,It may be true that rote learning is over-emphasized in Chinese education.Nonetheless,I found that this does not reflect the natural character of Chinese students.Given the appropriate classroom atmosphere and a chance to warm up,the students I met were naturally spontaneous and instinctively enjoyed drama.In some of the role-plays we acted out,certain students became so involved in their parts that they were bordering on an identity crisis!,Thanks to the politeness and warmth of Chinese students,I conquered my fear of speaking in public and became more self-confident.Most importantly,I met dozens of fine decent people and made numerous excellent friends.,It may be true that rote learn,18,临床常用诊疗技术课件,19,我曾经听说过一个谚语，它好像是说如果你在一个国家呆上三礼拜，你能写一本书，如果是三个月，能写一张明信片；而如果是三年的话，就什么也写不出来了!我现在就碰到了这个问题。我在中国已经生活了五年，所以我已经完全适应了这里的日常生活。这可不是什么应该抱怨的事，对吧?融入到一个不同的社会和文化氛围当中是一件值得满足的事情，不是吗?通常情况下是这么回事的。然而，当我负责一个描述我对中国感受的栏目时，这一情况却大大增加了我的写作难度。,在西方社会，学生生活包含学习与社会交往两个部分，而侧重点则是社会交往!中国学生的这种付出和干劲确实给我留下了深深的印象。当我还是一个学生的时候，我几乎不会为了与学习相关的活动而牺牲我的业余时间。除非是为了迎接考试，否则我的周末全都用于玩乐或者用于做兼职。我的中国学生却截然不同，他们似乎是