骨科二区胸椎内固定术术后护理查房

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,*,*,PPT,模板下载：行业,PPT,模板：,节日,PPT,模板：素材下载：,PPT,背景图片：图表下载：,优秀,PPT,下载：教程：,Word,教程：教程：,资料下载：课件下载：,范文下载：试卷下载：,教案下载：,A case of thoracic vertebral internal fixation surgery patients after nursing care rounds,一例胸椎内固定术术后患者的护理查房,Speaker&Physical examination,&PPT production,：石彩兰,Advisor,：王莉,Guangzhou medical university,General information一般资料,2024/11/20,Name:Huang lixuan黄李轩,Age:53-year-old Sex:male,bed number:GK2021,Date of admission:March 23th,2021,Chief complaint主诉:Low back pain three months,increased with numbness of both lower limbs a month.腰痛三月，加重伴双下肢麻木一月,Diagnosis:Thoracic tumor(胸椎肿瘤),Patients condition病情汇报,2024/11/20,Admission:T 37.0 C,P 70 times/min,R 20 times/min,BP 120/60 mmHg.,Surgery:2021-03-24,general anesthesia with thoracic spine tumor resection(全麻下胸椎肿瘤切除)+thoracic internal fixation胸椎内固定术,Auxiliary check辅助检查：,2024/11/20,2021-02-15，广州市番禺区第二人民医院腰部CT提示：L3/4、L4/5椎间盘膨出，L5/S1椎间盘突出，腰椎退行性病变，胸12椎体骨质破坏。,2021-03-21，解放军第四五八医院腰椎MR提示：1、胸9、12椎体及椎旁异常信号影，考虑肿瘤，骨髓瘤可能性大；胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；2、腰2、4椎体占位性病变；3、腰3/4、4/5椎间盘膨出；4、腰椎退行性病变,Auxiliary check辅助检查：,2021-03-24，我院全身骨显像：第10胸椎骨代谢异常局灶性增高活泼。结合病史，考虑肿瘤性病变与椎体压缩性骨折相鉴别。,2024/11/20,2021-03-24，我院胸部正侧位：1、双肺及心膈未见异常。2、T9椎体压缩性改变胸,Auxiliary check辅助检查：,2024/11/20,项目名称,结果,参考范围,单位,提示,癌胚抗原,5.71,0-5,ug/L,细胞角蛋白,19,片段,3.36,0-3.3,ug/L,白细胞计数,22.7,3.59.5,10,9,/L,血红蛋白,158,130175,g/L,正常,总蛋白,63.1,6585,g/L,尿素,/,肌酐,30.71,1524,Ratio,补体单体,0.14,0.160.38,g/L,白蛋白,35.3,4055,g/L,总胆汁酸,17.1,09.67,umol/L,Auxiliary check辅助检查：,2024/11/20,工程名,项目名称,结果,参考范围,单位,提示,丙氨酸氨基转移酶,205,950,U/L,-,羟丁酸脱氢酶,205,72182,U/L,天门冬氨酸氨基转移酶,69,1540,U/L,乳酸脱氢酶,294,120250,U/L,-,谷氨酰基转移酶,74,1060,U/L,肌酸激酶同工酶,MB,活性,26,025,U/L,总胆固醇,5.85,3.005.18,mmol/L,高密度脂蛋白胆固醇,2.09,1.161.42,mmol/L,Basic treatment&medication根本治疗&用药：,2024/11/20,PO：多烯磷脂酰胆碱胶囊易善复、丁二磺酸腺苷蛋氨酸肠溶片喜美欣；,IV：注射用帕瑞昔布钠特耐；,IM：鼠神经生长因子注射剂恩经复；,Ivgtt：五水头孢唑林注射剂新泰林、醒脑静、注射用丹参多酚酸盐、地塞米松磷酸钠注射液&甘露醇注射液、小牛皮提取物注射液斯普林、骨肽注射液鼓键、甲泼尼龙琥珀酸钠针甲强龙、申捷单唾液酸四己糖神经节苷脂钠注射液、头孢曲松他唑巴坦针优他能。,Limb brake制动,analgesic止痛，nutritional support营养支持 and other symptomatic treatment,床边体查,2024/11/20,Results of physical examination(,体查结果,),Current condition:,patients with thoracic internal fixation on the 15th day after surgery,lower limb numbness(下肢麻木无力),postoperative术后 wound dressing clean,no bleeding exudate,渗液 no waist pain,dizziness头晕 and other symptoms,and consciousness is clear，appetite(食欲)is well and have a good spirit.His sleep is well now,and defecate and urinate is normal.,2024/11/20,T,、,P,、,H,、,R,、,Bp,Specialty专科情况:,Double lower limbs tactile双下肢 feel normal.The strength of lower limbs level。The operative wound dressings is dry and clean,no bleeding,drainage(渗液).,Nursing diagnosis护理诊断,1、Risk of falls:associated with long bedside lower limb muscle weakness下肢肌无力,2024/11/20,3,、,Lack of knowledge:related to lack of disease-related knowledge,2,、,decline of self-care ability:related to long bed rest,Risk of falls:associated with long bedside lower limb muscle weakness下肢肌无力,Nursing measures:,1,Tell the patient and family members to stay with patient all the time,and if need help ring that call nurses.,2,change the position should obey with the three steps,that is lying 30 seconds,sit up 30 seconds,and stand 30 seconds before the walk in order to avoid orthostatic hypotension(体位性低血压),especially at night.,3,When walking dizziness,lower limb weakness,and gait instability and can not move,immediately sit down in situ(原地),and call help.,4,wear anti-skid slippers拖鞋 and the appropriate适宜的 clothes in order to avoid tripping,and take bed bar when sleep at bed.,2024/11/20,Nursing target:,the patient did not fall,Nursing evaluation:,patients did not fall during hospitalization,.,2,、,decline of self-care ability:related to long bed rest,2024/11/20,Nursing objectives:,patients can adapt to the state of decline of self-care ability,and Life needs can be satisfied during hospitalization.,Nursing measures:,(1)explain the importance of cleaning-care to the patient.,(2)do morning care in order to increase the comfort of patient:wash face,wash hands,oral care,warm water wipe擦 back,etc.,(3)keep warm while operation,and avoid exposure to the patient too long to prevent colds.,(4)Keep the bed clean and dry.,(5)help patient eating,dressing,into the toilet and other life care.,Nursing evaluation:,patients adapt to the state,and,The decline of self-care ability during hospitalization has improved.,2024/11/20,3,、,Lack of knowledge:related to lack of disease-related knowledge,Nursing Objective:,The patient can describe the disease-related knowledge,Nursing measures:,(1)confirm the patients concerns about the disease and future lifestyle by talking,and explain or guide the patients concerns.,(2)use easy to understand language to the patient to introduce the course and treatment.,(3)Distribute health education prescription regularly.Provide the necessary learning materials for the patient.,(4)encourage patients to ask questions,and answer to patient patiently .,Nursing Rating:,Patients can describe disease-related knowledge durin