2011年妇产科护理查房

2011年妇产科查房 时间:2011年3月11日 地点:医生办公室 主持人:李蓁 胡飞英 主查学生:胡彬彬 杨超 参加人员:胡彬彬 杨超 卓秋红 林素姐 等妇产科实习生 病例诊断:子宫肌瘤 目的:通过对子宫肌瘤临床病例的讨论，应用护理程序对该患者进行护理评估、诊断、计划、实施、评价，掌握该疾病的相关定义、病因、分类、临床表现、治疗、护理措施、健康指导等，以便更好地护理同种的病人，达到预期的护理目标，促进患者早日康复。 疾病知识简介 1.定义:子宫肌瘤(Hysteromyoma)又称子宫平滑肌瘤，是女性生殖器最常见的一种良性肿瘤。多无症状，少数表现为阴道出血，腹部触及肿物以及压迫症状等。如发生蒂扭转或其他情况时可引起疼痛。 2.病因:子宫肌瘤确切病因不明，可能与体内雌激素水平过高，长期受雌激素刺激有关。由于子宫肌瘤生长较快，当供血不良时，可以发生不同变性。肌瘤愈大，缺血愈严重，则继发变性愈多。 3.分类: 根据肌瘤所在子宫的不同部位，而分为以下几类: 1、肌壁间肌瘤 肌瘤位于肌壁内，周围均为肌层所包围，初发病时多为此类肌瘤，故最常见，约占60,70,。 2、浆膜下肌瘤 肌壁间肌瘤向浆膜而发展，并突出于子宫表面，与浆膜层直接接触，约占20,。如突入阔韧带两叶之间生长，即为阔韧带内肌瘤。 3、粘膜下肌瘤 肌壁间肌瘤向宫腔内生长，突出于子宫腔内，与粘膜层直接接触，约占10,-15%。此瘤可使子宫腔逐渐增大变形，并常有蒂与子宫相连，如蒂长可堵住子宫颈口或脱出于阴道内 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 4、子宫颈肌瘤 较少见，肌瘤在子宫颈部位生长，因生长部位低，可嵌顿于盆腔内，产生压迫症状，手术切除困难，易损伤输尿管、膀胱。 子宫肌瘤常为多发性，并且以上不同类型肌瘤可同时发生在同一子宫上，称为多发性子宫肌瘤。 4. 临床表现: (1)月经改变:为最常见的症状，表现为月经周期缩短、经量增多、经期延长、不规则阴道流血等。 (2)腹块: 腹部胀大，下腹扪及肿物，伴有下坠感。 (3)白带增多:白带增多，有时产生大量脓血性排液及腐肉样组织排出伴臭味。 (4)疼痛:一般患者无腹痛，常有下腹坠胀、腰背酸痛等，当浆膜下肌瘤蒂扭转时，可出现急性腹痛肌瘤红色变时，腹痛剧烈且伴发热。 (5)压迫症状:肌瘤向前或向后生长，可压迫膀胱、尿道或直肠，引起尿频、排尿困难、尿潴留或便秘。当肌瘤向两侧生长，则形成阔韧带肌瘤，其压迫输尿管时，可引起输尿管或肾盂积水;如压迫盆腔血管及淋巴管，可引起下肢水肿。 (6)不孕:肌瘤压迫输卵管使之扭曲，或使宫腔变形以致妨碍受精卵着床，导致不孕。 (7)继发性贫血:若患者长期月经过多可导致继发性贫血，出现全身乏力、面色苍白、气短、心慌等症状。 病历介绍 5059床，住院号400516，蔡叶青，女，48岁，患者于入院前3年外院体检查B超发现子宫实质性占位，月经无明显改变，无尿频、肛门坠胀感，无腹痛、发热、纳差、进行性消瘦，白带正常，无异味，下腹未扪及肿物，未予重视。入院前12天于我院体检发现子宫肌瘤明显增大(较大约61×53mm)，今要求入院手术治疗，门诊拟以“子宫多发性肌瘤”收住院。发病以来，患者食欲、睡眠好，精神好，大小便正常，体重无明显增减。月经史:14 4/30，lmp2011.01.28，pmp2010.12.28，无痛经，白带量少，无异味。既往无“肝炎、结核、伤寒”等传染病史，无“糖尿病、心脏病、血液病、甲亢、中枢神经系统疾病”史，无射application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 线辐射及毒物接触史，无药敏及食物过敏史，无外伤、输血史，预防接种史不详。入院时查体:T:36.6? P:80次/分 R:20次/分 BP:100/60mmHg。神志清楚，心肺无异常，腹微隆。妇检:外阴阴道正常，宫颈轻度糜烂，无肥大，宫体 +前位，如孕2个月大，表面凹凸不平，质硬，可活动，无压痛。双侧附件区未扪及明显肿物，无压痛。入院后给予完善血尿粪常规、血生化、凝血功能、白带常规、输血前免疫全套、CA125、AFP、CEATCT、胸片、心电图及彩超等辅助检查;并已将病情告知患方，其要求手术，签字为证，于2011年2月11日07:30在腰麻下行“腹式全子宫切除术”，术程顺利，术毕安返病房。查体:T:36.8? P:68次/分 R:21次/分 BP:110/64mmHg及予以一级护理，吸氧，心电监护，留置导尿及消炎，补液，营养支持，禁食等处理。经过8天精心治疗后患者于2011-02-15出院。 一、护理评估: (1)病史:了解病人的一般情况如年龄、职业、体重、药物过敏史、婚育状况、 末次月经、疾病史等。 (2)妇科情况:外阴:已婚已产式，发育正常，无白斑、潮红，阴毛分布正常。 阴道:未见异常分泌物，粘膜无潮红、出血点，后穹窿不饱满。 宫颈:轻度糜烂，触之无出血，无肥大，宫口闭，未见组织物堵塞。 +宫体:宫体前位，如孕2个月大，表面凹凸不平，质硬，可活动，无压痛。 附件:左附件区可扪及一大小约2.5cm×2.0cm包块，囊性感，表面光滑， 无压痛，活动度一般，右附件区无增厚、压痛。 (3)心理社会评估:了解病人有无不适，告知手术的情况及术后的恢复情况， 了解病人的心理反应。 二、 以上病史，提出以下护理诊断: (1)焦虑:与担心手术是否顺利及术后恢复有关 (2)知识缺乏:缺乏疾病发生，发展、治疗及护理知识 (3)自我形象紊乱:与手术切除子宫有关 (4)疼痛:与手术创伤有关 (5)潜在并发症:感染、下肢静脉栓塞 三、 护理措施: application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical (一) 术前护理: 1(一般护理:病人术前应补充高蛋白、高热量、丰富维生素、易消化少渣饮食。 2.病情监测:A.阴道流血:严密监测生命体征，了解有无头晕、乏力、眼 花、面色苍白等症状;观察阴道出血的时间、量、色及性状，正确评估 阴道出血量。B.腹痛:注意观察腹痛的部位、性质、程度。 3.按医嘱查血常规、尿粪常规、血型交配等检查，术前给予备皮、阴道冲洗、肠道灌洗及导尿等准备。 4.心理护理:与患者及家属交流，告知其手术的有关知识，缓解患者术前的紧张和焦虑。 (二)术后护理: 1.密切观察病情变化: (1)注意病人至清醒，每30分钟测血压、脉搏、呼吸一次共三次或至平稳， 或每小时测血压、脉搏、呼吸一次共6次至平稳。 (2)注意输液，输血的速度及有否渗入皮下。 (3)持续导尿24小时，注意尿管通畅及尿颜色，必要时记录尿量或24小时出 入量。 (4)测体温、脉搏、呼吸每日4次。三天无异常后改每日测1次。 (5)沙袋置腹部6小时取出，随时观察，注意切口有无渗血，并保持敷料干燥 勿使脱落和移动。 2.环境:给病人提供安静舒适的休息环境，限制陪伴避免高声喧哗。 3.卧位:给病人去枕平卧6小时。术后第二天应采取半卧位，有利于腹腔引流， 应定时翻身,注意肢体的活动,以帮助病人的恢复。 4.心理护理:术后病人的疼痛与不适是术后前三天不良心理反应的主要原因，护 士应协助病人减轻疼痛，解除不适。 5.疼痛的护理:主要措施有保持安静的环境，6小时以后腹部捆腹带，帮助创伤 口的固定,有利于咳嗽及床上活动,半卧位以减轻腹部肌张力，以而 减轻切口的疼痛，按医嘱给止痛药。 6.营养及饮食:术后6小时后可进流质饮食，但应避免牛奶，豆浆等产气食物， 以防肠胀气。肛门排气后改为半流质再逐步进渡到普食。 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical 7.预防并发症:协助病人按时翻身擦背及早期活动，并注意观察病人手术后第一 次排尿、排气、做好护理记录。 四、护理评价: 1.病人自述疼痛减轻，无疼痛苦表情，并安静入睡。 2.病人能做一些力所能及的自我护理。 3.病人没有口渴，皮肤干燥等体液不足的体征。 4.病人体温维持正常，血浆指标正常，切口无红、肿、热、痛征象。 五、健康教育: 1.饮食:病人出院后维持均衡的饮食，进食高热量，高蛋白，易消化，含纤 维多的食物，预防便秘。指导病人注意劳逸结合，保持心情愉快。 2.复诊:定时服药、定期复查，一般在术后一个月复查，如出现高热、阴道 出血、休克、异常分泌物或切口红肿疼痛、化脓等情况应立即就诊。 休息:居室保持清洁通风、注意个人卫生，保持外阴清洁，保持心情愉快。 3. 4.运动:术后2月内避免提重物，抱小孩、拖地板、登高取物等动作，以防 伤口裂开，半年内避免从事增加盆腔充血的活动，如久坐、跳舞等。 5.性生活:术后6-12周内避免性生活和阴道灌洗，避免引起感染。 提问: 胡飞英老师:手术后病人送回病房，如何接收及指导病人家属, 杨超答:1.首先应观察病人的神志，如大声呼叫病人的名字，看病人有无反应。 2.给予心电监护，氧气吸入，并观察生命体征.。 3.指导家属为其活动双下肢。 4.给予去枕平卧6小时并禁食。 5.观察切口敷料有无渗血、引流管有无通畅。 李蓁老师:导尿管如何护理, 胡彬彬答:?在操作过程中注意保护病人，严格执行无菌技术操作原则。 ?每天会阴护理2次。 ?每日定时更换集尿袋，及时排空集尿袋，并记录尿量。 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical ?观察尿量、尿色，在病情允许的情况下，鼓励病人多饮水以增加尿量。 ?如有护送做检查，应排空尿袋，夹闭导管，站立时尿袋不高于腰部。 ?下床活动时注意引流管的固定、通畅，避免受压、扭曲等。 胡飞英老师:子宫肌瘤患者注重的饮食有哪些, 卓秋红答:1、饮食宜清淡，不食羊肉、虾蟹、鳗鱼、咸鱼、黑鱼等发物。 2、忌食辣椒、麻椒、生葱、生蒜、白酒等刺激性食物及饮料。 3、禁食桂圆、红枣、阿胶、蜂王浆等热性、凝血性和含激素成分的食品。 4、多食瘦肉、鸡肉、鸡蛋、鹌鹑蛋、鲫鱼、甲鱼、白鱼、白菜、芦笋、芹菜、 菠菜、黄瓜、冬瓜、香菇、豆腐、海带、紫菜、水果等。 李蓁老师:子宫肌瘤引发尿频的原因, 林素姐答:子宫肌瘤会引发尿频的，肌瘤向前或向后生长，可压迫膀胱、 尿道或直肠，引起尿频、排尿困难、尿潴留或便秘。当肌瘤向 两侧生长，则形成阔韧带肌瘤，其压迫输尿管时，可引起输尿 管或肾盂积水;如压迫盆腔血管及淋巴管，可引起下肢水肿。 胡飞英老师:通过刚才的学习，我们加深了对子宫肌瘤的知识，并掌握了相应的 护理措施。随着临床诊断技术和治疗措施的不断发展，我们护理人员也要不 断学习，与时俱进，不断提高我们的护理技术，努力为患者的健康服务，创 造一个和谐，友爱的医疗环境。今天大家或多或少有点收获，望大家以后能 理论结合临床更好地为病人服务，今天查房就到此为止。 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image checki recovery operation wash stomach operation catheter operation chest abdominal puncture operation lumbar puncture operation heart electric guardianship electrical cardioversion law operation breathing machine using tracheal intubation operation moving vein puncture operation critical patients life support technology (including heart lung recovery and trauma patients life support) 3. high requirements (1) learning disease species and the cases number requirements: heart lung recovery Hou integrated syndrome 5 cases, and more organ function obstacles integrated levy 3 cases (2) clinical knowledge, and skills requirements: three cavity two SAC tube oppression bleeding operation; mechanical ventilation of indications, and Different characteristics of the illness and the offline method. (3) foreign language, teaching, research and other requirements: foreign literature review or book report 1. (Nine) heavy syndrome guardianship Ward 2 months 1. Rotary purpose master: common species of diagnosis and emergency processing; common emergency drug (heart lung recovery and the vascular activity drug, and buck drug, and anti-rhythm disorders drug, and solutions spasm flat breath drug, and anti-epilepsy drug) of refers to levy, and side effects and clinical