原发性甲状腺机能亢进症

原发性甲状腺机能亢进症 原发性甲状腺机能亢进症临床路径 ,2011年版, 一、原发性甲状腺机能亢进症临床路径住院 ,一,适用对象。 第一诊断为原发性甲状腺机能亢进症,ICD -10:E05.0, 行甲状腺次全切除手术(ICD-9-CM-3:06.3902)。 ,二,诊断依据。 根据《中国甲状腺疾病诊治指南》,中华医学会内分泌学分会编著～2008年第1版,、《甲状腺外科》,人民卫生出版社～2005年第1版,及全国高等学校教材《外科学》,人民卫生出版社～2008年第7版,。 1.临床甲亢症状和体征。 2.甲状腺弥漫性肿大,触诊和B超证实,。 3.血清TSH浓度降低～甲状腺激素浓度升高。 4.眼球突出和其他浸润性眼征。 5.胫前粘液性水肿。 6.甲状腺TSH受体抗体,TRAb或TSAb,阳性。 以上标准中～1、2、3项为诊断必备条件～4、5、6项为诊断辅助条件。 ,三,选择治疗的依据。 根据《中国甲状腺疾病诊治指南》,中华医学会内分泌containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 学分会编著～2008年第1版,、《甲状腺外科》,人民卫生出版社～2005年第1版,及全国高等学校教材《外科学》,人民卫生出版社～2008年第7版,。 甲状腺次全切除手术适用于: 1.甲亢长期药物治疗无效或效果不佳的, 1312.甲亢甲状腺药物或碘放射性核素治疗后复发, 3.甲状腺较大对周围脏器有压迫或胸骨后甲状腺肿, 4.疑似与甲状腺癌并存者, 5.妊娠期甲亢药物控制不佳者～可以在妊娠中期,13-24周,进行手术。 ,四,标准住院日为5-8天。 ,五,进入路径标准。 1.第一诊断必须符合ICD-10 E05.0原发性甲状腺机能亢进症疾病编码。 2.有手术指征患者, 3.患者的甲亢病情稳定～术前准备有两种方法～可在门诊完成: ,1,术前应用抗甲状腺药物基本控制甲亢症状后～改服2周碘剂～再进行手术, ,2,对症状较轻的患者开始即用碘剂～2-3周后甲亢症状得到基本控制～可进行手术, 4.当患者合并其他疾病～但住院期间不需要特殊处理也containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 不影响第一诊断的临床路径流程实施时～可以进入路径。 ,六,术前准备1-2天。 1.必需的检查项目: ,1,血常规、尿常规、便常规+潜血, ,2,肝肾功能、电解质、凝血功能、感染性疾病筛查 ,乙肝、丙肝、艾滋病、梅毒等,, ,3,心电图、胸部X线检查, ,4,甲状腺功能检查、抗甲状腺抗体、甲状腺球蛋白, ,5,请耳鼻喉科会诊了解声带情况。 2.根据患者病情可选择: ,1,气管正侧位, ,2,肺功能、超声心动图检查和血气分析等, ,3,甲状腺同位素扫描、甲状腺B超。 ,七,预防性抗菌药物选择与使用时机。 按照《抗菌药物临床应用指导原则》,卫医发〔2004〕 285号,执行。通常不需预防用抗菌药物。 ,八,手术日为入院第3-4天。 1.麻醉方式:气管内插管全身麻醉、局麻或颈丛麻醉。 2.手术方式:甲状腺次全切除术。 3.术中用药:麻醉常规用药。 4.输血:根据术前血红蛋白状况及术中出血情况而定。 5.病理学检查:术中行冰冻病理学检查～术后行石蜡切 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 片病理学检查。 ,九,术后住院恢复2-5天。 1.生命体征监测～严密观察有无出血及甲状腺危象等并发症发生。 2.视具体情况尽早拔除尿管、引流管。 3.指导患者术后饮食。 4.实验室检查:必要时复查血常规、血生化、甲状腺功能等。 ,十,出院标准。 1.无切口感染、引流管拔除。 2.生命体征平稳～可自由活动。 3.饮食恢复～无需静脉补液。 4.无需要住院处理的其它并发症或合并症。 ,十一,变异及原因分析。 1.术前检查提示甲亢症状未能有效控制～则暂缓手术。 2.术中冰冻提示甲状腺炎或甲状腺癌等～转入相应路径。 3.合并胸骨后巨大甲状腺肿有可能需要开胸手术。 4.术后出现并发症需要进行相关的诊断和治疗。 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 二、原发性甲状腺机能亢进症临床路径 适用对象:第一诊断为原发性甲状腺机能亢进症(ICD-10:E05.0) 行甲状腺次全切术(ICD-9-CM-3:06.3902) 患者姓名: 性别: 年龄: 门诊号: 住院号: 住院日期: 年 月 日 出院日期: 年 月 日 标准住院日:5-8 天 住院第2-3天 日期 住院第1天 (手术前1天) ? 上级医师查房 ? 询问病史及体格检查 ? 完成术前准备与术前评估 ? 完成住院病历和首次病程记录 ? 根据检查检验结果进行术前讨论，确定治疗方案 ? 开具检查检验单 ? 如考虑有恶性转入相应临床路径 主 ? 上级医师查房与术前评估 ? 完成必要的相关科室会诊 要 ? 初步确定诊治方案和特殊检查项目 ? 术前1天申请手术及开手术医嘱 诊 ? 完成上级医师查房记录、术前讨论、术前小结等 疗 ? 完成术前总结、手术方式、手术关键步骤、术中工 注意事项等 作 ? 向患者及家属交代病情及手术安排，围手术期注 意事项 ? 签署手术知情同意书、自费用品书、输血同 意书、麻醉同意书或签授权委托书 长期医嘱: 长期医嘱: ? 外科二级护理常规 ? 患者既往基础用药 ? 饮食(依据患者情况定) 临时医嘱: 临时医嘱: ? 会诊单 ? 血常规+血型、尿常规、便常规+潜血 ? 术前医嘱: 重 ? 凝血功能、生电解质、肝肾功能、感染? 1)常规准备明日在气管内全麻下行甲状腺次全切点 性疾病筛查、甲状腺功能、抗甲状腺抗除术 医 体、甲状腺球蛋白 ? 2)备皮 嘱 ? 心电图、胸部X线检查 ? 3)术前禁食6小时、禁饮2小时 ? 甲状腺B超，气管正侧位、肺功能、超? 4)麻醉用药 声心动图(视患者情况而定) ? 术中特殊用药带药 ? 耳鼻喉科会诊 ? 带影像学资料入手术室 ? 其他:根据患者其他基础疾病情况而定 ? 预约ICU(视情况而定) ? 入院介绍 ? 静脉抽血 ? 入院评估 ? 健康教育 主要 ? 健康教育 ? 饮食指导 护理 ? 活动指导 ? 疾病知识指导 ? 饮食指导 ? 术前指导 工作 ? 患者相关检查配合的指导 ? 促进睡眠(环境、药物) ? 心理支持 ? 心理支持 病情 ? 无 ? 有，原因: ? 无 ? 有，原因: 变异 1. 1. 记录 2. 2. 护士 签名 医师 签名 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 住院第3-4天(手术日) 日期 术前与术中 术后 ? 陪送患者入手术室 ? 麻醉医师完成麻醉记录 主 ? 麻醉准备，监测生命体征 ? 完成术后首次病程记录 要 ? 施行手术 ? 完成手术记录 诊 ? 保持各引流管通畅 ? 向患者及家属说明手术情况 疗 ? 术中行冰冻病理学检查，术终行工 常规病理学检查 作 长期医嘱: 长期医嘱: ? 甲亢常规护理 ? 甲状腺次全切除术后常规护理 ? 禁食 ? 一级护理 ? 禁食 重 临时医嘱: ? 颈部切口引流接负压袋吸引并记量 点 ? 术中冰冻检查 ? 尿管接尿袋(视手术时间而定) 医 嘱 临时医嘱: ? 吸氧 ? 床边备气管切开包 ? 血常规及生化检查(必要时) ? 健康教育 ? 体位与活动:平卧，去枕6小时，协助改变体位 ? 饮食:术前禁食禁饮 (半坐卧位)，指导颈部活动 ? 术前沐浴、更衣，取下假牙、饰? 按医嘱吸氧、禁食、禁饮 物 ? 密切观察患者情况 ? 告知患者及家属术前流程及注意? 疼痛护理 主要 事项 ? 留置管道护理及指导 护理 ? 指导术前注射用药后注意事项 ? 心理支持(患者及家属) 工作 ? 术前手术物品准备 ? 陪送患者入手术室 ? 术中根据患者病情决定留置尿管 ? 床边放置气管切开包 ? 心理支持(患者及家属) ? 无 ? 有，原因: 病情 1. 变异 记录 2. 护士 签名 医师 签名 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the 住院第4-6天 住院第5-8天 日期 (术后第1-2天) (出院日) ? 上级医师查房 ? 上级医师查房 ? 观察病情变化，包括颈部、耳前叩击征及声? 观察病情变化，包括颈部、耳前叩击征及声 音情况等 音情况等 ? 观察引流量和性状，视引流情况拔除颈部引? 观察引流量和颜色 主 流管及尿管 ? 住院医师完成常规病程记录 要 ? 检查手术切口，更换敷料 ? 必要时予相关特殊检查 诊 ? 分析实验室检验结果 ? 明确是否符合出院标准 疗 ? 维持水电解质平衡 ? 完成出院记录、病案首页、出院证明书等 工 ? 住院医师完成常规病程记录 ? 通知出入院处 作 ? 通知患者及家属 ? 向患者告知出院后注意事项，如康复、 返院复诊、后续治疗及相关并发症的处理等 ? 出院小结、诊断证明书及出院须知交予患者 长期医嘱:(参见昨天医嘱) 长期医嘱:(参见左列) ? 甲状腺手术后常规护理 ? 二或三级护理(视情况) ? 一级护理 ? 患者既往基础用药 ? 半流 重 ? 拔除颈部引流管接袋并记量 临时医嘱: 点 ? 化痰药 ? 补充进食不足的液体支持 医 ? 患者既往基础用药 ? 并发症处理(必要时) 嘱 ? 预约切口拆线 临时医嘱: ? 适当补充葡萄糖液和盐水液体支持 出院医嘱: ? 切口换药并拔除引流 ? 出院带药 ? 拔除尿管 ? 体位:指导患者下床活动及颈部活动 ? 体位与活动:自主体位，指导颈部活动 ? 观察患者病情变化 ? 指导饮食 ? 指导饮食 ? 协助或指导生活护理 ? 遵医嘱拔除尿管 ? 出院指导 主要 ? 疼痛护理 ? 办理出院手续 护理 ? 生活护理(一级护理) ? 复诊时间 工作 ? 心理支持 ? 作息、饮食、活动 ? 服药指导 ? 清洁卫生 ? 疾病知识 病情 ? 无 ? 有，原因: ? 无 ? 有，原因: 变异 1. 1. 记录 2. 2. 护士 签名 医师 签名 containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the containing gross errors, should immediately test if determined when monitoring data contain a large systematic errors, you should analyze ... 10.9.1 10.9 quality inspection and acceptance monitoring of equipment inspection and delivery inspection all our procurement monitoring equipment shall be as provided in section 10.2 of the terms of this technology, inspection and acceptance of delivery, and should include monitoring equipment factory inspection and test reports and delivery acceptance, acceptance certificate information supervising people. 10.9.2 monitoring instruments installed inbuilt quality check each measuring point measuring instruments and equipment after completion of installation, Embedment, immediately to inspect and test the quality of equipment installation, Embedment, and confirmed by the supervisor to check the quality before being allowed to begin monitoring contract work. Section 10.10 of completion on completion of each observation all monitoring equipment installed after laying, of 52nd of the references to this agreement the terms of the contract provisions, apply to the supervisor to monitor the project's acceptance of special, and according to the technical provisions 16.1. the