胸外科护理常规

胸外科护理常规 胸外科护理常规目录 1 气胸护理常规 2 血胸护理常规 3 肋骨骨折护理常规 4 肺大泡护理常规 5 肺癌护理常规 6 食管癌护理常规 7 纵膈肿瘤护理常规 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 气胸护理常规 气胸指胸膜腔内积气。一般分为闭合性气胸、开放性气胸和张力性气胸三类。 闭合性气胸:伤后伤口迅速闭合，胸膜腔与外界不相通。小量气胸，肺萎陷在30%以下，1-2 周内可自行吸收，不需治疗;大量气胸，有较明显的症状合体征，应行胸膜腔穿刺抽气。开放性气胸:胸膜腔经胸壁伤口与外界大气直接沟通，空气可通过胸壁伤口随呼吸自由出入胸膜腔。因胸膜腔内负压消失，吸气时，健侧胸膜腔负压升高，与伤侧压力差增大，纵隔向健侧进一步移位;呼气时，两侧胸膜腔压力差减少。纵隔移回伤侧，导致纵隔位置随呼吸而左右摆动，称为纵隔扑动，引起呼吸和循环功能严重障碍。表现有严重呼吸困难、紫绀和休克;胸壁可见吮吸性伤口，并随呼吸发出“嘶嘶”声。立即用敷料(最好是凡士林纱条)封闭胸部伤口，变开放性气胸为闭合性气胸防止气体继续进出胸膜腔。及早行胸膜腔抽气、清创、胸膜腔闭式引流。 张力性气胸:较大肺泡、支气管破裂或较大较深的肺裂伤，其裂口与胸膜腔相通，形成活瓣，吸气时，空气从裂口进入胸膜腔内，而呼气时活瓣关闭，空气只能进入不能排出，使胸膜腔内压力不断增高，压迫伤侧肺使之逐渐萎缩，并将纵隔推向健侧，挤压健侧肺，产生呼吸和循环功能严重障碍。表现出现极度呼吸困难，大汗、紫绀、烦躁不安、昏迷、休克，胸膜腔穿刺有高压气体冲出。处理:立即排气(在锁骨中线第2 肋间插入粗针头)，及早行胸膜腔闭式引流。 一、护理评估 1.既往有无肺气肿病史，了解有无慢性支气管炎、支气管哮喘、肺气肿等过去史，有无外来暴力及锐器伤、有无手术史、有无药物过敏史等。 2.病情评估 2.1 本次发作的诱因，如举重物、用力排便、体育运动外来暴力及锐器伤等，既往有无类似发作史及治疗情况。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 2.2 患者有无胸闷、气短、呼吸困难、胸痛、咳嗽、咳痰，大汗、紫绀、烦躁不安、昏迷、休克等情况。 3.各种特殊检查和实验室检查结果等如:X 线、CT 等。 4.患者营养情况，是否消瘦、食欲等。 5.了解患者的心理状况，对疾病的认知程度。 6.患者意识、生命体征、氧饱和度、伤口疼痛、伤口敷料、皮肤情况。 7.听诊两肺呼吸音、咳嗽、咳痰的性质、量，能否行有效的深呼吸等。 8.胸腔引流管引流情况:胸管固定是否完好，是否通畅，引流液的量、性质、色等。 9.患者床上活动及下床活动情况。 10.用药后的观察。 11..患者安全评估，有无跌倒/坠床的危险。 二、主要护理问题/护理点 气体交换受损、疼痛、清理呼吸道低效、低效性呼吸型态、知识缺乏、自理能力缺陷、有感染的危险、有意外拔管的危险。 存在并发症:出血、肺不张、肺部感染、心律失常等。 三、护理措施 1.一般措施 1.1 按胸外科护理常规 1.2 病情观察:病人有无胸闷、胸痛、咳嗽、呼吸困难的程度，必要时给予吸氧。 1.3 活动与休息:半卧床休息，避免用力、屏气及剧烈活动。 1.4 控制肺部感染:遵医嘱给有效抗生素及雾化吸入，控制支气管炎症，解除支气管痉挛，减少呼吸道分泌物。对有张力性气胸或开放性气胸患者，立即行胸腔闭式引流减压和引流。 1.5 饮食与营养:可进食高蛋白、高热量、富含维生素的饮食。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 1.6 用药护理:遵医嘱给有效抗生素及雾化吸入，并观察用药后的反应，胸闷、胸痛，咳嗽、呼吸困难的程度是否改善。 1.7 做好心理指导:介绍有关疾病的健康知识，减轻病人的紧张情绪。指导禁烟，鼓励病人练习深呼吸和有效排痰，练习床上排大小便。 1.8 协助做好检查。胸部X 线摄片和CT 检查，肺功能及动态心电图。 1.9 做好安全防护，防止意外发生。 1.10 做好胸腔闭式引流的护理。 四、健康教育 宣教加强饮食的重要性，可进食高蛋白、高热量、富含维生素、易消化的食物为主:如1. 蛋类、瘦肉、鱼类、豆制品、新鲜蔬菜和水果。同时应多食粗纤维食物以保持大便通畅。 2.鼓励病人床上床下活动，宣教早期活动的意义。 3.宣教和指导正确的深呼吸、有效咳嗽。 4.宣教各种药物的名称、剂量、作用和副作用。有出院带药的做好相应的宣教。 5.解释胸管放置的目的、意义及注意事项。 6.如出现胸闷、胸痛、呼吸困难等情况应及时就诊。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 血胸护理常规 血胸指胸部损伤导致的胸膜腔积血。多因胸部损伤所致，肋骨断端或利器损伤胸部均可能刺破肺、心脏、血管导致胸膜腔积血。大量持续出血所导致的胸膜腔出血称为进行性血胸。 一、护理评估 1.是否受外来暴力、利器刺伤，有无药物过敏史。 2.病情评估: 2.1 有无呼吸急促、肋间隙饱满、气管移向健侧、患侧胸部叩诊呈浊音、呼吸音减低或消失。 2.2 生命体征、氧饱和度、是否有面色苍白、四肢湿冷等情况。 3.各种特殊检查和实验室检查结果等如:胸部X 线、胸部B 超、血红蛋白、血细胞比容。 4.了解患者的心理状态，对疾病的认识程度等。 5.用药情况:遵医嘱给予补液、抗感染、化痰、营养支持等。 6.患者安全评估，有无跌倒/坠床等危险。 二、主要护理问题/护理点 疼痛、体液不足、气体交换受损、清理呼吸道低效、活动无耐力、皮肤完整性受损的危险、潜在的并发症:肺部和胸腔感染。胸腔闭式引流。 三、护理措施 1.按胸外科护理常规 2.维持有效的心排出量和组织灌注量 2.1 建立静脉通路并保持通畅，积极补充血容量和抗休克:按医嘱合理安排和输注晶体和胶体溶液，根据血压和心肺功能状态控制补液速度。 2.2 密切监测生命体征:重点检测生命体征和观察胸腔闭式引流液量、色和性质，若每小时引流量超过200ML 并持续3 小时以上，引流出的血液很快凝固，胸部X 线显示胸腔大片the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 阴影，说明有活动性出血的可能，应积极做好开胸手术的术前准备。 2.3 促进气体交换，维持呼吸功能，观察呼吸的型态、频率及深浅度的变化。 2.4 根据病情给予鼻塞吸氧或面罩吸氧，观察血氧饱和度变化。 3.活动和休息:生命体征平稳取半卧位休息，有利于呼吸引流及减轻疼痛。 4.饮食与营养:可进食高蛋白、高碳水化合物、富含维生素的饮食。 5.用药护理:按医嘱给予药物治疗，注意观察用药后的效果和反应。 6.切口护理:观察切口敷料有无渗血，切口愈合情况，注意切口有无红肿热痛等异常情况，如有异常及时汇报医生进行处理。 做好胸腔闭式引流管的护理。 7. 8.做好患者的心理护理，保持良好的心理状态，促进疾病的愈合。 四、健康宣教 1.注意安全，防止发生意外事故。 2.宣教加强饮食的重要性，可进食高蛋白、高热量、富含维生素、易消化的食物为主:如蛋类、瘦肉、鱼类、豆制品、新鲜蔬菜和水果。同时应多食粗纤维食物以保持大便通畅。 3.宣教和指导正确的深呼吸、有效咳嗽。 4.宣教各种药物的名称、剂量、作用和副作用。有出院带药的做好相应的宣教。 5.解释胸管放置的目的、意义及注意事 6.如出现胸闷、胸痛、呼吸困难等情况应及时就诊。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 肋骨骨折护理常规 肋骨骨折是指肋骨的完整性和连续性中断，是最常见的胸部损伤。肋骨骨折可分为单根或多根多段骨折，同一肋骨也可有一处或多处骨折，肋骨骨折多见于第4-7 肋，因其长而薄，最易折断。连枷胸:多根多处肋骨骨折，因胸壁失去完整肋骨的支持而软化。吸气时，胸腔内负压增高，软化的胸壁向内凹陷;呼气时，胸腔内负压减低，软化的胸壁向外凸出，称为反常呼吸运动(又称连枷胸)。若软化区域较大，呼吸时两侧胸膜腔内压力不平衡，可引起纵隔扑动，影响静脉回流和气体交换，导致缺氧和二氧化碳潴留，严重者可出现呼吸和循环衰竭。 一、护理评估 1.是否受外来暴力、严重骨折疏松或有晚期肿瘤肋骨转移的，有无特殊用药史。 2.病情评估: 2.1 局部骨折部位疼痛，深呼吸、咳嗽或体位改变时是否加重，有无皮下气肿。 2.2 有无咯血、气急、呼吸困难、发绀、反常呼吸或休克等。 2.3 生命体征、氧饱和度、两肺呼吸音情况。 3.各种特殊检查和实验室检查结果等如:X 线、CT、血红蛋白、血细胞比容。 4.了解患者的心理状态，对疾病的认识程度等。 5.用药情况:遵医嘱给予补液、抗感染、化痰、营养支持等。 患者安全评估，有无跌倒/坠床等的危险。 6. 二、主要护理问题/护理点 疼痛、气体交换受损、清理呼吸道低效、活动无耐力、潜在并发症:肺部和胸腔感染。 三、 护理措施 1.按胸外科护理常规 2.维持有效的气体交换 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 2.1 现场急救:采取紧急措施对危及生命的病人给予急救、对出现反常呼吸的病人可用厚棉垫加压包扎以减轻或消除胸壁的反常呼吸运动，促进患侧肺复张。 2.2 清理呼吸道分泌物，鼓励病人咳出分泌物和血性痰，対气管插管或切开，应用呼吸机辅助呼吸者，加强呼吸道管理，包括吸痰和湿化。 2.3 密切观察生命体征、神志、胸腹部活动以及气促、发绀、呼吸困难等情况，若有异常及时汇报医生并协助处理。 3.固定:用肋骨固定带固定胸廓、限制肋骨断端活动有利于减轻疼痛。 4.活动和休息:取半卧位休息，有利于呼吸及减轻疼痛。 5.止痛:讲解疼痛的原因，安慰病人，讲解缓解疼痛的方法，必要时给镇痛药物。 6.饮食与营养:可进食高蛋白、高碳水化合物、富含维生素的饮食。 7 用药护理:按医嘱给予药物治疗，注意观察用药后的效果和反应。 8.做好患者的心理护理，保持良好的心理状态，促进疾病的愈合。 四、健康宣教 1.注意安全，防止发生意外事故。 2.合理休息，加强营养的摄入。 3.3 个月后复查胸部X 线，了解骨折愈合情况。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 胸腔镜下肺大泡切除护理常规 肺大泡指大泡性肺气肿，是一种局限性肺气肿，肺泡高度膨胀，肺泡壁破裂并相互融合而形成，一般是由小支气管的活瓣性阻塞所引起。 一、护理评估 1.既往有无肺气肿病史，了解有无慢性支气管炎、支气管哮喘、肺气肿等过去史， 有无手术史、有无药物过敏史等。 2.病情评估 2.1 本次发作的诱因，如举重物、用力排便、体育运动等，既往有无类似发作史及治疗情况。 2.2 患者有无胸闷、气短、呼吸困难、胸痛、咳嗽、咳痰、寒战和发热等情况。 3.各种特殊检查和实验室检查结果等。 4.患者营养情况，是否消瘦、食欲等。 5.了解患者的心理状况，对疾病的认知程度。 6.术后评估 6.1 手术后诊断、术中出血、麻醉、镇痛情况。 6.2 患者意识、生命体征、氧饱和度、切口疼痛、切口敷料、皮肤情况。 6.3 听诊两肺呼吸音、咳嗽、咳痰的性质、量，能否行有效的深呼吸等。 6.4 胸腔引流管引流情况:胸管固定是否完好，是否通畅，引流液的量、性质、色等。 6.5 患者床上活动及下床活动情况。 6.6 用药后的观察。 7.患者安全评估，有无跌倒/坠床的危险。 二、主要护理问题/护理点 气体交换受损、疼痛、清理呼吸道低效、知识缺乏、自理能力缺陷、有感染的危险、有意the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 外拔管的危险，PC:出血、肺不张、肺部感染、心律失常、DVT 等。胸腔闭式引流管的护理。 三、护理措施 1. 一般措施 1.1 按胸外科护理常规 1.2 病情观察:病人有无胸闷、胸痛、咳嗽、呼吸困难的程度，必要时给予吸氧。 1.3 活动与休息:半卧床休息，避免用力、屏气及剧烈活动。 1.4 术前控制肺部感染:遵医嘱给有效抗生素及雾化吸入，控制支气管炎症，解除支气管痉挛，减少呼吸道分泌物。对有张力性气胸或持续漏气患者，或双侧肺大泡同期手术者，术前先行胸腔闭式引流减压，保证手术安全。 1.5 饮食与营养:可进食高蛋白、高热量、富含维生素的饮食。 1.6 用药护理:遵医嘱给有效抗生素及雾化吸入，并观察用药后的反应，胸闷、胸痛，咳嗽、呼吸困难的程度是否改善。 1.7 做好心理指导:介绍有关疾病的健康知识，减轻病人的紧张情绪。 1.8 协助做好术前检查，胸部X 线摄片和CT 检查，肺功能及动态心电图。 1.9 做好安全防护，防止意外发生。 2.术后措施 2.1 按胸外科术后护理常规护理。 2.2 严密观察生命体征变化，检查各种引流管连接及通畅情况，根据需要给氧。 2.3 活动与休息:病情平稳，完全清醒后即改30?斜坡位，当天以床上活动为主，根据病情逐步增加活动量，鼓励病人早期下床活动。 2.4 饮食与营养:术后六小时根据医嘱进食流质饮食，术后第一天起进食半流质，宜以高蛋白、高热量、富含维生素、易消化的食物为主:如蛋类、瘦肉、鱼类、豆制品、新鲜蔬the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 菜和水果。同时应多食粗纤维食物以保持大便通畅。 2.5 用药护理:根据医嘱给与抗感染、化痰、营养支持治疗，并观察用药的效果和反应。 2.6 疼痛护理:单纯一侧镜下肺大泡结扎术，患者疼痛较轻，而双侧同期手术及行胸膜固定术患者，术后疼痛则较重，患者因怕痛而不敢咳嗽，导致气管、支气管内分泌物不易排出，严重者可导致肺叶或肺段不张;同时疼痛可使患者潮气量下降，呼吸频率降低，并抑制自发呼吸，加重肺泡通气不足。因此，术后及时有效的止痛对预防肺部并发症是很重要的，根据医嘱使用杜冷丁，并评估药物使用前后生命体征。 2.7 做好术后的基础护理和生活护理，使患者舒适。 2.8 呼吸道管理:加强肺功能锻炼，术前进行正确的呼吸训练外，术后在充分止痛的基础上尽早让患者坐起咳嗽、排痰，指导患者作深呼吸运动，吹气球等呼吸功能锻炼，常规雾化吸入，以促进肺早日复张。 2.9 做好胸腔闭式引流的护理 2.10 切口护理:观察切口敷料有无渗血、渗液及切口愈合情况，如有异常及时汇报医生。 2.11 术后并发症的观察及护理:术后主要并发症为肺泡漏气，表现为胸腔闭式引流管内持续排出气体。需嘱患者有痰咯出，但不鼓励咳嗽，同时观察肺部呼吸音的变化及肺膨胀情况。轻微漏气可不必处理，较明显漏气则需封闭肺破口。 2.12 做好术后心理护理，保持良好的心理状态，促进疾病早日康复。 四、健康教育 1.宣教术前加强饮食的重要性，可进食高蛋白、高热量、富含维生素、易消化的食物为主:如蛋类、瘦肉、鱼类、豆制品、新鲜蔬菜和水果。同时应多食粗纤维食物以保持大便通畅。 2.指导禁烟，鼓励病人练习深呼吸和有效排痰，练习床上排大小便。将胸腔镜术的基本步骤、与一般开胸术的区别，优点和术中、术后注意事项向患者及家属进行了耐心细致地讲解，从而取得了最佳配合。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 3.鼓励病人早期下床活动，宣教术后早期活动的意义。 4.宣教和指导正确的深呼吸、有效咳嗽。 5.宣教各种药物的名称、剂量、作用和副作用。有出院带药的做好相应的宣教。 6.解释术后胸管放置的目的、意义及注意事项。 7.保持切口的清洁干燥，洗澡时注意保护切口。 8.如出现胸闷、胸痛、呼吸困难等情况应及时就诊。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 肺癌护理常规 肺癌:肿瘤细胞源于支气管粘膜后腺体，常有直接扩散、区域性淋巴结和血行转移，早期常有刺激性干咳和痰中带血呼吸道症状，病情进展速度与细胞的生物特性有关。 一、 护理评估 1.了解患者年龄、职业、生活坏境及吸烟史、家庭史，了解有无高血压、糖尿病、冠心病、慢性支气管炎等过去史，有无手术史，有无特殊用药史，及其他部位肿瘤病史。 2.病情评估。 2.1 了解患者是否有发热、胸闷、胸痛、咳嗽、咳痰、痰中带血，咯血、气急等情况。 2.2 意识、生命体征、血糖等情况。 2.3 患者局部有无发绀、贫血、有无杆状指(趾)。 3.患者营养情况，有无低蛋白血症、贫血、及食欲情况。 4.各种特殊检查和实验室检查结果等 5.了解患者的心理状态，对疾病的认识程度，对手术治疗有何顾虑。 6.亲属对患者的关心程度、支持力度、家庭对手术的承受能力。 7.术后评估: 7.1 手术后诊断，手术方式，术中出血，输血，麻醉，镇痛情况。 7.2 意识、生命体征、氧饱和度、疼痛、切口敷料、皮肤情况。 7.3 患者两肺呼吸音、咳嗽、咳痰的性质、量、呼吸形态、以及呼吸功能锻炼情况等。 7.4 胸腔闭式引流管，固定是否妥当，是否通畅，引流液的量、色、性质等。 7.5 患者用药情况等。 7.6 患者的活动能力。 7.7 肛门排气，排便情况。 7.8 患者各项特殊检查和实验室检查情况。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 8.患者安全评估，有无跌倒/坠床、以及压疮等危险。 二、 主要护理问题/护理点 疼痛、气体交换受损、清理呼吸道低效、焦虑与恐惧、知识缺乏、有感染的危险、有引流失效的危险、活动无耐力、营养失调低于机体需要量、PC 出血、肺不张、支气管胸膜瘘、心律失常、水电解质紊乱、下肢静脉血栓形成等。 三、 护理措施 1.一般措施。 1.1 按胸外科一般护理常规。 1.2 病情观察:观察生命体征变化，观察是否有发热、胸闷、胸痛、咳嗽、咳痰等情况。 1.3 活动与休息:适度活动，保证充足的睡眠和休息，重病人需卧床休息，给予半卧位或半坐位，缺氧者及时予吸氧，做好呼吸道管理，预防感染，保持室内空气流通，预防感冒，吸烟者，绝对忌烟。 1.4 饮食与营养:给予高蛋白，高热量，高维生素饮食，增强体质。 1.5 用药护理，按医嘱给予化痰，抗感染等药物治疗，并观察用药后的效果和反应。 1.6 做好基础护理和生活护理。 1.7 协助做好各项检查，如:CT、肺功能、心电图、支气管镜等做好相关检查前的准备和教育工作。 1.8 做好术前准备工作，指导患者练习腹式深呼吸及有效咳嗽、咳痰、练习床上大小便。讲解术后引流管放置的目的及注意事项。按医嘱给予术前用药。 1.9 做好心理护理，建立良好护患关系，充分理解患者及家属对检查、治疗、预后的期望心情，消除患者恐惧心理，积极配合治疗和护理。 1.10 做好安全防护，防止意外发生。 2.术后护理 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 2.1 按胸外科术后护理常规。 2.2 密切观察患者意识、血压、脉搏、体温、切口敷料、及胸部体征变化，观察有无胸腔内出血，观察有无感染、肺不张、及支气管胸膜瘘等并发症。 2.3 予合适体位:血压平稳后采用半坐卧位，肺叶切除者可采用半卧或左右侧卧位，肺段切除或契形切除者，尽量选择健侧卧位、全肺切除者，可采用1/4 侧卧位，有血痰或支气管瘘者因取患侧卧位，避免采用头低足高位。 2.4 用药护理:遵医嘱使用止血、化痰、抗炎、营养支持药物，合理安排补液顺序，严格掌握输液量和速度，防止前负荷过重而导致肺水肿，全肺切除术后应控制钠盐摄入，24小时补液量，宜控制在2000ml 内，速度以20-30 滴/mm 为宜。 2.5 活动与休息。鼓励患者早期下床活动，术后第1 日，生命体征平稳，可协助下床或床边活动，如出现头晕、气促、心动过速、心悸、出汗等症状时应立即停止活动，术后第2日起，可扶持患者室内行走3-5 分钟，后根据患者情况逐渐增加活动量，另外，促进手臂和肩关节的运动从麻醉清醒后的被动运动到术后第1 日的主动运动，逐步增加。 2.6 饮食与营养:一般术后6 小时，即可进食，清淡流质、半流质饮食。进食后无任何不适，逐步改为普食，饮食宜为高蛋白、高热量、丰富维生素，易消化，保证营养，促进伤口愈合。 2.7 疼痛护理:教会患者家属使用镇痛泵，如疼痛严重时可适当给予镇痛药，使用吗啡，杜冷丁等药物前后必须评估生命体征。 2.8 呼吸道管理:鼓励并协助患者深呼吸及咳嗽，每1-2 小时1 次，定时给患者叩背，遵医嘱予以雾化吸入，稀释痰液、解痉抗感染。痰多不易咳出者，必要时可纤支镜吸痰。 2.9 做好基础护理和生活护理，如口腔护理，会阴护理，使患者舒适。 2.10 胸腔闭式引流管按常规护理。 2.11 切口护理:观察切口敷料有无渗血、渗液及切口愈合情况，如切口有红肿热痛情况，the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 及时汇报医生，及时处理。 2.12 做好术后心理护理，保持良好的心理状态，促进疾病的早日好转。 四、 健康教育 1.戒烟、使患者了解吸烟的危害，早期戒烟。 2.宣教各种药物的名称，剂量，作用和副作用。出院带药做好相应宣教。 3.解释术后各种引流管放置的目的、意义、注意事项等。 4.保持良好营养状况，注意每天保持充分休息与活动。 5.指导患者出院后数星期内，仍应进行呼吸运动及有效的咳嗽。 6.保持良好的口腔卫生，避免出入公共场所或与上呼吸道感染者接近，避免居住或工作于布满灰尘，烟雾及化学刺激物品的环境。 7.保持切口清洁干燥，洗澡时注意保护切口，若有伤口疼痛，剧烈咳嗽及咯血等症状或有进行性倦怠情形，应返院复诊。 8.接受化学药物治疗者，在治疗过程中应注意，血象的变化，定期返院复查血细胞和肝功能。 9.鼓励患者保持良好的心理状况，积极应对疾病。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 食管癌护理常规 食管癌是一种常见的消化道肿瘤，起源于食道粘膜，多数为鳞癌，食道下段和喷门内部有粘膜下层腺组织发生腺癌。食管癌可发生于食管任何部位，其中以中段多见。 一、护理评估 1.了解患者年龄，性别，婚姻，职业，居住地和饮食习惯等，有无糖尿病和高血压病，冠心病等病史，了解家族中有无肿瘤病人，有无手术史，有无特殊用药史。 2.病情评估。 2.1 了解病人有无吞咽困难，呕吐，进食后哽咽感，胸骨后针刺样疼痛或烧灼感，并随病情进展而逐渐加重。 2.2 意识，生命体征，血糖等情况。 2.3 营养情况，病人有无体重减轻，消瘦，贫血，脱水或衰弱。 2.4 有无触及锁骨上淋巴结肿大和肝肿块。 2.5 疼痛情况，包括疼痛部位，程度性质。 2.6 发热情况，有无午后低热等。 3.各种特殊检查和实验室检查情况等。 4.病人的疾病认识程度有无心理问题。 5.患者家属的关心程度，支持力度，家庭经济承受能力等。 术后评估: 6. 6.1 手术后诊断，手术方式，术中出血，输血，麻醉，镇痛等情况。 6.2 意识，生命体征，氧饱和度，疼痛，切口敷料，皮肤弹性及完整性情况。 6.3 患者两肺呼吸音，咳嗽，咳痰的性质、量、呼吸功能锻炼情况等。 6.4 各引流管道情况，如胃管，胸腔闭式引流管，腹腔负压引流管，导尿管固定是否完好，是否通畅、引流液的量、色、性质等。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 6.5 深静脉导管是否妥善固定，是否通畅，TPN 营养支持情况。 6.6 患者的活动能力。 6.7 患者各项特殊检查和实验室检查情况等。 6.8 患者用药情况。 6.9 肛门排气，排便情况。 二、主要护理问题/护理点 疼痛、体液不足、清理呼吸道低效、低效型呼吸型态、有感染的危险、有引流失效的危 险、皮肤完整性受损的危险、营养失调低于机体需要量、焦虑、活动无耐力、知识缺乏、 PC: 出血、吻合口痿、吻合口狭窄、乳糜胸、水电解质酸碱失衡、下肢静脉血检形成。 三、护理措施 1.一般措施。 1.1 按胸外科一般护理常规。 1.2 病情观察，观察患者吞咽困难程度及进食情况，观察胸骨后疼痛的性质、程度、及体温、脉搏、血压等生命体征变化。 1.3 活动与休息:患者适度运动，保证充足的睡眠和休息。 1.4 饮食和营养:进食高热量、高蛋白、丰富维生素的流质和半流质饮食，若患者进食时感食道粘膜有刺痛，可给予清淡无刺激的食物，避免进食生、冷、硬的食物，只能进食流质而营养状况较差者，可补充液体、电解质，提供肠内、肠外营养。 1.5 用药护理，按医嘱给予药物治疗，注意观察用药后的效果和反应。 1.6 做好基础护理和生活护理。 1.7 协助做好各项检查，如:食道钡餐造影，胸腹部CT、超声内镜检查，动态心电图等，相关检查前的准备和教育工作。 1.8 做好呼吸道准备，对吸烟者，劝其严格戒烟，指导并训练患者有效咳嗽，咳痰和腹式the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 深呼吸。 1.9 做好胃肠道准备，术前一周遵医嘱给予患者口服抗菌药物，术前3 日改流质饮食，术前晚行清洁灌肠后禁食、禁饮，术日晨予留置胃管。 1.10 做好其余术前准备和教育，指导床上大小便，遵医嘱予术前用药等。 1.11 做好心理护理，保持患者情绪稳定，积极配合治疗和护理。 1.12 做好安全防护，防止意外发生:如跌倒、坠床、压疮等。 2.术后措施 2.1 按胸外科术后护理常规。 2.2 密切观察患者意识，血压，脉搏，体温，及胸腹部体征的变化，观察胸腔内有无活动性出血。 2.3 活动与休息，生命体征平稳后取半卧位休息，当天以床上活动为主，根据病情逐渐增加活动量，鼓励患者早期下床活动。 -4 日，待肛门排气，胃肠减压引流量减少，拔除胃2.4 饮食与营养，术后持续胃肠减压3 管，24 小时后，若无呼吸困难，胸内剧痛，患侧呼吸音减弱及高热等吻合口瘘症状时可开始进食。先试饮少量水，术后5-6 日可给全清流质，术后3 周后患者若无特殊不适，可进食，宜少食多餐，细嚼慢咽，在禁食期间根据医嘱予静脉营养支持。 2.5 用药护理:根据医嘱给予化痰、抗痰、营养支持等各项药物治疗，观察用药后的效果和反应。 2.6 疼痛护理:术后如有镇痛泵，做好相应的护理，疼痛严重时遵医嘱适当予镇痛药物，使用吗啡、杜冷丁等药物前后必须评估生命体征。 2.7 做好基础护理和生活护理，如口腔护理，会阴护理等，勤换衣裤，使患者舒适。 2.8 呼吸道管理:指导患者进行深呼吸和有效咳嗽，咳痰锻炼。协助做好翻身、拍背，促使痰液排出，如痰液粘稠，可给予雾化吸入，化痰药物等。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 2.9 胃肠减压，深静脉导管，胸腔闭式流管、腹腔负压引流球按常规护理。 2.10 切口护理:观察切口敷料有无渗血，渗液及切口愈合后情况，注意切口有无红肿、热、痛等异常情况，如有异常，及时汇报医生，及时处理。 2.11 做好术后心理护理，保持良好的心理状态，促进疾病早日好转。 四、健康教育 1.禁食期间宣教禁食的重要性，并注意口腔清洁，可进食后应少量多餐，由稀到干，逐渐增加食量，并注意进食后的反应，避免进食刺激食物与碳酸饮料，避免进食过快、过量及 硬质食物，避免进食花生、豆类等，以免导致吻合口瘘，餐后取半卧位，防止食物反流及呕吐，也利于肺膨胀和引流。 2.鼓励患者多下床活动，宣教术后早期活动的意义。 3.宣教指导正确的深呼吸和有效的咳嗽、咳痰。 4 宣教各种药物的名称、剂量、作用和副作用，出院带药做好相应宣教。 5.解释术后各引流管放置的目的、意义，注意事项等，做好管道宣教。 6.保持切口的清洁，干燥。 7.鼓励患者保持良好的心态，积极应对疾病。 8.保证充分的睡眠，劳逸结合，逐渐增加活动量。 9.加强自我观察，若术后3-4 周再次出现吞咽困难时，可能为吻合口狭窄，应及时就诊。 10.定期复查，坚持后续治疗。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 纵膈肿瘤护理常规 纵膈肿瘤是发生在纵膈的肿瘤，大部分为原发纵膈良性肿瘤，极少数为恶性肿瘤，常见有神经纤维瘤、畸胎瘤、胸腺瘤。 一、护理评估 1.既往有无心脏病等病史，了解有无高血压、糖尿病、贫血、营养不良、吸烟等过去史;有无手术史等;有无特殊用药史。 2.病情评估: 2.1 本次发作的诱因，既往有无类似发作史及治疗情况。 2.2 意识、生命体征、血糖、血压等情况。 2.3 疼痛情况，包括疼痛发作时的部位、性质、时间等。 2.4 有无吞咽困难、胸闷，呼吸困难或血管症状、肺部感染、咯血或心包填塞。 2.5 有无肢体活动及皮肤感觉障碍，观察有无脊髓损伤的体征。 各种特殊检查和实验室检查结果等，如CT 、MRI。 3. 4.患者营养情况，有无贫血、营养不良等情况。 5.了解患者的心理状态，对疾病的认知程度。 6.术后评估 6.1 手术后的诊断、手术方式、术中出血、输血、麻醉、镇痛情况。 6.2 意识、生命体征、氧饱和度、疼痛、切口敷料、皮肤情况。 6.3 患者两肺呼吸音、咳嗽咳痰的性质、量、呼吸功能锻炼情况。 6.4 引流管道情况，如纵膈引流管、胸腔闭式引流管等的固定是否完好，是否通畅，引流液的量、色、性质等。 6.5 患者活动能力。 6.6 肛门排气排便情况等。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 6.7 尿量，观察尿液的量、色、性状等。 6.8 患者各项特殊检查和实验室检查情况等; 6.9 用药情况。 7.患者安全评估，有无跌倒/坠床等的危险。 二、主要护理问题/护理点 疼痛、焦虑、知识缺乏、心输出量减少、清理呼吸道低效、低效型呼吸型态、自理能力缺陷、皮肤完整性受损的危险、PC:出血、感染、栓塞、乳糜胸、吻合口瘘、胸腔积液、支气管胸膜瘘、肺不张、心律失常。纵膈引流管、胸腔闭式引流管的护理。 三、护理措施 1.一般措施 1.1 按胸外科一般护理常规。 1.2 病情观察:密切注意有无胸闷、胸痛，观察疼痛的部位、性质、时间、体温、脉搏、血压的变化，如患者出现脉搏细速、血压下降的休克症状，应立即通知医生，做好手术准备。 1.3 活动与休息:卧床休息，视病情轻重制定合理的活动计划。 1.4 饮食与营养:清淡易消化饮食多吃新鲜蔬菜水果，忌烟酒，保持大便通畅。 1.5 用药的护理:按医嘱给与药物治疗，注意观察用药后的效果和反应。 1.6 胸腺瘤伴重症肌无力的护理:(1)严格记录胆碱能药物的剂量、用法、时间;(2)观察有无胆碱能药物过量症状，如痉挛性腹痛、腹泻、多汗及瞳孔缩小;(3)观察有无呼吸和吞咽功能衰竭等现象;(4)禁用氨基糖苷类药物;(5)床旁备好气切包、吸引器、人工呼吸机等抢救药品及胆碱能药物。 1.7 做好基础护理和生活护理。 1.8 协助做好各项检查。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 1.9 做好术前准备和教育，指导深呼吸、有效咳嗽锻炼，指导床上大小便等，按医嘱给予术前用药等。 1.10 做好心理护理，保持情绪稳定，积极配合治疗和护理。 1.11 做好安全防范，烦躁不安者拉起床栏，防止意外发生。 2.术后措施 2.1 按胸外科术后护理常规。 2.2 密切观察患者意识、血压、脉搏、体温、呼吸及胸痛症状，判断其性质，遵医嘱使用药物。密切观察心电图变化，及时发现心律失常等征象。观察有无胸腔内出血，有无支气管胸膜瘘、心包填塞等并发症。密切观察有无重症肌无力出现。巨大纵膈手术后注意有无肢体活动及皮肤感觉障碍，观察有无脊髓损伤的体征。观察有无声音嘶哑，防止压迫喉返神经。 2.3 活动与休息:生命体征平稳后取半卧位，当天以床上活动为主，根据病情逐步增加活动量，鼓励患者早期下床活动。适当休息，精神紧张影响睡眠者，给予适量镇定剂。便秘时给 予开塞露。 2.4 饮食与营养:肛门排气后可进清淡易消化饮食多吃新鲜蔬菜水果，忌烟酒，保持大便通畅，维持水电解质平衡。吞咽困难或摄入不足可静脉补液或鼻饲。 2.5 用药护理:根据医嘱给予各种药物治疗，观察用药后的效果及反应。 2.6 疼痛的护理:术后有镇痛泵，做好相应的护理;疼痛严重给予适当镇静药物，使用吗啡、杜冷丁等药物前后必须评估生命体征。 2.7 做好术后基础护理和生活护理，使患者舒适。 2.8 呼吸道管理:指导患者进行深呼吸和有效咳嗽锻炼，协助翻身拍背，促进痰液排出，如痰液粘稠，可适当给予雾化吸入;必要时给予抗生素;防止肺不张、肺炎、窒息的并发the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use 症。 2.9 有胸腔闭式引流管、纵膈引流管者按常规护理。 2.10 切口护理:观察切口敷料有无渗血、渗液及切口的愈合情况;注意切口有无红肿、热、痛等异常情况，如有异常及时汇报医生，及时处理。 2.11 做好术后心理护理，保持良好的心理状态，促进疾病早日康复。 四、健康宣教 1. 指导患者可进食清淡易消化食物，多吃新鲜蔬菜水果，忌烟酒，保持大便通畅，维持水电解质平衡。 2.鼓励患者多下床活动，宣教术后早期活动的意义。 3.宣教和指导正确的深呼吸、有效咳嗽排痰。 4.宣教各种药物的名称、剂量、作用和副作用等。出院带药做好相应的宣教。 5.解释术后各种引流管放置的目的、意义、注意事项等。 6.保持切口清洁干燥，洗澡时注意保护切口。 7.鼓励患者保持良好的心理状态，积极应对疾病。如出现胸闷、胸痛呼吸困难等症状或切口红肿、热痛、渗液等，应及时就诊。 the drawings, first to become familiar with the drawings, mainly about the following aspects: 1) pages of drawings and diagrams, maps; 2) a comprehensive understanding of drawing; 3) finding of design-driven dimensions (), do not resize and adjust the size; 4) questioned the drawings; 5) develop buries a construction programme and technical clarification; 6) clear corners and special treatment; 7) controlled construction drawings to verify construction scheme and design. (2) at the construction site to find subject planted area: various engineering, first on the scene to find planted area, it must first understand the curtain wall installation section, and some projects are all curtain wall, the entire project is a region-wide, only partial walls, the zone is local. (3) identify the axis positioning: positioning the drawings shown in axis compared with the actual construction site to find out exactly where the axis positioning, axis positioning function are: 1) to help determine the origin of curtain walls; 2) acceptance of the installation is accurate; 3) adjust errors, and determine the error range. (4) find anchor points: according to site to find the exact location of the axis, according to the drawings provided by the content determine the positioning point; number of anchor points shall not be less than two points. Repeated measurements determine the location points must ensure that the positioning is correct. (5) take level (level): level (minor works available in horizontal pipe), the two anchor points determine the horizontal position. Level according to use