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02-消化-03-胆总管结石临床路径

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02-消化-03-胆总管结石临床路径02-消化-03-胆总管结石临床路径 胆总管结石临床路径 ,2009年版, 一、胆总管结石临床路径标准住院流程 ,一,适用对象。 第一诊断为胆总管结石,ICD-10:K80.3/K80.5, 行胆总管内镜下取石术(ICD-9-CM-3:51.8802) ,二,诊断依据。 根据《实用内科学,第12版,》,复旦大学医学院编著~人民卫生出版社,~《消化内镜学,第2版,》,科学出版社,等国内、外临床诊疗指南 ?胆绞痛、梗阻性黄疸、急性胆管炎,即Charcot三联征:腹痛、黄疸、发热,或胆源性胰腺炎。 ?辅助检查,超...
02-消化-03-胆总管结石临床路径
02-消化-03-胆总管结石临床路径 胆总管结石临床路径 ,2009年版, 一、胆总管结石临床路径标准住院流程 ,一,适用对象。 第一诊断为胆总管结石,ICD-10:K80.3/K80.5, 行胆总管内镜下取石术(ICD-9-CM-3:51.8802) ,二,诊断依据。 根据《实用内科学,第12版,》,复旦大学医学院编著~人民卫生出版社,~《消化内镜学,第2版,》,科学出版社,等国内、外临床诊疗指南 ?胆绞痛、梗阻性黄疸、急性胆管炎,即Charcot三联征:腹痛、黄疸、发热,或胆源性胰腺炎。 ?辅助检查,超声、CT或MRCP,怀疑或提示胆总管结石。 ,三,治疗方案的选择。 根据《临床技术操作规范-消化内镜学分册》,中华医学会编著~人民军医出版社,~《实用内科学,第12版,》,复旦大学医学院编著~人民卫生出版社,~《消化内镜学,第2版,》,科学出版社,等国内、外临床诊疗指南 1.急诊手术:急性胆管炎。 2.择期手术:患者本人有微创治疗意愿,生命体征稳定,无重要脏器衰竭表现,能耐受ERCP操作者。 ,四,标准住院日为7-10天。 to the fuel tank in a timely manner, and to install gasket between the tank and lid, tighten all bolts evenly on the oil tank cover, should body checking, testing team, reset, filling a job completed. Throughout the work process to prevent oil spills or spills to the ground, the site requirements the used oil properly. 4.1.12.3 transformer drying 4.1.12.3.1 transformers need to be dried should be based on the synthetic analysis-judgment to determine field test data 4.1.12.3.2 If the transformer needs to be dry, the temperature must be monitored. 4.1.12. ... Clean on the inside wall before installation, explosion-proof membrane film should complete airway completely skewed on the tank cap, install the tilt direction according to the provisions of the factories, no special provisions, should be inclined to the conservator. 4.1.12.8 install 4.1.12.8.1 installation of dryer dryer lid rubber pads must be removed to make it smooth, generally in the middle of the lid with the right amount transformer oil filtration effect. 4.1.12.8.2 drying oil seal should be properly installed, the oil level should be above the oil level line. Relay and 4.1.12.9 gas 4.1.12.9.1 gas thermometers installed relays and thermometer installation should be tested or verified and qualified. 4.1.12.9.2 gas relay should be installed horizontally, should relay on both sides of the pipe axis is flat with the transformer tank cover, allows access to the reservoir at one end slightly higher. 4.1.12.9.3 transformer thermometer for transformer oil is injected on the top cover to seal it. 4.1.12.9.4 signal contact connection should be correct, as per drawing requirements. 4.1.12.10 insulating oil transformer oil 4.1.12.10.1 transformer must be tested after passing into the transformer. 4.1.12.10.2 oil from the tank bottom valve into the oil, add and oil should be injected through special valves for oil storage tank, oil ,五,进入路径标准。 ?第一诊断必须符合ICD-10:K80.3/K80.5胆总管结石疾病编码。 2.当患者同时具有其他疾病诊断~但在住院期间不需要特殊处理也不影响第一诊断的临床路径流程实施时~可以进入路径。 ,六,入院第1-2天。 1.必需的检查项目: ,1,血常规~尿常规~大便常规,潜血, ,2,肝肾功能、电解质、血糖、血淀粉酶、血型、RH因子、凝血功能、感染性疾病筛查,乙肝、丙肝、艾滋病、梅毒等, , ,3,腹部超声、心电图、胸片。 2.根据患者病情可选择:超声心动、腹部CT 、MRCP等。 ,七,选择用药。 1.抗菌药物:按照《抗菌药物临床应用指导原则》,卫医发〔2004〕285号,执行~并结合患者的病情决定抗菌药物的选择与使用时间。 2.造影剂选择:碘过敏试验阴性者~选用泛影葡胺,碘过敏试验阳性者~选用有机碘造影剂。 ,八,内镜治疗,即ERCP,日为入院第3-4天。 1.操作前应用静脉镇静药、解痉药及口咽部局部麻醉剂。 2.行无痛内镜时~术中需监测生命体征~术后要在内镜to the fuel tank in a timely manner, and to install gasket between the tank and lid, tighten all bolts evenly on the oil tank cover, should body checking, testing team, reset, filling a job completed. Throughout the work process to prevent oil spills or spills to the ground, the site requirements the used oil properly. 4.1.12.3 transformer drying 4.1.12.3.1 transformers need to be dried should be based on the synthetic analysis-judgment to determine field test data 4.1.12.3.2 If the transformer needs to be dry, the temperature must be monitored. 4.1.12. ... Clean on the inside wall before installation, explosion-proof membrane film should complete airway completely skewed on the tank cap, install the tilt direction according to the provisions of the factories, no special provisions, should be inclined to the conservator. 4.1.12.8 install 4.1.12.8.1 installation of dryer dryer lid rubber pads must be removed to make it smooth, generally in the middle of the lid with the right amount transformer oil filtration effect. 4.1.12.8.2 drying oil seal should be properly installed, the oil level should be above the oil level line. Relay and 4.1.12.9 gas 4.1.12.9.1 gas thermometers installed relays and thermometer installation should be tested or verified and qualified. 4.1.12.9.2 gas relay should be installed horizontally, should relay on both sides of the pipe axis is flat with the transformer tank cover, allows access to the reservoir at one end slightly higher. 4.1.12.9.3 transformer thermometer for transformer oil is injected on the top cover to seal it. 4.1.12.9.4 signal contact connection should be correct, as per drawing requirements. 4.1.12.10 insulating oil transformer oil 4.1.12.10.1 transformer must be tested after passing into the transformer. 4.1.12.10.2 oil from the tank bottom valve into the oil, add and oil should be injected through special valves for oil storage tank, oil 室观察至清醒~并经麻醉医师同意后返回病房。 3.术中可能使用胆管支架或鼻胆引流管。 4.ERCP术中明确胆管结石~先行EST或球囊扩张~然后网篮和,或,球囊取石。 ,九,治疗后住院恢复3天。 1.必须复查的检查项目:血常规、肝肾功能、电解质、血淀粉酶。 2.术后用药:应用覆盖革兰阴性杆菌和厌氧菌~并主要从胆汁排泄的广谱抗菌药物。 3.严密观察有否胰腺炎、胆道感染、穿孔、出血等并发症~并作相应处理。 ,十,出院标准。 1.一般状况好~体温正常~无明显腹痛。 2.实验室检查基本正常。 3.无需要住院治疗的并发症。 ,十一,变异及原因。 1.出现并发症,ERCP相关性胰腺炎、胆道感染、出血、穿孔及麻醉意外者,等转入相应临床路径。 2.合并胆道狭窄、占位者转入相应临床路径。 3.巨大结石需要内镜下机械或激光碎石~多次镜下取石等转入相应临床路径。 4.合并胆囊结石、肝内胆管结石者转入相应临床路径。 to the fuel tank in a timely manner, and to install gasket between the tank and lid, tighten all bolts evenly on the oil tank cover, should body checking, testing team, reset, filling a job completed. Throughout the work process to prevent oil spills or spills to the ground, the site requirements the used oil properly. 4.1.12.3 transformer drying 4.1.12.3.1 transformers need to be dried should be based on the synthetic analysis-judgment to determine field test data 4.1.12.3.2 If the transformer needs to be dry, the temperature must be monitored. 4.1.12. ... Clean on the inside wall before installation, explosion-proof membrane film should complete airway completely skewed on the tank cap, install the tilt direction according to the provisions of the factories, no special provisions, should be inclined to the conservator. 4.1.12.8 install 4.1.12.8.1 installation of dryer dryer lid rubber pads must be removed to make it smooth, generally in the middle of the lid with the right amount transformer oil filtration effect. 4.1.12.8.2 drying oil seal should be properly installed, the oil level should be above the oil level line. Relay and 4.1.12.9 gas 4.1.12.9.1 gas thermometers installed relays and thermometer installation should be tested or verified and qualified. 4.1.12.9.2 gas relay should be installed horizontally, should relay on both sides of the pipe axis is flat with the transformer tank cover, allows access to the reservoir at one end slightly higher. 4.1.12.9.3 transformer thermometer for transformer oil is injected on the top cover to seal it. 4.1.12.9.4 signal contact connection should be correct, as per drawing requirements. 4.1.12.10 insulating oil transformer oil 4.1.12.10.1 transformer must be tested after passing into the transformer. 4.1.12.10.2 oil from the tank bottom valve into the oil, add and oil should be injected through special valves for oil storage tank, oil 二、胆总管结石临床路径表单 适用对象:第一诊断为胆总管结石(ICD-10:K80.3/K80.5) 行胆总管内镜下取石术(ICD-9-CM-3:51.8802) 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7-10天 时间 住院第1天 住院第2天 住院第3-4天 ? 病史采集和体格检查 ? 上级医师查房,明确下一? 上级医师查房 主 ? 完成病历书写 步诊疗计划 ? 完成三级查房 要 ? 评估患者全身状况及合? 根据化验检查结果评价内? 行ERCP取石术 诊 并症 镜治疗的适应证与禁忌症 ? 术后密切观察生命体疗 ? 完善常规检查 ? 对患者及家属进行相关宣征及腹部体征,复查化工 教 验指标,警惕操作并发作 ? 进行术前准备,向患者及症 家属交代病情,并签署知? 补液治疗,并应用广谱 情同意书 抗菌药物 长期医嘱: 长期医嘱: 长期医嘱: ? 消化内科护理常规 ? 消化内科护理常规 ? 消化内科护理常规 ? 二级护理 ? 二级护理 ? 特级护理 ? 低脂半流食 ? 低脂半流食 ? 术前禁食水 重 临时医嘱: 临时医嘱: ? 应用覆盖革兰阴性杆 ? 血、尿、大便常规+潜血 ? 次晨禁食 菌和厌氧菌的广谱抗点 ? 肝肾功能、电解质、血? 碘过敏试验 菌药物、生长抑素等 糖、血淀粉酶、脂肪酶、? 带药:镇静药、解痉药、? 静脉补液 医 凝血功能血型、RH因泛影葡胺或有机碘造影临时医嘱:(术后) 子、感染性疾病筛查 剂、麻醉用药 ? 复查血常规 嘱 ? 腹部超声、心电图、胸? 预约ERCP ? 复查肝功、电解质 片 ? 术后2小时及6小时复 ? 超声心动、腹部CT、查血淀粉酶、脂肪酶 MRCP(必要时) 主要? 协助患者及家属办理入? 基本生活和心理护理 ? 基本生活和心理护理 护理 院手续 ? 进行关于内镜检查宣教并? 观察ERCP后患者病情工作 ? 进行入院宣教 行内镜检查前准备 变化,如有异常及时向 ? 静脉抽血 医生汇报 病情 ?无 ?有,原因: ?无 ?有,原因: ?无 ?有,原因: 变异 1( 1( 1( 记录 2( 2( 2( 护士 签名 医师 签名 to the fuel tank in a timely manner, and to install gasket between the tank and lid, tighten all bolts evenly on the oil tank cover, should body checking, testing team, reset, filling a job completed. Throughout the work process to prevent oil spills or spills to the ground, the site requirements the used oil properly. 4.1.12.3 transformer drying 4.1.12.3.1 transformers need to be dried should be based on the synthetic analysis-judgment to determine field test data 4.1.12.3.2 If the transformer needs to be dry, the temperature must be monitored. 4.1.12. ... Clean on the inside wall before installation, explosion-proof membrane film should complete airway completely skewed on the tank cap, install the tilt direction according to the provisions of the factories, no special provisions, should be inclined to the conservator. 4.1.12.8 install 4.1.12.8.1 installation of dryer dryer lid rubber pads must be removed to make it smooth, generally in the middle of the lid with the right amount transformer oil filtration effect. 4.1.12.8.2 drying oil seal should be properly installed, the oil level should be above the oil level line. Relay and 4.1.12.9 gas 4.1.12.9.1 gas thermometers installed relays and thermometer installation should be tested or verified and qualified. 4.1.12.9.2 gas relay should be installed horizontally, should relay on both sides of the pipe axis is flat with the transformer tank cover, allows access to the reservoir at one end slightly higher. 4.1.12.9.3 transformer thermometer for transformer oil is injected on the top cover to seal it. 4.1.12.9.4 signal contact connection should be correct, as per drawing requirements. 4.1.12.10 insulating oil transformer oil 4.1.12.10.1 transformer must be tested after passing into the transformer. 4.1.12.10.2 oil from the tank bottom valve into the oil, add and oil should be injected through special valves for oil storage tank, oil 住院第4-5天 住院第5-6天 住院第7-10天 时间 (术后第1天) (术后第2-3天) (出院日) ? 观察患者腹部症状和? 观察进食/水后患者腹部? 上级医师查房、确定能 体征 症状和体征变化 否出院 ? 上级医师查房,根据? 上级医师查房,根据? 通知患者及家属出院 ERCP造影结果,明确ERCP造影结果,明确下? 向患者及家属交代出主 下一步诊疗计划 一步诊疗计划 院后注意事项 要 ? 复查异常化验指标 ? 复查异常化验指标 ? 准备出院带药 诊 ? 对患者坚持治疗和预? 对患者坚持治疗和预防? 通知出院处 疗 防复发进行宣教 复发进行宣教 ? 将出院记录副本交给工 患者 作 ? 如果患者不能出院,在 病程记录中说明原因 和继续治疗的方案如 果患者可以出院 长期医嘱: 长期医嘱: 长期医嘱: ? 消化内科护理常规 ? 消化内科护理常规 ? 出院带药 ? 一级护理 ? 二级护理 ? 门诊随诊 重 ? 试饮水 ? 流食 ? 应用覆盖革兰阴性杆? 应用覆盖革兰阴性杆菌 点 菌和厌氧菌的广谱抗和厌氧菌的广谱抗菌药 菌药物 物 医 ? 静脉输液 ? 静脉输液 临时医嘱: 临时医嘱: 嘱 ? 血常规、肝功能、电解? 血常规、肝功能、电解质 质(必要时) (必要时) ? 复查血淀粉酶、脂肪酶 ? 复查血淀粉酶、脂肪酶 ? 腹部超声 ? 基本生活和心理护理 ? 基本生活和心理护理 ? 帮助患者办理出院手主要 ? 监督患者用药 ? 监督患者用药 续、交费等事宜 护理 ? 领取出院带药 工作 病情 ?无 ?有,原因: ?无 ?有,原因: ?无 ?有,原因: 变异 1( 1( 1( 记录 2( 2( 2( 护士 签名 医师 签名 to the fuel tank in a timely manner, and to install gasket between the tank and lid, tighten all bolts evenly on the oil tank cover, should body checking, testing team, reset, filling a job completed. Throughout the work process to prevent oil spills or spills to the ground, the site requirements the used oil properly. 4.1.12.3 transformer drying 4.1.12.3.1 transformers need to be dried should be based on the synthetic analysis-judgment to determine field test data 4.1.12.3.2 If the transformer needs to be dry, the temperature must be monitored. 4.1.12. ... Clean on the inside wall before installation, explosion-proof membrane film should complete airway completely skewed on the tank cap, install the tilt direction according to the provisions of the factories, no special provisions, should be inclined to the conservator. 4.1.12.8 install 4.1.12.8.1 installation of dryer dryer lid rubber pads must be removed to make it smooth, generally in the middle of the lid with the right amount transformer oil filtration effect. 4.1.12.8.2 drying oil seal should be properly installed, the oil level should be above the oil level line. Relay and 4.1.12.9 gas 4.1.12.9.1 gas thermometers installed relays and thermometer installation should be tested or verified and qualified. 4.1.12.9.2 gas relay should be installed horizontally, should relay on both sides of the pipe axis is flat with the transformer tank cover, allows access to the reservoir at one end slightly higher. 4.1.12.9.3 transformer thermometer for transformer oil is injected on the top cover to seal it. 4.1.12.9.4 signal contact connection should be correct, as per drawing requirements. 4.1.12.10 insulating oil transformer oil 4.1.12.10.1 transformer must be tested after passing into the transformer. 4.1.12.10.2 oil from the tank bottom valve into the oil, add and oil should be injected through special valves for oil storage tank, oil
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