胸外科护理查房最终版优秀PPT.ppt

SpontaneousPneumothoraxThoracicsurgerynursingwardroundThespeaker:WuhanPolytechnicUniversity自发性气胸自发性气胸Page 2Group division of labornCase-甄媛媛甄媛媛nEtiology and classificationn-于广平于广平 马莹马莹nClinical manifestationsn-蒋娟蒋娟nAuxiliary examination and-桓秀山桓秀山 刘严逸夫刘严逸夫 Therapeutic principlesn Nursing measuresn-毛雅琴毛雅琴 潘娟潘娟 王辉王辉n Health educationn-李飘飘李飘飘 赵娟赵娟 Page 3CASE PatientYuWeichengmale17yearsWithpainatleftchestanddifficultybreathing,chestdistress10days.Pastmedicalhistory:Alwaysbodyhealth,denyhistoryofotherseriousdiseasesanddrugallergy.Historyofpresentdisease:Withoutanyobviouscause,hefeltpainattheleftchestanddifficultybreathing,chestdistress10daysago.Nofever,lowhead,cough,haemoptysis,lackofpower,nightsweatandsoon.Atfirstdidnotpayattentiontothese,butsymptomsfornoease.Achestradiographyshowedthattheleftlungtissuecompressionby85%.Physicalexamination:T37.3,P96/min,R20/min,BP140/80mmHgIntelligenceclear,trachealatthecenterofneck.Theleftbreathsoundsalittleweak.Diagnosticexamination:WBC11.4109,N8.05,L18.1Admissiondiagnosis:SpontaneousPneumothoraxPage 4病例病例患者：患者：余炜成，男，余炜成，男，1717岁岁 左侧胸痛、胸闷伴呼吸困难左侧胸痛、胸闷伴呼吸困难1010天。天。既往史：既往体健，否认其他重大疾病病史及既往史：既往体健，否认其他重大疾病病史及药物过敏史。药物过敏史。现病史：患者于现病史：患者于1010天前无明显诱因，自感左侧天前无明显诱因，自感左侧胸痛、胸闷，偶有呼吸困难，无发热、咳嗽、胸痛、胸闷，偶有呼吸困难，无发热、咳嗽、咳痰、咯血、心慌、乏力、盗汗、声嘶等不适。咳痰、咯血、心慌、乏力、盗汗、声嘶等不适。起初未予留意，症状持续无明显缓解，胸片检起初未予留意，症状持续无明显缓解，胸片检查，提示：左侧肺组织压缩查，提示：左侧肺组织压缩85%85%左右。左右。体格检查：体格检查：T 37.3,P 96 T 37.3,P 96次次/分分,R 20,R 20次次/分分,BP 140/83mmHg,BP 140/83mmHg,神智清晰，皮肤巩膜无黄神智清晰，皮肤巩膜无黄染，气管居中，左侧呼吸音稍弱，未明显干湿染，气管居中，左侧呼吸音稍弱，未明显干湿罗音。罗音。协助检查：协助检查：WBC 11.4 109,N 8.05,L WBC 11.4 109,N 8.05,L 18.1 18.1 入院诊断：入院诊断：左侧自发性气胸左侧自发性气胸Page 5Etiology and classification病因及分类病因及分类THE SPEAKER:THE SPEAKER:于广平于广平Page 6The cause of spontaneous pneumothoraxnClassification of one Spontaneous pneumothorax Trauma pneumothorax Artificial pneumothoraxnClassification of two Closed pneumothorax Open pneumothorax Tension pneumothoraxPage 7The cause of spontaneous pneumothoraxnWhen a trigger causes alveolar pressure rise sharply,lesions of the lung and pleural rupture occurs,the pleural cavity is communicated with the air,airflow will flow into the thorax lead to the formation of spontaneous pneumothorax.Clinical manifestations临床表现与体征临床表现与体征蒋娟蒋娟Page 9Clmical manifestations （临床表现）（临床表现）：Suddenchestpain（突然（突然发生胸痛），发生胸痛），difficultyinbreathing（呼吸困难），（呼吸困难），chesttightness(胸闷胸闷)，inseverecasesirritability、profusely、cyanosis（严峻者（严峻者烦躁担忧、大汗、紫绀）烦躁担忧、大汗、紫绀）acceleratedrespiration（呼吸（呼吸加快），加快），pulsebreakdownandevendeath（脉搏细数甚（脉搏细数甚至死亡）。至死亡）。Page 10Signs（体征）：（体征）：Fracheal shift to the contralateral（气管向健侧移（气管向健侧移位）。位）。Ipsilateral chest full（患侧胸部饱满）（患侧胸部饱满）weakening or disappearance of resiratory motion（呼吸运动减弱或消逝）（呼吸运动减弱或消逝）。Percussion drum sound（叩诊呈鼓音），（叩诊呈鼓音），fremitus and decreased breath sound（语颤呼吸音减弱）。（语颤呼吸音减弱）。Auxiliary examination 协助检查协助检查THESPEAKER :桓秀山桓秀山11 Auxiliary examination1.X-ray 2.CT 3.Pleural cavity angiography4.Thoracoscopic12Auxiliary examination1 1.X-ray examination is the most.X-ray examination is the most reliable method of diagnosis of reliable method of diagnosis of pneumothorapneumothoran nTypical pneumothorax X-ray Typical pneumothorax X-ray findings of the pneumothorax part findings of the pneumothorax part through the brightness increase,no through the brightness increase,no markings,the pulmonary hilar markings,the pulmonary hilar atrophy,higher density,and the atrophy,higher density,and the edge of the visible hairline-like edge of the visible hairline-like visceral pleura shadow;visceral pleura shadow;n nContralateral lung compensatory Contralateral lung compensatory emphysema,lung markings;emphysema,lung markings;n nTrachea with Concurrent pleural Trachea with Concurrent pleural fluid or blood,fluid levels can be fluid or blood,fluid levels can be seen.seen.n nmediastinal shift to the mediastinal shift to the contralateral;contralateral;nX线检查是诊断气胸最牢靠的方线检查是诊断气胸最牢靠的方法。法。n典型的气胸典型的气胸X线表现为气胸部分线表现为气胸部分透亮度增加，无肺纹理，肺向透亮度增加，无肺纹理，肺向肺门萎缩，密度增高，其边缘肺门萎缩，密度增高，其边缘可见发线样脏层胸膜阴影；可见发线样脏层胸膜阴影；n健侧肺可有代偿性肺气肿，肺健侧肺可有代偿性肺气肿，肺纹理增粗；纹理增粗；n气管与纵隔可向健侧移位；气管与纵隔可向健侧移位；n并发胸水或血液时，可见到液并发胸水或血液时，可见到液平面。平面。13Auxiliary examinationn n2.CT Is more sensitive to 2.CT Is more sensitive to the diagnosis of a small the diagnosis of a small amount of gas in the amount of gas in the pleural cavitypleural cavityn nClearly shows a small Clearly shows a small amount of pneumothorax amount of pneumothorax and lung tissue and lung tissue overlapping parts of the overlapping parts of the pneumothorax;pneumothorax;n nLocation,extent determine Location,extent determine the pleural product gas;the pleural product gas;n nMay found emphysema May found emphysema blister;blister;n nEasy to identify the Easy to identify the limitations of limitations of pneumothorax and lung pneumothorax and lung bullae.bullae.n2.CT 对胸腔内少量气体的对胸腔内少量气体的诊断较为敏感诊断较为敏感n可清晰地显示少量气胸和与肺可清晰地显示少量气胸和与肺组织重叠部位的气胸；组织重叠部位的气胸；n确定胸腔积气的位置、程度；确定胸腔积气的位置、程度；n有可能发觉肺气肿疱；有可能发觉肺气肿疱；n易于鉴别局限性气胸和肺大疱。易于鉴别局限性气胸和肺大疱。143.Pleural cavity angiographynThis method can clear the pleural surface,easy to clear the cause of pneumothorax.When the lung compression area in 30%40%when the contrast is appropriate,bulla is lobe profile within a single or multiple cystic low density shadow;a bubble spray performance for pleural phenomenon,especially when patients with cough,due to intrapulmonary pressure increases,this phenomenon is more obvious.n此方法可以明白胸膜此方法可以明白胸膜表面的状况，易于明表面的状况，易于明确气胸的病因。当肺确气胸的病因。当肺压缩面积在压缩面积在30%40%时行造影为宜，时行造影为宜，肺大泡表现为肺叶轮肺大泡表现为肺叶轮廓之内单个或多个囊廓之内单个或多个囊状低密度影；胸膜裂状低密度影；胸膜裂口表现为冒泡喷雾现口表现为冒泡喷雾现象，特殊是当患者咳象，特殊是当患者咳嗽时，由于肺内压增嗽时，由于肺内压增高，此征象更为明显。高，此征象更为明显。154.ThoracoscopicnThoracoscopy can easily detect pneumothorax etiology,flexible operation,can reach the interlobar fissure,apex,hilar,almost no blind spots,observe the visceral pleura with no rips,pleura without bullae of lung and chest cavity with no adhesive joint.n胸腔镜可以较简洁地发胸腔镜可以较简洁地发觉气胸的病因，操作敏觉气胸的病因，操作敏捷，可达叶间裂、肺尖、捷，可达叶间裂、肺尖、肺门，几乎没有盲区，肺门，几乎没有盲区，视察脏层胸膜有无裂口、视察脏层胸膜有无裂口、胸膜下有无肺大泡及胸胸膜下有无肺大泡及胸腔内有无粘连带。腔内有无粘连带。16 Principles of treatment 治疗原则治疗原则17Principles of treatment1.Conservative treatment2.Exhaust treatment3.Operation treatment18 1.Conservative treatment Mainly applicable to the Mainly applicable to the stability of a small amount of stability of a small amount of closed pneumothoraxclosed pneumothorax Specific methods:strict Specific methods:strict bedresanalgesic drugs.bedresanalgesic drugs.t,oxygen,bronchodilator t,oxygen,bronchodilator.bronchospasm,granting the.bronchospasm,granting the sedative and sedative and 主要适用稳定型小量闭主要适用稳定型小量闭合性气胸合性气胸 具体方法：严格卧床具体方法：严格卧床休息、给氧，支气休息、给氧，支气 管管痉挛者运用支气管扩痉挛者运用支气管扩张剂，酌情赐予冷静张剂，酌情赐予冷静镇痛等药物。镇痛等药物。192.Exhaust treatment1.张力性气胸病情紧急可行紧急排气张力性气胸病情紧急可行紧急排气2.胸腔穿刺抽气适用小量气胸，呼困胸腔穿刺抽气适用小量气胸，呼困较轻，心肺功能尚好的闭合性气胸。较轻，心肺功能尚好的闭合性气胸。3.胸腔闭式引流适用不稳定气胸，呼胸腔闭式引流适用不稳定气胸，呼困明显，交货张气胸，反复发生气困明显，交货张气胸，反复发生气胸的病人胸的病人nTension pneumothorax in critical condition feasible emergency exhaustn2 pleural puncture exhaust apply a small amount of pneumothorax,respiratory difficulties lighter,the closed pneumothorax heart and lung function is still good.nClosed thoracic drainage unstable pneumothorax applicable call trapped obvious,delivery Zhang pneumothorax,recurrent pneumothorax patients20Operation treatment ThoracoscopicThoracoscopic and and ThoracotomyThoracotomy21 胸腔镜胸腔镜 通过二至三个通过二至三个“钥匙孔钥匙孔”，在电视影像监视协助下完成过在电视影像监视协助下完成过去由传统开胸进行的操作手术。去由传统开胸进行的操作手术。其本质是用其本质是用“腔镜腔镜”做手术，做手术，相对于传统的开刀手术具有创相对于传统的开刀手术具有创伤小、复原快、住院时间短等伤小、复原快、住院时间短等技术特点技术特点ThoracoscopicComplete operating traditional thoracotomy surgery in the past two tothree key hole in the TV image monitoring aid.By its very nature is laparoscopic surgery,relative to traditional open surgery with less trauma,recovery faster,shorter hospital stay andother technical features22 外科手术治疗外科手术治疗 手术的目的是结扎或切除肺大疱、或胸膜修补、手术的目的是结扎或切除肺大疱、或胸膜修补、或对壁层胸膜切除或摩擦促使其与脏层胸膜粘连，或对壁层胸膜切除或摩擦促使其与脏层胸膜粘连，防止气胸复发防止气胸复发。SurgicaltreatmentThe purpose of surgical The purpose of surgical ligation or resection of bullae,ligation or resection of bullae,or pleural repair or resection or pleural repair or resection or friction parietal pleura or friction parietal pleura procure its visceral pleural procure its visceral pleural adhesions,and to prevent the adhesions,and to prevent the recurrence of pneumothorax.recurrence of pneumothorax.23NursingdiagnosisandmeasuresTHESPEAKER:王辉、毛雅琴、潘娟王辉、毛雅琴、潘娟24护理诊断护理诊断NursingdiagnosisimpairedGasexchangepain(painatchest)TheriskofinfectionActivitieswithoutendurancenutritionalteredknowledgedeficit护理措施护理措施NursingmeasuresPage 281.Impaired Gas exchangenMeasuresn：n a.Observe patients Temperature，breathing，pulse，n blood pressuren b.Observe patients bony thorax movement and the rang of n the respiratory notion,and auscultation patients breathingn soundn c.Keep the thoracic closed drainage system fixed,be closed n tightly and be unobstructed.(保持闭式引流装置固定、密闭等）保持闭式引流装置固定、密闭等）n d.Observe the fluctuation of the water column,colorn e.To change the thoracic regularity,and prevent retyograden infectionPage 29Closed drainage of thoracic cavity1.Positive pressure continuous exhaust method.2.Continues the negative pressure exhaust method.DrainagebottlePage 30positionpsychologicalnutritionenvironmentmedicinepainPage 31 The risk of infectionn1.To keep respiratory tract unobstructed promptly eliminate sputumn2.Do oral care,prevent secondary infectionn3.Keep closed drainage system sterilePage 32Activities without endurance a.Complete bed rest,take half-clinostatism.b.Ask the patient to avoid to hold his breath and to cough intensity.c.Giving low flow oxygen.Page 33 Malnutritionn1.Give high proteinn2.High vitaminn3.Light easy to digest foodPage 34Lackofknowledgea.Avoidpressureshockb.Keepwarmc.keepbowelsopenPage 35 Nursing analysis 1.impairedGasexchange 2.pain 3.Theriskofinfection4.Activitieswithoutendurance1.The nursing of breathing difficulties2.The nursing of Chest pain3.To prevent infection of nursing4.To strengthen the nursing of painproblemsNursingkeypointsPage 36Thoracic closed drainage of nursing（胸腔闭式引流的护理）（胸腔闭式引流的护理）npurpose：1.The discharge pneumatosis,effusion,hemorrhagen 2.Promote lung complex zhangn 3.Keep mediastinal normal positionnThe location of the catheter:1.The gas with side second n intercostal clavicle middlen2.Liquid with side 7,8 rib clearance of axillary line and axillary n line place aftern3.The pus by means of x line in the vomica lowest placenNursing key pointsPage 37Tube drawingDrainage situation protect from infectionObservation conditionKeep pipeline closed and openThoracic closed drainage nursing胸胸腔腔闭闭式式引引流流的的护护理理HealthEducationTHEPEAKER:李飘飘、赵娟李飘飘、赵娟381.Thecause,typeandcureofPneumothorax2.Thepurposeofthoraciccloseddrainageandattention3.thepurposeofstartingexerciseearly4.Lungfunctionwereexercisepurposeandmethod5.dietfordiscovery6.Convalescencerehabilitationactivitiesofthemethodandthemattersneedingattention7.dischargeguidance39Earlyactivitiesofthemethodsandsignificance1.promotethewholebodyfunctionrecovery2.Promotethebloodcirculation3.Promotegastrointestinalperistalsis4.Promoteurinationfunctionrecovery40Methods:1.deepbreath,sputum,assistkeelover,takeback,andsmoothbloodpressureaftertakehalfdecubitus;2.Thenextdayhelpedbythesidesofthebed,onthebedcanbeactivitiesduringtheupperlimbs,andflexionandexercise;3.4dayslatergraduallyoffthebedactivities,firstinbedsidestand,andgraduallyintheindoorwalkslowly,anddiscretionarygooutforawalk4.seriouslyillweakandcomplicationsandactivityrestrictionpatientscantgetupearly,butstillneedtoadheretothebedactivities.41Lung function were exercise purpose and method1).lung function exercise to let the lung lobe full expansion,to increase alveolar surface tension,increase the vital capacity,improve lung function2).cough training prevent pulmonary infection42Page 43Dietnbefore:eat easy digestive less slag food (易消化少渣易消化少渣饮食食)nEarly postoperative:easy to digest,less gas of food （易消化、少（易消化、少产气食物）气食物）nPostoperative terminal:high protein,high quantity of heat,high vitamin food（高蛋白、高（高蛋白、高热量、高量、高维生素食物）生素食物）Convalescencerehabilitationactivitiesofthemethodandannouncementsn(1)with functional exercise machine or to blow a balloon on lung function training,pay attention to exercise dont overexert.n(2)do not carry excessive physical activity,prevent excessive draw-off and violent action.n(3)the daily with lateral upper limb raised exercise,in case of thoracic deformity44(1)afterdischargeshouldbecombinedwithworkandrest.(2)oftenkeeptheairfresh.Preventrespiratoryinfections.(3)regularaccordingtophysicianschargedtooutpatient.Ifthereisachesttightness,shortnessofbreath,chestpainwaitforasymptom,shouldpromptmedicalattention.(4)developgoodhabits.Everydaydorespiratoryfunctionexercise.(5)togiveupsmoking.Dischargeguidance45感谢您的关注感谢您的关注