腹腔鏡治療卵巢囊腫查房課件

云南省第一人民醫(yī)院護(hù)理雙語查房--快速康復(fù)護(hù)理在腹腔鏡治療卵巢囊腫圍手術(shù)期的應(yīng)用Bilingual

NursingRoundFast-tracknursinginperioperativeoflaparoscopictreatmentforOvariancyst生殖婦科1護(hù)理查房的目的(Thepurposeofthisnursinground)

熟悉卵巢囊腫的圍手術(shù)期護(hù)理BefamiliarwiththeperioperativenursingforOvariancyst掌握快速康復(fù)醫(yī)學(xué)理念，應(yīng)用于婦科腹腔鏡手術(shù)的圍手術(shù)期護(hù)理MastertheFast-trackconception,andapplyingynecologicallaparoscopicsurgeryinperioperativenursingcare加強(qiáng)護(hù)患溝通能力，提高更好的服務(wù)

Strengthenthecommunicationskills,toprovidebetterservice2關(guān)鍵詞（keywords）Bil-雙Bilingual[ba?'l??gw(?)l]

NursingRound雙語查房Bilateral

[ba?'l?t(?)r(?)l]雙側(cè)

=onbothsides（雙側(cè)卵巢囊腫:bilateralovarian[??‘ve?r??n]cysts[s?st]）腹腔鏡：laparoscopy[,l?p?'r?sk?p?]（-scopy腔鏡，eg）.hysteroscopy[hist?'r?sk?pi]宮腔鏡）術(shù)前preoperative（前：Pre-）術(shù)中intraoperative（中：intra-）（手術(shù)-Perative）術(shù)后postoperative

（后：Post-）快速康復(fù)外科：Fast-tracksurgery(FTS)病人自控麻醉泵：Patientcontrolledanalgesia[,?n(?)l'd?i?z??]

=PCA微創(chuàng)手術(shù):Minimallyinvasive[?n've?s?v]surgery3“FTS”的相關(guān)理念快速康復(fù)外科（最早在世紀(jì)初由丹麥外科醫(yī)生提出并倡導(dǎo)付諸實(shí)踐。它是指在術(shù)前、術(shù)中及術(shù)后的各個(gè)階段廣泛運(yùn)用已經(jīng)實(shí)踐證實(shí)的各種行之有效的途徑和方法，以減少外科手術(shù)病人的并發(fā)癥和應(yīng)激反應(yīng)，促進(jìn)患者手術(shù)后的康復(fù)，改善預(yù)后，促進(jìn)健康。Fast-tracksurgery(FTS)(asearlyasatthebeginningofthecenturybyaDanishsurgeonsandinitiatesintopracticeisputforward.Itreferstothepreoperative,intraoperativeandpostoperativestageswereconfirmedpracticewidelyusedavarietyofeffectivewaysandmethods,inordertoreducethecomplicationsandsurgicalpatientsstressresponse,promotepatientsrecoveryaftertheoperation,improvetheprognosis,promotehealth.4“FTS”的相關(guān)理念（2）LassenK,SoopM,NygrenJ,etal.Consensusreviewofoptimalperioperativecareincolorectalsurgery:EnhancedRecoveryAfterSurgery(ERAS)Grouprecommendations.ArchSurg,2009,144(10):961-969.5FTS干預(yù)措施(1)吳茜，陳靜娟等，多學(xué)科合作快速康復(fù)外科模式中護(hù)理的作用,中國護(hù)理管理[J]，2014,14（2），215-218術(shù)前評估與優(yōu)化患者信息減輕壓力液體治療緩解疼痛特殊護(hù)理（引流管）經(jīng)口營養(yǎng)活動與鍛煉術(shù)后加快康復(fù)術(shù)前術(shù)后6“FTS”TIPS術(shù)前準(zhǔn)備充分的術(shù)前準(zhǔn)備縮短術(shù)前禁食禁飲的時(shí)間術(shù)后護(hù)理保暖和心理護(hù)理完備充分的疼痛護(hù)理早期經(jīng)口進(jìn)食和早期活動重視術(shù)后休息和睡眠7“FTS”TIPS充分的術(shù)前準(zhǔn)備：完備的護(hù)理健康教育，強(qiáng)調(diào)充分履行告知義務(wù)和健康宣教的責(zé)任，充分告知病人手術(shù)各個(gè)環(huán)節(jié)和相關(guān)注意事項(xiàng)。Sufficientpreoperativepreparation,Completenursinghealtheducation,emphasizingthefullperformanceoftheinformobligationandtheresponsibilityofthehealtheducation,filling

eachlinkpointstoinformpatientsandrelatedmattersneedingattention.8“FTS”TIPS縮短術(shù)前禁食禁飲的時(shí)間有研究表明，長時(shí)間禁食水會導(dǎo)致病人的饑餓，口渴，脫水，煩躁等不良應(yīng)激和由此產(chǎn)生的血容量減少以及低血糖等的病理生理變化，會極大的增加手術(shù)的不耐受性。ToshortenthetimeofbanningfoodandfliudinpreoperativeResearchhasshownthatbanning

foodandfliudforalongtimecanleadtothepatient'shunger,thirst,dehydration,irritabilityandotheradversestress,

theresultingbloodvolumedecreaseandthepathologyofhypoglycemiaandphysiologicalchanges,willgreatlyincreasethesurgeryisnottolerated.9縮短術(shù)前禁食禁飲的時(shí)間

Themajorpurposeofwithholdingfoodandfluidbeforesurgeryistopreventaspiration.Lengthyrestrictionoffoodandfluidisunncessary.TheAmericansocietyofanesthesologistshasresultedinnewrecommendationsforpersonsundergoingelectivesurgerywhoareotherwisehealthy.Therecommendationsdependontheageofthepatientandtypeoffoodeaten.Forexample,adultsareadivsedtofastfor8hoursaftereatingfattyfoodand4hoursafteringestingmilkproducts.Mostpatientsarecurrentlyallowedclearliquidsupto2hoursbeforeanelectiveprocedure.10“FTS”TIPS早期經(jīng)口進(jìn)食和早期活動。有研究表明，長時(shí)間禁食水會導(dǎo)致手術(shù)病人內(nèi)環(huán)境紊亂，且兩者呈負(fù)相關(guān)。禁食時(shí)胃腸蠕動緩慢、不規(guī)律；而進(jìn)食時(shí)胃腸蠕動則有力、頻繁和有規(guī)律。Earlyfeedingandearlyactivities.Researchhasshownthatbanning

foralongtimecanleadtosurgerypatientsEnvironmentaldisturbance,andnegativelycorrelatedwithboth.Whenfastinggastrointestinalprayermoveslow,irregular;Whileeatinggastrointestinalscrewmotionstrongly,frequently

andregularly.11早期經(jīng)口進(jìn)食術(shù)后保證早期的保溫工作及宣教工作，術(shù)后3小時(shí)麻醉清醒后可飲10～20mL水，觀察患者有無不適癥狀，半小時(shí)后再增加飲水量50～100mL.(3)Theinsulationworkoftheearlypostoperativeandmissionarywork,after3hoursawakeanesthesiacandrink10~20mLwater,observingthepatient`ssymptoms,andaddingwaterquantityinhalfanhour50~100mL.(3)李玉文，何婉珠等，快速康復(fù)護(hù)理模式在腹腔鏡治療卵巢囊腫圍手術(shù)期的應(yīng)用研究，臨床醫(yī)學(xué)工程[J]，2016,23（3）379-380.12早期活動鼓勵(lì)患者術(shù)后早期進(jìn)行活動，術(shù)后6小時(shí)進(jìn)行半坐臥未出現(xiàn)頭暈等不適癥狀后，再進(jìn)行床上活動，漸進(jìn)式床旁活動，初次活動在5分鐘內(nèi),在上述的基礎(chǔ)下，可進(jìn)行床旁的慢走，漸漸增加走的路程(4).Earlypostoperativeactivities,encouragepatientsafteroperation6hourstohavehalfsit,ifthereisnosymptomssuchasdizziness,canhavebedactivity,progressiveactivitiesbythebed,thefirstactivityin5minutes,onthebasisoftheabove,walkingbesidethebed,canbegraduallyincreasejourney.(4)單葵順,鄧晨暉.快速康復(fù)外科理念在手術(shù)室護(hù)理中的應(yīng)用[J].廣東醫(yī)學(xué),2014,35(4):637-639.13Howtouse'fts'intoperioperative?如何將“快速康復(fù)外科”的理念運(yùn)用下述患者的圍手術(shù)期？14病史匯報(bào)（Casereport）床號：08姓名：馬麗性別：女年齡：30歲現(xiàn)病史：患者因不孕癥就診，B超示雙側(cè)卵巢囊腫（左側(cè)5.5*3.5cm，5.3*3.9cm，右側(cè)2.2*1.8cm）,有生育要求，要求手術(shù)治療。既往史：否認(rèn)外傷、手術(shù)輸血史及過敏史生育史：0-0-0-0

BedNo.:NO.08Name:MaryGender:femaleAge:30yearsoldHpi:Patientwithinfertility,Bultrasonicshownbilateralovariancysts(leftsideofthe5.5*3.5cm,3.5*3.9cm,rightsideof2.2*1.8cm)，fertilityrequirement，requiressurgery.Pastmedicalhistory:Denythathistoryoftrauma,surgery，bloodtransfusion，anddrugallergy;Reproductivehistory:0-0-0-015查體（Physicalexamination）體溫36.9℃，脈搏88次/分，呼吸18次/分，血壓113/73mmHg。神志清楚，一般情況好，神清。腹平軟，無壓痛及反跳痛。外陰：婚型，陰毛分布正常；陰道：通暢，少量白色分泌物；宮頸：柱狀，光滑；無舉擺痛；宮體：前位，常大，表面光滑，無壓痛；雙附件區(qū)(陽性體征)：右附件區(qū)可觸及一約7*5cm的包塊，質(zhì)中等，輕壓痛，左附件去未觸及明顯異常Temperature36.9℃,pulse88/cent,breathing18timesperminute,bloodpressureis113/73MMHG.Conscious,generallygood.Abdominalplainsoft,notendernessandbouncepainful.Vulva:marriagetype,pubichairnormaldistribution;Vagina:smoothasmallamountofwhite

discharge;Thecervical:columnar,smooth;Noplacepain;From:front,normol

large,smoothsurface,notenderness;Adnexamassa(Positivesigns):therightareacantouchamassabout7*5cm,lighttenderness16診斷（Diagnosis）

【入院日期】：2016-12-15【擬手術(shù)日期】：2016-12-16

【術(shù)前診斷】：雙側(cè)卵巢囊腫【擬施手術(shù)名稱】：腹腔鏡下卵巢囊腫剝除術(shù)【麻醉方式】：全麻【Admissiondate】December15，2016【Proposedsurgerydate】:December16,2016【Preoperativediagnosis】:Bilateralovariancysts【Intendstooperateon】:Laparoscopicsurgery【anesthesia】:Generalanesthesia.17術(shù)前腸道準(zhǔn)備

（

Thebowelpreparationforthesurgery）17:0019:0021:0022:0000:00半流質(zhì)導(dǎo)瀉劑0.9%NS500ml+20%甘露醇250ml常規(guī)灌腸一次禁食不禁飲禁食、禁飲手術(shù)前晚手術(shù)當(dāng)天18手術(shù)記錄（Theoperationrecords）【手術(shù)日期】：10:15December16,2016【實(shí)施手術(shù)名稱】：腹腔鏡下雙側(cè)卵巢巧克力卵巢囊腫剝除術(shù)+盆腔粘連松解術(shù)【麻醉方式】：全麻【出血量（Bleeding)】：300ml【管道】：腹腔引流管1根，留置尿管1根【病人自控鎮(zhèn)痛泵（PCA）】：是19護(hù)理診斷（Thenursingdiagnosis）恐懼：與擔(dān)心手術(shù)失敗有關(guān)，擔(dān)心不能妊娠有關(guān)Fear：worryabouttheoperationfailure,andworrycannotpregnant術(shù)前舒適的改變：與長時(shí)間禁食、禁飲有關(guān)Preoperativecomfortablechange:relatedtothebannedfromfoodanddrinkforalongtime疼痛：與術(shù)后麻醉失效有關(guān)Pain:associatedwithpostoperativeanestheticfailure有導(dǎo)管滑脫的危險(xiǎn)Riskofcatheterslipping有感染的危險(xiǎn)：與手術(shù)有關(guān)Riskofinfection:associatedwithoperation20護(hù)理措施（Thenursinginterventions）恐懼：向病人介紹卵巢囊腫的有關(guān)知識，增強(qiáng)患者信心，聯(lián)合家屬給予患者術(shù)前術(shù)后的心理支持Introducetothepatientontheknowledgeofovariancyst,enhancepatient'sconfidence,jointfamiliesforthepatientaboutpreoperativeandpostoperativewithpsychologicalsupport21術(shù)前舒適的改變：與長時(shí)間禁食、禁飲有關(guān)Canweuse“FTS”intointervention?22護(hù)理措施（Thenursinginterventions）術(shù)前舒適的改變：與長時(shí)間禁食、禁飲有關(guān)17:0019:0021:0022:0000:00半流質(zhì)導(dǎo)瀉劑0.9%NS500ml+20%甘露醇250ml常規(guī)灌腸一次禁食不禁飲禁食、禁飲手術(shù)前晚手術(shù)當(dāng)天Patient`sfeeling：Thirsty,hungry,anddizzy！Canweuse“FTS”intointervention?23護(hù)理措施（Thenursinginterventions）疼痛定時(shí)翻身，協(xié)助患者采取舒適臥位安慰病人，緩解其焦慮和恐懼感各種操作時(shí)動作輕柔合理使用麻醉鎮(zhèn)痛泵（PCA）Timingturn,helppatientstotakecomfortablelyingpositionComfortthepatients,alleviatetheanxietyandfearAllkindsofoperationisgentleAnesthesiaanalgesiapump24護(hù)理措施（Thenursinginterventions）防導(dǎo)管滑脫妥善固定（fixed）懸掛警示標(biāo)示（score=10），床頭交接向家屬及患者行防導(dǎo)管滑脫的健康宣教早日拔管drainagetubeurinetube25傳統(tǒng)的圍手術(shù)期護(hù)理Thetraditionalperioperativenursing包括入院宣教、術(shù)前指導(dǎo)、解答患者疑問，按照常規(guī)的腹腔鏡手術(shù)準(zhǔn)備和外科護(hù)理常規(guī)進(jìn)行護(hù)理，要求患者術(shù)前口服導(dǎo)瀉劑，12小時(shí)禁食，

4～6小時(shí)前禁飲水；術(shù)后根據(jù)麻醉方式采去枕平臥或平臥，血壓平穩(wěn)后，采取側(cè)臥位或半臥位，于患者肛門排氣后方可進(jìn)食、水。2627護(hù)理措施（Thenursinginterventions）術(shù)前舒適的改