1、PPT模板下载：行业PPT模板：节日PPT模板：素材下载：PPT背景图片：图表下载：优秀PPT下载：教程：Word教程：教程：资料下载：课件下载：范文下载：试卷下载：教案下载：A case of thoracic vertebral internal A case of thoracic vertebral internal fixation surgery patients after nursing fixation surgery patients after nursing care roundscare rounds一例胸椎内固定术术后患者的护理查房一例胸椎内固定术术后患者的护理查房
2、Speaker&Physical Speaker&Physical examination examination&PPT production&PPT production：石彩兰：石彩兰AdvisorAdvisor：王莉：王莉Guangzhou medical university Guangzhou medical university General informationGeneral information（一般资料）（一般资料）2023-1-8Name:Name:Huang lixuanHuang lixuan（黄李轩）（黄李轩）Age:Age:53-year-old Sex:m
3、ale 53-year-old Sex:male bed number:bed number:GK2017 GK2017 Date of admission:Date of admission:March 23th,2017March 23th,2017Chief complaintChief complaint（主诉）（主诉）:Low back pain three Low back pain three months,increased with numbness of both months,increased with numbness of both lower limbs a mo
4、nth.lower limbs a month.（腰痛三月，加重伴双下（腰痛三月，加重伴双下肢麻木一月）肢麻木一月）Diagnosis:Diagnosis:Thoracic tumor(Thoracic tumor(胸椎肿瘤胸椎肿瘤)PatientPatients conditions condition（病情汇报）（病情汇报）2023-1-8Admission:Admission:T 37.0 T 37.0 C,P 70 times/C,P 70 times/min,R 20 times/min,BP 120/60 min,R 20 times/min,BP 120/60 mmHg.mmHg
5、.Surgery:2017-03-24,general Surgery:2017-03-24,general anesthesia with thoracic spine tumor anesthesia with thoracic spine tumor resection(resection(全麻下胸椎肿瘤切除全麻下胸椎肿瘤切除)+thoracic)+thoracic internal fixationinternal fixation（胸椎内固定术）（胸椎内固定术）Auxiliary checkAuxiliary check（辅助检查）：（辅助检查）：2023-1-8（2017-02-1
6、52017-02-15，广州市番禺区第二人民医院）腰部，广州市番禺区第二人民医院）腰部CTCT提示：提示：L3/4L3/4、L4/5L4/5椎间盘膨出，椎间盘膨出，L5/S1L5/S1椎间盘突出，椎间盘突出，腰椎退行性病变，胸腰椎退行性病变，胸1212椎体骨质破坏。椎体骨质破坏。（2017-03-21，解放军第四五八医院）腰椎，解放军第四五八医院）腰椎MR提示：提示：1、胸胸9、12椎体及椎旁异常信号影，考虑肿瘤，骨髓瘤可能椎体及椎旁异常信号影，考虑肿瘤，骨髓瘤可能性大；胸性大；胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；椎体异常信号影，脂肪沉积与血管瘤鉴别；2、腰、腰2、4椎体占位性病变；
7、椎体占位性病变；3、腰、腰3/4、4/5椎间盘膨出；椎间盘膨出；4、腰椎退行性病变、腰椎退行性病变Auxiliary checkAuxiliary check（辅助检查）：（辅助检查）：（2017-03-242017-03-24，我院）全身骨显像：第，我院）全身骨显像：第1010胸椎骨胸椎骨代谢异常局灶性增高活跃。结合病史，考虑肿瘤性代谢异常局灶性增高活跃。结合病史，考虑肿瘤性病变与椎体压缩性骨折相鉴别。病变与椎体压缩性骨折相鉴别。2023-1-8（2017-03-24，我院）胸部正侧位：，我院）胸部正侧位：1、双肺及心、双肺及心膈未见异常。膈未见异常。2、T9椎体压缩性改变胸椎体压缩性改变胸
8、Auxiliary check（辅助检查）：2023-1-8项目名称项目名称结果结果参考范围参考范围单位单位提示提示癌胚抗原癌胚抗原5.715.710-50-5ug/Lug/L细胞角蛋白细胞角蛋白1919片段片段3.363.360-3.30-3.3ug/Lug/L白细胞计数白细胞计数22.722.73.59.53.59.5101099/L/L血红蛋白血红蛋白158158130175130175g/Lg/L正常正常总蛋白总蛋白63.163.165856585g/Lg/L尿素尿素/肌酐肌酐30.7130.7115241524RatioRatio补体单体补体单体0.140.140.160.380.1
9、60.38g/Lg/L白蛋白白蛋白35.335.340554055g/Lg/L总胆汁酸总胆汁酸17.117.109.6709.67umol/Lumol/LAuxiliary check（辅助检查）：2023-1-8项目名项目名项目名称项目名称结果结果参考范围参考范围单位单位提示提示丙氨酸氨基转移酶丙氨酸氨基转移酶205205950950U/LU/L-羟丁酸脱氢酶羟丁酸脱氢酶2052057218272182U/LU/L天门冬氨酸氨基转移酶天门冬氨酸氨基转移酶696915401540U/LU/L乳酸脱氢酶乳酸脱氢酶294294120250120250U/LU/L-谷氨酰基转移酶谷氨酰基转移酶747
10、410601060U/LU/L肌酸激酶同工酶肌酸激酶同工酶 MBMB活性活性2626025025U/LU/L总胆固醇总胆固醇5.855.853.005.183.005.18mmol/Lmmol/L高密度脂蛋白胆固醇高密度脂蛋白胆固醇2.092.091.161.421.161.42mmol/Lmmol/LDiagnosis:Thoracic tumor(胸椎肿瘤)4,wear anti-skid slippers（拖鞋）and the appropriate（合适的）clothes in order to avoid tripping,and take bed bar when sleep at
11、 bed.Nursing evaluation:patients did not fall during hospitalization.3、Lack of knowledge:related to lack of disease-related knowledgePPT模板下载：行业PPT模板：3、腰3/4、4/5椎间盘膨出；1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.Speaker&Physical examination
12、1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.The decline of self-care ability during hospitalization has improved.3、腰3/4、4/5椎间盘膨出；Surgery:2017-03-24,general anesthesia with thoracic spine tumor resection(全麻下胸椎肿瘤切除)+thoracic internal fixat
13、ion（胸椎内固定术）Limb brake（制动）,analgesic（止痛），nutritional support（营养支持）and other symptomatic treatmentNursing evaluation:patients did not fall during hospitalization.胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；Discharge instruction（出院指导）：A case of thoracic vertebral internal fixation surgery patients after nursing care rounds
14、一例胸椎内固定术术后患者的护理查房3、Lack of knowledge:related to lack of disease-related knowledge(3)Distribute health education prescription regularly.3,When walking dizziness,lower limb weakness,and gait instability and can not move,immediately sit down in situ(原地),and call help.Basic treatment&medication（基本治疗&用药）
15、：2023-1-8POPO：多烯磷脂酰胆碱胶囊（易善复）、丁二磺酸腺苷蛋氨酸多烯磷脂酰胆碱胶囊（易善复）、丁二磺酸腺苷蛋氨酸肠溶片（喜美欣）；肠溶片（喜美欣）；IVIV：注射用帕瑞昔布钠（特耐）；注射用帕瑞昔布钠（特耐）；IMIM：鼠神经生长因子注射剂（恩经复）；鼠神经生长因子注射剂（恩经复）；IvgttIvgtt：五水头孢唑林注射剂（新泰林）、醒脑静、注射用丹：五水头孢唑林注射剂（新泰林）、醒脑静、注射用丹参多酚酸盐、地塞米松磷酸钠注射液参多酚酸盐、地塞米松磷酸钠注射液&甘露醇注射液、小牛皮甘露醇注射液、小牛皮提取物注射液（斯普林）、骨肽注射液（鼓键）、甲泼尼龙琥提取物注射液（斯普林）、骨肽
16、注射液（鼓键）、甲泼尼龙琥珀酸钠针（甲强龙）、（申捷）单唾液酸四己糖神经节苷脂钠珀酸钠针（甲强龙）、（申捷）单唾液酸四己糖神经节苷脂钠注射液、头孢曲松他唑巴坦针（优他能）。注射液、头孢曲松他唑巴坦针（优他能）。Limb brakeLimb brake（制动）（制动）,analgesic,analgesic（止痛），（止痛），nutritional nutritional supportsupport（营养支持）（营养支持）and other symptomatic and other symptomatic treatmenttreatment床边体查床边体查2023-1-8 Results
17、of physical examination(体查结果)Current condition:Current condition:patients with thoracic internal fixation on the 15th day after patients with thoracic internal fixation on the 15th day after surgery,lower limb numbness(surgery,lower limb numbness(下肢麻木无力下肢麻木无力),postoperative),postoperative（术后）（术后）wou
18、nd dressing clean,no bleeding exudate,wound dressing clean,no bleeding exudate,（渗液）（渗液）no waist pain,no waist pain,dizzinessdizziness（头晕）（头晕）and other symptoms,and consciousness is clearand other symptoms,and consciousness is clear，appetite(appetite(食欲食欲)is well and have a good spirit.His sleep is w
19、ell)is well and have a good spirit.His sleep is well now,and defecate and urinate is normalnow,and defecate and urinate is normal.2023-1-8T、P、H、R、BpSpecialty（专科情况）（专科情况）:Doublelowerlimbstactile（双下肢）（双下肢）feelnormal.Thestrengthoflowerlimbslevel。Theoperativewounddressingsisdryandclean,nobleeding,draina
20、ge(渗液渗液).Nursing diagnosis（护理诊断）1 1、Risk of falls:associated with long bedside lower Risk of falls:associated with long bedside lower limb muscle weaknesslimb muscle weakness（下肢肌无力）（下肢肌无力）2023-1-83、Lackofknowledge:relatedtolackofdisease-relatedknowledge2、declineofself-careability:relatedtolongbedres
21、tRisk of falls:associated with long bedside lower limb muscle weakness（下肢肌无力）Nursing measures:Nursing measures:1,1,Tell the patient and family members to stay with patient all the Tell the patient and family members to stay with patient all the time,and if need help ring that call nurses.time,and if
22、 need help ring that call nurses.2,2,change the position should obey with the three steps,that is lying change the position should obey with the three steps,that is lying 30 seconds,sit up 30 seconds,and stand 30 seconds before the walk in 30 seconds,sit up 30 seconds,and stand 30 seconds before the
23、 walk in order to avoid orthostatic hypotension(order to avoid orthostatic hypotension(体位性低血压体位性低血压),especially at),especially at night.night.3,3,When walking dizziness,lower limb weakness,and gait instability and When walking dizziness,lower limb weakness,and gait instability and can not move,immed
24、iately sit down in situ(can not move,immediately sit down in situ(原地原地),and call help.),and call help.4,4,wear anti-skid slipperswear anti-skid slippers（拖鞋）（拖鞋）and the appropriate and the appropriate（合适的）（合适的）clothes clothes in order to avoid tripping,and take bed bar when sleep at bed.in order to a
25、void tripping,and take bed bar when sleep at bed.2023-1-8Nursing target:the patient did not fallNursingevaluation:patientsdidnotfallduringhospitalization.2、decline of self-care ability:related to long bed rest2023-1-8Nursing objectives:patients can adapt to the state of decline of self-care ability,
26、and Life needs can be satisfied during hospitalization.Nursing measures:(1)explain the importance of cleaning-care to the patient.(2)do morning care in order to increase the comfort of patient:wash face,wash hands,oral care,warm water wipe（擦）back,etc.(3)keep warm while operation,and avoid exposure t
27、o the patient too long to prevent colds.(4)Keep the bed clean and dry.(5)help patient eating,dressing,into the toilet and other life care.Nursing evaluation:patients adapt to the state,andThe decline of self-care ability during hospitalization has improved.2023-1-83、Lack of knowledge:related to lack
28、 of disease-related knowledgeNursing Objective:The patient can describe the disease-related knowledgeNursing measures:(1)confirm the patients concerns about the disease and future lifestyle by talking,and explain or guide the patients concerns.(2)use easy to understand language to the patient to int
29、roduce the course and treatment.(3)Distribute health education prescription regularly.Provide the necessary learning materials for the patient.(4)encourage patients to ask questions,and answer to patient patiently .Nursing Rating:Patients can describe disease-related knowledge during hospitalization
30、health educationhealth education（健康教育）（健康教育）2023-1-81,functionalexercise:Teachpatientturnthebodylikeaxisturn(轴线翻身轴线翻身),raisingstraightlegexercise（直腿抬高运动）（直腿抬高运动）,quadricepsfemorisisotoniccontractionexercise（股四头机等长收缩运动）（股四头机等长收缩运动）andthecorrectwaytogetupandliedown.2,preventlunginfection:changetheposi
31、tionconstantly,andencouragepatientstodoaneffectivecoughaction,turnbacktoshoot（翻身拍背）（翻身拍背）regular,promotelungsecretions（分泌物）（分泌物）andaccumulationofsputum（积痰）（积痰）discharge.3earlyexercise:topreventsofttissueadhesions（粘连）（粘连）andspinejoint（脊柱关节）（脊柱关节）activitydecreased,andaffectingthespinemovement,whichres
32、ultinginchronicpaininthewaist(腰腰)andlowbackmuscleatrophy（腰背肌废用性萎缩）（腰背肌废用性萎缩）.4,thepreventionofpressuresores:Inordertopreventtheformationofpressuresores,itneedtodoagoodjobonmissionwork,andteachpatientsandtheirfamiliestomastertheturningskills.Anddonotplugwhenusethepotty(便盆便盆),inordertoavoidtodamagethe
33、skin.Discharge instruction（出院指导）：2023-1-84,regular outpatient review,if the lower back discomfort or lower limb numbness timely treatment1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.2,Tell patient to strengthen nutrition intake,and enhanc
34、e physical fitness(增强体质),to guide the high protein intake,high vitamin diet.3,Explain the importance of the time to activities in detail,in order to ensure the stability of the internal fixation(内固定),and get out of the ground to activities must wear brace(支具),and standing walking time should not be
35、too long.Practice the exercise of bending bent flexion(弯腰前屈)after 3 months，and sleep at a hard bed.(3)keep warm while operation,and avoid exposure to the patient too long to prevent colds.General information（一般资料）2,change the position should obey with the three steps,that is lying 30 seconds,sit up
36、30 seconds,and stand 30 seconds before the walk in order to avoid orthostatic hypotension(体位性低血压),especially at night.Current condition:(2)do morning care in order to increase the comfort of patient:wash face,wash hands,oral care,warm water wipe（擦）back,etc.PPT模板下载：行业PPT模板：4,wear anti-skid slippers（拖
37、鞋）and the appropriate（合适的）clothes in order to avoid tripping,and take bed bar when sleep at bed.&PPT production：石彩兰Diagnosis:Thoracic tumor(胸椎肿瘤)(1)explain the importance of cleaning-care to the patient.2、T9椎体压缩性改变胸Provide the necessary learning materials for the patient.Practice the exercise of ben
38、ding bent flexion(弯腰前屈)after 3 months，and sleep at a hard bed.Date of admission:March 23th,2017结合病史，考虑肿瘤性病变与椎体压缩性骨折相鉴别。Name:Huang lixuan（黄李轩）1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；Age:53-year-old Sex:male（2017
39、-02-15，广州市番禺区第二人民医院）腰部CT提示：L3/4、L4/5椎间盘膨出，L5/S1椎间盘突出，腰椎退行性病变，胸12椎体骨质破坏。The decline of self-care ability during hospitalization has improved.Auxiliary check（辅助检查）：4,the prevention of pressure sores:In order to prevent the formation of pressure sores,it need to do a good job on mission work,and teach
40、patients and their families to master the turning skills.Risk of falls:associated with long bedside lower limb muscle weakness（下肢肌无力）胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；3、腰3/4、4/5椎间盘膨出；4,the prevention of pressure sores:In order to prevent the formation of pressure sores,it need to do a good job on mission work,
41、and teach patients and their families to master the turning skills.(1)explain the importance of cleaning-care to the patient.1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.1,Tell the patient and family members to stay with patient all the t
42、ime,and if need help ring that call nurses.1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.Nursing evaluation:patients did not fall during hospitalization.Nursing objectives:patients can adapt to the state of decline of self-care ability,and
43、 Life needs can be satisfied during hospitalization.1,Tell the patient and family members to stay with patient all the time,and if need help ring that call nurses.4,the prevention of pressure sores:In order to prevent the formation of pressure sores,it need to do a good job on mission work,and teach
44、 patients and their families to master the turning skills.4,the prevention of pressure sores:In order to prevent the formation of pressure sores,it need to do a good job on mission work,and teach patients and their families to master the turning skills.4,wear anti-skid slippers（拖鞋）and the appropriat
45、e（合适的）clothes in order to avoid tripping,and take bed bar when sleep at bed.肌酸激酶同工酶 MB活性4,the prevention of pressure sores:In order to prevent the formation of pressure sores,it need to do a good job on mission work,and teach patients and their families to master the turning skills.Diagnosis:Thoraci
46、c tumor(胸椎肿瘤)Auxiliary check（辅助检查）：Ivgtt：五水头孢唑林注射剂（新泰林）、醒脑静、注射用丹参多酚酸盐、地塞米松磷酸钠注射液&甘露醇注射液、小牛皮提取物注射液（斯普林）、骨肽注射液（鼓键）、甲泼尼龙琥珀酸钠针（甲强龙）、（申捷）单唾液酸四己糖神经节苷脂钠注射液、头孢曲松他唑巴坦针（优他能）。胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；(1)explain the importance of cleaning-care to the patient.(1)confirm the patients concerns about the disease and
47、future lifestyle by talking,and explain or guide the patients concerns.(2)do morning care in order to increase the comfort of patient:wash face,wash hands,oral care,warm water wipe（擦）back,etc.(3)Distribute health education prescription regularly.Speaker&Physical examination4,wear anti-skid slippers（
48、拖鞋）and the appropriate（合适的）clothes in order to avoid tripping,and take bed bar when sleep at bed.PPT模板下载：行业PPT模板：4,regular outpatient review,if the lower back discomfort or lower limb numbness timely treatment（2017-02-15，广州市番禺区第二人民医院）腰部CT提示：L3/4、L4/5椎间盘膨出，L5/S1椎间盘突出，腰椎退行性病变，胸12椎体骨质破坏。3,When walking
49、dizziness,lower limb weakness,and gait instability and can not move,immediately sit down in situ(原地),and call help.胸3、8椎体异常信号影，脂肪沉积与血管瘤鉴别；1,Tell patient to exercise insistently after discharge,but should avoid fatigue(劳累),and prevent trauma（外伤）.Risk of falls:associated with long bedside lower limb m
50、uscle weakness（下肢肌无力）Nursing target:the patient did not fallProvide the necessary learning materials for the patient.3,Explain the importance of the time to activities in detail,in order to ensure the stability of the internal fixation(内固定),and get out of the ground to activities must wear brace(支具)
