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1、Good is good, but better carries it.精益求精，善益求善。surgicalnursing-Surgicalnursing外科护理学Instrumentpacks595器械包Postoperativecare597术后护理Abdominalsurgery598腹部外科Aural603耳部/听觉Integument605皮肤Ophthalmic608眼睛Orthopedic611矫形外科Reproductivetractsurgery614生殖道外科Thoracicsurgery618胸腔外科Urogenitaltractsurgery620泌尿道外科Manyof
2、thelistedsurgicalproceduresmaynotbeperformedintheaverageclinicalsetting.however,atonepointoranother,technicianswillbefacedwithhavingtoexplainaparticularproceduretoaclient.许多列举的手术操作在普通的临床环境没有办法操作。然而，技术人员经常会面临要将特殊的操作解释给主人。Thesedescriptionsarenotmeantasdirectionsonhowtoperformtheprocedure,butratheraqui
3、cksynopsisthatwillallowthetechniciantopreparefortheprocedure,managepatientcare,andclearlyexplaintheprocedureandaftercaretoaclientwhosepetmaybeundergoingtheseprocedures.这些描述不是作为如何进行手术操作的指导，而是一种能够让技术人员准备手术，进行患畜护理的概要和能够将患畜即将面临的操作和术后护理清晰的将给主人。Witheverysurgicalprocedure,painmanagementneedstobeaddressedan
4、dhandled.Refertochapter8,PainManagement,formoreinformation.对于每个手术操作，疼痛管理都是需要强调和给予的。可以参考第八章，疼痛管理获得更多的信息。Instrumentpacks器械包Thesepacksareexamplesoftheinstrumentsincludedinbasicsurgicalpacks.Eachclinicwillneedtoorganizepacksthatbestfittheirsurgerytypeandsurgeon.Eachsurgeonhaspreferencesonindividualtypes
5、ofinstrumentsfordifferentsurgeries.Eachpackmayincludegauze,laparotomypads,towels,salinebowl,needles,sutures,andscalpelblades,ortheymaybepreparedseparately.以下的器械包是器械的例子，包括基本的外科包。每个诊所要组织器械包使它更适合不同的外科手术类型和外科医生。每个外科医生对于不同的手术会选择个人喜好的器械。每个器械包应该包含纱布，毛巾，缝针，手术刀片，创巾等或者它们需要单独包装。Basicsurgicalpacks基本外科器械包Abdomin
6、alpack腹部手术器械包Abdominalforceps腹部镊子Abdominalretractors腹壁牵开器BalfourretractorGeneralsurgicalpack一般的外科包GroovrddirectorHemostats止血钳Needleholders持针器Retractors牵引器Scalpelhandle解剖刀柄Scissors剪刀Spayhook卵巢牵引钩Thumbforceps按捏镊,组织镊Tissueforceps组织镊Towelclamps巾钳Lacerationpack伤口缝合器械包Hemostats止血钳Needleholder持针器Scalpelhan
7、dle解剖刀柄Scissors剪刀Thumbforceps按捏镊，组织镊Ophthalmicpack眼科器械包Eyelidforceps眼睑镊Eyelidretractor开睑器,睑牵开器Hemostats止血钳Lacrimalcannulas泪管插管Needleholders持针器Scalpelhandle解剖刀柄Scissors剪刀Thumbforceps有齿镊Orthopedicpack矫形外科器械包Bonedrill骨钻Bonechuckandkey骨卡盘和钥匙Bone-cuttingforceps骨剪Bone-holdingforceps持骨钳Boneraspsandfiles骨锉和
8、？GiglihandlesandwireMallet鼓槌Osteotome骨凿,骨刀RothopedicwirePeriostealelevator骨膜起子,骨膜分离器,骨膜剥离器Pincutter剪钉钳,钢丝钳,断针钳Retractors牵引器SennretractorVolkmannretractorRongeurs修骨钳,咬骨钳Wire-cuttingscissors线剪Thoracicpack胸部手术器械包Generalsurgicalpackinstrumentswithlonghandles常规外科器械包内的长柄器械Ribretractors肋骨牵开器Wilsonribspread
9、erWilson肋骨牵开器Bone-cuttingforceps骨剪Right-angleforceps直角钳Vesselclamps导管夹,动脉止血钳Bulldogclamp显微外科用的无损伤钳，动脉夹Specializedsurgicalpacks特殊的外科器械包Manyinstrumentsmaybeusedonlyonoccasionandshouldbesetasideinseparatepacks.Instrumentsweakenwithconstantscrubbingandautoclavingandshouldthereforenotbesubjectedtounneces
10、sarysterilization.Theinstrumenttypeandnumberincludedineachofthesepackswilldependonsurgeonpreference.许多器械只是偶尔使用，应该单独打器械包。经常的刷洗和高压灭菌会使器械变钝，因此不应该进行不必要的灭菌。Biopsy/thephinepack活组织检查包Curettepack刮匙包Hemostatpack止血钳包Implantset植入物放置Periostealelevatorpack骨膜起子,骨膜分离器,骨膜剥离器包PinsetRetractorpack牵引器包Screwsetsuctionti
11、psandtubingpack螺丝钉吸引头和？包Postoperativecare术后护理Thesuccessofeachsurgicalprocedureoftenliesinthepatientcarethatfollowstheprocedure.Thisoftenendswiththeclienttocontinueathomecare.Clearandconciseinstructionsarecriticaltoenablethistransitiontooccursuccessfully.Clientsshouldbestronglyencouragedtophoneforany
12、questionsorconcernsarise.Follow-upphonecalls1-2daysafterasurgicalprocedurebythestaffwillalsoencourageclientcommunication.每个外科手术操作的成功经常基于对患畜的术后护理。这些经常以主人将患畜接回家后继续护理而终止。清晰简要的说明是使这个过渡成功的关键。应该鼓励患畜主人在有任何疑问和担心打电话来咨询。应该鼓励医务人员外科手术后的1-2天给主人打电话进行交流。Skillbox12-1/Standardpostoperativecareinstructions技术表格12-1/标准
13、的术后护理说明Feedonlyhalfofthenormalfoodandwaterthefirsteveningaftersurgery外科手术当天晚上只要喂平常食量和水量的一半Checkincisiondailyforredness,swelling,discharge,orodor每日检查伤口是否发红、肿胀、渗液或者有异味Preventlicking,chewing,orrubbingatincisionlineorsutures制止动物舔舐、拒绝或者摩擦缝线Keeptheanimaland/orbandagesdryandclean保持动物的包扎绷带干燥清洁Avoidbathingor
14、swimminguntilsutureremovalorfor5-7dayswithscSutures在未拆线之前禁止洗澡和游泳？Phonethedoctorifanyofthefollowingoccur:RepeatedvomitingExtremelistlessnessBleedingordischargeLossofappetitefor24hoursOpenedincisionlines如果遇到以下情况请致电医生：反复呕吐、非常没有精神、出血或者渗出、24小时没有食欲、伤口开线Skillbox12-2/preventinglicking,chewing,orrubbingatinc
15、isionsiteorsutures技术表格12-2/制止动物舔舐、拒绝或者摩擦伤口或者缝线1useanelizabethancollar(e-collar,neckbrace,etc.)atalltime1要一直带着伊丽莎白圈2applyabandage(e.g.,softpaddedbandage,hobbles,orschroeder-thomassplintwithsheetaluminum)2应用绷带（软垫绷带？或者铝片schroeder-thomas夹板）3Foul-tastingsubstance(e.g.,bitterapple,atropine,tabasco,orthumb
16、-suckingpreparations)3使用异味物质（药西瓜瓤、阿托品、辣椒粉、吮指癖制止剂）4covertheareawithasock,babyt-shirt,orstockinette4将术部用短的幼儿T恤或者？覆盖5bodybrace,sidebar,ortail-tipprotectorTable12-1abdominalsurgeryprocedureAbdominalsurgerydefinitionl Seeparticularsurgeryindicationsl Seeparticularsurgerypreparationinstrumentsl Abdominalp
17、ackl Electrocauteryl Gauzesponges/laparotomypadsl Generalsurgicalpackl Retractorpackl Salinebowll Saline,warmedl Suctiontipsandtubingpackpatientl SeeparticularsurgerySurgicaltechniquel Thorganorareatobeexaminedshouldbeexteriorizedandpackedwithsalinemoistenedgauzespongesl Alltissuesmustbekeptconsiste
18、ntlymoistwithwarmsalinel Handlingoftheinternalorgansmustbedonecarefullytoavoidfurtherdamage,butsecureenoughtonotallowleakageofthebowelcontentsintothesurgerysitel Provideclean,steriledrapes,towels,gloves,andinstrumentsforabdominalclosurel Patientshouldbemonitoredforexcessivebloodloss,contaminationofp
19、ertonealcavity,andantendencytovomitwithorganmanipulationcomplicationsprocedurall Abscessl Dehiscencel Gastricorintestinalperforationl Hemorrhage(e.g.,poorhemostasisandinadvertantinjurytovascularorgans)l Ileusl Intestinalstricturel Pancreatitisl Peritonitis/sepsis(e.g.,contaminationwithgastrointestin
20、altract(GIT)content)l Pleuraleffusionl Failureofintendedsurgeryl Adhesionsbetweenvisceralsurfacespatientl Hyperthaermiawithprolongedproceduresl Abdominalpainl Fecalincontinencel Feverl Tenesmus/constipation/dyschezial VomitingFollow-upPatientcarel NPOfor12-24hoursl Analgesiapostoperativelyl Monitora
21、bility,frequency,andappearanceofdefecationl Standardpostoperativecarel Confineandrestrictactivityuntilsuture/stapleremovalorasdirectedbyDVMClenteducationl Recheck/sutureremovalin_daysl Medication:_l Labresultsin_daysTable12-1腹部外科操作步骤腹部外科定义l 见详细外科说明适应症l 见详细外科说明准备器械l 腹部外科包l 电烙器l 纱布海绵/剖腹术垫子l 常用外科填塞物l 牵
22、引器包l Salinebowll 温生理盐水l 吸引头和管包患畜l 见详细外科说明外科技术l 需要从腹部取出进行检查的器官或者区域需要用生理盐水润湿的纱布海绵包裹覆盖l 需要使用温的生理盐水让所有的组织保持湿润l 处理内脏的时候必须要仔细，避免对组织的进一步损伤，要尽量避免肠内容物漏入外科手术区域l 为腹腔闭合提供干净无菌的布单、毛巾、手套和器械l 需要监控患畜是否有过度失血，？腔污染和器官操作引增加的呕吐的可能性并发症程序l 脓肿l 开裂l 胃肠穿孔l 出血（止血功能弱或者未注意损伤到了脉管器官）l 肠梗阻l 肠狭窄l 胰腺炎l 腹膜炎/败血症（胃肠道内容物污染）l 胸膜积液l 预期外科手术
23、失败l 脏面粘连患畜l 卵泡膜细胞增殖症使发情延长l 腹部疼痛l 大便失禁l 发烧l 里急后重/便秘/大便困难l 呕吐后续患畜护理l 禁食12-24小时l 术后镇痛l 监测排便能力、频率和表现l 标准的术后护理l 限制活动直到拆线或者由兽医进行指导客户教育l 在_天复查/拆线l 药物治疗方案：l _天获得实验室结果Table12-2abdominalsurgery(continued)procedureAbdominalherniaAnalsacculectomycolotomydefinitionl Repairofaholeintheabdominalwallthatisallowinga
24、norganorpartofanorgantoprotrudel Removalof1orbothanalsacsandassociatedanalsacductl Incisionmadeintothecolonindicationsl Intestinalobstructionand/orstrangulationdamagel Correctionoflong-termanalsacinfectionandneoplasial Full-thicknessbiopsyandforeignbodyPatientpreparationl Dorsalrecumbencyl Prepare3o
25、neithersideofthehernial Ventralrecumbencywithrearlegsdrapedoverendoftableandtailsecuredcraniallyl Preparea4radiusaroundanusl Expressanalsacs,evacuateasmuchofthefecesfromthecolonaspossible,andpackrectumwithspongesl Closed；instillself-hardeninggelorresinintosac(s)toberemovedl multipleenemastoriskofinf
26、ectionandtovisibilityl Dorsalrecumbencyl PrepareentireventralabdomenSurgicaltechniquel Anincisionismadeovertheherniaanddissecteddowntotheherniaorifice,Anyadhesionsareremovedandtheorgansand/orvisceraarereturnedtotheperitonealcavity.Theedgesofhernialorificearesharplyfreshenedandsuturedclosed.Routinecl
27、osureoftheabdomenisperformedl Closed:thehardenedsacisisolated,andanincisionismadeoverthesac.Thesurroundingtissueisgentlydissectedawayfromthesac,andthesacandductareremoved.Theareaislavagedwithwarmedsaline,andtheremainingtissueisclosedinaroutineclosure.l Open:Theanalsacorificeisvisualizedandagrooveddi
28、rectorisplacedintothesacorificetothemostventralaspect.Anincisionismadealongthegrooveddirector,andtheentiresacandductaredissectedout.Theareaislavagedwithwarmedsaline,andtheremainingtissueisclosedinaroutinclosurel Acaudalmidlineabdominalincisionismade.Theaffectedareaisexteriorizedandpackedwithsaline-m
29、oistenedgauzesponges.Staysuturesareplaced,andthecoloniccontentsaremilkedawayfromtheintendedincisionsite.Anincisionismadeintothecolon,andtheforeignbodyisremovedorbiopsyspecimentstaken.Thecolotomyisclosed,andtheabdomenisflushedwithwarmsaline.Thecolotomyiscoveredandtackedwithapieceofomentum,androutinec
30、losureoftheabdomenisperformed.notesl Clienteducation:chronicherniasmaynotrequiresurgicalinterventionl Instruments:closed:self-hardeninggelorresinandadministrationequipmentOpen:grooveddirectorl Surgery:careful,atraumaticdissectionwithminimalmuscledamageisessentialtoprevervenerveandsphincterfunctionl
31、Patientcare:hotpackthesurgicalsiteimmediatelyaftersurgeryandantibioticsfor7-10dayspostoperativelyl Clienteducation:hotpackincisiontwicedailyuntilsutureremovall Surgery:staysuturesmaynjotbenecessary,especiallyifsurgicalassistantispresentl Patientcare:antibioticsduringsurgeryandpostoperatively(onlyifc
32、ontaminationissuspected)Table12-2腹部外科（继续）程序步骤腹部疝气Analsacculectomy肛门腺囊结肠切开术定义l 修复能够使部分器官或者整个器官突出腹壁的洞l Removalof1orbothanalsacsandassociatedanalsacductl 移除一个或者双侧的肛门腺囊和？l 结肠切开适应症l 肠梗阻或窒息,绞窄损伤l 校正长期的肛门腺囊感染和瘤形成l Full-thicknessbiopsyandforeignbodyl 增厚部位的活组织采样和异物患畜准备l 背侧斜卧l Prepare3oneithersideofthehernial
33、 准备双侧的疝气l Ventralrecumbencywithrearlegsdrapedoverendoftableandtailsecuredcraniallyl Preparea4radiusaroundanusl Expressanalsacs,evacuateasmuchofthefecesfromthecolonaspossible,andpackrectumwithspongesl Closed；instillself-hardeninggelorresinintosac(s)toberemovedl 多次灌肠可以降低感染的风险并且增加可视度l 背侧斜卧l 准备整个腹部腹侧外科技
34、术l 从疝气表面切开至疝孔，除去粘连物并将器官或脏器还纳入腹膜腔。将疝孔边缘切割形成新鲜创，并由缝线闭合。常规闭合腹腔l 封闭式：坚硬的囊相对独立，在囊上做切口。轻柔的分离囊、囊管和囊周围的组织。用温生理盐水冲洗周围区域，将剩余的组织常规闭合l 开放式：肛周腺囊的口是可见的，将有槽探针从囊孔置于大部分腹侧位置。沿着有槽探针周围做切口将整个囊和管切除。用温生理盐水冲洗附近区域，常规闭合剩余组织l 后腹部中线切口。受影响的区域是从腹腔取出的脏器，需用生理盐水浸润的纱布海绵包裹，将伤口周围的缝处置好，将结肠内容物从预计的切口处挤走。将结肠切开，将异物取出或者进行活组织标本采样。将结肠封闭，用温生理盐
35、水冲洗腹腔。用网膜将结肠覆盖，常规闭合腹腔。注意l 客户教育：慢性疝气不需要外科手术的干预l 器械闭合式：自我凝固的凝胶或者树脂及其投药的装置开放式：有槽的探针l 外科：仔细的最小损伤肌肉进行切割以保护神经和括约肌的功能l 患畜保护：术后对伤口进行热敷，并进行消毒7-10天l 客户教育：热敷伤口两次知道拆线l 外科手术：尤其是外科助手在的情况下，staysutures是非必须的。l Patientcare:antibioticsduringsurgeryandpostoperatively(onlyifcontaminationissuspected)l 患畜护理：术中和术后需要抗生素治疗（只
36、有如果怀疑污染的时候）Table12-3abdominalsurgety(continued)procedureenterotomyGastric-dilatationvolvulus(GDV)seechapter5,emergencycareGastrotomydefinitionl Incisionmadeintothesmallintestinesl Torepositionthestomachandthespleenintheircorrectlocationandrestoretheirbloodcirculationl Fixthestomachtotheabdominalwall
37、topreventfurthertorsionl IncisionmadeintothestomachIndicationsl Examinationforulcers,strictures,orneoplasia,full-thicknessbiopsy,andforeignbody(FB)removall Astomachthatdilatesandtwistsarounditscentralaxisl Full-thicknessbiopsyandforeignbody(FB)removalPatientpreparationl Dorsalrecumbencyl Prepareenti
38、reabdomenl Orogastricdecompressionorneedletrocarizationl Dorsalrecumbencyl Preparemidsternumto2-3inchesbelowtheumbilicusl Dorsalrecumbencyl Preparebottomthirdofthesternumto2-3inchesbelowtheumbilicusSurgicalthchniquel Amidlineabdominalincisionismade.Theaffectedareaisexteriorizedandpackedwithsaline-mo
39、istenedgauzesponges.Staysuturesareplaced,andthebowedcontentsaremilkedawayfromtheintendedincisionsite.Anincisionismadeintotheintestines,andtheFBisremovedorbiopsyspecimenstaken.Theintestinesareexaminedforviabilityandrecection,andanastomosisisperformedifnecessary.Theenterotomyisclosedwithapieceofomentu
40、mandtacked,androutineclosureoftheabdomenisperformed.l Amidlineabdominalincisionismade.Furtherorogastricdecompressionisperformedifnecessaryviaanorogastrictubeorsuction,Thespleenisevaluatedforrotationandnecrosis.Asplenectomyisperformedifthereissplenicnecrosis.Gastroplexyisthenperformedontherightsideof
41、thedogbyoneofmanymethods,Theabdomenisthenclosednwithroutineclosure.l Acranialmidlineabdominalincisionismade.Thestomachisexteriorizedandpackedwithsalinemoistenedgauzesponges.Staysuturesareplaced.Thestomachisexcisedintoandsuctionedfreeofliquidcontents.TheFBisremovedorbiopsyspecimenstaken.Thestomachisc
42、losedinamulti-layerfashion,lavagedwithwarmedsaline,andpossiblycoveredwithomentum.Theabdomenisclosedroutinely.notesl Surgery:staysuturesmaynotbenecessary,especiallyifasurgicalassistantispresentl Surgery:enterotomyincisionsareusuallymadeintissueadjacenttotheFBratherthandirectlyoveritforbetterincisionh
43、ealingl Instruments:orogastrictubel Patientcare:monitorelectrolytes,bloodgases,hematocrit(Hct),totalprotein(TP),urinaryoutput,electrocardiogram(ECG),andcentralvenouspressure(CVP)asnecessary,andkeepNOPfor24-48hoursl Clienteducation:feedsmallmeals3-4timesdaily,andavoidexerciseaftereachmeal.l NoneTable
44、12-4abdominalsurgery(continued)procedureIntestinalresectionandanastomosisHepatectomy,partialdefinitionl removalofadiseasedornonviablesectionoftheintestinesandrepairtothebowelwithend-to-endbowelreattachmentl removalof80%oftheliverIndicationsl anonfunctioningsectionofbowelpossiblycausedbyforeighbody,n
45、eoplasia,intussusception,bowelnecrosis,fecalinfiltrativeboweldisease,orvolvulusl biopsy,neoplasia,necrosis,abscess,orhemorrhagePatientpreparationl dorsalrecumbencyl preparethecaudalendofthesternumtothepubisl coagulationtestsandthrombocytecountSurgicaltechniquel aventralmidlineabdominalincisionismade
46、.Theareaoftheintestinestoberesectedisexteriorized,packedwithsalinemoistenedgauzesponges,andmajorvesselsareligated.Thebowelcontentsaremilkedawayfromthesite,andabdominalforcepsareplaced.Thediseasedportionisremoved,andoneofmanytypesofsuturepatternsmaybeusedtoallowcompleteclosureoftheintestines.Bowelcon
47、tentsaremilkedbackintheanastomosissitetoassurenoleakage,TheentireabdomenisflushedwithwarmedsalineifcontaminationissuspectedThesiteofanastomosisisthenflushedwithsalineandanantimicrobialsolutionandcoveredwithapieceofomentum.Routineclosureoftheabdominalwallisperformed,l aventralmidlineabdominalincisionismade,Gauzespongesareplacedbetweentheliveranddiaphragmforbettervisualiz