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1、Page 1胸外科护理查房最终版Page 2CASE PatientYuWeichengmale17yearsWithpainatleftchestanddifficultybreathing,chestdistress10days.Pastmedicalhistory:Alwaysbodyhealth,denyhistoryofotherseriousdiseasesanddrugallergy.Historyofpresentdisease:Withoutanyobviouscause,hefeltpainattheleftchestanddifficultybreathing,chest
2、distress10daysago.Nofever,lowhead,cough,haemoptysis,lackofpower,nightsweatandsoon.Atfirstdidnotpayattentiontothese,butsymptomsfornoease.Achestradiographyshowedthattheleftlungtissuecompressionby85%.Physicalexamination:T37.3,P96/min,R20/min,BP140/80mmHgIntelligenceclear,trachealatthecenterofneck.Thele
3、ftbreathsoundsalittleweak.Diagnosticexamination:WBC11.4109,N8.05,L18.1Admissiondiagnosis:SpontaneousPneumothoraxPage 3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
4、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。起初未予注意，症状持续无明显缓解，胸片检起初未予注意，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 T 37.3,P 96 P 96次次/分分 ,R 20R 20次次/分分 ,BP 140/83mmHg BP 140/83mmHg,神智清楚，皮肤巩膜无黄神智清楚，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。辅助检查：辅助检查：WBC 11.4
5、 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 4Etiology and classification病因及分类病因及分类THE SPEAKER:THE SPEAKER:于广平于广平Page 5The cause of spontaneous pneumothoraxnClassification of one Spontaneous pneumothorax Trauma pneumothorax Artificial pneumothoraxnClassification of two
6、Closed pneumothorax Open pneumothorax Tension pneumothoraxPage 6The 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 form
7、ation of spontaneous pneumothorax.Clinical manifestations临床表现与体征临床表现与体征蒋娟蒋娟Page 8Clmical manifestations （临床表现）（临床表现）：Suddenchestpain（突（突然发生胸痛），然发生胸痛），difficultyinbreathing（呼吸困难），（呼吸困难），chesttightness(胸闷胸闷)，inseverecasesirritability、profusely、cyanosis（严重（严重者烦躁不安、大汗、紫绀）者烦躁不安、大汗、紫绀）acceleratedrespirati
8、on（呼（呼吸加快），吸加快），pulsebreakdownandevendeath（脉搏细数甚至死亡）。（脉搏细数甚至死亡）。Page 9Signs（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（呼吸运动减弱或消失）（呼吸运动减弱或消失）。Percussion drum sound（叩诊呈鼓音），（叩诊呈鼓音），fremitus and de
9、creased breath sound（语颤呼吸音减弱）。（语颤呼吸音减弱）。Auxiliary examination 辅助检查辅助检查THESPEAKER :桓秀山桓秀山10 Auxiliary examination1.X-ray 2.CT 3.Pleural cavity angiography4.Thoracoscopic11Auxiliary examination1 1.X-ray examination is the most.X-ray examination is the most reliable method of diagnosis of reliable meth
10、od 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 atroph
11、y,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
12、 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可靠的方线检查是诊断气胸最可靠的方法。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
13、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。12Auxiliary 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
14、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 th
15、e 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可可清清晰晰地地显显示示少少量量气气胸胸和和与与肺
16、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有可能发现肺气肿疱；有可能发现肺气肿疱；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。133.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 pr
17、ofile 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此方法可以明了胸膜此方法可以明了胸膜表面的情况，易于明表面的情况，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
18、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，特别是当患者咳象，特别是当患者咳嗽时，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。144.ThoracoscopicnThoracoscopy can easily detect pneumothorax etiology,flexible operation,can reach the interlobar fissure,apex,hilar,almost no blind spots,observe the
19、visceral pleura with no rips,pleura without bullae of lung and chest cavity with no adhesive joint.n胸腔镜可以较容易地发胸腔镜可以较容易地发现气胸的病因，操作灵现气胸的病因，操作灵活，可达叶间裂、肺尖、活，可达叶间裂、肺尖、肺门，几乎没有盲区，肺门，几乎没有盲区，观察脏层胸膜有无裂口、观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。15 Principles of treatment 治疗原则治疗原则16Principles of treatment
20、1.Conservative treatment2.Exhaust treatment3.Operation treatment17 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 bedresana
21、lgesic 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 管管痉挛者使用支气管扩痉挛者使用支气管扩张剂，酌情给予镇静张剂，酌情给予镇静镇痛等药物。镇痛等药物。182.Exhaust treatment1.张力
22、性气胸病情危急可行紧急排气张力性气胸病情危急可行紧急排气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,res
23、piratory 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 patients19Operation treatment ThoracoscopicThoracoscopic and and ThoracotomyT
24、horacotomy20 胸腔镜胸腔镜 通过二至三个通过二至三个“钥匙孔钥匙孔”，在电视影像监视辅助下完成过在电视影像监视辅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、恢复快、住院时间短等伤小、恢复快、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 monitori
25、ng aid.By its very nature is laparoscopic surgery,relative to traditional open surgery with less trauma,recovery faster,shorter hospital stay andother technical features21 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。Surgicaltreatmen
26、tThe 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,a
27、nd to prevent the adhesions,and to prevent the recurrence of pneumothorax.recurrence of pneumothorax.22NursingdiagnosisandmeasuresTHESPEAKER:王辉、毛雅琴、潘娟王辉、毛雅琴、潘娟23护理诊断护理诊断NursingdiagnosisimpairedGasexchangepain(painatchest)TheriskofinfectionActivitieswithoutendurancenutritionalteredknowledgedeficit护理措
28、施护理措施NursingmeasuresPage 271.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 fixe
29、d,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 28Closed drainage of thoracic cavity1.Positive pressure continuous exhaust method.2.Continues the
30、negative pressure exhaust method.DrainagebottlePage 29positionpsychologicalnutritionenvironmentmedicinepainPage 30 The risk of infectionn1.To keep respiratory tract unobstructed promptly eliminate sputumn2.Do oral care,prevent secondary infectionn3.Keep closed drainage system sterilePage 31Activitie
31、s 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 32 Malnutritionn1.Give high proteinn2.High vitaminn3.Light easy to digest foodPage 33Lackofknowledgea.Avoidpressureshockb.Keepwarmc.keepbo
32、welsopenPage 34 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 35Thoracic closed drainage
33、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 a
34、xillary n line place aftern3.The pus by means of x line in the vomica lowest placenNursing key pointsPage 36Tube 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37
35、1.Thecause,typeandcureofPneumothorax2.Thepurposeofthoraciccloseddrainageandattention3.thepurposeofstartingexerciseearly4.Lungfunctionwereexercisepurposeandmethod5.dietfordiscovery6.Convalescencerehabilitationactivitiesofthemethodandthemattersneedingattention7.dischargeguidance38Earlyactivitiesofthem
36、ethodsandsignificance1.promotethewholebodyfunctionrecovery2.Promotethebloodcirculation3.Promotegastrointestinalperistalsis4.Promoteurinationfunctionrecovery39Methods:1.deepbreath,sputum,assistkeelover,takeback,andsmoothbloodpressureaftertakehalfdecubitus;2.Thenextdayhelpedbythesidesofthebed,onthebed
37、canbeactivitiesduringtheupperlimbs,andflexionandexercise;3.4dayslatergraduallyoffthebedactivities,firstinbedsidestand,andgraduallyintheindoorwalkslowly,anddiscretionarygooutforawalk4.seriouslyillweakandcomplicationsandactivityrestrictionpatientscantgetupearly,butstillneedtoadheretothebedactivities.4
38、0Lung 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 infectionPage42Dietnbefore:eat easy digestive less slag food (易消化少渣易消
39、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
40、 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 deformity43(1)afterdischargeshouldbecombinedwithworkandrest
41、.(2)oftenkeeptheairfresh.Preventrespiratoryinfections.(3)regularaccordingtophysicianschargedtooutpatient.Ifthereisachesttightness,shortnessofbreath,chestpainwaitforasymptom,shouldpromptmedicalattention.(4)developgoodhabits.Everydaydorespiratoryfunctionexercise.(5)togiveupsmoking.Dischargeguidance44感谢您的关注感谢您的关注Page 46此课件下载可自行编辑修改，仅供参考！此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力做得更好！谢谢感谢您的支持，我们努力做得更好！谢谢