結(jié)腸癌術(shù)后造瘺口并發(fā)癥的護(hù)理Contents1.病例簡(jiǎn)介2.治理方法3.護(hù)理評(píng)估4.護(hù)理計(jì)劃5.健康教育.Logo

Logo病歷簡(jiǎn)介一般資料姓名：李秀英性別：女年齡：73歲民族：漢職業(yè)：退休婚姻：已婚籍貫：陜西漢中文化程度：高中入院途徑：門診入院方式：步行入院日期：2011-12-29

入院診斷：直腸癌前切除術(shù)后并吻合口及陰道瘺入院原因：發(fā)現(xiàn)瘺口半月余.Logo

Logo入院查體一般資料姓名：李秀英性別：女年齡：73歲民族：漢職業(yè)：退休婚姻：已婚籍貫：陜西漢中文化程度：高中入院途徑：門診入院方式：步行入院日期：2011-12-29

入院診斷：直腸癌前切除術(shù)后并吻合口及陰道瘺入院原因：發(fā)現(xiàn)瘺口半月余.Logo

Logo主訴：便血2月現(xiàn)病史：

患者2月無明顯原因及誘因出現(xiàn)便血，大便后少量鮮血，次數(shù)正常，下腹部伴有隱痛，與當(dāng)?shù)蒯t(yī)院以“痔瘡”。

既往史：否認(rèn)高血壓、冠心病、糖尿病病史，否認(rèn)其他傳染病史，否認(rèn)食物、藥物過敏史，否認(rèn)手術(shù)外傷史。個(gè)人史：否認(rèn)經(jīng)常外出就餐，否認(rèn)輸血及血制品運(yùn)用史，否認(rèn)傳染病患者密切接觸史，預(yù)防接種史不詳。過敏史：否認(rèn)食物、藥物過敏史。.Logo

Logo現(xiàn)病史：

患者26年前體檢發(fā)現(xiàn)HBsAg（+），當(dāng)時(shí)肝功能正常，無明顯不適癥狀，間斷服用藥物治療。8月前體檢考慮為肝癌可能性大，肝硬化、食管下段-胃底靜脈曲張、少量腹水。于4月1日在我院行肝動(dòng)脈化療栓塞治療，腫瘤大小為72*67mm，此次為進(jìn)一步治療入院。

入院后核磁檢查提示：建議行介入術(shù)治療，并于7.22日在局麻下行介入治療。

既往史：否認(rèn)高血壓、冠心病、糖尿病病史，否認(rèn)其他傳染病史，否認(rèn)食物、藥物過敏史，否認(rèn)手術(shù)外傷史。個(gè)人史：否認(rèn)經(jīng)常外出就餐，否認(rèn)輸血及血制品運(yùn)用史，否認(rèn)傳染病患者密切接觸史，預(yù)防接種史不詳。過敏史：否認(rèn)食物、藥物過敏史。.Logo

Logo睡眠：正常排泄：正常自理程度：生活可自理對(duì)疾病的認(rèn)識(shí)：部分了解生命體征：

T36.5℃，P80次/分，R18次/分，BP130/80mmHg體格檢查：一般狀況良好，肝掌陽性，皮膚黏膜無黃染，雙下肢不腫，胸腹部情況良好，無帶入管路，無牽引。.Logo

Logo輔助檢查日期項(xiàng)目檢查結(jié)果2011-7-13心電圖竇性心律正常ECG2011-7-15核磁腫瘤強(qiáng)化建議行介入術(shù)治療2011-7-13

超聲

肝內(nèi)實(shí)性占位，肝右葉可及大小約80*67mm的不均回聲，邊界尚清，其內(nèi)可及動(dòng)脈樣血流信號(hào).Logo

Logo實(shí)驗(yàn)室檢查

7-127-18

總膽紅素12.77.5

丙氨酸氨基轉(zhuǎn)移酶37.465

門冬氨酸氨基轉(zhuǎn)移酶34.442

白細(xì)胞4.53.95

鉀離子3.513.41

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Logo護(hù)理診斷

1.潛在并發(fā)癥：上消化道出血

2.潛在并發(fā)癥：有肝癌破裂出血的危險(xiǎn)

3.有感染的危險(xiǎn)

4.潛在并發(fā)癥：有出血的危險(xiǎn):與介入術(shù)后有關(guān)

5.有皮膚完整性受損的危險(xiǎn)：與介入術(shù)后需長(zhǎng)時(shí)間臥床有關(guān)

6.營(yíng)養(yǎng)失調(diào)：低于機(jī)體需要量

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