护理查房2.pptVIP

护理查房 结肠癌术后护理 Nursing round Postoperative nursing for colonial cancer patients 普通外科二病区 师兰香 general surgery department unit 2 Lanxiang Shi 护理评估Nursing assessment 病史 8床李艳秋，女50岁， 初中文化 Health history Bed 8，LiYanQiu female ,50-year old, middle-school education 护理评估Nursing assessment 2009年6月出现腹痛 2009年8月出现下腹痛大便变细，便中带血 diarrhea since June 2009 Abdominal pain , stool with blood and became thinner on Auguest 2009 护理评估Nursing assessment 2009年11月5日行肠镜检查，结果提示左半结肠癌 为行手术治疗于2009年11月7日由门诊收入我科。 10年前行子宫切除术 Underwent endoscopy on November 5th 2009, the result suggested left colon cancer admitted for surgery on November7th2009. urectomy ten years ago 护理评估Nursing assessment 入院查体 一般情况好，腹部有一条约6到7厘米长的手术疤痕 Physical examination she is in good condition, there was a scar about 6-7 cm long in the abdomen and the rest were normal. 护理评估Nursing assessment 治疗 2009年11月20日在全麻下行左半结肠切除术，于11月30日痊愈出院。 Treatment She was performed left colectomy under general anstheasia on November 20th 2009 and discharged on November30th2009 术后护理诊断Postoperative nursing diagnosis 疼痛：与手术切口有关 清理呼吸道无效 :与疼痛和麻醉有关 知识缺乏 ：缺乏术后康复知识 ? pain:related to the incision ineffective airway clearance ：related to pain ,anesthesia knowledge deficit ：lack of recovery knowledge 主要诊断及护理措施 main diagnosis and implementation 疼痛：与手术切口有关 评估疼痛程度，向病人解释疼痛的原因，鼓励病人战胜疼痛，必要时遵医嘱给予止疼药。 告知病人咳嗽时按压伤口 pain:related to the insion assess the degree of the pain,explain the reason and encourage the patient to overcome the pain. If necessary,give her drugs as doctor’s order to reduce the pain press the incision when she cough 主要诊断及护理措施 main diagnosis and implementation 清理呼吸道无效:与疼痛和麻醉有关 有效咳嗽 咳嗽时按压伤口 给予雾化吸入，叩背 ineffective airway clearance :related to pain ,anesthesia effctive cough press the insion when she cough mobilization