培训课件--外科新业务学习.ppt

* * 术后疼痛不仅影响患者的生活质量，还可能带来一系列的生理影响，如图所示（以下内容主要为增进对本张幻灯片的理解，可酌情删减）。 手术后的内分泌改变所导致的水和电解质代谢异常主要表现为水钠潴留，功能性细胞外液减低，液体向细胞内转移； 此外，疼痛造成交感神经兴奋性增强会导致心脏做功增加和氧消耗增加，同时，血压也有可能升高，甚至可能导致脑卒中和心肌缺血； 在肺功能方面，研究证实，即使不做手术，2小时以上的全身麻醉和机械通气也可能会导致肺不张；另外膈肌功能减退导致不能有效咳嗽，不能清除呼吸道分泌物也可能造成肺不张和肺炎； 第四方面，术后疼痛可能导致静脉淤滞、血液粘稠度增高，加上术后活动减少，将增加深静脉栓塞甚至肺动脉栓塞的危险； 第五方面，术后疼痛可减低胃肠道蠕动，增加恶心、呕吐、麻痹性肠梗阻的发生机会，同时也是延长住院时间、增加医药费用的主要原因之一； 第六方面，如果术后疼痛治疗不充分会导致外周或中枢敏化，进而导致急性疼痛转化为慢性疼痛。 疼痛按照时程分类，以3个月为界可分为急性疼痛 ≤3个月 和慢性疼痛 3个月 根据此标准，我们熟知的手术后疼痛属于哪种类型呢，关于这个问题，中华医学会2009年在线发表的《成人手术后疼痛处理专家共识》给出了明确的答案。 专家共识指出，手术后疼痛是临床最常见和最需紧急处理的急性伤害性疼痛。 此外，更强调指出：如果不能在初始状态下充分被控制，急性疼痛可能转化为慢性疼痛。 * 美国一项调查研究表明，82%的患者在手术后至出院后2周存在术后疼痛，这些患者中一半以上为轻到中度疼痛，这不得不引起我们对轻中度术后疼痛的重视。 * 对于关节科，医患比较关注术后功能恢复，而且术后早期就要进行功能锻炼，此时疼痛和炎症反应严重阻碍患者功能康复，而阿片类药物对运动痛疗效较差，且不具有抗炎作用。 * 250 patients who had undergone surgical procedures in- and outpatient in the past year completed a questionnaire about their experiences with pain before and after surgery. The most common concern that patients expressed prior to surgery was experiencing pain 59% , which was cited more often than concerns about whether the surgery would improve their condition 51% or whether they would fully recover 46% . 58% of the sample reported pain prior to surgery. Despite receiving treatment for pain, 82% reported pain in the immediate postsurgical period end of surgery up to 2 weeks after discharge and 75% reported pain after discharge. More than two thirds of patients reported pain of moderate to severe intensity, and extreme pain was reported by 18% overall and 8% after discharge. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97:534-540. * The pain management standard operation process includes three contents. First is Assessment is basic, the nurse should Assess all patients routinely for pain and Record assessment data in a way that facilitates reassessment and follow-up. Secon