[医学]消化系统疾病病人的健康评估.pptVIP

消化系统疾病患者的健康评估 Health Assessment of The Digestive System 学习目标 熟悉肠胃系统的正常功能 认识肠胃系统的异常表现 掌握肠胃系统的评估要点 熟悉肠胃系统评估技巧 分辨不同年纪、性别、疾病谱在消化系统的表现 GI System Assessment 消化系统评估 健康史: 生活背景Biographical and demographic data 目前健康状况 Current Health 过去健康病史 Past Health history 家族史 Family Health 心理社会因素 Psychosocial Factors 系统回顾 Review of system Demographic Data背景资料评估 Gender Age Marital Status Working condition Women (calcium), elderly (inadequate food intake, gastric ulcer, colon cancer), teenagers (Duodenal ulcers, gastric cancers) may have different health problem and nutritional needs. Current Health Assessment 目前健康评估 评估主诉是否出现： 恶心、呕吐 吞咽困难：梗阻与疼痛 不消化 ：反酸或嗳气 腹痛 呕血、便血 腹泻、便秘 腹水 黄疸 体重及食欲改变. Past Health History 过去病史 Bleeding-iron deficiency anemia Liver Disease: protein malnutrition Peptic Ulcer With bleeding Jaundice Gallbladder sisease Pancreatitis Cancer Change of bowel habits Tarry stools Unexplained weight loss or gain Health History of The GI System Health Perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-Rest Pattern Congitive-preception pattern Self-Perception, self-concept pattern Role-relationship pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Value-belief pattern Assess for Medications药物评估 Use of Aspirin, NAISD (Nonsteroidal anti-inflammatory drugs) –gastritis/bleeding是否使用阿斯匹林，非激素类止痛药，胃出血 Antacids: type and frequency 制酸剂，种类、频率 Laxatives or stool softeners? 软便剂 Dietary Supplement: vitamins,minerals, herbs, amino acids 食品补充，维生素、草药、蛋白质 Assessment for Allergies 评估过敏史 Food allergies: hives or dyspnea Food intolerance: GI abdominal cramping, flatulence, or diarrhea (lactose intolerance) Comment food allergies items: nuts, shellfish, cow’s milk, food additives Assessment for Family History GI problem may associate with family history and environment factors. Ulcerative colitis 溃疡性结肠炎 Crohn’s Disease 克罗恩病 Alcoholism 酗酒 Liver diseases 肝脏疾病 Family history of DM, anemia, jaundi