急性腹膜炎護(hù)理個(gè)案分析

1、,急性腹膜炎護(hù)理個(gè)案分析,,,目錄,健康評(píng)估,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and

2、 may lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí),急性腹膜炎是由細(xì)菌感染，化學(xué)刺激或損傷所引起的外科常見的一種嚴(yán)重疾病。多數(shù)是繼發(fā)性腹膜炎，原于腹腔的臟器感染，壞死穿孔、外傷等。其主要臨床表現(xiàn)為腹痛、腹部壓痛腹肌緊張，以及惡心，嘔吐，發(fā)燒，白血球升高，嚴(yán)重時(shí)可致血壓下降和全身中毒性反應(yīng)，如未能及時(shí)治療可死于中毒性休克。部分病人可并發(fā)

3、盆腔膿腫，腸間膿腫、和膈下膿腫，髂窩膿腫、及粘連性腸梗阻等。,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrog

4、ates and may lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí),腹膜的生理功能：①潤滑作用②防御作用③吸收作用④滲出與修復(fù)作用,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle wit

5、h decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí),Background,Surrogate decision makers for in

6、capacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferen

7、ces. 。,相關(guān)知識(shí)|分類,1.原發(fā)性腹膜炎 原發(fā)性腹膜炎臨床上較少見，是指腹腔內(nèi)無原發(fā)病灶，病原菌是經(jīng)由血循、淋巴途徑或女性生殖系等而感染腹腔所引起的腹膜炎。多見于體質(zhì)衰弱，嚴(yán)重肝病患者或在抗病能力低下的情況下，或腎病、猩紅熱、營養(yǎng)不良并發(fā)上呼吸道感染時(shí)均可致病，尤其是10歲以下的女孩多見。膿液的性質(zhì)椐菌種而不同，常見的溶血性鏈球菌的膿液稀薄而無臭味，膿汁和血培養(yǎng)可找到溶血性鏈球菌和肺炎雙球菌。臨床上常有急性腹痛、嘔吐、

8、腹瀉，并迅速出現(xiàn)脫水或全身中毒癥狀。,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may

9、 lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí)|分類,2.繼發(fā)性腹膜炎 繼發(fā)性腹膜炎是臨床上最常見的急性腹膜炎，繼發(fā)于腹腔內(nèi)的臟器穿孔，臟器的損傷破裂，炎癥和手術(shù)污染。主要常見病因有闌尾炎穿孔，胃及十二指腸潰瘍急性穿孔，急性膽囊炎透壁性感染或穿孔，傷寒腸穿孔，以及急性胰腺炎，女性生殖器官化膿性炎癥或產(chǎn)后感染等含有細(xì)菌之滲出液進(jìn)

10、入腹腔引起腹膜炎。絞窄性腸梗阻和腸系膜血管血栓形成引起腸壞死，細(xì)菌通過壞死之腸壁進(jìn)入腹腔。導(dǎo)致腹膜炎。其他如腹部手術(shù)污染腹腔，胃腸道吻合口漏，以及腹壁之嚴(yán)重感染，均可導(dǎo)致腹膜炎。,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of

11、care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí)|臨床表現(xiàn),兩大主要癥狀：腹痛、惡心嘔吐腹痛：最主要，持續(xù)性劇烈，腹壓增加及體位變換可加重。病灶部位最為顯著。惡心、嘔吐：早期反射性，晚期麻痹型嘔吐

12、。全身中毒癥狀：體溫升高，脈搏增快。全身感染中毒癥狀。,Background,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogat

13、es and may lead to treatment that does not align with patients’ preferences. 。,相關(guān)知識(shí)|轉(zhuǎn)歸,一般年輕體壯者，抗病能力強(qiáng)，腹膜病變自行修復(fù)而痊愈如果感染局限為膈下膿腫，盆腔膿腫則需切開引流年老體弱，病變嚴(yán)重，治療不當(dāng)或不及時(shí)則感染可迅速擴(kuò)散而形成彌漫性腹膜炎，或麻痹性腸梗阻由于腹膜吸收了大量毒素以致發(fā)生中毒性休克，可導(dǎo)致多臟器衰竭,Background

14、,Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does

15、not align with patients’ preferences. 。,相關(guān)知識(shí)|治療,治療原則上是積極消除引起腹膜炎的病因，并徹底清洗盡腹腔內(nèi)存在的膿液和滲出液，或促使?jié)B出液盡快吸收、局限。急性腹膜炎的治療可分為非手術(shù)治療和手術(shù)治療兩種。,,,Part 1,Background,Surrogate decision makers for incapacitated, critically ill patients often

16、struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients’ preferences. 。,一般資料,,,主訴：腹痛1日現(xiàn)病史：患者自訴于2019年3月16日22

17、點(diǎn)左右無明顯誘因出現(xiàn)上腹部絞痛，呈持續(xù)性疼痛，無放射痛，伴惡心、非噴射性嘔吐，嘔吐物為胃內(nèi)容物，無發(fā)熱、寒戰(zhàn)，疼痛不能忍受，休息后緩解不明顯，自行購買藥物治療效果欠佳，今日就診我院急診科，給予完善上腹部CT提示：肝周少量積液，橫結(jié)腸擴(kuò)張積氣，食管下段賁門處粘膜稍增厚，建議胃鏡檢查，腹部彩超提示腹腔積液。遂急診以“腹痛”收入我科。病程中患者神志清，精神欠佳，急性病容，未進(jìn)食水，睡眠差，有腹痛、腹脹，無發(fā)熱、寒戰(zhàn)，無反酸、燒心，無胸悶、心悸

18、、氣短，無咳嗽、咳痰，無噯氣、呃逆，無黃疸，小便正常，近期體重?zé)o明顯改變。體格檢查：腹膜刺激征明顯,入院評(píng)估,,,輔助檢查,,,健康功能型態(tài),健康功能與健康管理營養(yǎng)代謝排泄活動(dòng)運(yùn)動(dòng)睡眠休息認(rèn)知感知自我概念角色關(guān)系應(yīng)對(duì)與應(yīng)激耐受型態(tài),,,Part 2,,,護(hù)理計(jì)劃單,疼痛：與腹膜炎癥刺激有關(guān)營養(yǎng)失調(diào)：低于機(jī)體需要量 有體液不足的危險(xiǎn)：與腹膜腔內(nèi)大量滲出有關(guān)知識(shí)缺乏：缺乏有關(guān)本病的病因和預(yù)防知識(shí)心理護(hù)理社會(huì)干預(yù)

19、相關(guān)護(hù)理措施,,,Part 2,,,健康教育,飲食指導(dǎo)：發(fā)病時(shí)患者應(yīng)禁食，腸鳴音恢復(fù)后，再進(jìn)少量的流質(zhì)飲食，從低脂、低糖、低蛋白流質(zhì)開始，以后逐步增加飲食，但應(yīng)禁忌高脂肪食物，食物以少量多餐為主?；顒?dòng)與休息：病人應(yīng)絕對(duì)臥床休息，以降低機(jī)體代謝率，增加臟器血流量，促進(jìn)組織修復(fù)和體力恢復(fù)。,,,健康教育,日常生活指導(dǎo)（1）避免暴飲暴食，選擇易消化、低脂、無刺激性食物，如有類似病史，尤為 注意。（2）積極治療相關(guān)疾病，注意清淡飲食，少