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當(dāng)前位置:考試網(wǎng)  > 試卷庫  > 學(xué)歷類  > 自考  > 自考專業(yè)(護(hù)理)  >  男性, 65 歲,有“痔瘡”病史 10 年。近期出現(xiàn)大便帶血,為進(jìn)一步診治到醫(yī)院就診。直腸指檢可觸及包塊, 隨后行纖維結(jié)腸鏡檢查, 經(jīng)病理診斷為直腸癌, 癌變部位距離肛門 4cm。今日在全麻下行經(jīng)腹會(huì)陰聯(lián)合直腸癌切除術(shù) (Miles 術(shù)),左下腹行永久性結(jié)腸造口, 留置骶尾部及腹腔引流管,術(shù)后安返病房。 T:36.7°C, HR:108 次/分, BP:110/70mmHg 。左下腹傷口紗布覆蓋,吸氧,靜脈補(bǔ)液。術(shù)后尿量較少,患者主訴疼痛,口渴。 請回答: (1)術(shù)后病情觀察的重點(diǎn)是什么? (2)目前患者主要的 2 個(gè)護(hù)理診斷 /問題是什么? (3)患者結(jié)腸造口開放前的護(hù)理要點(diǎn)是什么?
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男性, 65 歲,有“痔瘡”病史 10 年。近期出現(xiàn)大便帶血,為進(jìn)一步診治到醫(yī)院就診。直腸指檢可觸及包塊, 隨后行纖維結(jié)腸鏡檢查, 經(jīng)病理診斷為直腸癌, 癌變部位距離肛門 4cm。今日在全麻下行經(jīng)腹會(huì)陰聯(lián)合直腸癌切除術(shù) (Miles 術(shù)),左下腹行永久性結(jié)腸造口, 留置骶尾部及腹腔引流管,術(shù)后安返病房。 T:36.7°C, HR:108 次/分, BP:110/70mmHg 。左下腹傷口紗布覆蓋,吸氧,靜脈補(bǔ)液。術(shù)后尿量較少,患者主訴疼痛,口渴。

請回答:

(1)術(shù)后病情觀察的重點(diǎn)是什么?

(2)目前患者主要的 2 個(gè)護(hù)理診斷 /問題是什么?

(3)患者結(jié)腸造口開放前的護(hù)理要點(diǎn)是什么?

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正確答案:

(1)直腸癌手術(shù)范圍較大, 術(shù)后易滲血, 故術(shù)后 24h 內(nèi)除應(yīng)嚴(yán)密觀察血壓、 脈搏的變化外,還需觀察傷口有無滲血,各種引流液的色、質(zhì)、量,警惕發(fā)生內(nèi)出血;直腸癌術(shù)中易污染,術(shù)后要注意體溫變化,及時(shí)發(fā)現(xiàn)切口感染、腹腔膿腫及吻合口瘺。

(2)患者主要的 2 個(gè)護(hù)理診斷 /問題

1)自理缺陷:與手術(shù)創(chuàng)傷、術(shù)后引流、人工肛門有關(guān)。

2)自我形象紊亂:與結(jié)腸造口、人工肛門的建立、排便方式的改變有關(guān)。

(3)結(jié)腸造口開放以前, 應(yīng)注意保護(hù)腸管, 造瘺結(jié)腸要用凡士林紗布或生理鹽水紗布外敷,及時(shí)更換被滲液浸濕的外層敷料, 并注意觀察造口血液供應(yīng)以及腸段有無回縮、 出血、 壞死等情況。

答案解析:

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