带状疱疹三区终极版

护理临床查房

Clinicalnursingwardround

国际住院部二科三区I.M.CInpatientDept.2Ward.3人员介绍会诊医师consultingstaff查房目的

RoundGoals掌握带状疱疹的护理。熟悉带状疱疹的病因、临床表现及治疗方法。Acquirethenursing

ofVZV.Befamiliarwiththe

theriskfactors,clinical

manifestation

and

treatmentofVZV.

查房目的RoundGoals提升护理人员的英文水平和学习兴趣

PromotetheEnglish

levelandenhancetheinterestofnurses

inEnglishlearning.

Part1inquiry问诊病例报告

CaseReport阳吉菊女69岁D:Hello,MrsYang,mynameisDrDu,IamadoctorofInternalMedicine.Iwillbelookingafteryou,howcanIhelpyou?P:Yesplease!D:Howoldareyou?P:69

病例报告

CaseReport现病史患者主因阵发头痛1年，加重2天。于4月10日为进一步检查收入我科。PresentHistoryD:Pleasetellmewhat’swrongwithyou?P:Ihavehadbadheadachefor2days.D:Haveyouhadthispainbefore?P:Comeinwavesforayear.

病例报告

CaseReport现病史无明显诱因阵发右侧头痛，为针刺样。无头晕、呕吐、视物模糊等伴随症状,睡眠不佳。PresentHistoryD:Pleasepointtowhereyoufeelpain?P:Onmyrightside.D:Tellmewhatthepainislike?P:stabbing，itkeptmeawake.D:Doyouhavedizzinessorvomit?P:No.D:Doyouhaveblurringofvision?P:No.病例报告

CaseReport现病史头颅CT无出血灶。PresentHistoryD:Haveyouhadanytestsrecently?P:IhadaheadCTandnohemorrhage.病例报告

CaseReport既往史

有腔隙性脑梗死病史否认冠心病、高血压、糖尿病史否认药物过敏史预防接种史不详PreviousHistory

D:Doyouhaveanyexistingmedicalhealthproblem?P:Lacunarinfarction.D:Doyouhaveanyallergies?P:No,notthatIknowof..D:Areyourvaccinationscurrent?P:Iamnotsure.病例报告

CaseReport家族史家族中无类似病史，否认家族遗传病史。FamilyHistory

D:Doyouhaveafamilyhistoryofhealthproblems?P:No病例报告

CaseReport个人史生于原籍否认疫区居住史否认毒物接触史,无烟酒等不良嗜好PersonalHistoryD:Whereareyoulivedin?P:WhereIwasborn.D:Isthereanythingyouneedtotellmethatyouthinkwillbeuseful?P:No.病例报告

CaseReportD：你还有什么问题需要问我吗？P：现在没有。D：如果你有什么问题，你可以问护士，如果她不知道怎么办，她会找知道的人来帮助你。D:Arethereanyquestionsyouwouldliketoaskme?P:No,notrightnow.D:Ifyouhaveanyproblems,pleaseaskthenurse,ifshecan’thelpyou,shewillfindsomeonewhocan.病例报告

CaseReportP：好的，非常感谢。D：不客气，再见。P:Ok,thanksverymuch.D:You’rewelcome,seeyoulater.

经查阅病历、详细询问病史及查体后指示：患者目前头痛部位以右侧头皮皮疹处为著，无颅内高压症状及体征，建议联系皮肤科专家会诊进一步明确，密切观察病情。Reviewingthecase,detailedinquiringmedicalhistoryandexaming,itisindicatedthatthepatientheadachelocationmainlyattherightscalprash,have’tsymptomsandsignsofintracranialhypertension.

Recommendedcontactdermatologisttodiagoseandobsevepatient’scondition.病例报告

CaseReport

Part2groupconsultation会诊会诊groupconsultation查体：右侧头皮、耳后、颈部散在小片片状红斑、丘疹，其上散在水疱，部分破溃渗出，触痛。诊断为带状疱疹。外用青鹏软膏口服盐酸伐昔洛韦1g3/日维生素B1片20mg3/日甲钴胺片500mg3/日普瑞巴林胶囊75mg2/日Dermatologyconsultation:clusterredpapulesonexaminationfoundthatleftback,adiagnosisofherpeszoster.Externaluse:Qingpengointment.Takeorally:Threetimesadaygallowayhydrochloricacid;ThreetimesadayvitaminB1;Threetimesadayapieceofcobaltamine;Twotimesadaylyricacapsule.

Part3Groupdiscussion小组讨论带状疱疹是由水痘--带状疱疹病毒(varicella-zostervirus,VZV)引起的一种沿某一脊神经或颅神经单侧分布的簇集性水疱和神经痛为特征的病毒性皮肤病。Herpeszosteriscausedbythevaricella-zostervirusaalongaspinalnerveorthedistributionofthecranialnerveunilateralclusterblisterandneuralgiaoftheviralskindiseases.定义Definition诊断Diagnosis病变皮肤出现簇集成群水疱，沿一侧周围神经呈带状分布。有明显的神经痛，伴局部淋巴结肿大。中间皮肤正常。theblisteralongonesideoftheperipheralneverontheattachedskin.Hasobviousneuralgia,withlocallymphnodeenlargement.Middlenormalskin.诊断Diagnosis从水疱液中分离chu病毒或检测VZV，HSV抗原或DNA是鉴别诊断唯一可靠的方法。Findthevzv、theHSVantigenorDNAistheonlyreliablereasonforthediagnoise.病因及发病机制

Etiologyandpathogenesis

VZV

呼吸道黏膜respiratorymucosa

血液blood

颅神经的感觉神经

水痘

varicella

隐性感染inapparentinfection

脊髓后根神经节

机体抵抗力下降

VZV被激活

沿感觉神经下行

支配区域的皮肤复制

水疱blister

神经炎neuritis典型表现Generalmanifestation前驱症状：轻度乏力、低热、纳差等全身症状，患处皮肤自觉灼热感或者神经痛，触之有明显的痛觉敏感，持续1～3天，亦可无前驱症状即发疹。Weak,low-gradefever,poor

appetite,loucalburningheatsensationorneuralgia,obvioussenseofpainlast1-3days,beforeblister,alsoblisterwithnoformanifestation.典型表现Generalmanifestation好发部位：肋间神经、颈神经、三叉神经和腰骶神经支配区域。Predilection:theskingovenedbyintercostal

nerve,cervial

nerve,trigeminal,lumbosacralnerve.典型表现Generalmanifestation出疹特点：首先出现潮红斑，很快出现粟粒至黄豆大小的丘疹，簇状分布而不融合，继之迅速变为水疱，疱壁紧张发亮，疱液澄清，外周绕以红晕，各簇水疱群间皮肤正常。Redspotfirstly,papulesoon,andthentheblisterwithcircumambientflush.典型表现Generalmanifestation皮损特点：沿某一周围神经呈带状排列，多发生在身体的一侧，一般不超过正中线。ZonationInjuryalongsomeofperipheralnerve,alwaysoneofthesideofthebody,notcrossthemidline.典型表现Generalmanifestation神经痛，可在发病前或伴随皮损出现，老年患者常较为剧烈。病程一般2～3周，水疱干涸、结痂脱落后留有暂时性淡红斑或色素沉着。

Neuralgiabeforetheblisterorfollowingtheskininjury,especiallytheolder.Courseofthedieasealways2-3weeks,temporaryerythema.特殊表现Specialmanifestation眼带状疱疹

三叉神经眼支受累，眼睑红肿，结膜充血，可累及角膜形成溃疡性角膜炎，疼痛剧烈。herpeszosterophthalmicusEyelidsredswollen、

conjunctivalcongestionandmaybetheulcerative

keratitiswithseverepainbysufferingfromtheeyebranchoftrigeminal.特殊表现Specialmanifestation耳带状疱疹

病毒侵犯面神经及听神经所致，表现为外耳道或鼓膜疱疹。可出现面瘫、耳痛及外耳道疱疹三联症，称为Ramsay—Hunt综合征。herpeszosteroticus

此患者即为此特殊类型！特殊表现Specialmanifestation带状疱疹后遗神经痛

带状疱疹常伴有神经痛，在发疹前、发疹时以及皮损痊愈后均可发生，但多在皮损完全消退后或者1个月内消失，少数患者神经痛可持续超过1个月以上。minorityNeuralgialastsmorethan1month.

特殊表现Specialmanifestation其他不典型带状疱疹

顿挫型；不全型；大疱型、出血性、坏疽型和泛发型；播散型带状疱疹。

Others

Forme

fruste(only

neuralgia);incomplete(red

spot,papule);big

blister;bleeding,gangrenous,generalizedanddisseminated.全身治疗Systemictreatment抗病毒治疗（尽早应用伐昔洛韦）止痛药干扰素皮质醇类激素Antiviraltherapy(usevalaciclovirasearlyaspossible)PainkillerInterferonCortisolhormone局部治疗Localtreatment复方锌铜溶液或3%硼酸溶液作局部湿敷，外用3%～5%阿昔洛韦霜，1%喷昔洛韦霜，干扰素α-2b涂布剂，0.5%酞丁安搽剂等。眼部带状疱疹可用3%阿昔洛韦眼药水，0.5%碘苷液，干扰素α眼药水点眼，3～4次/d。Wetpackingwithcompoundzinccoppersolution,3%~5%Acyclovir、1%Penciclovir、α-2b

interferon、0.5%

Ftibamzone

applecations3%Acyclovin

eyedrop、0.5%lodineglycosidesliquid、αinterferon

3-4timeseverydayfortheherpeszosterophthalmicus局部治疗Localtreatment物理疗法：可用紫外线局部照射，音频电疗法和氦氖激光照射消炎止痛，缩短病。针刺疗法。Naturopathy:irrradiatewithultravioletrays,heliumandnitrogenlaster；audioferquencycurrenttherapyAcupuncturetherapy

护理诊断

Nursingdiagnosis

1.疼痛

2.舒适的改变

3.皮肤完整性受损4.焦虑

Pain

Comfort,alteredSkinintegrity,impairedAnxiety护理措施NursingIntervention

诊断1:疼痛

--与疾病引起的神经痛有关护理措施--遵医嘱给予镇痛剂--做好心理护理，充分发挥心理镇痛效应。PainrelatedtotheneuralgiaImplementation--Givetheanalgesicasthedoctor’solder--Psychologicalnursing

护理措施NursingIntervention

诊断2:舒适的改变

--与所患疾病引起疼痛及体位受限有关护理措施1.密切观察病情变化，取舒适卧位。2.尽量保持病房安静，减少不良刺激。

Comfort,altered

--related

tothepainandlimitedposition

Implementation

--Observethechangesofillnessclosely,getthecomfortablelyingposition

--Reducethepessimal

stimulation护理措施

NursingIntervention

诊断3:皮肤完整性受损

--与疾病引起的水疱破裂有关Skinintegrity,impaired--relatedtotheblistersrupture

护理措施NursingIntervention

Implementation

--Antiphlogosis、arefactionmainly

--No

scratching,improvepatienttraining,topreventthespreadoflesions.

护理措施1.疱疹处以消炎、干燥为主。2.不要搔抓患处，加强患者宣教，避免病灶扩散。改英文部分护理措施

NursingIntervention护理措施3.泡液未破：阿昔洛韦乳膏涂抹。4.疱疹破溃后：双氧水、生理盐水清洗，再用0.5%甲硝唑液局部湿敷。Implementation--Acyclovirapplecationswiththewholeblister--Douchewithhydrogenperoxideandnormalsaline、localwetpackingwith0.5%

metronidazolewhenrupture.护理措施NursingIntervention

诊断4:焦虑--与担心疾病预后有关。

ActivityIntolerance

--relatedtotheillness’prognosis护理措施

NursingIntervention

护理措施1.向病人及家属讲解疾病相关知识、成功治疗经验，增强战胜疾病的信心。2.宣传重视预防颈椎病，避免情绪波动，及时开导患者，缓解颈椎病的症状和预防复发。Implementation--introducetheinformationabouttheVZVandthesuccessfultreatmentexperiencestothepatiencesandtherelatives.--disseminatetopreventcervicalspondylosis,avoidmoodswing.护理措施

NursingIntervention

护理措施2.宣传重视预防颈椎病，避免情绪波动，及时开导患者，缓解颈椎病的症状和预防复发。Implementation--disseminatetopreventcervic