外科护理学课件第07章手术前护理2016-3-27

第七章

手术前后病人的护理(perioperativecare)

外科护理教研室主讲人：袁华职称：讲师2023/4/30吉林大学护理学院袁华2围手术期perioperation广义：指从护士迎接病人进入外科病房到病人术后痊愈出院回家转入社区护理机构继续康复这段时期。狭义：确定手术治疗时起，至与这次手术有关的治疗基本结束为止的一段时间。2023/4/30吉林大学护理学院袁华3围手术各期护理重点手术前期评估和纠正可能增加手术危险性的心理和生理问题，增强病人对手术的耐受性；向病人及家属提供有关手术的知识和指导。2023/4/30吉林大学护理学院袁华4围手术各期主要护理要点手术中期配合医生和麻醉师安全地实施麻醉和手术手术后期加强监护，维持各系统正常的生理功能减轻病人的疼痛和不适预防或减少术后并发症提供健康指导，制定康复计划Surgery

Emergency:upperairwayobstruction,急症手术：最短时间，尽快Urgency:acuteappedicitis,completeobstruction,限期手术：不宜延迟，尽早Elective:thyroidnodule,lipoma,择期手术：充分准备，尽善第二节

手术前病人的护理

PreoperativecarePreoperativeEvaluations/assessmentPreoperativepreparationPreoperativeEvaluations/assessmentNeedacompleteassessmentofpatient’shealthaimsto:ReducemorbidityandmortalityassociatedwithsurgeryPreventunnecessarycancellationsReducehospitalstayPreoperativeEvaluations/assessment1History2Physicalassessment3Physiologicalstatusassessment4Investigations5Proposedsurgery（Relatedtoanaesthesiaandthesurgery）2023/4/30吉林大学护理学院袁华93心理和社会支持状况的评估

Physiologicalstatusandsocialsupportassessment2023/4/30吉林大学护理学院袁华104辅助检查常规生化检查：血、尿、粪常规；血液生化：肝功能、肾功能、电解质、血糖心血管功能：心电图肺功能：胸部X

线检查血液系统功能：出凝血时间、血型、交叉配血

RoutinePreoperativetests

1-CBC,FBPallpatients.

2- PT/PTTallpatientsandthoseonanticoagulants.

3-Electrolytes,Urea,Liverfunction.4-ECGallpatients>40Ys.

Echocardiogram

AbnormalECG,ischemicheart….

5-Chestx-rayAllpatients>30Ys.6-Bloodsugarlevel7-Typeandcrossmatch2023/4/30吉林大学护理学院袁华125预行手术情况Proposedsurgery手术的目的及手术的名称

手术的方式及手术的范围

手术的时间及手术的性质护理诊断nursingdiagnosis（一）营养失调：低于机体需要量（二）有感染的危险

（三）焦虑恐惧：术前不良的心理反应（四）知识缺乏：有关手术、麻醉、术前配合的（五）睡眠形态紊乱（六）疼痛

2023/4/30吉林大学护理学院袁华14术前护理措施Ⅰ

Pre-operativepreparation（一）术前常规准备RoutinecarefortheAdultPatient1术前心理护理和支持

psychologicalsupport2术前生理准备

physicalPreparation

3术前指导-适应性训练

PreoperativeTeaching（二）术日晨的护理（三）特殊术前处理术前护理措施

Pre-operativepreparation（一）心理准备（二）一般准备与护理术前生理准备术日晨的护理（三）特殊准备与护理ⅡNurseestablishesatrustingtherapeuticrelationshipwithpatient.

(FromGriffinAG,PotterPA:Clinicalnursingskills&techniques,ed7,St.Louis,2010,Mosby.)Thetherapeuticrelationshipiscentraltoallnursingpractice.Forexample,inmentalhealthandcommunitynursing,thetherapeuticrelationshipmaybetheprimaryinterventiontopromoteawarenessandgrowthand/ortoworkthroughdifficulties.Inotherareasofnursingpractice,forexampleICU,thetherapeuticrelationshipmaybemoreinthebackground,servingastheinterventionthroughwhichcomfort,support,andprovisionofcarearefacilitated.Regardlessofsettingandclinicalsituation,thetherapeuticrelationshipalwaysneedstobeestablished.

Establishmentofatherapeuticrelationshiprequiresreflectivepractice.Thisconceptincludestherequiredcapacitiesof:self-awareness,self-knowledge,empathy,awarenessofboundariesandlimitsoftheprofessionalrole.SBARisatechniqueusedforpromptandappropriatecommunicationinthehealthcareorganizations.SituationBackgroundAssessmentRecommendation术前一般准备2.1保证充足的睡眠和休息promoterest2.2饮食准备

NPOaftermidnight2.3胃肠道准备Enemaorbowelpreparation2.4术区皮肤准备SkinPreparation2.5药物准备及试敏Premedication2.6交叉配血、备血Prepareblood2.7特殊准备Specialorders2.3EnemaorbowelpreparationBowelpreparation:leftsidecolonorrectum -mechanicalbowelprep -antibioticbowelprep2023/4/30吉林大学护理学院袁华22胃肠道准备饮食:术前12h禁食，4h禁水。灌肠：术前一日应用0.1%～0.2%肥皂水灌肠或用开塞露等方法导泻。肠道手术：病人入院开始应少渣饮食，术前1~2日应流质饮食。术前三天起口服肠道不吸收抗生素，术前一日晚或术日晨清洁灌肠。NGtube（Nasogastrictubes）

2023/4/30吉林大学护理学院袁华23皮肤准备SkinPreparation接近手术时间常规手术部位的皮肤准备洗浴：清洁手术野皮肤，氯已定、酒精清洗。备皮：毛发影响手术，剃除毛发clipper。

Instructthepatienttobathe/showertheeveningbeforeormorningofsurgery.Dr.AidahAbuElsoudAlkaissiDivisionofIntensiveCareandAnaesthesiologyUniversityofLinköpingSweden

SkinPreparation接近手术时间clipperisthefirststepinthepreventionofwoundinfectionInstructthepatienttobathe/showertheeveningbeforeormorningofsurgery.Menshouldbecleanlyshaved.DuringtheprocedurethenurseshouldProvidethecomfort,safetyandprivacyofthepatientexplainthepurposeandmethodoftheprocedureshouldobservethepatient´sgeneralcondition,particularlytheconditionoftheskinundertreatmentAnycontraindicationtotheprocedureshouldbedocumentedPremedication麻醉前用药预防性应用抗生素Giveprophylacticantibioticstosomepatientslike:

Majoroperations.Patientshavingshunts.BreastimplantsforeignbodiesDMOnsteroidspatients2.7Specialorders2.7.1bloodtranfusion2.7.2NG -decompress:obstruction -evaluatedUGIB -deceasepostoperativebowelileus2.7.3bladdercatheter -operativetime>3hr -monitorurine:bleed,resuscitation -decompressionforoperativeview2.7.4venousaccessandhemodynamicmonitoring2.7.5preoperativehydration

3术前指导-适应性训练3.1深呼吸deepbreathingexercise3.2咳嗽运动coughingexercise3.3翻身、体位改变Turingexercise3.4术中体位指导3.5肢体功能锻炼Extremitiesexercise3.6指导床上使用便盆3.7早期运动earlyambulation2023/4/30吉林大学护理学院袁华30有效咳嗽和深呼吸的意义减轻伤口疼痛增加肺部通气量，有利于肺膨胀去除肺内分泌物，预防术后肺部感染。促使肺再扩张，改善肺部循环。2023/4/30吉林大学护理学院袁华35早期离床活动术后１２-２４小时，可让病人坐于床沿，双腿下垂。术后２４-４８小时，让病人下床，协助病人走几步。以后根据病人的情况，在室内走动，以病人不产生疲倦为原则。2023/4/30吉林大学护理学院袁