外科护理学肠梗阻

张某，男性，48岁阵发性腹痛、恶心、呕吐、停止排便、排气三天。

2年前曾行阑尾切除术。入院检查：T37.8℃P110次/分BP16/11Kpa呈急性病容，神志清Casestudy整理ppt腹部膨隆见肠型及蠕动波，肠鸣音亢进有气过水声，腹部压痛明显，以右侧腹为重，有轻度腹肌紧张及反跳痛，叩诊为鼓音。X线：肠胀气，肠管增粗并有液平面。血液检查：WBC13×109/LN92%Na+120mmol/LK+3.0mmol/L血糖10.5mmol/LCasestudy整理ppt肠梗阻Intestinalobstraction泰山医学院张爱华整理ppt

Whenevergastrointestinalluminalcontentispathologicallypreventedfrompassingdistally

Conception任何原因引起的肠内容物不能正常运行，顺利通过肠道时，称为肠梗阻〔intestinalobstruction)。整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.Theextentofobstruction5.ProgressionofobstructionClassification整理ppt１.AccordingtoitsBasiccauses机械性肠梗阻〔mechanicalobstruction〕动力性肠梗阻〔dynamicobstruction〕血运性肠梗阻〔obstructionofvascularsupplyorigin〕Classification整理pptClassificationmechanicalobstruction〔verycommon)A.肠腔堵塞B.肠管受压粘连带压迫ascaridhernia整理pptmechanicalobstructionC.肠壁病变inflammatoryneoplasticClassification整理ppt

DynamicobstructionCauses:

NervalreflexortoxinstimulationClassification麻痹性肠梗阻〔Paralyticileus〕：acutediffuseperitonitis,abdominaloperation,retroperitonealhematomaandinfection痉挛性肠梗阻〔Spasticobstruction〕

Classification整理pptObstructionofvascularsupplyoriginthrombosisorembolism,thenintestinalparalysisClassification整理ppt1.按梗阻发生的原因2.按肠壁有无血运障碍单纯性肠梗阻

(Simpleobstruction)绞窄性肠梗阻

(Strangulationobstruction)IntussceptionVolvulusClassification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.按梗阻发生的部位高位肠梗阻(highobstruction)低位肠梗阻(lowobstruction)Classification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.按梗阻发生的程度完全性肠梗阻(completeobstruction)不完全性肠梗阻(Incompleteobstruction)Classification整理ppt1.AccordingtoitsBasiccauses2.Vascularsupplytointestinalwall3.Obstructionlevelorsite4.Theextentofobstruction5.按梗阻发生的速度急性肠梗阻(Acuteobstruction)慢性肠梗阻(chronicobstruction)Classification整理pptPathophysiology

整理pptSimplemechanicalobstruction梗阻以上肠蠕动增多(contractsvigorously)梗阻以上肠管膨胀(distention)梗阻以下肠管瘪陷膨胀和瘪陷交界处为梗阻所在肠管局部变化Pathophysiology整理pptAcutecompleteobstruction

肠腔压力↑→静脉回流受阻→肠壁水肿、增厚、呈暗红色→动脉血运受阻→肠管变成紫黑色→坏死、穿孔。Pathophysiology肠管局部变化整理pptChronicincompleteobstruction

梗阻以上肠腔扩张、肠壁代偿性肥厚腹壁视诊常可见扩大的肠型和肠蠕动坡。Pathophysiology肠管局部变化整理ppt全身性病理生理改变主要由于体液丧失、肠膨胀、毒素的吸收和感染所致Pathophysiology整理ppt体液丧失(loseofbodyfluid)引起水、电解质紊乱与酸碱失衡全身性感染和毒血症腹膜炎和中毒(peritonitisandpoisoning)shockrespirationandcirculationdisorder)Pathophysiology全身性病理改变整理pptClinicalManifestations整理ppt痛吐胀闭

张某，男性，48岁阵发性腹痛、恶心、呕吐出大量草绿色液体，1天后出现腹胀、3天来无排便。

2年前曾行阑尾切除术

ClinicalManifestations整理pptClinicalManifestationsPain（痛）Vomitting（吐）Distension（胀）Constipation（闭）整理ppt痛吐胀闭特点

胀痛持续性疼痛,阵发性加剧阵发性绞痛持续性绞痛StrangulationClinicalManifestationsParalyticileusmechanicalobstructionobstructionofvascularsupplyorigin整理ppt痛吐胀闭特点

出现早且频繁出现晚、次数少且量多次数多且量多次数少且量少暗红或血性液体high/StrangulationLowobstructionCompletelyincompletelyStrangulationClinicalManifestations整理ppt痛吐胀闭腹部膨隆肠腔扩张ClinicalManifestations整理pptHowtoobservedistention？

腹部膨隆腹壁紧张、皮肤发亮呼吸困难、不能平卧

X线检查血气痛吐胀闭ClinicalObservations整理ppt机理痛吐胀闭

肠管失去蠕动功能肠蠕动不能正常推进ClinicalManifestations整理ppt痛吐胀闭特点完全停止排便、排气屡次少量排便、排气早期有少量排便、排气粘液样血便CompletelyincompletelyhighStrangulationClinicalManifestations整理ppt

ClinicalManifestationsR↑、HR↑、BP↑痛吐胀闭脱水、电解质紊乱、酸碱失衡肠壁缺血坏死、穿孔毒素吸收→毒血症shock整理ppt

Abruptonsetwithcontinousacuteabdominalpain.earlyvomittingshockManifestationofperitonitis。T↑P↑

。Asymmetricaldistention,localbulge,ormasswithtenderness。Characteristicofstrangulationintestinalobstruction〔1〕整理pptHemicvomitus,drainageConservativetreatmentinvainandnoimprovementinsymptomsandsignsX线检查符合绞窄性肠梗阻特点Characteristicofstrangulationintestinalobstruction〔2〕整理ppt鱼骨刺状胀大肠袢Characteristicofstrangulationintestinalobstruction整理pptaccessoryexamination整理ppt1.化验检查血红蛋白值↑血细胞比容↑尿化重↑白细胞、中性粒细胞↑粪便、血气分析血电解质、尿素氮肌酐Accessoryexamination整理ppt2.X检查

立位或侧卧位透视或拍片。可见多数液平面及气胀肠袢。Accessoryexamination气液平面整理pptDiagnosis

整理pptCaseReviewT37.8℃P96次/分BP126/78mmHg腹部膨隆，见肠型及胃肠蠕动波肠鸣音亢进，有气过水声叩诊呈鼓音右侧腹部压痛明显X线提示有气液平整理pptmustmakeclearthefollowingquestionsWhetherintestinalobstructionexists?Whethertheobstructionismechanicalordynamic?Whethertheobstructionissimpleorstrangulationobstruction?Whethertheobstructionishighorlow?Whethertheobstructioniscompleteorincomplete?

Diagnosis整理pptTreatment&NursingCare整理ppt

预防和纠正水、电解质、酸碱平衡紊乱解除梗阻治疗原那么Treatment&NursingCare整理ppt为什么要求患者禁食？如何指导患者禁食？禁食胃肠减压解痉止痛补液电解质抗感染

Treatment&NursingCare整理ppt目的：排液、排气，减轻腹胀，病情观察护理要点：有效引流关注引流液的量、颜色、性质及其变化禁食胃肠减压解痉止痛补液电解质抗感染Treatment&NursingCare整理ppt未明确诊断之前：如何执行四禁严密观察下应用解痉止痛剂

禁用吗啡类止痛剂

禁食胃肠减压解痉止痛补液电解质抗感染Treatment&NursingCare整理ppt提供补液的可靠依据〔记录出入量〕补液量补充电解质配合纠正酸中毒禁食胃肠减压解痉止痛补液电解质抗感染Treatment&NursingCare整理ppt合理应用抗生素抗生素的配伍应用的时间观察疗效、观察副作用实施营养支持禁食胃肠减压解痉止痛补液电解质抗感染Treatment&NursingCare整理ppt解除梗阻手术治疗适用于各种类型的绞窄性肠梗阻、肿瘤及先天性肠道畸形引起的肠梗阻，以及非手术治疗无效的病人。Treatment&NursingCare整理ppt原那么和目的在最短手术时间内，以最简单的方法解除梗阻或恢复肠腔的通畅。Treatment&NursingCare整理pptoperation

A.解除梗阻原因的术式

如粘连松解术整理pptB.肠切除肠吻合术C.短路手术整理pptD.肠造口和肠外置术整理ppt如肠切开取异物，肠扭转复位术。整理pptSpecialintestinalobstruction整理ppt较为常见，发生率20-40%Causes：手术：最多炎症：肠粘连肠梗阻条件：①肠腔缩窄②粘连牵扯成角③粘连带压迫④肠袢套入粘连环⑤肠袢在粘连处扭转一定条件粘连性肠梗阻整理pptTreatment非手术疗法较好①口服生植物油②解痉剂③经胃管缓慢注入氧气，驱虫每周岁80—100ml，最大不超过1500ml整理ppt性质：闭袢性肠梗阻绞窄性肠梗阻扭转方向：顺时针旋转多见程度：轻：3600以下重：2—3转部位：小肠、乙状结肠肠扭转〔volvulus)整理ppt1.小肠扭转多见于青壮年诱因：饱食后剧烈活动病症特点：①腹痛发作急骤②牵涉腰背部③喜胸膝位或蜷曲侧卧位④呕吐频繁、腹胀不显⑤易休克整理ppt2.乙状结肠扭转多见于老年人，常有便秘习惯，除腹部绞痛外，有明显腹胀，而呕吐一般不明显。低压灌肠：量常少于500mlX线平片：马蹄状双腔充气肠袢钡灌：尖端呈“鸟嘴〞形整理ppt整理ppt治疗

死亡率15—40%

原因：就诊过晚治疗延误

方法：及时手术

方式：①扭转复位术②肠切除术整理pptsummary整理pptConceptionWhenevergastrointestinalluminalcontentispathologicallypreventedfrompassingdistally整理pptClassificationmechanicalobstructiondynamicobstructionobstructionofvascularsupplyoriginSimpleandstrangulationobstructionHighandlow