心肺功能不全的物理治療診斷與治療：Lect20 術(shù)后患者康復(fù)管理

1、1Lecture 20 第20講Physiotherapymanagement to surgical patients術(shù)后患者康復(fù)管理Lecture Series on Cardiopulmonary Physiotherapy心肺康復(fù)系列講座2All elective surgical proceduresrequire:可選手術(shù)步驟需要Pre-operative preparation術(shù)前準(zhǔn)備 safe surgical intervention安全手術(shù)干預(yù) optimal recovery最佳康復(fù) minimise risk/complications減少風(fēng)險(xiǎn)/并發(fā)癥3Effect o

2、f drugs藥物效果Effect of pain疼痛效果Effect of immobility制動(dòng)效果Effect of surgery手術(shù)效果Complications requiring physiotherapy interventions:需要物理治療干預(yù)的并發(fā)癥：respiratory system呼吸系統(tǒng) FRC 功能殘氣量 mucociliary activity粘膜纖維運(yùn)動(dòng) ventilation (pain)通氣（痛）musculo-skeletal sys.肌肉骨骼系統(tǒng) muscle length & strength肌肉長(zhǎng)度和力量 gastric-motility胃動(dòng)

3、力circulatory system循環(huán)系統(tǒng) blood flow (DVT)血流4Role of the physiotherapist: 物理治療師的角色Pre-op considerations術(shù)前考慮pre-op risk factors術(shù)前風(fēng)險(xiǎn)因素intra-operative risks手術(shù)期間風(fēng)險(xiǎn)establish rapport建立友好關(guān)系identify (predict) high risk patients who are likely to develop post-operative pulmonary complications (PPC)確定（預(yù)見(jiàn)）可患術(shù)后心肺

4、并發(fā)癥的高風(fēng)險(xiǎn)患者5Role of the physiotherapist: 物理治療師的角色Pre-op considerations術(shù)前考慮pre-op risk factors:術(shù)前風(fēng)險(xiǎn)因素Age 年齡smoking history 吸煙史sputum and cough 咳&痰body weight (obesity) 體重（肥胖）co-mobility (respiratory; cardiovascular; cancer) 聯(lián)合動(dòng)力（呼吸；心血管；癌癥）cardio-pulmonary fitness (exercise tolerance)心肺適能（運(yùn)動(dòng)耐力）6Role of

5、the physiotherapist:物理治療師的職責(zé)Intra-operative considerations手術(shù)期考慮incision site 切口位置explain to patient (position of iv, drains, urinary catheter) 告知患者（靜脈點(diǎn)滴位置、導(dǎo)尿管）teach wound support 傳授傷口保護(hù)type of surgery (likelihood of post-operative nasogastric intubation)手術(shù)類(lèi)型（術(shù)后鼻胃插管）duration of anaesthesia 麻醉時(shí)間7Struc

6、tures in the abdominal cavity腹腔結(jié)構(gòu)8Structures in the abdominal cavity腹腔結(jié)構(gòu)Pancreas胰腺9Common incision sites 常用切口位置10Endoscopy visual inspection of any cavity in the body by an endoscope內(nèi)鏡檢查-使用內(nèi)窺鏡對(duì)機(jī)體任意腔體進(jìn)行視覺(jué)檢查Endoscopic cholangiogram flexible endoscope through the mouth into the duodenum, a contrast age

7、nt injected via a catheter to highlight the calibre of the bile ducts 內(nèi)鏡膽管造影照片-靈活內(nèi)窺鏡探頭從口至十二指腸，通過(guò)導(dǎo)管注射相關(guān)藥劑到膽管Endoscopic retrograde cholangiopancreatography (ERCP)內(nèi)鏡逆行膽管胰造影術(shù)Endoscopic procedures 內(nèi)鏡檢查11ERCP內(nèi)鏡逆行膽管胰造影術(shù)ERCP showing duodenum area of papilla with stent and bile visible (stent inserted from t

8、he stomach, up the common bile duct to drain the gall bladder)內(nèi)鏡逆行胰膽管造影顯示十二指腸乳頭區(qū)的支架和膽汁（支架從胃插入，上至膽總管到膽囊管）12Laparoscopy - examination of the interior of the abdomen by means of a laparoscope 腹腔鏡檢查-使用腹腔鏡檢查腹腔內(nèi)部Laparoscopic surgery 腹腔鏡手術(shù)Abdominal image on tv screens電視屏幕顯示腹腔圖像Uterine Fibroid子宮纖維瘤13Laparos

9、copic cholecystectomy 腹腔鏡膽囊切除術(shù) resection of the gall bladder with the help of a laparoscope腹腔鏡膽囊切除術(shù)14Laparoscopic colonic surgery 腹腔鏡結(jié)腸手術(shù) resection of parts of the colon through the laparoscope 腹腔鏡部分結(jié)腸切除Hand-assisted laparoscopic colectomy 內(nèi)窺鏡結(jié)腸切除術(shù)15Advantages of endo- or laparoscopic approach 內(nèi)窺鏡/腹

10、腔鏡手法的優(yōu)點(diǎn)Compared to open surgery:與開(kāi)放手術(shù)相比smaller incision less insult to the body切口小-機(jī)體更少損傷less painful 疼痛較少less interference to diaphragmatic function 隔膜功能影響減少able to be mobilized earlier 能夠早期開(kāi)始活動(dòng)general anaesthesia always necessary except for microsterilisation 除微創(chuàng)手術(shù)外通常需要全身麻醉16Complications 并發(fā)癥gas l

11、eak 氣體漏出abdominal distension for abdominal procedures 腹部膨脹bile leak after gall-bladder surgery膽囊切除后膽汁漏出colonic surgery:結(jié)腸手術(shù)ureteral/bowel injury輸尿管/腸手術(shù)mal-rotation of anastomosis 接合處病態(tài)旋轉(zhuǎn)17Common types of surgery常見(jiàn)手術(shù)類(lèi)型Thoracic 胸椎A(chǔ)bdominal 腹部Head & Neck 頭&頸Vascular 血管Neuro-surgery 神經(jīng)手術(shù)Mastectomy 乳房切除術(shù)

12、18Abdominal surgery:腹部手術(shù)Hiatus hernia repair 疝氣修復(fù)Oesophagectomy 食管切除術(shù)Resection of gastric ulcer胃潰瘍切除 vagotomy迷走神經(jīng)切除術(shù)Cholecystectomy 膽囊切除術(shù)19Abdominal Aortic Aneurysm repair (AAA) 腹部大動(dòng)脈瘤修復(fù)Abdominal surgery: 腹部手術(shù)20Aortic aneurysm stenting 大動(dòng)脈瘤支架21Pancreatic-duodenectomy (Whipples) 胰腺切除術(shù)removal of pancr

13、eas, bile duct, partial removal of stomach, duodenum 胰腺，膽道，部分胃部、十二指腸切除Abdominal surgery: 腹部手術(shù)cancer of the head of pancreas胰頭癌22Cystectomy 膀胱切除術(shù)Colectomy 結(jié)腸切除術(shù)Abdomino-perineal resection 腹會(huì)陰切除術(shù)removal of colon / rectum結(jié)腸-直腸切除(the patient should be made aware of the need to use a colostomy bag) 患者應(yīng)被告

14、知將會(huì)運(yùn)用人工肛門(mén)袋Abdominal surgery:腹部手術(shù)23Hysterectomy子宮切除術(shù)Werteheims hysterectomytotal abd. hysterectomy, bilateral salpingo oophorectomy, lymph nodes腹腔子宮切除術(shù)，雙邊輸卵管卵巢切除術(shù)，淋巴結(jié)Prostatectomy 前列腺切除術(shù)Trans-urethral resection of prostate (TURP)經(jīng)尿道前列腺切除術(shù)（經(jīng)尿道前列腺電切）Abdominal surgery:腹部手術(shù)24Head & Neck surgery 頭頸部手術(shù)For

15、cancer of the tongue, pharynx, larynx 舌、咽、喉癌Radical neck dissection 根治性頸部淋巴清掃術(shù) removal of cancer, lymph nodes 腫瘤、淋巴結(jié)切除 tracheostomy care 氣管切開(kāi)護(hù)理25Vascular surgery 血管手術(shù)Embolectomy 栓子清除術(shù)26A = patent right external iliac artery右髂外動(dòng)脈B = filling defects in the right femoral artery (arrow)充盈缺損的右股動(dòng)脈（箭頭）C= l

16、eft ventricular thrombi 左心室血栓27Vascular surgery 血管手術(shù)Percutaneous transluminal angioplasty經(jīng)皮腔內(nèi)血管成形術(shù)Patentflow after successfulPTA成功經(jīng)皮腔內(nèi)血管成形術(shù)后血流InflationofBalloon氣球?qū)Ч芘蛎汸assage of ballooncatheter to area of occlusion栓塞處氣球?qū)Ч芡ǖ?8Femoral-popliteal bypass 股-腘旁路Vascular surgery 血管手術(shù)Superficial femoralartery

17、 occlusion表淺股后動(dòng)脈栓塞Vein Graft靜脈移植Anastomosis of common femoral artery to popliteal artery股動(dòng)脈到腘動(dòng)脈吻合29Vascular surgery 血管手術(shù)Aorto-bifemoral bypass 股旁大動(dòng)脈分支Anastomosis ofdescending aortato both common femoral arteries降主動(dòng)脈至股動(dòng)脈吻合30Neuro-surgery 神經(jīng)手術(shù)Monitoring of intra-cranial pressure 監(jiān)控顱內(nèi)壓Mastectomy乳房切除術(shù) a

18、 treatment of breast cancer 治療乳腺癌Removal of the entire breast (including the nipple and the areola) 切除整個(gè)乳房（包括乳頭和腺體）Lumpectomy can be considered if the tumor is smaller than of the breast, radiation therapy however is necessary如腫瘤小于乳房，可考慮腫瘤切除術(shù)，同時(shí)考慮放射療法31Lumpectomy & Mastectomy乳房腫瘤切除術(shù)&乳房切除術(shù)32Breast re

19、construction / prosthesis乳房重建/假體植入33Treatment 治療Hormone therapy激素療法Radiotherapy 放射療法Chemotherapy 化療34Role of physiotherapy物理治療師的責(zé)任Maintenance of effective lymphatic drainage in affected upper limb 保持受累上肢有效的淋巴引流Psychological support 心理支持35Lymphatic drainage 淋巴引流3637Role of the physiotherapist: 物理治療師的

20、職責(zé)Pre-op considerations 術(shù)前考慮knowledge of the surgical procedure 掌握手術(shù)流程prediction of high risk patients 預(yù)期高風(fēng)險(xiǎn)患者Risk assessment (prediction) tool風(fēng)險(xiǎn)評(píng)估工具38Role of the physiotherapist: PT職責(zé)Pre-op procedures 術(shù)前步驟establish rapport / education/ teaching of certain skills 建立關(guān)系/教育/傳授相關(guān)技能Communication 交流breath

21、ing techniques 呼吸技巧secretion removal techniques去除分泌物的技巧39Role of the physiotherapist: PT 職責(zé)Pre-operative role 術(shù)前職責(zé)problem identification 問(wèn)題確認(rèn)risk prediction 風(fēng)險(xiǎn)評(píng)估establish rapport 建立關(guān)系treatment if necessary 必要的治療education / advice 教育/建議40Role of the physiotherapist: PT 職責(zé)Intra-operative consideration

22、 手術(shù)期間考慮type of anaesthesia 麻醉類(lèi)型duration of anaesthesia 麻醉時(shí)間duration of surgery手術(shù)時(shí)間haemodynamicchanges during surgical procedures 手術(shù)步驟中血液動(dòng)力的改變41Post-operative management 術(shù)后管理improve/maintain ventilation 提高/保持通氣improve/maintain lung volume提高/保持肺容量improve circulation 提高循環(huán)improve/maintain muscle length, strength, joint range提高/保持肌肉長(zhǎng)度，力量，關(guān)節(jié)活動(dòng)范圍optimise mobility 優(yōu)化活動(dòng)能力Role of the physiotherapist: PT 職責(zé)42Post-operative management 術(shù)后管理Positioning 體態(tài)、姿勢(shì)pain relief疼痛緩解(timing, what drug, which route) 時(shí)間、藥物、路徑application of appr