消化系統(tǒng)疾病患者的健康評估HealthAssessmentofThe

1、學(xué)習(xí)目標(biāo)熟悉腸胃系統(tǒng)的正常功能認(rèn)識腸胃系統(tǒng)的異常表現(xiàn)掌握腸胃系統(tǒng)的評估要點熟悉腸胃系統(tǒng)評估技巧分辨不同年紀(jì)、性別、疾病譜在消化系統(tǒng)的表現(xiàn) GI System Assessment 消化系統(tǒng)評估健康史: 生活背景Biographical and demographic data目前健康狀況 Current Health過去健康病史 Past Health history家族史 Family Health心理社會因素 Psychosocial Factors系統(tǒng)回顧 Review of system Demographic Data背景資料評估 GenderAgeMarital StatusWor

2、king condition Women (calcium), elderly (inadequate food intake, gastric ulcer, colon cancer), teenagers (Duodenal ulcers, gastric cancers) may have different health problem and nutritional needs. Current Health Assessment 目前健康評估評估主訴是否出現(xiàn)： 惡心、嘔吐吞咽困難：梗阻與疼痛不消化 ：反酸或噯氣腹痛嘔血、便血腹瀉、便秘腹水黃疸體重及食欲改變. Past Health

3、 History 過去病史Bleeding-iron deficiency anemiaLiver Disease: protein malnutrition Peptic Ulcer With bleedingJaundiceGallbladder siseasePancreatitisCancerChange of bowel habitsTarry stools Unexplained weight loss or gain Health History of The GI SystemHealth Perception-health management patternNutritio

4、nal-metabolic patternElimination patternActivity-exercise patternSleep-Rest PatternCongitive-preception patternSelf-Perception, self-concept patternRole-relationship patternSexuality-reproductive patternCoping-stress tolerance patternValue-belief pattern Lewis, 2004, p.955Assess for Medications藥物評估U

5、se of Aspirin, NAISD (Nonsteroidal anti-inflammatory drugs) gastritis/bleeding是否使用阿斯匹林，非激素類止痛藥，胃出血Antacids: type and frequency 制酸劑，種類、頻率Laxatives or stool softeners? 軟便劑Dietary Supplement: vitamins,minerals, herbs, amino acids 食品補(bǔ)充，維生素、草藥、蛋白質(zhì)Assessment for Allergies 評估過敏史Food allergies: hives or dys

6、pnea Food intolerance: GI abdominal cring, flatulence, or diarrhea (lactose intolerance)Comment food allergies items: nuts, shellfish, cows milk, food additives Assessment for Family HistoryGI problem may associate with family history and environment factors. Ulcerative colitis 潰瘍性結(jié)腸炎Crohns Disease

7、克羅恩病Alcoholism 酗酒Liver diseases 肝臟疾病Family history of DM, anemia, jaundice, hepatitis, Pancreatitis, obesity, irritable bowel syndrome. 糖尿病家族史、貧血、黃疸、肝炎、胰臟炎、肥胖、小腸激惹癥候群Psychosocial History 心理社會病史Occupation: environmental toxins (lead, mercury, carbon tetrachloride) Travel: Pathogens (protozoa, parasit

8、es),eating raw shellfish, swimming in polluted water Diet habits change Assessment of GI SystemAbdomen Inspection 視診skin intact, smooth 皮膚完整、平滑Contour: flat, rounded, no distention or irregular contour 形狀，腹脹、不規(guī)則形狀Rashes, discoloration, scares, petechiae, striate, dilated veins 紅疹、變色、疤痕、青紫、橫紋、擴(kuò)張靜脈Per

9、istaltic movement if pt has obstruction of the bowel 小腸阻塞可見腸蠕動運(yùn)動Abdominal pulsation 腹部可見脈動Review of System系統(tǒng)回顧Mouth:oral lesions, excessive salivation, mouth dryness, oral ulcer Dental cavity: floss usageWater supply with fluoridate? Dentist for teeth cleaningPeriodontal diseaseTrouble tasting, chew

10、ing or swallowing?Assessment of the GI systemMouth Lips: symmetry, color, hydration, lesions, nodules, position of teeth (malocclusion), dental caries, color of mucosa and gums, swelling or lesions, leukoplakis lesion （白斑）Tonsils: redness, swelling, lesions, ulcers, Tongue: color, moisture, atrophy,

11、 abnormal coating, swelling, lesions, symmetry movement, difficulty to swallow (Dysphagia 吞咽困難)Assessment for Oral Disorders Stomatitis: Aphthous ulcer (unknown), 口腔潰瘍Herpes Simplex (HSV infection), 皰疹Oral candidiasis-Thrush (Candida Albicans fungus infection)念珠球菌感染Assess for immunosuppression, prol

12、onged antibiotic use, pain, tenderness, bleeding, oral intake/nutrition （免疫低下者，長期使用抗生素者、疼痛、壓痛、出血、營養(yǎng)進(jìn)食情況）Assessment of Oral DisorderPremalignant tumor：惡性腫瘤前期 Leukoplasia 白斑Erythroplakia 紅斑Tumor of the oral cavity: Basal cell or Squamous cell carcinoma Risk factor: tobacco and long term alcohol consum

13、ption, Very Hot beverages, 檳榔評估吞咽困難 （Dysphagia）口腔疾?。?吞咽時梗阻與疼痛，感覺吞咽時間延長，口腔潰瘍扁桃體炎咽炎咽壁濃腫、腫瘤急性喉咽喉頭水腫喉癌Assessment of the Salivary Glands 唾液腺Sings of inflammationInactivity of the gland caused by medication or prolonged NG tube, NPODry mouth Bad breath order from bacteria accumulated in the mouth due to i

14、nsufficient salivary. Assessment of Esophagus食管評估Dysphagia 吞咽困難Regurgitation 反流: reflux can affect respiratory tractPain 疼痛Heartburn or pyrosis 燒灼感評估吞咽困難（Dysphagia） 食管疾病食管炎食管潰瘍食管狹窄食管異常或先天性異常食管裂孔疝噴門口失馳緩癥食管癌Assessment of GI SystemAbdomenAuscultation: Air and fluid move through the GI tract, soft click

15、s and gurgles q5-15 sec. Normal bowel sound: irregular 4-5/minHyperactivity: Loud, high-pitch sound of the GI tract, 10/min-GI bleeding, acute gastroenteritis3. Hypoactivity: few bowel sound (listen for 5 minutes or 1 minute each quadrant (absence of bowel sounds does not mean absence of bowel peris

16、talsis)Assessment of GI SystemAbdomenPercussion/Palpation 疼痛部位、性質(zhì)（鈍、絞痛）腹肌柔軟度、是否出現(xiàn)壓痛或反跳痛、劇烈絞痛拌有高腸鳴音（腸梗），腹部包塊、液波震顫如門脈高壓腹水、腹脹、陣痛、是否反射至右肩（膽結(jié)石），或后背及中上腹（胰腺炎），右下腹反跳痛（闌尾）炎癥刺激，腹壁是否緊張痙攣，如穿孔可導(dǎo)致腹肌高度緊張 （ abdominal rigidity）、強(qiáng)直“板樣腹”腹部疼痛的病因與特征 1腹部臟器扭轉(zhuǎn)或阻塞 （Organ obstruction or twisting）: intermittent collicky pain,

17、 間斷性絞痛under umbilicus associate with small bowel在臍部位與小腸有關(guān). distended abdomen with no flatus or bowel movement, 腹脹，缺乏排氣或腸蠕動bowel sound may change from high pitch to absent 腸鳴音由高音到消失腹部疼痛的病因與特征2腹部臟器炎癥：Peritoneal inflammation (Perforated ulcer, ruptured spleen, ruptured appendix) Steady aching pain over

18、 area of inflammation, 在炎癥部位疼痛pain increased with motion, 活動時疼痛增加may associate with shock if pain is severe 過度疼痛時可能與休克有關(guān)腹部疼痛的病因與特征3腹部臟器血管狹窄或梗阻 Vascular Catastrophe (Aortic aneurysm or mesenteric infarction) 2-3 days mild tomoderate pain and hyperperistalsis followed by severe abdominal pain 中等度疼痛，腸蠕

19、動增加，腹部疼痛厲害Back and flank pain are common with aortic aneurysms. 主動脈瘤常見后背或腰部疼痛Assessment for Regurgitation評估反流（反酸）Regurgitation 是指酸性胃液反流到口腔的現(xiàn)象。導(dǎo)因：炎癥、潰瘍、腫瘤使噴門擴(kuò)約肌松弛，胃逆蠕動增加，使胃酸容易反流入口腔，侵蝕食管，容易引起酸性胃液反流入口，胸骨后燒灼感Assessment of Vomiting 患者的嘔吐物需要仔細(xì)評估量、色、性質(zhì)、頻率、反射性嘔吐？誘發(fā)因素？是否帶血樣？是否呈咖啡色樣液體，嘔吐后生理變化患者有哪些過去病史、現(xiàn)在疾病導(dǎo)致嘔

20、吐或嘔血？食管、胃、十二指腸、粘膜、潰瘍、癌癥、胰膽疾病等因素需要評估評估腹水Assessment of Ascites 腹腔內(nèi)過多液體積聚，分為漿液性、血性、濃性、乳糜性，依照腹水中的蛋白含量、比重、細(xì)胞量而區(qū)分。引起腹水原因包括：肝硬化、重度肝炎、腹膜炎、癌癥、心衰竭等。評估腹水影響：呼吸、皮膚完整性、血清蛋白缺失、體重變化、行動、活動度，舒適程度評估黃膽Assessment of Jaundice 膽紅素代謝障礙使血中膽紅素濃度升高，滲入組織、皮膚、鞏膜、粘膜，呈黃色。正常血清總膽紅素 8.55-17.1 umol/L (0.5-1mg/dl, 升高到34.2umol/L (2mg/dl

21、), 臨床可見黃膽。評估：皮膚干燥、騷癢、外觀影響，小便顏色深茶色Assessment of the Liver and Spleen Hepatomegaly 肝臟腫大: enlargement of liver, liver edge 1-2cm below costal margin (possible Hepatitis 肝炎, venous congestion 靜脈充血, metastatic carcinoma腫瘤轉(zhuǎn)移)Splenomegaly脾臟腫大: Enlargement of spleen (possible portal hypertension 門靜脈高壓, infe

22、ction感染) 下胃腸道系統(tǒng)癥狀評估分析：時間：出現(xiàn)時間及持續(xù)，突發(fā)？是否與進(jìn)食有關(guān)性質(zhì)與量：敘述疼痛性質(zhì)，深、悶痛、彌散性疼痛，腹瀉與血便性質(zhì)部位：反射其它部位，涉及肝臟、脾臟、闌尾區(qū)、直腸？誘因：壓力、食物、藥物相關(guān)表現(xiàn)：生活影響、食物不耐受、黃疸、腹水、腹部絞痛等下胃腸道健康評估腹部評估：腹脹、腫塊、對等性、明顯的腸蠕動、臍或腹股溝疝氣、腸鳴音、腹水、腹痛區(qū)是否反射性疼痛、反跳性疼痛（Rebound tenderness)肛門與直腸： 痔瘡、脫肛、皮膚完整性、紅疹、潰瘍、肛裂（Anal Fissure）、瘺管（Anal Fistula）、膿腫（Anorectal abscess）Ass

23、essment of the Bowel Elimination 年齡與性別：Colorectal cancer 常見于年紀(jì)長者、男性潰瘍性結(jié)腸炎 Ulcerative colitis 常發(fā)生于中年白種人，猶太人Diverticular disease 常見于已開發(fā)國家精制食物攝取較多Assessment for Bowel EliminationAscites 腹水 Diarrhea 腹瀉Constipation 便秘Melena 便血Pain in Rectal or Abdominal :腹部疼痛或肛門疼痛Assessment of Diarrhea and Constipation D

24、iarrhea: acute or chronic ( 2 months of diarrhea評估腹瀉后生理變化：滲透壓升高、消化不完全、腸蠕動過快、腸內(nèi)容物水份高、消化不完全急性腹瀉：與細(xì)菌感染有關(guān)、與進(jìn)食感染源有關(guān)，包括菌痢評估腹瀉 Diarrhea腹瀉性質(zhì)、頻率、量。是否腹痛及里急后重感？是否有腸粘膜破壞？濃樣血便？水樣便？飲食不潔？細(xì)菌感染？常見的致病菌為：大腸桿菌、沙門菌、輪狀病毒、腸病毒、血吸蟲等?？梢揽赡艿母腥就緩皆u估致病因素。 評估便血消化道出血，由肛門排出，顏色與出血量、時間、部位有關(guān)。下消化道出血，近直腸肛門部位，停留時間短：鮮紅上消化道出血，通過腸道，Hb 與腸道硫化物

25、結(jié)合，形成黑色便 （Tarry Stool）鑒別：腸道細(xì)菌感染或炎癥，腸道腫瘤、息肉、痔瘡、克羅恩病、腸套疊等。 評估便秘Constipation結(jié)腸性便秘：結(jié)腸內(nèi)的機(jī)械梗阻，結(jié)腸蠕動減少、結(jié)腸痙攣直腸性便秘：直腸肛周病變所致，生活習(xí)慣改變，排便習(xí)慣不正確，常服用瀉藥或灌腸，導(dǎo)致直腸粘膜感受器的敏感性降低， 常發(fā)生于老年人及長期臥床休息者。 Physical Assessment Annus and Rectum Assess for : Tenderness, 壓痛Masses, 腫塊hemorrhoids, 痔瘡Prolapsed, 脫垂Rectal mucosa smooth, 直腸粘膜

26、平滑Stool negative for blood 便血陰性 Aging Patient GI Assessment 年長者腸胃系統(tǒng)評估Mouth: Loss of teethDecreased taste buds, decreased sense of smell 胃蕾減少，嗅覺下降Decreased volume of saliva 唾液減少Atrophy of gingival tissue 牙齦萎縮Aging Patient GI Assessment 年長者腸胃系統(tǒng)評估Esophagus 食管Decreased tone and motility 降低張力及動力Aging Pat

27、ient GI Assessment 年長者腸胃系統(tǒng)評估Abdominal WallThiner and less taut Decrese in number and sensitivity of sensory receptors More visible peristalsisStomach: Decreased acid secretion, atrophy of gastric mucosa 降低胃酸分泌，胃粘膜萎縮Aging Patient GI Assessment 年長者腸胃系統(tǒng)評估Small Intestines :小腸Decreased secretion of most digestive enzymes, 消化液分泌減少Decreased moltility-complain of indigestion 動力降低，主述“不消化”Liver: 肝臟Decreased size and lowered in position 降低尺寸及位置Aging Patient GI Assessment 年長者腸胃系統(tǒng)評估Large intestine, anus, rectum: 大腸、肛門、直腸Decreased anal sphincter tone and n