腎積水護(hù)理查房課件

護(hù)理查房腎積水第十病區(qū)第1頁NursingRoundsHydronephrosis

WardTen

第2頁病史摘要患兒,女,11月,于2023年03月03日因B超發(fā)覺左腎積水二月余而入院。患兒近日來無發(fā)熱,大便正常,腎臟動態(tài)顯象及GFR測定示：腎小球?yàn)V過率功能正常，左腎中度積水—因左輸尿管上段狹窄所致。入院后完善有關(guān)檢查,予2023年3月05日在全麻下行左腎盂輸尿管成形術(shù),術(shù)后生命體征平穩(wěn),于03-07拔除導(dǎo)尿管，當(dāng)天能自行解小便，無疼痛。03-10拔除后腹膜負(fù)壓吸引管，03-15拔除輸尿管支架管，現(xiàn)腎造瘺引流管固定良好，引流通暢。第3頁Briefhistory

Children,female,10monthsold,wasfoundlefthydronephrosisbyBultrasonicandwashospitalizedonMarch3th,2023byB-February.Childrenhasnofever,defecateisnormalinrecentdays,theKidneydynamicmanifestationsandGFRdeterminationdisplay:theglomerularfiltrationrateisnormal,renalwatermoderate–becauseoftheleftuppersegmentureter

wasnarrow.Afteradmissionperfectrelevantinspection,angioplastyofleftrenalpelvisandureteronundergeneralanesthesiaMarch5,2023,withstablevitalsignsaftersurgery,catheterwasremovedon03-07,itcouldurinatebyitselfwithnopain,peritonealsuctiontubewasremovedon03-10,ureteralstentwasremovedon03-15,nephrostomydrainagetubeisfixedwell,drainageisunobstructed.第4頁護(hù)理評定術(shù)前評定(1)身體評定(2)心理和社會支持情況術(shù)后評定

(1)康復(fù)情況(2)心理認(rèn)知情況(3)預(yù)后判斷第5頁NursingassessmentPreoperativeAssessment(1)physicalassessment(2)psychologicalandsocialsupportPostoperativeevaluation(1)rehabilitationcondition(2)PsychologicalCognition(3)prognosis第6頁護(hù)理診斷1.知識缺乏(家屬):缺乏術(shù)前準(zhǔn)備知識,注意事項(xiàng)2.有感染危險(xiǎn):與術(shù)后抵抗力下降，留置引流管有關(guān)3.軀體移動障礙：與置引流管有關(guān)4.有皮膚完整性受損危險(xiǎn)：與長期臥床，活動受限有關(guān)。5.有體液不足危險(xiǎn)：與嘔吐有關(guān)6.焦慮(家屬):擔(dān)心術(shù)后預(yù)后不良

第7頁NursingDiagnosis1.lackofknowledge(family):lackofpreoperativepreparationknowledgeNotes2.theriskofinfection:relatedtopostoperativedecreasedresistance,indwellingdrainagetube3.physicalmobilitybarriers:relatedtothedrainagetube4.theriskofimpairedskinintegrity:relatedtolong-termbedrest,limitedmobility.5.theriskofinadequatefluid:relatedtovomiting6.anxiety(family):fearofpoorprognosisaftersurgery第8頁預(yù)期目標(biāo)

1.術(shù)前家屬掌握有關(guān)注意事項(xiàng)2.患兒留置導(dǎo)尿期間無感染發(fā)生3.患兒能合適進(jìn)行活動4.患兒皮膚完整性得到保護(hù)，不發(fā)生破損。5.患兒體液保持平衡，生命體征平穩(wěn)6.患兒家屬術(shù)后能夠掌握有關(guān)配合治療護(hù)理辦法第9頁ExpectedOutcomes1.Familymembershaverelevantpreoperativeprecautions2.Childrenwithnoinfectionoccurredduringthecatheterization3.Childrencanproperlyconductactivities4.Childrenskinintegrityprotected,withnodamaged.5.Childrenhumoralbalance,vitalsignssmoothly6.Children’s

familycanmasterrelevantcooperatecurenursingmethodspostoperative第10頁護(hù)理措施

第11頁Nursingmeasures

第12頁知識缺乏護(hù)理措施1.評定家屬文化程度,接收能力2.患兒排尿或排便后,指導(dǎo)家屬及時(shí)清洗會陰部,保持會陰部清潔3.指導(dǎo)家屬給患兒多飲水4.指導(dǎo)家屬為患兒注意保暖,避免呼吸道感染,以免延誤手術(shù)第13頁Nursingmeasuresoflackofknowledge1.Toestimatefamilyeducation,reception2.Toguidethefamilycleanthegenitaliaintimetokeeptheperineumcleanafterchildren’surinationordefecation3.Toguidethefamilymemberstogivechildrenwithdrinkingwatermore4.toguidefamilymemberstokeepwarm,avoidrespiratoryinfectionsforchildren,soasnottodelaysurgery第14頁預(yù)防感染護(hù)理措施1.觀測患兒體溫變化，每日測體溫二次2.保持傷口敷料干燥清潔,避免污染3.妥善固定各根引流導(dǎo)管,避免扭曲折疊,保持引流通暢。集尿袋每日更換,嚴(yán)格執(zhí)行無菌操作。4.遵醫(yī)囑予呋喃西林液，聚維酮碘清洗消毒會陰。5.遵醫(yī)囑使用抗生素靜脈滴注。6.指導(dǎo)家屬合理飼養(yǎng)，加強(qiáng)營養(yǎng)。7.遵醫(yī)囑予靜脈滴注抗生素8.給予患兒多喝水,起到自凈作用9.病室空氣負(fù)離子消毒，預(yù)防交叉感染。第15頁Nursingmeasurestopreventinfection1.Observechildrentemperaturechanges,measure

temperaturetwice

daily2.Keepthewoundcleananddrydressingtoavoidcontamination3.Toproperlyfixtherootcatheter,topreventdistortionoffolding,maintainingunobstructeddrainage.Urinecollectionbagschangedaily,implementthesterileoperationstrictly.4.Asphysiciandirectedusenitrofurazonesolution,povidone-iodineperinealcleaninganddisinfection.5.AsphysiciandirecteduseAntibioticsintravenousdrip.6.Toguidefamliyrationalfeeding,strengthennutrition.7.Asphysiciandirecteduseintravenousantibiotics8.Togivechildrenwithdrinkingwatermore,inordertoself-purification9.Patientsnegativeiondisinfectionofroomairtopreventcross-infection第16頁軀體移動障礙護(hù)理措施

1.患兒活動時(shí)固定好輸液管道，和穿刺部位。2.指導(dǎo)家長幫助患兒床上翻身及活動。3.妥善固定腎造瘺管,輸尿支架管，導(dǎo)尿管，后腹膜負(fù)壓吸引管，各個(gè)導(dǎo)管標(biāo)簽清楚。4.勿牽拉勿壓迫,保持各根導(dǎo)管通暢,勿折疊勿扭曲。第17頁Nursingmeasuresofbodymovingbarrier1.infusioninchildrenwithactivities,fixedpiping,andthepuncturesite.2.Toguideparentstohelpchildrenwithbedturnoverandactivities.3.Properlyfixednephrostomy,urinaryoutputframetubes,ureters,retroperitonealsuctiontubes,eachtubelabelclearly.4.Donotpullpressuretomaintainpatencyofthecatheters,donotdistortthefold.第18頁預(yù)防皮膚完整性受損護(hù)理1.保持床鋪干燥平整，會陰部墊尿布或一次性橫單。2.每班觀測評定有沒有皮膚受損征兆如：潮紅，壓痕。3.通知家屬每日給患兒溫水擦身，更換清潔衣褲。4.會陰部妥善護(hù)理，避免大小便污染。5.通知家屬經(jīng)常給患兒翻身主要性。每2-4小時(shí)翻身一次。

第19頁Nursingofpreventingskinintegritydamaged1.Keepbeddryingleveloff,theperineummatdiapersorone-timehorizontallist.2.Observewhetherskindamageassessmentsigneveryshiftsuchas:flushandcreasing.3.Notifyfamilytobrushwithwarmwater,replacethecleanpajamas.4.perineumproperlynursing,preventingurinepollution.5.Notifyfamilytheimportanceforrollingoverchildrenoften.rollingoveritevery2-4hours.

第20頁

預(yù)防體液不足護(hù)理

1.遵醫(yī)囑按時(shí)完成輸液，注意輸液速度，量，輸液部位皮膚。2.觀測患兒皮膚粘膜有沒有脫水表現(xiàn)。3.準(zhǔn)確統(tǒng)計(jì)二十四小時(shí)尿量。4.觀測統(tǒng)計(jì)嘔吐次數(shù)及嘔吐物量。5.教會家屬正確給患兒口服ORS液。第21頁

Nursingofpreventinghumoraldeficiency1.Asphysiciandirectedfinishinfusion,payattentiontoinfusionspeed,quantity,infusionpartsskin.2.Observationchildrenskinmucosawhetherdehydrated3.Accuratelyrecord24-hoururinevolume.4.Observationrecordsvomitingandfrequencyvomitaquantity.5.TeachfamilytogivechildrenwithoralORSfluid.第22頁家屬焦慮護(hù)理措施1.評定家屬焦慮原因及程度2.經(jīng)常與家屬溝通,介紹有關(guān)手術(shù)效果及預(yù)后情況,取得家屬信任3.教會家屬觀測尿液顏色及性狀。4.教會家屬精確計(jì)算尿量并統(tǒng)計(jì)。5.提議穿質(zhì)地柔軟內(nèi)衣褲，用棉質(zhì)尿不濕。第23頁Nursingoffamiliesanxietymeasures1.Assessfamily’sanxietyreasonsanddegree.2.communicationwiththefamilyoften,tointroducetheoperationeffectandprognosis,obtainsthefamilytrust.3.Totea