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1、血栓性肺栓塞 Pulmonary Thromboembolism,Postoperative complications,HemorrhageHypoxiaParalytic ileusConstipation Pneumonia and atelectasisPulmonary embolism,ShockThrombophlebitisUrinary retentionWound dehiscenceWound eviscerationWound infection,肺栓塞Pulmonary embolism,肺栓塞PE是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或综合症的总称包括Pu
2、lmonary Thromboembolism(PTE)、脂肪栓塞综合症、羊水栓塞、空气栓塞等,肺栓塞可发生于单侧也可发生于双侧,后者多于前者,右肺多于左肺,下肺多于上肺,肺栓塞发病原因,1.年龄与性别 2.血栓性静脉炎,静脉曲张 3.心肺疾病 4.创伤手术5.肿瘤 癌症6.制动 血流速度7.妊娠和避孕药 孕妇 8.其他 如肥胖超过标准体重20%者,手术,手术盆腔手术截石位,肺栓塞的常见症状,(1)呼吸困难（PTE最多见的症状）(2)胸痛(3)咯血（小量）(4)惊恐(5)咳嗽(6)晕厥（可为PTE的唯一或首发症状）(7)腹痛,体格检查,心脏血管系统体征：心动过速，低血压休克等呼吸系统体征：气管
3、移向患侧（累积全肺），病变部位叩诊浊音，听及哮鸣音和干湿啰音，肺部血管杂音 其他：发热,(一)急性大面积肺栓塞(二)中等大小的肺栓塞:胸骨后疼痛及咯血(三)肺的微栓塞：可以产生成人呼吸窘迫综合征(四)肺梗死：常有发热轻度黄疸,肺栓塞的预防,虽然肺栓塞的栓子可来源于全身任何体静脉系统和右心房室但最多还是来自下肢深静脉 肺栓塞的最重要预防是针对下肢血栓性静脉炎和深静脉血栓形成,栓子来源于深静脉系统绝大多数的肺栓塞是以下肢静脉病开始以肺疾病终结栓子最多来自骨盆或四肢静脉有人统计“母血栓”85%来自下肢,肺栓塞的预防,静脉曲张,人群临床表现表现,预防,压力疗法活动,压力疗法,优点改善深静脉及浅静脉血液
4、流动速度减少深静脉血液返流情况改善淋巴回流减低浅静脉压力,压力疗法,方法压力袜压力绷带压力泵,压力疗法,压力袜compression stockingsCompression stockings steadily squeeze your legs,helping your veins and leg muscles move blood more efficiently.They offer a safe,simple and inexpensive way to keep blood from stagnating after general surgery.,压力疗法,压力袜一级（14-
5、17mmHg）轻度压力轻微，早期静脉曲张,压力疗法,压力袜二级（18-24mmHg）中度压力严重静脉曲张DVT深静脉栓塞治疗及预防静脉性溃疡,压力疗法,压力袜三级（25-35mmHg）强中度压力严重静脉曲张严重慢性静脉性高血压治疗及预防大直径腓肠肌静脉性溃疡,压力疗法,压力袜皮肤的潜在性坏死穿着不当会引致摩擦或压力性损伤，皮肤敏感止血带作用（穿好弹力袜或用弹力绷带后要注意病人的足部血运循环）,压力疗法,如何穿压力袜时间方法,压力袜的保养用中性洗涤剂避免阳光直接照射,压力疗法,压力绷带轻度压力14-17mmHg中度压力18-24mmHg强度压力25-35mmHg加强度压力60mmHg,压力绷带,
6、压力绷带非弹性压力弹性压力,压力绷带,非弹性压力形成一有效泵力将血液泵回心脏低休息压高活动压适用于活动量较多的病人,压力绷带,弹性压力减少表面静脉及穿孔静脉之管腔维持静脉瓣膜功能不全之功能重建深静脉之正常血液流量减少微细血管内及外的压力差别减少微细血管之扩张及肿胀重建正常毛细血管高休息压中等高活动压适用于活动量较少的病人,压力泵pneumatic compression,Use of pneumatic compression.This treatment uses thigh-high or calf-high cuffs that automatically inflate with ai
7、r every few minutes to massage and squeeze the veins in your legs and improve blood flow.,肢 体 活 动,被动主动,被动运动,主动运动,预防静脉曲张的最好办法就是多运动。静脉曲张宜间歇性跑步适可而止，注意休息。长期坚持,静脉曲张自会痊愈。,自我护理,尽量避免负重体力劳动，严重者应卧床休息，将患肢位置高于心脏水平下床活动或外出时，应穿弹力袜或使用弹力绷带，每天起床后，就穿上弹力袜，晚上睡觉时再脱下。在日常生活中，要养成良好的排便习惯。,自我护理,避免长时间站，蹲或坐，应经常让腿做抬高、放下的运动。避免经常提
8、超过10千克的重物。保持正常体重，以免因超重使腿部静脉负担增加。每晚检查小腿是否有肿胀情况。戒烟。晚上睡觉时，将腿垫高约15厘米。养成每天运动腿部1小时的习惯，散步、快走、骑自行车、跑步皆可。,surgery,Moving as soon as possible after surgery can help prevent pulmonary embolism and hasten recovery overall.Heparin or warfarin(Coumadin)therapy.to people at risk of clots before and after an operat
9、ion,深部血栓性静脉炎Deep ven thrombophlebitis,Description Thrombophlebitis is an inflammation of a vein,often accompanied by clot formation.,分类及临床表现,Assessment,Calf or groin tenderness or pain with or without swellingWarm skin that is tender to touchHomans sign(Aching or cramping pain.Vein feels hard and co
10、rdlike and is tender to touch.Homans sign),Interventions,Provide bed rest as prescribedElevated the affected extremity above the level of the heart as prescribedAvoid using the knee gatch or pillow under the kneesDo not massage the extremityProvide thigh high or knee-high antiembolism stockings as p
11、rescribed to reduce venous stasis and assist in the venous return of blood to the heart,Administer intermittent or cotinuous warm,moist compresses as prescribedPalpate the site gently,monitoring for warmth and edema Measure and record circumferences of the thighs and calvesMoniter for shortness of b
12、reath and chest pain,which can indicate pulmonary emboli,Administer trombolytic therapy if prescribed,which must be initiated within 5 days after the onset of symptoms.Administer heparin therapy as psrescribed to prevent enlargement of the existing clot and prevent the formation of new clots.Monitor
13、 activated partial prothrombin time during heparin therapy.,Instructions,Instruct the client concerning the hazards of anticoagulation therapyRecognize the signs and symptoms of bleedingAvoid prolonged sitting or standing,constrictive clothing,or crossing legs when seatedElevate the legs for 10 to 2
14、0 minutes every few hours each day.Plan a progressive walking program.,Inspect the legs for edema,and measure the circumference of the legs.Wear antiembolism stockings as prescribed.Avoid smoking.,Avoid any medocations unless prescribed by the physician.Instruct the client concerning the importance
15、of follow-up physician visits and laboratory studies.Obtain and wear a Medic-Alert bracelet.,个案分析,患者 男性 77岁 09年11月2日入院 入院诊断：前列腺增生症 尿潴留入院状态：排尿困难5年，无心脏，呼吸系统疾病病史 静脉曲张多年，行动自如手术：于11月4日双阻滞麻醉下行TUTP术(两微米)手术时间两小时术后平卧，持续膀胱冲洗11月11日病人呼吸费力，给予间断吸氧11月13日14时下床活动时，突然神志不清，大汗，口吐白沫，心跳呼吸停止。立即给予抢救，16时病人自主心跳恢复，呼吸未恢复，双侧瞳孔散大。立即转入ICU病房继续抢救。诊断为急性肺栓塞，右髂静脉血栓形成。11月20日10时病人心跳停止，临床诊断死亡,
