Health education of surgical inpatient nursing

Topic 1: Health knowledge education of gastroduodenal ulcer

-Preoperative preparation and postoperative care

Preoperative preparation:

1. Diet should be adjusted, and foods with high nutritional value, such as milk, eggs and fish, should be selected. Supplemented by fruits containing vitamins, eat less and eat more meals, and the staple food is mainly soft rice and noodles.

2. Use the bedpan on the preoperative exercise bed for defecation after operation. Practice deep breathing and coughing skills.

3. Clean the intestine one day before operation, and guide the swallowing action when placing the gastric tube in the morning.

Postoperative care:

1. It is normal that the body temperature is lower than 38℃ and 5℃ three days after operation, and it is absorbed by surgery and does not need treatment.

2. Keep the drainage tube unobstructed, don't squeeze it, and be careful not to pull the drainage tube to prevent it from falling off when you turn over and get out of bed. Give oral care to patients with gastric tube inserted twice a day.

3. Drink a small amount of water on the day of extubation, 4-5 tablespoons each time, 1-2 hours 1 time. Fasting milk, foods with high sugar content, so as not to cause bloating, eating less and eating more meals, and fasting hard, oily, fried, strong tea, peppers and other irritating foods.

4. Get out of bed early: sit up on the first day after operation and move joints and muscles on the bed. If there are no contraindications, start to help the bed the next day to promote intestinal peristalsis and prevent intestinal adhesion.

5. Exercise properly, don't lift more than 10 kg within six weeks, and keep a good mood. Topic 2: Health knowledge education on cholecystitis and gallstones.

-Etiology, preoperative and postoperative guidance and discharge.

Etiology:

Biliary tract infection-caused by bile retention and invasion of bacteria or parasites.

The formation of gallstones is mainly related to the increase of cholesterol metabolism, bile retention, biliary parasites and biliary tract infection.

Clinical manifestations:

Cholecystitis-paroxysmal pain in the right upper abdomen, which often occurs after greasy diet or full meal, can radiate to the right shoulder, accompanied by nausea, vomiting and fever.

Cholelithiasis-abdominal pain, paroxysmal colic and tenderness in the right upper abdomen and under xiphoid process. Chills, high fever, jaundice.

Treatment: Surgery is mainly surgical treatment.

Preoperative guidance:

1. The diet should be light and easy to digest, avoiding fatty foods such as fat meat, frying and frying, and supplementing vitamins B, C and K.

2. Jaundice with itchy skin should be scrubbed with drugs or warm water as instructed to relieve symptoms. Don't scratch with your hands to prevent infection.

Don't smoke before operation to reduce the chance of lung infection.

4. Special inspection.

5. Before operation, enema 1 time every day, and gastric tube and urinary tube were placed in the morning.

Postoperative guidance:

1. 6 hours after operation, the blood pressure is stable, and taking a semi-recumbent position is beneficial to drainage.

2. Try to get out of bed the next day after operation to promote intestinal peristalsis and prevent intestinal adhesion.

3. Keep the drainage tube unobstructed, do not fold the drainage tube, and be careful not to pull it when turning over or getting out of bed to avoid falling off.

4. Diet: After pulling out the gastric tube, you can eat a diet with high protein, high cellulose and low fat and foods containing vitamins B and K.

5.t tube care: keep the drainage tube unobstructed, and don't fold, squeeze or fall off to avoid biliary peritonitis. Generally, the tube is clamped for about 2 weeks, and extubation can be considered after 48-72 hours without discomfort. It is feasible to perform biliary manometry or T-tube radiography before extubation.

Discharge guidance:

1. Keep a good mood and restore the bile secretion function of gallbladder through proper physical exercise.

2. Because of cholecystectomy, bile will not be stored in the gallbladder, and the digestion and absorption of fatty foods will be affected. Therefore, we should eat a high-protein and low-fat diet, do not eat fat and fried foods, eat more fruits, and avoid overeating.

3. If diarrhea occurs, send a thin paste stool test 2-3 times a day. If there are no red blood cells and white blood cells in normal stool, it may be the reason why eating a small amount of fatty food can't be absorbed well.

4. If you leave the hospital with a T-tube, there may be stones left in the bile duct. After the operation, you will go to the outpatient operating room according to the doctor's advice and take them out through the T-tube to avoid suffering from the operation again.

If the wound is red, swollen, painful or has a high fever, please come back for a follow-up visit. If there are no special circumstances, the clinic will check it after one month.

6. After the wound is taken out for 24 hours, you can take a bath without covering the gauze. Topic 3: Breast Cancer Health Education (reposted)

-Preoperative guidance and postoperative functional exercise

1. Etiology: It is related to estrogen changes and endocrine disorders.

2. Symptoms: painless breast mass.

3. Treatment:

(1) surgical treatment.

(2) radiotherapy.

(3) hormone therapy.

(4) chemotherapy.

4. Preoperative guidance:

(1) Keep a good mood.

(2) Eat a nutritious diet with high protein, high calories and high vitamins to improve the body's resistance.

(3) Breast cancer patients during pregnancy and lactation should immediately terminate pregnancy and weaning.

(4) Skin preparation in operation field: Special attention should be paid to the cleaning of nipple and areola. If skin grafting is needed, the skin of the donor site should be prepared. If there is skin ulcer, change the dressing twice three days before operation 1 day, and wipe the skin around the ulcer with alcohol for disinfection.

5. Postoperative functional exercise: In order to reduce the influence of scar contraction on the function of the affected limb, you can do wrist bending with fists, elbow bending for 3-4 days, shoulder exercise for 5 days, shoulder exercise for 7 days and affected limb exercise for 9- 12 days after operation. First, topic 4: Perioperative health education (zt) for patients with gastric cancer.

Educational content

1. Implement protective medical measures and give psychological guidance.

If the patient's family members require confidentiality, they should cooperate with the implementation of protective medical measures, but they should explain the condition and obtain cooperation. According to the different conditions of patients, we should actively give psychological counseling and explain relevant medical knowledge to patients patiently, meticulously and easily.

2. Preoperative guidance

(1). Dietary guidance: When patients with gastric cancer generally have symptoms, they are in the middle and late stages, and their body consumption is high, so they often have malnutrition symptoms. Should eat more nutritious, digestible, non-irritating, less residue diet, eat less meals. Those with severe obstruction should fast and be supplemented with high-energy nutrition or elemental diet intravenously according to the doctor's advice.

(2) Gastrointestinal preparation: fully explain the importance of gastrointestinal preparation to patients, and ask patients to eat liquid diet, such as lean broth, milk, vegetable soup, etc. The day before the operation. Clean enema and fasting at night before operation, indwelling gastric tube in the morning, and gastric lavage with 300 ~ 500 ml warm normal saline every night for three days before operation to facilitate the smooth operation.

(3) Preoperative education: Practice urination in bed one week before operation to avoid urinary tract infection caused by indwelling catheter for a long time after operation. Teaching patients to cough effectively three days before operation is beneficial to prevent postoperative pulmonary complications. According to the operation method, explain the content, purpose and precautions of preoperative preparation to patients one day before operation, and ensure patients to sleep at night before operation.

3. Postoperative guidance

(1). Body position and activity guidance: Explain to patients and their families the importance of taking a semi-recumbent position after operation, which is conducive to smooth breathing and gastric tube drainage, at the same time, it can relieve incision pain and appropriately increase activity. You can sit up one month after operation, move indoors for 3 ~ 4 days, and move in the corridor after removing stitches for 7 ~ 10 days, which is beneficial to the recovery of gastrointestinal function.

(2) Nursing instruction of gastric tube: Explain the importance of gastric tube to patients and their families. Under normal circumstances, a small amount of dark red or brown gastric juice can flow out of the gastric tube within 24 hours after operation, generally not exceeding 300 ~ 600 ml, and the amount will gradually decrease and stop automatically. If there is a large amount of blood flowing out of the stomach tube within 24 hours after operation, there may be anastomotic bleeding, and the medical staff should be reported immediately for timely treatment. 24 ~ 48 hours after operation, if the gastric juice decreases and the color is normal, the intestinal peristalsis will recover, and the gastric tube will be removed when the anus is exhausted.

(3) Dietary guidance: fasting after operation. After removing the gastric tube, you can drink a small amount of water that day, 4 ~ 5 tablespoons each time, once every 2 hours. If there is no discomfort, you can give a proper amount of liquid diet the next day, 50 ~ 80ml； each time; On the third day, a total liquid diet was given, each time 100 ~ 150 ml. If you return to normal after surgery, you can eat a low-sugar semi-liquid diet such as porridge on the fourth day and eat soft food two weeks later. Staple food and side dishes should be nutritious and easy to digest. However, if the patient has symptoms such as nausea and bloating after eating, he should still stop eating.

(4) Observation of complications and nursing guidance: If the patient has symptoms such as abdominal distension, palpitation, sweating, dizziness, fatigue, vomiting, collapse and diarrhea after eating, especially after eating sweets 10 ~ 20 minutes, it may be dumping syndrome. Lying flat for a few minutes at this time can alleviate the above symptoms, and asking patients to lie flat for 20 ~ 30 minutes after eating in bed can prevent or alleviate the above symptoms. If you still feel abdominal pain and fever one day after operation, and you can see more liquid and stomach contents flowing out of the incision, it indicates that anastomotic leakage has occurred. At this time, we should continue to suck the discharged gastrointestinal fluid under negative pressure, keep the skin around the fistula clean and dry, and apply zinc oxide ointment for protection to prevent intestinal fluid from corroding the skin.

4. Discharge guidance

(1). Instruct patients to eat correctly and regularly, eat less and eat more meals within one month after operation, and then gradually eat normally according to their physical recovery.

(2) Patients are required to rest within one month after discharge, take part in light labor after two months, and engage in light labor after three months according to their recovery.

(3) Feel comfortable and avoid mental stimulation.

(4). Check regularly according to the doctor's advice. Hernia repair

1 preoperative finger guidance

(1) If you have a chronic cough, you should take oral cough medicine before operation to cure it, because coughing will increase abdominal pressure;

(2) If you have constipation, you can take honey water, paraffin oil and foods containing cellulose. Such as spinach, to relieve constipation;

(3) If you smoke, please quit smoking immediately, because smoking aggravates bronchitis and cough, which is not conducive to surgical recovery;

(4) Keep warm to avoid catching a cold;

(5) Practice using the toilet in bed to avoid dysuria caused by not being used to defecating in bed during bed;

(6) Please buy a bag of salt before operation.

2 finger guidance after operation

(1) Wrap the salt with a dry towel and press it on the wound to prevent bleeding. 12-24 hours later;

(2) Observe the wound dressing for massive bleeding;

(3) It is not advisable to take a semi-supine position too much, so as not to increase abdominal pressure and affect the healing of the surgical repair site. Usually I will lie on my back for three days after surgery. If you take a semi-recumbent position the next day, your knees should be flexed, and a soft pillow should be placed under your knees to relax the abdominal wall and reduce tension.

(4) Keep the wound dry. If it is wet, change the dressing in time to avoid incision infection;

(5) Diet: liquid food or soft food can be eaten 6- 12 hours after operation, and general food can be eaten the next day;

(6) After the operation, the bladder temporarily loses its sexual function due to anesthesia or surgical stimulation. You may have difficulty urinating, and we will induce urination or place a catheter before operation;

(7) Please keep warm to avoid catching a cold and coughing.

3 guidance outside the hospital

(1) Please combine work and rest and gradually increase the activity. Generally do not take part in heavy physical labor for three months. Don't lift heavy objects;

(2) Drink plenty of water and eat a high-fiber diet, such as vegetables and fruits, to prevent constipation;

(3) If you have heart and lung diseases, please treat them as soon as possible, because repeated coughing will lead to hernia again.

Hand operation of thyroid gland

1 preoperative finger guidance

(1) Practice posture: practice neck hyperextension before operation (as shown on the next page). The method is to lie in a semi-recumbent position, with the pillow under the shoulder and the head tilted back. Among them, 1.5 ~ 2 hours/day for patients with thyroid tumor, 2 ~ 2.5 hours/day for patients with nodular goiter and 2.5 ~ 3.5 hours/day for patients with hyperthyroidism, step by step;

(2) Keep calm and don't be nervous. If you have insomnia, you can take diazepam orally as prescribed.

(3) If you have symptoms of exophthalmos, you can take a semi-recumbent position, which is helpful to relieve eye congestion. You can wear black glasses for protection and apply eye ointment when sleeping.

(4) Eat foods with high calories and vitamins before operation, such as fish, meat and fruit. Because the disease makes your metabolism vigorous and consumes a lot;

(5) Routine examinations you need to do: In addition to routine examinations of hematuria and biochemical electrolytes, you also need to do (the following examinations are all done by the staff of our hospital's escort center):

① Cervical radiography: To know whether the esophagus is compressed and whether the nodule is calcified;

② Electrocardiogram examination: Understand the heart function;

③ Laryngo-cervical examination: Understand the vocal cord function;

(6) Your preoperative medication:

Drugs such as 1. tabazole can control the symptoms of hyperthyroidism, but it can make goiter and congestion, which is not conducive to surgery;

2 oral iodine: it is to reduce congestion and make the thyroid gland shrink and harden, which is conducive to surgery; Administration: three times a day, starting from 5 drops a day, giving 1 drop to 15 drops a day, and then maintaining it until surgery; For example, 5 drops in the morning, middle and evening of the first day; 6 drops in the morning, noon and evening of the next day; 7 drops in the morning, 7 drops in the middle and 7 drops in the evening on the third day, and so on to 15 drops. Methods Iodine solution was sucked with 1mL empty needle and added to steamed bread, cakes and other foods according to the specified number of drops. The above drugs should be taken according to the doctor's advice.

2 finger guidance after operation

(1) After you come back from the operating room, you should take a semi-recumbent position, which is conducive to breathing and drainage of wound exudate.

(2) If you feel that there is secretion in the pharynx, you just need to cough regularly. Severe cough will stimulate the surgical site and lead to ligation and bleeding;

(3) Please speak less after operation and let the vocal cords and throat rest;

(4) Liquid food 65438+ can be taken 0-2 days after operation to reduce dysphagia and throat discomfort. If you have a headache and cough, you can take semi-solid foods, such as cakes and noodles.

(5) Please take the following measures to relieve the pain;

① Avoid overstretching the neck. Excessive bending can compress the trachea, and excessive stretching can cause traction pain;

② Move your head slowly; There should be no rapid head movements;

③ When standing, please support your head with your hands to prevent the pain caused by suture pulling;

④ If you find any of the following situations, please inform the doctors and nurses immediately:

A. Abnormal sensation around the mouth and limbs, numbness, limb tremor and convulsion;

B. the incision is red, swollen and painful;

C. Difficulty in breathing, voice change, oppressive feeling, tight neck and excessive exudation;

D. the heartbeat is accelerated, the body temperature is higher than 39℃, and you are sleepy.

3 guidance outside the hospital

(1) Please ask the nurses and doctors about the dosage, usage and side effects of the drugs taken out of the hospital.

(2) If it is a total thyroidectomy patient, it is necessary to take thyroxine replacement therapy for a long time;

(3) If hoarseness and aphonia occur, which is the manifestation of laryngeal nerve damage, please apply drugs to promote nerve recovery appropriately, combined with physical therapy and acupuncture to promote rehabilitation, and gradually recover within 3-6 months;

(4) After the stitches are removed for 2 weeks, the neck can be moved back, forth, left and right to prevent scar contraction;

(5) You need to do regular activities, which will help stimulate the remaining thyroid gland to function;

(6) Diet:

① In the hypothyroidism stage after operation, the calorie intake should be reduced to prevent weight gain;

② Avoid eating foods with thyroid inhibition (radish, soybean, etc.). );

③ Do not eat chili, cinnamon, ginger, white tartaric acid, bamboo and other foods. Nursing care of patients with pancreatic head cancer undergoing surgery

Pancreatic head cancer accounts for 2/3-3/4 of pancreatic cancer, which is an increasing number of digestive system tumors in recent years, with high malignancy, rapid development, difficult early diagnosis and poor prognosis. The clinical manifestations are upper abdominal pain, fullness discomfort and digestive tract symptoms caused by pancreatic and bile duct obstruction and increased intraluminal pressure. Jaundice caused by tumor compression or invasion of common bile duct is gradually aggravated, accompanied by itchy skin, slow pulse and bleeding tendency; Weight loss and fatigue caused by diet reduction, indigestion, lack of sleep, cancer energy consumption, etc. Once the cancer of pancreatic head is diagnosed, if there is no distant metastasis, resection of pancreatic head and duodenum or anastomosis of gallbladder with jejunum or duodenum should be performed as soon as possible. External fistula, namely percutaneous transhepatic biliary drainage (PTCD) or cholecystostomy. Common nursing problems include: ① Sleep disorder; ② Constipation; ③ Risk of oral mucosal changes; ④ Risk of skin injury; ⑤ Potential complication-infection; ⑥ Potential complications-lack of body fluids; ⑦ Lack of knowledge: knowledge about percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP); Lack of knowledge: postoperative rehabilitation nursing knowledge.

First, sleep disorders.

Related factors:

1 Abdominal pain, fullness and discomfort.

2 itchy skin.

Main performance:

1 Complain that I can't sleep because of itchy skin or sleep interruption due to epigastric pain.

Patients are restless and have poor sleep quality, which is characterized by mental fatigue, fatigue and inattention.

Nursing objectives:

1 The patient complained of lack of sleep, indicating that he was more energetic after sleep.

Patients can express and master methods that are conducive to promoting sleep.

Nursing measures:

1 Provide a quiet and comfortable rest environment in the ward to avoid the influence of bad stimulation.

2. Instruct patients to take a comfortable lying position, such as lateral lying and slight flexion of lower limbs, so as to relieve local pressure or tension caused by cancer and relieve pain and fullness in upper abdomen.

Bathe the patient with warm water every day, keep the skin clean and dry, and avoid using alkaline soap or shower gel that is too irritating to the skin.

Tell patients to wear cotton and soft underwear, change it in time after pollution, and keep underwear clean and dry.

Remind patients to avoid drinking stimulating and exciting drinks such as coffee or strong tea water before going to bed, and drink a cup of warm milk or listen to light music before going to bed to promote sleep.

If necessary, give sedatives and hypnotics according to the doctor's advice, and evaluate the effect after taking them.

Key assessment:

1 Whether the patient's sleep quality has improved.

Whether the patient has mastered the inducement to reduce the influence of sleep.

Second, constipation

Related factors:

1 Obstruction of pancreas and bile duct leads to bile or pancreatic juice obstruction and gastrointestinal digestive dysfunction.

2 improper diet.

Main performance:

1 complained that defecation was laborious and painful, and the stool was dry and hard.

The frequency of defecation is reduced, and the mass can be touched in the left lower abdomen.

Nursing objectives:

1 The patient complained that constipation symptoms were relieved or disappeared.

Patients master the methods of promoting the formation of defecation or keeping the stool soft and hard, and establish the habit of regular defecation.

Nursing measures:

1 Encourage patients to eat and increase the cellulose content in the diet, and eat bananas at the same time to promote stool excretion.

2 instruct patients to replenish enough water every day, and drink 1500-2000mL and 1 cup (200-250mL) before going to bed.

Teach patients to do abdominal massage in the direction of intestinal peristalsis.

4 urge patients to live a regular life and avoid consciously suppressing defecation.

5. Guide patients to develop the habit of regular defecation.

If necessary, use laxatives or give low-pressure enema according to the doctor's advice.

Key assessment:

1 Is the patient's stool regular and regular?

Patients complain whether defecation is easy and painless.

Third, there is a risk of oral mucosal changes.

Related factors:

1 Low water intake or fasting.

2 body temperature is too high, and saliva secretion is reduced.

3 when indwelling gastric tube, mechanical friction damages oral mucosa.

4. After general anesthesia intubation.

Main performance:

1 complained of dry mouth and sore throat.

Chapped lips, erosion of tongue surface and congestion of throat.

Nursing objectives:

1 The patient complained of fresh mouth and no discomfort.

There is no abnormal change in oral mucosa/tissue.

3. Patients master general oral care methods.

Nursing measures:

1 Observe and record the current situation of patients' oral mucosa/tissues, and choose appropriate oral care methods.

Give patients oral cleaning care and improve oral hygiene, and instruct them to brush their teeth in the morning and evening and after meals.

3 During the high fever period, encourage patients to drink more water and rinse their mouths with Dobby solution.

During fasting and indwelling gastric tube, patients should be given oral care with normal saline every day to prevent oral complications.

5 if the lips are chapped, apply a little paraffin oil to protect them; If the tongue surface is cracked or eroded, after oral care, apply gentian violet liquid locally to diminish inflammation; People with congestion and pain in the throat are given steam inhalation or ultrasonic atomization inhalation.

6 provide patients with a light, nutritious and moderate soft and hard diet, and avoid eating irritating diets such as overheating, supercooling, being too hard and being too spicy.

Key assessment:

1 Whether the patient's oral mucosa/tissue has abnormal changes.

2. Does the patient complain that the oral cavity is clean and comfortable?

Fourth, there is a risk of skin damage.

Related factors:

1 jaundice causes itchy skin.

Postoperative multi-tube drainage, such as abdominal drainage tube and jejunostomy, etc.

Stay in bed for a long time and don't understand the importance of bed activities.

Main performance:

1 complained of itchy skin and had to scratch it.

Two people complained of skin pain in the compression area.

There are scratches, redness, tenderness and even skin damage in the compressed area of the bony process.

Nursing objectives:

1 The patient's skin is intact.

Patients can describe self-protection measures to prevent skin damage.

Patients can understand and accept skin care.

Nursing measures:

1 Explain the causes of skin itching to patients and preach the measures to protect skin;

(1) Don't scratch your skin when it itches, so as not to scratch it.

(2) Wipe or bathe with warm water every day, and avoid using rough towels and irritating soap or shower gel.

(3) Wear cotton underwear and keep it clean and dry.

(4) antipruritic agents can be used appropriately.

2 Pay attention to skin care during bed rest:

(1) Massage the skin of the osteophyte and the compressed part with safflower alcohol regularly to promote local blood circulation.

(2) Encourage and assist patients to turn over, every 2 hours/kloc-0 times, and reduce the time of local skin compression.

(3) If necessary, put a balloon, cotton ring or sleeping air cushion bed on the compressed part of the bony protuberance.

(4) Keep the bed clean, dry, flat and free of slag.

(5) Don't use the broken toilet to avoid dragging.

(6) Wash the perianal region and vulva with warm water in time after defecation to keep the local skin clean and dry.

3 during fasting, provide nutrition to patients through veins and other channels; When eating, encourage patients to eat more nutritious diets such as high protein and vitamins to prevent malnutrition from further reducing their resistance.

4 keep the skin around the orifice of abdominal drainage dry, and change the dressing in time when it is wet to prevent skin damage and infection.

Key assessment:

1 Whether the patient correctly grasps the measures of skin self-care.

2 Whether patients cooperate with nursing.

3 whether the skin is damaged.

The potential complication of verb (abbreviation of verb)-infection

Related factors:

1 surgical incision.

2 Multi-tube drainage after operation.

3 all kinds of invasive operations.

4 phlegm and blood stasis.

Main performance:

1 high body temperature.

2 incision progressive pain, redness, swelling or purulent secretion.

3 The skin around the drainage port is red and swollen or has purulent secretion.

4 drainage fluid is turbid or purulent fluid flows out.

The patient has obvious bladder irritation or lung auscultation of dry and wet rales.

Nursing objectives:

1 The surgical incision healed as scheduled.

The skin around each drainage port is normal.

No bladder irritation or other complications occurred in the patient.

Nursing measures:

1 closely monitor vital signs. The body temperature can reach 38.5℃ within 48-72 hours after operation, which is a normal reaction. If the body temperature continues to rise, you can be alert to the occurrence of infection.

2 Listen to the patient's chief complaint, and know whether the incision has progressive pain, redness and other inflammatory symptoms at any time.

3 properly fix the drainage tube and keep it unobstructed to prevent the accumulation of drainage fluid from causing abdominal infection.

Observe the nature of drainage fluid frequently, record and find the signs of infection early.

If there is a catheter, disinfect the urethral orifice with 0. 1% bromogeramine cotton ball twice a day or give a vulvar swab to prevent retrograde infection of the urinary system.

Teach patients the correct method of expectoration, encourage patients to cough up sputum, and prevent falling pneumonia.

7. Often auscultate the patient's lung breathing sounds to find out whether there is phlegm and whether there is a thickening of breathing sounds.

8 Use antibiotics rationally according to the doctor's advice to prevent infection.

Key assessment:

1 Whether the patient's temperature is normal.

2 Whether there are signs of infection in susceptible parts.

Symptoms Cancer invades the stomach and duodenum, causing digestive and absorption disorders and hematemesis or melena.

Main performance:

1 Dry skin with poor elasticity.

Fast heart rate, pulse rate, low blood pressure, less urine and high urine specific gravity.

Vomiting and black stool.

4. Excessive bleeding of abdominal drainage tube.

Nursing goal: The patient's body fluid balance is characterized by stable vital signs, good skin elasticity and normal urine volume and urine specific gravity.

Nursing measures:

1 Observe the patient's skin elasticity, mucosal condition and mental state.

Observe and record the drainage volume and characteristics, and pay attention to the occurrence of complications such as biliary fistula or pancreatic fistula.

Record the 24-hour liquid inflow and outflow in detail, especially the patient's urine volume and urine specific gravity.

According to the doctor's advice, intramuscular injection of vitamin K 1 in time can improve blood coagulation function.

5. Ensure smooth liquid input and prevent insufficient fluid replacement.

6 If hematemesis and melena occur, you should:

(1) Quick rehydration to keep patency.

(2) Cross blood collection, ready for blood transfusion.

(3) Observe and record the amount of bleeding.

(4) Let the patient's head lean to one side to prevent suffocation.

(5) Comfort patients and make them calm.

(6) according to the doctor's advice to give hemostatic drugs, and actively assist the doctor to take hemostatic measures.

Key assessment:

The skin elasticity of 1 is good.

2 Whether the vital signs are stable.

3 What is the hemostatic effect?

7. Lack of knowledge: knowledge of percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP).

For details, please refer to the related contents in the Standard Nursing Plan for Patients with Cholangiocarcinoma.

Lack of knowledge: knowledge of postoperative rehabilitation nursing

Related factors:

1 Never had this disease.

2. Lack of information sources.

Main performance:

1 asked the medical staff about the above knowledge.

The patient showed anxiety.

Nursing objectives:

1 Patients can tell the main points and significance of various rehabilitation measures.

2 have a certain degree of understanding of chemotherapy and can persist in accepting it.

Nursing measures:

1 explained the postoperative rehabilitation measures and their significance to patients.

(1) Early activities, such as turning over in bed and getting out of bed, are beneficial to the recovery of intestinal function and the prevention of intestinal adhesion.

(2) Keep the wound dressing clean and dry to prevent all kinds of drainage tubes from coming out, twisting and being blocked by pressure.

(3) After stitches are removed, the wound should still be covered with sterile gauze to prevent damp and infection.

(4) Eat a reasonable diet, and enter a diet with high protein, high calorie and high vitamins to improve the body's resistance.

(5) Quit smoking and drinking, avoid irritating food, eat a little more, and avoid overeating.

Explain the necessity, safety and precautions of chemotherapy to patients.

Tell patients to check regularly and find early signs of recurrence in time, and see a doctor at any time when their condition changes.

Key assessment:

1 Does the patient take correct self-care measures?

2 Whether the patient understands and accepts chemotherapy.