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39.女性, 48 岁,突发上腹痛 6 小时,伴高热,皮肤巩膜发黄。既往:胆总管结石 2 年。体检:一般情况差, T39.8°C,P120 次/分,R24次 /分,BP80/60mmHg,四肢湿冷,皮肤发花,心肺( -),腹软,右上腹压痛( +),反跳痛( +),肌紧张( +),Murphy 征( +),肠鸣音弱。

问:

(1)医疗诊断是什么?

(2)目前治疗原则是什么?

(3)列举目前 2 个护理诊断 /问题。

(4)护理要点有哪些?

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正确答案:

(1)医疗诊断: 急性梗阻性化脓性胆管炎。

(2)治疗原则:手术为主。

(3)目前主要的护理诊断 /问题:

1)疼痛与胆道炎症有关。

2)体温升高与感染有关。

(4)缓解疼痛和控制感染

1)关注病人疼痛主诉,加强心理支持。

2)定时监测体温,必要时给予物理降温。

3)合理应用药物,并做好疗效和副作用观察。①解痉镇痛剂:胆道疾病主要通过解痉达到止痛目的,必要时可用镇痛剂,但禁用吗啡,吗啡可使 Oddi 括约肌痉挛,加重病情。②抗生素:宜选用对肝脏毒性较小的抗生素。 ③中医中药: 采用疏肝利胆、 清热利湿、 解毒攻下、开窍及回阳救逆等方法,有一定疗效。

4)重视生命体征变化:注意体温波动,感染转归,定时监测血压、脉搏,及时发现并处理休克。

5)动态观察腹部症状和体征改变:观察腹痛、腹部压痛、反跳痛、肌紧张的程度、范围,黄疸变化,食欲情况,大、小便色泽,病人有无呕血、黑便等。

6)注意识别脱水、电解质及酸碱失衡征象。

7)及时了解实验室和其他辅助检查结果。

答案解析:

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