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泌尿外科小讲课之输尿管结石课件

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泌尿外科小讲课之输尿管结石PPT 泌尿外科小讲课之输尿管结石课件 泌尿外科小讲课 小讲课泌尿系结石 输尿管结石输尿管结石 泌尿外科小讲课之输尿管结石 小讲课ppt课件
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *1 泌尿外科小讲课 • ——输尿管结石 • 护理本科:钟代霞 • 纪晓东 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (一)概述与病因学 (二)临床表现与诊断 (三)辅助检查与治疗 (四)护理措施与健康教育 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (一)概述与病因学 1、概述 2、病因学 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1、概述 • 输尿管结石绝大多数来源于肾脏,包括肾结 石或体外震波后结石碎块降落所致。由于尿盐晶 体较易随尿液排入膀胱,故原发性输尿管结石极 少见。有输尿管狭窄、憩室、异物等诱发因素时 ,尿液滞留和感染会促使发生输尿管结石。输尿 管结石大多为单个,左右侧发病大致相似,双侧 输尿管结石约占2~6%。临床多见于青壮年,20 ~40岁发病率最高,男与女之比为4.5∶1,结石位 于输尿管下段最多,约占50~60%。输尿管结石 之上尿流均能引起梗阻和扩张积水,并危及患肾 ,严重时可使肾功能逐渐丧失。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2、病因学 • (1)输尿管狭窄:输尿管结石容易嵌顿在3个生理性狭窄处,即肾盂输尿管 连接处、输尿管跨越髂血管处及输尿管膀胱壁段。 • (2)环境因素:地理环境和气候,且具有一定的地区性。山区、沙漠、热带和 亚热带地域尿石症发病率较高,这主要与饮食习惯、温度、湿度等环境因素有关。 • (3)饮食因素:饮食不良是形成输尿管结石的重要原因。有资料表明,饮食中 大量摄入动物蛋白、精制糖,可增加上尿路结石形成的危险性。其他如脂肪、嘌呤、草 酸、钙、磷、微量元素、维生素等都会影响尿结石的形成。营养状况好,动物蛋白摄入 过多时,容易形成肾结石。 • (4)水分摄入:任何破坏水的摄入量与损失量平衡的因素如出汗过多,都会使 尿液中钙和盐的过饱度增加,有利于尿结石的形成。反之,大量饮水使尿液稀释,能减 少尿中晶体形成。 • (5)疾病因素:有些输尿管结石的形成与遗传性疾病有关,如胱氨酸尿症、家 族性黄嘌呤尿等。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二)临床表现与诊断 1、临床表现 2、诊断 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1、临床表现 Ø Text Ø Text Ø Text 1.1疼痛 结石活动或引起输尿管完全梗阻时可引起肾绞痛,典型表现为 突发性疼痛,剧烈难忍,多在深夜至凌晨发作,持续数分钟至 数小时不等。疼痛位于腰部或上腹部,沿输尿管放射至同侧下 腹和会阴部,可至大腿内侧。疼痛性质为刀割样阵发性绞痛, 发作时病人精神恐惧,坐卧不安,面色苍白、冷汗,甚至休克 ,可伴恶心、呕吐。结石位于输尿管膀胱壁段和输尿管口,可 伴有膀胱刺激征及尿道和阴茎头部放射痛。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Ø Text Ø Text Ø Text 1.2血尿与并发症 病人常有肉眼或镜下血尿,后者常见。有些病人活动后 出现镜下血尿是其唯一表现。 结石并发急性肾盂肾炎或肾积脓时,可有发热、畏寒、 脓尿、肾区压痛。结石引起肾积水时,可在上腹部触及增大 的肾脏,双侧上尿路完全梗阻时可导致无尿,甚至出现尿毒 症。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Ø Text Ø Text Ø Text 2、诊断 根据典型的临床表现,结合实验室检查及B超,X线检查 ,多数上尿路结石不难诊断,但不应满足于此,应同时了解 结石的部位,大小,数目及有无梗阻和感染,肾功能受损的 情况,结石成分和形成结石的原发病因,了解结石成分和形 成结石的病因,有利于采取措施预防结石的复发。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三)辅助检查与治疗 1、辅助检查 2、治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1、辅助检查 • 1.1实验室检查 • 1.血清检查: 钙,磷,尿酸,血浆蛋白,血二氧化碳结合力,钾, 钠,氯,肌酐等。 • 2.尿液检查 • (1)尿常规:蛋白阴性或微量,酸碱度因结石成分不同而异,镜检 可见红细胞,如合并感染,可见到脓细胞,有时尿中可见到结晶和结 晶团块。 • (2)尿培养及细菌药物敏感试验。(3)24h尿液分析:测定钙,磷, 尿酸,草酸,胱氨酸,镁,钠,氯化物,枸橼酸,肌酐等。 • 3.结石成分分析 • 4.特殊代谢检查: 如肾小管酸中毒的尿液检查,甲状旁腺功能亢 进的代谢检查,高钙尿的实验室检查等。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 辅助检查 • 1.2影像学检查 • 1.泌尿系平片和断层平片 • 2.排泄性尿路造影 • 3.B型超声检查:结石表现为特殊声影,能发现平片上不能显示的 小结石和透X线结石,可了解结石梗阻对肾脏结构的影响。 • 4.膀胱镜检查和逆行肾盂造影:膀胱镜检查不作为常规检查, 它适用于排泄性尿路造影仍诊断不明的情况,如静脉肾盂造影。 • 5.CT :对X光线不显影的尿酸结石,CT可以确诊。 • 6.输尿管肾镜检查:KUB未显示结石而IVP显示有充盈缺损,不能 确诊,作此检查能明确诊断。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2、治疗 (1)病因治疗 (2)非手术治疗 (3)手术治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Ø Text Ø Text Ø Text (1)病因治疗 早发现、早诊断、早治疗。如切除甲状旁 腺瘤、解除尿路梗阻。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (2)非手术治疗 • 结石直径0.6cm、表面光滑、无尿路梗阻、无感染,纯 尿酸或胱氨酸结石的病人,可行非手术治疗。 • 1.饮食疗法 •(1)水化疗法:大量饮水是防治各种成分尿路结石简单而有效的方法。每 日饮水量在2500~4000ml,保持每日尿量在2000ml以上。 •(2)食物疗法:(a).含钙结石:低钙、低蛋白、低钠饮食,同时限制含 草酸多的食物,如菠菜、甜菜、茶等。(b)尿酸结石:低嘌呤饮食,忌食动 物内脏,限制各种肉类和鱼虾类等富含嘌呤的高蛋白食物。(c)胱氨酸结石 :限制含蛋氨酸的食物,如蛋、奶等。 • 2.药物治疗:对已排出的结石或经手术取出的结石做结石成分分析 ,确定药物治疗的方案。 •(1)调节尿PH:调节尿PH可增加结石的溶解度。 •(2)调节代谢:别嘌醇可降低血、尿的尿酸含量,可治疗尿酸结石 。 •(3)中药和针灸:可解痉、止痛,促进小结石的排出。常用中药有 金钱草、车前子,常用穴位有肾俞、膀胱俞等。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 非手术治疗 •(3)中药和针灸:可解痉、止痛,促进小结石的排出。常用中药 有金钱草、车前子,常用穴位有肾俞、膀胱俞等。 •(4)控制感染:根据尿细菌培养药物敏感试验选用合适的抗菌药物 控制感染。 •(5)解痉止痛:常用药物哌替啶、黄体酮。 •3.体外冲击波碎石(ESWL):在x线或B超定位下, 利用高能冲击波聚焦后作用于结石,使之分裂、粉碎成细砂 ,随尿液排出。碎石效果与结石部位、大小、性质、是否嵌 顿等因素有关。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (3)手术治疗 • 1.内镜取石或碎石术 • (1)经皮肾镜取石或碎石术(PCNL):适用于结石远端尿 路梗阻、质硬结石、残留结石、复发结石等。 • (2)输尿管镜取石或碎石术(URL):输尿管镜经尿道插入 膀胱,沿输尿管直视下套石或取石。 • (3)腹腔镜输尿管取石(LUL):适用于直径大于2cm的输 尿管结石,或经ESWL、输尿管手术失败者。 • 2.开放手术 • 适用于结石远端存在梗阻、部分泌尿系统畸形、结石嵌顿紧密、其 它治疗无效、肾积水感染严重或病肾功能丧失的尿石症病人。主要术 式有肾盂切开取石术、输尿管切开取石术等。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (四)护理措施与健康教育 1、常见护理诊断 2、非手术治疗及ESWL的护理 3、内镜取石术的护理 4、健康教育 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 1、常见护理诊断 • (1)急性疼痛:与结石刺激引起的炎症、损伤及 平滑肌痉挛有关 • (2)知识缺乏:缺乏预防尿石症的知识 • (3)排尿形态异常:与尿路梗阻有关 • (4)潜在并发症:感染、“石街”形成 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 2、非手术治疗及ESWL的护理 • 1.1非手术治疗的护理 • (1)缓解疼痛:卧床休息,指导病人做深呼吸、放松以减轻疼痛 ,遵医嘱使用解痉止痛药物,并观察疼痛的缓解情况。 • (2)鼓励病人大量饮水、多活动:可稀释尿液、预防感染、 促进排石。在病情允许的情况下,适当做一些跳跃运动或经常改变体 位,有助于结石排出。 • (3)病情观察:观察尿液的颜色与性状、体温及尿液检查结果, 及早发现感染征象。做结石成分分析,以指导结石预防与治疗。 • 2.2体外冲击波碎石(ESWL)的护理 • (1)术前护理 •A.心理护理:向病人及家属解释ESWL的方法、碎石效果及配合要求 ,解除病人的顾虑。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 非手术治疗及ESWL的护理 •B、术前准备:术前三天忌食产气食物,术日晨禁食,术晨型泌尿系 统x线平片复查,了解结石是否移位或排出。复查后用平车接送病人 ,以免结石因活动再次移位。 •C、术后护理: •(a)术后卧床休息6个小时,鼓励病人多饮水,增加尿量。 •(b)采取有效运动和体位。一般患侧在上,大结石碎石后患侧在下 ,利于结石随尿液缓慢排出。 •(c)并发症的观察与护理: • 1、血尿:多数病人术后均有暂时性肉眼血尿,一般不需处理。 • 2、发热:尿路感染引起发热,遵医嘱使用抗生素,高热者采 用降温措施。 • 3、疼痛:予以解痉止痛处理。 • 4、“石街”形成:是ESWL常见且较为严重的并发症之一。需立 即经输尿管镜取石或碎石。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三)内镜碎石的护理 • 1、术前护理 • (1)心理护理:像病人及家属解释内镜碎石术的方法和优点,术 中的配合要求及注意事项,解除病人的顾虑,使其更好的配合手术与 护理。 • (2)术前准备: • A、协助做好术前准备:除常规检查外,应注意病人的凝血功能是 否正常。 • B、体位训练:术中病人需取结石位或俯卧位,体位训练以提高病 人术中体位的耐受性。 • C、术前一日备皮、配血术前晚行清洁灌肠。 • 2、术后护理: • (1)病情观察:观察病人生命体征,尿液颜色和性状。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 内镜碎石术的护理 • (2)引流管护理: • A.尿管:妥善固定,保持引流通畅,防折叠挤压,观察引流出尿液 颜色、性质和量,掌握拔管指征。 • B.双“J”管:碎石术后于输尿管内放置双“J”管,可起到引流、内支 架的作用,还可以扩张输尿管,有助于小结石的排出,防止输尿管内 “石街”的形成。护理: • a:术后指导病人尽早取半卧位,多饮水、勤排尿,勿使膀胱过度 充盈引起尿液反流; • b:鼓励病人早期下床活动,避免活动不当(如剧烈活动、过度弯 腰、突然下蹲等)引起双“J”管滑脱或上下移位; • c:双“J”管一般留置4~6周,经B超或腹部摄片复查确定无结石残留 后,膀胱镜下取出双“J”管。 • (3)并发症的观察与护理 • A.出血:若术后短时间内引流出大量鲜红色血性液体,须警惕大 出血。应安慰病人,嘱其安静休息,及时报告医处理。除应用止血药 、抗生素等处理外,可夹毕造瘘管1~3小时,已达到压迫止血的目的 。若出血停止,病人生命体征平稳,可重新开放造瘘管。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 内镜碎石的护理 •B.感染:术后密切观察病人体温变化;遵医嘱应用抗生素,嘱病人多 饮水;保持各引流管通畅,留置尿管者应清洁尿道口与会阴部;造瘘 口的应定时更换敷料,保持皮肤干燥、清洁。 •c.疼痛:转移病人注意力,指导病人深呼吸。使用解痉止痛药 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (四)健康教育 • 1、尿石症的预防:结石的发病率和复发率很高,因而适宜的预防 措施对减少或延迟结石的复发十分重要。 •(1)嘱病人大量饮水:每日饮水2500~4000ml •(2)饮食指导:含钙结石者应合理摄入钙量,适当减少牛奶、奶制 品、豆制品、巧克力、坚果等含钙高的食物;草酸结石者,限制浓茶 、菠菜、番茄等食物;尿酸结石者不宜食用含嘌呤高的食物,如动物 内脏、豆制品、啤酒。避免大量摄入动物蛋白、精制糖和动物脂肪。 •(3)药物预防:草酸钙结石病人可口服维生素B6以减少草酸盐排出 ;口服氧化镁可增加尿中草酸溶解度。尿酸结石病人可口服别嘌呤醇 和碳酸氢钠,以抑制结石形成。 •(4)特殊性预防:伴甲状腺功能亢进者,必须摘除腺瘤或增生组织 。鼓励长期卧床者多活动,防止骨脱钙,减少尿钙排出。尽早解除尿 路梗阻、感染、异物等因素。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 健康教育 • 2.双“J”管的自我观察与护理:部分病人行碎石术后带 双“J”管出院,期间若出现排尿疼痛、尿频、血尿时,多为 双“J”管膀胱端刺激所致,一般多饮水和对症处理后可缓解 。嘱病人术后4周回院复查并拔出双“J”管。 • 3.复查:定期行X线或B超检查,观察有无残余结石或结 石复发。若出现腰痛、血尿等症状,及时就诊。 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 *27 • •Thank you!Thank you!
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