消化系統(tǒng)疾病病人的健康評估課件

消化系統(tǒng)疾病患者的

健康評估

HealthAssessmentof

TheDigestiveSystem學習目標熟悉腸胃系統(tǒng)的正常功能認識腸胃系統(tǒng)的異常表現(xiàn)掌握腸胃系統(tǒng)的評估要點熟悉腸胃系統(tǒng)評估技巧分辨不同年紀、性別、疾病譜在消化系統(tǒng)的表現(xiàn)

GISystemAssessment

消化系統(tǒng)評估健康史:生活背景Biographicalanddemographicdata目前健康狀況CurrentHealth過去健康病史PastHealthhistory家族史FamilyHealth心理社會因素PsychosocialFactors系統(tǒng)回顧ReviewofsystemCurrentHealthAssessment

目前健康評估評估主訴是否出現(xiàn)：惡心、嘔吐吞咽困難：梗阻與疼痛不消化：反酸或噯氣腹痛嘔血、便血腹瀉、便秘腹水黃疸體重及食欲改變.PastHealthHistory過去病史Bleeding-irondeficiencyanemiaLiverDisease:proteinmalnutritionPepticUlcerWithbleedingJaundiceGallbladdersiseasePancreatitisCancerChangeofbowelhabitsTarrystoolsUnexplainedweightlossorgainHealthHistoryofTheGISystemHealthPerception-healthmanagementpatternNutritional-metabolicpatternEliminationpatternActivity-exercisepatternSleep-RestPatternCongitive-preceptionpatternSelf-Perception,self-conceptpatternRole-relationshippatternSexuality-reproductivepatternCoping-stresstolerancepatternValue-beliefpatternLewis,2004,p.955AssessforMedications

藥物評估UseofAspirin,NAISD(Nonsteroidalanti-inflammatorydrugs)–gastritis/bleeding是否使用阿斯匹林，非激素類止痛藥，胃出血Antacids:typeandfrequency制酸劑，種類、頻率Laxativesorstoolsofteners?軟便劑DietarySupplement:vitamins,minerals,herbs,aminoacids食品補充，維生素、草藥、蛋白質(zhì)AssessmentforFamilyHistoryGIproblemmayassociatewithfamilyhistoryandenvironmentfactors.Ulcerativecolitis潰瘍性結(jié)腸炎Crohn’sDisease克羅恩病Alcoholism酗酒Liverdiseases肝臟疾病FamilyhistoryofDM,anemia,jaundice,hepatitis,Pancreatitis,obesity,irritablebowelsyndrome.糖尿病家族史、貧血、黃疸、肝炎、胰臟炎、肥胖、小腸激惹癥候群AssessmentofGISystem

AbdomenInspection視診skinintact,smooth皮膚完整、平滑Contour:flat,rounded,nodistentionorirregularcontour形狀，腹脹、不規(guī)則形狀Rashes,discoloration,scares,petechiae,striate,dilatedveins紅疹、變色、疤痕、青紫、橫紋、擴張靜脈Peristalticmovementifpthasobstructionofthebowel小腸阻塞可見腸蠕動運動Abdominalpulsation腹部可見脈動AssessmentoftheGIsystem

MouthLips:symmetry,color,hydration,lesions,nodules,positionofteeth(malocclusion),dentalcaries,colorofmucosaandgums,swellingorlesions,leukoplakislesion（白斑）Tonsils:redness,swelling,lesions,ulcers,Tongue:color,moisture,atrophy,abnormalcoating,swelling,lesions,symmetrymovement,difficultytoswallow(Dysphagia吞咽困難)AssessmentforOralDisordersStomatitis:Aphthousulcer(unknown),口腔潰瘍HerpesSimplex(HSVinfection),皰疹Oralcandidiasis-Thrush(CandidaAlbicansfungusinfection)念珠球菌感染Assessforimmunosuppression,prolongedantibioticuse,pain,tenderness,bleeding,oralintake/nutrition（免疫低下者，長期使用抗生素者、疼痛、壓痛、出血、營養(yǎng)進食情況）AssessmentofOralDisorderPremalignanttumor：惡性腫瘤前期Leukoplasia白斑Erythroplakia紅斑Tumoroftheoralcavity:BasalcellorSquamouscellcarcinomaRiskfactor:tobaccoandlongtermalcoholconsumption,VeryHotbeverages,檳榔評估吞咽困難（Dysphagia）

口腔疾?。?/p>

吞咽時梗阻與疼痛，感覺吞咽時間延長，口腔潰瘍扁桃體炎咽炎咽壁濃腫、腫瘤急性喉咽喉頭水腫喉癌Assessmentofthe

SalivaryGlands唾液腺SingsofinflammationInactivityoftheglandcausedbymedicationorprolongedNGtube,NPODrymouthBadbreathorderfrombacteriaaccumulatedinthemouthduetoinsufficientsalivary.評估吞咽困難（Dysphagia）

食管疾病食管炎食管潰瘍食管狹窄食管異常或先天性異常食管裂孔疝噴門口失馳緩癥食管癌AssessmentofGISystem

AbdomenAuscultation:AirandfluidmovethroughtheGItract,softclicksandgurglesq5-15sec.Normalbowelsound:irregular4-5/minHyperactivity:Loud,high-pitchsoundoftheGItract,>10/min-GIbleeding,acutegastroenteritis3.Hypoactivity:fewbowelsound(listenfor5minutesor1minuteeachquadrant(absenceofbowelsoundsdoesnotmeanabsenceofbowelperistalsis)腹部疼痛的病因與特征－1腹部臟器扭轉(zhuǎn)或阻塞（Organobstructionortwisting）:intermittentcollickypain,間斷性絞痛underumbilicusassociatewithsmallbowel在臍部位與小腸有關(guān).distendedabdomenwithnoflatusorbowelmovement,腹脹，缺乏排氣或腸蠕動bowelsoundmaychangefromhighpitchtoabsent腸鳴音由高音到消失腹部疼痛的病因與特征－2腹部臟器炎癥：Peritonealinflammation(Perforatedulcer,rupturedspleen,rupturedappendix)Steadyachingpainoverareaofinflammation,在炎癥部位疼痛painincreasedwithmotion,活動時疼痛增加mayassociatewithshockifpainissevere過度疼痛時可能與休克有關(guān)AssessmentforRegurgitation

評估反流（反酸）Regurgitation是指酸性胃液反流到口腔的現(xiàn)象。 導因：炎癥、潰瘍、腫瘤使噴門擴約肌松弛，胃逆蠕動增加，使胃酸容易反流入口腔，侵蝕食管，容易引起酸性胃液反流入口，胸骨后燒灼感AssessmentofVomiting患者的嘔吐物需要仔細評估量、色、性質(zhì)、頻率、反射性嘔吐？誘發(fā)因素？是否帶血樣？是否呈咖啡色樣液體，嘔吐后生理變化患者有哪些過去病史、現(xiàn)在疾病導致嘔吐或嘔血？食管、胃、十二指腸、粘膜、潰瘍、癌癥、胰膽疾病等因素需要評估評估腹水

AssessmentofAscites腹腔內(nèi)過多液體積聚，分為漿液性、血性、濃性、乳糜性，依照腹水中的蛋白含量、比重、細胞量而區(qū)分。引起腹水原因包括：肝硬化、重度肝炎、腹膜炎、癌癥、心衰竭等。評估腹水影響：呼吸、皮膚完整性、血清蛋白缺失、體重變化、行動、活動度，舒適程度Assessmentofthe

LiverandSpleenHepatomegaly肝臟腫大:enlargementofliver,liveredge>1-2cmbelowcostalmargin(possibleHepatitis肝炎,venouscongestion靜脈充血,metastaticcarcinoma腫瘤轉(zhuǎn)移)Splenomegaly脾臟腫大:Enlargementofspleen(possibleportalhypertension門靜脈高壓,infection感染)下胃腸道系統(tǒng)癥狀評估分析：時間：出現(xiàn)時間及持續(xù)，突發(fā)？是否與進食有關(guān)性質(zhì)與量：敘述疼痛性質(zhì)，深、悶痛、彌散性疼痛，腹瀉與血便性質(zhì)部位：反射其它部位，涉及肝臟、脾臟、闌尾區(qū)、直腸？誘因：壓力、食物、藥物相關(guān)表現(xiàn)：生活影響、食物不耐受、黃疸、腹水、腹部絞痛等下胃腸道健康評估腹部評估：腹脹、腫塊、對等性、明顯的腸蠕動、臍或腹股溝疝氣、腸鳴音、腹水、腹痛區(qū)是否反射性疼痛、反跳性疼痛（Reboundtenderness)肛門與直腸：痔瘡、脫肛、皮膚完整性、紅疹、潰瘍、肛裂（AnalFissure）、瘺管（AnalFistula）、膿腫（Anorectalabscess）AssessmentoftheBowelElimination年齡與性別：Colorectalcancer常見于年紀長者、男性潰瘍性結(jié)腸炎Ulcerativecolitis常發(fā)生于中年白種人，猶太人Diverticulardisease常見于已開發(fā)國家精制食物攝取較多Assessmentfor

BowelEliminationAscites腹水Diarrhea腹瀉Constipation便秘Melena便血PaininRectalorAbdominal:腹部疼痛或肛門疼痛AssessmentofDiarrheaandConstipationDiarrhea:acuteorchronic(>2monthsofdiarrhea評估腹瀉后生理變化：滲透壓升高、消化不完全、腸蠕動過快、腸內(nèi)容物水份高、消化不完全急性腹瀉：與細菌感染有關(guān)、與進食感染源有關(guān)，包括菌痢評估腹瀉Diarrhea腹瀉性質(zhì)、頻率、量。是否腹痛及里急后重感？是否有腸粘膜破壞？濃樣血便？水樣便？飲食不潔？細菌感染？常見的致病菌為：大腸桿菌、沙門菌、輪狀病毒、腸病毒、血吸蟲等。可依可能的感染途徑評估致病因素。評估便血消化道出血，由肛門排出，顏色與出血量、時間、部位有關(guān)。下消化道出血，近直腸肛門部位，停留時間短：鮮紅上消化道出血，通過腸道，Hb

與腸道硫化物結(jié)合，形成黑色便（TarryStool）鑒別：腸道細菌感染或炎癥，腸道腫瘤、息肉、痔瘡、克羅恩病、腸套疊等。評估便秘

Constipation結(jié)腸性便秘：結(jié)腸內(nèi)的機械梗阻，結(jié)腸蠕動減少、結(jié)腸痙攣直腸性便秘：直腸肛周病變所致，生活習慣改變，排便習慣不正確，常服用瀉藥或灌腸，導致直腸粘膜感受器的敏感性降低，常發(fā)生于老年人及長期臥床休息者。PhysicalAssessment

AnnusandRectumAssessfor:Tenderness,壓痛Masses,腫塊hemorrhoids,痔瘡Prolapsed,脫垂Rectalmucosasmooth,直腸粘膜平滑Stoolnegativeforblood便血陰性

AgingPatientGIAssessment

年長者腸胃系統(tǒng)評估Mouth:LossofteethDecreasedtastebuds,decreasedsenseofsmell胃蕾減少，嗅覺下降Decreasedvolumeofsaliva唾液減少Atrophyofgingivaltissue牙齦萎縮AgingPatientGIAssessment

年長者腸胃系統(tǒng)評估Esophagus食管Decreasedtoneandmotility降低張力及動力AgingPatientGIAssessment

年長者腸胃系統(tǒng)評估AbdominalWallThinerandlesstautDecreseinnumberandsensitivityofsensoryreceptorsMorevisibleperistalsisStomach:Decreasedacidsecretion,atrophyofgastricmucosa降低胃酸分泌，胃粘膜萎縮AgingPatientGIAssessment

年長者腸胃系統(tǒng)評估SmallIntestines:小腸Decreasedsecretionofmostdigestiveenzymes,消化液分泌減少Decreasedmoltility-complainofindigestion動力降低，主述“不消化”Liver:肝臟Decreasedsizeandloweredinposition降低尺寸及位置AgingPatientGIAssessment

年長者腸胃系統(tǒng)評估Largeintestine,anus,rectum:大腸、肛門、直腸Decreasedanalsphinctertoneandnervetorectalarea-fecalincontinence肛門擴約肌張力及神經(jīng)傳導下降，失禁Decreasedmusculartone,decreasedmotility-Flatulence,abdominaldistensionconstipation,fecalimpactio