帶狀皰疹三區(qū)終極版

護理臨床查房

Clinicalnursingwardround

國際住院部二科三區(qū)I.M.CInpatientDept.2Ward.3人員介紹會診醫(yī)師consultingstaff查房目的

RoundGoals掌握帶狀皰疹的護理。熟悉帶狀皰疹的病因、臨床表現(xiàn)及治療方法。Acquirethenursing

ofVZV.Befamiliarwiththe

theriskfactors,clinical

manifestation

and

treatmentofVZV.

查房目的RoundGoals提升護理人員的英文水平和學習興趣

PromotetheEnglish

levelandenhancetheinterestofnurses

inEnglishlearning.

Part1inquiry問診病例報告

CaseReport陽吉菊女69歲D:Hello,MrsYang,mynameisDrDu,IamadoctorofInternalMedicine.Iwillbelookingafteryou,howcanIhelpyou?P:Yesplease!D:Howoldareyou?P:69

病例報告

CaseReport現(xiàn)病史患者主因陣發(fā)頭痛1年，加重2天。于4月10日為進一步檢查收入我科。PresentHistoryD:Pleasetellmewhat’swrongwithyou?P:Ihavehadbadheadachefor2days.D:Haveyouhadthispainbefore?P:Comeinwavesforayear.

病例報告

CaseReport現(xiàn)病史無明顯誘因陣發(fā)右側頭痛，為針刺樣。無頭暈、嘔吐、視物模糊等伴隨癥狀,睡眠不佳。PresentHistoryD:Pleasepointtowhereyoufeelpain?P:Onmyrightside.D:Tellmewhatthepainislike?P:stabbing，itkeptmeawake.D:Doyouhavedizzinessorvomit?P:No.D:Doyouhaveblurringofvision?P:No.病例報告

CaseReport現(xiàn)病史頭顱CT無出血灶。PresentHistoryD:Haveyouhadanytestsrecently?P:IhadaheadCTandnohemorrhage.病例報告

CaseReport既往史

有腔隙性腦梗死病史否認冠心病、高血壓、糖尿病史否認藥物過敏史預防接種史不詳PreviousHistory

D:Doyouhaveanyexistingmedicalhealthproblem?P:Lacunarinfarction.D:Doyouhaveanyallergies?P:No,notthatIknowof..D:Areyourvaccinationscurrent?P:Iamnotsure.病例報告

CaseReport家族史家族中無類似病史，否認家族遺傳病史。FamilyHistory

D:Doyouhaveafamilyhistoryofhealthproblems?P:No病例報告

CaseReport個人史生于原籍否認疫區(qū)居住史否認毒物接觸史,無煙酒等不良嗜好PersonalHistoryD:Whereareyoulivedin?P:WhereIwasborn.D:Isthereanythingyouneedtotellmethatyouthinkwillbeuseful?P:No.病例報告

CaseReportD：你還有什么問題需要問我嗎？P：現(xiàn)在沒有。D：如果你有什么問題，你可以問護士，如果她不知道怎么辦，她會找知道的人來幫助你。D:Arethereanyquestionsyouwouldliketoaskme?P:No,notrightnow.D:Ifyouhaveanyproblems,pleaseaskthenurse,ifshecan’thelpyou,shewillfindsomeonewhocan.病例報告

CaseReportP：好的，非常感謝。D：不客氣，再見。P:Ok,thanksverymuch.D:You’rewelcome,seeyoulater.

經(jīng)查閱病歷、詳細詢問病史及查體后指示：患者目前頭痛部位以右側頭皮皮疹處為著，無顱內高壓癥狀及體征，建議聯(lián)系皮膚科專家會診進一步明確，密切觀察病情。Reviewingthecase,detailedinquiringmedicalhistoryandexaming,itisindicatedthatthepatientheadachelocationmainlyattherightscalprash,have’tsymptomsandsignsofintracranialhypertension.

Recommendedcontactdermatologisttodiagoseandobsevepatient’scondition.病例報告

CaseReport

Part2groupconsultation會診會診groupconsultation查體：右側頭皮、耳后、頸部散在小片片狀紅斑、丘疹，其上散在水皰，部分破潰滲出，觸痛。診斷為帶狀皰疹。外用青鵬軟膏口服鹽酸伐昔洛韋1g3/日維生素B1片20mg3/日甲鈷胺片500mg3/日普瑞巴林膠囊75mg2/日Dermatologyconsultation:clusterredpapulesonexaminationfoundthatleftback,adiagnosisofherpeszoster.Externaluse:Qingpengointment.Takeorally:Threetimesadaygallowayhydrochloricacid;ThreetimesadayvitaminB1;Threetimesadayapieceofcobaltamine;Twotimesadaylyricacapsule.

Part3Groupdiscussion小組討論帶狀皰疹是由水痘--帶狀皰疹病毒(varicella-zostervirus,VZV)引起的一種沿某一脊神經(jīng)或顱神經(jīng)單側分布的簇集性水皰和神經(jīng)痛為特征的病毒性皮膚病。Herpeszosteriscausedbythevaricella-zostervirusaalongaspinalnerveorthedistributionofthecranialnerveunilateralclusterblisterandneuralgiaoftheviralskindiseases.定義Definition診斷Diagnosis病變皮膚出現(xiàn)簇集成群水皰，沿一側周圍神經(jīng)呈帶狀分布。有明顯的神經(jīng)痛，伴局部淋巴結腫大。中間皮膚正常。theblisteralongonesideoftheperipheralneverontheattachedskin.Hasobviousneuralgia,withlocallymphnodeenlargement.Middlenormalskin.診斷Diagnosis從水皰液中分離chu病毒或檢測VZV，HSV抗原或DNA是鑒別診斷唯一可靠的方法。Findthevzv、theHSVantigenorDNAistheonlyreliablereasonforthediagnoise.病因及發(fā)病機制

Etiologyandpathogenesis

VZV

呼吸道黏膜respiratorymucosa

血液blood

顱神經(jīng)的感覺神經(jīng)

水痘

varicella

隱性感染inapparentinfection

脊髓后根神經(jīng)節(jié)

機體抵抗力下降

VZV被激活

沿感覺神經(jīng)下行

支配區(qū)域的皮膚復制

水皰blister

神經(jīng)炎neuritis典型表現(xiàn)Generalmanifestation前驅癥狀：輕度乏力、低熱、納差等全身癥狀，患處皮膚自覺灼熱感或者神經(jīng)痛，觸之有明顯的痛覺敏感，持續(xù)1～3天，亦可無前驅癥狀即發(fā)疹。Weak,low-gradefever,poor

appetite,loucalburningheatsensationorneuralgia,obvioussenseofpainlast1-3days,beforeblister,alsoblisterwithnoformanifestation.典型表現(xiàn)Generalmanifestation好發(fā)部位：肋間神經(jīng)、頸神經(jīng)、三叉神經(jīng)和腰骶神經(jīng)支配區(qū)域。Predilection:theskingovenedbyintercostal

nerve,cervial

nerve,trigeminal,lumbosacralnerve.典型表現(xiàn)Generalmanifestation出疹特點：首先出現(xiàn)潮紅斑，很快出現(xiàn)粟粒至黃豆大小的丘疹，簇狀分布而不融合，繼之迅速變?yōu)樗?，皰壁緊張發(fā)亮，皰液澄清，外周繞以紅暈，各簇水皰群間皮膚正常。Redspotfirstly,papulesoon,andthentheblisterwithcircumambientflush.典型表現(xiàn)Generalmanifestation皮損特點：沿某一周圍神經(jīng)呈帶狀排列，多發(fā)生在身體的一側，一般不超過正中線。ZonationInjuryalongsomeofperipheralnerve,alwaysoneofthesideofthebody,notcrossthemidline.典型表現(xiàn)Generalmanifestation神經(jīng)痛，可在發(fā)病前或伴隨皮損出現(xiàn)，老年患者常較為劇烈。病程一般2～3周，水皰干涸、結痂脫落后留有暫時性淡紅斑或色素沉著。

Neuralgiabeforetheblisterorfollowingtheskininjury,especiallytheolder.Courseofthedieasealways2-3weeks,temporaryerythema.特殊表現(xiàn)Specialmanifestation眼帶狀皰疹

三叉神經(jīng)眼支受累，眼瞼紅腫，結膜充血，可累及角膜形成潰瘍性角膜炎，疼痛劇烈。herpeszosterophthalmicusEyelidsredswollen、

conjunctivalcongestionandmaybetheulcerative

keratitiswithseverepainbysufferingfromtheeyebranchoftrigeminal.特殊表現(xiàn)Specialmanifestation耳帶狀皰疹

病毒侵犯面神經(jīng)及聽神經(jīng)所致，表現(xiàn)為外耳道或鼓膜皰疹?？沙霈F(xiàn)面癱、耳痛及外耳道皰疹三聯(lián)癥，稱為Ramsay—Hunt綜合征。herpeszosteroticus

此患者即為此特殊類型！特殊表現(xiàn)Specialmanifestation帶狀皰疹后遺神經(jīng)痛

帶狀皰疹常伴有神經(jīng)痛，在發(fā)疹前、發(fā)疹時以及皮損痊愈后均可發(fā)生，但多在皮損完全消退后或者1個月內消失，少數(shù)患者神經(jīng)痛可持續(xù)超過1個月以上。minorityNeuralgialastsmorethan1month.

特殊表現(xiàn)Specialmanifestation其他不典型帶狀皰疹

頓挫型；不全型；大皰型、出血性、壞疽型和泛發(fā)型；播散型帶狀皰疹。

Others

Forme

fruste(only

neuralgia);incomplete(red

spot,papule);big

blister;bleeding,gangrenous,generalizedanddisseminated.全身治療Systemictreatment抗病毒治療（盡早應用伐昔洛韋）止痛藥干擾素皮質醇類激素Antiviraltherapy(usevalaciclovirasearlyaspossible)PainkillerInterferonCortisolhormone局部治療Localtreatment復方鋅銅溶液或3%硼酸溶液作局部濕敷，外用3%～5%阿昔洛韋霜，1%噴昔洛韋霜，干擾素α-2b涂布劑，0.5%酞丁安搽劑等。眼部帶狀皰疹可用3%阿昔洛韋眼藥水，0.5%碘苷液，干擾素α眼藥水點眼，3～4次/d。Wetpackingwithcompoundzinccoppersolution,3%~5%Acyclovir、1%Penciclovir、α-2b

interferon、0.5%

Ftibamzone

applecations3%Acyclovin

eyedrop、0.5%lodineglycosidesliquid、αinterferon

3-4timeseverydayfortheherpeszosterophthalmicus局部治療Localtreatment物理療法：可用紫外線局部照射，音頻電療法和氦氖激光照射消炎止痛，縮短病。針刺療法。Naturopathy:irrradiatewithultravioletrays,heliumandnitrogenlaster；audioferquencycurrenttherapyAcupuncturetherapy

護理診斷

Nursingdiagnosis

1.疼痛

2.舒適的改變

3.皮膚完整性受損4.焦慮

Pain

Comfort,alteredSkinintegrity,impairedAnxiety護理措施NursingIntervention

診斷1:疼痛

--與疾病引起的神經(jīng)痛有關護理措施--遵醫(yī)囑給予鎮(zhèn)痛劑--做好心理護理，充分發(fā)揮心理鎮(zhèn)痛效應。PainrelatedtotheneuralgiaImplementation--Givetheanalgesicasthedoctor’solder--Psychologicalnursing

護理措施NursingIntervention

診斷2:舒適的改變

--與所患疾病引起疼痛及體位受限有關護理措施1.密切觀察病情變化，取舒適臥位。2.盡量保持病房安靜，減少不良刺激。

Comfort,altered

--related

tothepainandlimitedposition

Implementation

--Observethechangesofillnessclosely,getthecomfortablelyingposition

--Reducethepessimal

stimulation護理措施

NursingIntervention

診斷3:皮膚完整性受損

--與疾病引起的水皰破裂有關Skinintegrity,impaired--relatedtotheblistersrupture

護理措施NursingIntervention

Implementation

--Antiphlogosis、arefactionmainly

--No

scratching,improvepatienttraining,topreventthespreadoflesions.

護理措施1.皰疹處以消炎、干燥為主。2.不要搔抓患處，加強患者宣教，避免病灶擴散。改英文部分護理措施

NursingIntervention護理措施3.泡液未破：阿昔洛韋乳膏涂抹。4.皰疹破潰后：雙氧水、生理鹽水清洗，再用0.5%甲硝唑液局部濕敷。Implementation--Acyclovirapplecationswiththewholeblister--Douchewithhydrogenperoxideandnormalsaline、localwetpackingwith0.5%

metronidazolewhenrupture.護理措施NursingIntervention

診斷4:焦慮--與擔心疾病預后有關。

ActivityIntolerance

--relatedtotheillness’prognosis護理措施

NursingIntervention

護理措施1.向病人及家屬講解疾病相關知識、成功治療經(jīng)驗，增強戰(zhàn)勝疾病的信心。2.宣傳重視預防頸椎病，避免情緒波動，及時開導患者，緩解頸椎病的癥狀和預防復發(fā)。Implementation--introducetheinformationabouttheVZVandthesuccessfultreatmentexperiencestothepatiencesandtherelatives.--disseminatetopreventcervicalspondylosis,avoidmoodswing.護理措施

NursingIntervention

護理措施2.宣傳重視預防頸椎病，避免情緒波動，及時開導患者，緩解頸椎病的癥狀和預防復發(fā)。Implementation--disseminatetopreventcervic