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1、消化系统疾病患者的 健康评估 Health Assessment of The Digestive System,学习目标,熟悉肠胃系统的正常功能 认识肠胃系统的异常表现 掌握肠胃系统的评估要点 熟悉肠胃系统评估技巧 分辨不同年纪、性别、疾病谱在消化系统的表现,GI System Assessment 消化系统评估,健康史: 生活背景Biographical and demographic data 目前健康状况 Current Health 过去健康病史 Past Health history 家族史 Family Health 心理社会因素 Psychosocial Factors 系统回
2、顾 Review of system,Demographic Data 背景资料评估,Gender Age Marital Status Working condition Women (calcium), elderly (inadequate food intake, gastric ulcer, colon cancer), teenagers (Duodenal ulcers, gastric cancers) may have different health problem and nutritional needs.,Current Health Assessment 目前健康评
3、估,评估主诉是否出现： 恶心、呕吐 吞咽困难：梗阻与疼痛 不消化 ：反酸或嗳气 腹痛 呕血、便血 腹泻、便秘 腹水 黄疸 体重及食欲改变.,Past Health History 过去病史,Bleeding-iron deficiency anemia Liver Disease: protein malnutrition Peptic Ulcer With bleeding,Jaundice Gallbladder sisease Pancreatitis Cancer Change of bowel habits Tarry stools Unexplained weight loss o
4、r gain,Health History of The GI System,Health Perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-Rest Pattern Congitive-preception pattern Self-Perception, self-concept pattern Role-relationship pattern Sexuality-reproductive patter
5、n Coping-stress tolerance pattern Value-belief pattern,Lewis, 2004, p.955,Assess for Medications 药物评估,Use of Aspirin, NAISD (Nonsteroidal anti-inflammatory drugs) gastritis/bleeding是否使用阿斯匹林，非激素类止痛药，胃出血 Antacids: type and frequency 制酸剂，种类、频率 Laxatives or stool softeners? 软便剂 Dietary Supplement: vitam
6、ins,minerals, herbs, amino acids 食品补充，维生素、草药、蛋白质,Assessment for Allergies 评估过敏史,Food allergies: hives or dyspnea Food intolerance: GI abdominal cramping, flatulence, or diarrhea (lactose intolerance) Comment food allergies items: nuts, shellfish, cows milk, food additives,Assessment for Family Histo
7、ry,GI problem may associate with family history and environment factors. Ulcerative colitis 溃疡性结肠炎 Crohns Disease 克罗恩病 Alcoholism 酗酒 Liver diseases 肝脏疾病 Family history of DM, anemia, jaundice, hepatitis, Pancreatitis, obesity, irritable bowel syndrome. 糖尿病家族史、贫血、黄疸、肝炎、胰脏炎、肥胖、小肠激惹症候群,Psychosocial His
8、tory 心理社会病史,Occupation: environmental toxins (lead, mercury, carbon tetrachloride) Travel: Pathogens (protozoa, parasites),eating raw shellfish, swimming in polluted water Diet habits change,Assessment of GI System Abdomen,Inspection 视诊 skin intact, smooth 皮肤完整、平滑 Contour: flat, rounded, no distenti
9、on or irregular contour 形状，腹胀、不规则形状 Rashes, discoloration, scares, petechiae, striate, dilated veins 红疹、变色、疤痕、青紫、横纹、扩张静脉 Peristaltic movement if pt has obstruction of the bowel 小肠阻塞可见肠蠕动运动 Abdominal pulsation 腹部可见脉动,Review of System 系统回顾,Mouth:oral lesions, excessive salivation, mouth dryness, oral
10、ulcer Dental cavity: floss usage Water supply with fluoridate? Dentist for teeth cleaning Periodontal disease Trouble tasting, chewing or swallowing?,Assessment of the GI system Mouth,Lips: symmetry, color, hydration, lesions, nodules, position of teeth (malocclusion), dental caries, color of mucosa
11、 and gums, swelling or lesions, leukoplakis lesion （白斑） Tonsils: redness, swelling, lesions, ulcers, Tongue: color, moisture, atrophy, abnormal coating, swelling, lesions, symmetry movement, difficulty to swallow (Dysphagia 吞咽困难),Assessment for Oral Disorders,Stomatitis: Aphthous ulcer (unknown), 口腔
12、溃疡 Herpes Simplex (HSV infection), 疱疹 Oral candidiasis-Thrush (Candida Albicans fungus infection)念珠球菌感染 Assess for immunosuppression, prolonged antibiotic use, pain, tenderness, bleeding, oral intake/nutrition （免疫低下者，长期使用抗生素者、疼痛、压痛、出血、营养进食情况）,Assessment of Oral Disorder,Premalignant tumor：恶性肿瘤前期 Leu
13、koplasia 白斑 Erythroplakia 红斑 Tumor of the oral cavity: Basal cell or Squamous cell carcinoma Risk factor: tobacco and long term alcohol consumption, Very Hot beverages, 槟榔,评估吞咽困难 （Dysphagia） 口腔疾病：,吞咽时梗阻与疼痛，感觉吞咽时间延长， 口腔溃疡 扁桃体炎 咽炎 咽壁浓肿、肿瘤 急性喉咽 喉头水肿 喉癌,Assessment of the Salivary Glands 唾液腺,Sings of inf
14、lammation Inactivity of the gland caused by medication or prolonged NG tube, NPO Dry mouth Bad breath order from bacteria accumulated in the mouth due to insufficient salivary.,Assessment of Esophagus 食管评估,Dysphagia 吞咽困难 Regurgitation 反流: reflux can affect respiratory tract Pain 疼痛 Heartburn or pyro
15、sis 烧灼感,评估吞咽困难（Dysphagia） 食管疾病,食管炎 食管溃疡 食管狭窄 食管异常或先天性异常 食管裂孔疝 喷门口失驰缓症 食管癌,Assessment of GI System Abdomen,Auscultation: Air and fluid move through the GI tract, soft clicks and gurgles q5-15 sec. Normal bowel sound: irregular 4-5/min Hyperactivity: Loud, high-pitch sound of the GI tract, 10/min-GI b
16、leeding, acute gastroenteritis 3. Hypoactivity: few bowel sound (listen for 5 minutes or 1 minute each quadrant (absence of bowel sounds does not mean absence of bowel peristalsis),Assessment of GI System Abdomen,Percussion/Palpation 疼痛部位、性质（钝、绞痛）腹肌柔软度、是否出现压痛或反跳痛、剧烈绞痛拌有高肠鸣音（肠梗），腹部包块、液波震颤如门脉高压腹水、腹胀、阵痛、是否反射至右肩（胆结石），或后背及中上腹（胰腺炎），右下腹反跳痛（阑尾） 炎症刺激，腹壁是否紧张痉挛，如穿孔可导致腹肌高度紧张 （ abdominal rigidity）、强直“板样腹”,腹部疼痛的病因与特征 1,腹部脏器扭转或阻塞 （Organ obstruction or twisting）: intermittent collicky pain, 间断性绞痛 under um
