Bài giảng chăm sóc sức khỏe người lớn có bệnh ngoại khoa giảng viên nguyễn cẩm duyên biên soạn

r ( s BO GIAO DUG DAO TAO GIANG VIEN: NGUYEN CAM DUYEN (Luu hanh npi bp) i TRUING DAI HOC COU LONG A THU VIEN I I Vinh Long, 2019 ‘3 i ’ ' I •'I MUC LUC t JL & Trang Bai Noi dung l'! Vai tro nguai dieu duang ngoai khoa 2 Nhiem trung ngoai khoa 11 i Cham soc nguai benh tnrac mo 21 Cham soc nguai benh sau mo 27 Cham soc benh nhan gay me 44 a Cham soc benh nhan gay te 52 Cham soc benh nhan mb viem ruot thua cap 60 Cham soc benh nhan thung da day - ta trang 66 Cham soc benh nhan hau mon nhan tao 76 Cham soc benh nhan viem phuc mac 84 Cham soc benh nhan tac ruot 95 12 Cham soc benh nhan long ruot 105 13 Cham soc benh nhan thoat vi ben 108 14 Cham soc benh nhan soi mat 114 15 Cham soc benh nhan viem cap 126 41 I I h lid I CHVONG 1: VAI TRO NGtfCH DlEU DlTONG NGOAIKHOA MUC TIEU L Trinh bay duac vai tro cua nguai dieu dwcmg ngoai khoa Trinh bay duvc nhimgyeu cdu cua ngtrdi dieu du&ng ngoai khoa NOI DUNG DAICUONG 1.1 Trong benh vien chuyen khoa ngoai thuoc cac benh vien da khoa Cong tac cun chua benh, chu yeu la phlu thuat Vay nen nguoi di8u duong r4t can co tac phong nhanh nhen, chinh xac, khin truong cSp cuu ngubi benh Tuyet doi co y thuc vo khuSn cac thu thuat ngoai khoa, cham soc nguoi benh Dong thoi co tinh can than, ty mi su dung va bao quan cac loai may moc, dung cu y hoc hien dai de thuc hien cac ky thuat y hoc hien dai Do ngubi di£u dubng ngoai khoa cdn dat cac yeu c£u dac biet sau day: - Tinh thong nghiep vu, thao tay nghe, lam tot cac ky thuat ngoai khoa X - Thuc hien khdn truong, thao vat, chinh xac va nghiem tuc cac y lenh cua thay thuoc - Thubng xuyen co y thuc va tac phong vb khudn thuc hien cac ky thuat va ,cham soc ngubi benh ! - Lubn theo doi sat ngubi benh de phat hien sum nhung bien chung va dien bien xau cua benh, giup thdy thuoc quySt dinh xu tri kip thbi, dong thbi co cong tac tot vbi thay thubc de nhan dinh dung tinh trang cua ngubi benh va giai quyet tbt cac nhu cau cham soc ngubi benh 1.1.1 NHIEM VU DIEU DUCfNG NGOAI KHOA Nhan ngubi benh tu cac khoa, tu cap cuu, phong hoi sue, phong mo chuyen den Trai ngoai khoa mbi dbu co cuoc hoi chdn cung vbi gay me, phdu thuat vien d6 chon phuong phap gay me va phdu thuat thich hop cho tung ngubi benh Tuy theo tung benh vien, tung khoa dibu dubng se du bubi hop thong qua mb mbi hay moi tuan Di6u dubng khoa ngoai phai phbi hop vbi dibu dubng phong mb sap xep lich mb va len chuong trinh mb Di^u dubng khoa ngoai edn co kign thuc vb benh,v6 phuong phap phdu i thuat de lam cong tac tu tirdng va giao due cho nguai benh truac mo Khac veri noi khoa x «> nguai dieu dudng khoa ngoai phai chuan bi ngubi benh truoc mo va cham soc ngubi benh sau mb Noi den ngoai khoa la noi den vb khuan Ngubi dieu dubng lubn phai cap nhat kien thuc ve chbng nhiem khuan benh vien, lubn phai ap dung vb trung ngoai khoa tuyet dbi cham sbe ngubi benh nhu cham soc vet mb, dan luu Phong ngua nhiem trung cheo giua cac vet thuong tren cung ngubi benh hay giua ngubi benh vbi X •> \ X ngubi benh khac Ve cham soc, phuc hbi ngubi benh sau mb, dieu dubng ngoai khoa co •> z X nhiem vu phbng ngua bien chung sau mb, vat ly tri lieu cho ngubi benh, phuc hbi van dong sau mb Dinh dubng sau mb cung rat quan trong, ngubi benh can duoc cung cap dinh dubng nhung tung benh ly, timg phuong phap phau thuat ma dieu dubng se r X x x cung cap dinh dubng qua truyen dich, an bang mieng, dan luu nubi an Dieu dubng hubng dan, chuan bi cho ngubi benh vien vbi muc tieu phbng va tranh bien chung sau mb, tra ngubi benh ve vbi gia dinh, xa hbi vbi tinh trang tot nhat 1.1.2 MUC TIEU CUA DIEU DUONG NGOAI KHOA \ I n - Chan doan benh chinh xac Khac vbi nbi khoa, bac si can chan doan benh chinh xac thubng dua vao thu thuat hay phau thuat, lay benh pham gui giai phau benh ly de doc ket qua chinh xac - Dieu tri triet can Ngoai khoa thubng dieu tri bang each cat bb phan bi benh Vi du: cat rubt thua viem rubt thua - Dieu tri tarn thbi Phau thuat giup giai quyet nhung tac hay de giam dau, giam nhung trieu chung tam thbi, de co thbi gian nang cao the trang, giam tinh trang nhiem trung - Dieu tri phbng ngua Trong nhung trubng hop benh ly co nguy co cao trb ac tinh ve sau, dieu tri ngoai khoa can thiep bang phau thuat giup cat bb de loai trir nguy cor Vi du: cat polyp dai trang - Tham my Phau thuat giup ngubi chinh sua cor the binh thubng de trb nen dep hon - Tai tao chinh hinh Ngubi benh duoc chinh lai cor quan bi khuybt tat di dang bam sinh hay di tat sau chan thuemg bang chinh hinh giup lap lai chuc nang binh thubng, ngubi benh phuc hbi kha nang boat dong cube song thubng J - Ghep ccf quan Ngucri benh duac ghep mot bo phan cua ngubi khac de thay the bo phan da mat chuc nang cua minh 1.1.3 CAC VAN DE CO BAN KHI CHAM SOC BENH NHAN NGOAI KHOA * a t f > - Dap ung cac nhu cau ve ho hap - Giup benh nhan ve an uong, dinh dubng - Giup benh nhan bai tiet f ' - Giup benh nhan ve tu the, van dong va luyen tap - Dap ung nhu cau ngu va nghi ngoi - Giup benh nhan mac va thay quan ao - Giup benh nhan tri than nhiet - Giup benh nhan ve sinh ca nhan hang - Giup benh nhan tranh duoc moi nguy hiem nam vien - Giup benh nhan giao tiep - Giup benh nhan thoai mai ve tinh than va tu tin ngubng - Giup benh nhan cac boat dong vui choi, giai tri / X - Giup benh nhan co kien thuc ve y hoc ! 1.1.4 CHUC NANG CUA CAC DIEU DUONG PHONG MO a Bieu dir&ng truwng • ! Tiep nhan va dua ngubi benh vao bubng phau thuat theo y lenh ghi ho so benh an Phan cong y ta (dieu duong), ki thuat vien va ho li phuc vu cac cube phau thuat va thubng true de trinh trubng khoa duyet Kiem tra, don doc cac vien khoa thuc hien nghiem chinh quy che khoa phau thuat - gay me hoi sue Chuan bi day du co sb thubc, phuong tien, dung cu, vat lieu dung phau thuat va thiSt bi de s&n sang phuc vu cac cube phau thuat theo ke hoach va phau thuat c&p cuu Nhung dung cu hong, vb phai linh bb sung hoac thay the kip thbi Phan ebng y ta (dibu dubng) thuc hien ebng tac theo dbi, cham sbe ngubi benh sau ph£u thuat b khoa, bao cao kip thbi trubng khoa cac viec dot xu£t, nhung dien bien bat thubng cua ngubi benh de xu li kip thbi I 'i 9 r To chuc va kiem tra cong lac ve sinh, vo khuan, chong nhiem khuan va xu li chat thai theo quy dinh Tham gia phuc vu cac cuoc phau thuat va thuong true Phoi hop voi y ta (dieu duong) truong khoa ngoai de don nguoi benh den buong phau thuat va dua nguoi benh tu buong phau thuat ve khoa b Nhiem vu cua dieu dte&ng tiep dung cu - Giup phau thuat vien thuc hien cuoc phau thuat chuan bi va sap xep dung cu day du, dua dung cu cho phau thuat vien dung dong tac va phu hop cac thai diem cua cuoc phau thuat; - Xu ly dung cu phau thuat, trang thiet bi y te va vat tu tieu hao da su dung cho ca phau thuat theo quy dinh cua bo phan phau thuat; - Khong tu y bo ngoai chua duoc su dong y cua phau thuat vien c Nhiem vu dieu dwffng chay ngoai - Phoi hop cung cac kip phau thuat de dat tu the nguoi benh, dat ban tiep dat cua dao dien, bao ve diem ty de cua nguoi benh; - Bo sung dung cu phau thuat, vat tu tieu hao va cac phuong tien khac dung cho phau thuat; - Ho tro kip phau thuat va kip gay me - hoi sue dieu khien cac dung cu nhu dao dien, may hut, may noi soi, may chong rung; - Ghi chep day du, chinh xac cac vat tu tieu hao dung cho phau thuat cung nhu so > r luong ton du, so luong hu hong; - Giup van chuyen nguoi benh sang giuong hoac cang; - Linh mau hoac che pham mau duoc yeu cau, linh ve phai ban giao true tiep cho dieu duong vien hoac bac sy gay me - hoi sue da yeu cau d Nhiem vu cua dieu dic&ng gay me hoi sire Ban giao giua dieu duong phong mo va dieu duong phong hoi sue, nhan dinh tinh trang nguoi benh sau m6: dau chung sinh tdn, tri giac, v6t mo, ddn luu, ap luc tinh mach trung tarn, benh ly, phuong phap phdu thuat Luon trau d6i kien thuc chuyen mon va ky nang ve cham soc hoi sue cap cuu, su dung thao cac may moc, dung cu hoi sue, trau doi kien thuc ve chong nhiem khuan benh vien Luon ap dung vo trung ngoai khoa cham soc Biet thuc hien va hieu duoc lac dung phu cua thudc hdi sue Bi6t danh gia ngudi benh du lieu chuan de chuyen ngubi benh ve * ' khoa ngoai Ngoai ra, ngudi dieu dubng khoa hoi sue phai trang bi kien thuc giao tiep vdi ngudi benh khoa hoi sue ngudi benh thudng hon me, duoc dat noi quan, thd may; ngudi benh khdng the giao tiep bang idi noi ma chi bang dieu bo va chu viet Ngudi dieu duong tai khoa hoi sue vi the rat can trau doi kien thuc ve giao tiep bang cu chi, dieu bo, hieu biet tarn ly ngudi benh 1.1.5 TdCHLTCKiPMO - Su kSt hop va chuySn giao Ban giao giua diSu duong khoa ngoai vdi phdng mo chuyen ngudi benh tu khoa ngoai, cap cuu xudng phdng tien phau Ban giao giua dieu dudng khoa hau phau va dieu dudng phdng mo ngudi benh phau thuat hoan tat - Luong gia ngudi benh trudc mo Luong gia tinh trang ngudi benh ve dau chung sinh tdn, tri giac, tarn ly, tong trang ngudi benh Xet nghiem tiSn phau, ten ngudi benh, phuong phap gay me va chan doan trudc mo, phuong phap phau thuat du kien - Can thiep didu dudng md Duy tri su an loan cho ngudi benh, dung cu, tu the, anh sang, phau trudng Theo doi tinh trang sinh ly ngudi benh, mach, huyet ap, nhiet Thuc hien dung nhiem vu dieu dudng duoc giao mot cuoc mo: dieu dudng vong \ * ' va dieu dudng vdng ngoai Luon ket hop cung gay me va nhdm md thuc hien hoan hao phdu thuat cho ngudi benh sudt thdi gian phau thuat Ngudi diSu dudng ludn ap dung vd trung tuyet ddi suot qua trinh phau thuat, phai biSt phan biet thi sach, thi nhiem chu trinh phau thuat Hieu biSt va su dung dung cac dung dich tiet khuan, may mdc, dua dung cu dung quy trinh Phuc trinh lai day du diSn tien va nhung bat thudng md vao hd so DiSu dudng ludn dam bao mdi trudng phdng md an loan va vd khudn, chan chinh kip thdi nhung sai pham Danh gia tinh trang ngudi benh de chudn bi cho ngudi benh chuySn tu phdng mo sang phdng hoi sue nhu: dau chung sinh tdn, tri giac, chay mau Di chuyen ngudi benh an loan vS phdng hdi sue Ban giao ngudi benh cung diSu dudng phdng hdi sue Hien nay, cung vdi su phai trien khdng ngung cua phau thuat noi soi, ngudi diSu dudng can cap nhat kiSn thuc khdng chi nham phuc vu cho cuoc phau thuat ma biet each su dung va cham soc may mdc, biSt each xu tri cac loai may phdng md giup Nguai benh sot cao, bung gong cung, co cac trieu chung viem phuc mac Dieu duong cham soc hoi sue nguai benh thuc hien bu nuac, dien giai, sot, tho oxy, tu f 1 f the giam dau, thuc hien khang sinh va chuan bi trubc mo de mo cap cuu e Viem cap Sau mo soi mat nguai benh cd nguy co viem cap Dieu duong theo doi dau bung vung thuong vi, dau du doi non di, Amilase mau tang cao Dieu dudng hut lien tuc dan luu da day, khdng cho nguai benh an udng va chuan bi nguai benh trudc mo / cap cuu f Sot soi Nguyen tac phau thuat dudng mat la lay het soi, nhung nhieu trudng hap phau thuat vien khdng the lay het nen van sot soi Trong trudng hap ngudi benh giu dng dan luu Kehr ve nha va sau tai kham de tan soi qua Kehr nen dieu dudng hudng dan ngudi benh each cham sdc Kehr tai nha 14.4.4 GIAO DUG NGl/CH BENH x f r ' ' r Neu ngudi benh cd cat tui mat, thdi gian dau han che thuc an cd nhieu md, dau, trung, f • \ sua, chat beo Khoang 2-3 thang sau cho ngudi benh tap an dan lai binh thudng, han che ' x f r •> thuc an nhieu cholesterol Neu ngudi benh md sdi dudng mat nen cho ngudi benh udng * X \ t \ nhieu nude, an thuc an cd nhieu chat dinh dudng, tranh thuc an nhieu dau md, ve sinh an udng Tay giun dinh ky mdi 3-6 thang/lan, kiem tra sieu am dudng mat dinh ky Giao due ngudi benh xuat vien mang dng dan luu Kehr ve each cham sdc dng Kehr, sinh boat, tai kham CAU HOI LVONG GIA Trieu chiing lam sang cua soi mat Thue hien cham soc nguai benh sau mo soi mat f Thue hien theo doi bien chung sau mo Thue hien giao due sue khoe sau mo soi mat 124 I I CHtfONG 15: CHAM SOC BENH NHAN MO VIEM TUY CAP MUC TIED Trinh bay duoc trieu chung 1dm sang viem cap Cham soc duac cho ngucri benh viem cap Chuan bi duac cho ngiccri benh trudc mo Cham soc dupe cho ngudi benh sau mo NOI DUNG 15.1 BENH HOC Viem cap la lien trinh viem cap tinh cua Muc viem khac tu viem sung huyet den viem hoai tu Benh bien o tudi trung nien nam nhieu hon nu Tinh trang viem nang hay nhe muc tan pha tren mo Viem cap lien quan ddn benh ly soi duong mat, ruou, sau phau thuat, sau chup mat nguoc dong, sau thu thuat lay soi ong mat chu qua noi soi mat nguqc dong, chuyen hoa, nhiem doc, di ung, quai bi, thung ta trang: thuoc nhu Corticoid, Thiazide Diuretic, Oral Contrsceptic, Sulfonamide, Nonsteroidal Antiinflammator 15.1.1 NGUYEN NHAN VA CO CHE BENH SINH f f Su boat hoa cac he thong men nhat la x ' fltil ini! men Trypsin va Lipaza la vai tro chinh gay viem cap t- a Trypsin: Men co tac dung phan hiiy dam cac acide amin cho co the hap thu Binh thudng tiet Trypsin du-di dang khong boat dong la Trypsinogen Khi lining Hi-' xudng ruot nhb co Enterokinaza - ruot tidt ra, Trysinogen bi£n trypsin boat dong Ndu Trypsin bi boat hoa se gay ton th-uong trudc hdt cho he thdng mach mau: lam dan mach, u tre tudn hoan dan tdi phu n6 va rdi loan qua trinh cdp oxy cho te bao Ndu tinh trang tren v£n tiep diSn, thi6u dudng te bao mot 125 tram hem dan tai hoai tu va xuat huyet Ngudi ta cho rang su kich hoat Trypsin la pha dau tien ciia viem cap va phu ne la ton thuomg dan tien cua viem b Lipaza Lipaza diroc tiet dual dang khong boat dong Nhd co muoi mat Lipaza boat dong lam phan buy md trung tinh acide beo va glycerol Glycerol tan mrac f ' ? f r duac hap thu acide mo ket hop vai calcium cac vet nen Trong viem cap ta thay cac vet nen to nhd khong deu mau trang vang, nam rai rac khap d bung nhat la mac treo va mac ndi Ion Nhu vay su kich boat cac men la khdi dau ciia viem cap, sau nhanh chdng phat trien va gay nen nhung rdi loan tram do: - Cac men tham nhap vao co the qua mach mau va bach mach r f - Do dich xuat tiet phu ne lan rong vao mac treo, khoang sau phuc mac vao d bung Trong dich cd cac men da boat hoa, tiep tuc gay tieu huy to chuc - Do cac phan phan huy dd dang cac to chuc cung vdi cac doc to vi khuan cd boi nhiem bi hap thu vao mau - Do dau ddn kich thich lien tuc len tan cung cac than kinh cua tuy, cua dam rdi f > duong va gay rdi loan he noi tiet Vdi nhung nguy cu tren, ngudi benh nhanh chdng rai vao tinh trang rdi loan nghiem cac chuc nang song, nhiem ddc nang va tu vong Ty le tu vong cang cao neu nhu cd bien chung chay mau nang tren nen to chuc hoai tu c Cac nguyen nhan gay kich boat cac men tuy: - Do cd cac benh ly dudng mat: Sdi va viem dudng mat Nhieu tac gia nhan xet 30 - 35% viem cap co lien quan den benh dudng mat, benh dudng mat tang cao thi viem cdp cung tang theo Viem va sdi dac biet la sdi gay tic mat, chit hep ca Oddi lam dich mat trao nguac vao - Do co u dong dich tieu hoa d ta trang va hong trang (thay liet rudt, sau cit da day theo Billroth IL ) nen dich rudt cd Enterokinaza va mat se trao nguoc vao dng - Viem cap sang chan: + Sau noi soi nguac dong dng mat chu 126 I I + Sau phau thuat cac co quan lan can + Sau chan thucmg bung > f ' - Do di ung: thuc an thuoc uong, hoa chat i: - Do an uong qua muc lam bi kich thich manh, tiet mot luong dich qua muc , f binh thubng va u dong lai ong Mat khac gay phan xa dan mach nang, nhat la bua an co nhieu ruou, o benh nhan beo cao tuoi, co benh ly tim mach tiem an thi rat kho dieu chinh roi loan van mach sau bua an qua va viem cap de xay 15.1.2 BIEU H1EN LAM SANG a f>au bung Khdi dau dot ngot dau bung vung thuong vi hay 1/4 bung tren trai lan sau lung ben trai Dau du doi, lien tuc, dau sau ben tang, dau nhu choc thung ben f ' ' z Thubng xuat hien nau 24-48 gib sau an bua an nhieu thit, chat beo, co uong rupu Dau thubng khbng giam theo tu the, sau dung thuoc khang acid da day Dau that su la cang phbng, kich thich phiic mac, tac ong mat Con dau kem theo non bi, sau di ngubi benh van khbng giam dau Nhiet giam, bach c£u giam, huybt ap giam, mach nhanh Ngubi benh vang da, f nude tieu vang Bung cang chudng nhu dong ruot giam hay mat Tac ruot xuat hien gay cang chudng bung Kham bung cd de khang vung thupng vi Ddu Cullen: thay doi mau vung quanh ron su tarn nhuan cua mau doc theo day chang liem Dau Grey Turner: xuat hien mau xanh dich xuat tiet lan qua can sau than vung hong trai Phbi nghe tieng ran no, suy giam ho hap b Chodng Xu^t hien chay mau tuy, hay nhiem trung huybt tir nhung boat dong cua men Su gia tang kinin peptide nhu kallikrein va bradykinin la nguyen nhan mach mau gian, gia tang tham mao mach, thay doi van mach Suy than cap cung xay ngubi benh viem cap cd choang ( 127 15.1.3 TRIEU CHUNG CAN LAM SANG - Amylaza mau tang cao sau dau mot gio sau giam dan - Amylaza nu—6c tieu tang cao sau 12 den 24 gio - Bach cau tang, bach cau da nhan trung tinh tang - Roi loan dien giai nhat la Canxi mau giam - Toan mau - D-ubng mau tang la bieu hien xau - X.quang: bung nhieu hoi ruot nhat la dai trang - Sieu am: co the giup tim thay cac benh ly duong mat (soi, giun) gay viem cap .Tuyen to, bung co dich 15.1.4 BIEN CHUNG a Nang gid r r r La khoang tiep noi v6i hay bao xung quanh ben ngoai chua dich tiet, mo hoai tu, nhu plasma, men tuy, chat viem xuat tiet Trieu chumg cua nang gia la nguoi benh dau bung, sb co khbi u vung thuong vi, non, bubn non, chan an Amylase huyet van muc cao Khbi nang se tu giai quyet vong vai tuan nhung co le thung no gay viem phuc mac hay thung vao da day hay ta trang Thubng phau thuat noi vbi hong trang theo phuoug phap Roux-en-Y b Abces La khoang chua dich Ion tuy, la hau qua tu mo hoai tu Bieu hien lam sang: dau bung tren, bung co khbi u bat thubng, nhiet tang cao, bach cau tang, ap- xe tuy, dbi hoi phau thuat cap cuu de ngan ngira nhiem trung Bien chung he thong chinh la viem phbi va chubt rut calci mau Viem phbi la xuat tiet tir men < •> tham qua mang phbi 15.1.5 CHAN DOAN Amylase huyet tang vong 24-72 gib Su tang lipase huybt bb sung cho chan doan viem cap Vi benh quai bi, chan thuong nao, ghep than thi amylase mau cung tang cao Amylase nude tieu cung tang cao va tri nhieu Amylase nubc tieu tang hon 3.600UI/ngay 128 i _ Xet nghiem Amylase huyet Lipase huyet Amylase nude tie-u Test thu hai _ Budmg huyet Trj so binh thirong Tang>200UIL 3-3,4 pkatL _ Tang Tang _ Sinh benh hoc Te bao ton thuerng Tang cao Suy giam cua chuyen hoa chat xcr dan den ton thuerng te bao P va giai phdng glucagon Su hoa x& phdng cua calcium boi acid beo vimg m& bi hoai tu Giai phdng acid bdo tu boi lipase Calcium huyet Giam Triglyceride huyet Tang lipide mau Te bao ton thuerng Te bao ton thuong Bang 1: Xet nghiep chan doan viem cap 15.1.6 DIEUTRI a Dieu tri noi Han che tqm thdi hoqt dong men tuy: Thye hien thuoc: khang acid, khang H2 Dat ong thong da day: hut lien tuc, khong cho an uong Thue hien thuoc Atropin, hay Octreotide (Sandostatin) lam giam tiet dich Gidm dau cho ngudi benh: Tiem thudc giam dau theo y lenh, thuerng dung Atropin va Pethidin (khong cho Morphin vi gay co that co vong Oddi) Thue hien thuoc khang viem steroide (soludecadron) Chdng nhilm trung: Thue hien khang sinh theo y lenh Thue hien can bang nude va dien giai b Dieu tri ngoai Phau thuat Bang Nhan dinh dieu du&ng viem cap Du* kien chu quan Thong tin quan ve sue khoe: Tien su ban than: nghien ruon, benh ly soi during mat, chan thuerng bung, loet ta trang, nhiem triing, roi loan chuyen hoa Thuoc: dung thuoc Thiazide, Sulfonamide, Opiate, Furosemide 129 Oestrogen, Corti coide, Azathioprine, Phau thuat va nhung dieu tri khac: phau thuat mo da day, ta trang, dircmg mat Du* kien khach quan Tong trang: kich dong, lo lang, toat mo hoi, nhiet giam Da: doi man o vung bung, vang da khd moi mieng Ho hap: kho the, ran nd f Tim mach: choang, huyet ap giam, mach nhanh Tieu hoa: bung cang chudng, dau \ • r Dau hieu duong tinh: Amylase va lipase huyet tang, bach cau tang, tang dudng huyet, tang amylase nude tieu, sieu am bung bat thubng 15.2 QUY TRINH CHAM SOC NGlTdl BENH VIEM TUY CAP 15.2.1 NHAN DINH TINH TRANG NGl/CXl BENH • • • • ' / Dau bung du doi, lien tuc vung thuong vi Thudmg xuat hien sau bua an thinh soan, dinh dau tu 15-60 phut sau an, dau lan den nguc hay sau lung, dau tang nam ngua i ? r Tong trang ngudi benh rat de roi vao choang ngat Tim mach thieu dich, mach nhanh, huyet ap giam Trieu chung tieu hoa: non di, liet rudt Co" hoanh bi kich thich dich nhu nac cue, dau lan den ba vai Phdi: tran dich mang phdi lan tda, phdi tham nhiem, suy hd hap Tiet nieu: nude tieu giam dudi 400ml/gid hoai tu dng than 20%, cd vang da dau phu ne chen ep doan cudi dng mat chu Bung chudng, mem va cd dich luong trung binh Sd an sau thuong vi dau tang len, neu cd viem phuc mac thi bung de khang hoac gong cung Khi xuat huyet hay hoai tu tuy, cd the cd dau Grey Turner (thay ddi mau da vung hong lung) hoac dau Cullen (ddi mau da hay bam mau vung quanh rdn) Sieu am thay to, cd dich quanh tuy, cd khdi sieu am hdn hop (hoai tu tuy), ap-xe tuy, nhiet nd f t x tang, tdc lang mau tang, bach cau tang 15.2.2 CHAN DOAN CAN THIEP DIEU DUONG a Cham soc sue khoe va ngdn ngua viem cap Phong ngua nhung yeu to nguy co dua den viem cap Dieu duong can cung cap thong tin can thiet de giup ngudi benh dieu tri nhung benh ly cd nguy co viem 130 i I cap nhu' dieu tri dul diem soi mat Neu cd sdi tui mat hay sau mo sdi nen tranh nhung bua an nhieu thit ma, khdng udng ruau Tranh nhtmg thudc gay viem cap, nen tiem ngira phdng quai bi h Ngwd’i benh chodng viem cap \ r Theo doi sat dau chung sinh ton, luang gia tinh trang ngiibi benh, mau dong mach, chi so ap luc tinh mach trung tarn Thue hien khang sinh chdng nhiem trung \ f bdi tra nude dien giai cho ngubi benh, theo doi luong nude xuat nhap, theo ddi luung »> * ' nude tieu moi gib, xet nghiem chuc nang than, thuc hien thudc giam dau, giam tiet dich c Giam the tick dich non di, hut dich da day va han che an uong Bieu hien ngubi benh khat, gia tang dich xuat, da khd Nhan dinh tinh trang suy f f f tim, dau hieu choang tuan hoan, rdi loan nude va dien giai, nude xuat nhap, ap luc tinh mach trung tarn, can nang, dau chung sinh ton va ap luc mau moi gib hay thubng xuyen theo y lenh Thuc hien cung cap dich thay the Thuc hien thudc chong di, dat dng Levine theo doi nude xuat nhap chinh xac hon vira giup ngubi benh giam non, vua thoat dich da day giam chen ep Theo ddi xet nghiem Het, Hemoglobin, chu y Amylase mau va nude tieu (binh thubng 60-180 dem vi SomogylOOml), ion do, BUN, creatinine Ve sinh sach se sau non: ve sinh rang mieng giup ngubi benh thoai mai Theo ddi nhung dau hieu nhu kich thich, nhip tim nhanh, co rut ca d Kieu thff khdng hieu qua dau Nhan dinh va danh gia: kha nang thd, hit thb sau, ho, dam Ngubi benh dau tang nSm ngua Theo ddi mau dong mach, tinh trang bung dau, chudng Can thiep: hd trer hd hSp, thuc hien thb oxy, giup ngubi benh tu the nghi ngai, giam dau - tu the Fowler e Sw khd moi mieng dqt dng thong dq day, thudc uc che bdi tiet Bieu hien moi khd, lb niem mac mieng, giam tiet nude bot Nhan dinh tinh trang niem mac moi, ludi ngubi benh dd dieu tri kip thbi Cham sdc rang mieng moi gib, giu Sm moi mieng, cd thd thoa son vaseline Ghi chu chinh xac luong nude xuat nhap Cham sdc da thoang sach, dung chat lam am da, tranh khd da 131 f Thay dot dinh dit&ng lien quan den chan an, khong an qua dwd’ng tnieng, non di •> f bieu hien bffi giant can, yeu, met Quan sat phan dai lien co vang ma Cung cap dinh dudng du cac chat qua dudng truyen cho ngudi benh Thue hien ve sinh rang mieng va lam am moi, mieng / s giup ngudi benh tranh khd moi, mieng va cac benh ly ve mieng Danh gia chi so BMI cua ngudi benh 15.2.3 CHAM SOC NGtfCH BENH TRVOC MO TUY Viem cap chu yeu la dieu tri npi khoa, chi can thiep phau thuat co chi dinh cu r •» \ r the nhu viem hoai tu, viem xuat huyet, ngudi benh hoi sue khong hieu qua hay cd nguyen nhan khac nhu sdi ket Oddi •> r Tham dinh tinh trang nau bung cua ngudi benh va tim tu the giam dau cho ngudi benh Thue hien hut da day lien tuc: theo doi sat tinh chat, mau sac, so luong dich da day Khong cho ngudi benh an udng Dieu dudng thuc hien bu dich, thudc theo y lenh cua bac si, thuc hien y lenh thudc giam dau, giam viem cho ngudi benh Cong tac tu tudng cho ngudi benh an tarn Theo doi cac xet nghiem can lam sang: Amylase mau va nude tieu, ion do, creatinine Theo doi dau chung sinh ton cho ngudi benh: That hien sum dau hieu choang cho ngudi benh nhu mach nhanh, huyet ap giam Chu y neu ngudi benh sot tren 38°C thi edn bao bac si vi co the cd tinh trang nhiem trung 15.3 QUY TRINH CHAM SOC NGETdl BENH SAU MO 15.3.1 NHAN DINH TINH TRANG NGlTOl BENH Theo doi dau hieu khd thd, kieu thd, dau hieu thieu oxy Theo doi va phat hien sdm choang, dau hieu giam thd tich dich, theo doi nude tieu mdi gid, nude xuat nhap Nhan dinh tinh trang rdi loan nude va dien giai Tinh trang viem nhu: dau bung, bung chudng, amylase tang Tinh trang bung: nhu dong ruot, dau Hoat dong dng dan luu, tinh trang da: d chan dng ddn luu, vdt md Tinh trang dinh dudng ngudi benh: dau mat nude, can nang 132 i Tmh trang nhiem trung: nhiet cao Theo doi dau hieu chay mau sau mo: qua ong Levine, dan luu, dau churng sinh ton ' \ r Theo doi duong huyet, creatinine Theo doi sat dau chung sinh ton, tinh trang tri giac nguoi benh 15.3.2 CHAN DOAN CAN THIEF DIEU DtfONG a Ngum benh cd dau hieu khd thd sau mo The nam: neu ngudi benh chua tinh hay choang thi cho nam tu the thang dau bang, mat nghieng mot ben Neu ngudi benh tinh nen cho nam tu the semi-Fowler, hudng dan ngudi benh thd Thue hien oxy lieu phap cho ngudi benh Theo doi lien tuc tinh trang: oxy mau, dau hieu thieu oxy, nhip thd Can theo doi tinh trang bung chudng hay dau ngudi benh khdng tu thd binh thudng duoc b Ngud^i benh cd nguy eff choang sau mo tinh trang giam the tich dich qua mat mau, mat dich f \ r * Theo doi va chdng choang sau mo, theo doi dau chung sinh ton lien tuc, dau hieu r f chay mau, tong luong nude xuat nhap moi gid, dau hieu rdi loan dien giai tren lam sang, nude tieu, xet nghiem chuc nang than Theo doi dau thieu nude nhu khat, niem khd, da (+) Phat hiem sdm tren lam sang cac dau hieu thieu dien giai Thue hien bu nude va dien giai theo y lenh U am ngudi benh, giup ngudi benh an tarn c Bung chicdng sau mo ruot chtca hoqt dong Theo doi nhu dong ruot, non di, bung chudng, dich u dong ' Cho ngudi benh xoay trd, hudng dan hit thd sau, cho ngudi benh ngdi day hay n^m tu the Fowler (neu khdng cd dau hieu choang) De giiip cho nghi ngoi, didu dudng dat dng thong da day, nen hut lien tuc dng thong da day, theo doi tinh trang bung, vdng bung Chi rut ong thong da day ngudi benh hdt dau bung, amylase binh thudng Khdng nen cot ong lai ndu chua cd y lenh bac si Nghe nhu dong rudt, thudng ngudi benh sau md viem cap rat de suy kiet tinh trang nhin an, udng va mSt nude, nen van dong giup cd nhu dong rudt 133 d Nguy co' bien chicng sau mo viem lay cap Phat hien semi bien chumg viem cap nhu: dau bung tren, khoi u a thuomg vi, nhiet Theo dbi xet nghiem bao bac si thay cac chi so xet nghiem: Amylase, ion do, Transaminase, glycemie tang hay giam Phong ngira khong cho nguoi benh an uong neu nhu nguoi benh dau bung, tinh trang viem chua on dinh Thue hien nuoi duong nguoi benh bang dubng truyen dich, theo doi dau bung e Nguy co" nhiem triing vd ton thiro’ng da co nhieu dan lieu sau mo Nguoi benh mo co rat nhieu dan luu: dan luu tuy, dan luu tui mat, dan luu Kehr, mo thong da day, dan luu dubi gan, dan luu Douglas r r r Tat ca nen cau noi xuong chai vo triing va theo dbi dich, thubng chi rut co y kien cua phau thuat vien va tinh trang nguoi benh Neu cham soc dan luu tot se I giup giam phu ne tuy, dan luu mb hoai tu Phau thuat vien co the cat bo mot phan hay toan bo tuy, sau dat dan luu hau cung mac noi va dan luu Douglas Bac si cho •» \ bom rua va hut de nhung manh hoai tu trbi ngoai Can ngua dich trao lb quanh chan dan luu Viec tuoi rua va hut o dan luu thubng su dung huyet man ' * w dang truong vb triing va cho nguoi benh nam nghieng ve phia dan luu giup dich thoat de dang Can thay bang tham ubt dich quanh chan dan luu Nguoi benh sau mb se co nhieu dan luu va dan luu thubng tiet dich rat nhieu nen nguy co mat nubc cao Dong thbi, dich tiet qua nhieu nen kha nang viem lb da dich tir dan luu mang tinh chat an mon da co nguy co lam loet chan da noi dan luu va day la nguy co nhiem triing da rat cao Dieu dubng can cham soc da that sach se, cau nbi that tot va thay bang tham dich, thay tui dich de tranh dich chay nguoc vao hay tran da f Ngicffi benh cd nguy eff nhiem trung sau mo tinh trang nam lau De tranh nguy co nhiem triing hau phau dieu dubng can rut sbm thong tieu nguoi benh bn dinh Viem thubng bien chung viem phbi, tran dich mang phbi trai Nguoi benh dau va khbng dam thb, vi the dieu dubng can hubng dan nguoi benh each thb, xoay trb, ngbi day sbm 134 I Thai gian hoi phuc sau mo viem cap doi lau han, kem theo tinh trang suy kiet khong an uong nhieu nen viec van dong di lai cua nguoi benh han che, vi the loet tu the co nguy ca xay Dieu duang can xoay tra, tranh ti de, tranh dich tu dan luu d Iran da r g> Nguy cffsuy dinh dwffng nguvi benh khong dieoc an uong I Nhan dinh tinh trang dinh duong cua nguoi benh, dau mat nuac, can nang f r r Do luang va bao cao nuac xuat qua ong Levine, ong dan luu, nuac tieu, tinh mach trung tarn Theo doi duang huyet va duang nieu, de phong roi loan chi so duong huyet Theo doi tieu phan mo di cau Thue hien insuline theo y lenh truong hop viem man tinh •» f Dinh duong: an nguoi benh het dau bung, tinh trang viem da giam han cac trieu chung, amylase tro ve binh thuong Sau nit ong thong da day, cho r a * nguoi benh an loang nhe nhu sup, chat dam tang dan len nhung chii yeu la dam thuc vat, cho an nhieu nang luong, vitamin, nhieu chat co cung cap dien giai de tranh suy dinh duong Thuang sau 5-7 nguoi benh an lai, bat dau an nhung chat de tieu nhu sup rau hay bot khuay duang, cham soc rang mieng thuang xuyen h Ngiari benh chwa hieu rd ve benh Huang dan - giao due y te: nguyen nhan ciia benh thuang nhiem ky sinh tning duang ruot nen giao due nguoi benh ve sinh an uong, sinh hoat, tay giun dinh ky Truyen ba nhung doc hai ciia ruou nhSm giao due va huong dan nguoi nghien ruau, edn co nhung hinh anh tac hai ruou gay ra, nhat la nhung nguoi benh da bi viem thi viec ngung ruou la b&t buoc Nguoi benh co tien su viem can tranh nhung bua an thinh soan nhiSu thit va ma Nguai benh co tien str soi duang mat cung co nguy co viem rat cao, vi the can phau thuat sdm lay soi Khi nguoi benh dau d vung thuang vi va lan den sunn trai thi khong nen an uong va den benh vien 15.3.3 GIAO DUG NGUtH BENH Nguoi benh phai kieng ruou, kieng thuoc la, tranh an thuc an co ma, nhieu thit, hai san Dieu tri dut diem cac benh ly ve gan, mat nhat la benh soi mat 135 Tranh su dung cac loai thuoc co nguy co cao den viem Ve sinh an uong, tay giun dinh ky Tai kham theo lai dan Thue hien thuoc dung gid dung thdi gian dieu tri Hudng dan ngudi benh cac dau hieu cua cac bien chung nhu: Nang gia tuy: bung cd khdi u thuong vi sau an, dau cang tuc bung, la dau hieu nang gia sau mo Dieu dudng can hudng dan ngudi benh tai kham de phau thuat i i Viem tai phdt’ cd cac dau hieu dau bung thuong vi va lan sau lung, dau sau bua an thinh soan thi ngudi benh nhin an uong hoan loan va den benh vien r f f Ducmg huyet khong on dinh: ngudi benh se cd nguy co tang hay giam dudng huyet sau viem hay cat Dieu dudng hudng dan ngudi benh theo ddi sat xet nghiem f r r dudng huyet Tranh dung thuoc dudng huyet dang ddi Suy dinh dudng sau viem tuy: khong de ngudi benh suy dinh dudng, an day du cac chat dinh dudng, nhat la trai cay Can ngudi benh de danh gia tinh trang dinh dudng hang Do so benh tai phat nen ngudi benh khong dam an, dieu dudng nen hudng dan cu •> A * tAi^Aw / A the che no an uong CAU HOI LlTONG GIA Trinh bay duoc trieu chung lam sang cua benh viem cap Thue hien duoc quy trinh cham sdc ngudi benh trudc mo viem cap Thue hien duoc quy trinh cham sdc ngudi benh sau mo viem cap Theo ddi cac bien chung cua viem cap 136 i TAI LIEU THAM KHAO Dieu duang ngoai khoa tap Bo y te 2009 H' Dieu dtc&ng ngoai khoa tap Boy te 2014 Nguyen Dinh Hoi, Bai gidng Ngoai khoa cot sd, Trieu chicng hoc ngoai khoa dai hoc Duac TP Ho Chi Minh 2001, NXB Y hoc Benh hoc ngoai khoa sau dai hoc NXBQDND - HN 2002 tap 1, htip://soyle namdinh.QOv.vn/honie/hoat-dong-nganh/^ao-duc-siic-khoe/viem-liiy- nguven-nhan-va-hien-chuno- / 345 httpC/www.bachmai.gov.vn/en/tin-tuc-va-su-kien/y-hoc-thuong-thuc-menuleft- 32/4734-viem-tuy-cap-dien-bien-nhanh-cuc-nguy-hiem-the-hoai-tu-chi-con-l-co- hl hoi-song-sot html i.! k !1I 137 •3 :*»