N0-N1進階課程

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暖灸唐
7 years ago
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1 大腸直腸肛門外科大腸直腸肛門外科歐美已有60年以上獨立專科台灣已有30年以上獨立專科經驗 N0-N1護理進階課程造口治療室大腸鏡檢室肛門生理機能檢查室癌症登記檔案室專科住院醫師訓練玫瑰之友唐修治醫師 1 上課內容誘發原因 1. 內外痔 Mixed Hemorrhoids with prolapse 器官性靜脈回流心臟衰竭肝硬化腹壓上升懷孕攝護腺肥大腹部腫瘤 1) Prolapse 2) Stenosis with ulcer 2. 肛門廔管 Anal fistula 遺傳性 1) Abscess 2) Fournier s gangrene 便秘腸急躁症飲食習慣其他原因 3. 大腸直腸癌 4. 護理問題直腸腫瘤肛交 3 位置分類外痔齒狀線以外栓塞痔核肉蒂 2 4 鑑別診斷 n內痔齒狀線以內 n出血脫肛內外痔混合痔 5 6 1

2 內痔脫肛的分類痔瘡內科療法飲食控制排便習慣溫水坐浴痔瘡軟膏栓劑鐵劑第一度腫入肛門第二度便後自行退縮入肛門第三度需用手推入肛門第四度已無法推入肛門 7 避免便秘 8 糞便量每次約100公克纖維量決定巴布亞新幾內亞排便次數每天一次每次五分鐘飯後30分鐘排便糞便成份種瓜得瓜 9 糞便軟硬度種瓜得瓜 10 治療法纖維脂肪水份內科療法外科非手術法外科手術法

3 拿破崙滑鐵盧戰役 Open Hemorrhoidetomy 術後併發症疼痛約一週出血 1/200 排尿困難 1/10 肛門狹窄贅肉失禁什麼是肛門廔管症狀肛門膿瘍透腸粒仔膿包痔漏痔廔肛門周圍的硬塊會痛很像痔瘡輕微發燒類似感冒很少肛門出血肛門廔管肛門膿瘍切開後肛門周圍條狀硬塊反覆流出血濃液

4 10% perianal intersphincteric ischiorectal supralevator retrorectal

5 92 () ( ) 36, ( ) ( ) , , (6,753) 19% (5,025) 14% (4,677) 13% (4,040)11% (2,308) 6% (2,237)6% (1,318)4% (1,258)3% (1,157)3% (960)3% (6,552) 18% 36,285 20% 14% 10% (2,651) 9% (2,390) 5% (1,226) 22% (783) (5,659) 26, % 4% 3% 3% 3% (5,325) (3,561) (2,061) (975) (833) (793) 88 ( ) ( ) / / , < 5% 30 5

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7 1. Abdominal Perineal Resection(APR) 2. Restorative Proctectomy wit coloanalanastomosis 3. Lower/ (High) Anterior Resection / EEADouble-staple or Pull-through 4. (Extended) Left hemicolectomy / mesenteric tunnel 5. (Extended) Right hemicolectomy 6. Subtotal colectomy / ileostomy or ileosigmoidostomy 7. Total colectomy / J-pouch ileoanal anastomosis 8. Posterior / Total Pelvic Exenteration 9. Hartmanns procedure 10. TransrectalExcision (TRE) 11. Diversion procedure 1. Sigmoid colostomy (Loop or End) 2. Distal/ Proximal Transverse colostomy (Loop or End) 37 APR LAR (RHC, LHC, Subtotal colectomy) Foley Sump Penrose Foley 1 2 NPO 3 I/O, Karlex Hemovac output Foley care Foley care 4 Foley care U/A U/A IV line, NG out Nelaton, Neomycin Hemovac Wound care Wound care U/A Intake Intake & Output Intravenous fluid TPN Blood components Fluid challenge Feeding fluid NG feeding Jejunostomy feed Oral intake Output Urine GI tract NG Enterostomy, Colostomy Diarrhea Paralytic ileus Wound Change dressing Drainage (Sump.) Ventilation, Sweating 39 Intake & Output Balance Intake Output = 0 40 I/O Balance Cardiac Output Intake Output = 0 Urine output 0.5~1ml/kg/hr Children 1~2ml/kg/hr Intake Fluid challenge GI tract output >500ml/8hr Dehydration Replace half with Ringers Lactate solution 41 C.O. = Stroke volume * Heart rate S.V. Contractility * Preload Afterload Preload with CVP / Urine sp.gr. monitor 5-2 rule for CVP (0-10mmHg) 7-3 rule for PAWP (10-20mmHg) 42 7

8 The 5-2 rule for CVP < <1ml/kg/hr >1ml/kg/hr Malnutrition Overhydration >1.015 Dehydration Osmotic Polyuria 1 unit = 1ml/kg CVP reading <8 CVP/10 min <14 =14 > 5 cm rise 2-5 cm rise < 2 cm rise > 2 cm rise = 2cm rise 4 units/ 10 min 2 units/ 10 min 1 units/ 10 min 10 4 units 10 4 units Replacement of GI tract Non-Glucose solution! Isotonic for intestinal juice Rich in Potassium 20mEq/L Ringers Lactate is appropriate High K, Low Na & Hypotonic Gastric juice, Saliva and Right colon NSwith K is appropriate High bicarbonate Pancreatic juice Neostigmine Sennapur Dulcolax Austin powder, ; Dioctyl sodium sulfosuccinate Mineral oil

9 Dopamin 2~5 ug/kg/min Dopaminergic effect Vasodilation of renal and mesenteric vessels (redirection) Mild vasoconstricture of peripheral bed 5~10 ug/kg/min Inotropic effect on the myocardium leads to increased cardiac output and blood pressure >10 ug/kg/min peripheral vasoconstriction, shifting of blood from extremities to organs, decreased kidney function, and hypertension

大腸直腸外科住院醫師及實習醫師Orientation

大腸直腸外科住院醫師及實習醫師Orientation 長庚醫療財團法人林口長庚紀念醫院大腸直腸外科七年級實習醫學生教學訓練計劃長庚紀念醫院大腸直腸外科編印中華民國一二年九月目錄壹七年級實習醫學生訓練目標 2 貳大腸直腸外科訓練專科師資 5 參大腸直腸外科訓練教學資