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外科护理学

Medical-Surgical Nursing II

课程介绍 Course Introduction

学分:6 | 先修课:内科护理学 | 学期:第四学期

本课程讲授外科各系统疾病患者的护理,包括外科休克、感染、损伤患者的护理,以及普外科、骨科、泌尿外科、胸外科、神经外科、烧伤整形科等专科疾病患者的围手术期护理。课程强调手术前后护理评估、手术室护理配合、伤口护理、引流管护理、疼痛管理及康复指导,培养学生对外科急危重症患者的应急处理能力。

This course teaches nursing care for surgical patients across specialties, including surgical shock, infection, and trauma care, as well as perioperative nursing for general surgery, orthopedics, urology, thoracic surgery, neurosurgery, and burn and plastic surgery. The course emphasizes pre- and postoperative assessment, operating room coordination, wound care, drain management, pain management, and rehabilitation instruction, developing students' emergency response skills for critically ill surgical patients.

大作业 Final Project

作业标题:外科患者围手术期护理评估与护理方案制定

选择一个外科典型病例,进行围手术期护理评估,制定术前、术中、术后护理方案。提交完整围手术期护理计划。

Select a typical surgical case, conduct perioperative nursing assessment, and develop preoperative, intraoperative, and postoperative care plans. Submit a complete perioperative care plan.

实施步骤 Implementation Steps

示例:为一名腹部手术患者制定围手术期整体护理方案,比如腹腔镜胆囊切除术患者。你需要完成术前宣教、皮肤准备和禁食管理,术后监测生命体征和引流液性状,评估切口愈合和肠蠕动恢复情况,指导早期下床活动和渐进饮食,最后出院前进行伤口自我护理和复诊宣教。
步骤 1
外科病例选择与围手术期护理框架设计
本步骤的核心任务是选择一个外科典型病例,设计涵盖术前、术中、术后三个阶段的围手术期护理框架。外科护理的核心是围手术期护理,需要全面评估患者的手术耐受性,预防手术并发症,促进术后康复。选择的病例应具有代表性,能够体现外科护理的特点,如术前准备、手术室护理、术后监护、并发症观察、伤口护理、康复指导等。

• 选择典型外科病例:从普通外科(胆囊切除术、阑尾切除术、胃大部切除术、结直肠癌手术)、骨科(骨折内固定术、关节置换术)、泌尿外科、胸外科等中选择一个择期手术病例,获取完整的病史、体格检查、实验室检查、影像学检查和手术方案资料
• 设计围手术期护理框架:按照术前(入院至手术前)、术中(进入手术室至出手术室)、术后(返回病房至出院)三个阶段设计护理内容,每个阶段包含护理评估、护理诊断、护理目标、护理措施、效果评价,强调安全管理和并发症预防
• 确定评估工具和风险评估:准备围手术期专用评估工具,如ASA麻醉风险分级、手术风险评估表(POSSUM)、营养风险筛查(NRS 2002)、压疮风险评估(Braden)、跌倒风险评估、深静脉血栓风险评估(Caprini评分)、疼痛评估(NRS/VAS)
产出:病例摘要、围手术期护理框架图、评估工具清单、风险评估计划表| 质量标准:病例典型有代表性,护理框架系统全面、贯穿围手术期全程,风险评估工具选择专业
步骤 2
术前护理评估与术前准备
本步骤的核心任务是全面评估患者的手术耐受性,完成充分的术前准备,确保患者以最佳状态迎接手术。术前评估不仅关注疾病本身,更要评估患者的全身状况和重要脏器功能,识别手术风险因素。术前准备包括心理准备、身体准备、皮肤准备、胃肠道准备、呼吸道准备、药物准备等,是手术安全的第一道防线。

• 术前全面评估:系统评估患者的健康史(现病史、既往史、手术史、过敏史、用药史、家族史)、身体状况(生命体征、营养状况、各系统功能)、心理状况(焦虑程度、对手术的认知和期望)、社会支持状况,进行手术风险评估(ASA分级、心功能分级、肺功能评估),识别术前高危因素
• 术前身体准备:执行各项术前准备措施:呼吸道准备(戒烟、深呼吸训练、有效咳嗽训练、雾化吸入)、胃肠道准备(术前8-12小时禁食、4小时禁饮、清洁灌肠或口服泻药、留置胃管)、皮肤准备(手术区域皮肤清洁、剃毛或脱毛、皮肤消毒范围准备)、排尿排便准备、配血、药物过敏试验、术前晚睡眠护理
• 术前健康教育与心理护理:向患者和家属介绍手术相关知识(手术方式、麻醉方式、手术过程、ICU环境),进行术前训练(床上排便、翻身、呼吸功能锻炼、术后活动方法),讲解术后可能的不适和应对方法(疼痛、恶心呕吐、腹胀),进行心理疏导,减轻焦虑恐惧,签署手术知情同意书的护理配合
产出:术前护理评估单、风险评估记录表、术前准备核查单、健康教育记录、心理护理记录| 质量标准:术前评估全面深入、风险识别准确,术前准备规范充分、逐项落实,健康教育有效、患者心理状态稳定
步骤 3
术中护理配合与手术安全管理
本步骤的核心任务是分析手术室护理工作内容,包括手术患者的接送、手术体位的摆放、手术用物的准备、无菌技术的执行、手术过程的配合和手术安全的管理。手术室护理是外科护理的重要组成部分,要求严格的无菌观念、敏锐的观察能力和熟练的配合技能。手术安全管理是保障患者安全的核心,涉及患者身份识别、手术部位确认、物品清点、用药安全等多个环节。

• 手术患者交接与体位摆放:分析术前访视和患者接送流程(手术室护士病房接患者、身份核对、术前用药执行、安全转运),设计手术体位摆放方案(如仰卧位、侧卧位、俯卧位、截石位),说明体位摆放的要点(维持呼吸循环功能、避免神经血管受压、保护皮肤和眼睛、保证手术野暴露)和注意事项
• 手术配合与无菌技术:分析器械护士和巡回护士的职责分工,设计手术用物准备清单(器械、敷料、一次性物品、特殊耗材),说明无菌技术操作要点(外科手消毒、穿无菌手术衣、戴无菌手套、器械台管理、术中无菌原则维持),制定手术器械清点制度(术前、关体腔前、关体腔后、术后四次清点)
• 手术安全管理:设计手术安全核查流程(WHO手术安全核查表:麻醉实施前、手术开始前、患者离开手术室前三方核查),内容包括患者身份确认、手术部位确认、手术方式确认、麻醉安全核查、物品清点、用药安全、输血安全、标本管理,分析手术差错的常见原因和预防措施
产出:手术体位摆放方案图、手术室护士职责分工表、手术安全核查清单、无菌技术操作规范、手术物品清点制度| 质量标准:手术配合流程清晰,无菌技术要求严格,安全管理措施具体、体现患者安全目标
步骤 4
术后护理与并发症观察
本步骤的核心任务是制定术后护理计划,实施术后监护,观察和预防术后并发症。术后护理是围手术期护理的关键阶段,患者经历了手术创伤,需要密切监测生命体征和病情变化,做好疼痛管理、伤口护理、管道护理、饮食护理和活动指导。早期识别和处理术后并发症是术后护理的重点,直接影响患者的康复速度和预后。

• 术后监护与评估:制定术后监护计划,返回病房后即刻评估生命体征(每15-30分钟1次至平稳,逐渐延长间隔)、意识状态、伤口敷料渗血渗液情况、各种引流管(引流液颜色性状量)、疼痛程度、末梢循环,评估麻醉恢复情况(如全麻苏醒评分),记录出入量,监测实验室检查(血常规、电解质、血气分析)
• 术后常规护理:实施术后基础护理和专科护理:疼痛管理(PCA泵使用、止痛药、非药物镇痛)、伤口护理(观察愈合、换药、拆线时间)、管道护理(胃管、尿管、引流管的固定、通畅、观察、拔管指征)、饮食护理(禁食→流质→半流质→普食的过渡)、活动指导(术后早期下床活动的计划和指导)、心理护理
• 并发症观察与预防:系统观察和预防常见术后并发症:术后出血(伤口、消化道、腹腔内出血的观察和处理)、切口感染(红、肿、热、痛、脓性分泌物)、肺部感染(坠积性肺炎的预防:翻身拍背、深呼吸、有效咳嗽)、深静脉血栓形成(预防措施:早期活动、弹力袜、抗凝药物)、尿潴留、腹胀、压疮,制定并发症观察清单和应急处理流程
产出:术后监护记录单、术后护理计划表、并发症观察清单、管道护理记录、疼痛评估记录| 质量标准:术后监护严密细致,护理措施规范到位,并发症预防措施完善、观察敏锐、处理及时
步骤 5
外科护理病例总结与康复指导报告撰写
本步骤的核心任务是撰写完整的外科围手术期护理病例报告,制定出院康复指导计划。外科护理的最终目标是促进患者康复,使其顺利回归家庭和社会。病例报告应系统总结围手术期护理经验,体现外科专科护理思维和快速康复外科(ERAS)理念。出院康复指导是延续护理的重要内容,帮助患者在家中继续康复,预防并发症,提高生活质量。

• 撰写围手术期护理病例报告:按照外科护理病例报告规范撰写,包括病例介绍、术前护理评估与准备、术中护理配合(手术室护理)、术后护理与并发症观察、护理效果评价、讨论与体会,重点分析围手术期安全管理、并发症观察与预防、快速康复理念的应用
• 制定出院康复指导计划:根据患者的手术类型和恢复情况,制定个体化的出院康复指导计划,内容包括:伤口护理指导、活动与休息(活动量的逐渐增加、避免重体力劳动的时间)、饮食指导(饮食结构、营养补充、禁忌)、用药指导(药物名称、剂量、用法、不良反应)、复诊指导(复诊时间、复诊内容、出现哪些情况需及时就医)、心理调适
• 制作外科健康教育材料:制作一份针对该手术患者的健康教育手册或视频脚本,内容涵盖术前准备须知、术后早期康复锻炼(如呼吸功能锻炼、肢体功能锻炼、下床活动指导)、饮食营养、并发症预防、家庭护理要点、复查流程,图文并茂,通俗易懂,适合患者及家属阅读
产出:外科围手术期护理病例报告、出院康复指导计划、患者健康教育手册| 质量标准:病例报告完整规范、体现外科专科护理水平,康复指导个体化、实用性强,健康教育材料科学易懂

Steps

Step 1
Surgical Case Selection and Perioperative Nursing Framework Design
The core task of this step is to select a typical surgical case and design a perioperative nursing framework covering preoperative, intraoperative, and postoperative phases. The core of surgical nursing is perioperative care.

• Select typical surgical case: choose from general surgery (cholecystectomy, appendectomy, gastrectomy, colorectal surgery), orthopedics (fracture fixation, joint replacement), urology, thoracic surgery; select an elective surgery case; obtain complete history, physical exam, laboratory tests, imaging, and surgical plan
• Design perioperative nursing framework: design nursing content for preoperative (admission to surgery), intraoperative (OR entry to exit), postoperative (return to ward to discharge) phases; each phase includes assessment, diagnoses, goals, interventions, evaluation; emphasize safety management and complication prevention
• Determine assessment tools and risk evaluation: prepare perioperative-specific tools: ASA anesthesia risk classification, POSSUM surgical risk score, nutritional risk screening (NRS 2002), Braden pressure ulcer risk, fall risk, DVT risk (Caprini score), pain assessment (NRS/VAS)
Deliverable: Case summary, perioperative nursing framework diagram, assessment tool list, risk assessment plan | Quality standard: Typical and representative case, systematic and comprehensive framework covering entire perioperative period, professional risk assessment tool selection
Step 2
Preoperative Nursing Assessment and Preparation
The core task of this step is to comprehensively assess the patient's surgical tolerance and complete adequate preoperative preparation, ensuring the patient is in optimal condition for surgery.

• Comprehensive preoperative assessment: systematically evaluate patient's health history (present illness, past history, surgical history, allergies, medication history, family history), physical condition (vital signs, nutritional status, system function), psychological status (anxiety level, knowledge and expectations of surgery), social support; conduct surgical risk assessment (ASA classification, cardiac function, pulmonary function); identify high-risk factors
• Preoperative physical preparation: implement preoperative preparation measures: respiratory preparation (smoking cessation, deep breathing exercises, effective coughing training, nebulization), gastrointestinal preparation (NPO 8-12hrs for food, 4hrs for water, cleansing enema or oral laxative, NG tube placement), skin preparation (surgical site skin cleansing, shaving/depilation, skin disinfection range preparation), elimination preparation, blood cross-matching, allergy testing, preoperative sleep care
• Preoperative health education and psychological care: introduce surgery-related knowledge to patient and family (surgical approach, anesthesia, operative process, ICU environment); provide preoperative training (bedside toileting, turning, breathing exercises, postoperative mobility methods); explain possible postoperative discomforts and coping methods (pain, nausea/vomiting, abdominal distension); provide psychological counseling to reduce anxiety/fear; assist with informed consent process
Deliverable: Preoperative nursing assessment form, risk assessment record, preoperative preparation checklist, health education record, psychological care record | Quality standard: Comprehensive and in-depth preoperative assessment with accurate risk identification, standardized and thorough preoperative preparation, effective health education, stable patient psychological state
Step 3
Intraoperative Nursing Collaboration and Surgical Safety Management
The core task of this step is to analyze operating room nursing work, including patient transport, surgical positioning, instrument preparation, aseptic technique implementation, surgical collaboration, and surgical safety management.

• Surgical patient handover and positioning: analyze preoperative visit and patient transport process (OR nurse pickup from ward, identity verification, preoperative medication administration, safe transport); design surgical positioning plan (supine, lateral, prone, lithotomy); explain positioning key points (maintaining respiratory/circulatory function, avoiding neurovascular compression, skin/eye protection, surgical field exposure) and precautions
• Surgical collaboration and aseptic technique: analyze role division between scrub nurse and circulating nurse; design surgical supply list (instruments, dressings, disposable items, special supplies); explain aseptic technique key points (surgical hand scrub, gowning and gloving, instrument table management, maintaining sterile field); establish instrument count protocol (four counts: before surgery, before closing cavity, after closing cavity, after surgery)
• Surgical safety management: design surgical safety verification process (WHO Surgical Safety Checklist: three verifications: before anesthesia induction, before skin incision, before patient leaves OR); includes patient identity confirmation, surgical site confirmation, procedure confirmation, anesthesia safety check, item count, medication safety, transfusion safety, specimen management; analyze common causes of surgical errors and preventive measures
Deliverable: Surgical positioning diagram, OR nurse role division table, surgical safety checklist, aseptic technique standard, surgical item count protocol | Quality standard: Clear surgical collaboration workflow, strict aseptic technique requirements, specific safety management measures demonstrating patient safety goals
Step 4
Postoperative Nursing and Complication Observation
The core task of this step is to develop a postoperative care plan, implement postoperative monitoring, and observe and prevent postoperative complications. Postoperative care is the key phase of perioperative nursing.

• Postoperative monitoring and assessment: develop postoperative monitoring plan; assess vital signs immediately upon return to ward (every 15-30 min until stable, then gradually extend interval), consciousness, wound dressing (bleeding/drainage), various drains (drainage color/character/amount), pain level, peripheral circulation; assess anesthesia recovery (e.g., Aldrete score); record intake/output; monitor laboratory tests (CBC, electrolytes, blood gas)
• Routine postoperative care: implement basic and specialty postoperative care: pain management (PCA pump use, analgesics, non-pharmacological methods), wound care (healing observation, dressing changes, suture removal timing), drain care (NG tube, urinary catheter, drains: fixation, patency, observation, removal criteria), dietary care (NPO → liquid → semi-liquid → regular diet transition), mobility guidance (early ambulation plan and instruction), psychological care
• Complication observation and prevention: systematically observe and prevent common postoperative complications: postoperative hemorrhage (wound, GI, intra-abdominal bleeding observation and management), surgical site infection (redness, swelling, heat, pain, purulent discharge), pulmonary infection (hypostatic pneumonia prevention: turning, back tapping, deep breathing, effective coughing), DVT (prevention: early mobilization, compression stockings, anticoagulants), urinary retention, abdominal distension, pressure ulcers; create complication observation checklist and emergency management protocol
Deliverable: Postoperative monitoring record, postoperative care plan, complication observation checklist, drain care record, pain assessment record | Quality standard: Close and detailed postoperative monitoring, standardized and thorough nursing interventions, comprehensive complication prevention with keen observation and timely management
Step 5
Surgical Nursing Case Summary and Rehabilitation Guidance Report Writing
The core task of this step is to write a complete surgical perioperative nursing case report and develop a discharge rehabilitation guidance plan. The ultimate goal of surgical nursing is to promote patient recovery and successful return to family and society.

• Write perioperative nursing case report: following surgical nursing case report standards including case introduction, preoperative assessment and preparation, intraoperative collaboration (OR nursing), postoperative care and complication observation, nursing outcome evaluation, discussion and reflections; focus on perioperative safety management, complication observation and prevention, ERAS concept application
• Develop discharge rehabilitation plan: based on surgery type and recovery status, develop individualized discharge rehabilitation plan including: wound care instruction, activity and rest (gradual increase in activity, time to avoid heavy physical labor), dietary guidance (diet structure, nutritional supplementation, contraindications), medication guidance (drug names, dosage, administration, side effects), follow-up guidance (follow-up time, content, when to seek immediate care), psychological adjustment
• Create surgical health education materials: develop a health education manual or video script for this surgery patient, covering preoperative preparation instructions, early postoperative rehabilitation exercises (breathing exercises, limb function exercises, ambulation guidance), diet and nutrition, complication prevention, home care key points, follow-up process; illustrated and easy to understand for patients and families
Deliverable: Surgical perioperative nursing case report, discharge rehabilitation plan, patient health education manual | Quality standard: Complete and standardized case report demonstrating surgical specialty nursing level, individualized and practical rehabilitation guidance, scientific and understandable health education materials
步骤 2
术前评估
评估手术风险和术前准备情况
产出:术前评估
步骤 3
术中护理
制定手术室护理配合方案
产出:术中护理方案
步骤 4
术后护理
制定术后观察、并发症预防和康复方案
产出:术后护理方案
步骤 5
报告撰写
整理完整围手术期护理计划
产出:护理计划

Steps

Step 1
Case Selection
Select surgical case and collect preoperative data
Deliverable: Case Data
Step 2
Preoperative Assessment
Assess surgical risks and preoperative preparation
Deliverable: Preoperative Assessment
Step 3
Intraoperative Nursing
Develop operating room nursing plan
Deliverable: Intraoperative Care Plan
Step 4
Postoperative Nursing
Develop postoperative observation and rehabilitation plan
Deliverable: Postoperative Care Plan
Step 5
Report Writing
Compile complete perioperative care plan
Deliverable: Care Plan
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