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1、肠 梗 阻 Intestinal obstraction,Whenever gastrointestinal luminal content is pathologically prevented from passing distally,Conception,任何原因引起的肠内容物不能正常运行，顺利通过肠道时，称为肠梗阻（intestinal obstruction)。,1. According to its Basic causes 2. Vascular supply to intestinal wall 3. Obstruction level or site 4. The exte
2、nt of obstruction 5. Progression of obstruction,Classification,.According to its Basic causes 机械性肠梗阻（ mechanical obstruction） 动力性肠梗阻（dynamic obstruction） 血运性肠梗阻（obstruction of vascular supply origin）,Classification,Classification,mechanical obstruction（very common),A. 肠腔堵塞,B.肠管受压,粘连带压迫,ascarid,herni
3、a,mechanical obstruction,C. 肠壁病变,inflammatory,neoplastic,Classification,Dynamic obstruction,Causes : Nerval reflex or toxin stimulation,Classification 麻痹性肠梗阻 （Paralytic ileus ）： acute diffuse peritonitis, abdominal operation, retroperitoneal hematoma and infection 痉挛性肠梗阻（ Spastic obstruction ）,Class
4、ification,Obstruction of vascular supply origin,thrombosis or embolism, then intestinal paralysis,Classification,1. 按梗阻发生的原因 2. 按肠壁有无血运障碍 单纯性肠梗阻 (Simple obstruction) 绞窄性肠梗阻 (Strangulation obstruction),Intussception,Volvulus,Classification,1. According to its Basic causes 2. Vascular supply to intest
5、inal wall 3. 按梗阻发生的部位 高位肠梗阻(high obstruction ) 低位肠梗阻(low obstruction),Classification,1. According to its Basic causes 2. Vascular supply to intestinal wall 3. Obstruction level or site 4. 按梗阻发生的程度 完全性肠梗阻(complete obstruction) 不完全性肠梗阻(Incomplete obstruction),Classification,1. According to its Basic c
6、auses 2. Vascular supply to intestinal wall 3. Obstruction level or site 4. The extent of obstruction 5. 按梗阻发生的速度 急性肠梗阻(Acute obstruction) 慢性肠梗阻(chronic obstruction),Classification,Pathophysiology,Simple mechanical obstruction 梗阻以上肠蠕动增多(contracts vigorously) 梗阻以上肠管膨胀(distention) 梗阻以下肠管瘪陷 膨胀和瘪陷交界处为梗阻
7、所在,肠管局部变化,Pathophysiology,Acute complete obstruction 肠腔压力静脉回流受阻肠壁水肿、增厚、呈暗红色动脉血运受阻肠管变成紫黑色坏死、穿孔。,Pathophysiology,肠管局部变化,Chronic incomplete obstruction 梗阻以上肠腔扩张、肠壁代偿性肥厚 腹壁视诊常可见扩大的肠型和肠蠕动坡。,Pathophysiology,肠管局部变化,全身性病理生理改变 主要由于体液丧失、肠膨胀、毒素的吸收和感染所致,Pathophysiology,体液丧失(lose of body fluid) 引起水、电解质紊乱与酸碱失衡 全身
8、性感染和毒血症 腹膜炎和中毒(peritonitis and poisoning) shock respiration and circulation disorder),Pathophysiology,全身性病理改变,Clinical Manifestations,痛,吐,胀,闭,张某，男性，48岁 阵发性腹痛、恶心、呕吐 出大量草绿色液体，1天后出现腹胀、3天来无排便 。 2年前曾行阑尾切除术,Clinical Manifestations,Clinical Manifestations,Pain （痛）,Vomitting （吐）,Distension （胀）,Constipation
9、（闭）,痛,吐,胀,闭,特点,胀痛,Clinical Manifestations,Paralytic ileus,mechanical obstruction,obstruction of vascular supply origin,痛,吐,胀,闭,特点,出现早且频繁 出现晚、次数少且量多 次数多且量多 次数少且量少 暗红或血性液体,high / Strangulation,Low obstruction,Completely,incompletely,Strangulation,Clinical Manifestations,痛,吐,胀,闭,腹部膨隆,肠腔扩张,Clinical Mani
10、festations,How to observe distention？ 腹部膨隆 腹壁紧张、皮肤发亮 呼吸困难、不能平卧 X线检查 血气,痛,吐,胀,闭,Clinical Observations,机理,痛,吐,胀,闭,肠管失去蠕动功能 肠蠕动不能正常推进,Clinical Manifestations,痛,吐,胀,闭,特点,完全停止排便、排气 多次少量排便、排气 早期有少量排便、排气 粘液样血便,Completely,incompletely,high,Strangulation,Clinical Manifestations,Clinical Manifestations,R、HR 、
11、BP,痛,吐,胀,闭,脱水、电解质紊乱、酸碱失衡,肠壁缺血坏死、穿孔,毒素吸收毒血症,shock,Abrupt onset with continous acute abdominal pain.early vomitting shock Manifestation of peritonitis。T P 。 Asymmetrical distention,local bulge,or mass with tenderness。,Characteristic of strangulation intestinal obstruction（1）,Hemic vomitus,drainage Con
12、servative treatment in vain and no improvement in symptoms and signs X线检查符合绞窄性肠梗阻特点,Characteristic of strangulation intestinal obstruction（2）,鱼骨刺状,胀大肠袢,Characteristic of strangulation intestinal obstruction,accessory examination,1. 化 验 检 查 血红蛋白值 血细胞比容 尿化重 白细胞、中性粒细胞 粪便、血气分析血电解质、尿素氮 肌酐,Accessory exami
13、nation,2. X 检 查 立位或侧卧位透视或拍片。可见多数液平面及气胀肠袢。,Accessory examination,气液平面,Diagnosis,Case Review,T 37.8 P 96次/分 BP 126/78mmHg 腹部膨隆，见肠型及胃肠蠕动波 肠鸣音亢进，有气过水声 叩诊呈鼓音 右侧腹部压痛明显 X线提示有气液平,must make clear the following questions Whether intestinal obstruction exists? Whether the obstruction is mechanical or dynamic?
14、Whether the obstruction is simple or strangulation obstruction? Whether the obstruction is high or low? Whether the obstruction is complete or incomplete?,Diagnosis,Treatment & Nursing Care,预防和纠正水、电解质、酸碱平衡紊乱 解除梗阻,治疗原则,Treatment & Nursing Care,为什么要求患者禁食？ 如何指导患者禁食？,禁食,胃肠减压,解痉止痛,补液,电解质,抗感染,Treatment &
15、Nursing Care,目的：排液、排气，减轻腹胀，病情观察 护理要点： 有效引流 关注引流液的量、颜色、性质及其变化,禁食,胃肠减压,解痉止痛,补液,电解质,抗感染,Treatment & Nursing Care,未明确诊断之前： 如何执行四禁 严密观察下应用解痉止痛剂 禁用吗啡类止痛剂,禁食,胃肠减压,解痉止痛,补液,电解质,抗感染,Treatment & Nursing Care,提供补液的可靠依据（记录出入量） 补液量 补充电解质 配合纠正酸中毒,禁食,胃肠减压,解痉止痛,补液,电解质,抗感染,Treatment & Nursing Care,合理应用抗生素 抗生素的配伍 应用的时
16、间 观察疗效、观察副作用 实施营养支持,禁食,胃肠减压,解痉止痛,补液,电解质,抗感染,Treatment & Nursing Care,解 除 梗 阻 手术治疗 适用于各种类型的绞窄性肠梗阻、肿瘤及先天性肠道畸形引起的肠梗阻，以及非手术治疗无效的病人。,Treatment & Nursing Care,原则和目的 在最短手术时间内，以最简单的方法解除梗阻或恢复肠腔的通畅。,Treatment & Nursing Care,operation A. 解除梗阻原因的术式 如粘连松解术,B.肠切除肠吻合术 C.短路手术,D.肠造口和肠外置术,如肠切开取异物，肠扭转复位术。,Special inte
17、stinal obstruction,较为常见，发生率20-40% Causes：手术：最多 炎症： 肠粘连 肠梗阻 条件：肠腔缩窄 粘连牵扯成角 粘连带压迫 肠袢套入粘连环 肠袢在粘连处扭转,一定条件,粘连性肠梗阻,Treatment 非手术疗法较好 口服生植物油 解痉剂 经胃管缓慢注入氧气，驱虫每周岁80100ml，最大不超过1500ml,性质：闭袢性肠梗阻 绞窄性肠梗阻 扭转方向：顺时针旋转多见 程度： 轻：3600以下 重：23转 部位： 小肠、乙状结肠,肠扭转（volvulus),1.小 肠 扭 转 多见于青壮年 诱因： 饱食后剧烈活动 症状特点： 腹痛发作急骤 牵涉腰背部 喜胸膝位
18、或蜷曲侧卧位 呕吐频繁、腹胀不显易休克,2. 乙状结肠扭转 多见于老年人，常有便秘习惯，除腹部绞痛外，有明显腹胀，而呕吐一般不明显。 低压灌肠：量常少于500ml X线平片：马蹄状双腔充气 肠袢 钡灌：尖端呈“鸟嘴”形,治 疗 死亡率1540% 原因：就诊过晚 治疗延误 方法：及时手术 方式：扭转复位术 肠切除术,summary,Conception,Whenever gastrointestinal luminal content is pathologically prevented from passing distally,Classification,mechanical obstr
19、uction dynamic obstruction obstruction of vascular supply origin,Simple and strangulation obstruction High and low obstruction Complete and incomplete obstruction Acute and chronic obstruction,Clinical manifestations,Pain （痛）,Vomitting （吐）,Distension （胀）,Constipation （闭）,Clinical Observations,Reliev
20、ed or not Limited or diffused Intermittent or persistent,Times Quantity Color Nature,Bowel movement,Extent of abdominal distension Breathe,Pain,vomitting,distension,constipation,Treatment and nursing care,Principles of treatment,Correcting disturbance of water, electrolyte, acid-base and preventing infection Removal of the obstructing lesions,Treatment and nursing care,How should we nurses do ? Fasting Gastrointestinal decompression Analgesic drugs Fluid resuscitation and electrolyte supplement Antibiotics,Thank you,