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1、护理查房肾积水第十病区NursingRoundsHydronephrosisWardTen病史摘要患儿,女,11月,于2009年03月03日因B超发现左肾积水二月余而入院。患儿近日来无发热,大便正常,肾脏动态显象及GFR测定示：肾小球滤过率功能正常，左肾中度积水—因左输尿管上段狭窄所致。入院后完善相关检查,予2009年3月05日在全麻下行左肾盂输尿管成形术,术后生命体征平稳,于03-07拔除导尿管，当日能自行解小便，无疼痛。03-10拔除后腹膜负压吸引管，03-15拔除输尿管支架管，现肾造瘘引流管固定良好，引流通畅。Br
2、iefhistoryChildren,female,10monthsold,wasfoundlefthydronephrosisbyBultrasonicandwashospitalizedonMarch3th,2009byB-February.Childrenhasnofever,defecateisnormalinrecentdays,theKidneydynamicmanifestationsandGFRdeterminationdisplay:theglomerularfiltrationrateisnormal
3、,renalwatermoderate–becauseoftheleftuppersegmentureterwasnarrow.Afteradmissionperfectrelevantinspection,angioplastyofleftrenalpelvisandureteronundergeneralanesthesiaMarch5,2009,withstablevitalsignsaftersurgery,catheterwasremovedon03-07,itcouldurinatebyitselfwithn
4、opain,peritonealsuctiontubewasremovedon03-10,ureteralstentwasremovedon03-15,nephrostomydrainagetubeisfixedwell,drainageisunobstructed.护理评估术前评估(1)身体评估(2)心理和社会支持状况术后评估(1)康复状况(2)心理认知状况(3)预后判断NursingassessmentPreoperativeAssessment(1)physicalassessment(2)psychologica
5、landsocialsupportPostoperativeevaluation(1)rehabilitationcondition(2)PsychologicalCognition(3)prognosis护理诊断1.知识缺乏(家属):缺乏术前准备知识,注意事项2.有感染的危险:与术后抵抗力下降，留置引流管有关3.躯体移动障碍：与置引流管有关4.有皮肤完整性受损的危险：与长期卧床，活动受限有关。5.有体液不足的危险：与呕吐有关6.焦虑(家属):担心术后预后不良NursingDiagnosis1.lackofknowled
6、ge(family):lackofpreoperativepreparationknowledgeNotes2.theriskofinfection:relatedtopostoperativedecreasedresistance,indwellingdrainagetube3.physicalmobilitybarriers:relatedtothedrainagetube4.theriskofimpairedskinintegrity:relatedtolong-termbedrest,limitedmobilit
7、y.5.theriskofinadequatefluid:relatedtovomiting6.anxiety(family):fearofpoorprognosisaftersurgery预期目标1.术前家属掌握相关注意事项2.患儿留置导尿期间无感染发生3.患儿能适当进行活动4.患儿皮肤完整性得到保护，不发生破损。5.患儿体液保持平衡，生命体征平稳6.患儿家属术后能够掌握有关配合治疗护理的方法ExpectedOutcomes1.Familymembershaverelevantpreoperativeprecautio
8、ns2.Childrenwithnoinfectionoccurredduringthecatheterization3.Childrencanproperlyconductactivities4.Childrenskinintegrityprotected,withnodamaged.5.Childrenhumor
