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1、消化系统疾病患者的 健康评估HealthAssessmentof TheDigestiveSystem学习目标熟悉肠胃系统的正常功能认识肠胃系统的异常表现掌握肠胃系统的评估要点熟悉肠胃系统评估技巧分辨不同年纪、性别、疾病谱在消化系统的表现GISystemAssessment消化系统评估健康史:生活背景Biographicalanddemographicdata目前健康状况CurrentHealth过去健康病史PastHealthhistory家族史FamilyHealth心理社会因素PsychosocialF
2、actors系统回顾ReviewofsystemDemographicData背景资料评估GenderAgeMaritalStatusWorkingconditionWomen(calcium),elderly(inadequatefoodintake,gastriculcer,coloncancer),teenagers(Duodenalulcers,gastriccancers)mayhavedifferenthealthproblemandnutritionalneeds.CurrentHealthAs
3、sessment目前健康评估评估主诉是否出现：恶心、呕吐吞咽困难：梗阻与疼痛不消化：反酸或嗳气腹痛呕血、便血腹泻、便秘腹水黄疸体重及食欲改变.PastHealthHistory过去病史Bleeding-irondeficiencyanemiaLiverDisease:proteinmalnutritionPepticUlcerWithbleedingJaundiceGallbladdersiseasePancreatitisCancerChangeofbowelhabitsTarrystoolsUnexpla
4、inedweightlossorgainHealthHistoryofTheGISystemHealthPerception-healthmanagementpatternNutritional-metabolicpatternEliminationpatternActivity-exercisepatternSleep-RestPatternCongitive-preceptionpatternSelf-Perception,self-conceptpatternRole-relationshippatte
5、rnSexuality-reproductivepatternCoping-stresstolerancepatternValue-beliefpatternLewis,2004,p.955AssessforMedications药物评估UseofAspirin,NAISD(Nonsteroidalanti-inflammatorydrugs)–gastritis/bleeding是否使用阿斯匹林，非激素类止痛药，胃出血Antacids:typeandfrequency制酸剂，种类、频率Laxativesor
6、stoolsofteners?软便剂DietarySupplement:vitamins,minerals,herbs,aminoacids食品补充，维生素、草药、蛋白质AssessmentforAllergies评估过敏史Foodallergies:hivesordyspneaFoodintolerance:GIabdominalcramping,flatulence,ordiarrhea(lactoseintolerance)Commentfoodallergiesitems:nuts,shellfish
7、,cow’smilk,foodadditivesAssessmentforFamilyHistoryGIproblemmayassociatewithfamilyhistoryandenvironmentfactors.Ulcerativecolitis溃疡性结肠炎Crohn’sDisease克罗恩病Alcoholism酗酒Liverdiseases肝脏疾病FamilyhistoryofDM,anemia,jaundice,hepatitis,Pancreatitis,obesity,irritablebow
8、elsyndrome.糖尿病家族史、贫血、黄疸、肝炎、胰脏炎、肥胖、小肠激惹症候群PsychosocialHistory心理社会病史Occupation:environmentaltoxins(lead,mercury,carbontetrachloride)Travel:Pathogens(protozoa,parasites),eatingrawshellfish,swimminginpollu
