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重症腹部感染患者专科护理查房【PPT展示】

  • 2026-07-25 23:19:14
重症腹部感染患者专科护理查房【PPT展示】
重症腹部感染护理查房
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那个病人送来的时候，肚子硬得像木板。急诊剖腹探查，术中看到腹腔里全是浑浊的渗液，肠壁水肿得发亮，关腹都关不上，最后只能盖了个VSD临时封着回ICU。
我印象最深的是术后第一天测膀胱压，30cmH₂O。正常值是5到7，超过20就是腹腔间隔室综合征。这个病人的膈肌已经被顶到了极限，呼吸机打不进气，下腔静脉被压瘪了，补液也补不进去。
腹腔压力这个事，很多ICU护士容易忽略。触诊摸肚子觉得"有点胀"就过去了，但触诊根本不可靠，经膀胱测压才是金标准。测量方法不复杂：患者平卧，排空膀胱，注入25ml无菌生理盐水，测压管零点对齐腋中线髂嵴水平，呼气末读水柱高度。1cmH₂O换算成0.74mmHg。这个数值的意义在于——超过20还不干预，器官衰竭就开始了。
腹膜炎分继发性和三发性。继发性是穿孔或者透壁坏死之后，消化液和细菌漏进腹腔，化学刺激加细菌感染一起引爆的。三发性是最难搞的，初始治疗后免疫系统耗竭了，超级耐药菌或者真菌趁虚而入，死亡率极高。
护理诊断的优先级很清楚。组织灌注无效是首位的，感染性休克加腹腔高压，心脏回不来血，全身器官都在缺氧。其次是体液失衡，大量液体逃逸到第三间隙，血管里反而干了。然后是疼痛、营养这些问题。
感染源控制必须物理介入。抗生素对付弥漫性腹膜炎有一定作用，但包裹性的脓肿完全打不进去。经皮穿刺置管引流或者手术引流，把脓液物理性地移出体外，这个优先级高于任何药物。
第三间隙补液是个巨大的陷阱。毛细血管渗漏的时候，液体疯狂逃逸到腹腔。补得越多，肠道水肿越重，腹腔压力越高，然后渗漏更严重。这是一个闭环。CVP不能作为判断容量的唯一依据，渗漏高峰期要果断引入白蛋白把水分拉回血管里。
黎氏管是腹腔引流的核心设备。双套管结构，外管持续滴注生理盐水，内管接低负压吸引。冲洗液滴入量要小于等于吸引量，只进不出说明管路堵死了，必须立即手推冲洗。脓液太稠的时候，靠重力流不出来，负压才能把那些腐蚀性液体强行吸出。
腹腔开放的患者，VSD负压封闭是标准做法。持续负压约125mmHg，把炎症渗液源源不断吸走，同时靠应力把创缘往中间拉。护理上要维持负压稳定，观察引流液性状，敷料渗漏要及时更换。
引流液的颜色变化是直接的观察窗口。淡红血性转淡黄清亮是正常修复。如果变成黄白色、浑浊、恶臭，感染失控了。如果突然出现黄绿色、粪渣、粪臭，那是肠瘘或者胆瘘，灾难性的。
爆腹是腹部感染最惊悚的并发症。病人咳嗽或者用力的时候，切口突然裂开，肠管脱出。这时候绝对不能强行回纳，水肿的肠壁一碰就破。紧急措施是病人平卧屈膝降低腹压，无菌温盐水大敷料覆盖脱出肠管，通知手术室。
营养支持的时机很重要。休克期肠道血流被切断，绝对不能启动肠内营养，必须靠中心静脉泵入全肠外营养。但肠道不能无限期空置，黏膜绒毛3到5天不接触食物就会萎缩，屏障消失之后肠源性细菌直接入血。血流动力学稳定之后要尽早启动微量喂养，24到48小时内经鼻空肠管滴入，目的不是热量，是物理接触唤醒肠道功能。
多重耐药菌的防控在重症腹部感染后期尤其重要。CRE、鲍曼不动杆菌这些超级细菌一旦在ICU定植，传播速度极快。单间隔离是最基础的，引流废液要2000mg/L含氯消毒液浸泡30分钟才能倒掉。
抗生素策略先广谱重火力覆盖，病原学结果出来之后迅速降级。时间依赖性抗生素要严格遵守给药间隔，q8h就是q8h，不能随意合并。
静脉血栓预防在盆腔感染患者身上要格外重视。大创伤、盆腔高凝、腹腔高压三者叠加，静脉回流极慢，血栓发生率高。评估出血风险后尽早启用低分子肝素和气压泵。
效果评估的指标：膀胱压降到12以下，乳酸清除率达标，PCT和CRP断崖式下降，黎氏管引流清亮，肠鸣音恢复，自主排气。
拔胃管的时机在ERAS理念下被重新审视。传统做法是等到肛门排气，但长期留置胃管会破坏贲门括约肌，增加VAP风险。只要CT排除梗阻，胃液引流量持续小于200到300毫升，无恶心呕吐，就可以拔管。
出院之后带管和带造口的患者，家属的教育要做到位。造口底盘剪裁尺寸要精确，绝对不能允许排泄物直接接触皮肤，高浓度消化酶的腐蚀速度是惊人的。肠外瘘的患者可以用负压封堵技术，中心接低负压持续吸走肠液，保护周围皮肤。
最后说一句。腹部重症感染护理的特殊之处在于，很多时候敌人是"物理存在"的——脓液、高压、渗漏、梗阻。不靠药物，靠引流、靠测压、靠冲洗、靠营养时机。把这些物理手段落实到位了，病人的生存机会就大一分。每一个引流液的性状变化、每一次膀胱压的数值记录、每一次肠内营养的启动时机，都可能改变整个病程的走向。
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  1. CONNECT:[ UseTime:0.000769s ] mysql:host=127.0.0.1;port=3306;dbname=h_sjds;charset=utf8mb4
  2. SHOW FULL COLUMNS FROM `fenlei` [ RunTime:0.000941s ]
  3. SELECT * FROM `fenlei` WHERE `fid` = 0 [ RunTime:0.000342s ]
  4. SELECT * FROM `fenlei` WHERE `fid` = 63 [ RunTime:0.000311s ]
  5. SHOW FULL COLUMNS FROM `set` [ RunTime:0.000618s ]
  6. SELECT * FROM `set` [ RunTime:0.000231s ]
  7. SHOW FULL COLUMNS FROM `article` [ RunTime:0.000677s ]
  8. SELECT * FROM `article` WHERE `id` = 537257 LIMIT 1 [ RunTime:0.001601s ]
  9. UPDATE `article` SET `lasttime` = 1785191291 WHERE `id` = 537257 [ RunTime:0.002457s ]
  10. SELECT * FROM `fenlei` WHERE `id` = 64 LIMIT 1 [ RunTime:0.000258s ]
  11. SELECT * FROM `article` WHERE `id` < 537257 ORDER BY `id` DESC LIMIT 1 [ RunTime:0.000497s ]
  12. SELECT * FROM `article` WHERE `id` > 537257 ORDER BY `id` ASC LIMIT 1 [ RunTime:0.001757s ]
  13. SELECT * FROM `article` WHERE `id` < 537257 ORDER BY `id` DESC LIMIT 10 [ RunTime:0.002447s ]
  14. SELECT * FROM `article` WHERE `id` < 537257 ORDER BY `id` DESC LIMIT 10,10 [ RunTime:0.010935s ]
  15. SELECT * FROM `article` WHERE `id` < 537257 ORDER BY `id` DESC LIMIT 20,10 [ RunTime:0.000645s ]
0.096149s