2 Basic Information Clinical Pathway of Rib Fracture Complicated with Hemopneumothorax (Version 20 19) The Notice of the General Office of the National Health and Wellness Committee on Printing and Distributing Clinical Pathway of Related Diseases (Version 20 19) was issued by the General Office of the National Health and Wellness Committee on February 29th, 20 19 (National Health Office Medical Letter [2065438])
Notice of the General Office of the National Health and Wellness Committee on Printing and Distributing the Clinical Pathway of Diseases (20 19 Edition)
National Health Office Medical Letter [2019] No.933
Health and Health Committees of all provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps:
In order to further promote clinical pathway management, standardize clinical diagnosis and treatment behavior, and ensure medical quality and safety, our Committee revised the clinical pathway of 19, and formed 224 clinical pathways of diseases (version 20 19). It is hereby printed and distributed to you (which can be consulted in the column of medical administration on the website of the National Health and Wellness Committee) for the reference of health administrative departments at all levels and various medical institutions at all levels.
General Office of National Health and Wellness Committee
20 19 12.29
4 Clinical Paths The full text of the clinical pathway of rib fracture complicated with hemopneumothorax (version 20 19)
4. 1 1. Standard hospitalization procedure for clinical pathway of rib fracture complicated with hemopneumothorax 4. 1. 1 (1) Applicable objects The first diagnosis is rib fracture (ICD/kloc-0: S22.30) and multiple rib fractures (multiple rib fractures). Traumatic hemothorax (ICD 10: S27. 10) and traumatic hemopneumothorax (ICD 10: S27.20).
Closed thoracic drainage (ICD 9 cm 3: 34.04) was performed.
4. 1.2 (II) Diagnostic basis is based on Clinical Diagnosis and Treatment Guide: Volume of Thoracic Surgery (edited by Chinese Medical Association, People's Health Publishing House, 2009).
1. History: many injuries.
2. Clinical manifestations:
(1) Chief complaints: chest pain, cough, blood in sputum, shortness of breath and dyspnea;
(2) Signs: the respiratory movement of the affected side is weakened, the breath sounds are low or disappear, local tenderness and thoracic compression sign (+), and the typical clinical manifestations are bone rubbing and bone rubbing. Multiple rib fractures sometimes lead to abnormal breathing.
3. chest x-ray examination and CT.
4. 1.3 (3) The selection of treatment plan is based on Clinical Diagnosis and Treatment Guidelines and Volume of Thoracic Surgery (edited by Chinese Medical Association, People's Health Publishing House, 2009).
Thoracic closed drainage, full analgesia, chest band fixation.
4. 1.4 (4) Standard residence time ≤ 10 day. 4. 1.5 (5) The entry path standard is 1. The first diagnosis must conform to ICD 10:S22.30/S22.40 and S27. 10/20/.
2. When the patient is complicated with other diseases, but does not need special treatment during hospitalization and does not affect the implementation of the first-visit clinical pathway, he can enter the pathway.
4. 1.6 (6) Clear diagnosis and routine examination at admission should be ≤ 12 hours 1. Necessary inspection items:
(1) Blood routine, liver function test, renal function test, electrolyte;
(2)X-ray chest film and electrocardiogram;
(3) Coagulation function, pre-transfusion examination, blood type and infectious disease screening (hepatitis B, hepatitis C, syphilis, AIDS).
2. According to the patient's condition, optional examination items: osteoporosis-related bone metabolism examination, myeloma-related examination, chest CT, blood gas analysis, abdominal ultrasound, etc.
4. 1.7 (vii) Selection and use time of preventive antibiotics 1. According to the Guiding Principles of Clinical Application of Antibacterials (20 15 Edition) (Guo Wei Ban Yi Fa [2015] No.43), the selection and use time of antibiotics were determined according to the patient's condition.
2. It is recommended to use the first and second generation cephalosporins. Preventive medication time is 30 minutes before operation.
4. 1.8 (8) The operation day is 1. Anesthesia mode: local anesthesia.
2. Operation method: Closed thoracic drainage.
3. Intraoperative medication: antibacterial drugs.
4. Blood transfusion: It depends on the bleeding situation.
4. 1.9 (9) Postoperative hospitalization recovery ≤9 days 1. Items that must be rechecked: blood routine, liver and kidney function, electrolyte, chest X-ray, etc.
2. Postoperative medication: Antibacterials should be used according to the Guiding Principles for Clinical Application of Antibacterials (20 15 Edition) (No.43 of Guofeiban Yifa [2015]), and the selection and use time of antibiotics should be determined according to the patient's condition. It is recommended to use the first and second generation cephalosporins.
4. 1. 10 (X) emission standard 1. The patient's condition was stable, his body temperature was normal, the surgical incision healed well, and his vital signs were stable.
2. No complications and/or complications requiring hospitalization.
4. 1. 1 1 (XI) Variation and Cause Analysis 1. Tension pneumothorax and progressive hemothorax require thoracotomy and general anesthesia.
2. Postoperative complications such as lung infection, respiratory failure, heart failure, liver and kidney failure need to be prolonged.
4.2 Second, the clinical pathway of rib fracture complicated with hemopneumothorax is suitable for: the first diagnosis is rib fracture complicated with hemopneumothorax (ICD 10:S22.30/S22.40 with S27. 10/20).
Closed thoracic drainage (ICD9CM3:34.04) was performed.
Patient name: gender:? Age:? Clinic number:? Hospitalization number:
Date of hospitalization: year month day? Date of discharge: year month day? Standard hospitalization days: ≤ 10 days.
time
1 day hospitalization
(Operation Day)
The second day of hospitalization
owner
ask
examination
treat cordially
worker
work
□ Ask about medical history and physical examination.
□ Complete medical record writing.
□ Hua Kai List and Checklist
-The superior doctor makes rounds to confirm the diagnosis.
-Inform the patient's family members of the serious illness or critical illness (as the case may be), and sign the informed consent form for the operation.
□ Closed thoracic drainage under local anesthesia
□ Senior physician rounds
□ Complete the entrance examination.
□ Continue symptomatic support treatment.
□ Complete necessary consultations with relevant departments.
-to complete the superior doctor rounds and other medical records writing.
-explain the illness and matters needing attention to patients and their families.
heavy
main points
doctor
order
Long-term doctor's advice:
□ Nursing routine of thoracic surgery
□ Primary health care
□ diet
□ ECG monitoring
□ Oxygen inhalation
□ Chest strap fixation
□ Use analgesic drugs
-according to the condition of serious illness or critical notice.
□ Other doctor's advice
Temporary medical advice:
-Blood routine, liver and kidney function, electrolyte
□ X-ray chest film, electrocardiogram and abdominal B-ultrasound (if necessary)
-Coagulation function, pre-transfusion examination, blood type
□ Blood gas analysis (if necessary)
□ Non-invasive assisted breathing with ventilator (if necessary)
□ Closed thoracic drainage under local anesthesia
Long-term doctor's advice:
□ Patients' previous basic drug treatment
□ Use expectorant drugs
□ Other doctor's advice
Temporary medical advice:
□ X-ray chest X-ray
□ Other doctor's advice
primary
nurse
work
-introduce ward environment, facilities and equipment.
□ Admission nursing evaluation
□ Education
□ Observe the patient's condition changes.
state of illness
change
record
□ None? □ Yes, the reason is:
1.
2.
□ None? □ Yes, the reason is:
1.
2.
nurse
symbol
Certified doctor
symbol
time
Stay in hospital for 3 ~ 9 days
Hospitalization 10 days
(discharge date)
owner
ask
examination
treat cordially
worker
work
□ Senior physician rounds
-according to the physical examination, chest X-ray, CT results and previous data, determine the diagnosis and the need for thoracotomy.
□ Judge whether there are other diseases according to other examination results.
□ Prevention and treatment of complications
□ Symptom support therapy
□ Complete the course record.
-The superior doctors make rounds, evaluate, determine whether there are complications, and decide whether to leave the hospital.
□ Complete discharge records, home pages of medical records, discharge certificates, etc.
-explain to patients the matters needing attention after discharge, such as the time and place of returning to the hospital for follow-up, keeping the chest strap fixed for two weeks, avoiding exercise in the near future and exercising respiratory function.
heavy
main points
doctor
order
Long-term doctor's advice (treatment can be started the next day as appropriate):
□ Use antibacterial drugs (if necessary)
□ Other doctor's advice
Temporary medical advice:
-check blood routine, liver and kidney function and electrolyte (before discharge or when necessary)
□ Check X-ray chest film (before discharge or when necessary)
Unloading sequence:
□ Pay attention to rest, nutrition and avoid exercise.
□ Keep the chest strap fixed for two weeks.
□ Take medicine after discharge (if necessary)
□ Follow-up after half a month, and it is not appropriate to follow up.
primary
nurse
work
Observe the patient's condition changes, guide the patient to cough, expectoration and exercise respiratory function.
-guide patients to go through the discharge formalities.
state of illness
change
record
□ None? □ Yes, the reason is:
1.
2.
□ None? □ Yes, the reason is:
1.
2.
nurse
symbol
Certified doctor
symbol
5 Clinical Paths Clinical Paths of Rib Fracture Complicated with Hemopneumothorax (20 19 Edition). document