初治菌陰肺結核臨床路徑初治菌陰肺結核臨床路徑〔2016年版〕一、初治菌陰肺結核臨床路徑標準住院流程〔一〕適用對象。第一診斷為初治菌陰肺結核?！捕吃\斷依據。依據《中華人民共和國衛生行業標準肺結核診斷標準WS288-2008年版)·臨床病癥：可消滅發熱〔多為低熱、盜汗、乏力、咳嗽、咳痰、咯血或血痰、胸痛等。局部患者可無臨床病癥。體征：可消滅呼吸頻率增快、呼吸音減低或粗糙、肺部啰音等。輕者可無體征。影像學檢查：顯示活動性肺結核病變特征。細菌學檢查：痰涂片及痰培育陰性?？菇Y核治療有效。臨床可排解其它非結核性肺部疾患。痰結核分枝桿菌分子生物學檢測陽性。結核菌素〔PPD5TU〕皮膚試驗強陽性或γ-干擾素釋放試驗陽性或血清抗結核抗體陽性。肺外組織病理檢查證明結核病變。支氣管或肺部組織病理檢查證明結核性轉變。BALF〔支氣管肺泡灌洗液〕檢出抗酸桿菌。既往未經抗結核治療或抗結核治療時間少于1個月、肺內有病變且痰抗酸桿菌涂片鏡檢或分枝桿菌培育陰性同時具備1～9310～11項中任何一項可診斷為初治菌陰肺結核。〔三〕治療方案的選擇。依據《中國結核病防治規劃實施工作指南(2008年版)床診療指南·藥物治療：推舉治療方案：2HRZE/4HR或，E：乙胺丁醇。強化期使用HRZE方案治療2個月，連續期使用HR4個月。療程一般6個月。對于病情嚴峻或存在影響預后的合并癥的患者，可適當延長療程。特別患者〔如兒童、老年人、孕婦、使用免疫抑制劑以及發生藥物不良反響等〕可以在上述方案根底上調整藥物劑量或藥物。依據患者存在的并發癥或合并癥進展對癥治療?！菜摹?-14天。〔五〕進入路徑標準。第一診斷必需符合菌陰肺結核。當患者合并其他疾病，但住院期間不需要特別處理也不影響第一診斷的臨床路徑流程實施時，可以進入路徑?！擦匙≡浩陂g檢查工程。必需的檢查工程：血常規、尿常規、糞便常規；感染性疾病篩查〔乙肝、丙肝、艾滋病等；C痰抗酸桿菌涂片及鏡檢、痰分枝桿菌培育；胸片檢查；視力及視野檢測；心電圖。依據患者病情可選擇檢查工程：支氣管鏡檢查；痰分子生物學檢測；結核菌素皮膚試驗；γ-干擾素釋放試驗；胸部CT〔需與其他疾病鑒別診斷或胸片顯示不者；血清抗結核抗體檢測；胸部超聲〔疑心胸腔積液、心包積液患者；尿妊娠試驗〔育齡期婦女；相關免疫功能檢查〔疑心免疫特別患者；痰查癌細胞、血液腫瘤標志物〔癌胚抗原等〔合并腫瘤患者?！财摺吵鲈簶藴省ＥR床病癥好轉?；颊呖赡褪苤贫ǖ目菇Y核治療方案?！舶恕匙儺惣熬売煞治觥Ｏ麥鐕谰目菇Y核藥物不良反響。3.原有病情明顯加重，導致住院時間延長。二、初治菌陰肺結核臨床路徑表單適用對象：第一診斷為初治菌陰肺結核。患者姓名：性別：年齡：門診號：住院號：住院日期：年月日出院日期：年月日標準住院日：7-14天時間1-3天要診療工作<tdwidth=“291“valign=“top“style=“width:218.25pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:doublewindowtext1.5pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:109.45pt“><pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list詢問病史及進展體格檢查<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list初步評估病情<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list完成病歷書寫<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list完善必要檢查<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list依據病情對癥、支持治療<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list上級醫師查房，制定診療打算<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-align:none“>確定抗結核治療方案，簽署化療知情同意書，開頭抗結核治療<tdwidth=“259“valign=“top“style=“width:194.4pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:doublewindowtext1.5pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:109.45pt“><pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list全科病案爭論，上級醫師定期查房，完善診療打算<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list處理根底性疾病及對癥治療<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list依據患者病情調整、制定合理化療方案<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list觀看藥品不良反響<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list住院醫師書寫病程記錄重點醫囑<tdwidth=“291“valign=“top“style=“width:218.25pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:solidwindowtext1.0pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:226.45pt“>長期醫囑：<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list肺結核護理常規<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-align:none“>Ⅱ-Ⅲ級護理<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list普食<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>抗結核藥物治療臨時醫囑：<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list血常規、尿常規、糞便常規<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-align:none“>肝腎功能檢查〔含膽紅素、電解質、血糖、血尿酸、相關感染性疾病篩查、血沉、C反響蛋白<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list痰抗酸桿菌涂片鏡檢，痰分枝桿菌培育<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list胸CT檢查<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list支氣管鏡檢查<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list結核菌素皮膚試驗<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list血清抗結核抗體檢測<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list痰結核分枝桿菌分子生物學檢測<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>心電圖、腹部超聲檢查<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list視力、視野檢測<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list既往根底用藥<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list對癥治療進展其他相關檢查<tdwidth=“259“valign=“top“style=“width:194.4pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:solidwindowtext1.0pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:226.45pt“>長期醫囑：<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-align:none“>結核護理常規<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-alinnone“>Ⅲ級護理<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list普食<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>抗結核藥物治療臨時醫囑：<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list既往根底用藥<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list對癥治療<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list抗結核治療7-14天后復查血常規、肝腎功能〔含膽紅素〕<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list特別指標復查工作<tdwidth=“291“valign=“top“style=“width:218.25pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:solidwindowtext1.0pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:36.65pt“><pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list病房環境、醫院制度及醫護人員介紹<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>入院護理評估<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list告知各項檢查留意事項并幫助患者完成<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list18.0pt;layout-grid-mode:char;mso-layout-grid-align:none“>指導留痰<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list靜脈取血<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>入院安康宣教<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>心理護理<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>通知養分科患者飲食<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>完成護理記錄書寫<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list17.85pt;layout-grid-mode:char;mso-layout-grid-align:none“>執行醫囑，用藥指導<tdwidth=“259“valign=“top“style=“width:194.4pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:solidwindowtext1.0pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:36.65pt“><pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list觀看患者一般狀況及病情變化<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list檢驗、檢查前的宣教<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list做好住院期間的安康宣教<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list正確落實各項治療性護理措施<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list觀看治療效果及藥品反響<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list護理安全措施到位<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list賜予正確的飲食指導<pstyle=“margin-left:17.85pt;text-indent:-17.85pt;line-height:13.0pt;mso-line-height-rule:exactly;mso-list:l0level1lfo1;tab-stops:list了解患者心理需求和變化，做好心理護理病情變異記錄<tdwidth=“291“valign=“top“style=“width:218.25pt;border-top:none;border-left:none;border-bottom:solidwindowtext1.0pt;border-right:solidwindowtext1.0pt;mso-border-top-alt:solidwindowtext1.0pt;mso-border-left-alt:solidwindowtext1.0pt;padding:0cm5.4pt0cm5.4pt;height:42.4pt“>□無□有，緣由：1.2.<tdwidth=“259“valign=“top“style=“width:194.4pt;border-top:none;