留靜 李超男 闕獻(xiàn)琴 潘紅英
[摘要] 目的 研究全面護(hù)理干預(yù)在急診科患者氣管插管非計(jì)劃性拔管(unplanned extubation,UEX)中的應(yīng)用。 方法 選擇2017年9月~2018年8月間在我院急診科治療的非計(jì)劃性拔管患者68例作為研究對(duì)象,按照隨機(jī)數(shù)字法分為對(duì)照組和觀察組,每組34例,觀察組應(yīng)用全面護(hù)理干預(yù),對(duì)照組應(yīng)用常規(guī)護(hù)理,主要通過(guò)回顧性分析的方式來(lái)分析所有進(jìn)行非計(jì)劃性拔管的急診科患者的臨床資料,并且將護(hù)理問(wèn)題進(jìn)行記錄,另外將護(hù)理人員所進(jìn)行的護(hù)理工作進(jìn)行總結(jié),制定合理有效的對(duì)策措施。 結(jié)果 觀察組護(hù)理總有效率為94.12%,明顯高于對(duì)照組護(hù)理總有效率(73.53%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05),觀察組UEX發(fā)生率為8.82%,明顯低于對(duì)照組UEX發(fā)生率(38.24%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。觀察組護(hù)理滿意度優(yōu)于對(duì)照組。護(hù)理人員對(duì)非計(jì)劃性拔管的急診科患者進(jìn)行護(hù)理時(shí),可以通過(guò)對(duì)氣管插管進(jìn)行有效的固定、對(duì)鎮(zhèn)靜藥物進(jìn)行合理使用使用、進(jìn)行有效的肢體約束、加強(qiáng)護(hù)患溝通、加強(qiáng)對(duì)資歷較低護(hù)士的培訓(xùn)及護(hù)理操作規(guī)范等多種途徑來(lái)進(jìn)行相關(guān)的護(hù)理工作,可以有效的減少氣管插管拔除的發(fā)生率,大大減少護(hù)理糾紛。 結(jié)論 全面護(hù)理干預(yù)不僅能夠降低急診科非計(jì)劃性拔管的拔管率,還能顯著提高護(hù)理滿意度,值得在臨床推廣應(yīng)用。
[關(guān)鍵詞] 急診科;氣管插管;非計(jì)劃性拔管;護(hù)理
[中圖分類(lèi)號(hào)] R473.5 ? ? ? ? ?[文獻(xiàn)標(biāo)識(shí)碼] B ? ? ? ? ?[文章編號(hào)] 1673-9701(2019)25-0145-04
Application of comprehensive nursing intervention in unplanned extubation of tracheal intubation in emergency patients
LIU Jing1 LI Chaonan1 QUE Xianqin1 PAN Hongying2
1.Department of Emergency,Lishui Central Hospital in Zhejiang Province,Lishui 323000,China;2.Department of Nursing,Lishui Central Hospital in Zhejiang Province,Lishui 323000,China
[Abstract] Objective To study the application of comprehensive nursing intervention in unplanned extubation of tracheal intubation in emergency patients. Methods A total of 68 patients with unplanned extubation who were treated in the department of emergency of our hospital from September 2017 to August 2018 were enrolled in the study. They were divided into control group and observation group according to the random number rule, 34 cases in each group. The observation group was given comprehensive nursing intervention, and the control group was given routine nursing. The clinical data of all emergency department patients who underwent unplanned extubation were analyzed by retrospective analysis, and the nursing problems were recorded. The nursing work carried out was summarized and reasonable and effective countermeasures were formulated. Results The total effective rate of observation group was 94.12%, which was significantly higher than that of the control group(73.53%). The difference was statistically significant(P<0.05). The incidence of UEX in the observation group was 8.82%, which was significantly lower than that of the control group(38.24%),and the difference was statistically significant(P<0.05). The nursing satisfaction in observation group was also superior to the control group. The following measures could be taken for the care of patients with unplanned extubation, including effective fixation of tracheal intubation,rational use of sedative drugs,effective limb restraint, enhanced communication between nurses and patients, enhanced training for nurses,and strengthened nursing practices and so on, which could effectively reduce the incidence of tracheal extubation and greatly reduce nursing disputes. Conclusion Comprehensive nursing intervention can not only reduce the rate of extubation of unplanned extubation in the emergency department, but also significantly improve the satisfaction of nursing. It is worthy of clinical application.
[Key words] Emergency department;Tracheal intubation;Unplanned extubation(UEX);Nursing
患者在進(jìn)入急救室進(jìn)行治療時(shí),通常會(huì)根據(jù)其病情進(jìn)行導(dǎo)管插管輔助治療,但由于一些原因,導(dǎo)致患者在計(jì)劃之外產(chǎn)生了導(dǎo)管拔出的情況,主要包括患者自動(dòng)拔管或者由于其他因素導(dǎo)致的意外拔管[1-3]。這種情況也是目前進(jìn)行有創(chuàng)機(jī)械通氣比較常見(jiàn)的嚴(yán)重并發(fā)癥,經(jīng)過(guò)研究統(tǒng)計(jì)發(fā)生率在5.6%~15.7%。在診治急診科患者時(shí)通常會(huì)使用建立人工氣道使用機(jī)械通氣的方法,這也是最有效的搶救方式[4-6]?;颊咴诔霈F(xiàn)非計(jì)劃性拔管后,易并發(fā)氣道損傷、病情加重、再感染肺炎等并發(fā)癥,甚至?xí)?yán)重影響患者的生命安全。本次研究針對(duì)急診科患者氣管插管非計(jì)劃性拔管原因與護(hù)理要點(diǎn)進(jìn)行分析。
1 資料與方法
1.1 一般資料
本研究選取2017年9月~2018年8月在我院急診科治療的非計(jì)劃性拔管患者68例作為研究對(duì)象,按隨機(jī)數(shù)字表法分為對(duì)照組和觀察組,每組34例,觀察組應(yīng)用全面護(hù)理干預(yù),對(duì)照組應(yīng)用常規(guī)護(hù)理。兩組患者一般資料情況見(jiàn)表1。兩組患者一般資料比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。
表1 ? 兩組患者一般資料對(duì)比
1.2 護(hù)理對(duì)策
對(duì)照組采用常規(guī)護(hù)理,主要包括普通的健康宣教和固定措施,觀察組主要采用全面護(hù)理干預(yù)。
1.2.1 妥善固定導(dǎo)管 ?在患者導(dǎo)管固定的時(shí)候,要采用氣囊、膠布、寸帶三點(diǎn)固定方法,首先要使用膠布進(jìn)行“X”狀的固定粘貼,并且要求患者每日進(jìn)行更換,護(hù)理人員可以在口腔護(hù)理的基礎(chǔ)上對(duì)患者進(jìn)行更換。在膠布的選擇上可以使用具有較好黏性的膠布,尺寸為40 cm×2 cm,通過(guò)膠布將牙墊和導(dǎo)管之間進(jìn)行固定,另外還要在患者的導(dǎo)管與下唇出墊一塊紗布,通過(guò)寸帶將紗布以及牙墊和導(dǎo)管進(jìn)行固定。護(hù)理人員要每日進(jìn)行檢查和更換工作[7-8]。
1.2.2 采取有效的約束 ?患者在長(zhǎng)時(shí)間的治療以及導(dǎo)管的約束下,容易產(chǎn)生煩躁和意識(shí)不清的情況,因此容易產(chǎn)生嚴(yán)重的拔管傾向,對(duì)于這些患者可以進(jìn)行適當(dāng)?shù)闹w約束,進(jìn)行約束之前要與家屬溝通好,經(jīng)家屬同意之后再進(jìn)行約束[9]。
1.2.3 合理使用鎮(zhèn)靜劑 ?在患者經(jīng)受過(guò)長(zhǎng)期的置管治療之后,會(huì)產(chǎn)生煩躁的情緒,護(hù)理人員要針對(duì)患者的具體情況給予相應(yīng)的鎮(zhèn)靜劑和靜脈注射治療。
1.2.4 經(jīng)鼻氣管插管 ?在經(jīng)過(guò)1周治療后沒(méi)辦法撤機(jī)的患者,可以通過(guò)鼻氣管插管,在經(jīng)過(guò)鼻氣管插管之后,可以大大提高患者的耐受程度,增強(qiáng)固定效果[10]。
1.2.5 加強(qiáng)心理護(hù)理 ?護(hù)理人員要使用鼓勵(lì)和安慰的語(yǔ)言來(lái)緩解患者出現(xiàn)的不良心理。
1.2.6 合理分配人力資源 ?針對(duì)患者不同的病情給予不同程度的治療和看護(hù),對(duì)于重癥患者來(lái)說(shuō),要盡可能多安排護(hù)理人員進(jìn)行護(hù)理,以免出現(xiàn)急救時(shí)人員不足的情況,護(hù)理人員還需在患者平日住院期間,勤巡視多觀察,并且詳細(xì)記錄患者的情況。
1.2.7 嚴(yán)格護(hù)理操作 ?護(hù)理人員在進(jìn)行護(hù)理的時(shí)候,要嚴(yán)格遵守護(hù)理規(guī)則,為了預(yù)防患者出現(xiàn)導(dǎo)管滑落的情況,可以提前進(jìn)行護(hù)理演練?;颊咴诎l(fā)生非計(jì)劃性導(dǎo)管拔出率較高的時(shí)間段,要加強(qiáng)監(jiān)督和巡視,在指導(dǎo)幫助患者進(jìn)行翻身以及運(yùn)動(dòng)的時(shí)候,要注意導(dǎo)管的情況,避免出現(xiàn)滑落的現(xiàn)象[11-12]。當(dāng)患者出現(xiàn)非計(jì)劃性導(dǎo)管拔出時(shí),護(hù)理人員要及時(shí)通知醫(yī)生進(jìn)行治療,如果患者需要可以進(jìn)行簡(jiǎn)單的呼吸機(jī)輔助治療。護(hù)理人員還要配合醫(yī)生進(jìn)行再次插管,并且詳細(xì)記錄患者的身體情況。在事件發(fā)生及治療后,要將記錄下來(lái)的資料及時(shí)匯報(bào),填寫(xiě)好不良情況發(fā)生表,在下次發(fā)生時(shí)可根據(jù)經(jīng)驗(yàn)進(jìn)行處理。
1.4 觀察指標(biāo)
統(tǒng)計(jì)兩組患者的非計(jì)劃性拔管(Unplanned extubation,UEX)發(fā)生率,對(duì)比兩組患者的護(hù)理效果,分為顯效,有效和無(wú)效三種。顯效:患者的意識(shí)、配合度以及疾病等臨床癥狀顯著得到緩解;有效:患者的意識(shí)、配合度以及疾病等臨床癥狀部分得到緩解;無(wú)效:患者的意識(shí)、配合度以及疾病等臨床癥狀未得到緩解或更加嚴(yán)重[12]。滿意度評(píng)分量表分為環(huán)境設(shè)施、質(zhì)量安全、服務(wù)可及性、健康教育以及人文關(guān)懷五個(gè)方面,共包含20項(xiàng)條目,每個(gè)條目5分,總分100分,≥80分表示滿意,60~79分表示一般滿意,<60分表示不滿意[13]。
1.5 統(tǒng)計(jì)學(xué)方法
數(shù)據(jù)分析采用軟件SPSS16.0,計(jì)數(shù)資料采用百分比(%)表示,組間比較采用χ2檢驗(yàn),計(jì)量資料用(x±s)表示,采用t檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組患者護(hù)理效果比較
觀察組護(hù)理總有效率為94.12%,明顯高于對(duì)照組護(hù)理總有效率(73.53%),差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表1。
表2 ? 兩組患者護(hù)理效果比較[n(%)]
2.2 兩組UEX發(fā)生情況比較
觀察組的UEX發(fā)生率為8.82%,明顯低于對(duì)照組的UEX發(fā)生率(38.24%),差異具有統(tǒng)計(jì)學(xué)意義(χ2=8.1731,P=0.0042)。
2.3 兩組患者護(hù)理滿意度比較
觀察組的護(hù)理滿意度高于對(duì)照組,差異顯著(P<0.05)。見(jiàn)表3。
表3 ? 兩組患者護(hù)理滿意度比較[n(%)]
3 討論
在診治急診科患者時(shí)通常會(huì)使用建立人工氣道使用機(jī)械通氣的方法,也是最有效的搶救方式?;颊咴诔霈F(xiàn)非計(jì)劃性拔管后,易并發(fā)氣道損傷、病情加重、再感染肺炎等并發(fā)癥,甚至?xí)?yán)重影響患者的生命。目前造成患者非計(jì)劃性拔管的原因很多,首先是患者因素。第一,患者在危重癥的情況下會(huì)使用有創(chuàng)呼吸機(jī),通?;颊邥?huì)存在意識(shí)模糊以及淺昏迷的情況,在手術(shù)麻醉期間患者也會(huì)有不受控制的亂動(dòng)表現(xiàn),無(wú)法積極配合治療,不利于手術(shù)的順利進(jìn)行[14]。第二,患者在進(jìn)行氣管安置時(shí)通常會(huì)出現(xiàn)不舒適以及疼痛的現(xiàn)象因此容易造成拔管,另外,也有可能因?yàn)闄C(jī)械通氣與呼吸機(jī)之間產(chǎn)生對(duì)抗情況,導(dǎo)致拔管現(xiàn)象[15-16]。第三,針對(duì)治療期間神志清楚的患者來(lái)說(shuō),往往會(huì)由于自身疾病的特殊性不允許進(jìn)行脫機(jī)或者脫機(jī)不成功,另外也有可能是因?yàn)榛颊咦陨頁(yè)?dān)心無(wú)法承擔(dān)治療費(fèi)用而導(dǎo)致拔管[17-18]。第四,醫(yī)院給予患者家屬探視的次數(shù)較少,患者在進(jìn)行臨床治療和護(hù)理時(shí)缺少家屬的陪伴,其配合度明顯下降。第五,患者在夜間時(shí)會(huì)產(chǎn)生迷走神經(jīng)興奮,二氧化碳的滯留導(dǎo)致氣管插管非計(jì)劃性拔管。第六,患者在進(jìn)行插管后,由于護(hù)患溝通出現(xiàn)問(wèn)題導(dǎo)致拔管[19]。其次是導(dǎo)管因素。第一是插管方式出現(xiàn)問(wèn)題,其中主要包括口腔插管進(jìn)而鼻腔插管,口腔插管具有不穩(wěn)定性,容易導(dǎo)致固定膠布松動(dòng)的情況。另外在固定方面通常使用橡皮膏,容易產(chǎn)生松動(dòng),氣管滑脫的情況。第二是由于氣囊充氣不足而導(dǎo)致的氣管拔出。然后是醫(yī)護(hù)人員因素。第一,無(wú)法有效約束患者,加之家屬看見(jiàn)患者不舒適的情況也會(huì)私自進(jìn)行拔管[20]。第二,護(hù)理人員操作不當(dāng)引起導(dǎo)管拔出。第三,醫(yī)院護(hù)理人員不足,增加了氣管拔出情況的發(fā)生。
經(jīng)過(guò)相關(guān)的護(hù)理工作經(jīng)驗(yàn)和相關(guān)方式方法的總結(jié),發(fā)現(xiàn)可以通過(guò)多種途徑來(lái)提高急診科患者的護(hù)理質(zhì)量,減少非計(jì)劃性拔管的發(fā)生。這樣可以大大減輕護(hù)患之間的糾紛和矛盾,也可以提高患者的治療效果,提高治愈率。本次研究中觀察組應(yīng)用全面護(hù)理干預(yù),對(duì)照組應(yīng)用常規(guī)護(hù)理,研究結(jié)果證明,觀察組的護(hù)理效果、護(hù)理滿意度和非計(jì)劃性拔管發(fā)生率均優(yōu)于對(duì)照組,因此可以進(jìn)一步的應(yīng)用推廣。
[參考文獻(xiàn)]
[1] 易勇,石櫻.PDCA循環(huán)管理法在急診插管所致呼吸機(jī)相關(guān)肺炎的應(yīng)用[J].上海醫(yī)藥,2014,35(23):31-34.
[2] 陳林娟.急診困難氣管插管的護(hù)理配合[J].護(hù)士進(jìn)修雜志,2017,32(5):452-453.
[3] Driscoll A,Grant MJ,Carroll D,et al. The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis[J].Eur J Cardiovasc Nur,2018,17(1):6-22.
[4] 張靜.急診緊急氣管插管131例的護(hù)理體會(huì)[J].基層醫(yī)學(xué)論壇,2017,21(33):4731-4732.
[5] 顧月群,殷雅琴,胡海敏,等.改良口腔護(hù)理方法預(yù)防經(jīng)口氣管插管患者呼吸機(jī)相關(guān)性肺炎的效果研究[J]. 護(hù)理與康復(fù),2015,14(1):53-55.
[6] Curley MAQ,Wypij D,Watson RS,et al.Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial[J].JAMA,2015,313(4):379-389.
[7] Sturgess DJ,Greenland KB, Senthuran S,et al. Tracheal extubation of the adult intensive care patient with a predicted difficult airway–a narrative review[J].Anaesthesia,2017,72(2):248-261.
[8] 王宇,陳云云,周鴛,等.急診氣管插管患者首次口腔護(hù)理適宜時(shí)間分析[J].齊魯護(hù)理雜志,2018,24(10):82-84.
[9] Tischenkel BR,Gong MN,Shiloh AL,et al.Daytime versus nighttime extubations:A comparison of reintubation,length of stay, and mortality[J].Journal of Intensive Care Medicine,2016,31(2):118-126.
[10] 姜紅麗.強(qiáng)化護(hù)理干預(yù)策略在降低ICU氣管插管患者非計(jì)劃性拔管中的應(yīng)用[J].齊魯護(hù)理雜志,2015,21(3):73-74.
[11] Piriyapatsom A,Chittawatanarat K,Kongsayreepong S,et al.Incidence and risk factors of unplanned extubation in critically ill surgical patients:The multi-center Thai University-based surgical intensive care units study(THAI-SICU Study)[J].J Med Assoc Thai,2016,99(Suppl 6):S153-61.
[12] Dolan J,Looby SED.Determinants of nurses' use of physical restraints in surgical intensive care unit patients[J]. American Journal of Critical Care,2017,26(5):373-379.
[13] Sedlock EW,Ottosen M,Nether K,et al. Creating a comprehensive,unit-based approach to detecting and preventing harm in the neonatal intensive care unit[J]. Journal of Patient Safety and Risk Management,2018,23(4):167-175.
[14] Lucchini A,Bambi S,de Felippis C,et al. Oral care protocols with specialty training lead to safe oral care practices and reduce iatrogenic bleeding in extracorporeal membrane oxygenation patients[J].Dimensions of Critical Care Nursing,2018,37(6):285-293.
[15] 李琴,程曉紅.集束化模式預(yù)防COPD氣管插管患者呼吸機(jī)相關(guān)性肺炎的效果觀察[J].護(hù)理實(shí)踐與研究,2017, 14(18):37-39.
[16] Eskandari F,Abdullah KL,Zainal NZ,et al. Incidence rate and patterns of physical restraint use among adult patients in Malaysia[J].Clinical Nursing Research,2018, 27(3):278-295.
[17] Varndell W,F(xiàn)ry M,Elliott D.Exploring how nurses assess, monitor and manage acute pain for adult critically ill patients in the emergency department: protocol for a mixed methods study[J].Scandinavian Journal of Trauma,Resuscitation and Emergency Medicine,2017,25(1):75.
[18] 劉盼,梁蘇榮,王艷,等.兩種不同醫(yī)護(hù)協(xié)作模式在急診科氣管插管中的應(yīng)用[J].當(dāng)代護(hù)士:專(zhuān)科版,2018,25(3):95-96.
[19] Darby JM,Halenda G,Chou C,et al. Emergency surgical airways following activation of a difficult airway management Team in Hospitalized Critically Ill Patients:A Case Series[J].Journal of Intensive Care Medicine,2018,33(9):517-526.
[20] Cosentino C,F(xiàn)ama M,F(xiàn)oà C,et al. Unplanned Extubations in Intensive Care Unit:Evidences for risk factors. A literature review[J].Acta Bio Medica Atenei Parmensis,2017,88(5-S):55-65.
(收稿日期:2019-03-01)