Key words? Older people; Thoracotomy; Respiratory failure; nurse
Respiratory failure after thoracotomy is a cont
Key words? Older people; Thoracotomy; Respiratory failure; nurse
Respiratory failure after thoracotomy is a continuous process of a series of pathological changes and a serious complication after thoracotomy. Because of the degenerative changes of physiological functions of tissues and organs, the elderly are often accompanied by different degrees of pulmonary insufficiency before operation [1], and thoracotomy changes the normal respiratory function, which often leads to respiratory infection and severe respiratory failure [2]. Our hospital has strengthened all aspects of nursing care for 48 elderly patients with respiratory failure after thoracotomy, and achieved good results.
Clinical data of 1
1. 1 general data 48 patients with respiratory failure after thoracotomy, including 34 males and 4 females/kloc-0, aged 60 ~ 80 years. Among them, there were 6 cases of esophageal cancer, 28 cases of lung cancer, 5 cases of thymoma, 6 cases of thoracotomy and 3 cases of pulmonary suppuration. 34 cases of long-term smoking.
1.2 surgical methods The patients undergoing thoracotomy were placed in the surgical position, intubated under general anesthesia, combined with intravenous anesthesia, and covered with surgical towels after skin disinfection. The skin and subcutaneous tissue were layered in turn, and the pectoral muscle layer was cut by electrocoagulation, and then they clung to the upper edge of the posterior rib and entered the chest cavity. After the intrathoracic surgery, insert the rib retractor and close the incision.
1.3 Preoperative nursing Because the elderly have the characteristics of loneliness, loneliness, depression, paranoia and worry, nurses are required to have good psychological endurance and good language skills, patiently and meticulously answer questions and guide patients to understand their illness. Tell patients to quit smoking, teach patients abdominal breathing and effective cough methods, teach patients to blow balloons and do deep breathing exercises to prevent respiratory infections. Instruct patients to eat a high-protein, high-calorie and high-vitamin diet, and give intravenous high nutrition when necessary to correct nutritional disorders.
1.4 postoperative care and intensive monitoring: the elderly often have changes in the function of an organ and various reflexes. Therefore, it is necessary to keep the vital signs stable, carry out ECG monitoring, pay attention to the observation of venous pressure, peripheral circulation and urine volume, and prevent the imbalance of water and electrolytes, especially the changes of blood potassium. Strengthen the management of respiratory tract: with the increase of age, the morphological changes of respiratory organs include the expansion of respiratory bronchioles and alveolar ducts, the enlargement of alveolar pores, the decline of chest wall elasticity and respiratory muscle function. There are more chances to cause respiratory tract infection after operation. Therefore, low-flow oxygen inhalation should be continued for 20 hours after operation, and patients should be encouraged to cough sputum every 1 ~ 2 hours, and at the same time, the understanding of respiratory tract colonization bacteria after general anesthesia should be improved. Control the speed and quantity of infusion: the physiological function of the elderly is generally low, which has a great influence on symptoms such as consciousness, especially the symptoms of cardiac function will be covered up in various forms. In order to prevent the occurrence of pulmonary edema caused by excessive infusion speed and volume, we should strictly control the infusion speed and volume, and make proper rehydration according to the amount of urination. When the bowel sounds are restored and there is no nausea and vomiting, the diet can be gradually restored. After eating, patients should eat a small amount of food, and at the same time pay attention to giving soft food with high protein, high calorie, high vitamin and low residue, so as to increase the body's resistance, effectively complete deep breathing exercise and expectoration, and prevent respiratory failure. Due to some physiological changes in the elderly, the correct use and curative effect of antibiotics are directly affected. At the same time, the potential decline of renal function in the elderly is the main reason for the decrease of excretion of some drugs, so renal function must be considered when using antibiotics. Therefore, it is necessary to fully grasp the knowledge of interaction, toxicity and pharmacokinetics of various antibiotics, use antibiotics reasonably and effectively, and control the occurrence of respiratory tract infection.
1.5 observation and nursing of respiratory failure The most important thing in the treatment of respiratory failure is respiratory support and early mechanical ventilation to ensure the supply of oxygen to reduce mortality. Loss of physiological barrier and humidification of respiratory tract at constant temperature can cause dryness of mucous membrane, massive dehydration of respiratory tract and dryness of secretion, which is easy to form phlegm thrombus and block respiratory tract. At this time, respiratory humidification and humidification monitoring should be done well. Add quantitative distilled water to the humidifier of ventilator, and adjust the metering regularly. The temperature should be controlled at 32 ~ 35℃. The amount of respiratory humidification fluid depends on room temperature, body temperature, air humidity, ventilation, the amount and nature of patients, and the amount and nature of sputum should be no less than 250m 1 day. The suitable rate of respiratory tract humidification is 10 ~ 20 ml/h, and the airway is humidified with 0.5% sodium bicarbonate humidification solution, which has the following functions: ① softening and diluting sputum; (2) Inject a large amount of humidified liquid quickly, so as to promote the sputum to move up and down, and it is easy to cough up. On the other hand, the sputum attached to the tracheal wall and small airway is loose and falls off due to vibration, and it is not easy to form sputum thrombus; ③ It has ideal clearance effect on negative bacilli, prevents the abuse of antibiotics and the increase of drug-resistant strains, and reduces the pulmonary infection rate. Observe the expectoration of both lungs, the viscosity of each sputum aspiration, airway pressure, cough, etc., to understand the airway condition of patients, and at the same time take methods such as tapping the back and pressing the trachea to facilitate the discharge of sputum. However, for patients after esophageal surgery, sputum aspiration will increase chest pressure and aggravate sputum reflux or aspiration. Therefore, close observation should be made during sputum aspiration to ensure that the balloon of tracheal intubation is full, so as to avoid serious infection in the lungs. Check the position of tracheal catheter and the fixation of adhesive tape and dental pad every 4 hours to avoid one-lung ventilation caused by catheter displacement. Because of the rich intercostal nerve, long incision and big trauma, patients have obvious postoperative pain and dare not cough. Therefore, patients can use epidural analgesia pump or painkillers to relieve pain after operation. After the pain is relieved, patients are encouraged to cough and expectorate.
Results There were 23 cases of cardiac complications, 8 cases of atelectasis, 2 cases of incision infection and 5 cases of bronchopleural fistula. Except for 2 cases who died after operation, the rest were cured and discharged.
2 discussion
The most important pathophysiological changes of respiratory failure are the changes of respiratory physiology and pulmonary circulation hemodynamics, which lead to the decrease of residual volume in the lung, the decrease of lung compliance, oxygenation disorder and so on. , leading to severe hypoxemia and acidosis, as well as serious multi-organ function damage. In the mechanical ventilation treatment of elderly patients with respiratory failure, we try to avoid lung injury and provide patients with basic oxygenation and ventilation needs, that is, implement lung protection strategy to ensure basic oxygenation with the lowest oxygen concentration, minimum pressure and volume. During mechanical ventilation, the initial intubation time was 4 ~ 65438+72 h, and then it was changed to synchronous intermittent mandatory ventilation+pressure support mode (SIMV+PSV). The ventilation time was 4 ~ 12 times /min, and the PSV was 4 ~12 cmH2O, which was stable for 4 ~ 24 h, and the offline test could be interrupted for 4 hours.
Due to the atrophy of respiratory mucosa, ciliary movement is weakened and phagocytosis of macrophages is reduced in the elderly. At the same time, due to the stimulation of operation and anesthesia intubation, the amount of sputum increases, which is not suitable for coughing up, and it is easy to cause respiratory infection and respiratory failure. Therefore, before sputum aspiration, give the patient 100% oxygen 1 ~ 2 min, then place the sputum aspiration tube in the deepest part of the trachea, lift up 1 cm, and then open the negative pressure to attract pressure. 6.7 kPa, suck out while rotating, stop for one minute until there is secretion, and then quit quickly. The sputum aspiration time should not exceed 15 s each time to prevent the aggravation of hypoxia for a long time. Oxygen concentration should be increased for 3 ~ 5 min after sputum aspiration. For patients with excessive phlegm, it is difficult to suck sputum at one time, so sputum suction and oxygen inhalation should be carried out alternately.
After thoracotomy under general anesthesia, the patient's body resistance decreased, and gastric tube and tracheal intubation, oxygen inhalation, atomized inhalation and other interventions were carried out. , so that bacteria have a convenient passage, thereby increasing the probability of respiratory tract colonization of patients and increasing the risk of pneumonia. Therefore, postoperative care should strengthen protection, strictly aseptic operation, reduce the invasion of colonization bacteria, closely observe the color and viscosity of patients' sputum, and closely observe whether there are signs of respiratory infection [4]. And when necessary, regularly assist expectoration, atomization inhalation and nasal catheter sputum aspiration to reduce postoperative ventilation and atelectasis. Due to the characteristics of thoracic anatomy, it is necessary to open the intercostal space or cut off the ribs during thoracic surgery. The chest wall and intercostal nerve are more traumatic, and there are many kinds of monitoring tubes and drainage tubes after operation, which leads to more obvious discomfort and pain after operation than other patients. Patients with severe pain often do not cooperate with coughing and deep breathing exercise, which is easy to cause airway obstruction and insufficient ventilation, so that the exchange of oxygen and carbon dioxide between air in alveoli and blood in pulmonary capillaries is low and abnormal. Therefore, we should do patient and meticulous ideological work in nursing, let patients know the cause of pain, and help patients press their breasts with their hands when coughing, but it is advisable not to affect deep inhalation. At the same time, patients should be taught to lie in the left and right positions, drink water properly, and use analgesic drugs when necessary, but morphine and other drugs that inhibit the respiratory center are prohibited.
In short, the various functions of the elderly are in a stage of gradual decline, with reduced vital capacity, reduced gas exchange and weakened ability to eliminate carbon dioxide [6]. In addition, with the stimulation of surgery, it is easy to produce restrictive dyspnea, which affects the ventilation and ventilation function of the lungs and easily leads to hypoxemia or hypercapnia [7]. Therefore, strengthening respiratory care, early diagnosis, and timely taking comprehensive measures based on mechanical ventilation are the key to treat respiratory failure, with small tidal volume and positive low end-expiratory pressure.
refer to
? 1, beam Predictive nursing care of lung infection in elderly patients undergoing abdominal surgery [J]. Nursing research, 2002; 16(6):3 16.
2 Wang Li. Causes and countermeasures of acute respiratory failure after thoracotomy [J]. Western Medicine, 2005; 17(5):528? 9.
3, Wang,, et al. Analysis of respiratory failure in elderly patients after thoracotomy and mechanical ventilation treatment [J]. China Journal of Gerontology, 2004; 24(9):8 18? 9.
4 Moxiping. Respiratory management of elderly and high-risk patients after thoracotomy [J]. Journal of Guangxi Medical University, 2002; 19( 1):449.
5 Yu Shu Street, Li Jianping. Related factors, analgesia and nursing care of postoperative pain in thoracic surgery patients [J]. Journal of Practical Nursing, 2001; 17( 1):33? 5.
6 Tong Tanjun. Medical gerontology. Beijing: People's Health Publishing House, 1995: 32.
7 Yang Jianping. Anesthesia and perioperative care of elderly patients undergoing thoracotomy [J]. Journal of Suzhou Medical College,1996; 15( 1): 17 1.