2. Poor operation technology
3. Inappropriate puncture site
4, catheter needle indwelling time is too long
5. Improper fixing method
6. The infusion concentration is too acidic or too alkaline, or the incompatibility causes precipitation.
7. The patient's own pathophysiological condition, such as age or disease, leads to the fragility and inflammation of the blood vessel wall.
8. Osmotic pressure
9, infusion speed [edit this paragraph] classification of phlebitis 1, mechanical phlebitis:
1) Improper fixation method: the puncture site is not firmly fixed, causing the needle tube to slide.
2) The diameter of the selected catheter is too thick, which stimulates the blood vessel wall.
3) The puncture site is too close to the joint, and the needle tube and the blood vessel wall are constantly rubbed due to joint activity, resulting in inflammatory reaction.
2. Chemical phlebitis: Inadequate drug dilution, infusion acid, high alkalinity, high solute concentration and the difference of indwelling needle materials are all causes of chemical phlebitis.
3. Bacterial phlebitis: It is usually related to incorrect disinfection method, poor puncture technique, destruction of sterile state of infusion cannula and long indwelling time of catheter. [Edit this paragraph] Nursing measures Nursing care of peripheral vascular diseases
The diagnosis and treatment of vascular diseases of limbs certainly play a decisive role, but without the close cooperation of nursing, the expected purpose can not be achieved. As the saying goes, "three-point treatment and seven-point nutrition", through reasonable nursing, can alleviate the pain of patients, shorten the course of treatment and recover as soon as possible. Therefore, nursing plays a very important role in the treatment of vascular diseases of limbs.
Nursing characteristics:
1. Nursing has the characteristics of * * * and personalization: whether the lesion is in artery or vein, the peripheral circulation is damaged and the tissue blood perfusion is reduced. When the blood flow decreases to the point where it can't meet the oxygen and nutrition required by tissue metabolism, tissue ischemia and hypoxia will occur, which will show many similar symptoms in clinic, such as cold limbs, numbness, pain, pale skin and flushing, and the nutritional status will change. With the development of the disease, malnutrition changes such as limb collapse, infection and gangrene will gradually appear. Therefore, the nursing of arteriovenous diseases has certain characteristics. At the same time, the etiology, acute onset, severity, lesion scope and development of each disease are different, and the patients' work and living habits are different, and their clinical manifestations are also different. Therefore, the formulation of nursing measures should also vary from person to person, from illness to illness, from living conditions, and pay attention to individual differences.
2. Education and guidance for patients is the guarantee for the effective implementation of nursing plan: many methods of treatment and nursing for vascular diseases have their particularity and strict indications. If the arterial blood supply is insufficient, the affected limb should be below the heart level, and the symptoms can be alleviated. On the other hand, venous diseases are just the opposite. Elastic bandage can promote venous return, protect and support venous diseases, but if used improperly, it will aggravate blood stasis. It is very important for patients with venous diseases to choose the correct rest posture. Therefore, the nursing measures to maintain the tissue integrity of the affected limb are meticulous and trivial, which runs through the daily work and life of patients. Patients must also be guided and educated by professionals in order to cooperate with the implementation of various nursing programs and learn to carry out long-term self-health training.
3. Psychological care: The pain caused by tissue ischemia and hypoxia caused by vascular diseases is chronic and long-term, which reduces the patient's activity ability, affects sleep, makes his mood easily excited or inhibited, and makes him depressed and suicidal. The condition is aggravated, there are long-term unhealed ulcers, tissue gangrene needs amputation, hospitalization for many times, medical expenses increase, and the unit and family are in trouble; Or the abnormal appearance caused by lymphedema will cause psychological shock to varying degrees. Therefore, psychological nursing is an important part of patients' holistic nursing.
A, vascular disease * * * Some nursing problems and solutions.
In view of the common characteristics of vascular diseases, such as tissue ischemia caused by circulatory disorder, the primary purpose of nursing is to promote circulation, reduce tissue ischemia or prevent its further development. Secondly, it is necessary not only to alleviate the pain caused by ischemia, but also to prevent the damage of tissue integrity such as ulcer and gangrene caused by tissue malnutrition, and to educate and guide patients with disease knowledge and nursing techniques, so as to ensure that all nursing measures can be implemented smoothly and correctly, and to better achieve the purpose of controlling the disease and preventing complications.
(a) insufficient tissue perfusion
Nursing goal: to increase tissue perfusion and relieve clinical symptoms. In order to increase tissue perfusion and provide enough oxygen and nutrients for tissue metabolism, nursing measures mainly start with promoting the establishment of collateral circulation, avoiding vasospasm and protecting the affected limb.
1. Promote the establishment of collateral circulation: In patients with chronic arterial insufficiency, the insufficiency of collateral circulation directly affects tissue perfusion, and ischemic pain in the affected limb will limit the patient's activities, which is not conducive to the establishment of collateral circulation, and the muscles of the affected limb will shrink due to insufficient blood supply and disuse. Exercise in a planned and step-by-step manner and increase the amount of activity can promote the establishment of collateral circulation and increase the perfusion of surrounding tissues. Walking and Buerger exercise are often used.
2. Quit smoking and adjust your mentality: Nicotine, alcohol and mood swings will excite sympathetic nerves and cause vasospasm. Patients should be helped to quit smoking and drink less or no caffeinated drinks in their diet. Traumatic patients eat little or no irritating food. Patients with arteriosclerosis or diabetes should adhere to a low-fat and low-sugar diet.
3. Avoid oppressing the affected limb: too tight clothes, sitting cross-legged or crossing your legs on your knees, and putting things down in the popliteal fossa can compress blood vessels and affect arterial blood supply, which should be avoided as much as possible.
4. Keep warm: Contact with cold air and direct contact with cold objects will cause arterial contraction or spasm. Indoor temperature and humidity should be kept appropriate to avoid direct contact with cold water. Pay attention to keep warm when going out in cold season, and keep warm for half a month or a month earlier than normal people. Avoid exposing limbs. Clothes, pants, shoes and socks should be loose and soft.
5. Protect the affected limb from injury: The affected limb with insufficient arterial blood supply may have a lasting ulcer under slight stimulation. Therefore, scratching and forcibly scrubbing the affected limb should be avoided. Those with blisters, ulcers or gangrene should keep local cleanliness and take correct treatment methods for active treatment. Patients with severe blood supply deficiency should avoid taking a bath with hot water, so as not to increase tissue metabolism, aggravate tissue hypoxia, make the disease develop faster and aggravate symptoms.
(b) venous reflux disorder
Nursing goal: to reduce edema of the affected limb. In order to reduce venous stasis, promote venous return and reduce edema of affected limbs, nursing measures mainly start from the following aspects.
1. posture: the affected limb should be higher than the heart level under the action of gravity. Patients should avoid keeping the same posture for a long time. When they have to stand, they should constantly bend and stretch the affected limb to promote venous return through the action of muscle pump.
2. Exercise: For venous diseases of lower limbs, proper ground walking exercise can be carried out to promote the establishment of collateral circulation and improve venous return.
3. Others: Patients who often work standing or sitting should wear elastic bandages or elastic socks.
(3) improving pain symptoms
Nursing goal: pain relief or relief. Main nursing measures: promoting peripheral circulation, increasing tissue perfusion and promoting venous reflux are the fundamental measures to solve pain. Appropriate nursing measures can effectively relieve or relieve pain. In addition, the pain often occurs after activities or aggravates, so it is often manifested as less exercise and poor sleep, which makes patients fidgety, irritable or depressed and unable to actively participate in and cooperate with nursing staff to implement exercise plans. Therefore, proper and timely administration of analgesic drugs will promote patients to increase their activities and cooperation, thus making nursing measures easier to implement. The use of painkillers should be reasonable to prevent addiction.
(d) Nursing care of potential tissue integrity damage
Nursing goal: Do not cause or aggravate skin or tissue damage due to improper nursing. Vascular diseases, such as decreased tissue perfusion and malnutrition, all have potential problems of impaired integrity. The outermost skin tissue at the end of the limb is the most fragile part, which is easily injured by minor injuries. Once injured, it is easy to evolve into a long-term unhealed ulcer. Therefore, in the early stage of tissue perfusion reduction, it is necessary to start active and meticulous preventive skin care, especially the care of lower limbs and feet, and at the same time give vitamin B 1, C and high protein diet to strengthen nutrition and promote wound healing. If the disease develops rapidly and ulcer or gangrene appears in the tissue, it should be found in time and corresponding nursing measures should be taken.
(5) Nursing care of self-care defects
Patients with vascular diseases of limbs have completely or partially affected their self-care due to severe pain, ulcer, gangrene or swelling of their limbs. Or restrict that patient's activity due to the need of treatment. At the beginning of bed rest, nurses should take the initiative to implement bedside care, including assisting in eating, drinking, defecation, cleaning and entertainment, so as to meet the basic needs of patients and eliminate their sense of helplessness. We should comprehensively evaluate patients' self-care consciousness, self-care potential, learning desire and stress ability, work out training plans together with patients and their families, and suggest that their families provide patients with necessary material conditions and environment, encourage patients to study consciously, fully mobilize patients' self-care potential, reduce dependence on others, and gradually overcome psychological barriers of self-care defects. In the process of implementing the training plan, we should actively assist patients to complete the therapeutic self-care needs, make up for the lack of patients' self-care ability, and provide help and guidance for patients to establish a new self-care model.
Second, due to malnutrition, foot care of extremities with vascular diseases of limbs is prone to complicated and refractory complications such as ulcer, cellulitis or gangrene, which are due to insufficient arterial blood supply or venous reflux disorder, or lack of active preventive nursing measures and protective support measures for surrounding tissues from the early stage of the disease, or failure to adhere to long-term implementation. Ischemic malnutrition, the peripheral tissue of the affected limb, especially the outermost skin tissue of the human body, will gradually become thinner, dry and inelastic, which is easy to be chapped or broken due to trauma, hair will become sparse, fingernails will become thick, brittle or deformed, especially in the case of long-term malnutrition, it is difficult to trim fingernails, and tissue ischemia will cause sensory abnormalities, such as numbness, which is due to the participation of peripheral nerves. In view of the above situation, we should pay attention to the following aspects in the nursing of ischemic limbs.
(1) cleanliness
Wash your feet with warm water and mild and less irritating soap every day and dry them thoroughly with a towel, especially between your toes. Wipe gently to avoid scratching the skin and causing ulcers.
(2) Moisturize the skin
In order to avoid wet feet as much as possible, wear cotton socks with good moisture absorption and shoes with good air permeability, and change them every day. Don't wear canvas shoes or rubber shoes that make your feet sweat easily. To prevent dry skin, don't expose your feet to the sun. When the feet are too dry, you can apply a thin layer of lanolin or water-containing lubricant and gently wipe the skin. Avoid using emollients containing alcohol or perfume.
(3) Safety
Damage and oppression of surrounding tissues should be avoided as much as possible. Insist on practicing walking on the flat ground without obstacles; Don't go through the crowded crowd; Wear loose and comfortable shoes, don't wear high heels, and don't squeeze your toes. Before wearing shoes, check whether there are foreign objects in the shoes, do not walk barefoot, and wear protective socks at night; To prevent mosquito bites and itchy skin in summer, you can use antipruritic agents instead of scratching them with your hands; To trim your nails, first soak your toenails in warm water and cut them flat with a nail knife when the light is good. Patients with abnormal thickening or diabetes should be pruned more carefully. Warm water (about 32℃) is suitable for washing feet to prevent burns. Can't use hot water bag or electric mattress to directly contact the affected part of the affected limb; Keep warm, don't expose the focus to cold air, and don't wash hands, feet or swim in cold water.
(4) Exercise posture and foot movement can promote blood circulation and the establishment of collateral circulation. For patients with insufficient blood supply in lower limbs, Allen—Buerger exercise should be carried out regularly to relieve the pain of the affected limb, increase the collateral circulation of the affected limb and improve the insufficient blood supply in lower limbs. The method is: the patient lies on the bed, raising his lower limbs above 45 degrees until the skin of his feet turns white. This will empty the blood in the lower limbs. The time to raise the affected limb is 30 ~ 60s. Then the patient sits up, his lower limbs hang under the bed, and at the same time his feet do ankle adduction, abduction or flexion and extension. When exercising, the amplitude should not be too large or too fast until the skin of the affected limb is red or purple. The drooping time is generally 2 ~ 3min. Finally, the patient lay on his back 1 ~ 3min, and repeated the above exercises.
(5) Foot skin examination In a well-lit environment, carefully observe and record whether there are any redness, blisters, calluses or small crevasses on the peripheral skin every day; Whether there is swelling, redness and pain around the blood vessels.
Third, the care of foot ulcers and gangrene
Although there are meticulous preventive foot care measures, if the measures are not effectively implemented, the ischemic tissue is injured by compression, or the extremity tissue is not treated in time due to ischemia, or the effect is not good after treatment, the ischemic foot will still have ulcers or gangrene. Once it happens, it is generally difficult to heal, easy to be infected and disabled. After the occurrence of ulcer or gangrene, nursing staff should actively take measures for nursing. First of all, according to the location, size, depth, characteristics, secretions or inflammatory manifestations of the ulcer, it can be judged whether it is arterial or venous. Then combined with the patient's physical condition, whether there is diabetes, put forward a reasonable nursing plan, control infection, promote granulation tissue growth, and finally heal the ulcer.
(1) Prevention and control of infection
Any ulcer and gangrene have potential infection problems, and the infected wound is not easy to heal, so the infection should be prevented and controlled first. Local wound treatment: mainly to ensure adequate drainage and cleaning of ulcer wounds.
1. Wash the wound with 0.9% normal saline or 0.4% bromogeramine solution, and gently wipe it with cotton balls for several times to remove dirt;
2. Gently wipe the wound with a 3% cotton ball of hydrogen peroxide or pump hydrogen peroxide with a syringe for many times. If there is more dirt, there will be more foam when washing.
3. Repeat one or two steps repeatedly, and the bones or carrion that cannot be removed can be removed by itself without other methods;
4. Dry the wound with a dry cotton ball, and disinfect the wound with 75% alcohol cotton ball 1 time;
5. The interval of wound treatment varies according to the stage of disease development and the change of wound, generally two days. To prevent further infection. All treatments should be strictly sterile. Those with poor systemic resistance can be given broad-spectrum antibiotics according to the doctor's advice to prevent secondary infection or control infection. The scab formed on the wound must be removed. Excessive growth of granulation tissue or granulation edema will affect epithelial regeneration, making it difficult to heal wounds. Dressing should not be too tight, so as not to affect blood circulation and delay wound healing. The skin around the ulcer wound can be gently rinsed with warm water and neutral soap, and then dried with a cotton ball.
(2) Promote granulation growth and accelerate wound healing.
As long as there is enough blood supply, there is no infection or deterioration, the dressing is moist, breathable, granulation tissue grows rapidly and the wound heals quickly.
1. Local wound treatment: Bad tissue is not conducive to wound healing and is prone to secondary infection. The bad tissue on the ulcer surface should be removed in time to promote the decomposition of bad tissue. After the wound is completely cleaned, according to the nature of the wound, "egg butter medicine" and "Qufu Shengji powder" can be selected. For those with deep wounds, gauze soaked with drugs should be used for soft packaging, and sufficient drainage should be made to make granulation tissue gradually grow and fill from the bottom of the wound. If there is too much wound exudate, you can choose various absorbent dressings, such as hydrolyzed colloid and calcium alginate. In addition, in the event of unexplained fever, pain, bleeding, suspected anaerobic infection, or dressing prolapse, unclean dressing, increased pus, odor, etc. , should be replaced in time. However, whether it is a fresh wound or an infected wound, do not sprinkle anti-inflammatory powder and colored drugs (such as nail violet) in the wound during dressing change, so as not to affect the observation of the wound. Don't change the medicine too often. When removing the dressing, do not damage the new granulation tissue. At the same time, we should pay attention to whether there is allergic reaction to local medication.
2. Improve local circulation: prevent local oppression. Bedridden patients should turn over frequently to reduce the time of local oppression. If necessary, a bracket can be used. Buerger exercise can be used for ulcer caused by arterial insufficiency, which is beneficial to improve local circulation and increase collateral circulation. Ulcer caused by venous reflux disorder, raising the affected limb in bed, dressing with elastic bandage or wearing special elastic socks can promote venous reflux. But the most fundamental thing is to treat the primary disease and completely restore local circulation.
3. Improve the nutritional status of the whole body: the diet can be adjusted according to the living habits of patients, and the food should contain high protein and vitamins. Anemia, light can eat food with high iron content, heavy should be intermittent blood transfusion. If zinc sulfate is taken orally, it can provide trace zinc for the wound and promote the wound healing. Calcium can also relieve pain.
1. In case of phlebitis, remove the common indwelling needle and replace the puncture site. The inflamed part can be hot compressed, and the symptoms should be improved within 3 days. If there is no sign of improvement, you should inform your doctor to evaluate whether there is bacterial infection.
2. If phlebitis occurs in PICC (peripherally inserted central venous catheter), you can apply hot compress first. If it is mechanical or chemical phlebitis, the symptoms should be alleviated. If the symptoms persist and there is no sign of improvement, they need to be removed.
3. If wet and hot compress is carried out, you can use a wet and hot towel for hot compress, 20 minutes each time, 4 times a day.
4. If bacterial phlebitis is suspected, the doctor should be informed to carry out catheter needle and blood culture, and one of other veins and catheters should be taken as the diagnosis basis for blood culture.
5, if there is pus, should cultivate purulent liquid, need to use sterile cotton swabs; Before sampling, avoid disinfecting the skin to avoid affecting the culture of bacteria.
6. Raise limbs, promote blood circulation and repair.
7. If a chemical reaction is suspected, it should be recorded. It should be recorded according to the recording method formulated by intravenous infusion association in order to achieve the consistency of nurses' judgment standards.
8. Avoid puncturing the inflamed blood vessels again. Inflammatory blood vessels must be used after the symptoms are completely recovered and the elasticity is restored. [Edit this paragraph] phlebitis report classification (phlebitis report classification made by American Intravenous Infusion Association 1998)
phlebitis
0 no clinical symptoms
1+ Erythema with or without pain, with or without edema
2+ Erythema with or without pain, edema and vein stripe formation.
3+ erythema with or without pain, with or without edema, vein stripe formation, umbilical cord palpable.
suck up
0 no clinical symptoms
1 Pale skin, edema range less than inches (2.5cm), decreased skin temperature, and presence of pain.
2 Pale skin, edema ranging from 65,438+0 inches (2.5 cm) to 6 inches (65,438+0.5 cm), decreased skin temperature, with or without pain.
3. The skin is pale and transparent, the edema range is more than 6 inches (15cm), the skin temperature decreases, and mild to moderate pain can cause numbness.
4 the skin is pale and transparent, the skin is tight and faded, and there is liquid oozing; Skin contusion, edema range more than 6 inches (15cm), tissue depression after pressing the edema site; Decreased circulatory function, moderate to severe pain. Any dose of blood products, irritating or corrosive liquid leakage belongs to this level.
Transfusion pollution disease
Many people ask for transfusion as soon as they get sick. It is generally believed that infusion therapy is direct and effective, but I don't know that due to technical reasons, some infusion pollution sources will inevitably be brought into the human body during infusion, leading to acute reaction or potential harm caused by infusion.
Chemotherapy-related phlebitis protects vein
Before chemotherapy, patients should consider long-term treatment. Generally, blood vessels are used from the distal end to the proximal end and from the back to the inside, and the left arm and the right arm are used alternately. Because thrombosis is easy to form in veins of lower limbs, it is not suitable to use intravenous administration of lower limbs except for venous syndrome of upper limbs.
Second, avoid repeated puncture in the same part, and repeatedly draw blood when pushing the medicine to ensure that the needle is in the blood vessel.
Third, choose needles according to the diameter of blood vessels. The thinner the needle, the less damage to blood vessels. Scalp needles are usually used from 6.5 to 7.
Four drugs should be diluted lightly, intravenous injection should be delayed, and 2.0 ml of normal saline should be used before and after injection.
Fifthly, a small amount of blood in the needle is sucked back to maintain the negative pressure in the blood vessel before the needle is pulled out, and then the needle is pulled out quickly, and the puncture site is pressed with sterile cotton balls for 3 ~ 5 min, and at the same time, the puncture limb is raised to avoid blood backflow and ecchymosis in the eye of the needle, which is beneficial to puncture again in the future.
Treatment of liquid medicine leakage and phlebitis;
(1) If there is tingling, burning or edema at the injection site, it means that the liquid medicine is leaking, so it is necessary to stop taking the medicine immediately and replace the injection site.
(2) According to different chemotherapeutic drugs, different antidotes are used to seal the drug leakage site subcutaneously. For example, isotonic sodium sulfate such as vincristine can be used for the overflow of nitrogen mustard, mitomycin and gentamicin, and hyaluronidase can be used for leakage. Other drugs can be sealed with isotonic saline: 20 ml syringe can be used to extract antidote, and diamond injection can be taken around the leakage site. In order to prevent pain, it is necessary to inject 2 ml procaine locally, and if necessary, it can be injected repeatedly after 4 hours.
(3) Cold compress the leaking part or wet compress it with magnesium sulfate until the symptoms disappear.
(4) After phlebitis occurs, local hot compress can be performed, and turpentine ointment running according to blood vessels can be used externally or physical therapy can be performed.