The application of nursing procedures to patients' physical and mental holistic care can improve the therapeutic effect and prevent postoperative complications.
(A) the main nursing diagnosis
1, before operation
(1) Fear and anxiety: fear of surgery due to ignorance of the disease; Those who know the condition are all caused by organ defects and disfigurement.
(2) malnutrition, lower than the body's needs: reducing food intake due to loss of appetite; Cancer consumption; Because sympathetic nerve excitation is dominant, it inhibits the movement of digestive tract and the secretion of digestive glands, leading to loss of appetite.
(3) Comfort change, pain: cancer cells invade nerves.
2. After the operation
(1) Possibility of changes in vital signs: related to anesthesia and surgery.
(2) Comfort change, incision pain, and limb discomfort on the surgical side: caused by surgery.
(3) Possibility of limb edema on the surgical side: poor lymphatic and venous blood return caused by axillary lymph node dissection during operation.
(4) Skin integrity damage: caused by surgery.
(5) Lack of rehabilitation knowledge: Due to the lack of special education, the education level is limited.
(2) Nursing measures
1, before operation
(1) Provide all kinds of life care.
① Instruct patients to eat highly nutritious and digestible food, pay attention to the color, fragrance and taste of food, increase patients' appetite, meet the body's nutritional needs, store energy, and achieve the purpose of tolerance to surgery. ② Develop a good habit of defecation, keep the stool unobstructed, and give laxatives according to the doctor's advice when constipation occurs.
(2) preoperative preparation.
① Improve relevant inspection. ② The operation of venipuncture is skillful, which protects the vein and relieves the pain of patients. Venous puncture is not suitable for the affected limb after operation. (3) Prepare the skin in the operation area, especially the armpit. After washing with soapy water, flatten the skin with sterile scissors, cut off the armpit hair, then jump on talcum powder, tighten the skin and shave it off with a skin preparation knife to avoid damaging the skin. Those who need skin grafting should also prepare for the skin donor site.
(3) Strengthen health education and provide psychological support.
Because patients and their families are worried about the effect of the operation and the economic burden is too heavy, they show anxiety and depression. Nurses in charge should be concerned and considerate of patients, understand their psychological state, patiently listen to patients' complaints and give help, and introduce the information about the treatment progress and survival rate of breast cancer and the knowledge about diseases and operations to those who know the condition, so as to enhance their confidence in treatment. For patients with pain, the responsible nurse should contact with patients more, establish a good nurse-patient relationship, provide a quiet and comfortable environment, cooperate with doctors to use sedative and analgesic drugs appropriately, improve patients' bad mood, ensure rest and sleep, and make the body in the best condition for surgery.
2. After the operation
(1) Observe the changes of the disease closely. The patient was operated under continuous epidural anesthesia and intravenous anesthesia. After the operation, he should be placed on his back and his blood pressure, pulse and breathing should be closely monitored. After the patient is awake and his vital signs are stable, he should be given a semi-recumbent position to facilitate breathing and drainage, and to avoid or reduce edema of limbs on the surgical side. Observe whether the wound dressing is dry. In the early stage, local negative pressure suction or chest band dressing and sandbag pressure were used to help skin graft adhesion and avoid subcutaneous hematocele and effusion. Pay attention to whether the negative pressure drainage is unobstructed and the blood supply of the surgical limb.
(2) To prevent limb edema and dysfunction. Avoid venipuncture of limbs during operation and raise it appropriately. Three days after operation, the patient began to help the patient move his upper limbs, starting from the elbow and gradually expanding to the shoulder. The exercise method is to eat, comb your hair, wash your face and climb the wall with your fingers to promote blood circulation in your limbs.
(3) Strengthen psychological care. Because breast cancer surgery affects the physical beauty of patients, most patients are extremely depressed, showing irritability, inferiority, and even lack confidence in treatment. Nurses should not only actively communicate with patients to gain their full trust, but also try their best to adopt the most acceptable methods for patients, make frequent visits and talk more, introduce the necessity and importance of treatment, and educate patients about the adverse reactions of radiotherapy and chemotherapy and the preventive measures for their complications.
(4) Assist in life care. Postoperative patients' ability of self-care decreased during bed rest. Nurses in charge should give full help, partial assistance and support education according to Orem's self-care model to meet their self-care needs.
(5) diet care. The patient's diet after operation is very important. Besides increasing calories, protein, vitamins and inorganic salts should be added to promote tissue growth and wound healing.
(6) discharge guidance. Discharge guidance is one of the important contents of holistic nursing, which plays a certain role in helping patients understand and prevent diseases and promoting and restoring health. In nursing and treatment, patients should be educated in rehabilitation knowledge, including reasonable diet and functional exercise of limbs on the surgical side. Timely follow-up, regular radiotherapy and chemotherapy, record the treatment and nursing plan on the discharge medical record, and ask the family members to pay close attention to the psychological and illness changes of the patients. □ Our reporter Li Yongzai
Second, breast cancer radiotherapy nursing
1, radiotherapy reaction digestive tract reaction, irradiation field local skin reaction. Occasionally there are systemic reactions, such as leukopenia and general weakness.
Step 2: Care
2. 1 psychological care
Most patients think that cancer is an incurable disease, which is characterized by depression, fear and irritability. A few patients even give up treatment in despair. Some patients worry that their relatives and friends will despise themselves when they know their illness. Therefore, nurses should take the initiative to warmly welcome patients, help patients build confidence in overcoming diseases, and introduce the hospital environment and advanced radiotherapy equipment and technology to patients. Because patients are unfamiliar with radiotherapy, many questions arise. Nurses should tell patients in advance the precautions during radiotherapy, relax themselves during radiotherapy, don't be nervous, move their bodies at will, and let patients know the possible adverse reactions during radiotherapy. Help patients to eliminate anxiety and anxiety, and let patients actively cooperate to successfully complete radiotherapy.
2.2 Diet care
Some patients will have digestive system adverse reactions during radiotherapy, such as nausea, insensitivity to taste, loss of appetite, etc., which will affect food intake, lead to nutritional deficiency and decreased resistance, which is not conducive to normal tissue repair. Therefore, it is necessary to adjust the diet reasonably, avoid a single diet and maintain a balanced nutrition. Avoid foods that are too cold, too hot, greasy and spicy. Don't eat too full or too fast. Chew slowly and let the food be chewed fully, which is conducive to digestion and absorption, prevent abdominal pain and bloating caused by eating fast, and ensure that the body gets enough water.
2.3 Oral care
Nursing staff should keep the patient's oral cavity clean and hygienic, remove the residual food in the oral cavity, rinse their mouths after meals and brush their teeth 2 ~ 3 times a day. If you have an oral ulcer, rinse your mouth with light salt water or anti-inflammatory mouthwash several times a day.
2.4 skin care
Good skin care for patients can effectively prevent skin reactions. The skin tissue of breast cancer patients in radiotherapy site is thin, and the skin elasticity of patients after operation is poor, which is especially prone to skin reaction. Before radiotherapy, nursing staff should help patients to do personal hygiene and wear clean, soft and loose cotton underwear. Keep the bed clean, dry, soft and comfortable. Avoid rubbing and pressing the skin in the radiotherapy area, avoid using irritating bath lotion, and do not bathe with overheated water. Do not apply chemical ointment and tape to the irradiated area. If the skin is red, swollen, itchy and painful, please ask the patient not to scratch or scribble the medicine with his hands, and take the medicine according to the doctor's advice to effectively control the skin reaction and reduce the pain and mental burden of the patient.
2.5 Check the blood routine regularly
Observe the changes of white blood cells. If leukopenia is found, the body's immunity is reduced and there is a risk of infection, radiotherapy should be suspended. In addition to drug treatment, patients should be isolated in a protective way, and the ward should be ventilated and disinfected to keep the air fresh. Patients should pay attention to rest, reduce going out and visiting relatives, and keep patients clean and hygienic.
2.6 Patients should also pay attention to rest and exercise, do functional exercises of the affected upper limbs, keep blood flowing, dress the affected side first, and give take off your coat to the healthy side first.
3, discharge guidance
After discharge, patients should maintain good mood and emotional stability, pay attention to rest, don't be tired, pay attention to diet regulation, exercise properly, protect the skin at the radiotherapy site, and go to the hospital for reexamination regularly.
Third, breast cancer chemotherapy care
At present, surgery is still the main treatment for breast cancer. However, both basic and clinical studies have confirmed that 50% ~ 60% of breast cancer has micrometastasis at the time of clinical diagnosis, and simple surgical treatment cannot cure breast cancer. Therefore, chemotherapy, as a systemic treatment, has been paid more and more attention. Preoperative chemotherapy can promote the regression of local breast tumors and metastases, expand the indications of surgery and narrow the scope of surgery; It can also reduce the activity of cancer cells, prevent the spread of tumor cells during operation, control tiny metastatic foci not found in clinic, and reduce the metastasis of breast cancer; And tumor sensitivity to the chemotherapy regimen used. Practice has proved that preoperative chemotherapy has the advantage of reducing staging. Nursing is very important for the smooth progress of chemotherapy.
1, nursing problems
1. 1 fear 100% of patients have fear. The patient's fear mainly comes from two aspects. One is influenced by the misconception that "cancer = death" in society. Most people mistakenly believe that cancer is an incurable disease, and getting cancer is equivalent to being sentenced to death or suspended death. This fear of cancer mainly comes from the fear of death. The second is the fear of adverse reactions to chemotherapy. Because chemotherapy may cause serious adverse reactions such as vomiting, alopecia and local skin necrosis, most patients mistakenly think that chemotherapy drugs are a kind of poison. This fear mainly comes from ignorance of chemotherapy drugs, lack of chemotherapy knowledge and worry about self-image after chemotherapy.
1.2 The anxiety of anxiety patients mainly comes from the lack of knowledge. Because most patients mistakenly believe that surgery is the only way to treat diseases, the earlier surgery, the better. However, preoperative chemotherapy will prolong the waiting time of operation and aggravate the anxiety of patients.
1.3 This kind of depression mainly comes from patients with difficult family conditions. Worried about the family economy and strong sense of responsibility will make patients worry. Because preoperative chemotherapy prolongs the waiting time for surgery, hospitalization expenses will increase, patients' anxiety will also increase, and bad emotions will have a bad impact on recovery.
2. Nursing measures
2. 1 psychological care
2. 1. 1 Eliminate patients' fear of cancer, answer patients' questions honestly, patiently explain cancer-related knowledge to patients, and tell patients that cancer is not an incurable disease. With the development of medicine, many cancers can be cured, and some can even be cured and return to normal life; According to the patient's understanding and endurance, explain the illness properly, tell the patient the influence of bad mood on the disease and its prognosis, and tell the patient the successful cases in the past, so that the patient can eliminate the fear, establish the confidence to overcome the disease and actively cooperate with the treatment. In addition, patients should be given appropriate death education to alleviate their fear of death.
2. 1.2 Eliminate patients' anxiety, patiently and meticulously explain to patients the significance and necessity of preoperative chemotherapy, tell patients that surgery is not the only treatment method, let patients understand that the mood of medical staff is the same as that of patients, and doctors will try their best to cure them, so that patients can receive treatment happily.
2. 1.3 eliminate patients' fear of adverse reactions of chemotherapy, and explain the mechanism of action and possible adverse reactions of chemotherapy drugs to patients according to their understanding and tolerance. Pay attention to the artistry of conversation, talk to patients more, listen to patients' confidences patiently, and explain patients' questions patiently and carefully. Tell patients that chemotherapy drugs will make them uncomfortable, but before using chemotherapy drugs, preventive drugs and measures will be used. If there is still discomfort, medical staff will try to deal with it, so that patients can eliminate their ideological concerns, have the necessary psychological preparation and actively cooperate with the treatment.
2.2 Chemotherapy nursing
2.2. 1 medical data Before preparing for chemotherapy, the patient's height and weight should be measured, and blood routine, electrocardiogram, liver function, renal function and other test data should be prepared to fully understand the toxic and side effects of various chemotherapy drugs, so as to make corresponding treatment in case of adverse reactions.
2.2.2 Mastering skilled operation skills, protecting small veins and painless injection skills can alleviate patients' fear of chemotherapy. Nurses should master skilled operation techniques and rich professional knowledge, and select superficial veins of affected limbs in a planned way. Because intravenous infusion of the affected upper limb should be avoided after breast cancer surgery, postoperative infusion can only be carried out on the healthy side. In order to protect the healthy side vein, the superficial vein of the affected upper limb should be selected for preoperative chemotherapy.
2.2.3 Pay attention to oral hygiene and diet. Start with chemotherapy and do oral care twice a day to keep your mouth clean. Encourage patients to eat nutritious food, drink plenty of water and fresh juice rich in potassium ions to help patients make reasonable recipes.
2.3 Prevention and treatment of adverse reactions of chemotherapy
2.3. 1 Gastrointestinal reaction is the most serious and worrying side effect of chemotherapy reported by patients [3], which can lead to malnutrition and affect the treatment effect, and should be fully prepared. Create a good treatment environment, eliminate indoor odor, and guide patients to eat reasonably. Chemotherapy should not be carried out after a full meal or on an empty stomach. It is best to use chemotherapy drugs 2 to 3 hours after a meal. Diet should be less and diligent, and it is not advisable to eat greasy food during chemotherapy. 30 minutes before chemotherapy, intramuscular injection of phenamine 25mg and metoclopramide 20mg, or intravenous injection of antiemetic drugs such as Kangquan, Obitung, Jiang and Ondansetron. In the middle of chemotherapy, patrol the ward and talk to patients more to distract them. If possible, they can receive chemotherapy while listening to music and watching TV. Keep the stool unobstructed and give laxatives when necessary; Nausea and vomiting during chemotherapy should be treated in time, and those with severe vomiting should be given intravenous nutrition.
2.3.2 Bone marrow suppression is the most common side effect of chemotherapy drugs. At the same time of chemotherapy, leukocytosis drugs should be given according to the doctor's advice, and the blood picture should be checked regularly. When the white blood cell is lower than 1.0× 109/L, preventive use of antibiotics should be carried out according to the doctor's advice, isolation treatment and nursing should be implemented, medical treatment should be restricted, and cross infection should be avoided.
2.3.3 Hair loss The "special image of chemotherapy" caused by hair loss is a serious problem that affects patients' self-esteem. Therefore, patients should be informed of this possible problem before chemotherapy, so as to make full preparations. It can be prevented by wearing an ice cap during chemotherapy or tightening the scalp with rubber strip under the hair.
2.3.4 Prevention of extravasation of chemotherapy drugs can cause local tissue necrosis. Once skin ulcer is formed, it will not heal for a long time, and there is no effective treatment. Therefore, prevention is very important. Chemotherapeutic drugs should be prepared as required. First, blood vessels should be punctured with a liquid that does not contain chemotherapy drugs. After successful puncture and no liquid extravasation, the liquid containing chemotherapy drugs should be replaced. Intravenous injection, should be back to draw, see back to blood before injection. When injecting, the injection speed should not be too fast or too slow to avoid exudation and phlebitis. The injection time is 10 ~ 15 min. When dripping, you should patrol and observe regularly. After infusion or drip of chemotherapy drugs, replace it with liquid without chemotherapy drugs to flush the venous access.
2.3.5 Treatment of extravasation of chemotherapy drugs Once extravasation of chemotherapy drugs occurs, the injection should be stopped immediately, and the needle should be pulled out after injecting dexamethasone 5mg, and the ice should be kept for 24 hours. If the local area is still red and swollen after 24 hours, it should be coated with cortisone acetate ointment or wet compressed with dexamethasone. If there is pain, lidocaine and hydrocortisone sodium succinate should be used for local blocking, and dexamethasone and gentamicin should be alternately wet-compressed. Patients with obvious local necrosis and ulcer need surgical debridement.