Key words: spleen; Laparoscopy; Perioperative period; nurse
Delaitre first reported laparoscopic splenectomy (LS) in 199 1 [1]. LS technology in China started with 1994 12. LS surgery has the advantages of less trauma, less bleeding, less pain, less physiological function interference, quick postoperative recovery and short hospitalization time, and is widely used in clinic. From June 2008 to May 2009, laparoscopic cholecystectomy was successfully performed in 8 cases. The nursing experience is reported as follows.
Clinical data of 1
There were 5 males and 3 females, aged from 48 to 72 years, 5 splenic cysts, 2 cavernous hemangioma of the spleen, portal hypertension, esophageal varices and hypersplenism 1 case. All cases were operated under general anesthesia of tracheal intubation, and 1 case underwent LS operation and portal azygos devascularization, and abdominal drainage tube 1 root was routinely retained after operation. There was no conversion to laparotomy in this group, and the average hospitalization days were 6 days.
2 Preoperative nursing
2. 1 Psychological nursing: As LS is a new method of splenectomy in recent years, patients and their families are worried about the safety and efficacy of LS; All patients receiving LS suffer from chronic diseases and often feel depressed and pessimistic. Therefore, we should strengthen the psychological counseling for LS patients, fully mobilize their subjective initiative, educate them with relevant knowledge before and after surgery, explain the necessity of surgery, introduce the indications, methods and steps of laparoscopic surgery in detail, and play surgical CDs to understand its advanced nature and safety, so as to alleviate their fears, eliminate their ideological concerns, enhance their trust in medical staff, and cooperate with surgery and treatment with a good attitude.
2.2 Evaluate the general situation of patients: understand the patient's medical history, guide and assist all routine preoperative examinations, especially the coagulation mechanism and biochemical examination, understand the bleeding and coagulation time, platelet count, prothrombin time and liver function classification of patients, find and correct organ dysfunction in time, cooperate with doctors to improve preoperative preparation, and reduce the risk of surgery.
2.3 Health guidance: instruct patients to eat a high-protein, high-calorie and high-vitamin diet, improve nutrition and improve the body's tolerance to surgery; Proper exercise is conducive to maintaining physical strength and improving lung function; Some patients have low platelet count. Observe whether there is bleeding tendency in skin and mucosa, and guide patients to prevent trauma and bump when they are active. Smoking and drinking are forbidden before operation, and respiratory function exercises are carried out, such as deep breathing, training cough and expectoration.
2.4LS patients should be informed to pay attention to cleaning, air disinfection, window ventilation, warmth and avoid catching a cold before operation.
2.5 preoperative preparation
2.5. 1 Routine skin preparation before operation, with special attention to umbilical hole disinfection and laparoscopic splenectomy.
The surgical observation hole is close to the umbilical edge, and if it is not thoroughly cleaned, it is easy to cause incision infection [3].
2.5.2 Gastrointestinal preparation: In order to reduce flatulence in the intestinal cavity, the patients were instructed to avoid legumes and dairy foods that are easy to produce gas before operation, and fasted 12h before operation and water was forbidden for 6h; On the morning of operation, indwelling gastric tube for gastrointestinal decompression can reduce flatulence, which is beneficial to fully expose the surgical field and prevent intraoperative injury. Intubation is gentle, especially in patients with portal hypertension whose esophageal and gastric fundus veins are obviously dilated.
2.5.3 Test blood type, merge blood, and prepare red blood cells and platelets.
2.5.4 Preoperative indwelling catheter to empty bladder.
3 postoperative observation and nursing care
3. 1 Monitoring vital signs: continuous ECG monitoring after operation, monitoring the changes of heart rate, respiration, blood pressure, body temperature and blood oxygen saturation, observing complexion and mental state, peripheral circulation, abdominal wound bleeding and abdominal signs, paying attention to whether there is abdominal distension and pain, and recording in time.
3.2 Respiratory tract management: after anesthesia, take a semi-lying position or a sitting position, assist and guide effective methods of coughing and expectoration, and give atomized inhalation, turning over and patting the back to dilute the sputum, which is beneficial to discharge, encouraging and assisting early activities of getting out of bed and bedside.
3.3 Observation of abdominal drainage tube: After splenectomy, the drainage tube should be placed in the splenic fossa and properly fixed to avoid pressure, distortion, falling off and blockage, so as to keep smooth drainage. Observe and record the drainage volume, drainage volume characteristics and drainage volume color. If the drainage fluid gradually decreases and the characteristics are normal, the drainage tube can be removed after 2 ~ 3 days of B-ultrasound examination to confirm that there is no effusion in the splenic fossa.
3.4 Activities and Diet: When you are not awake after general anesthesia, lie flat on the pillow with your head tilted to one side to prevent secretion, vomiting and aspiration. Take a comfortable lying position after waking up, and the degree of trauma and pain in laparoscopic surgery is light.
Patients in this group can get out of bed the next day or the same day, which can effectively prevent complications such as intestinal adhesion and deep venous thrombosis. The patients in this group fasted on the day after operation and vented anus within 1 ~ 2 days. Gastrointestinal function recovered, patients were encouraged to eat, and gradually changed from liquid to semi-liquid to soft food to general food. Observe abdominal pain and abdominal distension after eating.
3.5 Observation and nursing care of postoperative complications
3.5. 1 bleeding: if the drainage fluid of abdominal drainage tube is bright red within 24 hours after operation, the hourly drainage volume is >; 150ml or patients with wet and cold skin, rapid pulse, decreased blood pressure and decreased urine output. To prove abdominal bleeding and shock, you should immediately notify the doctor for treatment. The postoperative bleeding in this group was below 50 ml.
3.5.2 Infection: including wound infection and lung infection. After LS, the immune function of the body is low and the anti-infection ability is reduced. Therefore, it is necessary to closely observe the changes of body temperature, blood leakage and local wound pain after LS. Under general anesthesia, tracheal intubation is easy to damage tracheal mucosa, and gastric intubation is easy to cause pharyngeal discomfort and cough. People who are afraid to cough because of postoperative wound pain are prone to lung infection. Correct guidance should be given after operation in combination with preoperative education. In this group 1 case, fever occurred on the 4th postoperative day, which was confirmed by examination as ascites. After symptomatic treatment, it improved, and the rest cases had no postoperative infection.
3.5.3 Thrombosis: After splenectomy, platelets abnormally rise, and blood is in hypercoagulable state, which is prone to thrombosis. We should closely monitor the changes of platelets and assist patients to move their limbs at an early stage. After 2 ~ 3 hours, you should do passive physical exercise. On the second day after operation, he was treated with Bid for 20 minutes each time according to the doctor's advice, so as to promote blood circulation of both lower limbs, avoid blood transfusion of both lower limbs and prevent venous thrombosis. At the same time, we should pay attention to observe whether there are symptoms such as abdominal pain, bloating, bloody stool, nausea and vomiting, etc., to prevent mesenteric thrombosis. If the patient has the above symptoms after operation, blood should be drawn immediately to check platelets and B-ultrasound should be performed. There was no venous thrombosis in this group.
3.5.4 Pancreatic fistula and ascites: The pancreatic tail may be damaged during LS, leading to pancreatic fistula. The patients who underwent LS+ portal azygos devascularization developed fever on the 4th day after operation, with body temperature >: 39℃ and a large amount of yellow clear exudate in the wound dressing, which caused abdominal pain, abdominal distension and vomiting. The abdominal drainage tube discharges yellow liquid.
4 discharge guidance
Health education for patients and their families, pay attention to keep warm and prevent colds; Pay attention to food hygiene, adjust diet reasonably, avoid overeating and quit smoking; Keep a happy mood and avoid mood swings; Combine work and rest, pay attention to rest and avoid heavy physical labor; Proper physical exercise, enhance resistance.
5 abstract
The popularity of laparoscopic splenectomy provides a new treatment method for patients, which is favored by clinicians and welcomed by patients [4]. It not only achieved the effects of less surgical trauma, less bleeding, less pain, less physiological function interference and rapid postoperative recovery, but also shortened the hospitalization time and reduced complications. Through careful nursing of undergraduate course, no nursing complications occurred in this group of cases, and the prognosis was good. With the continuous development of minimally invasive surgery, nurses are required to master the theoretical knowledge and strong nursing skills related to laparoscopy in order to meet various nursing needs and observe the subtle and important changes of patients' condition in time.