1. Causes of thrombosis
In 1946, Virchow proposed that there are three main factors of thrombosis: (1) hypercoagulable state of blood; (2) Injury of vein intima; (3) Slow venous blood flow.
2. Prevention of thrombosis
The preventive measures of thrombosis mainly include: (1) First, psychological work should be done well before operation, so as to reduce the psychological burden of patients and make them relax, and prevent patients from being too nervous to cause vasospasm, which will lead to difficulties in tube delivery after puncture. In order to prevent this situation, local anesthesia can be given when necessary to reduce the pain and fear brought to patients during puncture and increase the success rate of catheterization. (2) Nurses should have a high sense of responsibility, strictly carry out aseptic operation, and abide by operating procedures. When operating, they should use powder-free gloves. If it is talcum powder gloves, it must be washed with talcum powder, and the operation should be gentle. Gloves should try not to directly contact the pipe wall. (3) During puncture and catheter delivery, make the patient's upper limbs abduct to 90 degrees with the body as far as possible. When the catheter head reaches the patient's shoulder, the patient is required to turn the head 90 degrees to the puncture side and put the lower jaw close to the shoulder to avoid entering the jugular vein by mistake. However, nurses are required to operate gently and try to puncture successfully once, so as to avoid repeated puncture to damage the intima of blood vessels and prevent thrombosis. (4) After PICC catheterization, patients should be instructed: A, keep warm in winter, and the limb on the intubation side should not be excessively active, which will increase the mechanical stimulation of the catheter on the inner wall of blood vessels with the movement of the limb, but it can strengthen the hand movement on the intubation side, promote the blood return of the puncture upper limb and reduce the probability of thrombosis. B strengthen the patrol of patients with intubation, and remind patients to avoid oppressing the limbs on the intubation side. C inform the patient to report the discomfort such as limb pain on the catheter side in time for timely treatment.
3. Nursing care after thrombosis
If thrombosis is suspected, angiography or Doppler ultrasound should be performed immediately. After diagnosis, contact vascular surgery. In vascular surgery, thrombolytic drugs can directly act on embolus through PICC tube, and the catheter should be pulled out when thrombolysis is performed. Patients should be cared for during thrombolysis. (1) Psychological nursing: Nurses should actively communicate with patients to relieve their nervousness and fear, and explain the process of deep vein thrombosis and the necessity, safety and precautions of thrombolytic therapy, so that patients can understand the treatment situation, maintain a good mood and actively cooperate with treatment and nursing. (2) Nursing care of the affected limb: stay in bed for 7 ~ 14 days in the acute stage, raise the affected limb by 20 ~ 30 to promote blood return, measure the arm circumference of the affected limb at the same level as that of the healthy limb every day, observe and compare the swelling of the affected limb, observe the skin color, temperature, feeling and radial artery pulsation of the affected limb, and make records to judge the curative effect in time. (3) Pay attention to bleeding tendency, and monitor patients' blood routine, platelets, coagulation time and prothrombin time. (4) Prevent the formation of pulmonary embolism.
experience
Although the probability of thrombosis after PICC catheterization is very small, it will bring great psychological pressure and negative effects to patients, so we should try our best to prevent this complication and make PICC catheterization be well applied in clinic.
Common complications and prevention
1. Subcutaneous hematoma. Lack of experience in puncture and catheterization, poor mastery of skills, hasty action, unstable action, etc. , often make the indwelling needle puncture the blood vessel wall, forming subcutaneous hematoma. Therefore, nurses should master the puncture technique skillfully, and puncture should be light, steady and accurate. According to different vascular conditions, we should master the angle of needle insertion to improve the success rate of one puncture, so as to effectively avoid or reduce the occurrence of subcutaneous hematoma.
2. Liquid leakage. Improper selection of blood vessels, too small needle insertion angle, unstable fixation, patient's restlessness, incomplete entry of external cannula into blood vessels or too large contact area between cannula and blood vessel wall can all lead to fluid leakage. Symptoms such as local swelling and pain appear in light cases, and tissue necrosis can be caused in severe cases. In order to avoid liquid leakage, nursing staff should not only strengthen basic skills training, but also properly fix the catheter, guide patients to avoid excessive movement of the limbs of the indwelling needle, properly restrain the limbs when necessary, pay attention to the clothes above the puncture site not to be too tight, and strengthen the observation and nursing of the puncture site.
3. The catheter is blocked. The causes of catheter blockage are complicated, which are usually related to incomplete catheter flushing after intravenous infusion of high nutrition, improper selection of catheter sealing liquid, dosage and injection speed, abnormal coagulation mechanism of patients and so on. Therefore, the pipeline should be thoroughly flushed after intravenous infusion of high nutrition, and the pipeline should be sealed correctly after each infusion. According to the specific situation of patients, choose the appropriate sealing solution and dosage, and the injection speed should not be too fast. The study shows that the plugging rate of slow injection is obviously lower than that of fast injection.
4. Phlebitis. Phlebitis can be divided into chemical and infectious according to different causes. Its common symptoms are red, swollen, hot and painful blood vessels at the puncture site. During palpation, the pulse is as hard, rolling, slippery and inelastic as a rope. In severe cases, purulent secretions can be squeezed out at the local needle eye, which may be accompanied by systemic symptoms such as fever. Nursing staff should pay attention to the strict sterility of each operation link; Choose the vein as far away from the distal end of the blood vessel as possible and strive for a successful puncture; In order to reduce the occurrence of phlebitis, the catheter was washed with normal saline before and after infusion of drugs with strong stimulation to blood vessels.
5. Venous thrombosis. Venous thrombosis is common in slow-flowing veins. It is reported that the venous thrombosis of lower limbs in patients with long-term bed rest is three times that of upper limbs. In addition, repeated venipuncture at the same site with indwelling needle leads to vascular wall injury, which is also the trigger factor of thrombosis. In order to prevent venous thrombosis, the thick vein of upper limb should be preferred as far as possible during puncture, and attention should be paid to protecting blood vessels to avoid repeated puncture at the same site. For patients who stay in bed for a long time, we should try to avoid using indwelling needles in distal veins of lower limbs, and the indwelling time should not be too long.
Observation and nursing of complications
1. Be patient. Before catheterization, nurses should inform patients and their families of the purpose and significance of the application of intravenous indwelling needle, so that they can understand the nursing knowledge, common complications and preventive methods of intravenous indwelling needle, avoid excessive activity of indwelling limbs, keep the puncture site dry and clean during catheterization, and prevent complications such as infection, tube blockage and leakage.
2. Observe the local reaction. During the period of venous indwelling needle intubation, it is necessary to observe whether there is blood leakage, leakage, swelling and local inflammatory reaction at the puncture site, and find the early symptoms of complications in time. In case of local complications, local redness, swelling, fever, pain and other symptoms, extubation should be done immediately, and corresponding treatment should be given in time according to the situation, so as to promote blood circulation, restore vascular elasticity and relieve the pain of patients.
3. Nursing during catheterization. During the period of venous indwelling needle catheterization, we should strengthen the monitoring of vital signs and do a good job of comprehensive nursing. The skin around the puncture point should be disinfected with iodophor or iodine plus alcohol/kloc-0 every day, and covered with sterile dressing. During continuous infusion, the infusion set should be replaced every day 1 time. Heparin cap should replace/kloc-0 at least once a week. Pay attention to the patency of indwelling needle. In the process of infusion, we should closely observe the dripping speed to prevent excessive circulation load or adverse drug reactions caused by too fast infusion speed. Rapid infusion must prevent the liquid from dripping empty. In the case of arterial indwelling needle, monitoring should be strengthened to prevent accidents.