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腹腔鏡下腎癌根治術后護理

熱度0票  瀏覽16次 時間:2019年3月26日 11:29
  摘要: 目的 探討后腹腔鏡下腎癌根治術患者的圍術期護理方法。方法 通過對 15 例后腹腔鏡下腎癌根治術患者的護理工作進行總結分析。結果 患者順利完成手術, 術后恢復佳。結論 采取積極有效的護理措施, 如充分做好術前準備、術后密切觀察病情變化、做好引流管護理、及時處理并發癥、早期指導功能鍛煉等, 能及時發現病情變化, 減少并發癥, 提高患者的生活質量。
  關鍵詞: 腹腔鏡;腎癌根治;術后護理
  腎癌是我國成年人常見的惡性腫瘤,多見于 40~69 歲年齡組,男女之比為 2~3: 1,隨著微創技術的發展, 腹腔鏡手術在泌尿外科應用日益廣泛, 與開放手術相比, 腹腔鏡手術具有創傷小、出血少、恢復快、住院時間短、切口美觀等優點。現將本人在臨床護理工作中的體會介紹如下:
  1 資料與方法
  1.1 一般資料
  本組 15 例, 男 11 例, 女 4 例。年齡 45~72 歲, 平均54 歲。左側 5 例, 右側 10 例。 4 例因無痛性肉眼血尿就診,2 例腰部隱痛不適, 9 例無癥狀、體征(體檢時發現)。均行 B超、 CT 或 MRI 檢查, 影像學檢查均未發現局部淋巴結轉移和其他遠處轉移。腫瘤直徑 2.5~6.5cm。病理報告:腎透明細胞癌 7 例, 腎盂移行細胞癌 5 例, 原發性輸尿管移行細胞癌3 例。
  1.2 方法
  手術均采用全麻下氣管插管取健側臥位。經腹膜后入路,在腹腔鏡監視下行腎腫瘤切除術。
  1.3 護理
  1.3.1 術前護理
  心理護理不同年齡、性別、文化程度、家庭狀況的患者,對疾病的認識和產生的心理問題是不相同的, 但對疾病的恐懼和焦慮是最常見的心理問題。故術前應積極給予心理疏導,介紹同種疾病病友, 相互交流, 彼此說出心中感受, 以釋放心理壓力。主治醫生、責任護士主動向患者講解有關腹腔鏡的基本知識, 與開放手術的區別、優點及術后的注意事項,讓患者對手術有初步認識, 以減輕心理壓力。
  1.3.2 術后護理
  嚴密監測生命體征患者返回病房后采取去枕平臥 6~8h,頭偏向一側, 以免全麻術后或止痛泵藥物刺激引發嘔吐導致窒息的發生。給予持續低流量氧氣吸入 2~3L/min, 持續心電監護 24h, 密切觀察患者意識、體溫、脈搏、呼吸及血氧飽和度, 并詳細記錄。本組 1 例患者術后一側肺不張, 表現為胸悶、氣喘、呼吸淺慢, 經過吸氧、采取健側臥位、翻身、叩背、霧化吸入, 1~2d 后患者呼吸改善。
  腎周引流管護理腎周引流管應妥善固定, 翻身活動或搬動患者時, 注意防止滑脫; 經常擠壓引流管, 避免引流管扭轉、折疊, 阻礙引流; 及時觀察并記錄引流液的性質及引流量。一般 24h 內不超過 100ml, 48h 拔除引流管。若發現引流液顏色逐漸變紅, 短時間內引流量突然增多(200ml/h),應及時報告醫生處理, 以防繼發性出血發生。
  留置尿管護理應保持留置尿管通暢, 觀察尿液顏色、性質及量并記錄, 由于尿量的多少, 可反映術后腎功能; 若尿量偏少, 而補液量過多, 可導致心、肺衰竭或水、電解質紊亂。留置尿管期間, 應用碘伏行尿道外口擦洗 2 次/d, 預防逆行感染。一般情況下, 患者下床活動即可拔除尿管。
  1.4 并發癥的觀察與護理
  高碳酸癥的觀察與護理由于長時間持續高壓灌注, CO2在組織間隙中彌散被大量吸收而進入血液循環, 以致血液中CO2 超過了肺呼吸排出能力, 使患者表現為類似呼吸性酸中毒的癥狀[3], 應鼓勵深呼吸, 促進 CO2 排出, 并給予持續低流量氧氣吸入 3L/min, 以提高氧分壓, 降低 CO2 分壓。
  1.5 出院指導
  出院后 1~3 個月注意勞逸結合, 避免重體力勞動。指導患者合理營養飲食, 以清淡、低鹽、低脂、優質蛋白、低糖、多維生素為主, 脂肪的攝入應該以不飽和脂肪酸為主,如大部分植物油, 而大部分動物脂肪含飽和脂肪酸較高[4]。
  同時應保持心情愉快, 注意保護腎臟不濫用藥物。進行生物治療者, 如干擾素、白細胞介素等, 應注意給藥時間、劑量、療程及藥物的不良反應。告知患者按時來院復查, 如出現血尿、發熱、尿量減少等癥狀, 應及時來院就診。
  2 結果
  除 1 例患者由于術中出血多而采用中轉開放術, 其余患者手術均順利完成。 15 例患者術后均使用鎮痛泵, 術后 24~48h 進食, 術后第 2 天下床活動。出現 1 例肺不張, 胸悶,經翻身、叩背、超聲霧化吸入(2 次/d)及相應護理, 1~2d后恢復。 2 例術后出現體溫>38℃, 2~3d 后恢復正常。術后2~3d 拔除引流管, 5~10d 出院。
  3 討論
  泌尿系統中腎癌是僅次于膀胱癌發病率的惡性腫瘤,治療腎癌主要采取手術的方法,傳統的開放性術手術時間較長、創傷重、范圍廣,并且手術后患者易引發出血感染等并發癥,而新興的腹腔鏡下腎癌根治術與傳統開腹手術相比,具有患者流血少、恢復快、傷口小、住院時間短等優點,目前腎癌根治術已逐漸取代了傳統開放性手術,針對腹腔鏡下腎癌根治術患者的臨床護理。筆者認為,首先必須確定護理目標,心理護理以減輕或消除患者的焦慮、恐懼情緒;體位護理可增強患者的舒適感,并相應減輕或消除患者的疼痛;預防感染的護理使患者感染的危險性降低;飲食護理能維持患者良好的營養狀況;嚴密觀察確保患者的病情變化能及時發現,并進行處理。只有明確了護理目標,才能采取正確的針對性的臨床護理措施,并且進行護理評價,看護理措施是否有效。
  本文中我們通過給予患者有效的術前護理、心理護理和術后全面護理,結果 36 例患者手術順利完成。手術時間為 2.2~3.8h,平均 2.7h;手術過程中患者出血量為 43~108ml;手術后 1~2d 患者便可下床活動;手術過程中及手術后均沒有對患者進行輸血;并且患者沒有發生氣胸與大出血等并發癥;患者住院一周左右后痊愈出院。隨訪半年~兩年,患者均未腫瘤復發。再次證明對于腎癌患者進行腹腔鏡下腎癌根治術可縮短患者的住院時間,降低患者的創傷,提高患者的生存質量,做好相應的護理措施,可有效地助于患者積極接受治療,使患者順利度過圍術期,并可提高手術治療的成功率,提高患者生活質量。
  參考文獻
  [1]雷天淑.腹腔鏡腎癌根治術 62 例臨床護理[J].基層醫學論壇, 2013, 17(12): 1502-1504.
  [2]劉洋.經臍單孔腹腔鏡下腎癌根治術的護理體會[J].內蒙古中醫藥, 2013, 9: 157-158



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