棋牌大全下载安装

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                            1. 当前位置: 代写一篇论文多少钱 > 医学论文 > 术中患者低体温的危险因素与防护对策

                              术中患者低体温的危险因素与防护对策

                              时间:2019-03-09 13:34作者:刘燕梅 李莲英 李雪清
                              本文导读:这是一篇关于术中患者低体温的危险因素与防护对策的文章,手术患者术中鼻咽温度低于36 ℃定义为低体温,发生率达50%~90%。低体温可引起患者寒颤不适,增加机体耗氧量、术中出血和切开感染率,影响循环系统和中枢神经系统等,其中对心血管系统影响最大。

                                摘    要: 通过对影响患者术中低体温的心理、入室体温、能量摄入、高危人群、特殊类手术、环境温度、对体温管理不重视等危险因素和术前评估与心理护理、引入快速康复理念、关注特殊人群、加强保温措施及管理等防护措施进行综述,以提高医护人员对术中低体温防护意识,并有预见性地采取有效综合措施,真正的将低体温危害降到最低。

                                关键词: 手术; 低体温; 危险因素; 防护措施;

                                SHOUSHUHUANZHESHUZHONGBIYANWENDUDIYU36 ℃DINGYIWEIDITIWEN,FASHENGLVDA50%~90%[1]。DITIWENKEYINQIHUANZHEHANZHANBUSHI,ZENGJIAJITIHAOYANGLIANG、SHUZHONGCHUXUEHEQIEKAIGANRANLV,YINGXIANGXUNHUANXITONGHEZHONGSHUSHENJINGXITONGDENG,QIZHONGDUIXINXUEGUANXITONGYINGXIANGZUIDA[2]。DITIWENDUIHUANZHEWEIHAIJIDA,YINGXIANGSHUHOUKANGFU,JIANGDISHOUSHULIAOXIAOSHENZHIWEIXIESHENGMINGANQUAN,YICHENGWEIYIHUGONGZUOZHEGUANGFANGUANZHUDEREDIANWENTI。WEILEGENGHAODIWEITONGXINGTIGONGXUNZHENGYIJU,TONGGUOWENXIANHUIGU,DUISHOUSHUHUANZHESHUZHONGDITIWENDEWEIXIANYINSUHEFANGHUCUOSHIXINJINZHANZONGSHURUXIA。

                                1、 术中患者低体温的危险因素

                                1.1、 心理因素

                                HUANZHEDUISHOUSHUZHISHIQUEFA、JIWANGSHOUSHUSHIYOUBULIANGTIYAN、DUISHOUSHUCHUANGSHANGDANYOU,YOUQISHOUSHUGUOCHENGZHONGCHUYUQINGXINGZHUANGTAIDEHUANZHE,DOUHUICHUXIANJIAOLV、JINZHANGDENGXINLI。ERJIAOLVHUIYINGXIANGWEIXUNHUANHEHUIXINXUELIANG,RONGYIFASHENGDITIWEN[3]。

                                1.2、 入室体温

                                ZHANGQIANDENG[1]YANJIUXIANSHI,XIONGKESHOUSHUHUANZHESHUZHONGDITIWENFASHENGLVDA78.3%, logisticHUIGUIFENXIXIANSHI,RUSHITIWENJIAODI(ORZHI0.074,P<0.05)SHIHUANZHESHUZHONGDITIWENDEDULIWEIXIANYINSU。RUSHITIWENGAODIYUMAZUIHOUDIYIXIAOSHITIWENGAODIYOUGUAN。SHUQIANTIWENPIANDIDEHUANZHE,HEXINWENDUYUWAIZHOUWENDUTIDUJIAODA,HEXINRELIANGZAIFENBUZENGJIA,RONGYIFASHENGDITIWEN。SHOUSHUKAISHISHIHEXINTIWEN<36.5 ℃DEHUANZHESHUZHONGDITIWENFASHENGLVSHITIWEN>36.5 ℃HUANZHEDE20BEI[4]。

                                1.3、 能量摄入不足

                                为了确保胃排空,在麻醉时预防返流误吸,择期手术传统要求患者术前24∶00后禁食禁饮。长时间禁食禁饮会致摄入量不足,使患者发生能量代谢障碍产生低体温和寒颤。
                               

                              术中患者低体温的危险因素与防护对策
                               

                                1.4、 高危人群

                                LAONIANHUANZHETIWENDIAOJIEGONGNENGJIANTUIQIEDUOHEBINGMANXINGBING,JIASHANGMAZUI、SHUZHONGDALIANGCHONGXIYE、JIESHIWEISHUANGXIAZHIFUGAIKUNNAN,RONGYICHUXIANSHUZHONGDITIWEN[5];ERNIANLINGYUEDA,QINAISHOUYUECHA,DAICHANGNENGLIBUZU,HEXINWENDUXIAJIANGGENGKUAI[6];FASHENGLVGAODA50%~90%,YANZHONGYINGXIANGSHOUSHUXIAOGUOHESHENGHUOZHILIANG。XIAOERYOUYUTIWENDIAOJIEZHONGSHUFAYUWEICHENGSHU,TIBIAOMIANJIXIANGDUIJIAODA,SANREKUAI,PIXIAZHIFANGSHAO,YOUJIAOSHAODEJUERECENG,JIAZHISHENTIBILITESHU,DANGHUANJINGWENDUJIAODISHIYIFASHENGDITIWEN[7]。NIANLING<1SUIDEYINGERCHANGWENXIASHOUSHUSHIJIAN1 h,TIWENKEJIANG0.5 ℃,SHOUSHUSHIJIAN>2 hKEJIANG3~4 ℃。JIZHENSHOUSHUHUANZHEYOUYUSHUQIANZHUNBEIBUWANSHAN、SHOUSHUSHIYUREBUCHONGFEN、SHUIDIANJIEZHIHUNLUANDENGBINGLIZHUANGKUANGWUFAYOUXIAOJIUZHENG、SHOUSHUSHIJIANZHANG、SHURULIANGDADENGYUANYIN,ZHITIWENSANGSHIYANZHONG,SHIDITIWENGAOWEIRENQUN。

                                1.5、 特殊类手术缺乏相关护理指南

                              棋牌大全下载安装   KAIXIONG、KAIFUSHOUSHU,CHUANGMIANYUBAOLUMIANJIDA,ZAICHANGGUIBAOWENXIADITIWENFASHENGLVDA78.3%[1];HOULUYAOZHUISHOUSHUGUOCHENGZHONGXUYAOSHIYONGBINGYANSHUIHEDALIANGDESHENGLIYANSHUICHONGXIGUXIE,CHANGGUIBAOWENCUOSHIYIYOUFASHUZHONGDITIWEN[8];MINIAOWAIKESHOUSHU、FUKEGONGQIANGJINGSHOUSHUWEILEQUEBAOSHUYEQINGXI,SHUZHONGHUISHIYONGDALIANGCHONGXIYE,CHONGXIYEJINGCHANGHUIYICHU,JINSHISHOUSHUPUJIN,YEYIYINQIDITIWEN[9]。YOUYANJIU[10]BIAOMING,DUOSHUSHOUSHUSHIYIJINGDUIWEISHOUSHUQITIWENBAOHUZHONGSHI,DANQUEFAXIANGGUANHULIZHINAN。

                                1.6、 环境温度

                                HUANJINGWENDUZHIJIEYINGXIANGJITIWENDU。XIEYANHUDENG[11]YANJIUXIANSHI,DANGSHIWEN<22 ℃,DITIWENFASHENGLVMINGXIANSHANGSHENG,SUIZHESHIWENSHENGGAO,FASHENGLVZHUJIANXIAJIANG,RENWEISHIWENSHIDITIWENDEDULIWEIXIANYINSU。

                                1.6.1、 病区环境

                                HUANZHESHUQIANGENGHUANDESHOUSHUBINGFUBIJIAOKUANSONG,BURUPINGSHIDETIESHENYIFUBAONUAN,HENRONGYICHANSHENGHANLENGDEGANJUE[12]。

                                1.6.2、 手术室环境

                                SHOUSHUJIANKONGQIGUOLVQIYIBANANZHUANGZAISHOUSHUTAISHANGFANG,KONGQIDUILIUKEDAIZOUJITIRELIANG,SHIDUILIUSANREYOUZHENGCHANGDE12%SHANGSHENGZHI61%[13];TONGSHI22~25 ℃DEDIWENHUANJINGZENGJIALEJITIFUSHE、CHUANDAOSANRE,SHITIWENXIAJIANG[14]。

                                1.6.3、 PACU环境

                                SHOUSHUJIESHUHOU,HUANZHEXUYAOZAIPACUTINGLIUYIDUANSHIJIAN,ZAIGENGHUANZHUANYUNCHUANGDEGUOCHENGZHONGYOUYUDANXINGEZHONGGUANDAOBEIYIWAIBACHU,HUSHIHUIBAHUANZHEDEGAIBEIZANSHINAZOU,FASHENGYIYUANXINGQUTIBAOLU,HUANZHESHUNJIANJIECHUHANLENGKONGQI,RONGYIFASHENGHANZHAN。

                                1.7、 对体温管理不重视

                              棋牌大全下载安装   TIWENJIANCEZUOWEIWEISHOUSHUQIZHONGYAOSHENGMINGTIZHENG,WHOYU2015NIANYIJIANGWEISHUQITIWENJIANCELIERUWAIKEANQUANJIANYANBIAO(Surgical safety checklist)ZHONG[15],DANMUQIANWEIZHIBINGWEISHOUDAOZUGOUZHONGSHI[2]。SUIRANCAIYONGLEBEIDONGHUOZHEZHUDONGBAOWENDEFANGFA,DANSHIMEIYOUCHANGGUIJIANCESHUZHONGHEXINTIWENBIANHUA,DUISHUZHONGDITIWENDEFASHENGWEINENGJISHIFAXIANHEZUOJINKUAIFUWENCHULI。

                                2、 术中患者低体温的防护措施

                                2.1、 多学科团队协作(Multiple disciplinary team,MDT)团队对患者进行术前评估和心理护理

                              棋牌大全下载安装   YANJIU[16]BIAOMING,YIHUTUANDUILIANHETONGGUOJIJIZHUDONGDESHUQIANFANGSHINENGJIANGDISHOUSHUHUANZHEDEJIAOLVCHENGDUYOUYUYI、HUDANDUXUANJIAO。TONGGUOCHENGLIMDTTUANDUISHEDINGFANGSHIFANGAN,YOUSHOUSHUSHIZHUANKEHUSHIFUZELIANXIMAZUIYISHENGHEBINGFANGHUSHISANFANGGONGTONGJINXINGSHUQIANXUANJIAO,LEJIEHUANZHEXUQIU。SHOUSHUSHIGUANLIZHEYAOZHONGSHIHUANZHEXINLIHULI,ANPAIHULIRENYUANSHUZHONGQUANCHENGPEIBANYUHULI[17]。

                                2.2、 给患者预保温,维持体温在正常范围的较高值

                              棋牌大全下载安装   YUBAOWENSHIZHIZAIMAZUIYOUDAOQIAN,DUIJITIWAIZHOUZUZHIHUOPIFUBIAOMIANJINXINGJIAWEN,ZENGJIAWAIZHOUZUZHIRELIANG,JIANGDIWAIZHOUYUHEXINDEWENDUTIDU,JIANSHAOWENDUZAIFENBU;QUANMAHOUDI1GEXIAOSHI,HEXINTIWENKEJIANG1.0~1.5 ℃,QIZHONGYUE81%SHIYINJITIWENDUZAIFENBUDAOZHIDE;YUBAOWENSHIMUQIANWEIYIBEIZHENGMINGKEYOUXIAOZUZHIHUANZHEMAZUIHOUDI1GEXIAOSHINEIWEISHOUSHUQIDITIWENDECUOSHI[18]。MUQIANDUOTUIJIANSHIYONGCHONGQIJIARETAN,DANYOUYUHAOCAIJIAOGUI,HENNANZAILINCHUANGZHONGGUANGFANTUIGUANGSHIYONG。BENKESHIYANZHIDESHOUSHUCHUANG(ZHUANLIHAO:ZL 2013 2 0179808.1),ZAISHOUSHUCHUANGDIANNEIMAISHEYOUSHUANGPAIJIANKAILUOXUANXIANXINGZHUANGSHEZHIDERUANGUAN,TONGGUOJIANGRESHUIXUNHUANLIUDONG,YUANYUANBUDUANBUCHONGRELIANG,QIDAOHENGWENBAONUANZUOYONG。ZAIMAZUIQIANTIQIANKAIQIJIANGWENDUDIAOJIEZHI32~36 ℃YURESHOUSHUCHUANGDANYUAN,BINGCHIXUBAOWENZHILIKAISHOUSHUJIAN,KEYOUXIAOJIANGDISHUZHONGDITIWENFASHENG,QIEZHIZUOJIANDAN,CHENGBENDI,BUXUYAOZENGJIAHUANZHEDERENHEFEIYONG,ZAIWOYUANSUOYOUDESHOUSHUHUANZHEGUANGFANSHIYONG,XIAOGUOLIANGHAO[19]。

                                2.3、 引入快速康复理念——避免长时间禁食禁饮

                                KUAISUKANGFUWAIKELINIAN[20]RENWEI,SHUQIANYANGEJINSHI,MUDESHIYUFANGKENENGCHUXIANFANLIUHEWUXI,DANSHUQIANJINSHUI8 hHUOGENGZHANGHUIDAOZHIHUANZHESHUHOUFASHENGHENDUOBULIANGFANYINGHEBINGFAZHENG。XIANDAIMAZUIJISHUDEJINZHAN,YIDADAJIANGDILEQUANSHENMAZUIYOUDAO、CHAGUANHEBAGUANSHIFANLIUHEWUXI。SHOUSHUTUANDUIJIAQIANGGOUTONG,ZAIBAOZHENGCHANGDAOZHUNBEIXIAOGUODEJICHUSHANG,JINLIANGSUODUANHUANZHEJINSHIJINYINSHIJIAN,JIANSHAONENGLIANGXIAOHAODUIJITIBULIDECIJI[20];ZHANGYANGDENG[22]YANJIUFAXIAN,TANGYUCHULINENGYOUXIAOJIANSHAOSHUZHONGDITIWENDEFASHENG,FANGFASHIRANGHUANZHEZAISHUQIANWANSHANG20∶00~22∶00KOUFU800 mLHESHUQIAN2 hKOUFU400 mLTANGYUCHULIYE(MEI100 mLHANTANG12.5 g,285 mOsm/kg)。BINGFANGHUSHIHELIGUIHUAHULIGONGZUO,DUISHOUSHUHUANZHEYOUXIANZAISHUQIAN2 hJINXINGJINGMAISHUZHUYETI,YIZENGJIACHUREZUOYONGFANGZHIDITIWEN。

                                2.4、 关注特殊人群

                              棋牌大全下载安装   YAOTEBIEGUANZHULAONIANREN、YINGYOUERHEJIZHENSHOUSHUHUANZHE,YOUQISHIGAILEITESHURENQUNZHONGSHOUSHUSHIJIANZHANG、SHUYELIANGDADEHUANZHE,YAOZHIXINGGAOBIAOZHUNDEZONGHEBAOWENCUOSHI。

                                2.4.1、 动态调节室温

                                SHUQIANSHIWENLAONIANHUANZHEDIAOJIEZAI27~30 ℃,XINSHENGERHEZAOCHANERDIAOJIEZAI27~29 ℃[23],BINGWEICHIZHIPUJINWANBI。SHOUSHUHOUDI1GEXIAOSHILAONIANRENJIYINGYOUERKEDIAOZHI26 ℃[13],SHUZHONGZAIJINXINGDONGTAIDIAOJIE,DANBUYIDIYU24 ℃。

                                2.4.2、 动态调节加热设备温度

                                HUANERJINRUSHOUSHUSHI1 hNEI,JIAWENTANWENDUSHEDINGZAIGAODANG(43 ℃),KEYUFANGRELIANGZAIFENBUYINQIDEDITIWEN,1 hHOUDIAOWEIZHONGDANG(38 ℃),KEBIMIANHUANERBUSHIHEFASHENGRESUNSHI[7]。

                                2.4.3、 加温输液输血

                              棋牌大全下载安装   JIANGSHUYESHUXUESHEDINGWENDUWEI37℃,DUIYANZHONGCHUANGSHANGHUANZHEDENINGXUEMEIYUANSHIJIAN、DITIWENHEHANZHANFASHENGYOUYIDINGDEGAISHAN[24]。BINGGENJU“LING”PINGHENGSHUYEFANGANHUOMUBIAODAOXIANGYETIZHILIAOKONGZHIYETIRULIANG,BIMIANGUODUODEYETIDAIZOUJITIRELIANG。

                                2.4.4、 保持冲洗液有效温度

                                JIAWENCHONGXIYESHIYONGGUOCHENGZHONGYAOBIMIANQUCHUHOUZAISHOUSHUJIANDENGDAISHIYONGZHUJIANJIANGWENDEWENTI。BENYUANLIYONGSHOUSHUJIANYUANYOUYETICUNFANGJUJINXINGGAIZAO,FAMINGLESHOUSHUSHIYETIHENGWENXIANG(ZHUANLIHAO:ZL 2014 2 0386629.X)KEJIANGYETIJIAWENZHI35~37 ℃,JIYONGJIQU,JIEJUELEYETISHIYONGQIANJIANGWENDEWENTI,YEJIANSHAOLEXUNHUIHUSHIJINCHUSHOUSHUJIANDEPINCI。

                                2.5、 激发护理创新思维,使用恰当、科学的个性化保温措施

                                HULIGUANLIRENYUANYAOJIFAHULIRENYUANDECHUANGXINSIWEI,TONGGUOQINGJINGMONIPEIXUNFA,DUISHUZHONGDITIWENHULIXINGWEIJINXINGZHIDAO,YOULIYUTIGAOHUSHIXIANGGUANHULIZHISHIYUJINENG,TISHENGZHENGGEHULITUANDUIYUFANGSHUZHONGDITIWENDEYISHI[25],CONGERXUNQIUZUIQIADANG、ZUIKEXUEDEHULIFANGFA,JIANGDISHUZHONGDITIWENFASHENG。LIXUEQINGDENG[26]DENGYANZHIDESHUZIHUASHUINUANCHUANGYINGYONGYUSHIGUANAIGENZHISHUZHONG,JIANGDILESHUZHONGDITIWENFASHENG,TIGAOHUANZHESHUSHIDU;WANGMINGLINGDENG[27]ZIZHIMATIDIANLIANHENAOWAIKETIEMOZAIZHUIJIANKONGJINGSHOUSHUZHONG,YOUXIAOFANGZHISHUZHONGDITIWEN、SHUHOUHANZHANDEFASHENG;LIXUEQINGDENG[28]ZIXINGSHEJIBIAOBENSHOUJIQI,NENGGOUJIANSHAOMINIAOWAIKESHOUSHUCHONGXIYEJIXUEYEDEYICHU,BIMIANYINQIHUANZHEBUSHI,FANGZHISHUZHONGDITIWENFASHENG。

                                2.6、 加强保温细节管理

                              棋牌大全下载安装   HUSONGHUANZHERUSHOUSHUSHITUZHONGQUANCHENGBAONUAN,JIANSHAOTIBIAOBAOLU,JIYUZUGOUBAOGUO。KESHIYONGSHUANGCENGMIANBEI,DAITOUTAO、XIAZHICHUANDANLIWA、CHUANJIAOTAOZUDITIEJIAWENTIE[8]。SHOUSHUCHUANGDANYUANTIQIANYURE,RANGHUANZHETANGZAISHOUSHUCHUANGSHANGGANJUEWENNUANSHUSHIBINGCHIXUZHISHUBI,SHIHUANZHESHIZHONGCHUYUYIGEWENNUANDEHUANJING。SHUZHONGBAIFANGSHOUSHUTIWEIYINGZHUYIZHEGAI,BIMIANBUBIYAODEBAOLU,YOUQISHISHUZHONGCEWOWEI、FUWOWEI、JIESHIWEIDEHUANZHE,YOUYUSHENTIBUWEIXUANKONG,LENGKONGQIRONGYIYINGXIANGTIBIAOWENDU。XUNHUIHUSHIYAOQINGROUANYABEIZI,RANGBEIZISHUSHITIEFUHUANZHESHENTI。SHUHOUGUOPACUZHUANYUNCHUANGQIAN,BAGUANDAOZHENGLIHAO,ZUOHAOERJIYISHANGDEGUDINGKEYUFANGGUANDAOYIWAIBACHU,RANGHUANZHEJIXUSHIYONGSHUZHONGDEGAIBEI,JIANSHAODUOCIGENGHUANDAILAIHANLENGDEGANJUE。

                                2.7、 重视体温管理,持续术中患者体温监测

                                ZHONGSHISHUZHONGTIWENGUANLI,JISHIFAXIANDITIWENDEFASHENG,BINGCAIQUYOUXIAODECUOSHIJINXINGCHULI。YOUYANJIU[29]BIAOMING,SHUZHONGFASHENGDITIWEN,RUGUONENGJINKUAIHUIFU,HUIDUIHUANZHEDEWEIHAIJIANGDAOZUIDI,LIYUZAOQIKANGFU。QUANMASHOUSHUHUANZHEKESHIYONGBIYANWEN、GANGWENDENGJIANCE,FEIQUANMASHOUSHUHEFUSUHOUHUANZHE,KESHIYONGXINXINGWUXIANTIWENCHUANGANQICELIANGYEWOWENDU,KENENGDAIBIAOFEIXINZANGSHOUSHUHUANZHEDEHEXINTIWEN。

                                3、 小结

                              棋牌大全下载安装   YINQISHUZHONGDITIWENDEWEIXIANYINSUJIYOUNEIHUANJINGYINSURUHUANZHEXINLIYINSU、NIANLING、NENGLIANGBUZUDENG,YEYOUWAIHUANJINGYINSURUSHIWENGUODI、SHURUWEIJIAWENDEYETIYUSHUZHONGTIBIAOJITIQIANGZHANGSHIJIANBAOLUDENG。KEJIAN,RENHEDANYIDEFANGHUCUOSHIJUNNANYIDADAOYUQIDEXIAOGUO。ZHEIJIUYAOQIUYIHURENYUANSHUQIANZUOHAOPINGGU,YOUYUJIANXINGDICAIQUYOUXIAOZONGHECUOSHI;SHUZHONGJIANCEHUANZHEHEXINWENDU,JISHIFAXIANDITIWENFASHENGBINGDIAOZHENGBAOWENCUOSHI,QUANCHENGHEHUHUANZHE,ZUIDAXIANDUDIJIANGDISHUZHONGDITIWENDUIHUANZHEZAOCHENGDEWEIHAI。

                                参考文献

                                [1] 张倩,易杰,黄宇光.胸科手术患者术中低体温的危险因素[J].中华麻醉学杂志,2015,35(4):397-400.
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