精细化护理对于新生儿重症肺炎合并呼吸衰竭的影响研究

韩海玲淡 云卫文峰

精细化护理对于新生儿重症肺炎合并呼吸衰竭的影响研究

韩海玲①淡 云①卫文峰①

目的:探讨精细化护理对于新生儿重症肺炎(SPIN)合并呼吸衰竭(RF)的影响.方法:选取60例SPIN合并RF患儿,按照护理方式的不同将其分为观察组与对照组.观察组28例,实施精细化护理后接受治疗,其中男患儿16例,女患儿12例,日龄10～28 d,平均日龄(18.26±4.16)d,体重(2.4～4.4)kg,平均体重(3.11±0.44)kg.对照组32例,实施常规护理后接受治疗,其中男患儿14例,女患儿18例,日龄(10～28)d,平均日龄(18.33±4.07)d,体重(2.4～4.4)kg,平均体重(3.08±0.46)kg.分别对两组患儿进行血气分析指标pH、动脉氧分压(PaO2)、动脉二氧化碳分压(PaCO2)、呼吸频率(RR)、心率(HR)水平以及机械通气总时间、不良情况发生率和护理满意度进行分析.结果:观察组患儿实施精细化护理后pH值、PaO2、PaCO2、RR及HR水平明显优于对照组,差异具有统计学意义(t=4.36,t=3.83,t=-2.23, t=-12.11,t=-5.45;P<0.05);两组患儿机械通气总时间对比,观察组患儿实施精细化护理后,机械通气总时间明显低于对照组,差异具有统计学意义(t=-7.63,P<0.05);观察组患儿再插管率明显低于对照组,差异具有统计学意义(x2=3.83,P<0.05);观察组患儿家属对护理的满意度明显高于对照组,差异具有统计学意义(x2=18.49,P<0.05).结论:实施精细化护理能够有效改善SPIN合并RF患儿的血气分析指标、缩短机械通气治疗时间、缓解病情、降低再插管率,临床应用价值较高.

精细化护理;新生儿重症肺炎;呼吸衰竭;效果

韩海玲,女,(1973- ),本科学历,主管护师.咸阳市中心医院新生儿科,从事新生儿临床护理工作.

[First-author's address] Neonate Department, XianYang Center Hospital, Xianyang 712000, China.

新生儿重症肺炎(severe pneumonia in neonates,SPIN)合并呼吸衰竭(respiratory failure, RF)是新生儿期常见的急危重症[1].机械通气辅助抗感染综合治疗是治疗SPIN合并RF的常用方法,治疗期间配合科学、有针对性的护理干预措施能够有效提高治疗效果,可改善患儿预后[2].常规护理方法虽然能改善患儿症状,但是长期疗效欠佳,预后较差,难于达到预期的护理效果.本研究通过借鉴国内外先进护理策略,结合自身经验对传统护理方案进行了优化,在此基础上总结了一套可行的精细化护理干预方案,临床应用效果良好,故对其临床优势进行分析,以期为优化SPIN合并RF的护理方案提供参考依据.

1 资料与方法

1.1 一般资料

选取咸阳市中心医院2013年1月至2016年1月收治的60例SPIN合并RF患儿,按照护理方式的不同将其分为观察组与对照组.观察组28例,为实施精细化护理后接受治疗的SPIN合并RF患儿,其中男患儿16例,女患儿12例;日龄10～28 d,平均日龄(18.26±4.16)d;体重(2.4～4.4)kg,平均体重(3.11±0.44)kg.对照组32例,为实施常规护理后接受治疗的SPIN合并RF患儿,其中男患儿14例,女患儿18例;日龄(10～28)d,平均日龄(18.33±4.07)d;体重(2.4～4.4)kg,平均体重(3.08±0.46)kg.两组患儿在年龄、性别等方面相比无差异,具有可比性.本研究均在患者家属知情同意下进行,并通过医院伦理委员会批准同意.

1.2 纳入与排除标准

(1) 纳入标准:①符合"实用新生儿学(4版)"[3]中SPIN合并RF相关诊断标准;②经常规影像学、病原学结合临床表现确诊;③无先天性疾病.

(2) 排除标准:①合并其他急慢性疾病或严重器质性病变者;②家属或患儿不能配合完成本研究.

1.3 方法

两组患儿均常规给予雾化吸入、吸痰、吸氧以及抗感染等对症治疗,并监测血气分析指标.对照组患儿实施常规护理,包括保持病房温度、湿度和安静程度适宜,定时通风消毒,及时更换柔软棉质尿布,皮肤清洁,生命体征监测等.

观察组患儿在常规护理基础上实施精细化护理,其中包括下述:

(1)呼吸道管理.患儿治疗时由于呼吸道尚未发育完全,如果体位不当将会引起舌根后坠,从而引起喉梗阻.护理人员应加强患儿体位护理,保持舒适且适宜体位,使呼吸道顺畅,同时预防舌根后坠情况.定时进行翻身,翻身时床头抬高15～30°、拍背和体位引流,及时对患儿口腔、鼻腔以及呼吸道内分泌物进行清理,痰多者适量给予雾化吸入[4].

(2)心理护理.患儿发病后多数家属不免产生焦虑、无奈等负性情绪,部分家属甚至对于医师的治疗不配合,从而不利于患儿康复.因此,治疗过程中护士应密切观察患儿生命体征监测,加强家属心理护理,告知家属患儿疾病相关知识,及时与家长沟通交流,让家长配合护理工作,为患儿营造一个温馨的环境,促进患儿早期康复.

(3)喂养管理.采取母乳喂养的患儿宜在有饱感后停止;采取人工喂养的患儿则以体重和病情控制奶量,防止喂食过多溢奶、吐奶,堵塞呼吸道;不能进食患儿及时进行鼻饲[5].

(4)口腔护理.由于患儿发病年龄较小,多数采用人工喂养,护士应根据患儿体质量及病情计算奶量.母乳喂养时,应以患儿自觉饱感为宜,对于不能自主进食患儿可以采用鼻饲进食,尽量遵循多餐少饮的原则,避免溢奶.患儿喂养时应该抱起拍背,而后取头侧右卧位,减少吐奶.定时清洁口腔,并注意在喂食后让患儿进食适量温开水[6].

(5)抗感染护理.遵医嘱给予患儿抗感染药物治疗,注意按照患儿病情遵医嘱严格执行泵速,同时记录患儿出入量和大小便情况[7].

(6)加强疼痛管理.在给患儿输液或做治疗时喂糖水,同时与患儿语言交流,放舒缓的音乐,缓解患儿疼痛.

(7)出院指导.对于出院患儿应加强其家属出院教育,告知患儿家属出院后的注意事项,定期带患儿到医院检查,对于出现异常者应立即采取有效的措施处理.

(8)做好抚触.患儿哭闹时及时关注,给患儿以安慰、抚摸,减少患儿哭闹,提高患儿治疗配合度.

1.4 观察指标

对比两组患儿护理干预前后血气分析指标pH值、动脉血氧分压(arterial oxygen partial pressure, PaO2)、动脉二氧化碳分压(arterial carbon dioxide partial,PaCO2)、呼吸频率(respiratory rate,RR)、心率(heart rate,HR)水平以及机械通气总时间和不良情况发生率以及护理满意度.

护理满意度采用医院自制调查问卷对患儿家属进行调查,按照百分制评价护理服务,>90分为十分满意;70～90分为满意;<70分为不满意.

1.5 统计学方法

使用IBM SPSS Statistics 22统计学软件进行本研究数据分析,计量资料以均数±标准差(x-±s)表示,计数数据用百分比(%)表示,分别采用t和x2检验,以P<0.05为差异有统计学意义.

2 结果

2.1 血气分析指标

观察组患儿实施精细化护理后pH值、PaO2、PCO2、RR及HR水平改善明显优于对照组,差异有统计学意义(t=4.36,t=3.83,t=-2.23,t=-12.11, t=-5.45;P<0.05),见表1.

表1 两组患儿精细化护理干预后血气分析指标对比(±s)

表1 两组患儿精细化护理干预后血气分析指标对比(±s)

2.2 机械通气总时间

观察组患儿精细化护理后,机械通气总时间明显低于对照组,差异有统计学意义(t=-7.63,P<0.05),见表2.

表2 两组患儿机械通气总时间对比(x-±s)

2.3 不良情况

观察组患儿再插管率为3.57%,对照组再插管率为25%,两组比较,差异有统计学意义(x2=3.83, P<0.05).而呼吸机相关性肝肺损伤和死亡两组比较无差异,见表3.

表3 两组患儿不良情况对比[例(%)]

2.4 护理满意度调查

观察组患儿家属对护理的满意度明显高于对照组,差异具有显著性(x2=18.49,P<0.05),见表4.

表4 两组患儿护理满意度对比[例(%)]

3 讨论

SPIN是新生儿期发生率较高的急危重症,患儿此时不仅肺实质的炎性病变进展至更为严重程度而导致肺部换气功能受损,同时也因新生儿呼吸道发育不成熟且支气管平滑肌较薄、自洁能力较差更容易发生气道堵塞和并发RF,临床治疗较为棘手[9].因SPIN合并RF患儿病情危重,因此需要及时采取有效抗炎和改善呼吸道症状的药物进行治疗,同时给予机械通气改善呼吸功能[10].但专家指出,该时期辅助科学、系统的护理干预能够提高治疗效果,改善血气分析指标,降低病情严重程度[11].

精细化护理是一种源于发达国家的企业管理理念,主要核心内容就是落实护理管理责任,将临床护理责任具体化和明确化;精细化护理也是临床护理规范化的一种升华,通过对护理工作人员的责任落实,每位护理人员必将对自己的岗位观念、工作方式和习惯进行提升,使之在工作中更加细心尽心.Leininger-Hogan等[12]和Hoh等[13]的研究指出,SPIN合并RF患儿容易因呼吸道堵塞、溢奶及呕吐等多种因素导致机械通气治疗效果不佳,机械通气所致并发症发生风险大增.近年来,精细化护理在SPIN合并RF患儿中得到应用,且效果理想,该护理模式是本研究针对重症加强护理病房中SPIN合并RF患儿接诊的实际情况,结合国内先进护理理念,总结了一套包括呼吸道管理、喂养管理、口腔护理以及抗感染护理等在内的精细化护理方案[14-15].各项护理措施均针对SPIN合并RF患儿临床治疗中存在的问题及风险因素,不仅针对性强,而且十分人性化.通过呼吸道管理、喂养管理和口腔护理有效改善了患儿呼吸道堵塞情况,防范了体位不适,舌根后坠,鼻腔、口腔及呼吸道分泌物,溢奶、吐奶等多种呼吸道堵塞风险因素,显著提高了机械通气效果,降低了机械通气不良情况发生率,同时也改善了患儿舒适度[16-17].本研究结果也证实,观察组患儿护理后PaO2、PaCO2及RR水平改善效果明显优于对照组,机械通气总时间明显低于对照组,再插管率明显低于对照组.通过抗感染护理有效控制了患儿因滴注速度过快导致的不适,在良好控制治疗效果的基础上提高了患儿舒适度[18].本研究中观察组患儿护理后PCIS评分明显高于对照组,患儿家属对护理的满意度明显高于对照组,也证实了精细化护理干预在提高治疗效果、患儿舒适度以及整体护理服务质量方面的临床优势.但是,临床上对于单一采用精细化护理模式效果不理想,则可以联合其他方法护理,发挥不同护理模式优势,达到优势互补,提高临床治愈率,促进患儿早期恢复.

综上所述,实施精细化护理能够有效改善SPIN合并RF患儿的血气分析指标、缩短机械通气治疗时间、缓解病情、降低再插管率,临床应用价值较高.

[1]许平,贾焕荣,杨玉军,等.新生儿呼吸衰竭870例临床流行病学分析[J].中国新生儿科杂志,2013,28(3):172 -176.

[2]Liapikou A,Polverino E,Cilloniz C,et al.A worldwide perspective of nursing home-acquired pneumonia compared with community-acquired pneumonia[J].Respir Care,2014,59(7):1078-1085.

[3]邵肖梅,叶鸿瑁,邱小汕,主编.实用新生儿学[M].4版.北京:人民卫生出版社,2011:398-402.

[4]戴兰芬,陈宝昌,张海荣,等.集束化护理在应用NCPAP治疗婴幼儿重症肺炎并呼吸衰竭的研究[J].护士进修杂志,2013,28(13):1175-1176.

[5]孙丽娜.新生儿重症肺炎合并呼吸衰竭的护理[J].中国实用医药,2013,8(27):214-215.

[6]陈立晶,奇铁男.76例重症肺炎合并呼吸衰竭患者的护理观察[J].中国实用医药,2012,7(34):190-191.

[7]刘晓玲.精细化护理在新生儿重症肺炎合并呼吸衰竭护理中的应用效果[J].实用心脑肺血管病杂志,2015,23(1):154-155.

[8]管晓晓,颜默磊.综合性护理干预对重症监护病房感染性休克患者治疗效果的影响[J].中国现代医生,2014,52(3):90-93.

[9]Vollman KM.Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics[J].Intensive Crit Care Nurs,2013,29(5): 250-255.

[10]徐学英.无创正压通气治疗新生儿肺炎合并呼吸衰竭的效果观察[J].临床合理用药杂志,2015,8(29):145-146.

[11]Wilson S,Bremner AP,Hauck Y,et al.Evaluation of paediatric nursing-sensitive outcomes in an Australian population using linked administrative hospital data[J].BMC Health Serv Res,2013,8(13):396.

[12]Leininger-Hogan S.Pneumonia management in the intensive care setting[J].Crit Care Nurs Q,2011,34(2):110-115.

[13]Soh KL,Soh KG,Japar S,et al.A crosssectional study on nurses'oral care practice for mechanically ventilated patients in Malaysia[J].J Clin Nurs,2011,20(5-6):733-742.

[14]Chayama K,Takahashi S,Toyota J,et al.Dual therapy with the nonstructural protein 5A inhibitor,daclatasvir,and the nonstructural protein 3 protease inhibitor,asunaprevir,in hepatitis C virus genotype 1b-infected null responders[J]. Hepatology,2012,55(3):742-748.

[15]Chen YC,Chang YJ,Tsou YC,et al.Effectiveness of nurse case management compared with usual care in cancer patients at a single medical center in Taiwan:a quasi-experimental study[J].BMC Health Services Research,2013,13(1):202.

[16]Kenyon M,Mayer DK,Owens AK.Late and long-term effects of breast cancer treatment and surveillance management for the general practitioner[J].J Obstet Gynecol Neonatal Nurs,20 14,43(3):382-398.

[17]Leung TK,Chen CH,Tsai SY,et al.Effects of far infrared rays irradiated from ceramic material(BIOCERAMIC) on psychological stress-conditioned elevated heart rate,blood pr essure,and oxidative stress-suppressed cardiac contractility[J].Chin J Physiol,2012,55(5):323 -330.

[18]Yovita H,DjumhanaA,Abdurachman SA,et al. Correlation between anthropometrics measurements,prealbumin level and transferin serum with Child-Pugh classification in evaluating nutritional status of liver cirrhosis patient[J].Acta Med Indones,2014,36(4):197-201.

The effect of fine care on newborn with severe pneumonia combining with respiratory failure

HAN Hai-ling, DAN Yun, WEI Wen-feng

Objective: To discuss the influence of the fine care for newborn with severe pneumonia (SPIN) combining with respiratory failure (RF). Methods: 60 cases of SPIN with RF were selected and divided into the observation group and the control group. 28 cases of SPIN with RF in the observation group were received fine care observation group after treatment, in which 16 cases were male children and 12 cases were female children. The ages of these children were from 10d to 28d day, and their average age was 18.26 + 4.16 d. The weight was from 2.4kg to 4.4 kg, and their average weight was 3.11 + / - 0.44 kg. 32 cases of SPIN with RF in the control group were received routine nursing, in which 14 cases were male children and 18 cases were female children. The ages of these children were from 10d to 28d and their age was (10 ～ 28) d. Their average age was (18.33 + 4.07) d. The weight was from 2.4kg to 4.4 kg, and their average weight was 3.08 + / - 0.46 kg. Then we analyzed espectively respectively on two groups of children with pH, arterial blood gas analysis index of oxygen partial pressure (PaO2), arterial partial pressure of carbon dioxide (PaCO2), respiratory rate (RR) and heart rate (HR) level and the total time of mechanical ventilation, the incidence of adverse circumstance and nursing satisfaction. Results: The observation group with pH, PaO2, PaCO2, RR and level of HR after fine care is superior to the control group, and the differences were statistically significant difference (t= 4.36, 3.83, 2.23, 12.11, 5.45; P <0.05). The total time of mechanical ventilation in the observation group was significantly lower than the control group, and the difference was statistically significant difference (t=7.63, P<0.05). The reintubation rate of the observation group was obviously lower than the control group and the difference was statistically significant (x2=3.83, P<0.05). Family satisfaction of nursing in the observation group was obviously higher than that in the control group, and the difference was statistically significant (x2=18.49, P<0.05). Conclusion: Fine care can effectively improve the SPIN with RF with blood gas analysis index, shorten the time of mechanical ventilation therapy, alleviate the pain and reduce reintubation rate. It has higher clinical value.

Fine care; Severe pneumonia in neonates; Respiratory failure; Clinical effects

1672-8270(2016)07-0094-04 [中图分类号] R722.135

A

10.3969/J.ISSN.1672-8270.2016.07.029

①咸阳市中心医院新生儿科 陕西 咸阳 712000

2016-01-20