ERAS理念在高原地区结核性脓胸患者护理应用中的效果评价
Evaluation of the Effect of ERAS in the Nursing of Patients with Tuberculous Empyema at High Altitude
DOI: 10.12677/NS.2021.106129, PDF, HTML, XML, 下载: 308  浏览: 1,252 
作者: 娜吧错:甘孜藏族自治州人民医院,四川 甘孜
关键词: ERAS理念结核性脓胸临床护理效果评价 ERAS Tuberculous Empyema Clinical Nursing Effect Evaluation
摘要: 目的:评估ERAS理念在高原地区结核性脓胸患者护理应用中的效果。方法:将我院2018年10月至2020年3月诊治的216例高原地区结核性脓胸患者参照随机数字表法分成对照组和ERAS组,每组各108例,所有患者入院后均予以手术治疗,对照组进行常规护理,ERAS组在术前、术中和术后护理中融合ERAS理念进行护理,对比两组手术资料、护理效果、术后一般资料和对护理方式满意度的差异。结果:对照组和ERAS组在脓胸最大直径、手术时间、切口大小和术中失血量等手术资料对比无统计学差异(P > 0.05);ERAS组的护理效果总有效率(95.37%)高于对照组(81.48%),有统计学差异(P < 0.05);ERAS组的胸管留置时间、术后胸管引流量和术后住院时间均显著低于对照组(P < 0.05);ERAS组患者对护理方式的总满意度(94.44%)高于对照组(86.11%),组间对比有显著差异(P < 0.05)。结论:ERAS理念在高原地区结核性脓胸患者护理过程中的应用能够显著改善患者病情,对术后康复有促进作用,明显提升患者对护理方式的满意度,值得大力推广。
Abstract: Objective: Evaluate the effects of ERAS in the nursing application of high altitude tuberculous empyema patients. Methods: The 216 high altitude patients with tuberculous empyema diagnosed and treated in our hospital from October 2018 to March 2020 were divided into the control group and the ERAS group according to the random number table, with 108 cases in each group. All patients received surgical treatment after admission, the control group received routine care, and the ERAS group received nursing care with ERAS in preoperative, intraoperative and postoperative care. The differences in surgical data, nursing effect, postoperative general data and satisfaction with nursing style between the two groups were compared. Results: There were no significant differences between the control group and ERAS group in the operative data such as the maximum diameter of empyema, operation time, incision size and intraoperative blood loss (P > 0.05). The total effective rate of nursing effect in the ERAS group (95.37%) was higher than that of the control group (81.48%), which was statistically different (P < 0.05). The chest tube indwelling time, postoperative chest tube drainage and postoperative hospital stay in the ERAS group were significantly lower than those in the control group (P < 0.05). The total satisfaction of patients in the ERAS group with care methods (94.44%) was higher than that of the control group (86.11%), and there was a significant difference in the comparison between the groups (P < 0.05). Conclusion: The application of the ERAS in the nursing process of high altitude patients with tuberculous empyema can significantly improve the patient’s condition, promote postoperative rehabilitation, and significantly improve patients’ satisfaction with the nursing method, which is worthy of vigorous promotion.
文章引用:娜吧错. ERAS理念在高原地区结核性脓胸患者护理应用中的效果评价[J]. 护理学, 2021, 10(6): 805-810. https://doi.org/10.12677/NS.2021.106129

1. 前言

结核病在全球是严重的公共卫生问题之一,尤其是在中国等结核病高负担国家,据世卫组织统计每年新增确诊结核病例约14%为肺外结核病,有研究表明胸膜结核病是最常见的肺外结核病类型,占所有肺外结核病病例的三分之二,推测胸膜结核在结核病高发国家比较常见 [1]。胸膜结核病尽管进行了治疗仍可能发展为结核性脓胸(tuberculous empyema, TE),未经治疗或治疗不当的TE可能导致胸膜皮肤瘘、胸壁肿块以及肋骨和骨骼破坏等,从而导致慢性和致命的后遗症 [2]。除了保守的药物治疗外,手术治疗已成为结核性脓胸患者的强制性治疗选择。增强术后恢复(enhanced recovery after surgery, ERAS)是一种多模式、多学科的手术患者护理方法,最开始应用于结直肠手术,随后在许多外科专科手术中都被证明可显著改善外科手术后的临床结果 [3] [4]。虽然ERAS为各种外科手术领域的护理都提供了一些建议,然而关于这些方案在接受结核性脓胸手术的高原患者护理过程中应用的信息相对较少,因此,本研究将在我院2018年10月至2020年3月收治的216例TE患者纳入研究,分析ERAS理念在TE患者应用中的效果并进行评估,现报告如下。

2. 资料与方法

2.1. 一般资料

选取我院2018年10月至2020年3月诊治的216例结核性脓胸患者,参照随机数字表法将其分成对照组和ERAS组,每组各108例,纳入标准:均常年生活在海拔3000米以上的高原地区;均被确诊为结核性脓胸患者诊断标准;术前均接受至少2周标准抗结核治疗;脑、心、肝、肾无严重器质性疾病,无重度器质性疾病手术风险;抗痨治疗后病灶吸收明显;无支气管胸膜瘘或穿透胸壁的脓胸。排除标准:年龄小于14岁或大于70岁;抗痨治疗无效;胸膜增厚大于1.0 cm。所有患者均自愿参与,签署知情同意书,该研究经我院伦理委员会审批通过。对照组108例,其中男52例,女58例,年龄范围在28~65岁,平均年龄(55.26 ± 6.99)岁;ERAS组108例,男51例,女57例,年龄范围26~66岁,平均年龄(54.89 ± 5.25)岁。两组资料对比P > 0.05,可进行分组比较。

2.2. 方法

所有患者入院后均予以手术治疗。对照组进行常规护理,ERAS组在术前、术中和术后护理中融合ERAS理念进行护理 [5] [6],具体的不同主要有以下几点:术前护理,对照组术前整晚禁食,ERAS组术前晚饮用1 L 10%葡萄糖水溶液并且在术前3 h再次饮用500 ml 10%葡萄糖水溶液。术中护理,ERAS组额外注意术中保暖和减少术中出血,并液体静脉输入维生素C溶液。术后护理,ERAS组术后即可饮水,无恶心呕吐现象即可进食流质食物,在病情允许情况下术后第1天即可下床活动,对照组按常规护理。

2.3. 观察指标及判定标准

手术资料主要包括脓胸最大直径、手术时间、切口大小和术中失血量的观察记录。术后一般资料主要包括胸管留置时间、术后胸管饮料和术后住院时间的观察记录。护理效果的判定标准为患者症状的改善情况,如患者病情得到明显改善,脓腔消失并且胸腔内无积液积水判定为显效,如患者病情未得到改善,脓腔内有残留判定为无效,如患者病情有所改善,状况介乎两者之间判定为有效 [7]。患者护理满意度的评估采用自制问卷形式进行调查,两组患者不记名打分评价对护理方式的满意程度,80分以上为非常满意,60~80分为满意,60分以下为不满意。

2.4. 统计学处理

所有数据分析均在SPSS 22.0软件上进行。计量资料以平均值 ± 标准差( x ¯ ± s)表示,t检验进行比较,计数资料采用卡方检验进行比较,P < 0.05被认为差异具有统计学意义。

3. 结果

3.1. 两组患者手术资料对比

两组患者脓胸最大直径、手术时间、切口大小和术中失血量对比,组间对比,P > 0.05,均无统计学差异,见表1

3.2. 两组患者护理效果对比

ERAS组的护理总有效率(95.37%)明显高于对照组(81.48%),组间对比差异显著,P < 0.05,见表2

3.3. 两组患者术后一般资料对比

ERAS组的胸管留置时间、术后胸管引流量和术后住院时间均低于对照组,组间对比差异显著,P < 0.05,见表3

Table 1. Comparison of surgical data between the two groups ( x ¯ ± s)

表1. 两组患者手术资料对比( x ¯ ± s)

Table 2. Proportion of nursing effect of two groups [n(%)]

表2. 两组患者护理效果对比例[n(%)]

Table 3. Comparison of postoperative general data between the two groups ( x ¯ ± s)

表3. 两组患者术后一般资料对比( x ¯ ± s)

3.4. 两组患者护理总满意度对比

ERAS组对护理的总满意度明显高于对照组,组间对比差异显著,P < 0.05。见表4

Table 4. Proportion of total nursing satisfaction of two groups [n(%)]

表4. 两组患者护理总满意度对比例[n(%)]

4. 讨论

TE是胸膜慢性感染的结果,伴随着中性粒细胞的流入,随后出现化脓性渗出液,最终胸膜广泛增厚和钙化。根据美国胸科学会,它分为三个演变阶段:渗出期(清澈、粘稠且通常是无菌的积液)、纤维蛋白脓性期(出现浓稠、感染、脓性液体)和组织阶段(肉芽组织形成与肺包裹) [8]。虽然在过去的几十年里,TE的发病率随着强效抗结核药物、穿刺引流和适当的胸腔内抗纤溶药物以及手术方法等治疗手段的发展呈下降趋势,但最新的研究数据发现,艾滋病毒流行的增加将增加发展中国家患结核病的风险,并可能扭转该趋势,并且还有数据表明HIV感染者患TE后的死亡率显著高于非HIV感染者 [9]。一般来说,TE的治疗方法与常规细菌性脓胸相同,根据分枝杆菌敏感性进行常规抗结核治疗,然而为了控制感染并防止进一步发展为纤维胸,一般会在病情允许的情况下进行手术治疗 [10]。手术治疗具有多种优势,包括促进疾病状况和阶段的诊断、减轻感染、重新扩张受压的肺以及预防随后的慢性呼吸道病变。目前首选的几种手术方式包括引流术、灌洗术、电视辅助胸外科(VATS)清创术、去皮术、胸廓成形术和开窗胸廓造口术等,其中VATS去皮术取得了较好的临床结果并越来越多的被应用,随着该手术方案的广泛应用,制定合适的辅助方案以提高术后恢复和生活质量势在必行 [11]。ERAS理念目前已经被大多数胸外科医生和护理人员接受并开始采用,该理念的核心是在护理过程中采取一些措施以优化患者术前的营养和身体状况,最大限度地减少术中应激反应,并在术后更快地恢复正常生理状态 [12]。

在胸外科手术中,已有大量研究证实ERAS能够减少食管切除术的手术创伤和压力反应从而改善手术结果,包括缩短住院时间和减低术后发病率 [13]。还有针对肺切除术的多项研究证明,ERAS理念的融入能够减少住院时间、阿片类药物的使用和直接成本 [14] [15] 等。但还有观念认为,目前采用的一些肺外科手术ERAS理念使用来自其他外科领域的可转移证据,因此不一定适用于某些特定的手术 [16]。鉴于目前ERAS主要在肺切除术和食管切除术中得到较多的研究,在结核性脓胸手术中应用评估的研究还比较少,需要对更多患者进行随机对照试验以获得高质量的数据及建议。

本次评估ERAS理念在高原地区结核性脓胸患者护理应用中的效果,结果显示:ERAS组的护理效果总有效率(95.37%)高于对照组(81.48%),有统计学差异(P < 0.05);ERAS组的胸管留置时间、术后胸管引流量和术后住院时间均显著低于对照组(P < 0.05);ERAS组患者对护理方式的总满意度(94.44%)高于对照组(86.11%),组间对比有显著差异(P < 0.05)。

本研究存在两个局限,一个限制是样本数量有限,还有一个限制是因为患者以后可能去别的医院进行诊治因此无法得到ERAS理念对患者以后再入院、并发症和生活质量等因素的长期影响。

综上,本研究的结果表明,融合ERAS理念在高原地区结核性脓胸患者护理过程中的应用能够显著改善患者病情,对术后康复有促进作用,明显提升患者对护理方式的满意度,值得大力推广。

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