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Nursing ligation of esophageal varices

Date2013-08-26 14:00:46

Variceal ligation is a new treatment method that uses ligation of esophageal varicose vein ligation device to necrosis, to stop the bleeding and treatment of esophageal varices purposes. Upper gastrointestinal bleeding is a common emergency medicine, in the past, many patients due to causes of bleeding and hemorrhagic lesions in the active state is unknown, can not be confirmed in a short time, a great deal of pain to the patient, even life-threatening. My department from 2000 to endoscopic esophageal varices ligation treatment of bleeding, and achieved good preventive and therapeutic effects. Nursing now reported as follows.

First, clinical data

 General information: The group of 50 patients with decompensated cirrhosis are complicated by bleeding esophageal varices, 31 males and 19 females, aged 28 to 72 years, mean 50.1 years. The first eight cases of bleeding, the second hemorrhage in 14 cases, repeated bleeding in 18 cases, 10 cases for the prevention of bleeding. Patients underwent endoscopy confirmed esophageal variceal bleeding, vomiting average of 2 to 3 times the amount of more than 1000ml vomiting. 5 cases of elective surgery after ligation.  

2 methods: by EG-200 electronic gastroscope, the first conventional endoscopy, into the mirror to the cardia, carefully check the scope and extent of esophageal varices. Exit endoscopy, ligation device according to six bursts into the mirror again, starting from the cardia 1.75 cm at the start, showing the need ligation of varicose veins, starting endoscopic suction device. Continue to attract a few seconds after endoscopic visible lesions when inhaled inner tube, then vision was red, indicating that the cylinder has been filled with varicose veins. In this case the pulling wire is pulled strongly, during retraction of the inner cylinder, since the resistance of the outer cylindrical edge of the rubber ring to be securely set in the base of the ligation site. Stop suction, gas injection slowly, visible varicose vein ligation of the base is a rubber ring seize polypoid, the color gradually becomes purple. Should select the right thick varicose veins along the four weeks each ligation, avoid direct draw surface ulcers, erosions and obvious signs of varicose veins red. All varicose veins should generally once ligation, ligation of venous not prevent increased pressure due to bleeding.
 
3 Results: Four weeks after endoscopy, this group of 50 patients, 21 cases of first variceal ligation surgery completely disappeared, 27 cases of varicose veins reduced by 50%, two cases after the second treatment of varicose veins obvious thinning collapse.

Second, nursing

A psychological care : ligation of esophageal varices is a new method of treatment carried out in recent years , with simple operation , the patient less pain, fewer complications , inexpensive and so on. Nurses Patients and their families should be introduced ligation method of operation and postoperative complications may arise , steps, principles , prepared before the operation , intraoperative and postoperative precautions cooperation , self-care , reduce or eliminate their stress, fear, prevent upper respiratory tract infection, avoid coughing, keep stool , reduce abdominal pressure , after fasting, drink 3 d. Use acid , hemostasis , to reduce or eliminate the incidence of postoperative complications. Because patients longer duration, and there is repeated bleeding, have intense fear , it should be appropriate to comfort patients and their families , the rescue process to remain calm , confident , accurate, skilled operation , clean the patient vomit and excrement , to keep the mouth clean , again to avoid the smell of blood stimulation vomiting, increase the psychological burden of patients . Explain the purpose of the operation , methods and reactions that may occur, and account notes and with ways to make the patient to maintain optimism , actively cooperate in order to achieve the best therapeutic effect.  

2 preoperative examination: Except for routine preparation before endoscopy, the check liver function, blood, ECG, measuring prothrombin time (PT), activated partial thromboplastin time (APTT), platelet count, and establish a smooth infusion, transfusion channel with blood, ready suction and oxygen equipment, make emergency preparations. 12 h of fasting before surgery the patient is asked nurses ready to various rescue items.

3 Intraoperative care:

  patient care: nurse patient stand on the left side, left hand supporting patients with tight seams, pads, Nursing and remain recumbent stationary guide their whole body to relax, when inserted into the throat endoscopy, Nursing swallow, mouth breathing, in order to facilitate gastroscope passed the esophagus. If any of its own secretions flowing into the mouth next to the curved plate.
  close cooperation with doctors: doctors assist in the process of picking up endoscopic ligation operations department. Strict control of suction vacuum in 0.04 ~ 0.06 kPa. Too easily lead to negative varicose blood vessels rupture. If a large amount of bleeding, the preparation of ice saline plus epinephrine or thrombin, sprayed on the bleeding site to stop bleeding.
  intraoperative observation: Conditional underwent ECG monitoring, close observation of the patient's vital signs, facial expressions and gestures, tell your doctor promptly if abnormal measures taken. After ligation is complete, remove the seams to help patients pad, wipe secretions and blood, observe vital signs returned to the ward.

4 postoperative care:

  prevention and treatment of complications: postoperative complication rate of 5% to 25%, to detect and take active measures to reduce the incidence of postoperative complications as well as the key to improving the success rate of surgery.
  Prevention and treatment of general complications: ① esophageal stenosis: 3 patients had mild stenosis, after the appropriate application of antispasmodic drugs are alleviated, can be used in case of severe stenosis of the endoscopic dilatation. throat pain: 15 cases of 24 ~ 48 h after complaints throat pain, caused by fiber endoscopy repeated thrusts, explaining the reasons for causing pain to the patient, eliminating anxiety with saline or boric acid mouthwash, 2 ~ 3 d pain disappear. retrosternal discomfort: All patients had varying degrees of chest discomfort after, which was caused by ligation, usually 1 to 2 weeks after the disappearance of symptoms and who may be taking small doses of sedatives and analgesics.

Prevention and treatment of bleeding complications : generally 1 week after ligation of esophageal varices , ligation tissue loss , leaving shallow ulcers, high-risk period of early rebleeding occurred. First of all kinds of incentives to avoid : poor diet is a major cause , any increase in abdominal pressure can cause bleeding action , gastroesophageal reflux is also one of the factors . At the same time closely related to liver function in patients with recurrent bleeding and nutritional status. Second, we must strengthen the observation , to detect signs of bleeding ( vomiting blood , black stools , blood pressure , blood examination showed red blood cells , etc. ) . Finally, to actively cooperate with the doctor in time bleeding. Once a large number of postoperative vomiting or black stools occur :

① Dual rapid establishment of intravenous access , infusion, transfusion to ensure the effective circulating blood volume ;

② patients should be absolute bed , holding the airway open , keep warm , fasting ;

③ somatostatin can quickly reduce
portal pressure , and possessed significant hemostatic effect , doctor commonly used. Push the first loading dose of 250 μg, bolus injection speed should be slow , or will cause palpitations, nausea , and even induce vomiting and other adverse reactions. After intravenous injection with 250 μg / h slow intravenous infusion , once interrupted more than 3 min loading dose should be pushed Note 250 μg, it should be kept bolus patency and continuity ; ready for three balloon tube, if necessary oppression blood ;

④ closely observed and recorded consciousness, blood pressure, pulse , pale , limb temperature , the amount of bleeding, color, quality , and 24 h urine .
  

diet care: 1 week after the peak of re-bleeding, diet care is very important. After fasting 72 h, 72 h after no active bleeding can drink cold water, without the discomfort can eat rice, milk, etc., and then gradually transition to a low-salt no residue semi-liquid diet. 1 month after discharge only outside outside activity, diet avoid rough, raw chilled, spicy, crude fiber foods, non-drinking, tea, coffee, eating slowly and avoid overeating.

  rest and activity guide: Postoperative patient is asked to require absolute bed rest 24 ~ 72 h, 40 ° head up after lying position to avoid acid reflux, when turning gentle movements, 72 h can sit up in bed, one week after getting out of bed before, only go out a month later.
  oral care: good oral care, maintenance of oral hygiene, oral ulcers and prevent lung infections and other complications. Timely processing of nausea, vomiting, light can be used distracting way severe intramuscular injection metoclopramide.

5 Discharge Instructions: Patients should first establish the confidence to overcome the disease , maintain a good attitude . During done by your doctor with a stable condition while drugs have the law of life , should do their own dietary management , into digestible , easy to absorb food, to the long-term soft diet , eating should be done slowly . To observe defecation , if found black stools , dizziness , palpitation , cold sweats , etc. to timely treatment .

III Summary

Upper gastrointestinal bleeding is a common medical emergency , endoscopic hemostasis is an important means of modern treatment of gastrointestinal bleeding , and its launch was significantly shorter in patients with upper gastrointestinal bleeding bleeding time and reduce bleeding part , reduce the need for surgery . Operation is simple and requires no special equipment , bleeding , high efficacy, fewer complications, patients easily accepted , and reduce the economic burden of patients, is a method of treatment of upper gastrointestinal bleeding safe, economical , effective and promising . The group of 50 patients from the operation and care , appreciate the preoperative make the necessary preparations , patiently explained to obtain the cooperation of patients , intraoperative operate closely with doctors, gentle operation , observe , after a strict diet management, close observation of changes in vital signs , rational use of antacids on the successful completion of the course of the operation, to alleviate the suffering of patients, reduce and timely treatment of complications is significant.