Liver cirrhosis in our country is a kind of common disease, frequently occurring disease, clinical hepatic function decline and portal hypertension as the main performance, which caused by portal hypertension esophageal and gastric fundus varices rupture caused by upper digestive tract hemorrhage is the most common complication, often the amount of bleeding, disease fierce risks, often caused by hemorrhagic shock or induced hepatic encephalopathy and mortality rate can be as high as 40%~50%[1]. therefore, to take timely and reasonable treatment and careful and systematic nursing measures, to improve the clinical efficacy and reduce mortality caused by bleeding rate and reduce the complications has important significance. In recent years, 37 cases of cirrhosis with upper gastrointestinal bleeding were treated in our hospital. The patients were treated with active treatment and meticulous care. Now the clinical nursing experience is reported as follows.
1 clinical data.
1.1 general information, the 2011 January to December 2013 were liver cirrhosis complicated with hemorrhage of upper digestive tract (37 patients, including 28 male and 9 female patients; aged aged 20-74 years, average (46.8 + 6.7 years); were diagnosed by color Doppler ultrasound, endoscopy and related auxiliary examination confirmed the cirrhotic patients with esophageal and gastric fundus varices rupture and bleeding; the black 3, hematemesis volume less than 500 ml in 9 cases, 16 cases of haematemesis amount 500~<1 000 ml, 8 cases of 1 000~<1 500 ml, is more than or equal to 1 500 ml 1 cases.
1.2 treatment methods and results of the rapid establishment of effective venous access, giving oxygen, monitoring of vital signs, blood volume, blood transfusion, reducing the pressure of portal vein, application of hemostasis and acid suppression drugs. After active Department of internal medicine drug treatment and careful nursing, 31 cases were improved, 5 cases were improved after surgery, 1 cases were discharged from hospital.
2 nurse manager.
2.1 basic nursing patients in hemorrhage early need absolute bed rest, to avoid because of activity leads to an increase in abdominal pressure and induced hemorrhage, patients as far as possible in bed defecation, reduce unnecessary move; hematemesis occurred when head sideways, the timely removal of oral cavity accumulates blood to prevent choking and aspiration, and good oral care. Oral care 2~3 times per day during fasting, so as to keep the mouth clean; vomiting after the guidance of patients with mouth rinse to prevent oral infection. Long-term bedridden patients to keep the skin clean and dry, timing turn, keep the bed clean and dry; cut nails to prevent damage from scratching and bedsore. To keep the room quiet, clean ventilation, pay attention to keep warm, to help patients to maintain a comfortable position, to ensure that patients with rest.
2.2 emergency care to maintain airway patency, if necessary, with a negative pressure aspirator clear airway secretions, blood or vomit; given oxygen to ensure oxygen supply to the heart, brain and kidney; rapid establishment of the above two venous access, and cooperate with the doctors to quickly implement blood transfusion, fluid infusion, blood treatment and rescue measures. Treatment should avoid excessive blood transfusion and infusion resulted in increase in blood volume induced rebleeding; avoid using red cell suspension and sodium chloride injection supplement liquid, should be timely replenishment of plasma or other plasma substitute [1].
2.3 observe the change of the disease closely.
2.3.1 predictive nursing care in the treatment of liver cirrhosis combined with upper gastrointestinal bleeding in patients with more and more attention. Studies have shown, liver cirrhosis with esophageal and gastric fundus varices in patients with digestive tract hemorrhage rate of winter, spring was higher, the temperature is lower than 10 DEG C bleeding rate increased significantly. Therefore, for cirrhosis combined with upper gastrointestinal hemorrhage patients in the high time, should strengthen the inspection and monitoring of life signs, strengthen the foreseeable nursing consciousness. If nursing personnel in the clinical observation and rescue can do preventive measures, strengthen foresight consciousness, reduce or avoid the complications, ensure the smooth progress of the treatment can effectively improve clinical curative effect, shorten the bleeding time and improve the survival rate of patients.
2.3.2, close observation of the first signs in patients with liver cirrhosis and hemorrhage of upper digestive tract hemorrhage patients before there is often a upper abdominal discomfort and nausea. Hemorrhage, serious person can appear dizziness, palpitation, sweating, fast pulse, decreased blood pressure and other performance, patients at this time even if there is no obvious symptoms of vomiting, but has actually happened hemorrhage of upper digestive tract. Nursing staff should be aware of these signs of bleeding, dynamic observation of changes in the condition of the disease, immediately report to the doctor, and actively cooperate with the doctor to rescue work.
2.3.3 condition monitoring (1) student life signs, ECG monitoring in patients with blood pressure, pulse, respiration, blood oxygen concentration, every 2 ~ 4 h to measure body temperature 1 time, and record; (2) spirit and consciousness: monitoring in patients with irritable, indifference, confusion, sleepiness, lethargy and coma; (3) to observe the skin mucous membrane color, peripheral vein especially jugular venous distention; (4) of vomit and feces numbers, nature, color and volume of observation; (5) were recorded 24 h liquid intake and output; (6) regular reexamination blood routine, liver and kidney function, electrolyte.
2.4 psychological nursing in patients with liver cirrhosis due to the longer course of disease, and the prognosis is poor, the economic and psychological pressure larger, pessimism, depression, patients with hematemesis and hematochezia, greatly stimulated patients produce fear, tension, feel desperate and dying. These tensions can lead to the increased in patients with sympathetic nerve excitability, resulting in vascular tension increase induced or aggravated on digestive tract bleeding. The nursing staff to patients with psychological problems have deep understanding and accurate assessment of, rescue and patient to establish good mutual trust of the therapeutic relationship. In peacetime to often communicate with patients, using the psychological status of patients with communication skills to understand, compassion, care to patients, from all aspects and a variety of channels to encourage and support patients to establish the confidence to overcome the disease, let a patient to maintain the best physical and mental state, to actively cooperate with treatment and nursing.
2.5 diet nursing care is an important part of the comprehensive treatment of liver cirrhosis combined with upper gastrointestinal bleeding. Nursing staff to patients and their families to explain the importance of the plan, so that patients master the diet taboo, in strict accordance with the doctor's advice to eat. For patients with hematemesis should be absolute fasting, fasting for 24 to 72 hours, to be in stable condition, active bleeding stop before eating gradually from the liquid diet transition to semi liquid diet, diet and normal diet. Diet principle is few many meal, should eat foods rich in high calorie, high vitamin, avoid edible rough, hard, spicy food; and to the drinker advised the abstinence. For a small amount of bleeding or melena only patients can be given a light non irritating liquid diet can neutralize stomach acid to protect the wound. Serious liver cirrhosis or high blood ammonia, according to the condition of protein restriction; ascites should be low salt or no salt diet. The amount of water within the limits of about 1 000 ml / D, have significant hyponatremia limit in less than 500 ml / D [6], to prevent the increase of peritoneal effusion or induce hepatic encephalopathy, at the same time, we should pay attention to prevent the hypoproteinemia.
2.6 medication administration (1) vasopressor hormone and similar drugs: clinical often given pituitary blade element between 0.2 and 0.4 U / min continuous intravenous pump into, to a maximum of 0.8 U / min, venous pump into the posterior pituitary Ye Sushi should be diligent observation infusion and local skin, prevent liquid leakage, cause skin necrosis. If there is leakage, pain and phlebitis, immediately replace the blood vessels, with 50% magnesium sulfate wet compress, such as nausea, abdominal pain in a timely manner to reduce the concentration. Attention should be paid to the high dose of pituitary pituitrin on coronary vascular and intestinal circular muscle has strong contraction, can lead to abdominal pain, elevated blood pressure, arrhythmia, angina pectoris and myocardial infarction, so hypertension, coronary heart disease patients with caution. It is best to use micro electronic infusion pumps and strictly control the dripping speed, and instructing patients and their families not unauthorized transfer of drops fast speed, to avoid accidents. (2) somatostatin and its analogues: somatostatin can reduce the blood flow of internal organs and reduce the pressure of portal vein, which is the first choice for the treatment of esophageal and gastric varices bleeding. Octapeptide somatostatin analogue octreotide is the clinically most commonly used, safety, effective treatment of liver cirrhosis with upper digestive tract hemorrhage hemostatic. Common headed agent 100 g intravenous slow injection, following with 25-50 g sustainable intravenous drip. Intravenous injection process can not be interrupted, infusion of octreotide, the need to strictly control the drop speed, controlled by infusion pump, to prevent the patient fever, palpitations, nausea and other adverse reactions. Due to the drug can cause gastrointestinal peristalsis slows down, is not conducive to the discharge of intestinal hemorrhage, resulting in increased absorption of nitrogen, induced hepatic encephalopathy should, therefore, daily cleaning enema 1 times, also should pay attention to blood in the stool frequency reduce and cannot explain the bleeding stopped.
2.7 hospital guide cirrhosis complicated with hemorrhage of upper digestive tract rebleeding rate is very high, the rehabilitation discharged patients to according to the patients with different knowledge levels do cirrhosis digestive tract hemorrhage of basic knowledge, publicity and education, and make the patients and their families about cirrhosis of the liver fire tract hemorrhage etiology, predisposing cause, prevention and treatment knowledge. After discharge should be directed to the individual diet and life work to be properly arranged to avoid fatigue and other factors may lead to re bleeding. Let patients maintain a good attitude and stable mood, pay attention to regular review, medication on time, such as the discovery of black or bleeding signs should be timely to the hospital.
Upper gastrointestinal bleeding in patients with liver cirrhosis is a common complication and the main cause of death is, general relatively abrupt onset, rapidly changing, hematemesis and hematochezia occurred can lead to bleeding shock, induced hepatic encephalopathy, threaten the lives of patients. Patients the bleeding process in addition to the medical or surgical treatment, nursing staff with the height, carefully nursing to the patient's rehabilitation has an important role. Nursing staff should strengthen the sense of responsibility and mission of the disease, do basic care and condition monitoring, to be calm when the upper gastrointestinal bleeding, and actively cooperate with the doctor in a timely manner. Nursing staff on the patient's re bleeding and related complications should be predictable, timely and predictable changes in the disease, development and prognosis, so as to reduce or avoid complications, reduce the mortality rate of patients. As well as mental nursing and diet nursing, for psychological stress and diet self-control ability of patients, to the families of with hemorrhage, influencing factors and prevention of recurrence of patients to understand knowledge, reduce the psychological burden of patients, decreased in patients with hemorrhage relapse rate and disease death rate, for the clinical treatment of patients with a good foundation, and do a good job in discharge guidance, to improve the quality of life of patients.
Reference
[1] Wang Jing. Clinical nursing of 11 cases of liver cirrhosis complicated with upper gastrointestinal hemorrhage [J]. Journal of Qilu Nursing, 2011,17 (9): 54-56.
[2] Jia Xinping, Yang Jianqi, Wu Jie, et al. Effect of somatostatin on the effect of micro pump infusion on [J]. nursing research, 2006,20 (9A): 2039
[3] Rosalie, Ye Lingling, Li Xiaoming, et al. Investigation and analysis of the relationship between the upper gastrointestinal hemorrhage and the seasonal and circadian of portal hypertension [J]. China Journal of practical nursing, 2005,21 (10B): 57-59.
[4] Tao Dongmei. Chen Huimin, Qian Caihua, et al. A qualitative study on the physical and psychological experience of the patients with three cavity and two cystic duct: [J].'s Liberation Army Nursing Journal, 2007,24 (9A): 33-34.
[5] Chen Xiuwen, Chi Junxin, Wang Wei. Application of clinical nursing pathway in the implementation of holistic nursing care for patients with liver cirrhosis complicated with upper gastrointestinal bleeding [J]. Jilin medicine, 2009,30 (20): 2441-2442.
[6] Ni Fuqin, Wang Honglei. Nursing of patients with liver cirrhosis complicated with upper gastrointestinal bleeding [J]. Journal of practical nursing, 2010,26 (12): 18-19.
[7] Wang Cailian, high Quanle. Clinical nursing of patients with cirrhosis portal hypertension complicated with upper gastrointestinal bleeding [J]. China Journal of practical nursing, 2010,26 (10C): 21-22.