修回日期: 2019-12-23
接受日期: 2020-01-07
在线出版日期: 2020-01-28
腹腔镜手术具有创伤小, 出血少, 并发症少和术后容易恢复等优点, 尽管手术已经趋势成熟, 但是很多患者会表现出特有的高度心理敏感性以及强烈的手术应激等特点, 担心出现术后综合症, 如食欲欠佳, 腹泻等. 同质医疗理念是由医护人员共同组建, 共同协作开展临床医疗护理工作的团队. 本研究基于同质医疗理念的创新护理模式应用于胆囊切除手术患者的实际护理中, 以期为临床工作人员提供重要价值.
探讨同质医疗理念创新型护理实践对腹腔镜胆囊切除患者围术期应激反应的影响.
选择2017-04/2019-04在浙江省义乌市中心医院行腹腔镜胆囊切除患者80例为研究对象, 根据住院顺序编号输入Excel表, 采用随机数字表随机分为对照组和观察组各40例. 对照组给予常规护理, 如健康教育、心理疏导、饮食护理、术前护理和评估、病情护理、用药护理、术中术后常规护理和生命体征监测等护理. 观察组在对照组基础上给予同质医疗理念的创新型护理实践. 观察2组患者在术前(T0)1 d, 气腹后(T1)10 min, 手术结束时(T2)5 min时3个时间点应激指标变化情况, 包括心率(heart rate, HR)、平均动脉压(mean arterial pressure, MAP)和血糖变化, 同时抽取静脉血检测血浆去甲肾上腺素(noradrenaline, NE)、肾上腺素(adrenaline, E)水平和皮质醇水平.
对照组患者在T1, T2时HR、MAP和血糖均高于T0, 但在T2时间点较T1有所下降, 仍较T0时间点水平高(P<0.05); 而观察组HR、MAP和血糖变化趋势与对照组相同, 但各时间差异无统计学意义(P>0.05); 观察组HR、MAP和血糖在T1、T2时间点均低于对照组(P<0.05). 与T0时间点比较, 对照组在T1、T2时间点NE, E及皮质醇浓度均上升(P<0.05); 观察组在T1时间点上升(P<0.05), 在T2时间点下降(P<0.05). 与对照组T1、T2时间点比较, 观察组患者NE、E及皮质醇浓度均降低(P<0.05).
同质医疗理念的创新型护理实践能显著降低腹腔镜胆囊切除患者围术期应激反应, 有利于促进患者术后身体康复.
核心提要: 本研究将同质医疗理念应用于腹腔镜胆囊切除手术患者, 旨在为临床护理提供参考依据.
引文著录: 陈贵兴, 楼彦君. 同质医疗理念创新型护理实践对腹腔镜胆囊切除患者围术期应激反应的影响. 世界华人消化杂志 2020; 28(2): 76-80
Revised: December 23, 2019
Accepted: January 7, 2020
Published online: January 28, 2020
Laparoscopic surgery has the advantages of less trauma, less bleeding, fewer complications, and faster postoperative recovery. Although laparoscopic surgery has become mature, many patients still show unique characteristics of high psychological sensitivity and strong surgical stress, and worry about postoperative syndrome, such as poor appetite, diarrhea and so on. The concept of homogeneous medical care is a team jointly established by medical staff to carry out clinical medical care. In this study, the innovative nursing model based on the concept of homogeneous medical care was applied to the actual nursing of patients undergoing cholecystectomy in order to provide a reference for clinical staff.
To explore the influence of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy.
A total of 80 patients who underwent laparoscopic cholecystectomy at Yiwu Central Hospital of Zhejiang Province from April 2017 to April 2019 were selected as the subjects of the study. The patients were randomly divided into either a control group or an observation group with 40 cases each. Both groups were given routine nursing care, such as health education, psychological counseling, diet nursing, preoperative nursing and evaluation, condition nursing, medication nursing, intraoperative and postoperative routine nursing, and vital sign monitoring. The observation group was additionally given innovative nursing care based on the homogeneous medical concept. Changes in stress indicators, including heart rate (HR), mean arterial pressure (MAP), and blood glucose, were observed at one day before surgery (T0), 10 min after pneumoperitoneum (T1), and 5 min after surgery (T2) in the two groups, and venous blood was collected to detect plasma noradrenaline (NE), adrenaline (E), and cortisol levels.
In the control group, HR, MAP, and blood glucose at T1 and T2 were all significantly higher than those at T0 (P < 0.05), but their levels at T2 were slightly lower those at T1 and still higher than those at T0 (P < 0.05). The change trends of HR, MAP, and blood glucose in the observation group were similar to those in the control group, but the differences were not statistically significant among different time points (P > 0.05). HR, MAP, and blood glucose at T1 and T2 in the observation group were all significantly lower than those in the control group (P < 0.05). Compared with those at T0, the concentrations of NE, E, and cortisol in the control group significantly increased at T1 and T2 (P < 0.05). In the observation group, the concentrations of NE, E, and cortisol increased at T1 (P < 0.05) and decreased at T2 (P < 0.05). Compared with the control group, the concentrations of NE, E, and cortisol at T1 and T2 were all decreased in the observation group (P < 0.05).
Innovative nursing care based on the concept of homogenous medical treatment can significantly reduce the perioperative stress response of patients undergoing laparoscopic cholecystectomy, which is beneficial to promote the postoperative physical recovery of patients.
- Citation: Chen GX, Lou YJ. Effect of innovative nursing practice on stress response of patients undergoing laparoscopic cholecystectomy. Shijie Huaren Xiaohua Zazhi 2020; 28(2): 76-80
- URL: https://www.wjgnet.com/1009-3079/full/v28/i2/76.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v28.i2.76
随着医疗技术的快速发展, 腹腔镜已经成为胆囊切除术常用手术之一, 其具有创伤小, 出血少, 并发症少和术后容易恢复等优点, 已经逐渐代替传统开腹手术[1,2]. 尽管腹腔镜手术已经趋势成熟, 但是很多患者会表现出特有的高度心理敏感性以及强烈的手术应激等特点, 担心出现术后综合症, 如食欲欠佳, 腹泻等[3,4]. 故对胆囊切除手术患者实施全程化, 系统化的护理服务尤为重要. 同质医疗理念是由医护人员共同组建, 共同协作开展临床医疗护理工作的团队[5]. 因此我们将基于同质医疗理念的创新护理模式应用于胆囊切除手术患者的实际护理中, 效果满意.
选择2017-04/2019-04在浙江省义乌市中心医院行腹腔镜胆囊切除患者80例为研究对象, 根据住院顺序编号输入Excel表, 采用随机数字表随机分为对照组和观察组各40例. 对照组男22例, 女18例; 年龄36-75岁, 平均55.2岁±9.4岁; 职业: 农民8例, 退休12例, 干部15例, 工人5例. 观察组男23例, 女17例; 年龄38-76岁, 平均56.4岁±9.7岁; 职业: 农民9例, 退休14例, 干部13例, 工人4例. 2组性别、年龄、职业等资料比较, 差异均无统计学意义(P>0.05), 具有可比性. 纳入标准: (1)经B超或MRI检查明确诊断为胆囊结石者, 均符合手术指征者; (2)均行腹腔镜胆囊切除术者; (3)均经过患者及家属知情同意者; (4)均经过医院伦理委员会批准同意者. 排除标准: (1)严重心肝肾疾病者; (2)有严重精神或严重神经系统疾病者; (3)合并胰腺炎或感染者; (4)传统开腹行胆囊切除术者, 或术中转为开腹者; (5)依从性差者.
1.2.1 对照组: 给予常规护理, 如健康教育、心理疏导、饮食护理、术前护理和评估、病情护理、用药护理、术中术后常规护理和生命体征监测等护理.
1.2.2 观察组: 在对照组基础上给予同质医疗理念的创新型护理实践. 具体方法如下: (1)成立同质医疗理念创新型护理小组: 分别由2-3名护理经验丰富的护士和手术操作技能娴熟的医师组成, 要求工作能力强, 责任心强, 工作细心认真负责; (2)工作任务分配: 医师提供优质的治疗方案, 护理小组成员提供规范、优质的护理服务, 将服务理念构建并维护贯穿于患者术前、术后过程中, 把握人文护理行为, 为患者提供全程的持续性护理, 并实时动态对患者的病情进行观察和反馈, 及时告知主管医师; 并建立患者入院前, 住院期间及出院后档案资料; (3)采用创新型护理流程: 以临床路径和流程再造为基础, 以持续质量改进为监控目标制定创新型护理流程: (1)应用临床路径: ①为胆囊切除患者制定个人生活护理、心理疏导、健康宣教、术前护理、术中护理及术后护理等流程, 并制定标准化临床路径表格; ②表格内容包括术前检查、心理疏导、护理方法、护理人员、护理用品、操作程序、质量标准等内容; ③护理人员按照表格内容实施护理, 并给予效果评估, 对患者存在的问题或反馈的问题及时告知负责人, 并提出整改护理措施和方法; (2)应用再造流程: ①让患者熟悉病区环境, 并简单介绍手术室环境和人员配置, 给予术前心理护理和术中操作护理等3个流程进行再造; ②术中合理分配护理人员工作任务, 要求护士责任心强, 配合手术医生动作娴熟, 反应敏捷, 以提高手术效果; ③对术中可能出现的并发症做好预见性护理, 提前准备好相关抢救设备、药物等, 并放置在合适的位置以备提高抢救效率; (3)持续质量改进方案目标监控措施: ①计划: 以护理质量及工作效率为目标, 借鉴临床路径法及流程再造法, 制定胆囊切除护理管理流程; ②实施: 参与手术的护士严格执行护理流程, 并详细记录实施过程, 术前向患者及家属讲解注意事项, 常规监测和指导饮食, 术后鼓励早期下床活动, 伤口换药及引流管的色, 量与质等, 注意休息, 尤其做好心理疏导; ③检查: 护士对术中和术后遇到的问题及时向课题负责人反馈, 并进行整改和提出新的方法; ④处理: 将整改后的问题及时反馈给护理人员, 并对流程不合理地方进行修改, 修改后再实施, 以更好的进入下一个循环护理模式.
1.2.3 观察指标: 观察2组患者在术前(T0)1 d, 气腹后(T1)10 min, 手术结束时(T2)5 min时3个时间点应激指标变化情况, 包括心率(heart rate, HR)、平均动脉压(mean arterial pressure, MAP)、血糖变化, 同时抽取静脉血检测血浆去甲肾上腺素(noradrenaline, NE)、肾上腺素(adrenaline, E)水平和皮质醇水平.
统计学处理 采用SPSS 23.0软件分析数据. 重复测量计量资料以Mean±SD表示, 采用t检验; 计数资料以百分比(%)表示, 采用χ2检验. P<0.05为差异有统计学意义.
对照组患者在T1、T2时HR, MAP, 血糖均高于T0, 但在T2时间点较T1有所下降, 仍较T0时间点水平高(P<0.05); 而观察组HR, MAP, 血糖变化趋势与对照组相同, 但各时间差异无统计学意义(P>0.05); 观察组HR, MAP, 血糖在T1、T2时间点均低于对照组(P<0.05)(表1).
与T0时间点比较, 对照组在T1、T2时间点NE, E及皮质醇浓度均上升(P<0.05); 观察组在T1时间点上升(P<0.05), 在T2时间点下降(P<0.05). 与对照组T1、T2时间点比较, 观察组患者NE, E及皮质醇浓度均降低(P<0.05)(表2).
腹腔镜胆囊切除是临床肝胆外科常用术式之一. 由于患者术前焦虑, 术中受到气腹, 麻醉药物等影响和术后出现的并发症等因素使患者在入院时, 手术前准备期及术后恢复期均存在不同程度的应激反应[6], 相应的使患者血流动力学和神经内分泌功能也发生不同程度的改变, 过度的应激将成为致病因素, 导致患者出现一系列病理状态[7,8]. 因此, 如何减少甚至避免过度应激反应需要系统化、全程化护理干预. 同质医疗服务模式, 即要求医生, 护士及家属共同参与, 让患者从入院时享受全程, 系统, 优质的同质服务, 通过围术期护理减轻手术带来的应激反应[9,10].
由于手术刺激使机体表现为生理性应激, 通过促进交感神经兴奋, 分泌儿茶酚胺增加, 表现为心率加快, 血压上升和血糖应激性升高. 本研究结果表明, 对照组患者在T1、T2时HR, MAP, 血糖均高于T0, 但在T2时间点较T1有所下降, 仍较T0时间点水平高(P<0.05); 而观察组HR、MAP和血糖变化趋势与对照组相同, 但各时间差异无统计学意义(P>0.05). 由此说明, 通过同质医疗理念创新型护理干预后, 能有效减轻患者术中应激反应, 在一定程度上与护理服务理念的构建潜意识改变了患者的心理认知, 减轻了交感神经的兴奋性和手术产生的应激反应[11,12]. 观察组HR、MAP和血糖在T1、T2时间点均低于对照组(P<0.05), 也进一步说明同质医疗理念创新型护理干预的有效性.
为进一步通过应激产生的生化指标进行客观验证, 本研究对2组患者不同时间点的血浆NE、E和皮质醇变化水平进行比较, 结果表明, 与T0时间点比较, 对照组在T1、T2时间点NE、E及皮质醇浓度均上升(P<0.05); 这可能与术前患者焦虑激活肾素-血管紧张素-醛固酮系统, 释放一些神经内分泌调节因子所致[13], 也相应使得心率、血压等升高. 而观察组在T1时间点上升(P<0.05), 在T2时间点下降(P<0.05), 这可能与激活的肾素-血管紧张素-醛固酮系统失活有关[14]. 与对照组T1、T2时间点比较, 观察组患者NE、E及皮质醇浓度均降低(P<0.05), 说明同质医疗理念创新型护理干预能有效降低应激反应指标, 可能与改善患者术前心理焦虑有关.
本研究采用同质医疗理念创新型护理的优点: (1)制定标准化临床路径: 通过程序性、简洁性、计划性等路径护理管理, 不仅减轻医护人员工作量, 还可提高手术护理效果; (2)流程再造: 以现代管理学为基础, 对工作流程进行科学性设计, 以提高工作效率及质量; (3)持续质量改进管理: 通过计划、实施、检查及处理4个步骤提高护理管理质量[15].
综上所述, 同质医疗理念的创新型护理实践能显著降低腹腔镜胆囊切除患者围术期应激反应, 有利于促进患者术后身体康复.
对腹腔镜胆囊切除手术患者实施全程化, 系统化的护理服务尤为重要. 同质医疗理念是由医护人员共同组建, 共同协作开展临床医疗护理工作的团队, 目前在国内报道较少.
拓展同质医疗理念创新型护理实践在临床中的应用开展.
观察同质医疗理念创新型护理实践对腹腔镜胆囊切除患者围术期应激反应的影响效果.
采用随机对照研究, 将研究者分为2组. 对照组给予常规护理, 如健康教育、心理疏导、饮食护理、术前护理和评估、病情护理、用药护理、术中术后常规护理和生命体征监测等护理. 观察组在对照组基础上给予同质医疗理念的创新型护理实践.
观察组HR、MAP和血糖变化趋势与对照组相同, 但各时间差异无统计学意义(P>0.05); 观察组HR、MAP和血糖在T1、T2时间点均低于对照组(P<0.05). 观察组NE、E及皮质醇浓度在T1时间点上升(P<0.05), 在T2时间点下降(P<0.05). 与对照组T1、T2时间点比较, 观察组患者NE、E及皮质醇浓度均降低(P<0.05).
同质医疗理念的创新型护理实践能显著降低腹腔镜胆囊切除患者围术期应激反应, 有利于促进患者术后身体康复.
同质医疗理念的创新型护理实践能丰富临床护理学科内容.
学科分类: 胃肠病学和肝病学
手稿来源地: 浙江省
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| 1. | Schietroma M, Colozzi S, Pessia B, Carlei F, Amicucci G. The Effects of High-Concentration Oxygen on Inflammatory Markers in Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Surg Laparosc Endosc Percutan Tech. 2017;27:83-89. [PubMed] [DOI] |
| 2. | Sharma P, Gombar S, Ahuja V, Jain A, Dalal U. Sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2017;33:496-502. [PubMed] [DOI] |
| 3. | Neil L, Patel A. Effect of Dexmedetomidine Versus Fentanyl on Haemodynamic Response to Patients Undergoing Elective Laparoscopic Surgery: A Double Blinded Randomized Controlled Study. J Clin Diagn Res. 2017;11:UC01-UC04. [PubMed] [DOI] |
| 4. | Xiang X, Yuan X, Lian Y, Fang J, Wu Y. Effect of oxycodone hydrochloride combined with flurbiprofen axetil for intravenous patient-controlled analgesia in lower abdominal patients: A randomized trial. Medicine (Baltimore). 2018;97:e9911. [PubMed] [DOI] |
| 5. | Lu P, Yang NP, Chang NT, Lai KR, Lin KB, Chan CL. Effect of socioeconomic inequalities on cholecystectomy outcomes: a 10-year population-based analysis. Int J Equity Health. 2018;17:22. [PubMed] [DOI] |
| 6. | Ye F, Wu Y, Zhou C. Effect of intravenous ketamine for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A meta-analysis. Medicine (Baltimore). 2017;96:e9147. [PubMed] [DOI] |
| 7. | Eidy M, Fazel MR, Abdolrahimzadeh H, Moravveji AR, Kochaki E, Mohammadzadeh M. Effects of pregabalin and gabapentin on postoperative pain and opioid consumption after laparoscopic cholecystectomy. Korean J Anesthesiol. 2017;70:434-438. [PubMed] [DOI] |
| 8. | Ostlie DJ, Juang OO, Iqbal CW, Sharp SW, Snyder CL, Andrews WS, Sharp RJ, Holcomb GW, St Peter SD. Single incision versus standard 4-port laparoscopic cholecystectomy: a prospective randomized trial. J Pediatr Surg. 2013;48:209-214. [PubMed] [DOI] |
| 9. | Gupta P, Saxena A, Chaudhary L. Effect of Pregabalin Premedication on the Requirement of Anesthetic and Analgesic Drugs in Laparoscopic Cholecystectomy: Randomized Comparison of Two Doses. Anesth Essays Res. 2017;11:330-333. [PubMed] [DOI] |
| 10. | İnal MA, Ural SG, Çakmak HŞ, Arslan M, Polat R. Approach to Perioperative Hypothermia by Anaesthesiology and Reanimation Specialist in Turkey: A Survey Investigation. Turk J Anaesthesiol Reanim. 2017;45:139-145. [PubMed] [DOI] |
| 11. | Yao L, Wang Y, Du B, Song J, Ji F. Comparison of Postoperative Pain and Residual Gas Between Restrictive and Liberal Fluid Therapy in Patients Undergoing Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2017;27:346-350. [PubMed] [DOI] |
| 12. | Tandon A, Shahzad K, Nunes Q, Shrotri M, Lunevicius R. Routine preoperative blood group and save testing is Unnecessary for elective laparoscopic Cholecystectomy. J Ayub Med Coll Abbottabad. 2017;29:373-377. [PubMed] |
| 13. | Zhu JG, Guo W, Han W, Zhang ZT. Laparoscopic Transcystic Common Bile Duct Exploration in the Elderly is as Effective and Safe as in Younger Patients. J Laparoendosc Adv Surg Tech A. 2017;27:48-52. [PubMed] [DOI] |
| 14. | Gerard J, Luu MB, Poirier J, Deziel DJ. Acute cholecystitis: comparing clinical outcomes with TG13 severity and intended laparoscopic versus open cholecystectomy in difficult operative cases. Surg Endosc. 2018;32:3943-3948. [PubMed] [DOI] |
| 15. | Akatsu M, Ikegami Y, Tase C, Nishikawa K. Anesthetic Management of a Patient With Antimuscle-Specific Kinase Antibody-Positive Myasthenia Gravis Undergoing an Open Cholecystectomy: A Case Report. A A Case Rep. 2017;8:150-153. [PubMed] [DOI] |