Key words: tracheotomy; Method of dressing change; New progress
Patients with severe craniocerebral injury are easy to block the respiratory tract due to disturbance of consciousness, falling back of tongue, normal cough and swallowing reflex weakening or disappearing. In order to keep the respiratory tract unobstructed and relieve the symptoms of cerebral hypoxia and brain edema, tracheotomy is often needed in clinic. After tracheotomy, the respiratory pathway changed, which brought a series of new problems [1]. The quality of incision nursing directly affects whether there is infection or inflammation in the airway [2]. Therefore, strengthening the nursing care of tracheotomy patients' incision plays an important role in preventing postoperative subcutaneous emphysema, incision infection and lower respiratory tract infection. In the long-term nursing work, a set of economical and applicable tracheotomy dressing change methods was summarized, which significantly reduced the incidence of subcutaneous emphysema, incision infection and lung infection, shortened the number of dressing changes and tube piercing time, reduced the workload of doctors and nurses, and reduced the economic burden of patients and their families, and achieved good economic and social effects. This method is now reported as follows.
1. Clinical data
1. 1 General information:
Select 20 1 1 to 20 12 patients with severe craniocerebral injury complicated with tracheotomy 100, including 54 males and 46 females, with an average age of 45 years. Glasgow coma scale ≤8. There is no significant difference in age, sex, course of disease and etiology.
1.2 improve the method of dressing change before and after;
(1) After the previous tracheotomy, in order to prevent air leakage and secretion overflow around the incision, 4cm-9 cm 1-2 vaseline gauze strips were often used to block around the incision, and then the commonly used gauze pieces were cut into an E-shape, centered on the intubation, placed at the incision below the tracheal catheter and above the catheter in the opposite direction, and then fixed with adhesive tape. (2) The improved dressing change method is to fill the incision with vaseline gauze within one day after operation, take it out one day later, soak it in the mixed solution of 80,000 units of gentamicin and 0.9% normal saline with two strips of 4cm-9cm dry gauze, take it out after soaking, and routinely disinfect the incision according to the principle of aseptic operation. Then, the manufactured gentamicin gauze strip is folded in half with a long shaft and wrapped around the coat. After the upper surface is folded in half with gauze twice, a hole with the same size as the outer opening of the tracheal cannula is cut at the folding angle, and the hole passes through the outer opening of the tracheal cannula to cover the tracheal catheter. In order to prevent the sputum from polluting the dressing and water droplets from dripping on the dressing during atomization inhalation, a film slightly larger than gauze piece was made on the catheter with disposable film gloves to protect the neck incision and catheter.
2. Results: See the attached table.
Table 2 Comparison table of dressing change methods.
1.3 discussion
(1) When vaseline gauze was used to change the dressing at the incision of tracheotomy, the gauze continuously blocked the periphery of the incision, with high density and poor air permeability. When the patient turns over or inhales aerosol to cause irritating cough, the airflow will be blocked, so the gas will spread from the incision to the surrounding loose tissue, thus forming or aggravating subcutaneous emphysema. Gentamicin gauze strip has good air permeability, low density and certain humidity. Compared with vaseline gauze, it can not only reduce secretion overflow, but also evenly disperse the impact of airflow and reduce the chance of subcutaneous emphysema. (2) The poor permeability of vaseline gauze leads to poor drainage around the incision. Especially in the early stage of tracheotomy, a large amount of secretions gathered around the incision, which created conditions for the growth of bacteria. If the dressing is not cleaned in time, it is easy to cause incision infection. Clinical data show that most of tracheotomy incision infections are Klebsiella pneumoniae and Pseudomonas aeruginosa, and gentamicin is effective against gram-negative bacilli and Staphylococcus aureus, especially Pseudomonas aeruginosa [3]. The application of gentamicin gauze can effectively avoid the occurrence of incision infection, which is worthy of clinical application. (3) The E-shaped gauze piece is used to replace the dressing on and under the catheter. In the process of atomizing inhalation and sputum pollution, the adhesive tape used to fix gauze is easy to loosen, which leads to the dressing on it shifting or even completely leaving the catheter without adhesive tape. If the dressing is not changed again in time, the degree of incision pollution will be aggravated, thus causing incision infection. In the improved dressing change method, the center hole of the gauze piece on it passes through the tracheal catheter, and even if the adhesive tape is slightly loose, the gauze piece is not easy to leave the catheter, thus better protecting the incision and catheter. (4) The top film can prevent sputum pollution and water droplets from dripping on the dressing during atomization inhalation, thus protecting the dressing below. Transparent film can visually observe the wetting and pollution of the underlying dressing, so as to judge whether to replace the dressing. When sputum pollutes the adhesive plaster, only the adhesive plaster needs to be replaced, and the underlying dressing is clean and dry under the protection of the adhesive plaster without replacement, thus reducing the number of dressing changes, reducing the workload of nurses and the economic burden of patients and their families. (5) The amount of bacterial inoculation and the body's defense ability are the decisive factors for the occurrence of pulmonary infection, and the main reason for pulmonary infection is that the pollutants on the gauze pad are inhaled into the lungs. According to literature report [4], pulmonary infection is one of the most common diseases of hospital-acquired infection, accounting for 23.30% ~ 42.03% of hospital infection. The improved dressing change method ensures the cleanliness and relative sterility around the incision, reduces the growth of bacteria and greatly reduces the probability of lung infection. Thereby obviously shortening the average time of indwelling catheter for patients.
1.4 summary
Tracheotomy is an important and necessary means to treat severe craniocerebral injury and relieve airway obstruction, but it is followed by a series of problems. Therefore, nurses should do comprehensive nursing to prevent postoperative complications, and incision dressing change plays a key role. Compared with the traditional method, the improved dressing change method shows its superiority in many aspects. In the future work, we will constantly sum up experience and lessons and explore better methods of dressing change through incision.
refer to
1. Ge,, Lu Ying. Nursing experience of tracheotomy. China Practical Medicine [J], 2008,23 (3):168.
2. Yang Xining, Wei. Influence of two different nursing methods on tracheotomy wound infection [J]. Modern Clinical Nursing, 2008,7 (8): 27-28.
3. Chen Zhongying, Liu Tianpei, Yu Yang. Handbook of Clinical Drugs [M], 3rd Edition. Shanghai: Science and Technology Press, 1998, 167.
4. Wu Minsheng, Zhao and Chen Qiang. Analysis of pathogens and drug resistance of lower respiratory tract infection in patients with invasive mechanical ventilation in ICU [J]. Journal of Guangxi Medical University, 2007,24 (6): 877-879.
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