腰椎間盤髓核摘除術(shù)臨床護(hù)理路徑應(yīng)用研究

任　哲, 武艷瑾, 樊新園, 杜　嬌, 劉　英

(首都醫(yī)科大學(xué)附屬北京世紀(jì)壇醫(yī)院, 1. 脊柱外科, 2. 臨床藥物基地, 北京, 100038)

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腰椎間盤髓核摘除術(shù)臨床護(hù)理路徑應(yīng)用研究

任哲1, 武艷瑾1, 樊新園1, 杜嬌1, 劉英2

(首都醫(yī)科大學(xué)附屬北京世紀(jì)壇醫(yī)院, 1. 脊柱外科, 2. 臨床藥物基地, 北京, 100038)

目的探討腰椎間盤髓核摘除術(shù)相關(guān)護(hù)理路徑的應(yīng)用效果。方法通過(guò)分析138例腰椎間盤突出癥患者的臨床資料，隨機(jī)分為觀察組和對(duì)照組各69例，對(duì)照組患者給予常規(guī)護(hù)理，觀察組患者給予臨床護(hù)理路徑護(hù)理，護(hù)理結(jié)束觀察2組臨床護(hù)理療效。結(jié)果護(hù)理結(jié)束觀察組患者臨床有效率為92.75%, 對(duì)照組臨床有效率為79.71%, 比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05); 觀察組患者對(duì)臨床護(hù)理滿意65例(94.20%), 對(duì)照組滿意56例(81.16%), 比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05); 觀察組臨床住院時(shí)間、住院費(fèi)用顯著低于對(duì)照組，比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05); 觀察組有2例患者出現(xiàn)并發(fā)癥，發(fā)生率為2.90%, 復(fù)發(fā)率為0, 對(duì)照組出現(xiàn)并發(fā)癥患者有9例占比13.04%, 復(fù)發(fā)率為4.35%, 比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。結(jié)論臨床護(hù)理路徑用于腰椎間盤髓核摘除術(shù)患者臨床護(hù)理中可有效減輕患者疼痛、有效降低術(shù)后并發(fā)癥發(fā)生率，并加速患者恢復(fù)，臨床值得推廣。

腰椎間盤髓核摘除術(shù); 護(hù)理路徑; 臨床療效

腰椎間盤突出癥是指因腰椎間盤發(fā)生病變后在外力作用下導(dǎo)致椎間盤中的纖維環(huán)破裂，髓核組織可在破裂處脫出于椎管內(nèi)或后方[1-2]。腰椎間盤病發(fā)因素包括：長(zhǎng)期外力導(dǎo)致的損傷、遺傳因素、腰姿不正、突然重負(fù)、受寒、受潮等，患者患病后多表現(xiàn)為腰痛、馬尾神經(jīng)癥狀、下肢放射性疼痛[3-4]。腰椎間盤髓核摘除術(shù)時(shí)臨床治療腰椎間盤突出癥的治療方法之一，通過(guò)手術(shù)將受損突出的髓核摘除有效患者疼痛，術(shù)后給予患者一定的護(hù)理干預(yù)可有效提高臨床療效[5-6], 為探討有效的臨床護(hù)理方案，本研究分析了臨床護(hù)理路徑同傳統(tǒng)護(hù)理兩種護(hù)理方案的臨床療效，現(xiàn)報(bào)告如下。

1　資料與方法

1.1一般資料

2014年1月—2015年1月到醫(yī)院診治的腰椎間盤突出癥患者138例，年齡45～75歲，將其隨機(jī)分為觀察組和對(duì)照組各69例。觀察組男39例，女30例，年齡45～75歲，平均(53.63±6.21)歲；對(duì)照組男37例，女32例，年齡45～74歲，平均(54.39±5.35)歲。納入標(biāo)準(zhǔn)：全部患者經(jīng)CT檢查或X線平片檢查確診為腰椎間盤突出癥且均行髓核摘除術(shù)治療。排除嚴(yán)重肝腎、心肺疾病患者以及糖尿病、尿失禁患者。所有患者簽署知情同意書。2組患者的性別、年齡等臨床資料組間無(wú)顯著性差異(P>0.05)，具有可比性。

1.2方法

2組患者術(shù)后均給予基礎(chǔ)護(hù)理，對(duì)照組單純給予常規(guī)護(hù)理，觀察組采取臨床護(hù)理路徑表進(jìn)行護(hù)理。

1.2.1入院時(shí): ① 了解患者病情：接待患者入院后護(hù)理人員即對(duì)病患基本信息、病情、臨床癥狀、生命體征、常規(guī)化驗(yàn)進(jìn)行評(píng)估或檢測(cè)，檢測(cè)評(píng)估項(xiàng)目主要包括脈搏、護(hù)理、血壓、血糖、血常規(guī)、輸血前檢測(cè)、凝血功能、肝腎功能、傳染病史，X片、CT檢查、心電圖等。②確定護(hù)理方案：護(hù)理方案中術(shù)前護(hù)理主要包括飲食、活動(dòng)、排泄等方面，根據(jù)患者病史、病情、臨床指征制定針對(duì)性護(hù)理方案。

1.2.2住院1 d至術(shù)前：指導(dǎo)患者戒煙，細(xì)心講解麻醉方法和手術(shù)方法及手術(shù)風(fēng)險(xiǎn)，術(shù)前指導(dǎo)患者12 h禁食、4 h禁水并進(jìn)行藥物過(guò)敏試驗(yàn)，告知患者手術(shù)時(shí)間并在術(shù)前安排患者排空糞便，同時(shí)囑咐患者術(shù)前護(hù)理好個(gè)人衛(wèi)生，注意活動(dòng)、鍛煉方法，避免術(shù)前腰部在受損。為避免患者術(shù)后發(fā)生感染給予一定的抗菌藥物預(yù)防感染。

1.2.3手術(shù)日：手術(shù)當(dāng)日囑托患者及家屬保管好個(gè)人物品，安撫患者術(shù)前焦慮緊張情緒，準(zhǔn)備吸氧、吸痰設(shè)備及手術(shù)用具。

1.2.4術(shù)后: ① 術(shù)后觀察：術(shù)后觀察患者引流管性質(zhì)、切口引流量和生命體征指標(biāo)變化、鎮(zhèn)痛泵效果以及并發(fā)癥發(fā)生情況；小便失禁患者留置尿管處理。② 生活護(hù)理：對(duì)患者飲食、活動(dòng)、心理等方面進(jìn)行護(hù)理，術(shù)畢后絕對(duì)臥床12 h, 1周內(nèi)盡量臥床靜養(yǎng)；飲食上術(shù)后6 h內(nèi)禁食禁水之后給予半流質(zhì)軟食，避免食用高糖量食物，術(shù)后5 d飲食可適當(dāng)給予一定的高蛋白、高熱量、纖維素豐富的食物，食物以易消化、營(yíng)養(yǎng)豐富為主要標(biāo)準(zhǔn)。③ 恢復(fù)訓(xùn)練：術(shù)后初期指導(dǎo)進(jìn)行一定的軸線翻身訓(xùn)練以防并發(fā)癥發(fā)生，術(shù)后1周進(jìn)行腰背、腹肌功能訓(xùn)練，訓(xùn)練強(qiáng)度根據(jù)患者個(gè)人情況制定，根據(jù)患者恢復(fù)速度加強(qiáng)訓(xùn)練強(qiáng)度，訓(xùn)練中使用護(hù)腰帶分別進(jìn)行抬腿、踢腿、擴(kuò)胸等訓(xùn)練，患者可下床后每日起床后進(jìn)行站立、坐下、行走正確姿勢(shì)訓(xùn)練。④ 出院指導(dǎo)：出院前對(duì)同患者講解護(hù)腰帶使用方法和期限，盡量避免腰部負(fù)重，功能加強(qiáng)訓(xùn)練持續(xù)進(jìn)行，床鋪應(yīng)為應(yīng)硬板床，醫(yī)院記錄患者聯(lián)系方式以便隨訪工作進(jìn)行。全部患者隨訪1年統(tǒng)計(jì)復(fù)發(fā)率和并發(fā)癥發(fā)生率。

2　結(jié)　果

2.12組患者臨床療效比較

2組患者護(hù)理后臨床療效顯示觀察組患者臨床療效顯著優(yōu)于對(duì)照組，比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05), 見(jiàn)表1。

表1　2組患者臨床療效比較[n(%)]

與對(duì)照組比較, *P<0.05。

2.22組患者臨床滿意度比較

2組患者對(duì)護(hù)理的滿意程度，觀察組患者滿意度顯著高于對(duì)照組，比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05), 見(jiàn)表2。

表2　2組患者滿意率比較[n(%)]

與對(duì)照組比較, *P<0.05。

2.32組患者住院指標(biāo)比較

2組患者住院時(shí)間、住院費(fèi)用顯示，觀察組顯著低于對(duì)照組，比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，見(jiàn)表3。

表3　2組患者住院指標(biāo)比較±s)

與對(duì)照組比較, *P<0.05。

2.42組患者術(shù)后并發(fā)癥發(fā)生率及復(fù)發(fā)率比較

觀察組患者出現(xiàn)1例便秘，1例肺部感染，對(duì)照組患者出現(xiàn)便秘3例，發(fā)生肺部感染5例，神經(jīng)水腫1例；觀察組患者術(shù)后無(wú)復(fù)發(fā)患者，對(duì)照組3例患者術(shù)后復(fù)發(fā)，比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。

3　討　論

腰椎間盤突出癥是臨床常見(jiàn)疾病之一，隨著年齡的增長(zhǎng)、腰椎部位長(zhǎng)期磨損導(dǎo)致人體腰椎間盤髓核或纖維環(huán)等部位發(fā)生退行性變化，腰部長(zhǎng)期負(fù)重后即會(huì)引發(fā)腰椎間盤突出或脫出，脫出的椎間盤會(huì)壓迫到鄰近脊神經(jīng)根導(dǎo)致患者出現(xiàn)腰部疼痛、下肢麻木等臨床癥狀[7-9]。臨床患者多采用手術(shù)方式進(jìn)行治療，髓核摘除術(shù)在臨床治療中應(yīng)用廣泛，患者術(shù)后傷口恢復(fù)期間需對(duì)其進(jìn)行臨床護(hù)理工作，臨床護(hù)理路徑是臨床以患者患病類型及治療方法為參照，在治療過(guò)程中對(duì)進(jìn)行全程護(hù)理，該護(hù)理方法在臨床中應(yīng)用較廣泛[10-12]，本研究針對(duì)該方法用于腰椎間盤突出癥患者髓核摘除術(shù)后護(hù)理臨床療效進(jìn)行了分析，為臨床護(hù)理提供依據(jù)。

研究中給予觀察組患者臨床護(hù)理路徑，對(duì)照組患者則給予基礎(chǔ)護(hù)理，護(hù)理結(jié)束后對(duì)患者護(hù)理臨床療效進(jìn)行統(tǒng)計(jì)顯示觀察組患者臨床有效率顯著高于對(duì)照組。臨床護(hù)理路徑在患者入院其即開始對(duì)患者進(jìn)行護(hù)理，護(hù)理工作貫穿患者整個(gè)治療過(guò)程，避免了基礎(chǔ)護(hù)理對(duì)患者部分護(hù)理方面的疏漏，整個(gè)護(hù)理流程無(wú)間斷有效加強(qiáng)臨床療效。統(tǒng)計(jì)兩組患者滿意度情況亦顯示觀察組患者臨床滿意率顯著較高，患者術(shù)后身體上創(chuàng)傷較大，此時(shí)臥床不可活動(dòng)難免導(dǎo)致焦慮心理，因此加強(qiáng)術(shù)后飲食、活動(dòng)、心理等方面護(hù)理可有效改善患者心理，完整的臨床護(hù)理路徑對(duì)患者而言不僅可有效提高術(shù)后床創(chuàng)傷恢復(fù)，還能使患者有被呵護(hù)感，因此加強(qiáng)臨床護(hù)理路徑完整護(hù)理工作可有效提高臨床患者滿意度[13]。

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Application of clinical nursing pathway for lumbar discectomy patients

REN Zhe1, WU Yanjin1, FAN Xinyuan1, DU Jiao1, LIU Ying2

(1. Department of Spine Surgery; 2. Clinical Drugs Base, Beijing Shijitan Hospital AffiliatedofCapitalMedicalUniversity,Beijing, 100038)

ObjectiveTo investigate effect of nursing pathway for patients with lumbar discectomy. MethodsA total of 138 patients with lumbar disc herniation treated in our hospital were randomly divided into control group treated with routine care and observation group given clinical nursing pathway, clinical nursing efficacy of two groups was compared. ResultsThe clinical nursing efficacy was 92.75%, and was 79.71% in the control group, and there was statistically significant difference(P<0.05). A total of 65 patients(94.20%)in the observation group and 56 cases(81.16%)in the control group were satisfied with nursing, and there was statistically significant difference(P<0.05). Clinical hospital stay and hospital costs in the observation group were significantly lower than the control group, the difference was statistically significant (P<0.05). There were two patients(2.90%) in the observation group with complications and there were no patients with recurrence. There were 9 cases(13.04%) in the control group with complications, and its recurrence rate was 4.35%. The incidence of postoperative complications and recurrence of two groups were statistically significant difference (P<0.05). ConclusionThe clinical nursing pathway for lumbar discectomy patients can effectively reduce pain, reduce the incidence of postoperative complications and accelerate patients′ recovery, so it is worthy of promotion.

lumbar discectomy; nursing pathway; clinical efficacy

2016-05-15

R 473.6

A

1672-2353(2016)20-064-03DOI: 10.7619/jcmp.201620020