急性肿瘤溶解综合征CRRT治疗的护理分析

急性肿瘤溶解综合征CRRT治疗的护理分析 【摘要】目的:研究CRRT治疗急性肿瘤溶解综合征的临床护理效果。方法:选取我院于2010年1月 ~2013年12月收治的34例急性肿瘤溶解综合征患者,均给予CRRT治疗,分为对照组与观察组,分别实 施常规护理与综合护理,观察两组患者的效果。结果:治疗组的总有效率高于对照组,且各项临床指标水 平改善情况优于对照组,P<0.05,。结论:给予CRRT治疗急性肿瘤溶解综合征患者实施综合护理可提高 治疗效果,改善临床症状。 【关键词】CRRT,急性肿瘤溶解综合征,综合护理 Explore the CRRT treatment of acute tumor dissolve syndrome nursing measures 【 Abstract 】 Objective:To study the CRRT treatment of acute tumor dissolved syndrome clinical nursing effect. Methods: Selection our hospital in January 2010 to December 2013 were 34 cases of acute tumor dissolved syndrome patients, all give CRRT treatment, were divided into control group and observation group, implement routine nursing and comprehensive nursing care, respectively to observe the effect of two groups of patients. Results: The total effective rate in treatment group than the control group, and the clinical indexes level improvement is better than that of control group (P < 0.05). Conclusion:Give CRRT treatment in patients with acute tumor dissolved syndrome implement comprehensive nursing can improve the effect of treatment, improve the clinical symptoms. 【 key words 】 CRRT. Acute tumor dissolved syndrome; Comprehensive nursing care 前言 在接受治疗过程中，肿瘤患易发生急性肿瘤溶解综合征(ATLs)情况主要体现在肿瘤负荷 较大和细胞增殖迅速较快情况下，同时若患者对化疗药物敏感性非常强也会引发，因此ATLs 的发生对治疗效果产生一定的影响。临床研究证实采用CRRT治疗ATLs的效果较为显著，但需 要得到正确的护理配合才能发挥更大效果，本文针对上诉问进行了研究，选取了34例均采 用CRRT治疗的ATLs患者，其中17例采用综合护理，并与采用常规护理的患者进行对比分析， 现如下。 1资料与方法 1.1临床资料 选取我院于2010年1月~2013年12月收治的34例急性肿瘤溶解综合征患者，均给予CRRT 治疗，将其随机分为两组，对照组17例，男10，女7例，年龄11~60岁，平均年龄(28.4 ?10.6)岁;观察组17例，男9，女8例，年龄12~60岁，平均年龄(29.5?10.9)岁。 两组患者一般资料对比无显著性差异(P>0.05)，可进行组间比较。 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 1.2护理方法 对照组采用常规护理方法，在患者住院后按照常规方法进行护理。观察组在对照组基础上实施综合护理，即 1.2.1血流动力学监测 ATLs患者在接受CRRT治疗中需进行血液体外循环，此时患者的机体的电解质、酸碱紊乱现象很容易导致心律失常而至血流动力学不稳定，因此需要密切观察血流动力学以及各项临 [1]床体征变化。同时护理人员应当掌握ATLs的基本标准，若与治疗前相比血钙浓度降低25% [2]或者血尿酸、血钾、血磷、尿素氦较增高25,，则应及时医师进行处理。 1.2.2心理护理 待患者得知病情后会出现焦虑、恐惧等负面心理，护理人员应当增加与患者及其家属之间的沟通，重点讲解治疗方法和治疗后的效果，缓解患者不良心理反应，树立战胜疾病的自信，积极接受治疗。 1.2.3管道护理 采用CRRT治疗的关键要素是保证输入及回输通畅，避免管道受压、脱落或断开，同时也 [3]需要嘱咐患者尽量避免剧烈咳嗽、改变体位、异常烦躁。因深静脉置管内口紧贴血管壁而导致输入压力负值升高，则需整患者的体位，适当镇静。 1.2.4预防并发症 ATLs患者的机体抵抗能力通常会有所降低，又因肿瘤溶解过多导致机体无法承受而出现肾脏衰竭情况，因此需加强对这方面的重视。 1.2.5体温过低 置换液流量控制在2000—3000ml/h，而热量丢失较多则会相应的降患者接受CRRT治疗的 [4]低体温。护理人员应当密切观察患者体温变化，特别是下降幅度，观察末梢循环，是否发生畏寒、寒战情况。 1.3观察指标 观察血流动力学指标，如血尿酸、血肌酐、血钾、血磷、血钙、尿素氮;临床指标:四肢水肿、腹水。 1.4疗效评价标准 [5]根据肿瘤评价标准，通过CRRT与相应的护理方法治疗后，显效:四肢水肿及腹水彻底消退，各项临床指标均恢复正常;有效:四肢水肿及腹水彻底基本缓解，部分临床指标恢复正常;无效:四肢水肿、腹水变化以及各项临床指标不明显或无变化。 1.5统计学处理 本次所有研究资料均采用SPSS18.0统计学软件处理，计量资料采用均数加减标准差表示 2(?s)，计数资料采用t检验，组间对比采用X检验，P,0.05为差异具有显著性，具有x 统计学意义。 2 结果 2.1 两组患者临床治疗效果对比分析 观察组总有效率为88.2%;对照组总有效率为64.7%，两组患者效果对比有统计学意义(P<0.05)，如表1所示: 表1 两组患者临床治疗效果对比分析(n/%) 组别 n 显效 有效 无效 总有效率(%) 观察组 17 8(47.1) 7(41.2) 2(11.8) 88.2 对照组 17 4(23.5) 7(41.2) 6(35.3) 64.7 P值 <0.05 application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check Table 1 Two groups of patients with clinical effect contrast analysis(n/%) group n excellent effective invalid total effective rate(%) observation group 17 8(47.1) 7(41.2) 2(11.8) 88.2 control group 17 4(23.5) 7(41.2) 6(35.3) 64.7 P values <0.05 2.2 两组患者治疗前后各观察指标改变对比 两组患者在治疗前血尿酸、血肌酐、血钾、血磷、血钙、尿素氮、四肢水肿、腹水情况对比不具有统计学意义(P>0.05)，观察组患者治疗前后各指标改善对比有显著差异性，有统计学意义(P,0.01);对照组患者治疗前后各指标改善对比有显著差异性，有统计学意义(P,0.01);两组患者治疗后对比有显著差异性，有统计学意义(P,0.05)，观察组优于对照组，如表2所示: 表2 两组患者治疗前后各观察指标改变对比(?s) x 指标 对照组 观察组 治疗前 治疗后 治疗前 治疗后 血钾(mmol/L) 6.14?1.21 5.2?0.84 6.09?1.20 4.1?0.75 血钙(mmol/L) 1.23?0.24 2.01?0.55 1.26?0.26 2.22?0.60 血磷(mmol/L) 4.13?0.66 1.58?0.41 4.16?0.68 1.43?0.32 血尿酸(μmol/L) 620?55 410?35 615?51 384?24 尿素氮(mmol/L) 8.66?2.3 6.25?1.9 9.64?2.4 5.12?1.1 血肌酐(μmol/L) 131.41?10.25 115.51?5.6 131.23?10.64 96.52?5.8 四肢水肿 1.29?0.33 0.62?0.20 1.33?0.31 0.41?0.17 腹水 1.20?0.32 0.72?0.18 1.24?0.31 0.49?0.12 Table 2 Two groups of patients and the observation index change compared before and after the treatment(?s) x index control group observation group before treatment after treatment before treatment after treatment potassium(mmol/L) 6.14?1.21 5.2?0.84 6.09?1.20 4.1?0.75 blood calcium(mmol/L) 1.23?0.24 2.01?0.55 1.26?0.26 2.22?0.60 blood phosphorus(mmol/L) 4.13?0.66 1.58?0.41 4.16?0.68 1.43?0.32 blood uric acid(μmol/L) 620?55 410?35 615?51 384?24 urea nitrogen(mmol/L) 8.66?2.3 6.25?1.9 9.64?2.4 5.12?1.1 serum creatinine(μmol/L) 131.41?10.25 115.51?5.6 131.23?10.64 96.52?5.8 limb edema 1.29?0.33 0.62?0.20 1.33?0.31 0.41?0.17 ascites 1.20?0.32 0.72?0.18 1.24?0.31 0.49?0.12 3讨论 ATIs属于一种肿瘤急症，是因患者在化疗后部分肿瘤细胞被分解，在细胞内物质释放后 [6]导致体内平衡系统紊乱，进而造成代谢异常和电解质失衡。临床表现主要包括代谢性酸中毒、高钾血症、低钙血症和高磷血症，严重时会导致肾功能衰竭。临床治疗ATIs主要以CRRT为主，其可促进血液代谢废物排出体外，恢复体内平衡系统，但需要针对性的护理才能确保[7]治疗效果。综合护理可以在充分了解患者整体状况的基础上为患者的健康问题确立正确的护理诊断及制定相应措施，可有效提升临床治疗质量。同时护士对患者的病情变化掌握得更加清楚，能够为患者和家属及时提供需求和指导，掌握潜在的危险因素，从而完善治疗，application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 抓住护理要点，进行针对性的护理服务。 [8]根据相黄春丽报道，ATIs患者在手术前后进行综合护理干预，可显著提高患者的治疗 [4]效果，降低各种并发症情况，改善临床指标，提高护理质量，其有效率达到100.0%。本次 研究结果表明，观察组总有效率88.2%高于对照组64.7%，且血尿酸、血肌酐、血钾、血磷、 血钙、尿素氮、四肢水肿、腹水改善情况优于对照组，差异对比具有统计学意义(P<0.05)。 这说明针对ATIs患者采用综合护理模式可有效提高治疗效果，改善临床各项指标，提高患者 满意度，值得临床推广应用。然而本次研究的总有效率88.2%低于上述研究100.0%，这可能 与护理人员的技术水平或研究人数有关，应当针对这一情况继续增加研究对象，总结并分析 研究数据，不断完善护理人员的专业技术水平，为临床治疗提供更加准确的参考依据。 【参考文献】 [1]黄爽,杨菁,张蕊等.儿童成熟B细胞淋巴瘤并发急性肿瘤溶解综合征18例临床分析[J].中 华儿科杂志,2011,49(8):622-625. 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Journal of modern medicine and health care, 2012, 28 (1) : 120-121. application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check [8] Huang Chunli Huang Miaohuan, Sun Zhongwen etc. CRRT treatment of acute tumor dissolve syndrome [J]. Journal of nursing Chinese journal of practical nursing, 2011, 27 (z2) : 41 and 42. application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check