ingrijirea bolnavului cu tulburari digestive - atimures.ro · monitorizare alimentatie –ce, cat...
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Ingrijirea bolnavului cu tulburari digestive
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Rolul aparatului digestiv
Productia enzimelor digestive
Prlucrarea/digestia alimentelor
Absorbtie
Eliminarea alimentelor nedigerabile
Excretia produsilor toxici
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Bolile aparatului digestiv
Esofag
Stomac
Intestin subtire
Inestin gros/Rect
Ficat/colecist
Pancreas
Operatii
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Monitorizare
Alimentatie – ce, cat cand
Dureri abdominale – cand, caracter, durata, cedeaza
Greturi, varsaturi – cand, cat
Sonda gastrica, sonda jejunala - cat
Peristaltica – ascultatie!
Scaun – cate, cand, de ce fel
Drenuri – cat
Masurarea presiunii intraabdominale
Tonometria
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Masuraea presiunii intraabdominale (IAP)
Principiul vaselor comunicante presiunea este egala
in abdomen – masurabil oriunde
Masurabil – stomac, vezica urinara
La 2-4 ore
Normal:
– Respiratii spontane - 0 sau negativ
– Ventilatie mecanica – 7-11 cmH2O – presiune pozitiva
intrapleurala
– > 25 cmH2O (10 Hgmm) – sindrom de compartiment
abdominal
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Masurarea presiunii intraabdominale
Indicatii:
– Trauma abdominala – inchisa, penetranta
– Fractura de bazin
– Hematom retroperitoneal
– Pneumoperitoneu – perforatie organelor cavitare,
laparoscopie
– Ruptura de anevrism de aorta abdominala
– Ocluzie – mechanica, paralitica
– Pancreatita hemoragica
– Tumori abdominale
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Masurarea presiunii intraabdominale
Materiale necesare
– Tinuta sterila
– SNG/SUV
– Seringa de 60 ml
– Pensa
– Camera de presiune, prelungitor
– SF
– Punga colectoare
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Prin SUV– Montam punga pe cateter si ridicam – pe principiul vaselor
comunicante, coloana de urina se va ridica
– Presiune abdominala = coloana de urina in cmH2O
– 1 cm = 1 cmH2O 1 Hgmm = 1,36 cmH2O
– Camera de presiune – montat pe SUV
Aerisire, calibrare – ca la PVC
Prin SNG– Asemanator
Masurarea presiunii intraabdominale
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Masurarea presiunii intraabdominale
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Szindrom de compartiment abdminal
Simptome
– Meteorism
– Presiune intraabdominala (>25 cmH2O)
– Oligurie
– Hipertensiune intracraniana
– Disfunctie ventilatorie – diafragm inalt
Presiune inspiratorie mare
Hipoxie
Hipercarbie
Acidoza metabolica
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Complicatii
Modificari cardiovasculare
– ↑ CVP, PAP, PCWP, SzVR
– ↓ volum bataie
Renal
– ↓ perfuzie renala - oligurie
Aparat respirator
– ↑ presiune abdominala, diagragm inalt, presiune inspiratorie mare
– ↓ volum respirator - ↓ paO2, ↑ paCO2
SNC
– ↑ ICP, edem cerebral
Tub digestiv/ficat
– ↓ circulatia, ↓ pH – ulcer de stres, ischemie hepatica
Szindrom de compartiment abdminal
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Gastro-tonometria
Mucoasa gastrica
Determinare pH
– Determinare pCO2 mucos
– Determinare HCO3 seric
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Gastro-tonometria
Materiale:
– Tonometru cu balon (SNG)
– SF
Tehnica
– Montare SNG
– Umflare balon cu SF
– Evacuare dupa 30 minute
– Determinare pCO2 in laborator
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Montare SNG
Diagnostic si terapeutic
Evacuare stomac – activ, pasiv
Materiale necesare
– Sonda
– Ulei de parafina
– Punga colectoare
– Aspirator
– Leucoplast
– Apa, spray de lidocaina 10%
Daca pacient intubat:
+
- Laringoscop
- Pensa Magill
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Montare SNG
Tehnica Se explica bolnavulu manevra si ce trebuie sa faca
Indepartam proteza dentara
Analgezie locala cu spray de Lidocaina – nas si faringe
Aplicare ulei de parafina la capatul sondei
In pozitie sezanda, cu capul flectat se introduce sonda prin nas
pana in faringe
Se solicita bolnavului sa respire si sa inghita – in timp ce
inghite, avansam cu sonda
Se verifica pozitionarea sondei prin aspiratie
Fixare
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Montare SNG
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SNG
Indicatii:
Evacuarea stomacului – dgs., tratament
Spalaturi gastrice in intoxicatii
HDS
Varsaturi
Disfagii
Postoperator
Alimentatie enterala
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SNG
Contraindicatii
Substante corozive sau caustice
Fractura de baza de craniu (oro-gastric)
La pacient inconstient doar dupa IOT
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SNG
Complicatii Durere, discomfort
Leziuni mucoase ale cavitatii nazale, faringe, necroza
Rhinoragie
Dispnee, tuse – introducere in trahee
Esofagita de reflux
Varsaturi, regurgitare – cardie descisa
Hemoragie gastrica, esofagiana
Leziune de mucoasa gastrica
Perforatie gastrica
Iritatie vagala – bradicardie
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Spalatura gastrica
Pentru evacuarea stomacului
– Intoxicatii
– HDS
Materiale necesare – idem SNG
– Sonda (Fouché, Levin, Ewald)
– Seringa Guyon (50 ml)
– SF incalzit
– Galeata
– Carbune aktiv
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Spalatura gastrica
Montam sonda
Verificam pozitia
Aspiram
Introducem 150-200 ml SF
Aspiram
Repetam de 10-15 ori, pana se clarifica lichidul
Administram carbue activ pe SNG
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Spalatura gastrica
Complicatii
Idem complicatii SNG
Varsatura/regurgitare – aspiratie
Hipotermie – spalaturi reci
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Montarea sondei Blackmore
Uptura de varice esofagiene
Hemostaza prin cmpresiepe varice
Materiale necesare
– Idem SNG
– Sonde Blackmore/Linton/Minesota
– Seringa Guyon
– Manometru
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- Montam sonda
- Spalam stomacul
- Umflam balonul gastric cu 200-350 ml
aer
- Retragem sonda
- Umflam balonul esofagian cu 25-45
ml aer
- la12 ore verificam pentru hemoragie
- Dupa 36-72 ore evacuam aerul, prima
data din balonul esofagian, apoi din cel
gastric, aspiram secretiile si suprimam
sonda
Montarea sondei Blackmore
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Sonda Blackmore
Complicatii
Idem SNG
Ruptura esofagiana – presiune mare in balon
Necroza esofagiana – perioada prea lunga
Necroza gastrica
Obstructia cailor aeriene superioare – Sonda
prea lunga
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Punctie peritoneala=Paracenteza
Aspiratia lichidului peritoneal
Materiale necesare
– Echipament steril
– Antiseptic – betadina
– Seringi, ace, robinet cu 3 cai
– Prelungitor, punga colectoare
– Anestezic local
– Eprubete – laborator, morfopatologie
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Tehnica
Pregatim punga cu prelungitor si robinet
Asepsie, antisepsie
Anestezie locala
Punctie
Montam prelungitorul
Aspiram lichidul (ascita)
Punctie peritoneala=Paracenteza
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Complicatii
Perforatie intestinala
Perforatia colecistului
Infectie – local, general
Hemoragie
Hipotensiune – cantitate mare de ascita
Punctie peritoneala=Paracenteza
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Lavaj peritoneal
Dupa traumatism abdominal, pentru
dagnosticul leziunii de organ cavitar,
hemoperitoneu, coleperitoneu
Peritonita: puroi
Materiale necesare
– Idem paracenteza, +
– Cateter special
– Lichid de spalare (SF)
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Lavaj peritoneal
Tehnica
Sterilitate
Analgezie locala
Punctie
Montare cateter
Administrare SF in spatiul peritoneal
Evacuare lichid de spalare
Laborator
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Lavaj peritoneal
Complicatii
Idem punctie peritoneala +
Insuficienta respiratorie – prea mult lichid
perfuzat
Sechestrarea lichidului in spatiu peritoneal –
resorbtie
Hipotermia – lichid rece
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Gastroscopia
Scop:
– Diagnostic + biopsie
– Terapeutic - hemostaza
Se vizualizeaza:
– Esofg
– Stomac
– Duoden
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Gastroscopia
Materiale necesare– Endoscop
– Ulei de parafina
– Manusi
– Materiale pentru spalare
– Anestezic local
– Seringa Guyon – 50 ml
– SF
– Sistem de aspiratie
– Materiale de urgenta
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Gastroscopia
Tehnica:
Pregatirea bolnavului
– Se explica procedura
– Repaus alimentar 12 ore
– Premedicatie: sedativ (midazolam, diazepam) +
vagolitic (atropin)
Monitorizare, linie iv
Indepartarea protezei dentare
Pozitie laterala cu capul in extensie
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Gastroscopia
Tecnica
Anestezie locala
Spalatura gastrica
Piesa bucala/pipa Guedel
Lubrifierea sondei
Tehnica SNG de montare
Spalare/aspirare
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Gastroscopia
Complicatii
Nu se poate vizualiza esofagul/stomacul di cauza
hemoragiei sau secretiilor
Hemoragie – ruptura de varice esofagiene –
stabilizare HD (terapie volumica), sonda Blackmore,
interventie chirurgicala
Perforatie esofagiana
Aspiratie – intubatie, ventilatie mecanica, aspiratie,
antibiotice
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Scleroterapia varicelor esofagiene
Materiale necesare
Idem gastroscopie +
3 buc seringi 10 ml cu agent sclerozant
Tehnica
Idem gastroscopie +
Scleroterapia varicelor
Complicatii
Idem gastroscopie +
Scurgerea agentului sclerozant – necroza
Reactie alergica
Dureri retrosternale
Febra
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Clisma, tub de gaze
Evacuarea tubului digestiv inferior
– Investigare, preoperator
– Costipatie, stimularea peristalticii
Materiale necesare
– Rezervor, tubulatura
– Tub de gaze
– Pensa, ulei de parafina
– Plosca
– Manusi
– Lichid de spalare – temperatura corporala !!!
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Clisma, tub de gaze
Tehnica
Se explica bolnavului
Rezervor cu 500-1000 l
lichid de spalare
Lubrefiem sonda
Introducem in rect, cca 15 20 cm
Introducem lichidul de spalare
Masam abdomenul
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Clisma, tub de gaze
Complicatii
Nu se evacueaza – deshidratare
Iritatie vagala – bradicadie, hipotensiune –
atropina 0,5-1 mg iv
Leziune de mucoasa, hemoroizi - hemoragie
Perforatie rectala – sigmoidoscopie,
interventie chirurgicala
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Sigmoidoscopia/ colonoscopia
Examinaea rectului/intestinului gros + biopsie
Hemostaza, excizie de polipi,
Ligatura de hemoroizi
Materiale necesare
Clisma +
Endoscop
Propofol pentru sedare
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Sigmoidoscopia/ colonoscopia
Tehnica
– Pregatirea bolnavului, premedicatie
– Clism
– Linie IV, monitorizare
– Pozitie laterala
– Introdcerea endoscopului
– Aspiratie
Complicatii
– Clisma +
– Imposibilitate de vizualizare
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Alimentatie artificiala enterala
Indicatii Nu este permisa alimentatia (interventii abdominale)
Refuza alimentatia (anorexie, greva)
Nu pse poate alimenta (come, afectiuni ale cavitatii
bucale sau faringelui, traumatisme)
Lipsa de absorbtie (postoperator, fond psihic)
Tulburari de absorbtie (boli digestive)
Tulburari metabolice (hormonale)
Necesar caloric mare (stare hipercatabolica)
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Alimentatie artificiala enterala
Indicatii:
tubul digestiv este intact, dar nu se poatealimenta
– Tulburari de SNC
– AVC, embolie, TCC
– Come
– Anorexia
– TCF, afectiuni ale cavitatii bucale, faringe, esofag
– Postoperator
– Politrauma, arsuri
– Radioterapie, chimioterapie
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Alimntatie artificiala enterala
Contraindicatii
– Soc
– Ocluze mecanica
– Peritonita
– Ileus
– Ischemie mezenterica/infarct
Contraindicatii relative
– Greturi, varsaturi, diaree
– Ileus paralitic postoperator/posttraumatic
– Pancreatita acuta
– HDS (stomac, esofag)
– Diabet zaharat dezechilibrat, encefalopatie hepatica
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Alimentatie enterala
Tehnica
Prin SNG, gastrostoma
Se ridica toracele cu 30-45 grade
Substantele pot fi
– Normo- sau hiperosmolare
– Simple sau combinate
– Bolusuri de 100-300 ml la 3-4 ore
– Continuu cu nutripompa
– SNG se aspira inainte de fiecare bolus
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Alimentatie enterala
Tehnica
Sonda jejunala, jejunostoma
-in jejun
– predigerat
– normo-osmolar, simple
– La temperatura corpului
– Doar continuu cu nutripompa timp de 16 ore
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Alimentatie enterala
Dieta complet
– Hrana pasata, diluata
– + vitamine
– + minerale
– + oligoelemente
– + enzime digestive
Substante complexe (cu vitamine, oligoelemente):
– Diete polimer
– Diete monomer – aminoacizi, mono-si oligosacharide
– Diete speciale – insuficienta de organ
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Alimentatie enterala
Complicatii Iritarea mucoasei
Aspiratie traheobrnsica
– Bolnav comatos
Greturi, varsaturi, meteorism, colici
– Diete hiperosmolare
Diaree
– Edem de mucoasa, hiperosmolaritate
Complicatii metabolice
– Deshidratare
– Hiperglicemie
– Diselectrolitemii, avitaminoze
– Supraalimentatie – steatoza hepatica, disfunctie renala, diabet, productie CO2 accentuat
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Almentatie parenterala
preoperator:– casexie
– Neo esofagian, stenoza pilorica
postoperator:– pancreatita, peritonita
– sepsis
– Fistula intestinala
– Rezectie hepatica
– Laringectomie totala
posttraumatic:– politrauma, arsuri
– Leziune SNC
alte: – Sindrom de malabsorbtie
– enteropatie
– Pancreatita acuta sau cronica
– Insuficienta hepatica
– Hemorage gastro-intestinala
Indicatii:
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Alimentatie parenterala
Tehnica
CVC
Initiere lenta – 1. zi 50%
– 2. zi 75%
– 3. zi 100%
Nu se siteaza brusc → hipoglicemie
Scadere treptata paralel cu alimentatia enterala
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Ingrijirea bolnavului cu HDS
Monitorizarea functiilor vitale
1-2 linii periferice iv, CVC la nevoie
Terapie volemica, transfuzie la nevoie
Monitorizare PVC si diureza orara
Monitorizare hemoragie
Repaus la pat
SNG, lavaj gastric (SF, NaHCO3, adrenostazin,
noradrenalina)
Gastroscopie, hemostaza
Sonda Blackmore
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Ingrijirea bolnavului cu disfunctie hepatica
! Ruptura de varice esofagiene,
encefalopatie, ascita, insuficienta respiratore
Monitorizare:
– constienta, flapping tremor
– greutate
– Bilant hidric
– Paracenteza
– clisme
– Dieta
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Immunitate ↓ - sterilitate !
Escare – mobilizare
Prurit (icter)
– Spalaturi tegumentare cu apa rece
– Aplicare crema hidratanta
– Colestiramina
Psihoterapie
Ingrijirea bolnavului cu disfunctie hepatica