萬(wàn)玉梅，朱計(jì)蓮，周軍麗

(南昌大學(xué)第一附屬醫(yī)院神經(jīng)外科，南昌 330006)

常規(guī)護(hù)理措施對(duì)重型顱腦損傷患者顱內(nèi)壓的影響

萬(wàn)玉梅，朱計(jì)蓮，周軍麗

(南昌大學(xué)第一附屬醫(yī)院神經(jīng)外科，南昌 330006)

顱內(nèi)壓(intracranial pressure,ICP)增高是一種常見(jiàn)于顱腦損傷和腦血管性疾病的神經(jīng)外科臨床病理綜合征。在ICP監(jiān)測(cè)的護(hù)理中，應(yīng)確保監(jiān)護(hù)裝置正常和ICP監(jiān)測(cè)的準(zhǔn)確，隨時(shí)觀察并記錄病情和ICP數(shù)值。臨床上對(duì)于重型顱腦損傷的患者進(jìn)行的一系列常規(guī)護(hù)理措施，諸如口腔護(hù)理、氣管內(nèi)吸痰術(shù)、患者體位的改變、拍背、聽覺(jué)刺激等能使患者保持呼吸道暢通，預(yù)防患者感染、發(fā)熱和顱內(nèi)再度出血。本文總結(jié)顱腦損傷患者的相關(guān)護(hù)理技術(shù)和細(xì)節(jié)對(duì)ICP的影響。

顱內(nèi)壓監(jiān)測(cè)； 常規(guī)護(hù)理； 顱腦損傷； 顱內(nèi)壓增高

重型顱腦損傷患者的主要死因之一是傷后顱內(nèi)壓(intracranial pressure,ICP)迅速升高，引起腦血流循環(huán)障礙，最終導(dǎo)致腦疝形成而繼發(fā)腦死亡。傷后通過(guò)對(duì)ICP的監(jiān)測(cè)和腦血流量的評(píng)估是防止重型顱腦外傷患者繼發(fā)腦損害的關(guān)鍵措施[1-3]。目前，臨床上針對(duì)這類病情危重患者所進(jìn)行的一些相關(guān)護(hù)理措施可能引起患者ICP的增加，繼而導(dǎo)致更嚴(yán)重的后果。本文對(duì)口腔護(hù)理、氣管內(nèi)吸痰術(shù)、患者體位的改變和拍背、聽覺(jué)刺激等相關(guān)護(hù)理措施對(duì)ICP產(chǎn)生的影響以及對(duì)患者造成的后果作一綜述。

1 口腔護(hù)理

重型顱腦損傷的患者，特別是已行氣管插管或氣管切開的患者，口腔護(hù)理是必不可少的。近年來(lái)口腔護(hù)理措施已從疾病類型、護(hù)理頻率、持續(xù)時(shí)間上轉(zhuǎn)而更多的考慮其是否會(huì)引起患者ICP的增加。Szabo等[4]通過(guò)分析4項(xiàng)研究成果發(fā)現(xiàn)口腔護(hù)理會(huì)在一定程度上增加ICP而給患者帶來(lái)相關(guān)風(fēng)險(xiǎn)。然而，絕大多數(shù)研究[4-7]都把口腔護(hù)理作為重型顱腦損傷的常規(guī)護(hù)理，在這些研究中，口腔護(hù)理與ICP增加相關(guān)，但考慮到各項(xiàng)研究的樣本量較小，而且ICP的改變?cè)诳谇蛔o(hù)理過(guò)程中監(jiān)測(cè)較為困難，精確度有待提高，并且在整個(gè)觀測(cè)過(guò)程中還有其他因素會(huì)干擾研究結(jié)果，如不同口腔護(hù)理操作、呼吸道的管理、皮膚護(hù)理、體位等因素的影響。目前比較大樣本的臨床試驗(yàn)是由Prendergast等[5]在2009年完成的：收集了879例患者的臨床數(shù)據(jù)，發(fā)現(xiàn)口腔護(hù)理無(wú)一例患者出現(xiàn)ICP持續(xù)增加的現(xiàn)象，在操作后ICP會(huì)降到原先水平甚至更低，認(rèn)為口腔護(hù)理在臨床護(hù)理工作中可以作為一項(xiàng)常規(guī)操作。另外，在一項(xiàng)隨機(jī)對(duì)照試驗(yàn)[6]中，觀察者針對(duì)神經(jīng)外科ICU病房里的患者，比較使用手動(dòng)和電動(dòng)牙刷護(hù)理措施，并按照標(biāo)準(zhǔn)的口腔護(hù)理措施，每天2次，每次2 min進(jìn)行口腔清洗,發(fā)現(xiàn)ICP會(huì)在開始護(hù)理的操作中升高1.7 mmHg(0.226 kPa)，隨著護(hù)理結(jié)束ICP平均下降了2.1 mmHg(0.279 kPa)；2組不同的護(hù)理方式患者的ICP變化差異無(wú)統(tǒng)計(jì)學(xué)意義?；究梢哉J(rèn)為在口腔護(hù)理的過(guò)程中，患者ICP會(huì)有暫時(shí)性增加，并且ICP的短暫增加不會(huì)對(duì)患者的病情產(chǎn)生不良影響[7-8]。

2 氣管內(nèi)吸痰

氣管內(nèi)吸痰通常在已行氣管內(nèi)插管或氣管切開的患者中執(zhí)行的較多。早期研究[9-10]發(fā)現(xiàn)氣管內(nèi)吸痰會(huì)使患者的ICP平均增加2 mmHg(0.266 kPa)，隨之平均動(dòng)脈壓(mean arterial pressure，MAP)和腦灌注壓(cerebral perfusion pressure，CPP)也相應(yīng)增加，然而隨著ICP進(jìn)一步升高，MAP和CPP并未隨之出現(xiàn)進(jìn)一步改變。這表明吸痰與ICP增加沒(méi)有獨(dú)立的聯(lián)系，ICP增加可能是由于氣管刺激、咳嗽、缺氧等有關(guān)。Overend等[11-13]研究證實(shí)：在吸痰前患者可以存在短時(shí)間持續(xù)氧合過(guò)度，但要避免常規(guī)過(guò)度通氣。因此，對(duì)于氣管插管的患者，如呼吸道分泌物較多必須清理時(shí)，醫(yī)務(wù)工作者可執(zhí)行氣管內(nèi)吸痰；在給予吸痰前，建議給予患者短暫性氧合過(guò)度，但要避免過(guò)度通氣。ICP的增加與吸痰、氣道刺激和咳嗽有關(guān)，短暫的升高1～2 mmHg(0.133～0.266 kPa)，可視為安全性操作。

3 翻身與拍背

每隔2 h翻身拍背是護(hù)理重型顱腦損傷患者的常規(guī)措施。拍背，盡管沒(méi)有翻身常見(jiàn)，但在護(hù)理過(guò)程中常與翻身相結(jié)合。這些護(hù)理措施能有效地防止皮膚褥瘡、鍛煉肺功能和減少因長(zhǎng)期臥床的并發(fā)癥，但同樣會(huì)引起ICP增加。有研究[14]發(fā)現(xiàn)在給予患者翻身時(shí)，患者會(huì)出現(xiàn)暫時(shí)性的ICP增加，一般持續(xù)2～6 min。有研究[14-15]總結(jié)在翻身的1 min內(nèi)患者ICP沒(méi)有顯著性的改變(增加或者減少)，但翻身5 min后患者的ICP會(huì)下降。此外，單中心、多中心臨床試驗(yàn)及病案報(bào)道[16-19]均發(fā)現(xiàn)拍背時(shí)引起患者ICP的升高在一定范圍內(nèi)是安全的，有時(shí)拍背后患者的ICP會(huì)下降。

翻身拍背是一個(gè)非常重要的護(hù)理措施，用于防止患者出現(xiàn)褥瘡和減少長(zhǎng)期臥床所致的墜積性肺炎等危害。這些措施會(huì)在一開始引起ICP輕微增加，隨后會(huì)降到原來(lái)水平?？梢哉J(rèn)為此項(xiàng)護(hù)理措施對(duì)于重癥顱腦損傷患者ICP影響不大，屬于安全操作[11]。

4 聽覺(jué)刺激

對(duì)于神經(jīng)外科的一些重型患者，聽覺(jué)刺激對(duì)促進(jìn)和發(fā)現(xiàn)患者意識(shí)恢復(fù)有一定的幫助。臨床上，呼喊患者名字判斷其意識(shí)狀況是常規(guī)的護(hù)理措施。與此同時(shí)，護(hù)理人員會(huì)鼓勵(lì)家屬在床旁與患者交流以促進(jìn)其康復(fù)[12，20]。有研究[21-24]顯示聽覺(jué)刺激有助于神經(jīng)功能障礙患者功能的恢復(fù)。針對(duì)聽覺(jué)刺激對(duì)ICP的影響，有研究[25]報(bào)道床旁有家屬或護(hù)理人員進(jìn)行喚醒的聽覺(jué)刺激和沒(méi)有這項(xiàng)干預(yù)對(duì)ICP的改變無(wú)明顯差異。另一項(xiàng)研究[26]針對(duì)不同類型的聽覺(jué)刺激(分3組：戴耳塞、音樂(lè)刺激、病房的噪音刺激)對(duì)格拉斯哥評(píng)分(Glasgow coma scale,GCS)<9的腦外傷患者的影響，發(fā)現(xiàn)不同類型的聽覺(jué)刺激對(duì)患者ICP的改變差異統(tǒng)計(jì)學(xué)意義。聽覺(jué)刺激不會(huì)引起神經(jīng)功能損傷患者ICP的增加，被認(rèn)為是一個(gè)安全的護(hù)理措施。聽覺(jué)刺激甚至有可能降低ICP水平，特別是家屬的聲音。

5 小結(jié)

隨著現(xiàn)代化科學(xué)技術(shù)進(jìn)步，ICP監(jiān)護(hù)儀常常被用于動(dòng)態(tài)、早期監(jiān)測(cè)重型顱腦損傷患者，同時(shí)也越來(lái)越受到神經(jīng)外科醫(yī)護(hù)工作者的高度重視。ICP監(jiān)護(hù)儀的應(yīng)用，使臨床上在實(shí)施ICP監(jiān)測(cè)的同時(shí)為患者提供一系列護(hù)理措施來(lái)強(qiáng)化治療，并能早期發(fā)現(xiàn)患者ICP變化情況。臨床上的一系列常規(guī)護(hù)理措施諸如口腔護(hù)理、氣管內(nèi)吸痰術(shù)、患者體位的改變和拍背、聽覺(jué)刺激等都會(huì)在一個(gè)安全的范圍內(nèi)對(duì)患者ICP產(chǎn)生影響，而且對(duì)患者心理和生理功能的恢復(fù)和改善預(yù)后起著舉足輕重的作用。

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EffectofRoutineNursingProceduresonIntracranialPressureinPatientswithSevereCraniocerebralInjury

WANYu-mei，ZHUJi-lian，ZHOUJun-li

(DepartmentofNeurosurgery,theFirstAffiliatedHospitalofNanchangUniversity,Nanchang330006,China)

Increased intracranial pressure (ICP) is a common clinicopathological syndrome in craniocerebral injury and cerebrovascular disease.It is necessary to ensure that the monitoring device is normal and the ICP monitoring is accurate in ICP nursing care.In addition,illness condition and ICP values should be recorded at any time.A series of routine nursing measures,such as oral care,tracheal aspiration,position change,back-patting and auditory stimulation,have been used to keep airway open and to prevent infection,fever and intracranial rebleeding in patients with severe craniocerebral trauma.This paper summarizes the influences of nursing techniques and details on ICP in patients with craniocerebral injury.

intracranial pressure monitoring; conventional nursing; craniocerebral injury; increased intracranial pressure

2017-03-31

萬(wàn)玉梅(1981—)，女，本科，主管護(hù)師，主要從事神經(jīng)外科的護(hù)理研究。

R473.6

A

1009-8194(2017)09-0098-03

10.13764/j.cnki.lcsy.2017.09.038

(責(zé)任編輯：鐘榮梅)