付利紅 付 莉
不同體位護(hù)理對(duì)下肢動(dòng)脈硬化閉塞患者患肢氧分壓、疼痛和舒適度的影響
付利紅 付 莉
目的:探討平臥位、坐位、下肢下垂和下肢抬高4種體位護(hù)理對(duì)下肢動(dòng)脈硬化閉塞患者患肢氧分壓、疼痛和舒適度的影響。方法:選取2015年6月~2016年12月本院收治的60例下肢動(dòng)脈硬化閉塞患者,比較患者在不同體位時(shí)患肢的氧分壓、疼痛及舒適度評(píng)分。結(jié)果:下肢抬高體位的氧分壓最低。與平臥位和下肢抬高體位相比,下肢下垂和坐位體位的氧分壓均明顯較高,而疼痛評(píng)分均明顯較低;在4種體位中,下肢下垂體位的舒適度評(píng)分最低,即下肢下垂體位的舒適度最高;患肢氧分壓與疼痛評(píng)分呈明顯的負(fù)相關(guān)。結(jié)論:在下肢動(dòng)脈硬化閉塞患者的4種體位中,下肢下垂體位可更有效改善患肢的微循環(huán),從而明顯提高氧分壓、增加舒適度及減輕疼痛。
動(dòng)脈硬化閉塞;下肢下垂體位;微循環(huán);氧分壓;舒適度;疼痛
下肢動(dòng)脈硬化閉塞是由于下肢動(dòng)脈粥樣硬化斑塊形成,造成血管狹窄、閉塞,進(jìn)而導(dǎo)致肢體缺血、缺氧,通常患者足部易發(fā)生缺血性靜息痛,甚至潰瘍或壞疽,嚴(yán)重影響其日常生活[1]。該病常見于中老年人,其發(fā)病率呈逐年上升趨勢(shì)。目前,國(guó)內(nèi)通常根據(jù)下肢動(dòng)脈硬化閉塞患者的意愿更換體位。相關(guān)資料顯示[2],患者的患肢自然下垂可改善靜息痛的癥狀。但是尚未明確下肢下垂體位與患肢微循環(huán)的關(guān)系?;颊呶⒀h(huán)異??梢鹁植拷M織缺血缺氧,所以可通過(guò)改善微循環(huán)的灌注量以增加舒適度及促進(jìn)潰瘍的愈合。亦有相關(guān)研究表明[3],經(jīng)皮氧分壓可反映局部組織微循環(huán)的變化。本研究旨在探討不同體位對(duì)患肢氧分壓、疼痛和舒適度影響?,F(xiàn)報(bào)道如下。
1.1 一般資料 選取2015年6月~2016年12月本院收治的60例下肢動(dòng)脈硬化閉塞患者,納入標(biāo)準(zhǔn):(1)確診為下肢動(dòng)脈硬化閉塞。(2)年齡≥18歲。(3)踝肱指數(shù)(Ankle brachial index,ABI)<0.9。排除標(biāo)準(zhǔn):(1)不愿配合研究者。(2)糖尿病、貧血、自身免疫性疾病、肺部疾病者。(3)足部活動(dòng)受限者。(4)近期內(nèi)使用過(guò)β受體阻滯劑者。其中男44例,女16例。年齡60~88歲,平均(75.81±7.62)歲。病程l~26個(gè)月,平均(11.52±5.88)個(gè)月。單側(cè)閉塞者43例,雙側(cè)閉塞者17例。伴有靜息痛者16例,壞疽或潰瘍者27例,其余17例。Fontaine分期Ⅱa期8例,Ⅱb期13例,Ⅲ期13例,Ⅳ期26例。此外,本研究的患者及家屬均已簽署知情同意書。
1.2 方法
1.2.1 測(cè)量 所有患者入院后第1天,保持情緒穩(wěn)定,平臥休息30 min后,采用PeriFlux5000激光多普勒儀測(cè)量患肢足背氧分壓。檢查部位為足背部第1和第2足趾之間上2 cm處,祛除污垢,貼上固定環(huán)和不干膠,放置探頭,記錄穩(wěn)定時(shí)的氧分壓數(shù)值。測(cè)量平臥位的氧分壓值后,隨機(jī)數(shù)字表法選擇測(cè)量其余體位。每種體位持續(xù)至氧分壓值穩(wěn)定,時(shí)間約10 min,每種體位間隔5 min。所有患者均完成1個(gè)循環(huán)。
1.2.2 體位 (1)坐位。坐于床上,雙腿伸直。(2)平臥位。仰臥于床上,雙腿伸直。(3)下肢抬高位。仰臥于床上,雙腿伸直,利用抬高墊將患肢抬高約30°。(4)下肢下垂位。坐于床旁,雙腿下垂。
1.3 觀察項(xiàng)目 (1)以平臥位的氧分壓值為基礎(chǔ)值,氧分壓改變程度=(各體位氧分壓-平臥位氧分壓)/平臥位氧分壓。(2)無(wú)疼痛者,則采用0~10級(jí)線性視覺模擬評(píng)分法[4]評(píng)估舒適度,評(píng)分越低,舒適度越高;伴疼痛者,采用VAS疼痛量表評(píng)估各體位的疼痛程度。
1.4 統(tǒng)計(jì)學(xué)處理 應(yīng)用SPSS 22.0統(tǒng)計(jì)軟件,計(jì)量資料的比較采用多樣本的方差分析,等級(jí)資料的比較采用多樣本的秩和檢驗(yàn)。檢驗(yàn)水準(zhǔn)α=0.05。
2.1 各體位患肢氧分壓、疼痛、舒適度情況比較 在本研究中,無(wú)疼痛者有17例。與平臥位和下肢抬高體位比較,下肢下垂和坐位體位的氧分壓均明顯較高,而疼痛評(píng)分均明顯較低;4種體位中,下肢下垂體位的舒適度評(píng)分最低,即下肢下垂體位的舒適度最高。見表1。
表1 各體位患肢氧分壓、疼痛及舒適度評(píng)分情況
2.2 各體位氧分壓值的變化程度(表2)
表2 氧分壓值的變化程度(例)
由于下肢動(dòng)脈硬化閉塞患者的微循環(huán)血流發(fā)生異常,引起局部組織出現(xiàn)缺血、缺氧,從而造成靜息痛或皮膚潰瘍等癥狀的發(fā)生。相關(guān)研究顯示,一個(gè)能維持患肢血流的體位可明顯改善患者疼痛或潰瘍癥狀。經(jīng)皮氧分壓作為測(cè)量組織微循環(huán)的標(biāo)準(zhǔn)方法,可反映局部組織的血流灌注情況,提示局部組織的缺血程度[5]。
結(jié)果顯示,下肢抬高體位的氧分壓值最低,而下肢下垂體位則最高,同時(shí)下肢下垂體位的疼痛、舒適度評(píng)分均最低,即表明患肢在下肢下垂體位時(shí)的疼痛感輕、舒適度高。亦有相關(guān)研究表明[6],動(dòng)脈硬化患者在下肢下垂時(shí)的足背皮膚灌注壓明顯高于平臥位和下肢抬高體位。本研究中,下肢下垂體位和坐位分別可使患肢氧分壓增加,而下肢抬高體位可使大部分的患肢氧分壓降低。因此,對(duì)于下肢動(dòng)脈硬化閉塞患者的臨床體位護(hù)理,應(yīng)多以患肢下垂為主,防止抬高患肢[7]。在本研究中,伴有患肢疼痛者占71.67%(43/60),即對(duì)這43例患者進(jìn)行疼痛評(píng)分,而對(duì)其余的17例患者進(jìn)行舒適度評(píng)分。在不同體位的轉(zhuǎn)換時(shí),患肢的氧分壓值與疼痛評(píng)分均出現(xiàn)變化[8]。改善患肢的微循環(huán)后,氧分壓升高,疼痛程度明顯降低;故下肢動(dòng)脈硬化閉塞患者維持下肢下垂體位護(hù)理可明顯改善患肢的微循環(huán),有效緩解其疼痛程度,同時(shí)提升其舒適度[9]。另外,在本研究中,伴有潰瘍或壞疽的下肢動(dòng)脈硬化閉塞患者平臥位的氧分壓均<10 mmHg,當(dāng)轉(zhuǎn)為下肢下垂體位時(shí),幾乎全部患者的氧分壓>10 mmHg,其中部分患者>25 mmHg。亦有學(xué)者認(rèn)為[10],若患者足部氧分壓≥25 mmHg時(shí),則潰瘍有可能愈合;而<10 mmHg則潰瘍不能愈合。由此可見,下肢下垂體位可促進(jìn)患者的潰瘍與壞疽的愈合[11]。亦有相關(guān)研究顯示[12],平臥位、坐位、下肢下垂體位時(shí)的患肢足背皮膚灌注壓分別為25.3,40.6,73.4 mmHg,而潰瘍愈合患者的足背皮膚灌注壓均>40 mmHg;所以下肢下垂體位可明顯提高患肢的微循環(huán),從而促進(jìn)潰瘍的愈合[13]。
綜上所述,在下肢動(dòng)脈硬化閉塞患者的4種體位中,下肢下垂體位可更有效改善患肢的微循環(huán),從而明顯提高氧分壓、增加舒適度及減輕疼痛,具有非常重要的臨床推廣價(jià)值和護(hù)理實(shí)踐意義。由于本研究的樣本量較小,研究人群為老年人群,故排除伴有糖尿病的患者,但仍存在一定的局限性。同時(shí),本研究并未考慮時(shí)間因素的影響,雖保持下肢下垂體位可明顯改善足背的微循環(huán),但時(shí)間過(guò)長(zhǎng)可能造成患肢的水腫,因此,仍需加大樣本量、更嚴(yán)謹(jǐn)?shù)脑囼?yàn)作進(jìn)一步研究。
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Influenceofnursingindifferentpositionsonoxygenpartialpressure,painandcomfortlevelofaffectedlimbsofthepatientswitharterialsclerosisocclusion
FULi-hong,FULi
(Wuhan First Hospital,Wuhan 430000)
Objective: To explore the influence of nursing in four positions including horizontal position, sit position, lower limb drooping position, and lower limb raising position on oxygen partial pressure, pain and comfort level of affected limbs of the patients with arterial sclerosis occlusion. Methods: Selected 60 cases of patients with arterial sclerosis occlusion admitted to our hospital from June 2015 to December 2016, and they were compared for the oxygen partial pressure, pain and comfort level scoring of their affected limbs when they were in different positions. Results: The patients in the lower limb raising position had the lowest oxygen partial pressure. Compared with horizontal position and lower limb raising position, there was a significantly higher oxygen partial pressure and significantly lower pain score in the lower limb drooping position and sit position,. In the four positions, the comfort level scoring in the lower limb drooping position was the lowest, that is, there was the highest comfort level in the lower limb drooping position. The oxygen partial pressure was of significantly negative correlation with the pain score of affected limbs. Conclusion: Among the four positions of patients with arterial sclerosis occlusion, lower limb dropping position could effectively improve the microcirculation of affected limbs, so as to significantly improve the oxygen partial pressure and increase the comfort level and relive the pain of the affected limbs.
Arterial sclerosis occlusion;Lower limb drooping position; Microcirculation; Oxygen partial pressure; Comfort level; Pain
430000 武漢市 湖北省武漢市第一醫(yī)院普胸血管外科 付利紅:女,本科,護(hù)師
付莉
2017-05-15)
(本文編輯 劉學(xué)英)
10.3969/j.issn.1672-9676.2017.19.005