Nursing care of patients with buccal squamous cell carcinoma undergoing resection.
Combined radical operation of buccal cancer; Skin flap repair; nurse
Buccal carcinoma originated from the buccal mucosa of mandibular occlusal plane line, which was more common in the posterior cheek. It can also occur in the buccal mucosa at the junction of lips and cheeks, and the range is generally wide.
Most of them are well-differentiated squamous cell carcinoma, which is prone to lymph node metastasis, with a high metastasis rate of 30% ~ 50% [1]. No matter radiotherapy or surgical treatment in the early stage, the effect is good.
The nursing summary report of 30 patients with oral squamous cell carcinoma admitted in recent two years is as follows.
Clinical data of 1
From August 2007 to August 2009, 30 patients with buccal cancer were treated, including 20 males and 20 females 10, aged 45-70 years, with a course of 1 month to 1 year.
The focus of this group of patients with buccal cancer is located in the buccal mucosa of occlusal line, especially in the posterior cheek, which is often complicated with white spots and has a wide range.
At the initial stage, it is often manifested as a long-term incurable lump or ulcer. If complicated with infection, it will cause pain and different degrees of difficulty in opening, which will affect chewing; In the late stage, it often involves the upper and lower gums and jaws, and even invades the infratemporal space, which can penetrate the soft tissue of the cheek and infiltrate the skin, among which 8 cases have lymphatic metastasis.
Under general anesthesia, 22 patients underwent "extended resection of buccal squamous cell carcinoma, combined radical operation of affected cheek and neck, transfer and anastomosis of forearm vascular pedicle free flap and transfer and repair of abdominal free flap". Postoperative pathological report showed that the moderately well-differentiated squamous cell carcinoma of cheek was resected at 12 d after operation, and all flaps survived, and the donor site was removed at14 d.
The wound healed in one stage and was discharged about 1 month after operation. The treatment effect is satisfactory.
3 cases could not be treated surgically due to physical reasons, and 5 cases gave up treatment.
2 nursing
2. 1 preoperative care
2. 1. 1 psychological care: due to the lack of knowledge about diseases and surgical treatment, patients are afraid and do not cooperate with treatment.
In view of patients' bad emotions, communicate with patients more, comfort, care and considerate patients, introduce successful cases, encourage and enhance patients' confidence, realize the importance of early surgical treatment, and actively cooperate.
2. 1.2 donor site nursing: protect the forearm skin of donor site and avoid friction injury. It is forbidden to draw blood by venipuncture in this arm, so as to protect blood vessels and observe whether the local skin is damaged, swollen and scarred in time.
Take a bath at night before operation, and prepare the donor skin according to the scope of skin preparation.
2. 1.3 adaptive training: training patients in bed activities, effective cough and expectoration, simple communication methods such as sign language or writing. To adapt to the change of living habits after operation.
2. 1.4 Preoperative preparation: (1) Improve the pre-operative examination, such as electrocardiogram, chest radiograph, enhanced CT and color Doppler flowmetry to detect arterial puncture, blood routine, blood biochemistry, bleeding and coagulation time, liver and kidney function and hepatitis B in the donor flap area; ⑵ 1% ~ 3% hydrogen peroxide diluted gargle, three times a day, three days before operation, clean teeth, remove tartar and maintain oral hygiene; ⑶ Improve preoperative preparation: prepare skin (operation area, skin receiving area and skin donor area) before operation, match blood, abstain from drinking water, keep gastric tube and catheter, and inject atropine 0.5 mg intramuscularly 30 min before operation.
2.2 postoperative care
2.2. 1 Closely monitor the changes of the disease: due to severe surgical trauma and excessive bleeding during operation, they were sent to ICU for monitoring after operation. After waking up from general anesthesia, his vital signs were normal and he returned to the ward.
Continuously monitor the changes of vital signs, observe the bleeding and swelling of the wound, find the abnormality in time and report it to the doctor for treatment.
2.2.2 Posture nursing: Before anesthesia, lie on your back, take off your pillow for 6 hours, and tilt your head to one side. After anesthesia, lie flat and put the pillow down for 24 hours to maintain the blood supply of the flap. The second day after operation, it was changed to semi-recumbent position, the head of the bed was raised15 ~ 30, and the head was tilted to the affected side to reduce the swelling of the neck and the tension of the abdominal wound. The forearm skin donor area was pressed and bandaged, and the elevation was 65438+.
The donor site should be properly braked and local sandbags should be pressed to avoid frequent head movements, so as to avoid blood circulation disorder of the flap, limit rich facial expression activities such as chewing and talking loudly, and prevent vascular anastomosis from breaking.
2.2.3 Airway management: keep the respiratory tract unobstructed, suck out the secretions in the oral cavity and nasal cavity in time, and inhale them by atomization for 3 times /d after operation to relieve the edema and pain of the throat mucosa, and give expectorant drugs when necessary to encourage patients to cough effectively.
2.2.4 Observation and nursing of flap: Keep the ward environment clean, the temperature is 20 ~ 22℃, the humidity is 50% ~ 60%, keep warm to prevent blood vessel contraction, strengthen local braking after operation, reduce the tension of vascular pedicle after vascular anastomosis, keep the blood flow unobstructed, and avoid the flap from being compressed, so as to avoid reflux disorder.
The systolic blood pressure should be kept above 1 10 mmHg to increase the blood supply of the flap.
Because of the particularity of oral environment, vascular crisis is mainly observed by observing the texture, color, blood supply and tension changes of skin flap.
Most clinical crises occur within 3 days after operation [2]. Normal skin flap is pale pink or white, with clear dermatoglyphics or slight swelling, good elasticity and good capillary filling. It needs to be monitored for 5 days after operation, and the doctor should be informed immediately if any abnormality is found.
Vascular crisis is the most common complication after free flap transplantation. Whether the crisis flap can be successfully rescued depends on early detection of microcirculation disturbance and timely exploration of damaged blood vessels, which is the key to successful operation [3].
2.2.5 Diet care: After operation, a liquid diet with high protein, vitamins and calories, including nutritious milk powder, freshly squeezed juice and various nutritious soups, was injected through the stomach tube, 200 mL each time, once every 2 hours, so as to ensure adequate nutrition supply and promote wound healing.
After the suture removal in the flap area, it was changed to oral food, and gradually changed from full liquid food to semi-liquid food.
2.2.6 Drainage tube care: (1) Gastric tube: properly fixed to prevent falling off. Check whether the gastric tube is in the stomach before each food injection. Before and after food injection, 20 ml of warm boiled water should be injected to flush the lumen to prevent food decay and gastric tube blockage; ⑵ Neck negative pressure drainage tube: Nail the negative pressure box on the clothes with the height parallel to the surgical site, keep the drainage tube unblocked, and observe the color, quantity and nature of the shunt.
If a large amount of bright red liquid is drained within 3 hours after operation, postoperative bleeding can be considered and reported to the doctor in time.
Explain the purpose and precautions of drainage to patients, prevent the drainage tube from being pressed, twisted, folded and falling off during activities, replace the drainage box under aseptic operation every day, and accurately record the amount, color and nature of drainage fluid.
According to the indication of extubation, extubate in time; ⑶ Catheter: Keep the catheter fixed, drain smoothly, flush the bladder twice a day, clamp it regularly, and pull it out after the patient can get out of bed.
2.2.7 oral care: rinse mouth alternately with 1% ~ 3% H2O2 and 2% ~ 4 2%~4%NaHCO3 solution, three times a day, twice a day for oral care, to maintain oral hygiene and prevent oral wound infection.
This kind of patients have difficulty in opening their mouths due to intermaxillary traction after operation, and the wound is bandaged with pressure, so the oral care effect is not good. Therefore, the oral irrigation method is adopted, that is, using the principle of negative pressure suction, with a 30 mL syringe and a blunt needle, and suction is carried out along the patient's teeth and the parts that are easy to adhere. Pay attention to the patient's reaction, adjust the negative pressure to 0.02~0.04 kPa, and do not aim the suction tube and needle at the flap area for flushing twice a day.
2.2.8 Medication nursing: After operation, antibiotics and nutrition needles are injected intravenously, vasoconstrictors are not allowed, and vasodilators and anticoagulants are routinely used.
In this group, 30 mg papaverine was injected intramuscularly every 6 hours, once every 1 2 hours after1week, and the drug was stopped after two weeks.
After using this medicine, the risk of bleeding should be prevented. After each infusion, the patient should be instructed to press correctly and the pressing time should be extended appropriately.
In order to prevent hypokalemia during intravenous infusion of low molecular dextran, people with chapped lips and oral injuries should apply strong chlorine oil, and those with facial nerve injuries should take vitamin B6 and vitamin B 12 orally or intramuscularly. Patients with parotid gland lesions should take atropine 0.3 mg three times a day half an hour before meals to inhibit gland secretion, prevent salivary fistula, and promote wound healing and flap survival.
2.2.9 Wound care: Observe the bleeding and swelling of the wound and the survival rate of the flap, keep the oral cavity clean, keep the wound dressing clean and dry, change the dressing regularly and apply local pressure, carefully record the wound, report and deal with any abnormality in time, and take out stitches in time.
2.2. 10 life nursing: strengthen basic nursing, maintain personal hygiene and clean sheets, encourage eating more, turn over and get out of bed frequently when illness permits, prevent complications, ask patients' needs and give help in time.
2.3 discharge guidance
After discharge, strengthen nutrition, enhance physical fitness and maintain oral hygiene. Follow-up one month after operation, under special circumstances, and radiotherapy and chemotherapy three months after operation to consolidate the curative effect.
3 abstract
Squamous cell carcinoma of cheek is one of the common malignant tumors in oral and maxillofacial surgery. Early radical surgery combined with one-stage skin flap repair can alleviate the physical and mental pain of patients.
Repair and reconstruction of buccal cancer flap is a comprehensive operation combining the characteristics of microsurgery and plastic surgery. The artery and vein of the donor tissue flap are anastomosed with the recipient, so that the tissue flap can survive and the shape and function of the defect area can be restored.
This operation is difficult and traumatic, and requires strict postoperative care. It requires nurses not only to have rich clinical experience and comprehensive observation ability, but also to have comprehensive and skilled nursing operation skills, accumulate experience in clinical practice and provide better and better medical services for patients.
refer to
Bloom ND, RH, spiro. Retrospective analysis of buccal mucosa carcinoma [J].Am J Surg, 1980, 140(4):556-569.
[2] Jin Fang, Zhang Hongcun. 1 Nursing care of a successful case of large area free skin flap transplantation in children [J]. China Journal of Nursing, 2000,35 (9): 558-559.
, Zhang,,. Prevention and treatment of free flap crisis in oral and maxillofacial region [J]. Journal of Stomatology, 1999, 15( 1):4-7.
Clinical nursing experience of esophageal cancer resection II.
Objective: To explore the most effective nursing methods of esophagogastrostomy and esophagogastrostomy, so as to improve the effect of surgical treatment, reduce postoperative complications and relieve patients' pain.
Methods: 48 patients with esophagogastrostomy and esophagogastrostomy in our hospital were selected, and the curative effect and complications were observed through preoperative diet care, psychological care, respiratory preparation, gastrointestinal preparation, postoperative vital signs monitoring, observation of body position and the nature of pleural effusion, body temperature, gastric tube and health guidance after discharge.
Results: Among 48 cases, 4 cases had anastomotic leakage, 2 cases had pulmonary infection, and the remaining 42 cases had no serious complications after operation, and the curative effect was ideal.
Conclusion: Careful nursing before and after operation will improve the success rate of operation, reduce the occurrence of complications and promote the recovery of patients, which deserves attention.
Key words: resection of esophageal cancer; Nursing; clinical experience
Esophageal cancer is one of the common malignant tumors in China, and surgical resection is the first choice to cure it. However, surgical resection has great interference with cardiopulmonary function, long incision, great trauma, severe postoperative incision pain and many indwelling catheters, which has great influence on physiological function, so it is very important to care for patients with esophageal cancer [1].
According to the treatment data of 48 patients with esophageal cancer in our hospital from June 2065438 to June 2065438+June 2002, the nursing experience is analyzed as follows.
1 data and methods
There are 48 patients in this group, including 36 males and 65438 02 females, aged 45-70 years, with an average age of 57.5 years. All patients have dysphagia to varying degrees, or feel chest tightness and discomfort after barely eating. All patients have limited swallowing of dry food and can only eat semi-liquid food, and there is no persistent dull pain in chest and back, hoarseness and cough. All patients underwent chest X-ray, CT, fiberoptic bronchoscopy, esophageal barium meal, gastroscopy and other necessary examinations before operation. Among them, upper thoracic esophageal carcinoma 12 cases, middle thoracic esophageal carcinoma 26 cases and lower thoracic esophageal carcinoma 10 cases were diagnosed, and esophago-esophageal neck anastomosis or esophago-gastric stump anastomosis was performed selectively.
The cure rate of esophageal cancer and the incidence of postoperative complications depend on the quality of nursing. Effective nursing procedures should be followed when nursing such patients, and holistic nursing before and after operation should be carried out with patients as the center to improve the quality of life of patients.
2 nursing experience
2. 1 preoperative care
2. 1.65438+
On the premise that patients can eat, we should first evaluate their food intake and give them a semi-liquid or liquid diet with high protein, high calorie, high vitamins, inorganic salts and sugar. Instruct patients to eat with big mouths to prevent anastomotic stenosis, and follow the principle of eating less and eating more meals, with daily calories reaching 3500 kilocalories to enhance patients' resistance.
For patients who can't eat, drip water, electrolyte and heat intravenously; Pay attention to the temperature (38℃-40℃) and dropping speed (80- 100 drops/minute) of the nasal feeding solution, with the total amount of 200-300 mL each time.
2. 1.2 psychological nursing: nurses visit patients before operation, strengthen nurse-patient communication, introduce the purpose of the visit, and establish a good nurse-patient relationship. First of all, we should explain the necessity, feasibility and therapeutic effect of the operation. In view of the possible psychological problems of patients, nurses should sympathize with and understand patients, give comfort and encouragement, and avoid impatiently answering patients' questions. Try to meet patients' reasonable demands, conduct reasonable psychological counseling according to patients' knowledge and cultural background and psychological endurance, reduce patients' nervousness and fear of surgery, enhance patients' confidence in overcoming diseases, improve patients' courage in fighting diseases, cooperate and support surgical treatment and nursing with the best psychological state, and ensure smooth operation and active cooperation after surgery.
2. 1.3 respiratory care: supervise patients to ban smoking for at least 2 weeks before operation, atomize ambroxol to dilute sputum for patients with large amount of expectoration, guide patients to learn effective cough expectoration methods, promote the discharge of sputum and lung secretions, teach patients to breathe abdominal, and reduce the incidence of pleural effusion and atelectasis.
Patients with asthma, emphysema and chronic bronchitis should be given bronchodilators and antibiotics before operation to eliminate airway inflammation and further improve lung function.
2. 1.4 gastrointestinal care: First of all, keep the oral hygiene of patients. If there is inflammation in the esophagus, antibiotics should be used before operation; Change to semi-liquid diet the night before operation, clean enema twice to remove residual feces, fast in the morning of operation, put 1 sterile gastric tube in the morning, and lavage the stomach with warm salt water.
Pay attention to the gastrointestinal tract must be thoroughly cleaned to prevent intraoperative infection.