With the development and progress of medicine, the treatment level of leukemia has also been greatly improved. People are not only satisfied with the complete remission of the disease, but also begin to devote themselves to the research of making patients survive or even recover for a long time. In recent years, the complete remission rate and disease-free survival rate of leukemia have been significantly improved due to the wide application of high-dose combined chemotherapy, integrated traditional Chinese and western medicine treatment and gene therapy, especially hematopoietic stem cell transplantation. This puts forward new requirements for leukemia specialist nursing and further broadens the scope of nursing work. The following is a summary of its progress:
Progress of routine nursing
1. Nursing care of patients with high-dose combined chemotherapy
Chemotherapy is the most important and commonly used treatment for leukemia. High dose combined chemotherapy
Leukemia can improve the complete remission rate of leukemia and prolong the disease-free survival of patients, which has been widely used in China. But at the same time, it has certain toxic and side effects, especially on epithelial cells with strong proliferation ability, such as bone marrow cells, digestive tract epithelial cells, germ cells, etc., and also has certain toxic effects on important organs of the body, such as liver, kidney, heart, lung, nervous system and so on. Therefore, nursing work is extremely important.
(1) Nursing care of toxic and side effects of chemotherapy;
① Familiar with the toxic and side effects of commonly used chemotherapy drugs. Most chemotherapy drugs have gastrointestinal reactions.
And the toxicity of some drugs has its particularity. For example, cyclophosphamide can cause hemorrhagic cystitis, high-dose methotrexate can cause intractable oral ulcer, anthracyclines can cause cardiotoxicity, etoposide can cause alopecia, and vincristine can cause peripheral neuritis.
② The general health status of patients should be comprehensively evaluated before chemotherapy.
Make the corresponding nursing plan. Before chemotherapy, carefully clean your mouth with a soft toothbrush in the morning and before going to bed, and use light force to avoid injury. Rinse your mouth with chlorhexidine before and after meals to maintain oral hygiene. Check the patient's oral condition once a day to prevent oral ulcers. In order to prevent gastrointestinal toxicity, antiemetic drugs, such as sufuning and Konka, are used 30 minutes before chemotherapy. Closely observe and understand the patient's complaints of discomfort during chemotherapy, and deal with them in time if there is any abnormality. Liver and kidney function should be checked during medication, and heart rate should be monitored three times a day. The infusion speed should not be too fast.
③ Choosing intravenous chemotherapy drugs can stimulate and destroy venules, so it is necessary.
Choosing a vein with good elasticity and large wall thickness should hit the nail on the head, start from the distal vein in a planned way, and change the administration vein frequently. Pay close attention to observation when infusion of chemotherapy drugs to prevent extravasation and leakage of chemotherapy drugs. In order to prevent phlebitis caused by chemotherapy drugs, change the venipuncture site or choose another vein every day, and flush the catheter with normal saline before and after injecting chemotherapy drugs. If phlebitis occurs, magnesium sulfate wet compress or Jinhuangsan external application can be given. It is reported that hypertonic glucose and vitamin B are used.
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External application of mixed solution has a good effect on phlebitis.
(2) Nursing care of infection:
① Take gentamicin and sulfamethoxazole orally 1 day before gastrointestinal nursing chemotherapy.
Or norfloxacin; Take allicin or nystatin orally to prevent fungal infection.
(2) Care of skin and mucous membrane. High-dose chemotherapy will lead to severe bone marrow suppression and strict granulocytes.
Serious deficiency, bone marrow empty about 10 days. The cellular and humoral immune function is also significantly reduced, and the skin and mucosa are in direct contact with the outside world, which is extremely susceptible to infection. Therefore, measures should be taken to prevent the infection of eyes, ears, nose, mouth, anus and external genitalia. Use rifampicin eye drops or chloramphenicol eye drops twice a day, and apply peppermint oil or paraffin oil twice a day. Rinse your mouth with sodium bicarbonate to prevent fungal infection, rinse your mouth with metronidazole solution to prevent anaerobic infection, and take a sitz bath with 1∶5000 potassium permanganate solution every night and after defecation to clean your perineum.
(3) Nursing of Puncture Point In order to avoid infection and minimize puncture, it should be used before each puncture.
Disinfect with iodophor twice, and cover with sterile gauze or sterile cotton ball after successful venipuncture.
The above measures should be carried out at the same time, so as to avoid any part caused by inadequate care.
Infection. The patient's ward should be irradiated with ultraviolet rays twice a day, indoor utensils and floors should be scrubbed with disinfectant, and the room should be ventilated regularly. Restrict visits and allow patients to live in single rooms or isolation wards. If necessary, hematopoietic cell stimulating factors, such as recombinant human granulocyte-macrophage colony stimulating factor and granulocyte colony stimulating factor, should be used according to the doctor's advice to promote bone marrow stem cell differentiation and granulocyte proliferation. For the infection that has occurred, systemic antibiotics and local symptomatic treatment should be adopted according to the infection focus and strain type to control the infection and prevent the disease from getting worse.
(3) Hemorrhage nursing:
After high-dose chemotherapy, due to thrombocytopenia, mucosal ulcer and inflammatory changes, it is often
There are bleeding symptoms. Therefore, the prevention and nursing of bleeding is particularly important.
[[[[[Treatment progress of malignant pleural effusion and nursing care of intracavitary perfusion drugs]]]
Malignant pleural effusion is one of the common complications in patients with advanced cancer. At this time, patients with extensive lesions and poor constitution are not suitable for systemic chemotherapy, and effective local treatment can play a better palliative role. From June 2000 to February 2002, 35 patients with malignant pleural effusion were treated with intrapleural chemotherapy, which controlled pleural effusion and prolonged their lives. Nursing experience is summarized as follows.
1 data and methods
1. 1 General information: 35 cases, including male 18 cases and female 17 cases; The age ranged from 23 to 65 years, with an average of 565,438 0.5 years. Primary lung cancer 18 cases, gastric cancer 5 cases, breast cancer 7 cases, liver cancer 3 cases and lymphoma 2 cases. B-ultrasound diagnosis of pleural effusion. Among them, left pleural effusion 15 cases, right pleural effusion 18 cases and bilateral pleural effusion 2 cases.
Methods B-ultrasound localization 1.2. Puncture the chest wall under local anesthesia, insert the pig's tail catheter, and pull out the iron wire. After the pleural effusion flows out, the end of the catheter is connected with a three-way pipe and a negative pressure aspirator, and the catheter is fixed, covered with gauze and fixed with adhesive tape. The drainage volume shall not be greater than 1000ml each time, and it can be discharged repeatedly after the interval of1h. After the drainage fluid is reduced, the prepared chemotherapy drugs are perfused (1 time the next day, ***3 times). The drugs commonly used in chemotherapy are interleukin -2, cytidine, cisplatin, 5- fluorouracil, mitomycin, dexamethasone and so on. All of them are diluted with normal saline before use. Routine infusion 1000ml after chemotherapy, intravenous injection of ondansetron 8mg or granisetron 3mg.
2 nursing
2. 1 Routine preparation before chemotherapy, routine examination of coagulation time, blood routine, liver and kidney function, electrocardiogram, etc. Before chemotherapy, make sure that all the tests are within the normal range. Routine skin preparation before puncture. For patients with frequent cough, 0.03 ~ 0.06 g of codeine can be taken orally 1h before operation.
2.2 Psychological nursing introduces the basic principle and advantages of treatment to patients in detail, telling patients that this treatment method does not affect the normal physiological and anatomical structure, belongs to minimally invasive treatment, has low pain, high safety, thorough drainage and avoids pleural injury caused by repeated puncture. At the same time, it introduces the adverse reactions and treatment principles after chemotherapy, so as to alleviate the patients' nervousness and fear and make them cooperate with the treatment.
2.3 observation of illness
2.3. 1 Pay attention to the changes of patients' vital signs and pleural reaction. Patients in this group often have mild chest pain and low reaction, and their body temperature is about 38℃. Give them oral prednisone 10mg, intravenous antibiotics and hemostatic drugs.
2.3.2 Pay attention to the changes of patients' blood routine. In this group, the total number of white blood cells decreased in different degrees, with the lowest being 3.0×109/L. After subcutaneous injection of 75μg granulin 1 ~ 2 times /d, it can return to normal in 2 ~ 4 days.
2.3.3 Gastrointestinal reactions The most common toxic reactions of chemotherapy drugs are nausea and vomiting. After each chemotherapy, preventive intravenous injection of ondansetron 8mg or granisetron 3mg can make the blood concentration of patients stop vomiting reach the peak before nausea and vomiting, thus giving full play to the best curative effect.
2.4 Nursing care of puncture site and drainage tube after infusion of chemotherapy drugs requires patients to turn over frequently and change positions, especially within 1 ~ 2 hours after infusion, so that the drugs can fully contact the pleura. Change the dressing at the puncture site 1 time /d, and observe whether there is local inflammatory reaction. The drainage tube was washed with 50 ~ 100 ml of physiological saline containing α-chymotrypsin 100 mg, gentamicin 16000 U and dexamethasone 5mg every day/time /d to prevent the drainage tube from being blocked. Pay attention to the paste position of the drainage tube to prevent the tube from folding and breaking. After the tube was clamped for 65438 0.2 hours, the tube was released, and the amount, nature and bleeding phenomenon of drainage fluid were observed. Discharge liquid every day 1 time. 1 week, the hydrothorax can be extubated when it is no longer produced. In general, it can be stored for about 1 month at most.
2.5 After diet care and chemotherapy, all patients suffered from loss of appetite to varying degrees, and were instructed to eat mild and non-irritating food with high calorie, high protein, high vitamins and low fat, and to add condiments, such as sweetening and refreshing, when necessary, to stimulate appetite. The symptoms can be gradually relieved after 3 to 5 days of continuous chemotherapy.
3 experience
Placing chemotherapy drugs into pigtail catheter is safe and convenient, with little trauma, less pain for patients, avoiding repeated puncture, reducing the burden on doctors and patients, completely draining, adjusting the discharge speed of pleural effusion and not affecting the daily life of patients. Because of our careful observation and careful nursing operation, we found the abnormal situation in time and dealt with it actively. Through the clinical observation of 35 patients, there is no bleeding, tube breakage, tube pressure, tube detachment and tube breakage, which improves the treatment efficiency and the quality of specialized nursing.
[[[[[Diabetes emergency care]]]
1. Patients with diabetes history and physical assessment often complain about overeating, drinking, polyuria, weight loss, poor wound healing and frequent infection. They should be asked about their lifestyle, eating habits, food intake, family history of diabetes, weight and number of pregnancies. Patients with chronic complications of diabetes have cardiovascular and nervous system abnormalities. Patients with ketoacidosis have deep breathing, dehydration symptoms and consciousness changes.
2. Laboratory tests showed that fasting urine glucose was positive, fasting and postprandial blood glucose increased beyond the normal range, and blood triglyceride, cholesterol and lipoprotein increased; Patients with acidosis may have abnormal changes in urine ketone positive, electrolyte, blood PH and carbon dioxide binding capacity.
3. Psychological and social data Diabetes is a lifelong disease. The stress caused by the long course of disease and the dysfunction of multiple organs and tissues on patients' body and mind is likely to make patients feel anxious and depressed, lack confidence in the disease, or adopt an indifferent attitude towards the disease, thus failing to effectively cope with chronic diseases. Social environment, such as the response and support of patients' relatives and colleagues, is an important factor related to whether patients can adapt to chronic diseases and should be evaluated.
(2) Nursing diagnosis nursing plan and evaluation
1. Malnutrition and emaciation are related to the disorder of glucose, protein and fat metabolism caused by absolute or relative insufficiency of insulin secretion.
(1) The symptoms of polydipsia, polyuria and polyphagia in the target patients were relieved, and their weight increased, and their blood sugar was normal or tended to be normal.
(2) Nursing measures
1) diet care
Daily calorie calculation: according to the patient's gender, age and height, look up the table or calculate the ideal weight [ideal weight (kg)= height (cm)- 105], and then refer to the ideal weight and activity intensity to calculate the total daily calories required. Adult rest people are given 105- 125 kJ (25-30 calories) per kilogram of standard weight every day; Light manual workers 125- 146 kJ (30-35 kcal); Manual workers 146- 167 kilojoules (35-40 kilocalories); Heavy manual workers167 kj (above 40kcal).
Children, pregnant women, nursing mothers, malnutrition or wasting diseases should be increased as appropriate, and obese people should be reduced as appropriate, so that the patient's weight can be restored to about 5% of the ideal weight.
Protein, the distribution of fat and carbohydrate. The protein content in the diet is calculated as 0.8 ~ 1.2g per kilogram of adult's standard weight, and it can be increased to 0.2 ~1.5g per kilogram for children, pregnant women, wet nurses, malnourished people or people with wasting diseases. Fat is 0.6 ~1.0g per kg of standard weight per day; The rest are carbohydrates. According to the above calculation, protein accounts for about 12% ~ 15% of the total calories, fat accounts for about 30%, and carbohydrate accounts for about 50% ~ 60%.
Distribution of three meals: the above calories are converted into recipes according to the food composition table, and the distribution of three meals is generally 1/5, 2/5, 2/5 or 1/3, 1/3, l/3. The contents of three meals should be balanced, with carbohydrates, fat and protein in each meal, and should be quantified regularly, which is beneficial to slow down the absorption of glucose and increase the release of insulin. After eating this recipe for 2 ~ 3 weeks, blood sugar should drop. If it is not good, it is necessary to make necessary adjustments.
In recent years, the food exchange method has been widely used. In this method, food is divided into six categories: cereal, milk, meat, fat, fruits and vegetables, and the calorie per 80 kcal is taken as a unit, such as 25g of cereal rice, 30g of raw noodles and 25g of green (red) beans. Milk milk 1 10ml, milk powder 159, and soybean milk 200ml are each a unit; 25 grams of lean pork, 50 grams of lean beef, 55 grams of eggs and 50 grams of abalone are each a unit; 9g of fatty soybean oil, one unit of peanut 15g each; 200 grams of fruit apples and 750 grams of watermelons as a unit; 500~750g of spinach and 350g of radish, each of which is a unit. The same amount of food in each food is interchangeable, and the nutritional value is basically the same. Patients can make recipes according to the contents of different heat exchange parts. This method is rough, but it can increase the selectivity of food and make it convenient for patients to learn and master.
Patients should give up drinking. The staple food advocates coarse rice, flour and moderate miscellaneous grains, and avoids eating glucose, sucrose, honey and its products. The daily intake of animal protein in protein should be 1/3 of the total to ensure the supply of essential amino acids. Eat vegetable oil containing unsaturated fatty acids, avoid animal fat to reduce the intake of saturated fatty acids, and the amount should be less than 10% of total calories. Obese people should eat low-fat food (
2) Physical Exercise According to age, physical strength, illness and complications, guide patients to have regular physical exercise for a long time.
Physical exercise includes walking, jogging, cycling, aerobic exercise, Tai Ji Chuan, swimming and housework. The suitable activity intensity is that the patient's heart rate should reach 50% of the individual's maximum oxygen consumption, and the individual's heart rate at 50% of the maximum oxygen consumption =0.5 (individual's maximum heart rate-basal heart rate)+basal heart rate, in which the individual's maximum heart rate can be roughly estimated by 220- year-old, and the basal heart rate can be estimated by the pulse rate measured before getting up in the morning. The activity time is 20 ~ 40 minutes, which can be gradually extended to stop or longer, once a day, and it is best for those who use insulin or oral hypoglycemic drugs to exercise regularly every day; Obese patients can appropriately increase the number of activities.
The side effects of physical exercise include ① hypoglycemia; Its occurrence is related to activity intensity, time, meal time before activity, food type, blood sugar level before activity and drug use. Blood type diabetics who simply control their diet generally do not have hypoglycemia. ② Hyperglycemia and ketosis: The blood sugar level of diabetic patients treated with insulin is higher (> 13.3~ 16.7mmol/L). At the initial stage of exercise, sympathetic nerve is over-excited, catecholamine release increases, and blood sugar concentration can rise sharply. Insufficient insulin can cause ketosis or ketoacidosis. ③ Inducing cardiovascular accidents: Exercise can increase the burden on heart and brain, increase plasma volume, reduce vasoconstriction, and may induce angina pectoris, myocardial infarction and arrhythmia. ④ Motor system injury: including bone, joint, muscle or skin injury, foot skin ulceration or even ischemia and gangrene.
Matters needing attention in physical exercise are: blood sugar >; 13.3mmol/L or urine ketone positive people should not do the above activities. Patients with type ⅱ diabetes complicated with cardiovascular and cerebrovascular diseases or severe microangiopathy should be properly arranged according to the specific situation, and the systolic blood pressure should be >: 24kPa( 180mmHg). The activity time should be arranged after dinner. Exercise should be moderate, so as not to excite sympathetic nerve and islet A cells, cause glycogen decomposition and gluconeogenesis, and raise blood sugar. People who only rely on diet control or oral hypoglycemic drugs usually don't need to add food to their foreheads. Patients with type I diabetes often fluctuate between relative insulin deficiency and relative insulin excess when receiving insulin therapy, so we should grasp the relationship between insulin dosage, diet and activity. The former can lead to the increase of blood sugar, the increase of free fatty acids and ketone bodies, which has an adverse effect on metabolism because of the obvious increase of liver sugar output but no increase of glucose utilization during exercise. The latter is prone to hypoglycemia. ② Generally, you can supplement a small amount of extra food or reduce the amount of insulin before the activity. Injecting insulin under the abdominal wall before meals can slow down the absorption rate of insulin during activities. ③ The activity should not be too large and the time should not be too long. The appropriate time is 15 ~ 30 minutes. Attention to the above three points can prevent the occurrence of hypoglycemia after 1 diabetes. Check your feet before and after activities, and pay attention to the surrounding environment and buildings during activities to avoid injury. Take dessert with you and a card with your name, home address and illness in case of emergency.
3) Nursing and educating patients with oral hypoglycemic drugs to take medicine on time according to the dosage, and shall not increase or decrease at will.
Observe adverse drug reactions: The main side effect of sulfonylureas is hypoglycemia, especially in patients with hepatic and renal insufficiency and elderly patients. Other side effects include gastrointestinal reactions and occasional drug allergies, such as leukopenia, anemia, itchy skin and rash. The common adverse reactions of biguanides include anorexia, nausea, vomiting, bitter taste, metallic taste and diarrhea. There are occasional allergic reactions. Because biguanides promote anaerobic glycolysis and produce lactic acid, they can induce lactic acidosis in patients with liver and renal insufficiency, shock or heart failure.
The changes of blood sugar, GHB, FA, urine sugar, urine volume and body weight were observed, and the curative effect and drug dosage were evaluated.
4) Nursing observation of insulin therapy and prevention of adverse insulin reactions: ① Hypoglycemia reaction: It is related to excessive insulin dosage, eating disorder or excessive exercise, which is more common in patients with 1 type diabetes. It is characterized by dizziness, palpitation, sweating, hunger and even coma. For those with hypoglycemia, blood sugar should be detected in time, and sugary foods such as candy, biscuits and sugary drinks should be eaten according to the condition, or 20 ~ 30 ml of 50% glucose should be injected intravenously. Ensuring the effective dose and time of insulin, regular quantitative eating and moderate exercise are the keys to prevent hypoglycemia, including the preservation temperature of islets should not exceed 30℃ and avoiding violent shaking; There are two commonly used preparations in China: 40 or 100u per ml. Pay attention to the matching of syringe and islet concentration when using, and generally use lml syringe to extract liquid medicine to ensure accurate dosage. Ordinary insulin was injected subcutaneously before meals 1/2 hours, and protamine zinc insulin was injected subcutaneously 1h before breakfast. When long-acting insulin and short-acting insulin are mixed, short-acting insulin should be pumped first, then long-acting insulin should be pumped, and then mixed evenly. Reverse operation is not allowed to avoid mixing long-acting insulin with short-acting insulin, which will affect its quick effect. Patients should learn to eat according to the prescribed time and quantity, and reasonably arrange the daily exercise time and quantity. If the meal time is postponed, they can have some biscuits first. ② Insulin allergy: The main manifestations are local itching and urticaria after injection, and systemic rash is rare. Rare severe allergic reactions such as serum sickness and anaphylactic shock. ③ Atrophy or hyperplasia of subcutaneous fat at the injection site can cause insulin malabsorption, but it is rare in clinic. After stopping the injection at this site, you can slowly recover. Changing the injection site frequently to avoid injecting twice in the same site within two weeks can prevent the tissue at the injection site from shrinking or proliferating.
Teach patients the method of self-injection of insulin, and understand the adverse reactions of insulin and matters needing attention in use.
(3) The diabetic symptoms of the patients were significantly improved, their weight increased, and their blood sugar dropped to normal or tended to normal level.
2. The risk of infection is related to hyperglycemia, lipid metabolism disorder, malnutrition and microcirculation disorder.
(l) objectives
1) The patient was not infected.
2) Infected patients can be found and treated in time.
(2) Nursing measures
1) Diet Control the diet reasonably, ensure sufficient calories and protein supply, and enhance the body's resistance.
2) Control the possibility of infection, maintain oral and skin hygiene, scrub frequently and change clothes frequently. When injecting insulin, the local skin should be strictly disinfected to prevent infection.
3) Observe whether there are symptoms and signs related to infection, find them early and handle them in time.
I hope you are satisfied.