PICC穿刺点渗液不要慌,我们有“秘方”

2018-11-30 陈锦 中华现代护理杂志

经外周静脉置入中心静脉导管(PICC)已被广泛应用于临床,但是 PICC 留置期间也存在一些并发症,穿刺点发生渗液就是其中一种。而淋巴管损伤导致的淋巴管渗液是比较少见的,它可造成敷贴脱落,增加感染风险;同时渗液后需要频繁更换贴膜,不仅增加了护士的工作量,也加重了患者的经济负担。

经外周静脉置入中心静脉导管(PICC)已被广泛应用于临床,但是 PICC 留置期间也存在一些并发症,穿刺点发生渗液就是其中一种。而淋巴管损伤导致的淋巴管渗液是比较少见的,它可造成敷贴脱落,增加感染风险;同时渗液后需要频繁更换贴膜,不仅增加了护士的工作量,也加重了患者的经济负担。

淋巴管渗液的原因是什么?有没有更好的解决办法?相信一定是临床护士所困惑的问题。

案例分享

患者,男性,54岁,鼻咽癌,因治疗需要,于2018年5月9日在无菌操作下于右上臂经贵要静脉在B超下行PICC穿刺置管术,置管过程顺利,尖端位置正常,导管置入38厘米,外露6厘米。

于次日早晨护士床边交接班时发现患者穿刺点有透明水样液体和少许血性渗液,贴膜松动,为了能更好吸收穿刺点渗液,降低伤口感染,在常规消毒后给予6层2cm×2cm无菌纱布置于穿刺点上方,外用(9cm×14cm)康惠尔水胶体敷料覆盖穿刺点及周围皮肤。

5月11日白班接班查看患者PICC导管时,发现穿刺点处纱布已被渗透,渗液量明显增加,呈淡黄色水样液体和少许血性渗液。用10ml冲管液冲洗导管时,穿刺点渗液无改变,评估患者营养状况良好,考虑患者置管时损伤淋巴管导致淋巴管渗液。

立即给予维护,将穿刺点部位常规消毒后,取一片藻酸盐敷料 折叠成2cm×3cm的矩形并从中间剪一小口,再将PICC蓝色导管外露部分放在藻酸盐片的小口上,随即附着在穿刺点处,外用(9cm×14cm)康惠尔水胶体敷料覆盖。每班进行交接,密切关注患者穿刺点渗液情况。

5月13日用同样方法换药后,往后每两天一次予以同样方法换药2次后,患者穿刺点渗液明显减少,直至5月19日换药后未再出现渗液情况。

淋巴管渗液的原因

导管材质因素

在应用超声引导下改良塞丁格技术行上臂PICC置管时,穿刺针、血管鞘和导管必须在皮下走行较长距离,易造成皮下组织损伤,淋巴液或者组织间液渗出导致穿刺点渗液。

血管解剖因素

上肢浅淋巴管较多且位于皮下,常与浅静脉伴行。因肘淋巴结与腋淋巴结之间汇成淋巴丛,而前臂尺侧淋巴管又较丰富,若穿刺者对血管解剖不熟悉或反复穿刺,也会损伤浅表淋巴管,造成穿刺点持续渗液。

操作者技术因素

置管时横向扩皮切口过大或者二次扩皮,使导管周围组织的间隙过大,而在穿刺血管周围腔隙中有淋巴管通过,组织液可从穿刺点渗出。尤其是反复穿刺以及多次送管更易导致淋巴管损伤组织间液渗出。

淋巴管渗液的预防

1.规范PICC置管护士的资质准入,加强PICC导管风险及安全管理,制定标准化流程。

2.定期组织护理人员进行PICC相关知识培训、典型案例分享和操作示范等,不断提高业务水平,严格掌握PICC并发症的预防和处理。

3.置管前充分评估患者情况,对于血管条件差的患者选择肱静脉穿刺,成功率相比贵要静脉更高,因肱静脉旁无伴行的淋巴结,降低了淋巴结损伤而导致渗液的可能性。

4.专科护士操作时将扩皮刀由原来横向破皮改为绷紧皮肤后沿导丝纵向切开0.2cm的切口破皮,与导管走向一致,减小切口张力,避免反复扩皮,减少对淋巴管损伤。送入PICC导管时按1~2cm/次的速度缓慢轻柔送入导管。

5.选择合适的位置,正确固定导管。固定导管时避免蓝色导管部分弧度过小使穿刺点被牵拉,或导管压迫淋巴管而导致渗液过多,伤口不易愈合。

6.加强个性化宣教,对于发生淋巴管渗液的患者,告知其注意观察穿刺点敷料及渗液情况,有无贴膜松动,及时告知护士进行妥善处理。

知识链接

水胶体敷料是一种含有羧甲基纤维素钠(CMC)的敷料,它与创面接触的一层由果胶、明胶和CMC等构成,外层为聚氨酯薄膜。其可吸收渗出液,形成凝胶,保持创面适宜的温度和湿度,为创面提供一个良好的湿性愈合环境。

水胶体敷料促进伤口愈合原理及作用

1.有粘性,可形成密闭创面。能有效防止细菌入侵伤口,有利于创面的毛细血管和肉芽组织的形 成,从而加速创面愈合。

2.提供湿性愈合的环境

3.吸收少量渗液,促进上皮爬行。

4.该敷料透气防水且有不同大小和厚度,较薄的敷料可与皮肤贴合紧密。

5.敷料吸收渗液后可见敷料表层变白膨胀,便于评估敷料更换频率。

藻酸盐敷料成分为藻酸盐,是在海藻中提取的天然多糖碳水化合物,为一种天然纤维素。藻酸盐敷料是由藻酸盐组成的一种高吸收性能的功能性伤口敷料。该敷料接触到伤口渗出液后,发生膨胀形成藻酸钠凝胶,可在创面上形成柔软、潮湿的半固体物质屏障,能清洁创面,减少感染机会,并可防止痂皮形成,为伤口愈合提供理想的湿润环境,促进伤口愈合。

藻酸盐敷料促进伤口愈合的原理及作用

1.藻酸盐敷料中含有天然藻酸盐纤维和羧甲基纤维素钠,可促进肉芽生长。

2.高吸湿性。能快速、大量、垂直吸收渗液并形成凝胶的特点,并可有效保护创面及周围皮肤。

3.成胶性。吸收渗液后的藻酸盐敷料膨胀成藻酸钠凝胶,在创面上形成柔软、潮湿的半固体物质屏障,固着于渗液处而不易脱落,达到大量、垂直吸收渗液 。

4.促进伤口愈合。同时形成的藻酸钠凝胶半固体物质屏障可清洁创面,减少感染机会,并可防止痂皮形成,使创口接近生理状态的愈合环境。

5.抑菌性。密闭性好,使伤口与外界细菌隔绝,且微酸的环境有利于中性粒细胞发挥作用,增强局部杀菌能力,降低感染发生率。

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    2018-12-02 rgjl
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    2018-12-02 tomyang87
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    2018-12-02 zhs3884
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    2018-12-01 zhao..doctor..

    少受点放射线

    0

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