Chapter 1: nursing intervention analysis of neonatal intestinal obstruction

Congenital duodenal obstruction is a common digestive tract malformation in newborns, which can be divided into endogenous and exogenous according to the etiology. The common endogenous disease is duodenal atresia or stenosis caused by the obstruction of duodenal intestinal development. Common exogenous diseases include external compression of annular pancreas and intestinal rotation caused by pancreatic primordia failure. With the continuous improvement of perinatal medical imaging diagnosis technology, the detection rate of digestive tract developmental malformations in some late embryos has been continuously improved and treated in time. The traditional treatment is laparotomy, which has great trauma. With the extensive development of laparoscopy in pediatric surgery and the further maturity of basic techniques such as endoscopic anatomy and suture, laparoscopy has been gradually used in the diagnosis and treatment of neonatal abdominal diseases.

From July 2002 to March 20 1 1 year, 28 newborns with congenital duodenal obstruction were admitted to our hospital. All patients were cured after laparoscopic surgery. The nursing experience is reported as follows.

1 data and methods

Clinical data of 1. 1 Among the 28 children in this group, male 18 and female 10. Birth 1~27d, gestational age 32~4 1 week, birth weight 2 100~3750g. All the children discharged meconium normally within 2 hours to 7 days after birth, and showed symptoms of duodenal obstruction such as biliary vomiting.

1.2 The surgical methods were general anesthesia with tracheal intubation and tracheal block anesthesia.

18 cases of intestinal malrotation underwent Ladd operation; Six cases of duodenal diaphragm stenosis were treated by longitudinal incision of anterior wall, partial diaphragm resection and transverse suture. Two cases of duodenal atresia and two cases of circular pancreas underwent duodenal diamond anastomosis. From 2 to 5 days after operation, 26 cases were discharged on 7 ~ 13 days, and 2 cases of intestinal malrotation were cured again on the 7 th day after Ladd.

2 nursing

2. 1 Preoperative care Psychological care The child was hospitalized due to frequent vomiting, and the parents were uneasy and worried that the child could not bear the operation. First of all, we should patiently explain the necessity of surgery, the advantages of laparoscopic surgery, the possible surgical effects and complications. At the same time, it shows that we can switch to laparotomy, give parents full choices, and report the psychological status of their families to the competent doctor. Laparoscopic exploration was performed after parents agreed to sign.

Vomiting nursing to prevent aspiration (1): Due to the increased pressure in gastrointestinal cavity of children with duodenal obstruction, aspiration is easily caused by vomiting. Children should take a lateral or supine position with their heads tilted to one side. If you vomit, you should immediately remove the secretions in your mouth and nose, and pat your back to keep the respiratory tract unobstructed to prevent aspiration due to vomiting. (2) Gastrointestinal decompression and rehydration: no diet before operation, gastrointestinal decompression after operation; Because of vomiting and dehydration, it is necessary to replenish water for children, control the infusion speed, monitor blood gas, and maintain the balance of water and electrolyte while decompressing the gastrointestinal tract. Pay attention to the color and quantity of gastric juice, keep the gastric tube unobstructed and prevent vomiting; (3) Preoperative preparation: Wash the abdominal skin with soapy water, and wrap the umbilical cord after disinfection. The newborn's skin is delicate, so don't use too much force when cleaning, so as not to cause skin damage. In order to avoid bladder injury during operation and facilitate surgical field exposure and intraoperative monitoring, a catheter was placed before operation. The neonatal incubator is electrified to keep the temperature in the incubator, so that the baby can be put into the incubator after the operation.

2.2 Intraoperative Nursing In order to prevent neonatal hypothermia during operation, we should use a thermal radiation operating table, pay attention to keeping warm, and choose a heatable gas injector. The pressure of CO2 pneumoperitoneum is lower than 6, so as to reduce the accumulation of CO2. The vital signs, especially the partial pressure of carbon monoxide, should be closely monitored during the operation, and the pneumoperitoneum between lines should be cut off if necessary. In addition, keep the balance of water and electrolyte.

2.3 Postoperative care (1) was put into the neonatal incubator to keep warm, and the temperature changes of the children were noted. The development of neonatal thermoregulation center is immature, and the ambient temperature easily affects the rise and fall of body temperature. Newborns have relatively large body surface area, less subcutaneous fat and easy heat dissipation. Subcutaneous fatty acids contain more palmitic acid, which is easy to solidify and harden when it is cold, resulting in scleredema. Due to the long exposure time after operation, special attention should be paid to keeping warm after operation, all of them should be put into neonatal incubator and their body temperature should be monitored four times a day. The postoperative body temperature of this group of children is 35.2~38.5, and the box temperature is 28~33 according to the body temperature. (2) Close monitoring of vital signs. Before the child wakes up from anesthesia, there is a special person to watch and closely monitor vital signs and urine volume. Breathing and heart rate were measured every 15 minutes, and urine volume was measured every hour. Pay attention to the color and complexion of lips. Open the mask and inhale at a speed of 2 3L/ min. The percutaneous blood gas saturation of children under 36 weeks of pregnancy is maintained at 88%~93%, and that of children over 36 weeks is 90%~95%. Return to the ward after anesthesia, continue to monitor vital signs, and continue to inhale/kloc-0 through the mask for ~ 5 days to promote the discharge of residual CO2. Remove respiratory secretions in time, pay attention to keep the respiratory tract unobstructed, and if necessary, spray inhalation according to the doctor's advice, twice a day. (3) Continuous gastrointestinal decompression and nutritional support. After operation, no diet, gastrointestinal decompression, reduce the accumulation of proximal gastrointestinal fluid, reduce abdominal distension and promote the recovery of intestinal function. Connect the stomach tube to the disposable bag and place it under the stomach so that gas and stomach contents can be automatically discharged. Squeeze the gastric tube every 1 ~ 2 hours, and find out the reason when there is no gastric juice flowing out. Use a graduated disposable silicone gastric tube, and pay attention to the indwelling length of the gastric tube to prevent the gastric tube from slipping because it is polluted by nasal secretions and the adhesive tape is not firmly fixed. Pay attention to the recovery of intestinal functions such as abdominal distension, anal exhaust and defecation. Observe the tube for 24 hours, and try to feed water, 5~ 10ml each time, 1 time /2 hours. If there is no vomiting and bloating, stop gastrointestinal decompression. Start a small amount of feeding, gradually increase the amount of milk, pay attention to observe the defecation of children. If you have vomiting and abdominal distension, open it again and observe the color and amount of drainage fluid. The children in this group were forbidden to eat and drink for 2 ~ 5 days after operation, and were given gastrointestinal decompression and parenteral nutrition to ensure their nutritional needs. (4) Pay attention to observation, so as to find complications early. In this group, 2 children with intestinal malrotation developed mental discomfort, abdominal distension and yellow-green gastric juice vomiting on the 7th day after Ladd. Immediately after reporting to the doctor, he was diagnosed as intestinal obstruction by standing abdominal plain film, and was cured after intestinal resection and intestinal anastomosis again. (5) Prevent hospital infection. Newborns have defects in immune system, immature defense function and strong susceptibility to common pathogens. Intravenous infusion of cephalosporin antibiotics according to the doctor's advice, control of escort, daily replacement of distilled water in the box for humidification, keeping the bedding in the incubator clean, opening the window for ventilation every day after ultraviolet disinfection in the ward, oral nursing with warm saline twice a day, scrubbing skin wrinkles with warm water in the neck, behind the ears, armpits, groin and other parts, and keeping it dry, thus effectively preventing hospital infection. (6) Nursing after pneumoperitoneum and observation of puncture hole. After pneumoperitoneum, CO2 diffuses into blood or high pressure in abdominal cavity affects diaphragm movement, resulting in tidal volume reduction and CO2 retention, which is easy to cause hypercapnia. If postoperative breathing becomes shallow and PaCO2 _ 2 rises, be alert to hypercapnia. Although the incision of laparoscopic surgery is small, it is necessary to closely observe whether the incision is red, swollen, hot, painful, oozing blood and fluid after operation.

3 discharge guidance

It is very important to eat less and eat more meals because it takes a short time to resume feeding after operation. Parents are advised to observe the characteristics of their children's stools and adjust the feeding amount. Stand up and pat your back after each feeding to prevent vomiting caused by improper feeding. If you have symptoms such as nausea, abdominal distension and abdominal pain after eating, you should see a doctor at any time. 28 children in this group were followed up for 2~68 months, and their growth and development were normal. Two cases had intermittent vomiting 2 months after operation. After reoperation, it was found that the proximal jejunum adhered to ileocecum, and the incomplete obstruction was relieved and cured.

Laparoscopic surgery for neonatal congenital duodenal obstruction is safe and effective, with the characteristics of less trauma, early eating, quick recovery and beautiful appearance. Adequate preoperative preparation and comprehensive postoperative care are important guarantees to promote the early recovery of children.

Chapter two: Nursing experience of neonatal intestinal obstruction.

Neonatal intestinal obstruction is the most common emergency or relative emergency in neonatal surgery, with early onset, and its main clinical manifestations are vomiting, abdominal distension, delayed defecation or no defecation. The disease progresses rapidly and the diagnosis is difficult. It is reported that the death rate is as high as 60%. The author retrospectively analyzed the clinical data of 96 cases of neonatal intestinal obstruction in our hospital from April 2002 to May 2008, and summarized their nursing experience as follows.

Clinical data of 1

96 children in this group were treated 3 ~ 30 days after birth. Diseases are widely distributed, including digestive tract atresia, Hirschsprung's disease, congenital intestinal malrotation, meconium peritonitis, meconium embolism, pelvic tumor compression, diaphragmatic hernia, inguinal incarcerated hernia, digestive dysfunction and necrotizing enterocolitis.

2 nursing

2. 1 Psychological nursing before operation: Due to the difficulty of disease diagnosis, parents of children lack confidence in treatment psychologically, resulting in anxiety and fear. Therefore, psychological care for children's parents is of great significance. It is necessary to introduce them to the relevant knowledge of treatment, patiently and meticulously do a good job of psychological counseling and explanation, increase their confidence in treatment, and urge them to cooperate with treatment.

General nursing: Neonatal vomiting can easily lead to aspiration of pneumonia, and severe cases can suffocate and die. Therefore, we should do: effective gastrointestinal decompression; Maintain peripheral venous rehydration, ensure the balance of water, electrolyte and acid-base, and maintain the stability of internal environment; Give effective antibiotics; Improve the preoperative examination.

2.2 Postoperative nursing posture: After the operation, put the child in a warm box to inhale and lie flat to prevent vomiting and keep the respiratory tract unobstructed. After anesthesia, the body position should be changed regularly to prevent neonatal subcutaneous gangrene.

Diet: After operation, fasting drinking water, giving gastrointestinal decompression, stopping gastrointestinal decompression until intestinal function is restored, can gradually transition from sugar water to formula milk, and should follow the principle of from less to more, so as not to increase the feeding amount too quickly and cause frequent vomiting. The time of gastrointestinal decompression after enterostomy should be prolonged and the time of eating should be delayed appropriately.

Postoperative treatment: during fasting, fluid should be replenished to keep the balance of water, electrolyte and acid-base. Those who fast for a long time should be given parenteral nutrition and antibiotics should be used routinely. During infusion, the peripheral venous indwelling needle or deep venous catheter should be kept unobstructed to prevent infection.

Abdominal band dressing: the neonatal abdominal cavity capacity is relatively small and the abdominal wall is weak. After operation, the abdominal band should be bandaged to prevent the incision from cracking, but attention should be paid to the tightness of the abdominal band to avoid affecting the child's breathing.

Nursing of inner tube: We should pay close attention to protecting all kinds of drainage tubes in children to avoid falling off and ensure smooth drainage.

Observation of illness: Newborns have low tolerance to operation, so their vital signs should be closely observed after operation. Attention should be paid to: children's mental state and response to external stimuli; Whether there is no temperature increase or continuous fever; Whether there is persistent abdominal distension and vomiting, and whether the abdominal wall is red and swollen; Whether the mouth is red and swollen, and whether there is abnormal liquid flowing out. We should deal with the changes of the disease in time to prevent the occurrence of complications such as vomiting, asphyxia, aspiration pneumonia, subcutaneous gangrene of newborns, abdominal infection and intestinal fistula.

2.3 Health education should pay attention to scientific feeding and reasonable addition of complementary food after discharge; Keep the stool unobstructed; If you have symptoms such as vomiting and bloating, you should see a doctor in time.

3 discussion

Neonatal intestinal obstruction can occur in any section from duodenum to rectum and anus, and the cause is complicated. Due to the particularity of physiology, pathology and anatomy of newborns, the onset and development are urgent and rapid, and the mortality rate is high. Intestinal perforation, intestinal necrosis, peritonitis, toxic shock and pneumonia are serious complications that threaten children's lives. In effective nursing work, complications are often found early. Therefore, the nursing work of neonatal intestinal obstruction is difficult and complicated, and the requirements are very strict: (1) The neonatal ward (NICU) is a sterile intensive care unit, so parents can't accompany them, and nursing staff are needed to observe the changes of the child's condition at all times, and related complications can't occur because of poor observation; (2) Because the newborn can't communicate, it brings some difficulties to the observation of the disease, so it is necessary to cooperate with the doctor; (3) It is difficult to nurse newborns with intravenous infusion, especially with total parenteral nutrition, and the nursing requirements for intravenous indwelling needles are more demanding; (4) Because children are prone to internal environment disorder, the measurement of liquid inflow and outflow should be accurate; (5) indwelling drainage tube (such as enterostomy fistula, abdominal negative pressure drainage tube, gastric tube, urinary tube, etc.). ) are relatively slender, so it is necessary to strengthen protection and avoid blockage.