鼻肠管置管和护理.ppt

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,鼻肠管的置入方法及护理,1,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,2,营养方式及喂养途径的选择,床旁盲插鼻空肠管指征及禁忌症,置管方法介绍,鼻肠管的管理,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,常用营养方式,肠内营养,(EN),口服和管饲，首选 生理性途径,肠外营养,(PN),人为的治疗途径,混合营养（,PPN+PEN,）,“,全营养,”,3,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,否,管饲喂养,否,膳食摄入,是,膳食摄入,90,需要量,是,胃肠道是否有功能,肠外营养,管饲喂养适应证,4,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,概述,对不耐受经胃营养或有返流和误吸高风险的重症病人，宜选择经空肠营养（,B,级）,胃潴留、连续镇静或肌松、肠道麻痹、急重症胰腺炎病人或需要鼻胃管引流的病人。,中华医学会危重病人营养支持指导意见（草案），,2006,年,5,月,危重病人肠内营养途径的选择,5,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,幽门前,/,后喂养,鼻胃,(,肠,),管,造口管,胃,经皮内窥镜引导,下胃造口管,(PEG),球囊型胃造口管,（,G-Tube,）,肠,经皮内窥镜引导下胃造口螺旋型空肠管,(PEJ),空肠造口管,(Jejunokath),6,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,幽门后营养优点,改善肠内营养耐受性明显降低由胃、食道反流引起的误吸及呕吐,十二指肠喂养刺激胆囊收缩、加速小肠转运，增加胆囊收缩素及胰腺多肽的释放,空肠喂养不刺激胰腺分泌,7,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻肠管适应症,肠道功能基本正常而胃功能受损；吸入风险高的病人,重症病人反复呕吐，误吸返流：鼻胃管,46,，小肠内管饲,6,；重症病人胃肠动力紊乱：胃食管返流率,78,（脑损伤）胃瘫,重症胰腺炎早期,8,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻肠管禁忌症,食道静脉曲张,食道出血,严重肠道吸收障碍,肠梗阻,急腹症,9,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻肠管置管方法,床旁置管至胃,:,胃动力好,被动等待过幽门或应用药物促进,主动置管至十二指肠空肠,（盲插）,X,线透视下,内窥镜引导下,B超引导下,可视,其他,10,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,肠管的置管方法,床旁主动置管,置管前的物品准备、患者的准备,置管中的技巧和双人配合方法,置管后的肠管固定和确定方法,11,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管前的准备,鼻肠管、,20ml,注射器、听诊器、无菌纱布、石蜡油,物品准备,有无颅内压增高现象，生命体征稳定，吸痰（适应症患者）,患者的准备,胃复安,10mg IV,置管前用药,12,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管前的准备,物品准备,13,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第一步：置管至胃,14,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,禁食,4,小时，清理口鼻分泌物,右侧卧位置管，导管沾水润滑常规,置管入胃，判断在胃腔,第一步：置管至胃,15,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第一步：置管至胃,16,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第二步：,置管自胃到幽门后,确定已过幽门,直至,105cm,位置注入20cm空气,右下腹十二指肠段听,到沉闷的气过水声,每进10cm,连续注入100ml空气，,回抽小于20ml空气,17,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第二步：置管自胃到幽门后,-,用导丝判断导管有无打圈,18,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第二步：,置管自胃到幽门后,-,寻找最响亮的位置,的位置,19,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第二步：,置管自胃到幽门后,-,右下腹十二指肠段听到沉闷的气过水声,20,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程,第二步：,置管自胃到幽门后,-,连续注入,100ml,空气,回抽小于,20ml,空气,21,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管技巧,过咽部（约,15cm,处）,嘱患者吞咽，可从患者嘴里注入少量开水刺激其吞咽动作。,充分润滑管道,鼻刺激严重者，可予丁卡因行鼻粘膜表面麻醉。烦躁者与医生沟通予适当镇静,22,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管技巧,过贲门部（约,40-43cm,处）,充分润滑管道，遇到阻力，勿盲目用力置管,手法：以约,90,度旋转逐渐进管，不宜快进,右侧卧位,23,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管技巧,过幽门部（,70-75cm,处）,-,关键,体位：右侧卧位45度,推送方法：一只手捏住鼻端管子处，另一只手缓慢推送进管,方法一：以约,90,度旋转管子的手法，随患者的呼吸，在患者呼气时以每次,2cm,缓慢进管,方法二：胃内注气法置管：300-500ML（5-10ml/kg)，5分钟,不撤导丝，,随呼吸,轻柔缓慢进管，有,轻度摩擦阻力,，缓慢进管,75cm,，多数管端已通过幽门，继续轻柔进管,24,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程初判断方法,抽：颜色：金黄色；,PH,值：,PH7,在肠腔（制酸剂干扰）；,pH5,提示胃内。,25,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,置管过程初判断方法,听,：比较不同部位气过水声：,左上腹闻及管端在胃；,上腹中线最响亮管端在胃窦；,右上腹音调较高，管过幽门在十二指肠；,管端在十二指肠远段或空肠上段,高调气过水音 移至左下腹,感,：回抽时阻力大,26,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,注意事项,固定置管人员（可丰富盲插置管经验）,插管时如遇阻力明显增加,不应盲目用力进管；,如果阻力突然消失,提示管端折返胃腔。,以上二种情况,均应退管至胃（,50cm,）,刻度处重新进管。,27,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,确认导管位置,X,线拍片确认管道的位置（金标准）,28,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻胃肠管管理,输注营养液的卫生,输注方式的选择：营养泵,防止管道堵塞（脉冲式封管）,防止固定处皮肤损伤,口腔护理,29,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻胃肠管管理,妥善固定,75cm,依然在十二指肠,管道脱出,30,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻胃肠管管理,因鼻肠管的管腔内径细、置管时间长、输注营养液的浓度不定、输注速度慢、鼻饲中自管腔注入的药物碾磨不细、鼻饲后未及时脉冲式冲洗管腔致使药物沉渣积淀于管壁、营养素未调匀等因素有关。,管道堵塞,31,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,鼻胃肠管管理,使用肠内营养泵匀速输入营养液，太慢易堵管，大于,50ml/h,尽量使用液体状药物，使用固体时要充分研磨或溶解，注意配伍禁忌，分开注射,至少每隔,4h,用,30ml-50ml,温水脉冲式冲管一次；药物及输入前后应以,1030ml,温水冲洗管道,禁止鼻饲有渣溶液或粥,管道堵塞,32,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,预防管道堵塞（建议）,33,Presentation Title(Edit on Slide Master)|June 12015|Confidential,for Internal Use Only,堵管的处理,50ml,注射器注入温开水使用压力冲洗,+,负压抽吸交替进行，同时用手反复捏挤留置鼻空肠管鼻腔外部分，并调整患者的体位,用,50ml,注射器交替注入温开水及,5,碳酸氢钠溶液反复低压冲洗管道，冲管压力由小到大,34,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,堵管的处理,三通管接鼻肠管末端，关闭三通管两个通口，反复由主通口抽吸空气形成负压，后由侧通口负压原理吸引可口可乐或碳酸氢钠进入鼻肠管道内，浸泡,30,分钟后检查是否通畅,三通管的应用,35,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,Initial Long,Term,Replacement,EN,Delivery,Short,Term,Product Portfolio,产品系列,36,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,37,Nasogastric Feeding Tubes Portfolio鼻胃管系列,Portfolio:,DobbHoff,TM,ENTRIFLEX,TM,KANGAROO,TM,ARGYLE,TM,Pedi-Tube,TM,37,|,聚氨酯材质,更薄的管壁实现更细的管身，实现更优的流量,热敏性材料：在人体内变的柔软,光滑的表面能将堵塞风险降到最低,对预防管体萎缩和破损进行了改良,不透射线,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,38,ENTRIFLEX,TM,NG Tubes,Product Definition:,Slimmer weighted tip(3g&5g),较轻的重头,Hydromer coated,亲水润滑涂层,10,12Fr sizes,10,，,12Fr,大小,110,、,140 cm lengths,长度,Patented stylet,专利探针,100%polyurethane 100%,聚氨酯,38,|,Slim Weight,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,39,Kangaroo,TM,NG Tubes,Product Definition:,产品定义,Non-weighted,:,无重头,8,10,12 and 14 Fr,Polyurethane construction,聚氨酯材料,Dual port connector,双端口连接头,Radiopaque stripe,不透射线条纹,91cm,长度,39,|,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,40,Dobbhoff NJ/GD Tube,100%Polyurethane,radiopaque 100%,聚氨酯，不透,X,线,Hydromer coated,亲水润滑涂层,“Push”insertion over a guidewire,推入部分超过导丝,Simultaneous Gastric decompression and jejunal feeding,同时实现胃减压和肠营养,Unique:Adjustable length design,独一无二：可调节长度设计,8-10 spiraled gastric suction holes 8-10,个螺旋形的胃吸引孔,Separate suction&feeding port,吸引接口和营养输送接口分开,170 cm length(longest tube on the market 9 Fr Jejunal Tube/16 Fr overall diameter 170cm,（市场上最长的管,9Fr,空肠管,/16Fr,直径,170cm,长）,Ship case 2,40,|,2 Tubes In One,Presentation Title(Edit on Slide Master)|June 1,2015|Confidential,for Internal Use Only,Thank You for attention!,知识回顾,Knowledge Review,