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血压测量结果相距甚远!双上肢PICC置管患者的血压这样测!

2019-10-30 吴泽芳 中国护理管理

某日,医生气势汹汹地到护士站问道:"04床近三次的血压和前几次血压怎么相差那么大也没人反馈给我们啊?"

患者血压测量结果相距甚远,护士未汇报惹医生训斥,真相是这样......

一、案例介绍

某日,医生气势汹汹地到护士站问道:"04床近三次的血压和前几次血压怎么相差那么大也没人反馈给我们啊?"

主班护士查看护理记录,果然,最近几次血压为168/102mmHg上下,而前几次血压在120/80mmHg上下。

把责任护士叫来后,责任护士解释道:"该患者是一名造血干细胞移植行保护性隔离的患者,需持续心电监护及血氧饱和度监测,双侧手臂均置有PICC,前面几次测的是上肢血压,而后因为考虑上肢血压测量影响PICC使用,于是测得的是下肢血压,但没有在护理记录单上注明。"

测量部位不同导致的血压值的差异,间接引发了上述纷争的产生。上述案例中,血压测量有无问题?有无必要更换测量部位?

二、案例分析

1. PICC置管侧手臂是否能够进行血压测量?

血压是一种重要的监测指标,也是人体重要的生命体征,及时、准确的测定,才能确保患者生命健康。

PICC在血液肿瘤患者化疗中广泛应用,然而,血液肿瘤患者D-二聚体指标较高,血液多呈现高凝状态。

为了避免测血压时血管压力增大、阻碍血液回流,同时避免导管过分挤压导致堵塞或受损,延长导管使用时间,一定不要在置管侧进行血压测量。

且患者在化疗后骨髓抑制期,血小板很低,在PICC侧测量血压可能会因长期受压导致穿刺点渗血,增加护士的工作量和患者的费用。像这种双上肢不适宜监测血压的情况在乳腺癌患者中更是常见。

双上肢均置有PICC如何监测血压?

三、经验分享

1. 血压测量的替代选择

当双上肢均置有PICC时,应在下肢部位测量血压。临床上常用的测量下肢血压的方法有:腘动脉血压的测量和踝动脉血压测量。

腘动脉血压测量法需使用下肢专用袖带,正常情况下,同侧下肢血压比上肢血压高20-40mmHg,由于相差值较大,不宜为临床医生作为准确判断血压的依据。且患者需采取俯卧位,脱裤腿暴露至大腿膝部,对于正在输液的患者或术后痊愈时间较短的患者难以忍受。

踝动脉血压测量法不受体位的限制,仰卧位即可完成下肢血压的测量,测得结果与肱动脉接近。踝动脉血压测量由于测量部位较低,只需撸起一小段裤管,且小腿测量部位周径与上肢接近,使用常规上肢袖带测量出足背动脉血压也是合理的。

有关文献报道显示,无论男女,因为踝部周径和上臂非常接近,袖带宽度影响比较小,所以,测得血压值更加接近。除此之外,在血压测量中,不用替换袖带,临床工作更加便利。

2. 在危重症患者中,动脉血压监测比较适用

有创动脉血压监测当前已广泛应用于临床实践,是指在动脉内置入动脉导管,应用监护仪连续进行血压测量的一种方式。

有创动脉血压监测可准确、直观且连续地对血压动态变化进行观察,同时可直接采集动脉血进行血气分析,可有效避免反复穿刺导致血管损伤等不良情况,不仅有利于减少临床护理人员工作量,同时可避免反复穿刺给患者带来的痛苦,尤其适用于重症患者。

但是,在血液肿瘤患者中,动脉血压监测存在诸多弊端,如对患者有损伤,不易被接受;增加感染几率;多数患者可下床活动,动脉监测会造成不便,维护起来增加工作量等。

3. 腕式血压测量,了解一下?

腕式电子血压计工作原理是当腕套内装置的传感器位于脉搏明显处时,充气至收缩压上能收集血压的声音并转为信号,仪器将信号变为数字,在数秒钟内得到收缩压、舒张压及脉搏数字。

腕式电子血压计优点是小巧、简便、快捷、省时。据国外文献报道,90%以上的患者更倾向于用腕式电子血压计自测血压。但电子血压计由于灵敏度高,易受外界因素的干扰,其测量值准确性又总是受到质疑,人们对其是否可靠一直有争议。

笔者在查阅文献后,发现有人做了相关研究。

用臂式电子血压计测量肱动脉血压与腕动脉血压测量值进行比较,乳腺癌手术前同一患者的肱动脉血压测量与腕动脉血压测量的测量值,差异无统计学意义(P>0.05)。

测量腕动脉血压与测量踝动脉血压对置管侧上肢的影响比较,乳腺癌手术PICC置管后,测量腕动脉血压组与测量踝动脉血压组置管侧上肢并发症的发生率差异无统计学意义(P>0.05)。

说明特殊情况下,不宜测量肱动脉血压时,可以测量其腕动脉血压,为患者病情变化提供临床数据,为观察患者生命体征提供临床依据。

4. 还有其他办法吗?

(1)用输液港代替一侧PICC

(2)连续血压测量

近些年,越来越多的人开始研究基于脉搏波的连续血压测量方法。该方法突破了袖带加压的限制,极大地提升了测量时的舒适度。

其方法主要有两种。一种是脉搏波速法,该方法通过获得脉搏波波速或脉搏波传导时间来测量血压

另一种是脉搏波波形特征参量法,该方法通过分析脉搏波波形特征与血压的关系来进行血压测量。然而,这种研究还处在探索阶段。

相信在不久的将来,通过提取更多与血压相关的有效特征以及使用基于大数据的深度学习算法建模,研发出新款血压计,为测量者提供更准确的血压信息,将成为现实。

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    2020-09-09 12177770m58暂无昵称

    学习了

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    2019-10-31 tomyang87
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    2019-10-31 zhs3884
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    2019-10-30 thm112988

    0

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胃轻瘫是一种慢性胃病,其特征为恶心,呕吐,早饱,餐后饱胀和腹痛。本项研究评估了胃轻瘫患者的病因,症状,生活质量,胃排空,治疗和症状结果的在不同种族和性别中的差异。

证据:PICC在烧伤患者静脉通路管理中的更佳证据

临床问题PICC在烧伤患者静脉通路管理中的最佳证据有哪些?相关背景相较于CVC而言,在烧伤患者中使用PICC更容易穿刺、更安全以及更具成本效果1。然而,目前尚缺乏一致的证据比较PICC、CVC在烧伤患者静脉通路管理中的使用方式。证据来源本证据总结来源于Dr Jared Campbell PhD, BHSc (Hons). Evidence Summary. Peripherally Inser

PICC拔管时竟发生断裂!处理方法了解一下

PICC导管断裂是一个非常严重的置管并发症,因其少见,更应当加以重视,令护士知晓应急处置办法。

PICC穿刺点渗液不要慌,我们有“秘方”

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。

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