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Biliary obstruction caused by various reasons is a common clinical disease in hepatobiliary surgery. Patients with obstructive jaundice used percutaneous transhepatic biliary drainage (PTCD) to reduce jaundice. With the development of fiberoptic endoscopy, a new biliary drainage method, nasobiliary catheter drainage (ENBD), was born. It is a biliary drainage and decompression technology under direct vision of duodenoscopy. It has high success rate and few complications, which greatly improves the quality of life of patients. ENBD has been implemented since July 2003 for the treatment of common bile duct stones and suppurative cholangitis. It takes endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for stone removal, and then indwelling nasobiliary drainage. It has achieved good therapeutic results. The nursing summary is reported as follows.
1、 Clinical data:
1. General data: there were 13 males and 8 females; The age ranged from 50 to 80 years; There were 15 cases of common bile duct stones and 6 cases of suppurative cholangitis. All cases had varying degrees of jaundice, and some had upper abdominal pain.
2. ENBD catheterization method: insert through the mouth, first endoscopic cholangiography, after determining the blocking position, insert the guide wire into the bile duct above the blocking, select the bile duct with the widest drainage range, insert a slender polyethylene tube along the guide wire, and take out the guide wire after reaching the predetermined position. The nasobiliary duct is first led out from the mouth, and finally led out from the nostril with a nasal catheter and properly fixed.
3. Results: all the 21 cases were successful, and the postoperative jaundice and abdominal pain were gradually reduced or disappeared. Because of the history of mental depression before operation, 1 case had abnormal mental tension in the early stage after operation; Blood amylase increased slightly in 1 case in the early stage after operation.
2、 Care:
1. Preoperative psychological nursing: during preoperative preparation, it was found that patients and their families had varying degrees of tension and fear of ENBD, such as whether the intubation process could be tolerated and how the curative effect was. Therefore, the patient and family members should be patiently and carefully explained before the operation, and ENBD should be informed that it is a relatively advanced technology. It treats the disease through minimally invasive technology and can quickly alleviate the condition. During the operation, the endoscope has discomfort through the pharynx, the other reactions are generally tolerable, and there is generally no special discomfort after catheterization. Through preoperative psychological nursing, the patient can basically relieve his tension, and give preoperative intramuscular injection of diazepam 10mg. The patient can cooperate with the doctor, improve the success rate of catheterization and reduce the patient's pain.
2. Postoperative observation and nursing:
① Postoperative drainage tube nursing: after ENBD, the patient returned to the ward, connected the negative pressure drainage bag, and achieved double fixation outside the body, i.e. nasal wing side, cheek and bedside fixation. The patient was instructed to fast and stay in bed to reduce activities, so as to prevent catheter prolapse, and informed that there may be short-term gastrointestinal discomfort after swallowing and endoscopic tube placement due to local influence of throat, which can be gradually relieved, At the same time, the patient is repeatedly warned to protect the catheter during activities and sleep, do not pull the nasal bile duct, and pay attention to the length of the nasal bile duct outside the body to prevent it from prolapse. If a little prolapse is suspected, the catheter should not be forcibly transported in. The catheter should be fixed, and the bile drainage should be observed. If there is no bile outflow, it should be reported to the doctor for treatment in time. In short, patients should consciously protect the catheter, actively cooperate and assist in treatment and nursing.
② Observe the drainage fluid and determine the position of the catheter: since both the pancreas and bile duct open at the duodenal papilla, the catheter may be inserted into the bile duct or pancreatic duct. This requires the nursing staff to observe whether it is bile or pancreatic fluid, which can also be determined by angiography and B-ultrasound. It is very important to observe the change of drainage fluid clinically. If the drainage flow is small (50 ~ 200ml / D) and the luster changes from light yellow to colorless, the catheter may be placed in the pancreatic duct and should be reported to the doctor in time. Through clinical observation of the changes of drainage fluid, it is helpful for doctors to grasp the changes of the condition and adjust the treatment plan.
③ Relationship between the changes of bile color and drainage volume and the condition: observe the characteristics of bile drainage changes, (1) bile color: the bile of patients with long-term biliary obstruction is dark yellow or sauce oil color. After 2 ~ 4 days of unobstructed tube drainage, the color gradually turns light yellow, and abdominal distension and jaundice gradually reduce. Suppurative cholangitis, there can be a large number of yellow and white purulent flocs and sediment floating in the bile, which is easy to block the catheter. After the blockage is removed and the drainage is unobstructed, the symptoms such as abdominal pain and fever are significantly relieved. (2) Bile volume: after catheterization in patients with obstruction, the bile drainage volume can reach 400 ~ 1100ml / D, with an average of 500ml / d. with the relief of obstruction, the liver function is gradually improved. After some ENBD, the drainage volume is little, about 100ml / D, but the symptoms are significantly improved. This is because after the obstruction at the lower end of the bile duct is relieved and the inflammatory edema is eliminated, the sphincter function is restored, and part of the bile can be discharged into the duodenum through the periphery of the supported catheter.
④ Prevention of cholangitis and acute pancreatitis: ENBD is an important measure to relieve biliary obstruction, but improper treatment is easy to induce or aggravate infection. Antibiotics and enzyme inhibition were used routinely after operation. Check the blood amylase after operation. If the blood amylase value is abnormally increased and accompanied by severe upper abdominal pain, it should be suspected of acute pancreatitis.
4、 Summary:
As a minimally invasive treatment technology, ENBD can quickly relieve biliary obstruction, reduce biliary pressure and unobstructed drainage, so as to quickly alleviate the patient's condition, control infection and improve systemic poisoning symptoms. In clinical nursing, we should do a good job in perioperative psychological nursing, listen to the patient's main complaint after operation, understand the possible complications, closely observe the abdominal signs and drainage fluid properties, properly fix them, keep the drainage tube unobstructed, and prevent and treat complications in time.