本文選題：婦科腹腔鏡 + 老年患者　； 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：目的本研究通過(guò)對(duì)老年婦科腹腔鏡手術(shù)患者術(shù)中體位的改進(jìn),探尋在充分暴露術(shù)野的情況下既能減輕老年患者體位相關(guān)并發(fā)癥、又能提高其舒適度的手術(shù)體位。方法于2015年10月至2016年12月選取在鄭州大學(xué)第一附屬醫(yī)院手術(shù)室行婦科腹腔鏡手術(shù),并符合納入標(biāo)準(zhǔn)的100例老年患者為研究對(duì)象。依據(jù)納入順序采用隨機(jī)數(shù)字表法分為兩組,每組50例,對(duì)照組采用常規(guī)頭低足高截石位,觀察組采用改進(jìn)的頭低足高截石位。于麻醉誘導(dǎo)后(T1)、麻醉完成后平臥截石位(T2)、氣腹并頭低足高后5min(T3)、氣腹并頭低足高后30min(T4)及之后每30min(T5-T11)、氣腹解除后恢復(fù)平臥位5min(T12)、麻醉結(jié)束恢復(fù)清醒前(T13)測(cè)量患者的眼壓值;于手術(shù)全麻前擺好平臥截石體位后由患者填寫(xiě)手術(shù)體位舒適性量表,調(diào)查患者手術(shù)體位舒適度;并于術(shù)后24h、48h和72h對(duì)患者進(jìn)行隨訪,調(diào)查并記錄肩部疼痛情況和下肢疼痛麻木情況;術(shù)后對(duì)手術(shù)醫(yī)生、麻醉醫(yī)生和巡回護(hù)士進(jìn)行非結(jié)構(gòu)式訪談,以了解其對(duì)改進(jìn)后體位安置方法的評(píng)價(jià)。采用SPSS17.0統(tǒng)計(jì)軟件對(duì)收集的數(shù)據(jù)進(jìn)行處理分析,P0.05表示差異具有統(tǒng)計(jì)學(xué)意義�；颊咭话阗Y料中的定量資料采用t檢驗(yàn)、Mann-Whitney U檢驗(yàn),定性資料采用χ2檢驗(yàn);兩組患者術(shù)后肩痛發(fā)生率,下肢疼痛麻木發(fā)生率采用χ2檢驗(yàn);兩組患者同一時(shí)間點(diǎn)的眼壓值采用兩獨(dú)立樣本t檢驗(yàn)進(jìn)行比較;多個(gè)時(shí)間點(diǎn)的平均動(dòng)脈壓和眼壓值比較采用重復(fù)測(cè)量方差分析;兩組患者術(shù)后肩痛、下肢疼痛程度和手術(shù)體位舒適度的數(shù)據(jù)不服從正態(tài)分布,采用Mann-Whitney U檢驗(yàn)進(jìn)行比較,訪談資料采用Colaizzi現(xiàn)象學(xué)資料七步分析法。結(jié)果1.兩組患者平均年齡、BMI指數(shù)、術(shù)前眼壓平均值差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05);手術(shù)相關(guān)資料手術(shù)類型、手術(shù)時(shí)間、輸液量、出血量等比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。2.兩組患者不同時(shí)間點(diǎn)眼壓值的比較,在麻醉誘導(dǎo)后(T1)、麻醉完成后平臥截石位(T2)兩個(gè)時(shí)間點(diǎn),兩組患者眼壓值差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。在氣腹并頭低足高后5min(T3)-氣腹解除后恢復(fù)平臥位5min(T12)之間的每個(gè)測(cè)量時(shí)間點(diǎn)兩組患者眼壓值差異有統(tǒng)計(jì)學(xué)意義(P0.05);在T12階段兩組患者的眼壓值均始降低,觀察組平均眼壓為(19.60±0.82)mmHg,降至正常水平,而此時(shí)對(duì)照組平均眼壓值為(24.40±0.98)mmHg,雖有降低但仍高出正常眼壓范圍(正常眼壓范圍10-21mmHg);在麻醉結(jié)束恢復(fù)清醒前(T13)階段兩組患者眼壓值均降到正常水平。3.兩組患者的平均動(dòng)脈壓比較,在氣腹并頭低足高后5min(T3),觀察組患者的平均動(dòng)脈壓為(81.35±8.81)mmHg,對(duì)照組患者的平均動(dòng)脈壓為(85.17±8.08)mmHg,比較差異具有統(tǒng)計(jì)學(xué)意義(t=2.261,P0.05);氣腹并頭低足高后30min(T4),觀察組患者的平均動(dòng)脈壓為(84.84±10.65)mmHg,對(duì)照組患者的平均動(dòng)脈壓為的(89.02±9.08)mmHg,比較差異具有統(tǒng)計(jì)學(xué)意義(t=2.105,P0.05);除去T3、T4時(shí)間點(diǎn),T1、T2時(shí)間點(diǎn)以及T4之后的時(shí)間點(diǎn),兩組患者的平均動(dòng)脈壓比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。4.兩組患者術(shù)后下肢疼痛麻木發(fā)生率分是對(duì)照組為12/50(24%)、觀察組為4/50(8%),對(duì)照組與試驗(yàn)組比較差異有統(tǒng)計(jì)學(xué)意義(χ2=4.762,P0.05);兩組發(fā)生疼痛患者的VAS疼痛評(píng)分,對(duì)照組患者為(3.20±0.82)分,觀察組患者為(2.15±0.51)分,疼痛評(píng)分比較差異均有統(tǒng)計(jì)學(xué)意義(Z=-2.375,P0.05)。5.兩組患者術(shù)后肩部疼痛發(fā)生率分別是對(duì)照組為18/50(36%)、觀察組為6/50(12%),對(duì)照組與觀察組比較差異有統(tǒng)計(jì)學(xué)意義(χ2=7.895,P0.05);兩組患者發(fā)生術(shù)后肩痛的VAS疼痛評(píng)分,對(duì)照組平均得分為(4.20±1.25)分,觀察組平均得分為(1.78±0.51)分,疼痛評(píng)分比較差異均有統(tǒng)計(jì)學(xué)意義(Z=-3.501,P0.05)。6.兩組患者體位舒適度得分比較,對(duì)照組患者平均得分為(67.81±4.12)分,觀察組患者平均得分為(3.18±4.38)分,比較差異具有統(tǒng)計(jì)學(xué)意義(Z=-5.422,P0.05)。其中在生理、心理、環(huán)境三個(gè)維度的得分差異有統(tǒng)計(jì)學(xué)意義(P0.05)。7.非結(jié)構(gòu)式訪談結(jié)果顯示手術(shù)醫(yī)生、麻醉醫(yī)生和巡回護(hù)士對(duì)觀察組體位安置方法評(píng)價(jià)較好,觀察組的體位安置方法手術(shù)野暴露良好,不會(huì)影響手術(shù)醫(yī)生的操作,不會(huì)阻礙患者的呼吸。結(jié)論1.相比傳統(tǒng)的頭低足高截石位,改進(jìn)頭低足高截石位能有效減少老年患者術(shù)中眼壓值的升高,有利于老年患者手術(shù)安全。2改進(jìn)頭低足高截石位患者的體位舒適度較高,能有效減少患者術(shù)后下肢并發(fā)癥的發(fā)生并有利于減輕患者術(shù)后肩痛。
[Abstract]:Objective to explore the improvement of the postural position in the elderly gynecologic laparoscopic surgery, to explore the surgical posture which can reduce the body position related complications and improve the comfort of the elderly patients under the condition of full exposure of the surgical field. Methods from October 2015 to December 2016, the Department of gynaecology in the operation room, the First Affiliated Hospital of Zhengzhou University, was selected. Laparoscopic surgery was performed in 100 elderly patients, which were divided into two groups according to the order of inclusion, 50 cases in each group, and the control group adopted the normal head and low foot high osteotomy position, the observation group adopted the improved head and low foot high osteotomy position. After anesthesia induction (T1), the supine lithotomy position (T2), pneumoperitoneum after the anesthesia was completed, and pneumoperitoneum, 5min (T3) after lower foot and lower foot, 30min (T4) and 30min (T5-T11) after low foot of the lower foot, 5min (T12) of the supine position recovered after the pneumoperitoneum was relieved, and the intraocular pressure of the patients was measured before the end of anaesthesia (T13); the surgical posture Comfort Scale was filled in by the patients before the operation of general anesthesia and the comfort of the surgical posture was filled in, and the comfortable position of the patients was investigated. The patients were followed up with 24h, 48h and 72h after the operation to investigate and record the pain of the shoulders and the numbness of the pain of the lower limbs. After the operation, the surgeon, the anesthesiologist and the itinerant nurse were interviewed by unstructured interviews in order to understand the evaluation of the improved post position method. The data collected by the SPSS17.0 statistical software were processed. Analysis, P0.05 indicated that the difference was statistically significant. The quantitative data in the general data were t test, Mann-Whitney U test and chi 2 test for qualitative data. The incidence of shoulder pain in the two groups and the incidence of numbness of lower extremity pain were tested by chi 2 test, and the intraocular pressure values of the two groups were compared with two independent sample t test at the same time point. The average arterial pressure and intraocular pressure of multiple time points were analyzed by repeated measurement of variance. The data of shoulder pain after operation, the degree of pain of the lower limbs and the comfort degree of the surgical position were not subject to normal distribution in the two groups, compared with the Mann-Whitney U test, and the interview data were analyzed by the seven step analysis of the Colaizzi phenomenology data. Results the results of the 1. two groups were flat. The average age, BMI index, and preoperative intraocular pressure (IOP) mean difference was not statistically significant (P0.05); there was no significant difference in operation related data, operation time, infusion volume, bleeding volume, etc. (P0.05) the comparison of intraocular pressure at different time points in the.2. two groups, after anesthesia induction (T1), and two time points for the supine lithotomy position after the anesthesia was completed, There was no significant difference in intraocular pressure between the two groups (P0.05). There was a significant difference in the intraocular pressure between the two groups of two groups of patients after the recovery of 5min (T12) after the release of the lower foot of the pneumoperitoneum (T3) and the relieving of the pneumoperitoneum (P0.05). In the T12 stage, the intraocular pressure of the two groups was reduced, and the average intraocular pressure of the observation group was (19.60 + 0.82) mm. Hg, to the normal level, and at this time the average intraocular pressure of the control group was (24.40 + 0.98) mmHg, although there was a decrease but still higher the range of normal intraocular pressure (normal intraocular pressure range 10-21mmHg); the intraocular pressure of two groups of patients in the two groups before the end of the anesthesia recovery (T13) were all lower to the normal level of the.3. two group, and 5 after the lower foot of the pneumoperitoneum. Min (T3), the average arterial pressure of the patients in the observation group was (81.35 + 8.81) mmHg, the average arterial pressure of the control group was (85.17 + 8.08) mmHg, and the difference was statistically significant (t=2.261, P0.05), and the average arterial pressure of the patients in the observation group was (84.84 + 10.65) mmHg, and the average arterial pressure of the control group was 89.02 (89.02) (89.02). The difference was statistically significant (t=2.105, P0.05), and the average arterial pressure in the two groups was not statistically significant (P0.05) except T3, T4 time point, T1, T2 point and time after T4 (P0.05). The incidence of numbness in the lower limb pain in the two groups was 12/50 (24%), the observation group was 4/50 (8%), and the control group. Compared with the experimental group, the difference was statistically significant (x 2=4.762, P0.05); the VAS pain score in two groups of pain patients was (3.20 + 0.82), and the patients in the observation group were (2.15 + 0.51), and the difference in pain score was statistically significant (Z=-2.375, P0.05) in group.5. two, the incidence of shoulder pain was 18/5 in the control group, respectively. 0 (36%), the observation group was 6/50 (12%), the control group was significantly different from the observation group (x 2=7.895, P0.05); the two groups of patients had the pain score of shoulder pain after operation, the average score of the control group was (4.20 + 1.25) points, the average score of the observation group was (1.78 + 0.51) scores, and the difference of pain score was statistically significant (Z=-3.501, P0.05).6. two group. The score of the patient's body position comfort was compared, the average score of the control group was (67.81 + 4.12). The average score of the patients in the observation group was (3.18 + 4.38), and the difference was statistically significant (Z=-5.422, P0.05). The difference of score difference between the three dimensions of physiology, psychology and environment was statistically significant (P0.05).7. non structural interview results showed surgery Doctors, anesthesiologists and itinerant nurses have better evaluation of the placement of the observation group. The position of the observation group is well exposed in the surgical field, which does not affect the operation of the surgeon and does not obstruct the patient's respiration. Conclusion 1. compared with the traditional head and low foot high lithotomy position, the improvement of the head low foot high osteotomy position can effectively reduce the intraoperative eye of the elderly patients. The increase of pressure value is beneficial to the operation safety of the elderly patients with.2 to improve the comfort degree of the patients with low foot and high stone position, which can effectively reduce the incidence of postoperative complications of the lower extremities and reduce the shoulder pain after operation.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R473.6

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