영양문제와간호 부선주 09/09/2013
Enteral Feeding (tube feeding/ Gavage) - 관을통해위장관으로유동식을공급하는것 - 장의흡수가정상일때적용 2
위루술 : p.412 Youtube: http://www.youtube.com/watch?v=atqgkk0zw2s 3
위장관위치확인법 (p.410) Verify placement of tube before feeding (1) Inject a small amount of air into the tube and, with a stethoscope placed over the epigastric area, listen for the passage of air into the stomach. (2) Aspirate for presence of stomach contents; reinstill to avoid electrolyte imbalance (3) Test aspirate for acid ph (4) X-ray 4
경장영양 Nursing care (p.411) Intermittent feeding (1) Elevate head (2) Verify placement of tube (3) Introduce 30ml of water to verity the patency of the tube (4) Slowly administer the feeding at room temperature or body temperature; observe an question the client to determine tolerance (5) Administer 30ml of water to clear the tube at the completion of the feeding (6) Clamp the tubing and clean the equipment (7) Place client in sitting position for 1 hour after feeding (or right side-lying position) 5
TPN Nursing care (p.414) (1) Infuse fluid through a large vein: subclavian vein (high osmolarity) (2) Ensure proper placement of the line (chest X-ray after line insertion) (3) Precisely regulate the fluid infusion rate (use infusion pump) (4) Rapid infusion- hyperglycemia, circulatory overload. (5) Slow infusion hypoglycemia, because the body adapts to the high osmolarity of the fluid by secreting more insulin ( TPN should be gradually discontinued and started) (6) Use aseptic technique when handing the infusion or changing the dressing (7) Input/ output check (weights) (8) Check blood glucose, BUN/cre, electrolytes, urine glucose, AST/ALT (7) Monitor temperature (infection is the most common complication) 6
구강, 식도문제와간호 부선주 09/09/2013
GastroEsophageal Reflux Disease (GERD) Def.: 위내용물의역류 역류가장기간지속되면 식도점막의염증 ( 식도염 ) 식도조직이산자극에잘 적할수있도록원주상피로변함 (Barrett s epithelium) high risk of adenocarcinoma ( 선암 ) 8
GERD: 원인 Etiology 1) LES pressure 의저하 - Diet: 흡연, 고지방식이, 카페인, 초콜릿, 콜라, 커피, tea - Medication: ca. channel blockers, theophylline, NSAIDs - Hormone: estrogen, progesterone 수준의상승 2) 위산분비항진 3) 위의연동저하 : 위가비워지는시간지연 4) 중력과복압상승 : 누운자세, 비만, 변비, 임신, 무거운물체들기 5) 위장관삽관, 장기간구토후, 식도나위수술후 9
Signs & Symptoms 1) Heartburn ( 가슴앓이, 통증 ) 2) Acid regurgitation ( 산역류 ) 3) Dysphagia ( 연하곤란 ) 4) Odynophagia ( 연하통 ) 5) Eructation ( 트림 ), 기침, 재채기 GERD: 증상 10
GERD: 진단검사 진단검사 1) 식도내압측정 : LES pr. 저하확인 2) 24hours ambulatory ph monitoring: 위내용물의역류확인 (ph<4), 증상과역류상관관계확인 3) 내시경 : 식도염이나 Barrett s 식도확인 <24hour ambulatory ph monitoring> 11
GERD: 진단검사 4) 산관류검사 (Bernstein test): 환자의 epigastric pain이식도점막의산역류에의해생기는통증인지, 심장의문제로 ( 협심증 ) 생기는것인지알아보기위한것 : 비위관을식도에삽입하고 N/S 과 0.1% HCL을교대로하부식도에주입 ; 염산주입시통증호소하면역류성식도염. 12
GERD: 치료 Medical Management 1) 식습관 / 생활습관의개선 - 적은량을자주섭취, 천천히씹어삼킴 - 아주뜨겁거나찬음식, 양념이많은음식, 지방음식, 술, 커피, 초콜릿, 신쥬스는피함 - 금주, 금연 - 취침 3-4 시간전부터음식섭취피함 - 수면시침대머리부분을 10-15cm 상승 - 체중조절 - 꼭조이는옷, 구부리고무거운물건들기피함. 13
GERD: 치료 Surgical Management 1) Nissen fundoplication (Nissen 위저주름술 )< 그림 4-12> : LES 부분을 360 도감싸는것 간호 : p. 426 14
Hiatal Hernia 식도열공탈장 Hernia: 한쪽 body cavity 에있는내장이다른쪽 body cavity 로밀고들어가는것 Def.: 분문괄약근이커져서위의일부가흉곽속으로밀고올라가는것 Etiology 1) 횡경막근육 ( 식도열공주위의근육 ) 의약화, 2) 복강내압의증가 15
Hiatal Hernia: type Type 1) 활주형 (Sliding hernia) : 식도열공부위근육의약화가원인, 90% - 합병증 : 역류성식도염 1) 회전형 (Para esophageal hernia, Rolling hernia) - 합병증 : 폐색, 협착, 감돈, 장중첩 16
Hiatal Hernia: 증상 / 진단검사 활주형 Sliding hernia : 위산의역류증상 1) 가슴앓이 2) 흉골하통증 3) 트림, 연하곤란 회전형 Rolling hernia : 가득한느낌 1) 식후복부팽만감, 호흡곤란 2) 흉통 : 누운자세에서더심함. 진단 - 바륨연하 17
Hiatal Hernia: 치료 GERD 의관리와동일함. 증상완화에우선순위를두고조절이안되면외과적중재를실시함. (GERD 에서실시한동일한수술을진행 ) 생활습관교정 / 복압상승예방 - 꽉조이는옷을입지말것 - 변비예방 - 취침시머리상승 - 식후 bending, recumbent position 하지말것 - 몸무게조절 18
Esophageal Achalasia ( 이완불능증 ) Def.: 식도의어느한부분의신경에병변이있어연동운동이안되어연하된음식물이고여식도가확장된것 LES 가 swallowing 시반사적으로이완되어야하는데이것이실패함 (Auerbach s plexus 의변성 ) 연하곤란, 음식물역류가발생하게됨 19
Esophageal Achalasia: 증상 Signs & symptoms 1) Dysphagia: 초기증상, 고형식과액체의연하곤란 2) Regurgitation, 흡인가능성 3) Dyspnea, coughing 유발 : 팽창된식도때문 4) 트림을할수없어흉골하부의통증 진단검사 : Barium연하검사상하부식도의협착과입구쪽의확장식도내압 20
Esophageal Achalasia: 치료 Medical Management 1) Medication: LES tone을감소시키고, 연동운동을촉진 a) 항콜린성제제 b) 칼슘길항제 (nifedipine: Procardia, Adalat) 평활근이완 C) 질산염 (Long acting nitrate) 2) 식이조절 a) 부드럽고따듯한반고형식 b) 소량을자주섭취 c) 뜨겁거나찬음식, 자극적인음식을피함 d) 술, 담배를피할것 e) 증상이심하면 PEG, PEJ 이용 3) 자세변경 a) 삼킬때등을구부리기 b) 식후앉는자세를취할것 c) 조이는옷피할것 d) 취침시머리부분을상승시킬것 21
Esophageal Achalasia: 치료 Surgical Management 1) Balloon dilatation ( 풍선확장술 ) a) balloon 으로협착된 LES 를확장. b) 성공확률 : 60~85% c) 합병증 : 천공 - 체온상승, 가슴이나어깨의통증 2) 식도근절제술 (Heller s op). a) 근육섬유를절제하여확대. b) 80% 에서증상호전 c) 합병증 : 역류성식도염, restenosis 22
Esophageal Achalasia: 간호 Nursing Management 1) Imbalanced nutrition: less than body requirements related to dysphagia a) baseline wt. & daily wt. check b) I/O check c) fluid, 위장관영양 (PEG, PEJ) 2) Acute pain related to episode of gastric reflux a) Medication (antacid, histamine H2-receptor antagonist, proton pump inhibitor) b) Dietary change c) Positioning 23
Esophageal Diverticulum: type Type 1) 내압성게실 (Zenker) - 식도안의압력이높아발생되는게실 - 남성에게 3 배이상호발 - 가장흔한형태, 예방책없음 2) 견인성게실 (Rokitansky) - 주위조직의유착에의해식도벽이당겨져서발생되는게실 - 결핵성림프절염이주원인 24
Esophageal Diverticulum: 증상 / 치료 Signs & Symptoms - Dysphagia: 트림, 역류 - 구취 (halitosis): 게실내음식 + 타액의축적 + 박테리아증식 진단 : UGI endoscopy- 천공의위험으로금함 Medical Management : 식이와자세 1) Small frequent feedings of semi soft diet 2) Head elevation for 2 hours after meals 25