A case of gastric tube placement in a brain injury patient is shared

The condition observation recordelderly male, 73 years old, because of "walking accidentally fell to the head for 1 hour",diagnosis"brain bruising" admitted to hospitalWhen admitted to the hospital patient's drowsiness state, two-sided pupils and other large isospheres, diameter of 3mm, sensitive to light reflectionAfter admission to the hospital to the patient to absorb oxygen, electrocardiogram monitoring, nutritional brain cell drug infusion treatment6 days after the patient appeared eating cough, as ordered by the doctor to leave the nasal gastric catheter, patient irritability, suspension of nasal gastric catheter insertion, as directed by the doctor with physiological saline 4mL , right metamine 0.2g pump ingon, pump speed 2mL/h2 hours after the patient Ramsay sedation grade 4, the responsible nurse again to the patient to leave nasal gastric catheter, the patient irritable, resist, gastric tube disc in the mouth, placed unsuccessfully, then pulled out the gastric tube re-placedWhen the nasal gastric tube is placed again, the insertion will be 15cm, lift the patient's head, the tube placement process has resistance, still not successfulAfter communication with the on-duty physician, the patient has larynx spasms, high airway reaction, consider suspending gastric tube placement, increase the right metamine pump ingestion, from the original pump speed of 2mL to 5mL/h2.5 hours after the patient's sedation grade 5, again to the patient's nasal tube placed, when inserted will be tired, the patient's neck has resistance, cough, a moment's pause, successfully passed, with the water test smooth, there are bubbles exhaled, the patient's gastric tube in the trachea, immediately pull out the gastric tubeAfter 5 minutes re-entering, when inserted into the anosic, the patient's cough intensifies and the gastric tube is placed again in the trachea2 hours after the patient Ramsay sedation grade 4, before intubation to give the patient sputum in the mouth and nasal cavity, the nasal gastric tube slowly inserted into the throat, with a syringe slowly injected 0.02% of Lidocain 5mL to the nasal gastric tube, after the injection is done gently upward the patient's jaw, and then continue to insert the pipe, the patient is allowed to do the swallowing action, the patient can not be used to reduce the processRamsay's sedation graderatingthe of the of
the of the of the of the of the of the of the of the 1
st
the of the 1 the of anxiety, excitement or uneasi
ness
, and the of the of obedience and
quiet 3 of fall asleep,
and the response to the order is 4 for the order only
4 afall, response to mild shaking or loud sound stimulation ( br/ br/ br/ br/ br/ br/ br/ br/ br/ br/ br/ br/ br/ s br/ falladown, reaction to harmful stimuli such as force compression of the bed 6 fall asleep and not respond to the stimulus
Note: 2 to 5 is the ideal level of sedation; Patients are scored 1 time every 5 minutes after the first load
case summary analysis 1 From an anatomical structure, the throat, esophagus and back and forth adjacent together, the trachea entrance is larger than the esophagus, the gastric tube is easy to enter the trachea Both the trachea and the esophagus have a connection with the pharynx, and when you breathe, anorexia is open, and the passage to the airways is open Anerycartiling is closed when the dorsey swallows, the trachea is closed, such as the patient has struggled during the tube placement process, the gastric tube in the throat is easy to enter the trachea 2 The patient's stress response is strong, the throat has the distribution of the upper nerve, sensitive to stimulation, gastric tube stimulation causes nausea, vomiting, cough The throat muscle group shrinks strongly, which can make the tip of the gastric tube push into the mouth, to the difficulty of intubation 3 Incongruity of swallowing action: if the mental stress is too intense, the restless and uncooperative patient will cause the swallowing action to be too fast and ineffective, and the nurse will not be able to insert the gastric tube smoothly into the esophagus just when the patient swallows it 4 Patients with sputum are more viscous, heavy brain injury patients often have respiratory difficulties of care problems, resulting in more sputum and sticky Experience sharing 1 Pre-tube assessment of patients swallowing, coughing reflexes, restlessness, restless people to give calm Patients with swallowing and coughing reflexes, when the gastric tube stimulates the throat, easily causes the larynx to contract, cough or restlessness The application of sedatives to calm down, the throat muscle group in a relaxed state, conducive to the tube 2 Patients who are strongly uncooperative in their stress response, first find out the reasons for the non-cooperation, fully explain the work, and patiently guide the patient how to cooperate When intubation, the action is fast and fast, try to be successful once possible, to reduce the discomfort of patients If necessary, the gastric tube can be placed in the patient's nasal cavity, tongue body, tongue root, soft palate, throat sprayed 0.02% lidocain 3 to 5mL, so that it is asurface anaesthetic Make the local neuroreflection temporarily weaken or disappear, reduce the mechanical stimulation of the nasopharyngeal mucosa and throat when placing the tube, reduce the discomfort symptoms such as nausea, coughing, etc of the patient, and improve the success rate of gastric tube placement 3 Before intubation, check the nasal oral esophagus for obstruction In patients with brain injury, coughing and coughing occur during the placement of tubes When there is more sputum, before the tube should first absorb the oral, nasal and respiratory secretions, so as not to be placed in the tube because of stimulation caused the trachea spewed a large amount of sputum, blocking the respiratory tract and suffocation Sputum before the tube can effectively stimulate the patient's throat reflexive lysagulation reaction, conducive to the placement of nasal gastric tube, while reducing the occurrence of complications such as post-tube correlation pneumonia Li Donglan, Zhang Qin, Cui Wei Source: China Care Management