妊娠晚期下肢深静脉血栓形成患者抗凝剂皮下注射部位的研究
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摘要
目的探讨妊娠晚期下肢深静脉血栓形成患者注射部位的选择策略,为规范护理操作流程提供依据。方法将下肢深静脉血栓形成,需要抗凝剂皮下注射治疗的妊娠晚期患者46例,采用随机数字表法分为观察组和对照组各23例。观察组通过脐部做一水平线,经B超测定双侧前上侧腹部、前下侧腹部、中上侧腹部、中下侧腹部8个区域的皮下组织厚薄程度,在确定注射深度安全的情况下在腹部8个区域行轮换皮下注射;对照组选择部位为上臂部三角肌中、后区域轮换注射。比较两组注射后即刻、2 h疼痛评分,皮下淤斑和硬结的发生率及活化部分凝血活酶时间的变化。结果观察组注射后即刻、2 h疼痛评分,淤斑、硬结发生率显著低于对照组(均P <0. 01);两组治疗前后活化部分凝血活酶时间比较,差异无统计学意义(均P> 0. 05)。结论避开脐周(距脐10cm以内),在腹壁外侧缘8个区域内运用改良皮下注射技术对妊娠晚期患者行抗凝剂皮下注射安全、可行、有效。
Objective To explore appropriate selection strategies for anticoagulants subcutaneous injection sites in patients with lower extremity deep vein thrombosis( DVT) during the third trimester of pregnancy,and to provide evidence for standardization of the nursing cooperation process. Methods A total of 46 women diagnosed with lower extremity DVT during the third trimester of pregnancy and in need of subcutaneous injection of anticoagulants were randomized into 2 groups of 23 each. In the observation group,the abdominal wall was divided into 8 parts( bilateral upper anterior,lower anterior,upper medial and lower medial),then the thickness of the subcutaneous tissue in each part was determinedby doppler ultrasound; after that,the 8 parts were rotated to receive subcutaneous injection of anticoagulants on the condition of safe needle insertion depth. In the control group,middle and posterior regions of the deltoid muscle were alternated as injection sites. The degrees of local pain immediately after injection,and two hours after injection were evaluated by Numeric Rating Scale( NRS). The incidence rates of subcutaneous ecchymosis and induration,along with the changes in activated partial thromboplastin time( APTT) were observed. Results The NRS pain scores imme-diately after injection,and two hours after injection,and the incidence rates of subcutaneous ecchymosis and induration in the observation group were significantly lower than those of the control group( P < 0. 01 for all),whereas,pre-and post treatment APTT showed no significant difference between the two groups( P > 0. 05). Conclusion Modified subcutaneous injection of anti-coagulants at 8 outer parts( avoiding the peri-umbilical region and within 10 cm around the umbilicus) of the abdominal wall,is a safe and feasible for women developing DVT in the third trimester of pregnancy.
Objective To explore appropriate selection strategies for anticoagulants subcutaneous injection sites in patients with lower extremity deep vein thrombosis( DVT) during the third trimester of pregnancy,and to provide evidence for standardization of the nursing cooperation process. Methods A total of 46 women diagnosed with lower extremity DVT during the third trimester of pregnancy and in need of subcutaneous injection of anticoagulants were randomized into 2 groups of 23 each. In the observation group,the abdominal wall was divided into 8 parts( bilateral upper anterior,lower anterior,upper medial and lower medial),then the thickness of the subcutaneous tissue in each part was determinedby doppler ultrasound; after that,the 8 parts were rotated to receive subcutaneous injection of anticoagulants on the condition of safe needle insertion depth. In the control group,middle and posterior regions of the deltoid muscle were alternated as injection sites. The degrees of local pain immediately after injection,and two hours after injection were evaluated by Numeric Rating Scale( NRS). The incidence rates of subcutaneous ecchymosis and induration,along with the changes in activated partial thromboplastin time( APTT) were observed. Results The NRS pain scores imme-diately after injection,and two hours after injection,and the incidence rates of subcutaneous ecchymosis and induration in the observation group were significantly lower than those of the control group( P < 0. 01 for all),whereas,pre-and post treatment APTT showed no significant difference between the two groups( P > 0. 05). Conclusion Modified subcutaneous injection of anti-coagulants at 8 outer parts( avoiding the peri-umbilical region and within 10 cm around the umbilicus) of the abdominal wall,is a safe and feasible for women developing DVT in the third trimester of pregnancy.
引文
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[8]朱红芳,汤磊雯,贺晓莉,等.抗凝剂皮下注射护理规范的循证实践[J].中华护理杂志,2011,50(1):33-37.
[9]Mumoli N,Vitale J,Cocciolo M,et al.Accuracy of nurseperformed compression ultrasonography in the diagnosis of proximal symptomatic deep vein thrombosis:a prospective cohort study[J].J Thromb Haemost,2014,12(4):430-435.
[10]Avsar G,Kasik9i M.Assessment of four different me-thods in subcutaneous heparin applications with regard to causing bruise and pain[J].Int J Nurs Pract,2013,19(4):402-408.
[11]张菊霞,马玉霞,温玉洁,等.皮下注射低分子肝素时不同推注时间对皮下出血的影响[J].中华护理杂志,2014,49(2):233-235.
[12]Balci A R,Celebioglu A.Effect of injection duration on bruising associated with subcutaneous heparin:a quasi-experimental within subject design[J].Int J Nurs Stud,2008,45(6):812-817.
[13]李燕,许秀芳,吴小艳,等.低分子肝素两种皮下注射方法不良反应的对照研究[J].介入放射学,2018,27(1):83-86.
[14]中华医学会放射学分会介入学组.下肢深静脉血栓形成介入治疗规范的专家共识第二版[J].中华放射学杂志,2018,52(23):1813-1821.
[15]洪业.实用内科药物治疗学[M].北京:人民卫生出版社,2000:340,1119-1120.
[16]Lindqvist P,Dahlbck B,Mar3ál K.Thrombotic risk during pregnancy:a population study[J].Obstet Gynecol,1999,94(4):595-599.
[17]王明阳,不同部位皮下注射低分子肝素钙对皮下出血及疼痛的影响[J].临床医药文献杂志,2015,3(8):1439-1451.
[18]金歌,刘延锦,王俊平,等.表盘式轮换注射法在皮下注射低分子肝素中的应用[J].护理学杂志,2015,30(19):44-45.
[19]Kovacevich G J,Gaich S A,Lavin J P,et al.The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes[J].Am JObstet Gynecol,2000,182(5):1089-1092.
[20]Barras M A,Kirkpatrick C M,Green B.Current dosing of low molecular weight heparins does not reflect licensed product labels:an inter national survey[J].Br J Clin Pharmacol,2010,69(5):520-528.
[21]狄红月,王志伟.低分子肝素不同皮下注射方式不良反应的Meta分析[J].天津护理,2010,18(5):249-252.
[22]James A H.Venous thromboembolism in pregnancy[J].Arterioscler Thromb Vasc Biol,2009,29(3):326-331.
[2]Le Sage S,McGee M,Emed J D.Knowledge of venous thromboembolism(VTE)prevention among hospitalized patients[J].J Vasc Nurs,2008,26(4):109-117.
[3]Scurr J H,Machin S J,Bailey-King S,et al.Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights:a randomised trial[J].Lancet,2001,357(67):1485-1489.
[4]Autar R.A review of the evidence for the efficacy of Anti-Embolism Stockings(AES)in Venous Thromboembolism(VTE)prevention[J].J Orthop Nurs,2009,13(12):41-49.
[5]Chan H.Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin[J].JAdv Nurs,2001,35(6):882-892.
[6]Chenicek T E.Effects of injection duration on saite-pain intensity and bruising associated with subcutaneous administration of lovenox(enoxaparin sodium)[D].Tallahassee:The Florida State University,2004.
[7]开月梅,石兰萍,刘颜.规律轮换注射部位减轻低分子肝素致皮下出血的研究[J].护理学杂志,2004,19(5):3-4.
[8]朱红芳,汤磊雯,贺晓莉,等.抗凝剂皮下注射护理规范的循证实践[J].中华护理杂志,2011,50(1):33-37.
[9]Mumoli N,Vitale J,Cocciolo M,et al.Accuracy of nurseperformed compression ultrasonography in the diagnosis of proximal symptomatic deep vein thrombosis:a prospective cohort study[J].J Thromb Haemost,2014,12(4):430-435.
[10]Avsar G,Kasik9i M.Assessment of four different me-thods in subcutaneous heparin applications with regard to causing bruise and pain[J].Int J Nurs Pract,2013,19(4):402-408.
[11]张菊霞,马玉霞,温玉洁,等.皮下注射低分子肝素时不同推注时间对皮下出血的影响[J].中华护理杂志,2014,49(2):233-235.
[12]Balci A R,Celebioglu A.Effect of injection duration on bruising associated with subcutaneous heparin:a quasi-experimental within subject design[J].Int J Nurs Stud,2008,45(6):812-817.
[13]李燕,许秀芳,吴小艳,等.低分子肝素两种皮下注射方法不良反应的对照研究[J].介入放射学,2018,27(1):83-86.
[14]中华医学会放射学分会介入学组.下肢深静脉血栓形成介入治疗规范的专家共识第二版[J].中华放射学杂志,2018,52(23):1813-1821.
[15]洪业.实用内科药物治疗学[M].北京:人民卫生出版社,2000:340,1119-1120.
[16]Lindqvist P,Dahlbck B,Mar3ál K.Thrombotic risk during pregnancy:a population study[J].Obstet Gynecol,1999,94(4):595-599.
[17]王明阳,不同部位皮下注射低分子肝素钙对皮下出血及疼痛的影响[J].临床医药文献杂志,2015,3(8):1439-1451.
[18]金歌,刘延锦,王俊平,等.表盘式轮换注射法在皮下注射低分子肝素中的应用[J].护理学杂志,2015,30(19):44-45.
[19]Kovacevich G J,Gaich S A,Lavin J P,et al.The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes[J].Am JObstet Gynecol,2000,182(5):1089-1092.
[20]Barras M A,Kirkpatrick C M,Green B.Current dosing of low molecular weight heparins does not reflect licensed product labels:an inter national survey[J].Br J Clin Pharmacol,2010,69(5):520-528.
[21]狄红月,王志伟.低分子肝素不同皮下注射方式不良反应的Meta分析[J].天津护理,2010,18(5):249-252.
[22]James A H.Venous thromboembolism in pregnancy[J].Arterioscler Thromb Vasc Biol,2009,29(3):326-331.
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