1例居家患者无典型症状留置胃管误入气管的原因分析及预防对策

Cause analysis and prevention countermeasures of a patient who left a gastric tube and strayed into trachea without typical symptoms at home

我院管路小组成员在为出院带管的居家患者提供管路更换的上门服务过程中,出现1例胃管误入气管无典型症状致"吸入性肺炎、肺不张"的严重病例,患者一度出现神志模糊。本文从解剖因素、患者因素、胃管因素、护士因素、管理因素五个方面分析了胃管误入气管的原因,并根据原因制定了预防对策,对今后解决类似问题提供了参考依据,也为进一步做好管路临床护理工作有一定的借鉴作用。

Members of the pipeline team in our hospital appeared a serious case of ＂aspiration pneumonia and atelectasis＂ caused by a gastric tube entering the trachea without typical symptoms during the door-to-door service of providing pipeline replacement for discharged home patients with tubes. The patient was once delirious. This paper analyzes the causes of gastric tube straying into trachea from five aspects： anatomical factors, patient factors, gastric tube factors, nurse factors, and management factors, and makes preventive measures based on the causes, which provides reference for solving similar problems in the future and also has certain reference for further clinical nursing work of pipelines.