成人加護(hù)病房氣管內(nèi)插管病人使用【精品-】

1、Evidence-Based Nursing急護(hù)組楊素月 何雲(yún)仙 黃錦鳳 張青蕙 陳明圓 彭慧卿 洪香蓮 姜瑤娟 孫建萍 黃馨慧 張美琪 成人加護(hù)病房氣管內(nèi)插管病人使用鎮(zhèn)靜劑是否可降低氣管內(nèi)管自拔率報(bào)告大綱 前言背景描述實(shí)證護(hù)理動機(jī)及目的 實(shí)證護(hù)理五大步驟 結(jié)論與討論 未來護(hù)理方向前言 前 言1加護(hù)病房病人嚴(yán)重病況危急，且侵入性醫(yī)療措施裝置多，如呼吸治療管路、動靜脈導(dǎo)管、導(dǎo)尿管等等，病人必須接受疾病與治療引起的痛苦與焦慮。尤其以氣管內(nèi)插管仰賴人工呼吸器造成壓力反應(yīng)與傷害最為顯著。 前 言2加護(hù)病患放置氣管內(nèi)管多為挽救及維持生命Atkins et al., 1997，但氣管內(nèi)管放置常會導(dǎo)致身體、

2、心理的不適或溝通障礙，因而產(chǎn)生自拔氣管內(nèi)管情形彭， 1999 。病患自拔後常導(dǎo)致身體合併癥，包括呼吸道損傷、呼吸衰竭等， 發(fā)生率達(dá)8.513%林等， 2003， 國外統(tǒng)計(jì)約為1116% Jayamanne, Nandipati, & Patel, 1998 。 前 言3加護(hù)病房病人的焦慮的來源，是面對疾病的危脅及不可預(yù)期的未來，而疼痛及呼吸困難更會加重焦慮感受。適當(dāng)?shù)氖褂面?zhèn)靜劑可減少病人與呼吸器對抗所耗費(fèi)的能量，防止呼吸不適引起躁動，而發(fā)生自拔氣管內(nèi)管的危險(xiǎn)。背景描述背景描述1本院內(nèi)外科加護(hù)病房共46床，其中內(nèi)科15床主要收治內(nèi)科重癥病人，外科加護(hù)病房28床主要收治手術(shù)後重癥病人及少數(shù)內(nèi)科病人

3、，急診加護(hù)病房8床收治內(nèi)科為主外科為輔之重癥病人。背景描述2氣管內(nèi)管自拔滑脫率，乃為重癥加護(hù)病房品質(zhì) 監(jiān)測指標(biāo)中，極為重要指標(biāo)項(xiàng)目之。 統(tǒng)計(jì)本院與醫(yī)學(xué)中心，此項(xiàng)指標(biāo)結(jié)果如下：此問題有幾個層面影響性，故極需被重視改善日期萬芳醫(yī)院醫(yī)學(xué)中心94年01-12月0.89%0.78%95年01-07月0.78%0.41%病人平安醫(yī)療本錢工作士氣93-95年7月呼吸器使用率93-95年7月氣管內(nèi)管滑脫率95年閾值訂定0.81%實(shí)證護(hù)理動機(jī)與目的EBN的動機(jī)與目的除了現(xiàn)行執(zhí)行模式，有無更好的方法來改善？勸導(dǎo)、曉以大義? 綑綁約束？人力隨側(cè)在旁？重要的是: 知其所以然而為之! 故以EBN的精神，找出最正確醫(yī)療照

4、護(hù)介入模式， 以提供給病人更具平安且高品質(zhì)的就醫(yī)環(huán)境。實(shí)證護(hù)理五大步驟EBN五大步驟1整理出一個可以回答的問題2尋找文獻(xiàn)證據(jù)3嚴(yán)格評讀文獻(xiàn)4應(yīng)用於病人身上5對過程進(jìn)行稽核EBN-Thinking Matrix鎮(zhèn)靜(+)約束(+)最保險(xiǎn)了嗎？鎮(zhèn)靜(-)約束(+)想必不滿意鎮(zhèn)靜劑約束使用鎮(zhèn)靜(+)約束(-)這樣夠了嗎？鎮(zhèn)靜(-)約束(-)異常寫不完Step 1: 臨床問題PICO成人加護(hù)病房氣管內(nèi)插管病人Patient鎮(zhèn)靜劑Intervention 有無使用Comparision 氣管內(nèi)管自拔率Outcome Definition of TermsSE was defined as “medica

5、lly unplanned proximal or complete withdrawal of an endotracheal tube by a patient. Step 1: 臨床問題PICO成人加護(hù)病房氣管內(nèi)插管病人使用鎮(zhèn)靜劑是否可降低氣管內(nèi)管自拔率Step 2: 尋找文獻(xiàn)證據(jù) KEY WORDS Intensive Care Sedation Unplanned Extubation Self Extubation Quality Improvement Step 2: 尋找文獻(xiàn)證據(jù) EBMSEARCH FRAMEWORK搜尋實(shí)證文獻(xiàn)之架構(gòu)Evidence-based Medici

6、ne ReviewNGCPubMedSystematic Review(National Guide Clearinghouse)MEDLINE全文電子期刊政府研究資料全國碩博士論文館際合作搜尋策略CochraneLibrary搜尋實(shí)證文獻(xiàn)捷徑SUMsearch輸入key wordsSedationUnplanned ExtubationMeSH DatabaseStep 2: 尋找文獻(xiàn)證據(jù)SUM searchPractice GuidelinesNational Guideline Clearinghouse(NGC) 0PubMed (possible guidelines) 8Syste

7、matic reviewsDARE (includes Cochrane abstracts) 0 PubMed (possible systematic reviews) 0 Original researchPubMed 8NGC 0 documents DARE 0 documents PubMed 8 documents外鄉(xiāng)化資料 0外鄉(xiāng)資料中文期刊論文索引 0博碩士論文索引 0萃取文獻(xiàn)選取條件以鎮(zhèn)靜劑使用為介入措施Outcome:降低氣管內(nèi)管自拔率成人加護(hù)病房病人Step 3: 嚴(yán)格評讀文獻(xiàn)The Evidence Pyramid臨床研究證據(jù)等級研究證據(jù)的價(jià)值取決於其品質(zhì)及效度評讀文

8、獻(xiàn)的黃金標(biāo)準(zhǔn)中,以雙盲隨機(jī)對照臨床試驗(yàn) 得出的結(jié)果為最正確證據(jù)等級實(shí)證醫(yī)學(xué)之級別(美國健康照護(hù)政策及研究部)-US Agency for Health Care Policy and Research Classification (AHCPR, 1992)實(shí)證級別描 述I a收集若干較具規(guī)模具有隨機(jī)取樣及控制組(randomized controlled trials, RCT)對照所作之實(shí)證研究(Mata-analysis)I b至少由一組有良好之隨機(jī)化及控制組(RCT)之實(shí)驗(yàn)研究II a有控制組, 但不屬於隨機(jī)化II b至少有類似或接近完整之實(shí)驗(yàn)方法(quasi-experimental

9、 study)之實(shí)證研究III由描述性之實(shí)證研究,如:比較方法, 相關(guān)問題之探討, 或個案報(bào)告IV由專家會議所發(fā)表之報(bào)告或?qū)＜抑庖娢墨I(xiàn)評讀摘要(1-1) 【III】文章主題 Common factors of spontaneous Self-extubation in a critical care setting.作者 Jennifer A. Balon, CRNP, MSN, CEN. 出處International Journal of Trauma Nursing/Balon. 2001 July; 93-99文獻(xiàn)評讀摘要(1-2)研究目的：確認(rèn)哪些影響因素會造成重癥加護(hù)病人自發(fā)性

10、自我拔管(Spontaneous self-extubation；SSE)的產(chǎn)生。研究族群：以412總床數(shù)的教學(xué)醫(yī)院收集14個月，病人包含發(fā)生SSE有75病人次(排除4位病人資料不完整，共有68位病人，且研究樣本：75位病人中有50位(67%)男性、25位(33%)女性，平均年齡：55歲疾病診斷：38位(50%)般內(nèi)科、26位(35%)創(chuàng)傷個案、 9位(12%)心臟內(nèi)科、2位(3%)般外科文獻(xiàn)評讀摘要(1-3)研究目的 to measure the incidence of SSE and to identify common, preventable variables associated

11、 with SSE.Method 1. the new tool specifically defined an SSE event, & evaluated factors that may be associated with SSE 2. 包含2局部,由直接照護(hù)nurse (table 1), 及primary investigator (PI, table 2) 3.參於研究人員負(fù)責(zé)教育每一位加護(hù)病房護(hù)理人員文獻(xiàn)評讀摘要(1-4)研究結(jié)果 發(fā)生率: 38.5個自拔管者產(chǎn)生/ 每100的插管天數(shù)，會對影響;SSE=75 cases, Total of 209,46 intubated d

12、ays15%發(fā)生在插管後08小時,45%發(fā)生在插管後848小時,8%發(fā)生在插管後4872小時,17%在72120小時,15% 120小時;平均 intubation time before SSE 為65.05小時36%自拔成功, 59%是需再插管, 24%是1次的SE文獻(xiàn)評讀摘要(1-5)59% cases使用restrained, 21% cases 未用 拔管當(dāng)時有53% agitated, 89%當(dāng)時均可spontaneously to verbal command 護(hù)士病人比1:1, 13%; 1:2, 65%; 1:3, 16%; 1:4, 4%照護(hù)呼吸器43%為2臺, 53%為1

13、臺, 有3%為SSE發(fā)生時其主護(hù)離開負(fù)責(zé)的2位病人此篇3/4 病人沒用止痛鎮(zhèn)靜用藥文獻(xiàn)評讀摘要(1-5)被觀察到75%(56 cases)的SE，分別以手自拔(own hand, n=38) ，甩掉出(bucking, n=6)，舌頭頂出(tongued out, n=5)，咳嗽掉出(coughed out, n=4)，轉(zhuǎn)頭或轉(zhuǎn)頸(turning head or neck, n=3) the amount of pts secretions nearly 2/3 pt “none to small, 23%morderate, 11%large, 3%copous討論 本篇指出SSE的關(guān)聯(lián)性：

14、病人有high level of consciousness and lacked adequate sedation建議選擇適當(dāng)?shù)臉颖緮?shù)及同質(zhì)性的個案探討the relationship of continuous delivery of sedation and analgesia in preventing SSE in alert, intubated patients. 文獻(xiàn)評讀摘要(1-6)文獻(xiàn)評讀摘要(2-1) 【III】文章主題 A Quality Improvement and Risk Management Initiative for Surgical ICU Patie

15、nts：A Study of the Effects of Physical Restraints and Sedation on the Incidence of Self-extubation.作者 Frezza, E. F., Carleton, G. L., & Valenziano, C. P. 出處Ameraican Journal of Medical Quality.(2000) Vol15,221-225.文獻(xiàn)評讀摘要(2-2)研究目的：TO report the experience with 2528 patients evaluating the impact of r

16、e strains and sedation on decreasing S-E in critical patients研究族群：以585總床數(shù)的教學(xué)醫(yī)院收集19931996年，以18床內(nèi)外ICU，藉由護(hù)理人員通報(bào)SE異常報(bào)告來統(tǒng)計(jì)比較每一年的變化 文獻(xiàn)評讀摘要(2-3)Method 1.回溯性研究 2. based on incident report by each nurse after each SE, &development of a plan focused on set criteria 3.因?yàn)閕n 1992 SE incidence of SE was high than

17、 10% 4. pts who were agitated kept the restraints 5. sedation patterns were also explained 文獻(xiàn)評讀摘要(2-4)這篇文章沒有探討SE自拔後重插管及其他合併癥自拔後重插率為46%，其他的研究比較從2374%不等結(jié)果請見table 1.D班拔管率高因?yàn)樵S多個別性的治療及活動 增加，有學(xué)者指出D班護(hù)理的工作量大 2.E班與N班，多因夜班的工作人員不如D班文獻(xiàn)評讀摘要(2-4)Weaning is extubate patients right after the half-life of the sedati

18、ve drugs to avoid agitation when the sedation was completely weaned off.In fact, if the patient is agitated, the chance of SE increases. if his weaning parameters are not normal , more sedation and a later attempt are usually planned, leaving the patient intubated and therefore at risk of SE.文獻(xiàn)評讀摘要(

19、2-5)結(jié)論建議適當(dāng)?shù)氖褂眉s束與鎮(zhèn)靜劑作者認(rèn)為能降低SE 10 to 4% 增加awareness of potential SEThe appropriate use of restrains盡則的努力採用正確預(yù)防評量法利用人員教育做好預(yù)防及密切觀察文獻(xiàn)評讀摘要(2-6)文獻(xiàn)評讀摘要(3-1) 【III】文章主題 A sedation protocol for preventing patient self-extubation.作者 Jan Powers, RN, CCRN, MSN. 出處Dimensions of Critical Care Nursing.(1999), 18(2)

20、; 30-34文獻(xiàn)評讀摘要(3-2)研究目的critical care nurses can use the protocol to effectively manage agitation in intubation patients and prevent SEto development and use of a protocol for managing sedation intubation patientsto prevent injury from SE文獻(xiàn)評讀摘要(3-3)Method 當(dāng)使用此protocol, nurses first must assess for und

21、erlying cause of agitation & treat before administering drugs to suppress agitation此protocol包含 a loading dosethe starting infusion ratea maximum infusion rate 護(hù)理人員應(yīng)用上述3方式且使用了maximum rate仍無法manage pt agitation 則需通知醫(yī)師處理Modified Ramsay ScaleLevel-1 Patient anxious, agitated, or restlessLevel-2 Patient

22、cooperative, oriented, and tranquil.Level-3 Patient responds to commands only.Level-4 Patient responds to gentle shaking.Level-5 Patient responds to noxious stimuli.Level-6 Patient has no response to firm nail bed pressure or other noxious stimuli.文獻(xiàn)評讀摘要(3-4)Case Study護(hù)士使用藥物每15 reassess . 之後改為每24小時假

23、設(shè)病人又非在modify Ramsay Scale 23時 需持續(xù)評估(不只有agitation level, 需包含造成agitation 的因素)Using the sedation protocol during ventilatory weaning may decrease the pts anxiety & improve weaning outcomes文獻(xiàn)評讀摘要(3-5)Avoiding common mistakes不用於病人使用肌肉鬆弛劑及麻痺肌肉用藥，因護(hù)理人員無法評估 pts agitation此篇強(qiáng)調(diào)在weaning 時期不可將一切sedations & analg

24、esics停掉，以免增加躁動,增加SE, 及防礙weaning Compliance with using the protocol rose from 20% to 70% in one year, SE 由 7%降到了3%結(jié)論與討論結(jié)論與討論使用Sedation可以降低成人加護(hù)病房病人氣管內(nèi)管自拔率不建議單獨(dú)使用sedation,最好合併約束一起使用ICU能有protocol,使臨床護(hù)理人員評估需要時能立即使用使用sedation最開始應(yīng)每15分評估個案意識狀況Sedation程度維持病人平靜.合作.對指令有反應(yīng)當(dāng)病人躁動不安時,應(yīng)先排除其他原因-如疼痛.缺氧.電解質(zhì)不平衡等臨床應(yīng)用與成效

25、評值臨床應(yīng)用及成效評值臨床運(yùn)用:於SICU 神外插氣管內(nèi)管病人開刀後且有ICP monitor預(yù)期三天內(nèi)無法脫離呼吸管路者使用sedation-propofol Sedation程度-可配合指令成效:神外病人管路自拔率低於其他內(nèi)外科重癥病人Sedation-Level Ib文章主題: Postoperative Short-Team Sedation with Propofol in Cardiac Surgery作者: Ko, W.J et, al.出處J Formos Med Assoc. 1999 98(8):556-561.內(nèi)容摘要Patients receiving profopol

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33、-#SKBtld5)ZQIAskc3*XPHzria2&WOGxph91%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph9

34、1%UMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%VMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%VMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%VMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%VMEwog8+!TLDvne6-#SKBtld5)ZQIAskc4*XPHzria2&WOGxph91%VMEwog8+!TLDvne6-#SKCtld5)ZQIAskc

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