癌痛的評(píng)估與護(hù)理(漢譯英)

1、癌痛的評(píng)估與護(hù)理疼痛是癌癥病人普遍存在的癥狀。盡管在止痛方面取得了巨大進(jìn)展，但仍有三分之二 的癌癥病人到晚期都要忍受癌痛的折磨。因此，需要護(hù)士具備處理癌痛的多方知識(shí)，掌握正確評(píng)估方法和治療技術(shù)及恰當(dāng)?shù)淖o(hù)理。現(xiàn)就其綜述如下。1癌性疼痛的護(hù)理評(píng)估1.1 視覺模擬評(píng)分法（Viraal Aualort Scale ，簡(jiǎn)稱VAS）:該法比較靈敏，有可比性。具體做法是：在紙上面劃一條10 cm的橫線，橫線的一端為0,表示無痛；另一端為10,表 示劇痛；中間部分表示不同程度的疼痛。讓病人根據(jù)自我感覺在橫線上劃一記號(hào)，表示疼痛的程度。輕度疼痛平均值為2.57 1.04 ；中度疼痛平均值為 5.18 1.41

2、；重度疼痛平均值為 8.41 1.35。1.2 評(píng)估表法：它是由美國(guó)的McmilLan設(shè)計(jì)的疼痛估計(jì)表。即0等于無痛，1等于有疼痛感，但不嚴(yán)重；2等于輕微疼痛，病人不舒服；3等于疼痛，病人痛苦；4等于疼痛較 劇烈，有恐懼感；5等于劇痛。通過問答形式由病人做出具體描述。內(nèi)容包括：疼痛程度、部位、性質(zhì)、發(fā)作情況及伴發(fā)癥狀等。據(jù)報(bào)道此表設(shè)計(jì)合理，實(shí)用性強(qiáng)。1.3 口述評(píng)估法（Verbal Report） : Melzack擬定了 1份形容疼痛程度詞匯，如輕度疼痛、重度疼痛、陣痛、可怕的痛及無法忍受的疼痛等來幫助病人描述自己的疼痛，使病人更好地把疼痛加以表達(dá)，按010分次序報(bào)告，0分表示無痛，10分表

3、示劇痛。此法簡(jiǎn) 單，但不易發(fā)覺細(xì)微變化。2癌痛的止痛治療2.1藥物治療：世界衛(wèi)生組織（WHO）提出2000年消除癌癥患者疼痛的奮斗目標(biāo) 。其 提出的三級(jí)止痛方案是目前世界各地都在大力推行的癌前藥物治療準(zhǔn)則。也稱 按需給藥”，即一級(jí)止痛：輕度疼痛使用非麻醉性鎮(zhèn)痛藥 。如阿斯匹林、撲熱息痛等。二級(jí)止痛： 中度持續(xù)性疼痛或加重 ，使用弱麻醉劑。如強(qiáng)痛定、可待因、美散痛等。三級(jí)止痛：強(qiáng)烈 持續(xù)性疼痛，使用強(qiáng)麻醉劑，直到疼痛消失。如嗎啡、杜冷丁等。其主要給藥途徑有以下 幾種：2.1.1消化道給藥：藥物給藥近來提倡口服為主，對(duì)慢性癌痛采用布羅芬與美散痛合用取得了良好效果，用布羅芬600 mg與美散痛2.5

4、5 mg合用，效果優(yōu)于單獨(dú)應(yīng)用美散 痛，而不增加副作用。且對(duì)骨轉(zhuǎn)移癌痛也有較好的止痛效果。研究中未發(fā)現(xiàn)布羅芬對(duì)十二指腸粘膜有損傷，認(rèn)為布羅芬的安全性和較低的副作用是可取的。近年來開發(fā)的鹽酸雙氫嗎啡控釋片，克服了嗎啡的某些副反應(yīng)，又增加了鎮(zhèn)痛效果。已成為需要麻醉止痛時(shí)的首 選藥物。不能口服者也可直腸給藥。芬太尼、buprenophine也可舌下給藥。2.1.2連續(xù)皮下或靜脈給藥：當(dāng)大量口服止痛藥不能控制疼痛時(shí)，或有嚴(yán)重的胃腸道反應(yīng)如惡心、嘔吐等副作用時(shí)，需采用連續(xù)皮下或靜脈內(nèi)輸入麻醉劑：Sheider評(píng)估了這種方法，肯定了其給藥的安全性和效能 ，現(xiàn)已普遍應(yīng)用。2.1.3 皮膚給藥：近年來由于皮膚

5、生理研究和制藥技術(shù)的發(fā)展，皮膚與粘膜已經(jīng)作為給藥的新途徑。有報(bào)道，一次芬太尼貼敷止痛可達(dá)72 h。雖使用方便，但價(jià)格昂貴。另外，中藥外治法能使藥物經(jīng)皮膚吸收，起效快、安全、方便、毒副作用小。用藥10 min即可見效，總有效率79.2%。2.1.4 病人控制的止痛(Patient Controleel Analgesir ,簡(jiǎn)稱 PCA): PCA 方法 1984 年在美國(guó)被有效地應(yīng)用。其方法是患者擁有一個(gè)用計(jì)數(shù)電子儀控制的注藥泵。它可提供麻醉劑的劑量、劑量增減范圍和估計(jì)2次劑量的間隔最短時(shí)間，以及提供一個(gè)穩(wěn)定的注藥間隔周期。能更好地取得疼痛控制效果，減少麻醉劑用量，減少副作用。但其缺點(diǎn)是必須有

6、一定設(shè)備，且價(jià)格昂貴。并可引起藥物外滲、靜脈炎及感染等。目前已研制出新型控制止病 人的痛藥泵，分家庭用、護(hù)士用及防止用藥過量的PCA 3種類型。不僅可防止病人用藥過量，還可通過電腦程序控制持續(xù)輸液中的止痛藥濃度，以維持穩(wěn)定的止痛效果，防止病人出現(xiàn)劇痛。2.1.5麻醉技術(shù)控制癌痛：神經(jīng)阻滯在晚期癌痛病人中已應(yīng)用了多年，近年來提倡在早期癌痛患者中應(yīng)用。通過導(dǎo)管或泵，連續(xù)或間斷將藥物輸入硬膜外或鞘內(nèi)。此法避免了口服給藥和其他方法給藥的副作用，同時(shí)還減少了輔助藥物的應(yīng)用。但也有人報(bào)道，全身先用阿片類藥物治療的病人，脊柱內(nèi)再給阿片類藥物則無治療效果。2.1.6神經(jīng)外科技術(shù)控制癌痛：手術(shù)治療的目的是在周圍

7、神經(jīng)與中樞神經(jīng)之間某一點(diǎn)切斷產(chǎn)生疼痛的途徑。3癌痛的護(hù)理3.1 護(hù)理觀念的更新：迅速有效地減輕癌痛是護(hù)理的基本要求，也是護(hù)士基本的責(zé)任。因此，護(hù)士應(yīng)盡力發(fā)展提高癌痛的護(hù)理水平。癌痛的控制往往受病人、護(hù)士、藥物組合多種因素的綜合影響，而護(hù)士的密切觀察和及時(shí)提供適應(yīng)的止痛方法是控制癌痛重要因 素。這就需要護(hù)理教育計(jì)劃從基礎(chǔ)和臨床上對(duì)藥物的藥理學(xué)和用藥方式進(jìn)一步加強(qiáng)，樹立果斷采取各種治療手段，設(shè)法解除病人痛苦，提高病人生存質(zhì)量延長(zhǎng)生命的新觀念，嚴(yán)格遵守有效控制疼痛的指導(dǎo)原則。3.2護(hù)士的作用3.2.1準(zhǔn)確評(píng)估：在對(duì)癌痛控制過程中，疼痛的評(píng)估是第一重要環(huán)節(jié)。護(hù)士不僅要客觀地判斷疼痛是否存在，還要確定疼

8、痛的程度。在用藥前護(hù)士必須根據(jù)個(gè)體疼痛作出準(zhǔn)確 的判斷，采取相應(yīng)措施，才能有效地減輕病人的痛苦。通過對(duì)1 400名注冊(cè)護(hù)士問卷調(diào)查 表明，最佳處理疼痛的主要障礙是對(duì)疼痛估計(jì)不足，處理疼痛的知識(shí)不夠及病人不愿報(bào)告疼痛。因此，對(duì)護(hù)士而言更重要的是有關(guān)疼痛的處理和用以解除癌痛的標(biāo)準(zhǔn)教育。3.2.2準(zhǔn)確及時(shí)給藥：觀察效果及副作用。包括了解治療的基本原則，向病人說明接受治療的效果及幫助病人正確用藥，評(píng)估治療效果，向醫(yī)生報(bào)告以及副作用的防治等323 心理護(hù)理：要幫助病人樹立信心。因勢(shì)利導(dǎo)，調(diào)動(dòng)病人積極的心理因素 ，幫助 克服其消極的心理因素 。爭(zhēng)取病人信任，增強(qiáng)病人的安全感，穩(wěn)定情緒，解除焦慮。注意 分散

9、病人注意力。建立舒適家庭病房”，因?yàn)槭孢m可使心理生理異常減輕到最低程度 。Assessment and care of cancer painPain is com mon symptom of can cer patie nts. Despite the pain has madetreme ndous progress, but there are still two-thirds of can cer patie nts to have to putup with adva need cancer pain of torture. Therefore, nu rses have the

10、kno wledge ofhandling multi-cancer pain, to master the correct assessment and treatmenttechniques and appropriate care. Is on its review as follows.1 A n urs ing assessme nt of cancer pain1.1 Visual an alogue scale (Viraal Aualort Scale, referred to as VAS): The moresensitive method, there are compa

11、rable. Specifically: In the paper, draw a 10 cmabove the horiz on tal li ne, horiz on tal li ne of the end of 0, in dicati ng no pain; theother side of 10, said the pain; the middle part of the vary ing degrees of pai n. Feelthe patie nt accord ing to a uniform mark on the horiz on tal li ne, in dic

12、at ing the degreeof pain. Mild pain, mean 2.57 1.04; moderaiteapairage of 5.18 1.41;moderate to severe pain, average 8.41 1.35.1.2 Evaluati on form method: It was desig ned by the America n Pai n McmilLa n estimated table. That 0 equals no pain, 1 is equal to a pain, but not serious; 2 equals mild p

13、ain, patient discomfort; 3 is equal to the pain, the patient suffering; 4 is equalto more severe pain, there is fear; 5 equal to severe pain. Made through the Q & A specific description of the patient. Include: pain intensity, location, nature, and the con comita nt on set of symptoms. It is rep

14、orted that this table desig n is reas on able, practical.1.3 Oral Assessme nt Act (Verbal Report):Melzack 1 developed vocabulary to describe the degree of pain, such as mild pain, severe pain, pain, terrible pain and could not bear the pain to help patients describe their pain, so be patient to bett

15、er express the pain, accord ing to 0 the order of 10 reports, 0 points in dicati ng no pain and 10 points indicating severe pain. This method is simple, but difficult to notice subtle cha nges.2 An algesic treatme nt of cancer pain2.1 Drug treatme nt:World Health Orga nization (WHO) proposed in 2000

16、 toeliminate pain in patients with the goal of cancer. The proposed three-tier program is pain all over the world promoting the use of pre-cancerous drug treatment guideli nes.Also called on-dema nddelivery, that is a pain: mild pain, use ofnon-narcotic analgesics. Such as aspirin, paracetamol and s

17、o on. Second pain: moderate persiste nt pain or in crease, the use of weak an esthetic. If give n strong pain, codei ne, methad one pain. Three levels of pai n: a strong persiste nt pai n, with a strong an esthetic, un til the pain disappears. Such as morphi ne, pethidi ne and so on. The main route

18、of administration are the following:2.1.1 Gastr oin testi nal drug delivery: Rece ntly, the mai n advocate of oral drug delivery, chronic cancer pain using Bu Luofen methadone combined with the United States and achieved good results, with the United States with Bu Luofen 600 mg methad one 2.5 5 mg

19、comb in ati on, more effective tha n methad one alone pain,without in creased side effects. And the pain of bone metastasis has a better an algesic effect. Study found no Bu Luofe n duode nal mucosa injury, that the Bu Luofen security and lower side effects is desirable. In recent years the developm

20、ent of controlled-release morphine hydrochloride tablets hydrochlorothiazide and overcome some of the side effects of morphi ne, in creased the an algesic effect. Has become the first choice when the need for narcotic pain drugs. Those who can not be oral or rectaladm ini strati on.Fentanyl,bupre no

21、 phi nealso subli ngualadm ini strati on.2.1.2 Continuoussubcutaneousorintravenousinjection: Whena largenumber oforal painmedication cannot controlthe pain, or haveseriousgastr oin testi nal reacti ons such as n ausea, vomiti ng and other side effects, requiresthe use ofcon ti nu oussubcuta neousori

22、n trave nousan esthetic in put:Sheiderassessme ntof this approach, con firmedthe safetyof its adm ini strati on andperforma nee, is now widely used.2.1.3 Skin dose:In recent years, the physiology of the skin and pharmaceuticaltech no logy, drug delivery skin and mucous membra nes have bee n used as

23、a new way. It has bee n reported, a fentanyl pain patchi ng up to 72 h. Although easy to use, but expe nsive. In additi on, the Chin ese exter nal treatme nt to make drugs absorbed through the skin, rapid on set, safety, convenien ce, drug side effects. 10 min treatme nt to be effective, total effec

24、tive rate 79.2%.2.1.4 Patie nt-c on trolled an algesia (Patie nt Con troleel An algesir, referred to asPCA): 1984 PCA method was applied effectively in the Un ited States. The method is that the patie nt has an electr onic in strume nt con trolled by coun ter drug in fusi on pump. It provides ane st

25、hetic dose, dose range and the estimated in crease or decrease the in terval betwee n 2 doses of the shortest time, and provide a stable in terval betwee n injection cycles. Better access to effective pain con trol, reduce the amount of an esthetic age nts, reduce side effects. But its drawback is t

26、hat there must be some equipme nt, and expe nsive. And can cause drug extravasati on, phlebitis and in fecti on. Has developed a new type of con trol only the patie nts pai n medicati on pumps, domestic use, the nurse and to preve nt overdose PCA 3 types. Not only preve nt overdose patie nts, but al

27、so susta ined by the computer program con trol pain in fusi on drug concen trati on in order to mai ntain a stable an algesic effect, preve nt the patie nt developed severe pain.2.1.5 An esthesia con trol cancer pai n:Nerve block in patie nts with adva needcan cer has bee n in use for many years, in

28、 rece nt years to promote the applicati on of early cancer pain. Through the catheter or pump, continuous or intermittent epiduralor intrathecal drug importation.This method avoids the administrationof oralmedicati on and side effects of other methods, but also reduce the applicati on of adjuvants.

29、However, some reports, the body first with opioid therapy in patients with spinal opioids to give no treatme nt.2.1.6 Neural control of cancer pain surgical techniques: The purpose of surgical treatme nt of peripheral n erve and cen tral n ervous system is a point betwee n the way off to pain.3 Canc

30、er Pai n Care3.1 Renewing care: Quickly and effectively to reduce pain is the basic requireme nt of care is a basic resp on sibility of nu rses. Therefore, nu rses should try to develop sta ndards to improve the care of cancer pain. Can cer pain con trol are ofte n affected by patie nts, n urses, dr

31、ug comb in ati ons combi ned effects of many factors,and nurses to provide close observationand timely adaptation to pain is animportantfactor in controllingcancer pain. This requires that nursing educationprograms from basic and cli ni cal pharmacology of drugs and drug use means to further stre ng

32、the n and establish a firm to take a variety of treatme nts to try to relieve the suffering of patients and improve the quality of life in patients with life-prolonging new ideas, strict compliance with effective control of pain guidelines.3.2 The role of n urses3.2.1 Accurate assessme nt of:In the

33、course of pain con trol, pain assessme ntis the first important part. Nurses not only to objectively determine whether there is pain, but also to determine the degree of pain. Former nurse in the treatment of pain must be based on the in dividual to make accurate judgme nts, to take corresp onding measures, can effectively reduce the pain. By 1 400 registered nurses surv