評(píng)價(jià)疼痛管理.doc

1、我只翻譯了大概的內(nèi)容， 這篇文章主要是評(píng)價(jià)護(hù)士對(duì)手術(shù)后遭受劇烈急性疼痛病人的護(hù)理工作。評(píng)價(jià)責(zé)任護(hù)士的疼痛護(hù)理因?yàn)樘弁垂芾硎且粋€(gè)復(fù)雜的過(guò)程， 很難評(píng)價(jià)其療效。 這篇文章描述了一個(gè)有保證的研究，PURPOSE AND DESIGN OF THE QUALITYASSURANCE PROJECT The purpose of this quality assurance project was to? develop a quality assurance tool based on nursing research to track the effective-ness of painmanage

2、ment outcomes at the unit level,? determine whether the data collected by the tool would enhance the managers ability to identify weaknesses andstrengths of a pain management delivery system, and? facilitate improvements in the pain delivery system on a general surgical unit.The variables investigat

3、ed were the nurses knowledge and attitudes toward pain management, nursing interventions for pain and pain medication side effects, environmental barriers, and pharmacologic management.Thestudy took place at anurban community teaching hospital. Approval for the study was obtained from the Institutio

4、nal Review Board and the Nursing Research Committee.研究的變量是護(hù)士對(duì)疼痛醫(yī)學(xué)的知識(shí)和態(tài)度， 疼痛護(hù)理的干預(yù)和疼痛藥物治療的副作用，環(huán)境因素和藥理學(xué)的管理。 研究的地點(diǎn)是城區(qū)的教學(xué)醫(yī)院。 獲得了這兩個(gè)機(jī)構(gòu)的批準(zhǔn) the Institutional Review Board and the Nursing Research CommitteeTwenty-three nurses (60% response rate) on a general surgical unit completed theknowledge and attitudes

5、 test. In the same unit, a retrospective chart review (convenience sample) of 30 patients was completed on their second postoperative day following amajor abdominal surgery.普通外科病房的 23 位護(hù)士完成了知識(shí)和態(tài)度的考試。同一個(gè)病區(qū)，在經(jīng)歷腹部手術(shù)的第二天， 30 位病人完成了回顧性的圖表（抽樣樣本）An investigator-modified version of the1997 Ferrell and McCaf

6、fery s Knowledge andAttitudes Survey Regarding Pain was used to test the nurses. This test has been usedextensively since 1987. It has a reported test-retestreliability (r)greater than .80 and aninternal reliability (r)greater than .70. Permission was obtained from the author to usethe tool inwhole

7、or in part.意思是量表的來(lái)歷，得到量表作者的同意使用量表The test was modified to eliminate questions about childrencancerspain andpainbecause the focus on a general surgical unit is acute postoperative pain management.Modificationof the test by deleting references to cancer pain can be supportedbecause questions related t

8、o cancer pain may skew the results as general painmanagement and cancer pain management differ意.思是對(duì)量表進(jìn)行了許多的修改 Agroupof clinicians with experience in pain management, including a hospice nurse,an oncology nurse, and a surgical nursemanager, reviewed the final modified test.意思是有疼痛管理經(jīng)驗(yàn)的人員也參與了修改量表的工作In

9、an individual nursing unit, physical factors such as equipment location and availability of supplies affect the delivery of care.To obtain information about environmental barriers, which m ay contribute to the nurses abilitytoindeliver pain management care effectively, one question was added to the

10、end of the test. 在一個(gè)單獨(dú)的護(hù)理病區(qū)， 物質(zhì)的因素如設(shè)備和物資供應(yīng)影響護(hù)理的效果。 為了獲得可能影響護(hù)理療效的環(huán)境因素，考試中加了一道問(wèn)題。This question asked the nurses to rank order a list of potential environmental barriersthat might affect their ability to man age their patients這pain個(gè)為.問(wèn)題是讓護(hù)士排列出潛在可能影響他們護(hù)理效果的環(huán)境因素的次序。The nurses were also asked to write in

11、perceived barriers not on the list, which had been developed by the investigator with input from the unit manager. 護(hù)士還被要求寫出不在列表中能感覺(jué)到的因素。This question was scored separately from the knowledge questions這.個(gè)問(wèn)題與那些知識(shí)的問(wèn)題是分開(kāi)打分的。 The information obtained was used to determine the nurses ceptionr of environme

12、ntal influences in care delivery.這些信息用來(lái)確定護(hù)士對(duì)護(hù)理過(guò)程中環(huán)境影響的洞察力。Nursing care delivery was defined as the responsibility of nurses to do regularassessments of the patient settipaing, pain goals,administering pain medications, and minimizing side effects of pain medication. 護(hù)理內(nèi)容包括病人疼痛的常規(guī)護(hù)理，設(shè)置疼痛分?jǐn)?shù)，疼痛藥物管理，減少藥

13、物的副作用。Nursing care delivery also included the management of side effects and the administration of adjuvant therapy還.包括管理藥物副作用和輔助治療的實(shí)施5 An unusual event, side effect,was defined by the investigator as respiratory sedation/depression (respiration less than 8 breaths/min), nausea, hypotension, unrelie

14、ved pain, and itching. 在特殊事件中， 調(diào)查者定義副作用包括呼吸抑制， 惡心，低血壓，疼痛為緩解，和瘙癢 Adjuvant therapy was defined as the use of additional pharmacologic agents that potentiate the effect of the opioid輔.助治療是應(yīng)用能加強(qiáng)阿片類藥物作用的額外的藥物治療。To obtain data related to nursing care delivery and pharmacologic management, the Chart Audit

15、Analysis Tool was developed(Fig 1).為了獲得護(hù)理藥物治療效果的數(shù)據(jù)，調(diào)查表也調(diào)整了。 Chart data about the patient managementspain on the second postoperative day were recorded on the form.表格中記錄患者術(shù)后第二天疼痛治療的療效。 The use of a chart audit to obtain information on nursing care delivery and pharmacologic management can be a weak o

16、r an unreliable indicator of care delivery because of the difficulties in drawing conclusions from the documentation. 用數(shù)值計(jì)算的方式獲得護(hù)理和藥物效果的方式是不可靠的，因?yàn)閺牟v描記結(jié)果是困難的。7,9However, daily entries into the patient charts is a source of information about the patient shealth and response to care.日常記錄病人的圖表是病人健康和護(hù)理療

17、效的信息來(lái)源10 In addition, the information sought from the chart is objective, not subjective, and in this instance,missing data were coded as inadequate care另外.，圖表的信息是客觀的，不是主觀的，例如丟失的是記錄成不適當(dāng)?shù)淖o(hù)理表里的內(nèi)容：評(píng)價(jià)疼痛管理病歷號(hào)手術(shù)名稱年齡 神志情況手術(shù)日期術(shù)后第二天護(hù)理記錄1. 疼痛評(píng)估中是否記錄了生命體征的數(shù)據(jù)嗎？2. 表中有疼痛治療的目標(biāo)嗎？3. 術(shù)后第二天有副作用嗎？4. 第三題回答是，副作用是否迅速的被識(shí)別和

18、治療？5. 第三題回答是什么癥狀的治療與情況的變化相關(guān)？A 呼吸抑制 計(jì)量的改變不同的阿片類藥物抵抗的藥物管理路線的改變B 惡心計(jì)量的改變不同的阿片類藥物抵抗的藥物管理路線的改變C 低血壓計(jì)量的改變不同的阿片類藥物抵抗的藥物管理路線的改變D 疼痛為緩解計(jì)量的改變不同的阿片類藥物輔助治療管理路線的改變E 癢計(jì)量的改變不同的阿片類藥物抵抗的藥物管理路線的改變藥物學(xué)的管理6.方式PCA硬膜外連續(xù)的靜脈口服7.藥物的種類其他杜冷丁8.要求的頻率9.給予的頻率The Chart Audit Analysis Tool (Fig 1) categorized the collected chart dat

19、a into nursing care and pharmacologic management這.個(gè)表 The Chart Audit Analysis Tool(Fig 1 把收集的數(shù)據(jù)分成護(hù)理和藥物的管理兩部分。 The data were scored according to an adaptation of the scoring format used by JCAHO.根據(jù)調(diào)整過(guò)的 JCAHO 的計(jì)分形式給數(shù)據(jù)打分。The JCAHO scores evidence of hospital compliance with their standards by assigning

20、 points1point for yes, 3 for sometimes, and 5 for no. JCAHO 的得分的證據(jù)與他們的標(biāo)準(zhǔn)是一致的：是1 分，有時(shí)是 3 分，不是 5 分。Questions 1 through 4 on the form score JCAHO standards on nursing care delivery,which include the following: pain is assessed on all patients, pain goals are establishedon all patients, and changes in t

21、he patients conditionsare assessedandmanaged.1-4 是關(guān)于護(hù)理的，包括評(píng)估所有病人的疼痛，所有病人的疼痛目標(biāo)的建立和病人情況改變的評(píng)估和管理。3 The fifth question identifies the treatment of unusual events and the use of adjuvanttherapy,第五題確定不良事件的治療和輔助治療的使用while the sixth questionscores the method, type, administration route, and timing of pharma

22、cologic management第.六題是對(duì)方法，種類，管理路徑和藥理學(xué)的管理時(shí)機(jī)打分Questions 5 and 6score pain management against standards established by the APS and the AHRQ.5，6 題疼痛管理的打分與 the APS and the AHRQ 建立的標(biāo)準(zhǔn)是相反的Points were assigned to indicate the compliance with these guidelines,with a lower score indicating better compliance分

23、.數(shù)表示遵守指南的情況， 低分表示更好的遵守指南The purpose of this scoring system was to assign an overall score to elements of the data collected. 打分系統(tǒng)的目的是把一個(gè)整體的分?jǐn)?shù)歸結(jié)于收集的數(shù)據(jù)基礎(chǔ)。The tool was pilot tested on 4 patients to ensure that the information collected was clear and complete. 這個(gè)已在 4 個(gè)病人進(jìn)行了，來(lái)確保收集的信息是清楚完整的 The ideal scor

24、e of 8 would signify that the nursing interventions and thepharmacologic interventions met the standards for care of the patient on the second postoperative day.滿分 8 分表示護(hù)理和藥物的治療符合對(duì)術(shù)后第二天病人護(hù)理的標(biāo)準(zhǔn)。INITIAL DATA COLLECTION 原始數(shù)據(jù)的收集 Thirty-eight nurses, both RNs and LPNs,were sent the knowledge and attitude

25、s test and a demographic form. Twenty-three returned the completed test, for a 60% responserate. 對(duì) 38 位護(hù)士進(jìn)行了測(cè)試，只完成了 23 位，有效率 60%The respondents consisted of 1 male and 22 females, of which 16 were RNs and 7were LPNs. 包括 1 男性和 22 女性。Thirteen RNs had bachelor s degree,13位有學(xué)士學(xué)位 2 had associate degree,兩

26、位大專學(xué)歷 and 1 had a diploma in nursing一.位護(hù)校學(xué)位A convenience sample of 30 charts of patients on their second postoperative day after a major abdominal surgery was reviewed and the data were scored using the Chart Audit Analysis Tool. 30 位經(jīng)歷了腹部手術(shù)的病人在術(shù)后第二天的圖表作為抽樣的樣本，用 the Chart Audit Analysis Tool 進(jìn)行了數(shù)據(jù)的打

27、分。Patients had to be on the unit for the entire time after their release from postanesthesia care.必須在麻醉恢復(fù)后完整的時(shí)間統(tǒng)一病區(qū)的病人 Patients who had been in the intensive care unit were not included重.癥監(jiān)護(hù)是的不包括The types of surgeries included colon resection (13), release of small bowel obstruction (3), colectomy (

28、3), and others (11)外.科手術(shù)種類有結(jié)腸，小腸手術(shù)等RESULTSThe average score for the nurses was 69.4%(range = 48%87%) on the knowledge survey.護(hù)士知識(shí)水平調(diào)查的平均得分是 69.4%An ideal score would be 100%.滿分是 100% As suggested by Ferrell, there is no true passing score, as the test does not distinguish between knowledge and attit

29、udes. Ferrell 建議沒(méi)有合格分?jǐn)?shù)線，因?yàn)檫@個(gè)檢查不能區(qū)別知識(shí)水平和個(gè)人態(tài)度It is better to look at the percentage score of the individual questions or a group of questions.最好去看單個(gè)問(wèn)題的分?jǐn)?shù)或一組問(wèn)題的分?jǐn)?shù)6 The LPNsmean score of 67% was not significantly different (P = .59) from the RNs mean score of 70%LPNs.和 RNs 分?jǐn)?shù)沒(méi)有顯著的差異Table1 lists the scor

30、es on the investigator identified subscales and key knowledge and attitudes survey items.表 1 列出了調(diào)查項(xiàng)目的分值，關(guān)鍵的知識(shí)和態(tài)度調(diào)查的項(xiàng)目。The nurses demonstrated better knowledge of painmanagement assessment than that of the use of analgesics比.起止痛藥使用的知識(shí)，護(hù)士展示出更好的疼痛評(píng)估的能力。Seventy-four percent of the nurses correctly answe

31、red the 7 questions on painassessment.74%的護(hù)士答對(duì)了關(guān)于疼痛評(píng)估的問(wèn)題The nurses knew only 7.6 of 15 questions pertaining to the pharmacologic management of pain. 15個(gè)關(guān)于疼痛藥物管理的問(wèn)題護(hù)士只答對(duì)了 7.6 個(gè)As a result, a need for education about the pharmacology of analgesics was identified. 結(jié)果對(duì)護(hù)士關(guān)于疼痛藥物管理的教育是必須的An ideal score on

32、the Chart Audit Analysis Tool would be 8, indicating that all items received the best score possible量.表的滿分是 8，表示所有的項(xiàng)目得到了最好的結(jié)果A range of acceptable scores is possible (815) because items numbered 4 and 5 become applicable only if there is development of side effects.可接受的分?jǐn)?shù)是815，因?yàn)橹挥谐霈F(xiàn)負(fù)作用 4 和 5 題才會(huì)適用Th

33、e range of scores for the initial 30 charts reviewed was 16 to 28最.初的 30 個(gè)圖標(biāo)的分?jǐn)?shù)是 16 to 28Pain goals and pain assessments were not documented in the record病.例中沒(méi)有疼痛治療目標(biāo)和疼痛評(píng)估的記錄There is a need to improve documentation of pain goals and assessments.有需要加強(qiáng)痛治療目標(biāo)和疼痛評(píng)估的記錄Scores on the method of medication de

34、livery (83%), type of medication (93%), route ofmedication administration (80%), and medication timing (80%) indicated better compliance with the published standards數(shù).據(jù)表明符合建立的標(biāo)準(zhǔn)。Such a small sample, though, makes it difficultto come to a conclusion about theresults.小樣本不能得出最后的結(jié)論。The nurses reported s

35、everal environmental barriers tothedeliveryofpainmanagement care護(hù).士記錄了一些不利于疼痛護(hù)理環(huán)境因素The main barrier was an inadequate staffing level (91%). 主要的因素是不合理的人員編制The next most common barriers were caring for too many acutely ill patients (74%) and specific times of the day when they were too busy to provide

36、 pain care(44%).最常見(jiàn)的不利因素是有太多劇烈疼痛的病人要護(hù)理和護(hù)士太忙而護(hù)理不周。Educational plan教育方案Several areas were identified for improvement on the basis of these findings: documentation of pain assessmentsand goals, knowledge of the pharmacology of opioids and opioid adjuvants, and management of patientcontrolled analgesia要

37、.提高以下幾個(gè)方面： 痛治療目標(biāo)和疼痛評(píng)估的記錄，應(yīng)用阿片類藥物的知識(shí)， 病人自控止痛的管理。After reviewing these results with the nurse manager, an educational plan was developed for the staff. 在回顧了結(jié)果后，要對(duì)全體人員實(shí)施教育計(jì)劃。The intervention was a mandatory educational session, which was conducted on all shifts.對(duì)所有輪班進(jìn)行強(qiáng)制的干預(yù)。The objectives were to descr

38、ibe the JCAHO standards for pain management, identify the nurse s role in maintaining JCAHO standards,and recall dosage and side effects of drugs for acute pain management目.的是描繪 the JCAHO 疼痛管理標(biāo)準(zhǔn)， 確立護(hù)士在其中的任務(wù)回顧治療急性疼痛的藥物的計(jì)量和副作用。An independent study packet was developed that covered the purpose, general

39、 policies for administration, setup, patient education, and documentation of patient-controlled analgesia一.個(gè)獨(dú)立的研究包括潛在的目的，一般的管理政策，組織，病人的教育和病人自控的記錄Administrative actions行政行為In response to the current nursing shortage, the hospital developed a plan to hire a significant number of nurses in a short peri

40、od of time針.對(duì)現(xiàn)在護(hù)理的缺陷，醫(yī)院計(jì)劃在短期內(nèi)聘用大量的護(hù)士。This plan used innovative shift and pay options, which attracted experienced nurses to the institution. The hospital also developed a policy to identify and manage acutely ill patients on general units. The policy included reporting to the supervisor any newly ad

41、mitted or current patient with a status change who required observation, assessment,or monitoring hourly or more frequently. The supervisor then facilitated the patient s transfer to critical care/telemetry units. Awareness of the number of acutely ill patientsled to expanded critical care beds and

42、nursing staff. Even though the staff on this general surgical unit remained stable, these actions began after the initial data collection and may have affected the outcomes of the second data collection.主要講醫(yī)院采用的行政管理的計(jì)劃。SECOND DATA COLLECTION 第二次數(shù)據(jù)的收集A second set of 30 charts from the same general su

43、rgical unit was reviewed in thesame manner as the first set 14 months earlier. This second set of data was compared to the first set to determine whether a change in care delivery had occurred as a result of the educational inservice兩.次進(jìn)行對(duì)比Comparative results對(duì)比結(jié)果There was significant improvement in

44、the nurses carelivdery total score after the educational intervention (P .001). 在教育培訓(xùn)之后，護(hù)理有了顯著地提高On average, there was a 5.8-point improvement in the points scored. The internal consistency of the chart audit before the inservice was = .52 and after the inservice, = .62. Individual items on the tool

45、 were evaluated using Fisher Exact test.The mean of the preeducation group was 18.6 and the range was16to 28, compared to a mean of 12.8 and a range of 8 to 22 in the group after the inservice. Documentation of pain assessment and pain goals was completely missing prior to the inservice. Post inserv

46、ice, pain goals were documented 100%,and pain assessmentsalso showed asignificant improvement in documentation (P =5.2 10-16). The sample of patients audited after the inservice had fewer side effects ( ). Prompt2P= management.0027 of side effects is dependent on the occurrence of an unusual event,

47、which were fewer in the second group of patients. The educational intervention improved the documentation of pain assessmentand pain goals. The intervention appeared toinfluence management of side effects as demonstrated by an increase in the internal consistency of the tool after the intervention.

48、This suggests that the nurses may have been more consistent in the delivery of care after the inservice. Other factors, though,such as the patient age,s mental status, and physician orders, that can influence the pharmacologic management of pain were not identified bythe tool.以上的意思就是護(hù)理的各個(gè)方面比第一次均有了顯著

49、地提高NURSING IMPLICATIONS護(hù)理的含義The nurses in this quality assurancestudy had better knowledge regarding general pain management and pain assessment than they did about the use of analgesics. They showed a need for education in pharmacologic management. This may imply that with all the drugs to learn, pain management education has not been a priority. When continuing education programs are developed, education related to pharmacology should be included.以上意思是對(duì)于護(hù)士應(yīng)該加強(qiáng)對(duì)藥物藥理學(xué)的教育The results of this quality