评价疼痛管理.docx

1、我只翻译了大概的内容， 这篇文章主要是评价护士对手术后遭受剧烈急性疼痛病人的护理工作。评价责任护士的疼痛护理因为疼痛管理是一个复杂的过程， 很难评价其疗效。 这篇文章描述了一个有保证的研究，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 an urban community teaching hospital. Approval for the study was obtained from the Instituti

4、onal Review Board and the Nursing Research Committee.研究的变量是护士对疼痛医学的知识和态度， 疼痛护理的干预和疼痛药物治疗的副作用，环境因素和药理学的管理。 研究的地点是城区的教学医院。 获得了这两个机构的批准 the Institutional Review Board and the Nursing Research CommitteeTwenty-three nurses (60% response rate) on a general surgical unit completed the knowledge and attitud

5、es 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 位护士完成了知识和态度的考试。同一个病区，在经历腹部手术的第二天， 30 位病人完成了回顾性的图表（抽样样本）An investigator-modified version of the1997 Ferrell and McC

6、affery s Knowledge and Attitudes 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 an internal reliability (r)greater than .70. Permission was obtained from the author to use the tool inw

7、hole or in part.意思是量表的来历，得到量表作者的同意使用量表The test was modified to eliminate questions about children cancerspain andpain because the focus on a general surgical unit is acute postoperative pain management. Modification of the test by deleting references to cancer pain can be supported because questions

8、 related to cancer pain may skew the results as general pain management and cancer pain management differ意.思是对量表进行了许多的修改Agroupof clinicians with experience in pain management, including a hospice nurse, an oncology nurse, and a surgical nursemanager, reviewed the final modified test.意思是有疼痛管理经验的人员也参与

9、了修改量表的工作In 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 ad

10、ded to the end of the test. 在一个单独的护理病区， 物质的因素如设备和物资供应影响护理的效果。 为了获得可能影响护理疗效的环境因素，考试中加了一道问题。This question asked the nurses to rank order a list of potential environmental barriersthat might affect their ability to man age their patients这pain个为.问题是让护士排列出潜在可能影响他们护理效果的环境因素的次序。The nurses were also asked t

11、o write in perceived barriers not on the list, which had been developed by the investigator with input from the unit manager. 护士还被要求写出不在列表中能感觉到的因素。This question was scored separately from the knowledge questions这.个问题与那些知识的问题是分开打分的。 The information obtained was used to determine the nurses ceptionr o

12、f environmental influences in care delivery.这些信息用来确定护士对护理过程中环境影响的洞察力。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. 护理内容包括病人疼痛的常规护理，设置疼痛分数

13、，疼痛药物管理，减少药物的副作用。Nursing care delivery also included the management of side effects and the administration of adjuvant therapy还.包括管理药物副作用和辅助治疗的实施5 An unusual event, side effect,was defined by the investigator as respiratory sedation/depression (respiration less than 8 breaths/min), nausea, hypotensi

14、on, unrelieved pain, and itching. 在特殊事件中， 调查者定义副作用包括呼吸抑制， 恶心，低血压，疼痛为缓解，和瘙痒 Adjuvant therapy was defined as the use of additional pharmacologic agents that potentiate the effect of the opioid辅.助治疗是应用能加强阿片类药物作用的额外的药物治疗。To obtain data related to nursing care delivery and pharmacologic management, the C

15、hart Audit Analysis Tool was developed(Fig 1).为了获得护理药物治疗效果的数据，调查表也调整了。 Chart data about the patient managementspain on the second postoperative day were recorded on the form.表格中记录患者术后第二天疼痛治疗的疗效。 The use of a chart audit to obtain information on nursing care delivery and pharmacologic management can

16、be a weak or an unreliable indicator of care delivery because of the difficulties in drawing conclusions from the documentation. 用数值计算的方式获得护理和药物效果的方式是不可靠的，因为从病历描记结果是困难的。7,9However, daily entries into the patient charts is a source of information about the patient shealth and response to care.日常记录病人的

17、图表是病人健康和护理疗效的信息来源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.，图表的信息是客观的，不是主观的，例如丢失的是记录成不适当的护理表里的内容：评价疼痛管理病历号手术名称年龄 神志情况手术日期术后第二天护理记录1. 疼痛评估中是否记录了生命体征的数据吗？2. 表中有疼痛治疗的目标吗？3. 术后第二天有副作用吗？4. 第三题回答是，副

18、作用是否迅速的被识别和治疗？5. 第三题回答是什么症状的治疗与情况的变化相关？A 呼吸抑制 计量的改变不同的阿片类药物抵抗的药物管理路线的改变B 恶心计量的改变不同的阿片类药物抵抗的药物管理路线的改变C 低血压计量的改变不同的阿片类药物抵抗的药物管理路线的改变D 疼痛为缓解计量的改变不同的阿片类药物辅助治疗管理路线的改变E 痒计量的改变不同的阿片类药物抵抗的药物管理路线的改变药物学的管理6.方式PCA硬膜外连续的静脉口服7.药物的种类其他杜冷丁8.要求的频率9.给予的频率The Chart Audit Analysis Tool (Fig 1) categorized the collecte

19、d chart data into nursing care and pharmacologic management这.个表 The Chart Audit Analysis Tool(Fig 1 把收集的数据分成护理和药物的管理两部分。 The data were scored according to an adaptation of the scoring format used by JCAHO.根据调整过的 JCAHO 的计分形式给数据打分。The JCAHO scores evidence of hospital compliance with their standards b

20、y assigning points1point for yes, 3 for sometimes, and 5 for no. JCAHO 的得分的证据与他们的标准是一致的：是1 分，有时是 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 c

21、hanges in the patients conditionsare assessedandmanaged.1-4 是关于护理的，包括评估所有病人的疼痛，所有病人的疼痛目标的建立和病人情况改变的评估和管理。3 The fifth question identifies the treatment of unusual events and the use of adjuvanttherapy,第五题确定不良事件的治疗和辅助治疗的使用 while the sixth question scores the method, type, administration route, and tim

22、ing of pharmacologicmanagement第.六题是对方法，种类，管理路径和药理学的管理时机打分Questions 5 and 6score pain management against standards established by the APS and the AHRQ.5，6 题疼痛管理的打分与 the APS and the AHRQ 建立的标准是相反的Points were assigned to indicate the compliance with these guidelines,with a lower score indicating better

23、 compliance分.数表示遵守指南的情况， 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. 打分系统的目的是把一个整体的分数归结于收集的数据基础。The tool was pilot tested on 4 patients to ensure that the information collected was clear and complete. 这个已在 4 个病人进行了，来确保收集的信息是清楚完整的 Th

24、e ideal score of 8 would signify that the nursing interventions and thepharmacologic interventions met the standards for care of the patient on the second postoperative day.满分 8 分表示护理和药物的治疗符合对术后第二天病人护理的标准。INITIAL DATA COLLECTION 原始数据的收集 Thirty-eight nurses, both RNs and LPNs,were sent the knowledge

25、and attitudes test and a demographic form. Twenty-three returned the completed test, for a 60% responserate. 对 38 位护士进行了测试，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位有学士学位 2 had associ

26、ate degree,两位大专学历 and 1 had a diploma in nursing一.位护校学位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 位经历了腹部手术的病人在术后第二天的图表作为抽样的样本，用 the Chart Audit Analysis

27、Tool 进行了数据的打分。Patients had to be on the unit for the entire time after their release from postanesthesia care.必须在麻醉恢复后完整的时间统一病区的病人 Patients who had been in the intensive care unit were not included重.症监护是的不包括The types of surgeries included colon resection (13), release of small bowel obstruction (3),

28、 colectomy (3), and others (11)外.科手术种类有结肠，小肠手术等RESULTSThe average score for the nurses was 69.4%(range = 48%87%) on the knowledge survey.护士知识水平调查的平均得分是 69.4%An ideal score would be 100%.满分是 100% As suggested by Ferrell, there is no true passing score, as the test does not distinguish between knowled

29、ge and attitudes. Ferrell 建议没有合格分数线，因为这个检查不能区别知识水平和个人态度It is better to look at the percentage score of the individual questions or a group of questions.最好去看单个问题的分数或一组问题的分数6 The LPNsmean score of 67% was not significantly different (P = .59) from the RNs mean score of 70%LPNs.和 RNs 分数没有显著的差异Table1 li

30、sts the scores on the investigator identified subscales and key knowledge and attitudes survey items.表 1 列出了调查项目的分值，关键的知识和态度调查的项目。The nurses demonstrated better knowledge of painmanagement assessment than that of the use of analgesics比.起止痛药使用的知识，护士展示出更好的疼痛评估的能力。Seventy-four percent of the nurses cor

31、rectly answered the 7 questions on painassessment.74%的护士答对了关于疼痛评估的问题The nurses knew only 7.6 of 15 questions pertaining to the pharmacologic management of pain. 15个关于疼痛药物管理的问题护士只答对了 7.6 个As a result, a need for education about the pharmacology of analgesics was identified. 结果对护士关于疼痛药物管理的教育是必须的An ide

32、al score on the Chart Audit Analysis Tool would be 8, indicating that all items received the best score possible量.表的满分是 8，表示所有的项目得到了最好的结果A range of acceptable scores is possible (815) because items numbered 4 and 5 become applicable only if there is development of side effects.可接受的分数是815，因为只有出现负作用 4

33、 和 5 题才会适用The range of scores for the initial 30 charts reviewed was 16 to 28最.初的 30 个图标的分数是 16 to 28Pain goals and pain assessments were not documented in the record病.例中没有疼痛治疗目标和疼痛评估的记录There is a need to improve documentation of pain goals and assessments.有需要加强痛治疗目标和疼痛评估的记录Scores on the method of m

34、edication delivery (83%), type of medication (93%), route ofmedication administration (80%), and medication timing (80%) indicated better compliance with the published standards数.据表明符合建立的标准。Such a small sample, though, makes it difficultto come to a conclusion about theresults.小样本不能得出最后的结论。The nurse

35、s reported several environmental barriers tothedeliveryofpainmanagement care护.士记录了一些不利于疼痛护理环境因素The main barrier was an inadequate staffing level (91%). 主要的因素是不合理的人员编制The next most common barriers were caring for too many acutely ill patients (74%) and specific times of the day when they were too bus

36、y to provide pain care(44%).最常见的不利因素是有太多剧烈疼痛的病人要护理和护士太忙而护理不周。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 patientcontrolle

37、d analgesia要.提高以下几个方面： 痛治疗目标和疼痛评估的记录， 应用阿片类药物的知识， 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. 在回顾了结果后，要对全体人员实施教育计划。The intervention was a mandatory educational session, which was conducted on all shifts.对所有轮班进行强制的干预。The objectives

38、were to describe 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.的是描绘 the JCAHO 疼痛管理标准， 确立护士在其中的任务回顾治疗急性疼痛的药物的计量和副作用。An independent study packet was developed that covered the pur

39、pose, general policies for administration, setup, patient education, and documentation of patient-controlled analgesia一.个独立的研究包括潜在的目的，一般的管理政策，组织，病人的教育和病人自控的记录Administrative actions行政行为In response to the current nursing shortage, the hospital developed a plan to hire a significant number of nurses in

40、 a short period of time针.对现在护理的缺陷，医院计划在短期内聘用大量的护士。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

41、 any newly admitted 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 c

42、are beds and 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.主要讲医院采用的行政管理的计划。SECOND DATA COLLECTION 第二次数据的收集A second set of 30 charts from the sa

43、me general surgical 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 resultof the educational inservice两.次进行对比Comparative results对比结果There was significant imp

44、rovement in the nurses carelivdery total score after the educational intervention (P .001). 在教育培训之后，护理有了显著地提高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

45、 on the tool 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.

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

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

48、vention. 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.以上的意思就是护理的各个方面

49、比第一次均有了显著地提高NURSING IMPLICATIONS护理的含义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.以上意思是对于护士应该加强对药物药理学的教育The results of this quality