18例ARDS患者应用“糖果翻身法”实施俯卧位通气治疗的护理*

总结18例ARDS患者应用“糖果翻身法”行俯卧位通气治疗的护理。医护团队协作,结合肺保护性通气治疗策略,应用“糖果翻身法”成功实施了俯卧位通气治疗;同时落实俯卧位通气治疗期间的监测、人工气道的管理、镇痛镇静护理及营养支持。     

“三主”视角下《妇产科护理学》的课程思政教学实践

目的 探讨“三主”视角下《妇产科护理学》“课程思政”的教学实践及效果。方法 围绕教师队伍主力军、课程建设主战场、课堂教学主渠道3方面,采取强化教师思政育人意识与能力,完善课程思政系统、构建“LOVE”和“HEART”2大思政模块、丰富课堂教学方法等措施,在2019级护理本科生中进行《妇产科护理学》“课程思政”教学改革。结果 学生和督导评价中,教师德育能力均分超过上一年度,且获得了一些奖项;学生课堂互动参与度好、线上学习积极、期中考试和期末考试平均分超过80分,思政素养得分超过90分者占比超过80%。结论 “三主”视角下“课程思政”教学可提升教师思政育人能力,激发学生课程学习投入、提升学习效果和思政素养。     

“组团式”紧密型帮扶提升基层中医院护士中医护理服务能力的实践

目的 探索“组团式”紧密型帮扶提升基层中医院护士中医护理服务能力的方式及效果。方法 充分了解基层中医院的需求,成立中医护理帮扶专家团,并派驻中医护理骨干紧密型驻点帮扶。采取“双”式和“播种”式帮扶,强化人才培养;建立护理服务质控体系,引入科学管理理念;“手把手”指导+“传帮带”教学,促进学科发展;“师带徒”模式打造联动门诊,帮助基层医院提供高质量服务。结果 被帮扶医院中医护理服务能力显著提高,中医理论与操作评分较帮扶前明显提高（P<0.001）,其中中药涂药技术、蜡疗技术和经穴推拿技术3项操作进步最大;被帮扶医院护士对“组团式”紧密型帮扶总体满意度、教学计划安排满意度、授课内容满意度均达到99%以上;被帮扶医院成功开设中医特色护理门诊,培养了8名院级中医护理骨干人才。结论 对基层中医院实施“组团式”紧密型帮扶可有效提升被帮扶医院的中医护理服务能力,进而提高基层中医院中医护理服务质量。     

“以人为本”重症护理量表的汉化及信度效度检验

目的 翻译韩文版“以人为本”重症护理量表（Person-centered Critical Care Nursing,PCCN）,形成中文版“以人为本”重症护理量表,并分析其信度效度。方法 按照量表汉化的程序,得到原作者授权后,将韩文版“以人为本”重症护理量表翻译为中文,并接受跨文化调试,对天津市375名重症监护室护士进行调查,完成信度效度检验。结果 中文版“以人为本”重症护理量表表面效度与内容效度较好;共提取出共情、个性、尊重、舒适4个公因子,各因子的条目载荷均≥0.4,累计总变异率的解释率为70.113%,结构效度良好;总体Cronbach α系数为0.897,各维度的Cronbach α系数为0.816、0.766、0.771、0.871。验证性因子模型拟合度良好。结论 中文版“以人为本”重症护理量表具有良好的信度效度,适合中国ICU护士共情、个性、尊重、舒适等方面人文关怀能力的评估。     

肾移植患者基于“互联网+”延续护理的效果观察

目的 探讨“互联网+”延续护理在肾移植患者中的应用效果。方法 选择在我院初次行肾移植术成功的患者80例为研究对象,采用随机数字表法分为观察组和对照组各40例。对照组给予常规出院健康教育方式,观察组采取基于“互联网+”的延续护理健康教育方式。观察比较2组肾移植患者出院时、出院后1个月末、3个月末、6个月末免疫抑制剂服药依从性。结果 观察组肾移植患者出院后1个月末、3个月末、6个月末免疫抑制剂服药依从性得分高于对照组（P<0.05）。结论 “互联网+”延续护理可提高肾移植患者免疫抑制剂服药依从性。     

“互联网+母婴护理”精准服务模式的构建与实践

目的 构建“互联网+母婴护理”精准服务模式,为母婴人群提供不同类型的专业居家护理服务。方法 通过中山市“互联网+护理服务”线上平台,构建“互联网+母婴护理”精准服务模式,采取标准化培训,落实同质化护理管理,实践“互联网+母婴护理”精准服务。结果 我院“互联网+母婴护理”精准服务自2020年6月开展来,电话咨询评估215次,上门母婴护理服务103次,其中接受评价的产妇满意度（4.41±0.66）分,31名出诊护士职业满意度对该模式自评赞成率61.29%~100%。结论 构建的“互联网+母婴护理”精准服务模式,满足了人民群众延续性护理需求;同时拓展护士执业空间,提升护士专业价值,对促进护理服务业的改革与发展起到积极推动作用。     

新建医院护士扮演“神秘客户”体验门诊就医的质性研究

目的 深入了解护士参与“神秘客户”体验活动即“护士体验患者活动”后临床护士的真实感受,为新建医院服务模式优化、信息系统管理完善、护士训练培养策略提升提供有效依据。方法 运用质性研究方法,对符合纳入标准的15名护士体验活动后进行半结构化访谈,采用Colaizzi进行资料分析。结果 “神秘客户”体验活动后,参与护士接受访谈,提炼出个性化服务,专业指导需求,信息系统管理,疗愈环境设计,体验活动启发与改变5个主题。结论 “神秘客户”体验活动可根据门诊护理专业需求特色,打造个性化护理宣导;探寻新建医院信息系统无纸化管理前期不稳定的解决方法;开发拓展“神秘客户”体验活动用于护理的优化与改进,为新建医院初期服务模式、制度流程改进、护理人员培养提供有效依据,为营造优质的护理文化夯实基础。     

看不清的“小人”:Charles Bonnet综合征一例并文献复习

目的 分析Charles Bonnet综合征（CBS）的诊治要点,提高临床医师对该病的诊治水平。方法 报道1例CBS病例,并以 “Charles Bonnet综合征”“邦纳综合征”“Charles Bonnet syndrome”“幻视/ visual hallucination”为检索词,对以下数据库的相关论文进行检索:PubMed、中国生物医学文献服务系统（SinoMed）、CNKI、万方数据知识服务平台、维普中文科技期刊数据库、中华医学期刊全文数据库,收集并分析检索到的病例资料。结果 该例患者以幻视为首发症状,自述家中出现“小人”,但可以感知此为幻觉。患者精神评估未见异常,有自知力,无其他幻觉,明确诊断为CBS。予患者心理治疗,提高其对该病的认知水平,减轻其心理负担。检索文献收集到CBS病例14例,幻视表现多种多样,尚无明确有效的药物可以改善幻视。结论 CBS诊断困难,无明确有效的治疗药物,临床医师应注意提高对该病的诊治水平,降低误诊与误治率。     

“社区护理学”课程形成性评价体系构建

目的 构建“社区护理学”课程形成性评价体系,以更加客观、全面地评价学生的综合能力。方法 在文献回顾的基础上由研究小组初步拟定函询问卷,运用德尔菲法进行2轮专家函询,形成“社区护理学”课程形成性评价体系,包括评价指标和评价形式、标准、主体,并用层次分析法确定各指标权重。结果 2轮专家函询问卷回收率为100%,判断系数、熟悉系数和权威系数分别为0.872、0.846和0.820。变异系数为0~0.183,协调系数W为0.257和0.436。最终确立评价体系：评价指标包括3个一级指标,14个二级指标,19个三级指标;11个评价形式,35个评价标准和3个评价主体。结论 “社区护理学”课程形成性评价体系构建科学可靠,能够为客观、全面地评价学生学习效果提供量化参考依据。     

基于服务质量差距模型的“互联网+护理服务”质量评价指标研究

目的 基于服务质量差距模型构建“互联网+护理服务”质量评价指标,旨在推进和完善我国“互联网+护理服务”。 方法 通过系统文献研究、半结构式访谈、德尔菲法及优序图法确立医疗机构开展“互联网+护理服务”的质量评价指标。 结果 2020年9月—11月进行了2轮专家函询,2轮函询问卷的有效回收率均为100%,专家权威系数为0.82,肯德尔和谐系数分别为0.178和0.262。最终确立的“互联网+护理服务”质量评价指标包括一级指标6项（有形性、可靠性、保证性、响应性、移情性、易用性）、二级指标l8项和三级指标66项。 结论 该研究构建的“互联网+护理服务”质量评价指标具有较好的科学性和实用性,内容全面,可为我国开展“互联网+护理服务”的质量评价及服务指南的制订提供理论与实践依据。     

Anaphylaxis.

The syndrome of anaphylaxis is a life-threatening event in which the potential for patient morbidity and mortality is high. An understanding of the pathophysiology of anaphylaxis, the most serious of the allergic disorders, is paramount for its diagnosis. In addition to these elements, this article discusses newly recognized causes of anaphylaxis and reviews its treatment.     

Recognition and treatment of anaphylaxis

The aim of this paper is to discuss the recognition, treatment and investigation of anaphylaxis. Anaphylaxis is a severe, life‐threatening, generalized or systemic hypersensitivity reaction. It is characterized by rapidly developing life‐threatening airway and/or breathing and/or circulation problems usually associated with skin and/or mucosal changes. The incidence of anaphylaxis appears to be increasing. A wide range of triggers can cause anaphylaxis. Drugs are the commonest cause of anaphylaxis in hospital and foods in the out‐of‐hospital setting. Patients having anaphylaxis should be treated using the airway, breathing, circulation, disability, exposure (ABCDE) approach. Early treatment with intramuscular adrenaline is the treatment of choice for patients having anaphylaxis. Intravenous adrenaline must only be used when the patient is monitored and only by those skilled and experienced in its use. A raised serum mast cell tryptase suggests a diagnosis of anaphylaxis. All those who are suspected of having anaphylaxis should be referred to a specialist in allergy. Individuals at high risk of anaphylaxis where the trigger is difficult to avoid should carry an adrenaline auto‐injector and receive training and support in its use.     

Customizing Anaphylaxis Guidelines for Emergency Medicine

Background

Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition.

Objective

Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements.

Discussion

Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode—regardless of severity—is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as “possible anaphylaxis,” it is generally better to err on the side of caution and administer epinephrine.

Conclusion

We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.     

Management of anaphylaxis in the ED: A clinical audit

Anaphylaxis is one of the potentially life threatening conditions which present to the ED however there is no universal understanding or definitive diagnostic test to aid ED practitioners in its management. Evidence suggests this leads to confusion for ED staff and may compromise patient care.This paper reviews the existing evidence around the effective diagnosis, emergency treatment and long term management of anaphylaxis. It then describes a clinical audit which was carried out in the ED of a large UK University hospital.A retrospective audit design sampled all patients presenting with anaphylaxis in one calendar year, 146 cases were eligible for inclusion. The audit results were consistent with the existing understanding and showed widespread inconsistencies in the diagnosis and treatment of this patient group.The implications the findings may have for the wider ED nursing community are discussed and we conclude that further research and service development is needed to ensure the best possible care for patients with anaphylaxis.     

Abdominal anaphylaxis presenting as trauma: a recipe for delayed diagnosis

Background: Successful shock management requires prompt identification, classification, and treatment; however, the triage of patients with non-hemorrhagic shock to the trauma room can lead to delayed diagnosis with increased morbidity and mortality. Objective: Our goal is to emphasize the importance of shock identification and classification to facilitate the delivery of the appropriate and timely therapy, no matter how the patient is triaged. Case Report: We describe a patient triaged as a trauma patient with suspected hemorrhagic shock yet who was found to have anaphylaxis as the etiology of his condition. Abdominal anaphylaxis, a less recognized presentation of anaphylaxis, is reviewed and discussed. Conclusions: We hope to increase awareness of a less common presentation of anaphylaxis and discuss its management.     

A practical guide to anaphylaxis

Anaphylaxis is a life-threatening reaction with respiratory, cardiovascular, cutaneous, or gastrointestinal manifestations resulting from exposure to an offending agent, usually a food, insect sting, medication, or physical factor. It causes approximately 1,500 deaths in the United States annually. Occasionally, anaphylaxis can be confused with septic or other forms of shock, asthma, airway foreign body, panic attack, or other entities. Urinary and serum histamine levels and plasma tryptase levels drawn after onset of symptoms may assist in diagnosis. Prompt treatment of anaphylaxis is critical, with subcutaneous or intramuscular epinephrine and intravenous fluids remaining the mainstay of management. Adjunctive measures include airway protection, antihistamines, steroids, and beta agonists. Patients taking beta blockers may require additional measures. Patients should be observed for delayed or protracted anaphylaxis and instructed on how to initiate urgent treatment for future episodes.     

Food-dependent exercise-induced anaphylaxis

Food-dependent exercise-induced anaphylaxis (FDEIA) is a specific variant of exercise-induced anaphylaxis that requires both vigorous physical activity and the ingestion of specific foods within the preceding several hours. When patients present to the emergency department (ED) with allergic reactions, careful history regarding these 2 factors is required to establish the correct diagnosis. Correct diagnosis of FDEIA will allow patients to take control of their lifestyles and avert repeated events and ED visits. Two cases of FDEIA are presented, and the diagnosis, pathophysiology and therapy of food-dependent exercise-induced anaphylaxis are reviewed.     

Anaphylaxis. Vicious chain reaction

The etiologies of anaphylaxis are numerous. The presentation of an anaphylactic reaction may range from a minor skin rash to cardiovascular collapse, making the diagnosis vexing for healthcare providers. Recognition of the signs of an anaphylactic reaction can save lives. Prehospital providers must have a solid understanding of the pathophysiology of anaphylaxis, be able to recognize the signs of anaphylaxis and know the therapies used in the management of anaphylaxis.     

Emergency medical recognition and management of idiopathic anaphylaxis

Idiopathic anaphylaxis (IA) is a diagnosis of exclusion that is made when no identifiable causative factors can be found for an episode of anaphylaxis. IA is a potentially life-threatening disease that is the result of a nonimmunologic mast cell activation syndrome. Acute presentation and treatment of these patients is most often in the emergency department and is clinically the same as anaphylaxis from allergens. Since these episodes are unpredictable and often recurrent, these patients are at risk of death if not identified on acute presentation and managed appropriately. As an increasing number of patients are being diagnosed with IA, they will be presenting to emergency departments with initial and recurrent episodes of IA. Therefore, increased awareness of IA and coordinated care is needed so that the morbidity and mortality of this potentially fatal disease can be kept at a minimum.     

Reverse Takotsubo Cardiomyopathy in the Setting of Anaphylaxis Treated with High-dose Intravenous Epinephrine

Background

Takotsubo cardiomyopathy is seen, though rarely, in anaphylaxis treated with epinephrine. Stress cardiomyopathy is most likely to occur in middle-aged women. The underlying etiology is believed to be related to catecholamine release in periods of intense stress. Catecholamines administered exogenously, and those secreted by neuroendocrine tumors (e.g., pheochromocytoma) or during anaphylaxis have been reported to cause apical ballooning syndrome, or takotsubo syndrome. However, reverse takotsubo stress cardiomyopathy is rarely seen or reported in anaphylaxis treated with epinephrine.

Objectives

To report a case illustrating that high-dose intravenous epinephrine can trigger stress cardiomyopathy, and that the risk is heightened with inappropriate dosing in the treatment of anaphylaxis.

Case Report

We report a rare case of iatrogenic reverse takotsubo syndrome in a young woman who was inappropriately treated with high-dose intravenous epinephrine for mild anaphylaxis.

Conclusion

Inappropriately high doses of intravenous epinephrine can trigger stress cardiomyopathy. Emergency physicians should be familiar with the diagnosis, grading, and appropriate treatments of anaphylaxis to avoid this unnecessary complication.