ICU患者睡眠评估研究进展

睡眠障碍是ICU患者普遍存在的问题,有效的评估是改善睡眠质量的前提。由于ICU患者病情的特殊性,对其进行睡眠评估往往比较复杂。本文就ICU患者常用的主观和客观睡眠评估工具及方法进行阐述,以期为ICU医务工作者科学地评估和管理患者睡眠提供借鉴和参考。     

客观疼痛评估工具在ICU成人机械通气病人中的应用研究与特点分析

介绍ICU成人机械通气病人客观疼痛评估工具及应用情况,提出研制适合中国文化的评估ICU成人机械通气病人的客观疼痛评估工具,以改善病人的疼痛管理及其预后。     

ICU护士对危重患者疼痛护理相关知识与实践现状的分析

为了了解ICU护士对危重患者疼痛相关知识的掌握与实践现状,对某三级甲等医院129名ICU护士进行了调查。结果显示,ICU护士疼痛知识与态度调查平均正确率为35.2%;参加过疼痛学习班、有疼痛处理经验者回答正确率较高(P<0.05)。大多数ICU护士(76.7%)使用过疼痛强度评估量表,但无人使用过行为观察疼痛评估工具。ICU护士选择最能代表危重患者存在疼痛的行为是痛苦表情(66.7%)、皱眉(48.8%)和握紧拳头(46.5%)等。ICU护士认为积极的ICU团队、标准化疼痛评估工具及持续疼痛教育等是危重患者疼痛护理的重要促进因素,患者不能交流、缺少疼痛指南及评估工具、工作量大等是主要障碍因素。应强化对ICU护士的疼痛教育,鼓励应用行为指征对危重患者进行疼痛评估,营造良好的疼痛治疗护理环境,持续改进疼痛护理质量。     

危重症患者疼痛观察工具的研究进展

正疼痛,是由组织损伤引起的不愉快的感觉和情感体验[1],疼痛在重症监护室(intensive care unit,ICU)患者中十分常见并可能得不到充分治疗[2]。镇痛治疗是ICU治疗的重要组成部分[3],合理有效地评估疼痛是镇痛治疗的首要步骤,临床通过收集金标准即患者的自我报告或使用评估工具对患者进行疼痛评估[4]。美国疼痛管理学会(American Society of Pain Management Nursing,ASPMN)[4]、重症学会(Society of Critical Care Medicine,SCCM)[5]以及中国成人ICU镇痛和镇静治疗指南[3]多推荐使用危重症患者疼痛观察工具(critical-care pain observation tool,CPOT)作为ICU患者的疼痛评估工具。目前CPOT量表的适用人群、截止值等尚不明确,临床无法对疼痛程度进行准确判断并最终影响患者的疼痛体验。因此本文对量表的信效度研究、应用人群及截止值等进行综述,以期为医护人员更好地使用CPOT量表、开展疼痛管理提供参考依据。     

疼痛评估工具在重症监护病房住院患者中的应用与选择

正疼痛是重症监护病房(ICU)危重症患者常见的临床症状~([1])。近年,如何加强对ICU危重症患者的疼痛评估和治疗引起了大量学者的高度关注,并有学者针对ICU危重症患者疼痛评估工具的选择进行了深入研究~([2-3])。本研究复习近年国内外有关疼痛评估工具在ICU危重症患者中的应用现状,现综述如下。1 ICU住院患者疼痛管理的意义疼痛是危重症患者较为显著的临床症状,也是影响其机体代谢应激反应的主要因素~([4])。由于ICU     

寻找最佳的整体性急症疼痛评估工具

护理工作通常是收集患者的主观感受信息,并在诊断过程和有效的护理治疗过程中重新客观地解释这些信息。理想的疼痛评估工具应该能够描述患者的疼痛感受,使用患者和评估人员共用的语言。在急症评估中,观察与评估对有效实施护理和迅速治疗至关重要,评估需要全面而整体的方法。护士在评估疼痛、收集资料以及实施有效疼痛管理的过程中,言行要合乎伦理道德,体现人道主义精神,有职业责任感。紧急状态下,迅速关注躯体症状和疼痛评估有些矛盾,并非所有的疼痛均能立即致命,但疼痛均需处理。急症医疗状态下,时间是最紧缺的。理想的疼痛评估工具的条文…     

ICU腹部外科术后患者疼痛与睡眠关系的研究

目的:探讨ICU中疼痛是否为ICU睡眠障碍的确定影响因素,主观疼痛指标与客观疼痛指标的关系,主观睡眠质量与客观睡眠质量的关系。方法:一共入组40名ICU腹部外科择期术后病人,记录他们的年龄、Apache Ⅱ评分、VAS评分、按压止疼泵次数、脑电图得到的深睡眠百分比、浅睡眠百分比、主诉睡眠质量等参数。根据主诉睡眠的质量分为好、中、差三组,比较三组间深睡眠百分比的差异。比较VAS与按压止疼泵次数的相关性,比较深睡眠百分比与Apache II评分、VAS评分的相关性。结果:VAS和按压止疼泵的次数呈正相关(r=0.39,P=0.013),不同的主观睡眠质量其脑电深睡眠百分比存在明显差异(P=0.004),深睡眠所占百分比与VAS和Apache Ⅱ评分存在相关性(P<0.05)。结论:按压止疼泵次数可反映患者疼痛程度,深睡眠所占百分比可反映患者主观睡眠状况,ICU中睡眠质量与疼痛和疾病的严重程度有关。     

疼痛评估现状及新进展

疼痛是一种主观的感受,同一个人不同时间的疼痛感受和不同人在同一病情或处置下的疼痛感受变异都很大,影响疼痛的主观感受因素很多,促进或妨碍表达疼痛的因素也很多,因而很难客观而精确的计量和比较。由于疼痛能给患者造成多方面的损害,因此掌握有效的疼痛评估方法,选择使用有效的评估工具管理疼痛可以简化疼痛管理过程,使疼痛得到及时的干预。鉴于未缓解的疼痛会给患者造成多方面的损害,国际上出现了将疼痛作为“第五生命体征”的趋势[1]。即护理人员应该像测量体温、脉搏、呼吸、血压一样,去评估患者的疼痛并记录。同时提供相应的护理支持…     

重症监护疼痛观察工具临床应用的SWOT分析

重症监护疼痛观察工具(critical-care pain observation tool,CPOT)是一种以行为变化为评估指标的客观疼痛评估工具,主要用于无法用言语表达疼痛的ICU重症患者的疼痛评估和管理。本文运用SWOT[优势(S)、劣势(W)、机遇(O)、挑战(T)]分析方法,系统分析了CPOT在临床应用的优势、存在的问题、实施的机遇和挑战,为临床医护人员开展高质量的疼痛评估、制订疼痛管理策略和措施提供参考依据。     

ICU患者睡眠障碍及其评估方式的研究进展

目前临床上对ICU睡眠评估的形式主要有客观睡眠评估和主观睡眠评估。如应用多导睡眠图、体动记录仪、脑电双频指数进行客观评估,具有精确、可靠,采集的睡眠数据较多,适用人群广泛;但其操作复杂,花费较高,且需要专业人员协助监测或进行数据分析。应用Richards-Campbell睡眠量表、VSH睡眠量表、ICU睡眠问卷调查表、直接观察法等进行主观睡眠评估,具有简单易行、操作方便,对操作者的要求较客观评估低,且较为经济实用;应用人群主要为意识清醒患者。提出对ICU患者的睡眠评估,应根据患者的个体情况而选择适合的评估工具。在重症监护场所,患者自评或护士评估是较理想的睡眠评估方式,而非多导睡眠图。     

The sedation of critically ill adults: Part 1: Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU

The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients. The prevention or treatment of pain, anxiety, and delirium in the ICU is an important goal. But achieving a balance between sedation and analgesia, especially in critically ill patients on mechanical ventilation, can be challenging. Both under- and oversedation carry serious risks. In 2002 the Society of Critical Care Medicine, along with the American Society of Health-System Pharmacists, updated recommendations in its clinical practice guidelines for the sustained use of sedatives and analgesics in adults. This two-part series examines those recommendations that relate to sedation assessment and management, as well as the current literature. This month Part 1 also reviews pertinent recommendations concerning pain and delirium and discusses tools for assessing pain, delirium, and sedation. In August Part 2 will explore pharmacologic and nonpharmacologic management of anxiety and agitation in critically ill patients.     

Assessment and management of the trauma patient in pain

Optimum management of the critically ill trauma patient with pain combines a level of ongoing assessment that considers the intensity of the pain being experienced and the meaning of that pain to the individual. The physiologic responses of the critically ill patient to pain should be considered when assessing pain and when prescribing a particular medication and method of administration to relieve pain. Ongoing systematic assessment is critical so that patients are getting the maximal effects to keep them above their particular pain thresholds but below their sedation thresholds. Other modalities that are independent nursing functions, such as heat, distraction and positioning, should be an adjunct to medication prescribed for the overall care of the patient.     

Pain management

Postoperative pain management in the critically ill patient is a challenge for nurses. Knowing the basis of pain transmission and mechanisms of action of interventions can assist the critical care nurse in making clinical decisions regarding pain control for individual patients. There are a number of modalities available to treat postoperative pain including both pharmacologic and nonpharmacologic interventions. Techniques such as PCA not only can provide good analgesia, but allow the critically ill patient at least one aspect of control in the otherwise highly controlled environment of the critical care unit. Epidural or intrathecal analgesia, using either opioids or LAAs alone or in combination, provides excellent analgesic effect (with minimal side effects) and may improve patient outcomes. Nonpharmacologic techniques, unfortunately, are commonly overlooked as adjuncts to traditional analgesia routines because of the nature of the illness in the critically ill patient. Nonpharmacologic techniques of pain management have a place in the care of the critically ill when applied based on the assessment of an individual patient's needs and abilities to participate in his or her care. Ensuring optimal patient comfort can benefit critically ill patients and improve clinical outcomes.     

Acute pain and the critically ill trauma patient

Pain is a frequent experience throughout our lifetime, and each person responds in a different manner to every pain experience. Critically ill trauma patients are obviously more likely to experience pain due to their injuries or iatrogenic causes. To optimize pain management for trauma patients, critical care nurses must continually be aware of the potential for pain. However, pain assessment for critically ill patients is usually complicated by their inability to express the subjective component of their pain experience. Understanding the pathophysiology of pain facilitates the assessment of the objective components of pain. It is imperative for the critical care nurse to function as the patient advocate especially regarding pain management issues.     

Assessment of pain in the critically ill

Accurate assessment of pain in the critically ill is undoubtedly a challenge. In this setting, however, the nurse can rise to the challenge and have a significant impact on pain management. Some careful thought and planning may allow the nurse to adapt usual assessment tools for use by patients who have difficulty in communicating. When patients cannot communicate, having accurate knowledge about pain and about the patient's condition can help nurses to make appropriate use of behavioral and physiologic signs. More research is necessary to test specific pain assessment tools in ICU settings. In addition, more studies are needed to document the reliability and validity of scales based on behavioral and physiologic indicators of pain in critical care settings. In the meantime, nurses can take several steps to ensure adequate pain assessment: (1) use all means possible to document the patient's self-report of the pain experience, (2) supplement these ratings with behavioral and physiologic indicators of pain status, and (3) document findings to comunicate the patient's pain to others caring for the patient. A careful thorough attempt to assess pain can ensure better pain, outcomes as well as a quicker and more positive return to health.     

Pain assessment and management in critically ill intubated patients: a retrospective study.

BACKGROUND: Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally. OBJECTIVES: To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated. METHODS: Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack's theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients' self-reports of pain) and observable/objective (physiological and behavioral) categories. RESULTS: A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients' self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (<25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time. CONCLUSIONS: Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.     

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BackgroundEvidence suggests that critically ill patients’ pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients’ outcomes.ObjectivesTo investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.MethodsRandomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.ResultsA total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).ConclusionSystematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.     

Assessment and management of pain in the terminally ill

Regular assessment for the presence of pain and response to pain management strategies should be high priority in terminally ill patients. Pain management interventions are most effective when treatments are individualized based on the various physical and nonphysical components of pain at the end of life, and patients and family are educated and involved in the decision making. Opioids remain the cornerstone of pain management, and adjuvant analgesics and nonpharmacologic options are usually considered after relative stabilization of pain. This article describes the various issues that are pertinent to the assessment and treatment of pain in terminally ill patients.     

Clinical tools for the assessment of pain in sedated critically ill adults

Aim: This paper aims to review the evidence regarding pain assessment tools for sedated patients and to establish whether the use of a tool can be recommended in practice. Background: Pain assessment is a challenging area of critical care nursing practice, particularly among sedated patients. Tools to aid in assessing pain among this patient group have been developed and tested recently. Search strategy: In this systematic review five papers that tested pain assessment tools for sedated patients are discussed. These papers were identified via the CINAHL and MEDLINE databases using the search terms: ‘pain assessment’ and ‘sedated’ or ‘unconscious’ or ‘critically ill’ or ‘critical illness’ or ‘critical care’. Conclusions: The Behavioural Pain Scale (BPS) has been tested among the broadest range of patients and was found to be a reliable and valid tool in three studies. Research is needed to further demonstrate the reliability and validity of the Critical‐Care Pain Observation Tool (CPOT), as the paper of Gelinas et al. did not test its internal consistency and domain structure. The CPOT also needs testing among different critical care populations. The design of Odhner et al. study did not allow adequate testing of the Non‐verbal Pain Scale (NVPS). Implications for practice: The implementation of the BPS can be recommended in intensive care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions. The CPOT may also prove useful in assessing pain among sedated patients, but first requires further validation. Also, further research is needed into the effects of pain assessment tools on pain management practices and patient outcomes.