腹部手术后患者静脉自控镇痛护理管理方案的行动研究

发布时间：2018-06-07 06:41

本文选题：术后疼痛 + 疼痛管理　；参考：《第二军医大学》2014年博士论文

【摘要】：研究目的了解和分析腹部手术后患者静脉自控镇痛管理的现状；探究医护人员与患者参与及感知静脉自控镇痛管理现状的体验；探索我国腹部手术后患者静脉自控镇痛护理管理的有效方案；构建管理方案的护理质量评价指标体系；探讨该管理方案对改善术后镇痛护理质量的作用。研究方法本研究以行动研究为框架，分为五个阶段。第一阶段，发现问题：研究者在临床实践中发现腹部手术后患者在PCIA镇痛期间，因责任分工不明确和质量考评标准缺乏等诸多问题，导致术后疼痛控制不足，影响患者术后恢复和满意度。第二阶段，分析问题：对本研究提出的问题，进行文献和实证研究，分析总结PCIA管理现状及影响PCIA管理的因素和可能的解决途径。第三阶段，形成计划：在前期问题分析基础上，通过专家会议法形成解决问题的方案，即提出在麻醉医师指导下以护士为主体的PCIA护理管理方案。第四阶段，实施计划：针对提出的管理方案制定实践计划，选择某三甲医院普外科实施行动，通过观察法、访谈法收集行动中出现的问题及参与人员的意见和建议，结合研究者的反思，通过两轮行动干预，总结形成可供临床常态化推进的PCIA护理管理方案及其管理文本；同时，在前期研究基础上，通过德尔菲法构建PCIA护理质量评价指标体系。第五阶段，，评价结果：研究者通过对接受该护理管理方案行动干预的PCIA患者体验的质性访谈以及部分PCIA护理质量评价指标改善情况的分析，讨论该管理方案的实施效果。研究结果 1、PCIA广泛应用于腹部手术后患者的疼痛处理，但患者对PCIA的镇痛效果与服务质量不尽满意。经文献研究，影响PCIA管理质量的因素包括：①缺乏疼痛管理团队与管理规范；②护士与患者对疼痛的理解存在不一致性；③医护人员的术后疼痛相关知识与技能不足；④对患者的自护能力重视和提高不够等。 2、通过对医护人员以及患者参与术后PCIA体验的探究，提出解决PCIA管理质量问题的主要途径是：①加强对医护人员的术后疼痛相关知识与技能培训；②加强围手术期疼痛健康宣教，提高患者参与PCIA的自护能力；③建立麻醉医师指导下的以护士为主体的术后疼痛服务团队。 3、根据知信行理论、奥瑞姆自护理论初步构建了麻醉医师指导下的，以护士为主体的手术后患者PCIA护理管理方案，通过专家会议对管理方案进行修订；经过两轮管理方案的行动干预，修正形成了以麻醉医师为指导的、病房医生参与的、麻醉护士与病房护士为主体的沟通协作的PCIA管理团队，并按照护理角色的不同分别构建了麻醉护士与病房护士PCIA护理管理方案。 4、研究形成了与PCIA护理管理方案实施相配套的管理文本：包括①图文并茂的《PCIA宣教卡》；②信息齐全的表格式《PCIA护理记录单》；③实用的护理口袋书《手术后PCIA护理管理护士手册》。 5、通过德尔菲法，构建了包括要素质量、环节质量和终末质量3项一级指标、13项二级指标和38项三级指标并设置有指标权重值的PCIA护理质量评价指标体系。 6、行动小组对于符合实践条件的141例患者实施管理方案干预，其研究效果表明：①患者的PCIA宣教需求得到满足，患者参与PCIA的自护能力明显提高，术后主动汇报疼痛控制不足（长海痛尺评分≥4分）的患者比例显著增加（P0.05），不必要提前撤除PCA泵的患者比例显著减少（P0.05）；②患者对PCIA镇痛服务、不良反应处理的满意人数比例显著增加（P0.05）；③医生对疼痛护理工作的认可度得到提高；④麻醉护士与病房护士围绕PCIA实施的各个阶段，明确责任分工，相互沟通协作，为患者提供全程化镇痛护理。研究结论 1、护士作为患者的全面照护者，是术后疼痛管理的主体，其PCIA护理质量的高低直接影响患者术后恢复与生活质量。 2、建立麻醉医师指导的、外科医生参与的，麻醉护士与病房护士为主体的术后疼痛服务团队并开展PCIA护理管理实践，是解决目前手术后PCIA镇痛不足与服务不尽满意的切实可行方法。 3、PCIA护理质量评价指标体系为临床提供了评价PCIA护理质量的科学工具，有利于促进医院层面完善PCIA管理制度、改进管理流程并规范PCIA护理行为。 4、《PCIA宣教卡》、《PCIA护理记录单》与《手术后PCIA护理管理护士手册》是可供临床借鉴应用的PCIA护理管理文本。 5、本行动研究形成的PCIA护理管理方案，为规范我国的围手术期疼痛管理提供了指导性意见，对我国的急性疼痛服务团队建设有推进作用。
[Abstract]:research objective
To understand and analyze the status of patient-controlled intravenous analgesia management after abdominal operation, to explore the experience of the medical staff and patients participating in and perceiving the management of intravenous self-control analgesia; to explore the effective plan for the management of intravenous self-control analgesia after abdominal operation in China and to construct the evaluation index system of nursing quality of the management scheme; The management plan can improve the quality of postoperative analgesia.
research method
This study is divided into five stages in the framework of action research. The first stage is to find out the problem: the researchers found that in the clinical practice, the patients after abdominal operation during PCIA analgesia, due to the lack of responsibility division and the lack of quality assessment standards, lead to the lack of postoperative pain control, the postoperative recovery and satisfaction. The second order. Paragraph, analysis of the problem: the problems proposed in this study, literature and empirical research, analysis and summary of the status of PCIA management and the factors affecting the management of PCIA and possible solutions. The third stage, the formation of the plan: on the basis of the analysis of earlier problems, through expert meeting method to form a solution to solve the problem, that is, under the guidance of the anesthesiologist. The nurse as the main body of the PCIA nursing management program. The fourth stage, implementation plan: to formulate a practical plan for the proposed management plan, select a three a hospital department of general surgery implementation action, through the observation method, interview method to collect the problems and the opinions and proposals of the participants in the action, and the two rounds of action intervention combined with the researchers' reflection. The PCIA nursing management scheme and its management text for clinical normalization were summed up. At the same time, the PCIA nursing quality evaluation index system was constructed by the Delphi method on the basis of previous research. The fifth stage, evaluation results: the researcher interviewed the PCIA patient experience of the intervention of the nursing management case. And the improvement of some PCIA nursing quality evaluation indicators, and discuss the implementation effect of the management plan.
Research results
1, PCIA is widely used in the pain management of patients after abdominal surgery, but the patient's analgesic effect and service quality of PCIA are not satisfactory. The factors that affect the quality of PCIA management include: (1) lack of pain management team and management standard; (2) the difference of pain understanding between nurses and patients; (3) after the operation of medical staff Pain related knowledge and skills are not enough.
2, through the exploration of the PCIA experience after the operation of the medical and nursing staff and patients, the main ways to solve the quality problems of PCIA management are: (1) strengthening the knowledge and skill training for the postoperative pain of the medical staff; (2) strengthening the pain and health education in the perioperative period to improve the patient's ability to take part in the self-care of the PCIA; and to establish the guidance of the anesthesiologist. The next is a nurse oriented postoperative pain service team.
3, according to the theory of knowledge and credit, Orem's theory of self-care has preliminarily constructed the PCIA nursing management scheme, which is the main body of the anesthesiologist, and revised the management scheme through the expert meeting. After the action intervention of two rounds of management programs, the amendment was taken as the guidance of the anesthesiologist and the ward doctors participated. The PCIA management team of the anesthetic nurse and the ward nurse is the main body of communication and cooperation. According to the different nursing roles, the PCIA nursing management scheme of the anaesthetized nurse and the ward nurse is constructed respectively.
4, the research has formed the management text matching the implementation of the PCIA nursing management program: including (1) the pictorial ; (2) the complete table format ; (3) the practical nursing pocket book < post operation PCIA nursing management nurse manual >.
5, through the Delphi method, the PCIA nursing quality evaluation index system including factor quality, link quality and final quality 3 item level index, 13 item two level index and 38 three grade index and set index weight value is set up.
6, the action team carried out management program intervention for 141 patients who were in accordance with the practical conditions. The results of the study showed that: (1) the patients' PCIA needs to be satisfied, the patient's ability to participate in the self-protection of PCIA was obviously improved, and the proportion of patients who reported the lack of pain control (the long sea pain scale score more than 4) after the operation was significantly increased (P0.05). The proportion of patients who removed the PCA pump was significantly reduced (P0.05); (2) the proportion of patients satisfied with PCIA analgesia was significantly increased (P0.05); (3) the doctors' recognition of pain nursing was improved; (4) the anesthetic nurses and ward nurses focused on the various stages of the implementation of PCIA and made clear the division of responsibilities and communicated and collaborate with each other, The whole process of analgesia is provided for the patients.
research conclusion
1, nurses, as the comprehensive caregivers of patients, are the main body of postoperative pain management. The quality of PCIA care directly affects their postoperative recovery and quality of life.
2, the establishment of the anesthesiologist's guidance, the involvement of the surgeon, the postoperative pain service team of the anesthetic nurses and the ward nurses and the practice of PCIA nursing management are the practical ways to solve the lack of PCIA analgesia and not satisfactory service after the present operation.
3, the PCIA nursing quality evaluation index system provides a scientific tool for evaluating the quality of PCIA nursing, which is beneficial to improving the PCIA management system at the hospital level, improving the management process and standardizing the PCIA nursing behavior.
4, 5, the PCIA nursing management program, formed by this action research, provides guidance for standardizing perioperative pain management in our country and promotes the construction of acute pain service team in China.
【学位授予单位】：第二军医大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R473.6

【参考文献】