本文選題：術后疼痛 + 疼痛管理�。� 參考：《第二軍醫(yī)大學》2014年博士論文

【摘要】：研究目的 了解和分析腹部手術后患者靜脈自控鎮(zhèn)痛管理的現(xiàn)狀；探究醫(yī)護人員與患者參與及感知靜脈自控鎮(zhèn)痛管理現(xiàn)狀的體驗；探索我國腹部手術后患者靜脈自控鎮(zhèn)痛護理管理的有效方案；構建管理方案的護理質(zhì)量評價指標體系；探討該管理方案對改善術后鎮(zhèn)痛護理質(zhì)量的作用。 研究方法 本研究以行動研究為框架，分為五個階段。第一階段，發(fā)現(xiàn)問題：研究者在臨床實踐中發(fā)現(xiàn)腹部手術后患者在PCIA鎮(zhèn)痛期間，因責任分工不明確和質(zhì)量考評標準缺乏等諸多問題，導致術后疼痛控制不足，影響患者術后恢復和滿意度。第二階段，分析問題：對本研究提出的問題，進行文獻和實證研究，分析總結PCIA管理現(xiàn)狀及影響PCIA管理的因素和可能的解決途徑。第三階段，形成計劃：在前期問題分析基礎上，通過專家會議法形成解決問題的方案，即提出在麻醉醫(yī)師指導下以護士為主體的PCIA護理管理方案。第四階段，實施計劃：針對提出的管理方案制定實踐計劃，選擇某三甲醫(yī)院普外科實施行動，通過觀察法、訪談法收集行動中出現(xiàn)的問題及參與人員的意見和建議，結合研究者的反思，通過兩輪行動干預，總結形成可供臨床常態(tài)化推進的PCIA護理管理方案及其管理文本；同時，在前期研究基礎上，通過德爾菲法構建PCIA護理質(zhì)量評價指標體系。第五階段，，評價結果：研究者通過對接受該護理管理方案行動干預的PCIA患者體驗的質(zhì)性訪談以及部分PCIA護理質(zhì)量評價指標改善情況的分析，討論該管理方案的實施效果。 研究結果 1、PCIA廣泛應用于腹部手術后患者的疼痛處理，但患者對PCIA的鎮(zhèn)痛效果與服務質(zhì)量不盡滿意。經(jīng)文獻研究，影響PCIA管理質(zhì)量的因素包括：①缺乏疼痛管理團隊與管理規(guī)范；②護士與患者對疼痛的理解存在不一致性；③醫(yī)護人員的術后疼痛相關知識與技能不足；④對患者的自護能力重視和提高不夠等。 2、通過對醫(yī)護人員以及患者參與術后PCIA體驗的探究，提出解決PCIA管理質(zhì)量問題的主要途徑是：①加強對醫(yī)護人員的術后疼痛相關知識與技能培訓；②加強圍手術期疼痛健康宣教，提高患者參與PCIA的自護能力；③建立麻醉醫(yī)師指導下的以護士為主體的術后疼痛服務團隊。 3、根據(jù)知信行理論、奧瑞姆自護理論初步構建了麻醉醫(yī)師指導下的，以護士為主體的手術后患者PCIA護理管理方案，通過專家會議對管理方案進行修訂；經(jīng)過兩輪管理方案的行動干預，修正形成了以麻醉醫(yī)師為指導的、病房醫(yī)生參與的、麻醉護士與病房護士為主體的溝通協(xié)作的PCIA管理團隊，并按照護理角色的不同分別構建了麻醉護士與病房護士PCIA護理管理方案。 4、研究形成了與PCIA護理管理方案實施相配套的管理文本：包括①圖文并茂的《PCIA宣教卡》；②信息齊全的表格式《PCIA護理記錄單》；③實用的護理口袋書《手術后PCIA護理管理護士手冊》。 5、通過德爾菲法，構建了包括要素質(zhì)量、環(huán)節(jié)質(zhì)量和終末質(zhì)量3項一級指標、13項二級指標和38項三級指標并設置有指標權重值的PCIA護理質(zhì)量評價指標體系。 6、行動小組對于符合實踐條件的141例患者實施管理方案干預，其研究效果表明：①患者的PCIA宣教需求得到滿足，患者參與PCIA的自護能力明顯提高，術后主動匯報疼痛控制不足（長海痛尺評分≥4分）的患者比例顯著增加（P0.05），不必要提前撤除PCA泵的患者比例顯著減少（P0.05）；②患者對PCIA鎮(zhèn)痛服務、不良反應處理的滿意人數(shù)比例顯著增加（P0.05）；③醫(yī)生對疼痛護理工作的認可度得到提高；④麻醉護士與病房護士圍繞PCIA實施的各個階段，明確責任分工，相互溝通協(xié)作，為患者提供全程化鎮(zhèn)痛護理。 研究結論 1、護士作為患者的全面照護者，是術后疼痛管理的主體，其PCIA護理質(zhì)量的高低直接影響患者術后恢復與生活質(zhì)量。 2、建立麻醉醫(yī)師指導的、外科醫(yī)生參與的，麻醉護士與病房護士為主體的術后疼痛服務團隊并開展PCIA護理管理實踐，是解決目前手術后PCIA鎮(zhèn)痛不足與服務不盡滿意的切實可行方法。 3、PCIA護理質(zhì)量評價指標體系為臨床提供了評價PCIA護理質(zhì)量的科學工具，有利于促進醫(yī)院層面完善PCIA管理制度、改進管理流程并規(guī)范PCIA護理行為。 4、《PCIA宣教卡》、《PCIA護理記錄單》與《手術后PCIA護理管理護士手冊》是可供臨床借鑒應用的PCIA護理管理文本。 5、本行動研究形成的PCIA護理管理方案，為規(guī)范我國的圍手術期疼痛管理提供了指導性意見，對我國的急性疼痛服務團隊建設有推進作用。
[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.
【學位授予單位】：第二軍醫(yī)大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R473.6

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