“急性非创伤性腹痛分诊评估单”在急诊科的临床应用

[目的]探讨"急性非创伤性腹痛分诊评估单"在急诊科的临床应用。[方法]分诊护士以病人就诊卡号码尾数单双数将2012年5月—2012年10月到我院急诊科就诊的以腹痛为主诉的成年病人(>18岁,除外创伤性原因导致的腹痛)分为实验组和对照组。对照组凭经验进行分诊,实验组使用急性非创伤性腹痛分诊评估单分诊。比较两组的分诊时间、分诊准确率。[结果]使用急性非创伤性腹痛分诊评估单可以提高急性非创伤性腹痛病人分诊准确率、缩短分诊时间。[结论]通过急性非创伤性腹痛分诊评估单的制定和临床应用,提高了分诊的准确率,提高了对高危病人的识别率和病人的满意度。     

护理干预在急性非创伤性腹痛患者分诊中的应用

目的：探讨急性非创伤性腹痛患者分诊中护理干预的对策与流程。方法收集了2010年12月至2012年12月我院急诊科收治的300例急性非创伤性腹痛患者的临床资料进行详细研究，并随机将上述患者分为两组，150例对照组患者使用Ⅰ类分诊单进行分诊；150例治疗组患者使用专门的“非创伤性腹痛评估单”以及“诊断记录单”。结果治疗组患者的分诊诊断率（96．0％）、患者满意率（98．7％）显著高于对照组（74．7％、88．7％，P＜0．05），差异具有统计学意义。治疗组患者分诊时间（5．49±3．20）min与待诊时间（5．03±0．79）min显著低于对照组，差异有统计学意义（P＜0．05）。结论急性非创伤性腹痛患者分诊中，使用专业分诊单，能够显著优化护理流程、提高护理质量，为患者提供更优质服务，提高患者与医生满意度，值得进一步研究推广。     

优质护理服务在急性非创伤性腹痛分诊中的临床应用

目的 探讨优质护理服务的实施在急性非创伤性腹痛患者中的应用.方法 根据优质护理服务模式的要求和原则,对现有的急性非创伤性腹痛的分诊标准进行整改,使用新的分诊评估单,并通过加强业务培训,合理配置人力资源,比较优质护理服务模式实施前后急性非创伤性腹痛分诊的准确率,以及医生和患者对护理人员的满意度.结果 使用新的分诊评估单后,急性非创伤性腹痛的分诊时间、待诊时间及分诊准确率有明显提高,患者及医生对护理人员的满意度也大幅度提高,差异均有统计学意义(均P＜0.05).结论 使用急性非创伤性腹痛分诊评估单优化了服务流程,为急腹症患者提供优质、满意的护理服务,能帮助护士提高急腹症患者的分诊准确率,从而提高患者及医生对护理人员的满意度,同时护士自身的价值也得到了体现.     

常见易引起误诊的急性腹痛的分诊指南

3种引起腹痛的原因经常被误诊，而且出现医患诉讼的可能性较大，这些腹痛包括急性阑尾炎、腹主动脉瘤（AAA）破裂及异位妊娠。负责分诊护士应该按患者的症状及体征结合急性腹痛的分诊指南考虑到上述疾病。本指南建立在一项全面的最新的关于Medline、Proquest、Google相关研究的基础上，该研究对急性阑尾炎、腹主动脉瘤破裂及异位妊娠的危险因素及临床实践之间进行阳性及阴性对照研究。关键词包括腹痛、阑尾炎、腹主动脉瘤及异位妊娠、附带诊断、危险因素、急诊、分诊。排除原则包括儿童、创伤性腹痛及手术后腹痛患者。该研究可信的证据来自：前瞻性研究，包括序列分析及大样本研究；回顾性分析，包括条件控制研究，临床回顾及专家的意见．     

创伤性骨折后患者并发急性应激障碍的相关因素分析及防护

目的探讨创伤性骨折后患者并发急性应激障碍的相关因素并探讨预防护理措施。方法选择2018年6月至2019年6月68例创伤性骨折患者为研究对象,采用斯坦福急性应激反应问卷(SASRQ)调查患者急性应激障碍发生情况,采用多因素logistic回归分析创伤性骨折后并发急性应激障碍的相关因素。结果 68例创伤性骨折患者术后发生急性应激障碍21例,发生率30.88%。多因素logistic回归分析显示,伤后VAS评分 7分、重度创伤、既往创伤史、汉密尔顿焦虑量表(HAMA)评分 14分是创伤性骨折后并发急性应激障碍的独立危险因素(P 0.05)。结论创伤性骨折患者易发生急性应激障碍,受到焦虑情绪、重度创伤、既往创伤史、伤后VAS评分等多种因素影响,需根据相关因素开展针对性护理措施,以降低急性应激障碍发生风险。     

急性腹痛患者分诊误诊的原因及对策

目的：探讨急性腹痛患者分诊误诊的常见原因,降低分诊误诊率。方法：回顾分析2007-05/2008-04因腹痛到海南省农垦总医院就诊患者有2 160例。结果：共误诊89例,其中内科48例,外科30例,妇产科3例,儿科8例。结论：询问病史不详,分诊体检不认真,护士医学知识乏缺;是分诊误诊的主要原因,要提高急诊分诊准确率,除详细询问病史外,还要对患者强调的症状和体征进行分析。     

基层医院急诊科夜间急性腹痛临床分析

目的:探讨我院夜间急性腹痛常见病因及误诊因素,以便提高急诊腹痛的正确诊断率。方法:回顾性统计分析2010-12-2011-12我院急诊科夜间收治的426例急性腹痛患者的临床资料。结果:426例急性腹痛的病因依次为:急性胃(肠)炎、泌尿系结石、胆道疾病、急性阑尾炎、胰腺炎、肿瘤、溃疡、肠梗阻、尿路感染、心肌梗死、癔症、肺炎以及病因不明疾病;其中内科占66%,泌尿科占23%,普外科占11%。结论:急性腹痛是夜间最常见的疾患,急诊科是首站,须高度重视。与患者及家属耐心沟通,综合分析和判断,及时处理,才能减少误诊并避免医患矛盾。     

妊娠期急性腹痛的急诊分诊管理

总结妊娠期急性腹痛的急诊分诊管理。急诊分诊管理包括:实施腹痛分诊程序,采用PQRST分诊模式,以良好的沟通技巧、正确的护理体检提高收集患者资料的正确性,对诊断不明的腹痛患者跟踪随访。2010年7月至2011年6月,对576例妊娠期急性腹痛患者实施急诊分诊管理,急诊分诊的正确率从上年的91.2%升至95.9%,同时提高了护士的工作效率及患者满意度。     

急诊护士分诊急诊非创伤性胸痛病人体验的质性研究

[目的]探讨急诊科护士对急性非创伤性胸痛病人分诊的工作体验。[方法]采用现象学研究方法,对衡阳市三级甲等医院7名急诊科分诊护士进行半结构式访谈。[结果]关于急诊科护士对非创伤性胸痛病人的分诊体验提炼出病人主诉很重要、缺乏分诊工具、急诊科护士储备不足、建设胸痛中心至关重要4大主题。[结论]构建统一的急性胸痛护理分诊工具是当前亟须解决的问题。     

影响急腹症患者分诊准确率的因素与对策

回顾190例急腹症患者的分诊,发生分诊失误13例。造成分诊失误的因素有疾病因素、患者和家属因素及分诊护士因素。掌握急腹症分诊技巧,认真实施分诊,加强对患者和家属的宣教,制定分诊护士准入标准,提高分诊护士素质,是降低急腹症分诊失误率的有效措施。     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.