ICU 患者谵妄危险因素分析

目的：通过评分系统分析患者ICU谵妄发生的危险因素。方法对440例患者分别在入ICU即刻与出ICU时应用焦虑自评量表（ SAS）、抑郁自评量表（ SDS）及ICU谵妄筛查表（ ICDSC）进行评价,同时记录发生ICU综合征的各种可能危险因素及入ICU及出ICU时的急性生理与慢性健康评分（ APACHEⅡ）。分别对危险因素与出ICU时SAS、SDS及ICDSC评分的关系进行多元线性回归分析。结果患者转出ICU后,APACHE Ⅱ评分、SAS、SDS及ICDSC各项评分分别为（9．8±3．2）,（43．8±11.3）,（43．1±10．8）与（2．43±2．00）分,进入ICU时分别为（17．3±5．5）,（48．3±12．7）,（48．5±12.3）,（1．36±0．81）分,差异有统计学意义（t值分别为7．549,3．004,3．780,－3．329;P＜0．05）。逐步多元回归分析显示,SAS评分与住院天数、出院 APACHE Ⅱ评分、引流管数量相关（R2＝0．515,F ＝14.139,P＜0．001）;SDS评分与住院天数、引流管数量相关（R2＝0．444,F＝16．395,P＜0．001）;ICDSC评分与文化程度、住院天数、机械通气时间、出院APACHE Ⅱ评分相关（ R2＝0．803,F＝39．769,P ＜0.001）。结论 ICDSC诊断ICU谵妄的敏感性较高,可用于ICU谵妄的筛查。随着住ICU天数的增加,发生ICU谵妄的可能性增加。     

The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses

ObjectiveThis study aims to investigate the effect of nonpharmacological intervention training on delirium recognition and the intervention strategies of intensive care (ICU) nurses.MethodThis is a quasi-experimental study conducted using a pretest–posttest design. The study sample included a total of 95 patients staying in the medical ICU of a university hospital and 19 nurses working in these units. The data were collected using the Patient and Nurse Introduction, Confusion Assessment Method for the ICU, and Delirium Risk Factors, and Non-pharmacological Interventions in Delirium Prevention Forms.ResultsDelirium was identified in 26.5% and 20.9% of the patients in the pre- and posttraining phase, respectively. Patients with delirium had a longer duration of stay in the ICU, lower mean Glasgow Coma Scale score and a higher number of medications in daily treatment (p < 0.05). The risk of delirium increased 8.5-fold by physical restriction and 3.4-fold by the presence of hypo/hypernatremia. The delirium recognition rate of nurses increased from 7.7% to 33.3% in the post-training phase.ConclusionOur study results show that training can increase the efficiency of ICU nurses in the management of delirium.     

Self-efficacy of caring for patients in the intensive care unit with delirium: Development and validation of a scale for intensive care unit nurses

BackgroundImproving the self-efficacy of intensive care unit nurses for delirium care could help them adapt to the changing situation of delirium patients. Validated measures of nurses' self-efficacy of delirium care are lackingObjectivesThe objective of this study was to develop a Delirium Care Self-Efficacy Scale for assessing nurses' confidence about caring for patients in the intensive care unit and to examine the scale's psychometric properties.MethodsDraft scale items were generated from a review of relevant literature and face-to-face interviews with intensive care unit nurses; content validity was conducted with a panel of five experts in delirium. A group of nurses were recruited by convenience sampling from intensive care units (N = 299) for item analysis of the questionnaire, assessment of validity, and reliability of the scale. Nurse participants were recruited from nine adult critical care units affiliated with a hospital in Taiwan. Data were collected from August 2020 to July 2021.ResultsContent validity index was 0.98 for the initial 26 items, indicating good validity. The critical ratio for item discrimination was 14.47–19.29, and item-to-total correlations ranged from 0.67 to 0.81. Principal component analysis reduced items to 13 and extracted two factors, confidence in delirium assessment and confidence in delirium management, which explained 66.82% of the total variance. Cronbach's alpha for internal consistency was 0.94 with good test–retest reliability (r = 0.92). High scale scores among participants were significantly associated with age (≥40 years), work experience in an intensive care unit (≥10 years), delirium education, and willingness to use delirium assessment tools.ConclusionsThe newly developed Delirium Care Self-Efficacy Scale demonstrated acceptable reliability and validity as a measure of confidence for intensive care nurses caring for and managing patients with delirium in the intensive care unit.     

The lived experience of delirium in intensive care unit patients: A meta-ethnography

ObjectivesThe objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state.Review methodsThe study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search.Data sourcesMEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool.ResultsBased on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, “a perturbing altered reality” and four main themes were identified: “disturbed sense of time”, “omnipresent feeling of fear”, “impact of human connection”, and “perceiving surreal events”. These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU.ConclusionsCritically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.     

Triggers and nursing influences on delirium in intensive care units

Among care providers, nurses have the most influence on the occurrence of delirium in patients. To identify and investigate the risk factors associated with delirium and analyse the nurse's influence on delirium, a secondary data analysis approach was used with clinical data from the electronic medical record and health care provider data from the management information systems of a university hospital. Data of 3284 patients (delirium = 688, non‐delirium = 2596) hospitalized in the medical and surgical intensive care units containing 2178 variables were analysed. Donabedian's structure‐process‐outcome model was applied to categorize the factors for multilevel hierarchical logistic regression analysis. Sixteen factors (10 patient factors, 1 provider factor, 1 environmental factor, 2 nursing intervention factors and 2 medical intervention factors) were identified as significant in the final model. Longer intensive care unit experience of nurses did not decrease the risk of delirium. Greater number of nursing intervention needs and greater use of restraints were associated with an increased risk of delirium. The duration of nursing career did not affect the reduction of the risk of delirium. Nurses should therefore endeavour to acquire nursing experience specific for delirium care and attend training courses for delirium management.     

Risk factors for delirium after surgery for craniocerebral injury in the neurosurgical intensive care unit

BACKGROUNDPostoperative delirium is common in patients who undergo neurosurgery for craniocerebral injury. However, there is no specific medical test to predict postoperative delirium to date.AIMTo explore risk factors for postoperative delirium in patients with craniocerebral injury in the neurosurgery intensive care unit (ICU). METHODSA retrospective analysis was performed in 120 patients with craniocerebral injury admitted to Hainan People’s Hospital/Hainan Hospital Affiliated to Hainan Medical University, The First Affiliated Hospital of Hainan Medical University, and The Second Affiliated Hospital of Hainan Medical University between January 2018 and January 2020. The patients were categorized into groups based on whether delirium occurred. Of them, 25 patients with delirium were included in the delirium group, and 95 patients without delirium were included in the observation group. Logistic regression analysis was used to explore the association between sex, age, educational level, Glasgow coma scale (GCS), complications (with or without concussion, cerebral contusion, hypoxemia and ventricular compression) and site of injury and delirium. RESULTSThe GCS score above 8 and concomitant disease of cerebral concussion, cerebral contusion, hypoxemia and ventricular compression, and damage to the frontal lobe were associated with delirium in patients admitted to neurosurgical intensive care unit (ICU) (all P < 0.05). However, age, sex, administration more than three medicines, and educational level were not significantly associated with the onset of delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05). Multivariate logistic regression analysis showed that GCS score above 8, cerebral concussion, cerebral contusion, hypoxemia, ventricle compression, and frontal lobe disorders were independent risk factors for delirium in patients with craniocerebral injury in the neurosurgical ICU (P < 0.05).CONCLUSIONGCS score, concussive concussion, cerebral contusion, hypoxemia, ventricle compression, and damage to frontal lobe are risk factors of postoperative delirium.     

重症监护病房谵妄患者24 h连续睡眠监测及褪黑素动态水平变化的研究

目的：动态监测及分析重症监护病房（ICU）谵妄患者睡眠特点和褪黑素水平的变化。方法采用前瞻性观察性研究方法,对2013年12月至2014年4月滨州医学院附属医院ICU住院超过72 h的患者采用ICU意识模糊评估法（CAM-ICU）进行评估,根据有无谵妄序贯收集患者并分为谵妄组及非谵妄组。入组后所有患者采用多导睡眠仪连续24 h动态监测睡眠状况;监测期间每4 h留取1次静脉血,采用酶联免疫吸附试验（ELISA）检测血浆褪黑素水平。结果共收入ICU住院患者18例,其中谵妄患者9例。多导睡眠监测分析显示,所有患者均存在睡眠障碍,表现为快动眼期（REM期）睡眠减少〔为（5.91±5.26）%〕,觉醒频繁〔觉醒指数为（15.40±12.79）次/h〕,而3期睡眠处于低限水平〔为（14.67±11.10）%〕。与非谵妄组相比,谵妄组患者REM期缺失差异有统计学意义〔（0.10±0.20）%比（8.83±3.81）%,t＝4.782,P＝0.001〕。动态检测褪黑素的结果显示,所有患者褪黑素水平昼低夜高的分泌节律性均丧失,谵妄组与非谵妄组各时间点褪黑素水平差异无统计学意义（时间效应F＝1.370、P＝0.287,组间效应F＝1.646、P＝0.250,交互效应F＝1.558、P＝0.247）。谵妄组褪黑素水平在06：00及14：00时出现两个高峰,分别为（137.84±62.21）ng/L和（148.24±58.87）ng/L,最低值出现在22：00,为（64.47±26.97）ng/L;而非谵妄组褪黑素峰浓度出现在02：00,为（63.52±39.75）ng/L,最低值出现在10：00,为（44.87±11.19）ng/L。结论 ICU患者存在睡眠障碍,谵妄患者REM期缺失较非谵妄患者明显。ICU患者褪黑素分泌均失去正常昼低夜高的节律性变化,谵妄患者褪黑素峰值移至日间出现。     

Effect of nocturnal sound reduction on the incidence of delirium in intensive care unit patients: An interrupted time series analysis

IntroductionDelirium in critically-ill patients is a common multifactorial disorder that is associated with various negative outcomes. It is assumed that sleep disturbances can result in an increased risk of delirium. This study hypothesized that implementing a protocol that reduces overall nocturnal sound levels improves quality of sleep and reduces the incidence of delirium in Intensive Care Unit (ICU) patients.MethodsThis interrupted time series study was performed in an adult mixed medical and surgical 24-bed ICU. A pre-intervention group of 211 patients was compared with a post-intervention group of 210 patients after implementation of a nocturnal sound-reduction protocol. Primary outcome measures were incidence of delirium, measured by the Intensive Care Delirium Screening Checklist (ICDSC) and quality of sleep, measured by the Richards-Campbell Sleep Questionnaire (RCSQ). Secondary outcome measures were use of sleep-inducing medication, delirium treatment medication, and patient-perceived nocturnal noise.ResultsA significant difference in slope in the percentage of delirium was observed between the pre- and post-intervention periods (−3.7% per time period, p = 0.02). Quality of sleep was unaffected (0.3 per time period, p = 0.85). The post-intervention group used significantly less sleep-inducing medication (p < 0.001). Nocturnal noise rating improved after intervention (median: 65, IQR: 50–80 versus 70, IQR: 60–80, p = 0.02).ConclusionsThe incidence of delirium in ICU patients was significantly reduced after implementation of a nocturnal sound-reduction protocol. However, reported sleep quality did not improve.     

体验式教学法在ICU新护士培养中的应用

目的 探讨体验式教学法在重症医学科新护士培养中的作用,为临床新护士培养提供依据.方法 将2011年至2012年进入重症医学科工作的新护士79名分成实验组41名和对照组38名.实验组护士采用体验式教学法进行岗前培训2个月.对照组护士采用常规方法进行岗前培训2个月.对2组培训效果进行比较.结果 实验组理论知识考核及技能操作考核评分,均高于对照组.在舒适护理方面,实验组在生理舒适及心理舒适两方面的评分均显著高于对照组.实验组对体验式教学的认同度较高.结论 体验式教学法有利于新护士掌握理论知识及技能操作,同时也能够更好地为患者实施舒适护理,有利于提高ICU新护士的专业技能和素质,同时可以提高对重症患者的护理质量.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.     

ICU培训在神经疾病专科护士培训中的应用与效果评价

目的 总结神经疾病专科护士培训过程中加入ICU培训内容的经验,以提高神经疾病专科护士培训效果.方法 对两批来自全军的共40名学员在为期3个月的专科培训过程中加入ICU临床学习2周,培训前问卷调查,培训前后理论,操作考核对照.学员回所在医院2个月后手机短信调查.对培训效果进行总结分析.结果 培训后学员在重症监护理论知识,护理技术操作和急救仪器使用熟练掌握方面均有了显著性提高(P＜0.05).培训后短信调查结果显示,ICU学习对学员的工作产生积极影响,占92.5％ (n=40),学员均认为专科护士培训加入ICU合理,占100％(n=40).结论 专科护士培训中加入ICU培训是提高专科护士临床业务能力的有效途径,科学高效的培训模式是确保神经疾病专科护士培训质量的有力保证.     

Determining intensive care unit nurses' perceptions and practice levels of spiritual care in Turkey

Purpose: The purpose of this study is to determine the validity and reliability of the Turkish version of the Spiritual Care Perceptions and Practices Scale and to evaluate factors that may be effective in providing spiritual care by general intensive care unit (ICU) nurses. Background: Spiritual needs are necessary to offset spiritual deficiencies or support moral strength. During hospitalization, patients with critical conditions and their families tend to become anxious because of fear of the unknown and an uncertain future. Spiritual issues become prominent concerns for these patients and their families. Method: The data of the study were collected from a university hospital, two public hospitals and two private hospitals. A total of 170 nurses were in the ICU of these hospitals, and 123 nurses (79·4%), agreed to participate and, were included in this study. Prior to the study, an information sheet was provided to all nurses to explain the purpose and procedures of the survey. The demographic data form of ICU nurses and the Nurses' Spiritual Care Perceptions and Practices Scale were used for data collection. Results: A statistically significant difference was found between the marital status of the nurses and the total scale mean score. It was also determined that ICU nurses are in a better position regarding their perception levels of spiritual care compared to their practice levels of spiritual care, and nurses with a higher perception of spiritual care also have higher scores in the practice of spiritual care. Conclusions: ICU nurses were found to be inadequate in spiritual care practices. Study findings may be used to improve the support of nurses, to ensure sensitive spiritual care in their daily practices. Relevance to clinical practice:: ICU nurses should be aware of the importance of spiritual care and develop tools for assessing the spiritual needs of patients.     

Nurses' and physicians' approaches to delirium management in the intensive care unit: A focus group investigation

BackgroundDelirium in the intensive care unit (ICU) is common, but reliable evidence-based recommendations are still limited.ObjectivesThe aim of our study was to explore nurses' and physicians' experiences and approaches to ICU delirium management.MethodOur study had a qualitative multicentre design using interdisciplinary focus groups and framework analysis. Participants were strategically selected to include nurses and physicians with experience in delirium management at five ICUs in four out of five regions in Denmark.ResultsWe conducted eight focus group interviews with 24 nurses and 15 physicians; median ICU experience was 9 years (range 1–35). The main issues identified were (1) the decision to treat or not to treat ICU delirium based on delirium phenotype, (2) the decision to act based on experience or evidence, and (3) the decision to intervene using nursing care or medications. ICU delirium was treated with pharmacological interventions in patients with signs of agitation, hallucinations, and sleep deprivation. The first choice of agent was haloperidol or olanzapine. Agitated and combative patients received benzodiazepines, propofol, or dexmedetomidine. Calm delirious patients were managed with non-pharmacological solutions. Physicians recommended pro re nata (PRN) orders to prevent over medication, whereas nurses opposed PRN orders with the fear that it would increase their responsibilities.ConclusionOur study described an algorithm of contemporary delirium management in Danish ICUs based on qualitative inquiry. When evidence-based solutions are unclear, nurses and physicians rely on personal experience, collective experience, and best available evidence to determine which patients to treat and what methods to use to treat ICU delirium. Delirium management still needs clear objectives and guidelines with evidence-based recommendations for first-line treatment and subsequent treatment options.     

Evaluation of progressive early rehabilitation training mode in intensive care unit patients with mechanical ventilation

BACKGROUNDMechanical ventilation is a common resuscitation method in the intensive care unit (ICU). Unfortunately, this treatment process prolongs the ICU stay of patients with an increased incidence of delirium, which ultimately affects the prognosis.AIMTo evaluate the effect of progressive early rehabilitation training on treatment and prognosis of patients with mechanical ventilation in ICU.METHODSThe convenience sampling method selected 190 patients with mechanical ventilation admitted to the Fourth Hospital of Hebei Medical University from March 2020 to March 2021. According to the random number table method, they were divided into the control and intervention groups. The control group received routine nursing and rehabilitation measures, whereas the intervention group received progressive early rehabilitation training. In addition, the incidence and duration of delirium were compared for the two groups along with mechanical ventilation time, ICU hospitalization time, functional independence measure (FIM) score, Barthel index, and the incidence of complications (deep venous thrombosis, pressure sores, and acquired muscle weakness).RESULTSIn the intervention group, the incidence of delirium was significantly lower than in the control group (28% vs 52%, P < 0.001). In the intervention group, the duration of delirium, mechanical ventilation time, and ICU stay were shorter than in the control group (P < 0.001). The FIM and Barthel index scores were significantly higher in the intervention group than the control group (P < 0.001). The total incidence of complications in the intervention group was 3.15%, which was lower than 17.89% in the control group (P < 0.001).CONCLUSIONProgressive early rehabilitation training reduced the incidence of delirium and complications in ICU patients with mechanical ventilation, which improved prognosis and quality of life.     

The development of a delirium knowledge test for intensive care nurses: A validity and reliability study

ObjectivesThis study aimed to determine the validity and reliability of the Delirium Knowledge Test for the Intensive Care Nurse.MethodThe item analysis and reliability of the test was assessed in a sample of 274 nurses working in the internal and surgical adult intensive care units of one public and three university hospitals in Turkey between 15 May and 15 August 2017. Content and face validity, item analysis and reliability coefficients were used to evaluate the psychometric properties of the test.ResultsThe item difficulty index and item discrimination index of the questions included in the draft form of the 40-item test were found to range from 0.22 to 0.93 and from 0.06 to 0.51, respectively. At the end of the analyses, 14 items were excluded from the draft test, 11 according to the item difficulty index and 3 according to the item discrimination index. Correspondingly, the final version of the test consisted of 26 questions. The item difficulty index of the final test was 0.22 to 0.79, and the item discrimination index was 0.20 to 0.51. The difficulty level of the final test was found to be 59%, and the Cronbach’s alpha reliability coefficient was 0.83.ConclusionThe results of the study showed that the test had good content and face validity and reliability for measuring the delirium knowledge of intensive care nurses.