改进护生带教方法 提高临床教学质量

目的：探讨改进实习护生带教方法对临床教学质量的影响。方法：将2003年7月～2004年6月100名实习护生随机分为两组，即实验组和对照组各50例，其中实验组护生采用由护理部确立各病区出科操作考核项目的目标带教法，对照组采用出科操作考核项目由各病区带教老师随意考核方法。实习结束后由护理部配合学校组织统一的理论及技术操作考核。观察两组理论、操作考核成绩。结果：实验组的理论、操作考核成绩高于对照组。两组比较差异有显著性（P〈0．01）。结论：确定各病区出科操作考核项目的目标带教法可提高临床教学质量。     

研讨式带教模式在手术室护生临床教学中的应用

目的：探讨研讨式带教模式在手术室护生临床教学中的应用方法及效果。方法：将112名手术室实习护生随机分为实验组和对照组各56名,对照组采用传统的带教方法,实验组在对照组基础上采用研讨式带教模式,比较两组教学效果。结果：实验组护生考核成绩高于对照组（P ＜0.05）,实验组临床科研能力、临床教学能力、临床管理能力优于对照组（P ＜0.05）,实验组教学满意度高于对照组（P ＜0.05）。结论：研讨式带教模式能有效提高手术室护生的实习效果,提高临床教学质量。     

骨科临床实习带教中引入任务驱动教学法的效果评价

目的探讨在骨科临床实习带教中引入任务驱动教学法的必要性。方法按照骨科临床实习大纲要求,将实习护生114名随机分为实验组56例和对照组58例,对照组采用传统的教学方式,实验组采用应用任务驱动教学法。结果实验组护生的理论及技能操作考核成绩明显优于对照组（P〈0．01）;实验组93．10％以上的护生认为任务驱动教学法优于传统教学方式,提高了学习兴趣,有利于综合能力的提高。结论在临床实习带教中应用任务驱动教学法,不仅能提高临床教学质量,还有利于学生综合能力的培养及提高学习兴趣。     

临床教学路径在ICU护生带教中的应用及效果

目的:探讨临床教学路径在ICU实习护生带教中的应用及效果.方法:将60名ICU实习护生在入科时随机分为对照组和实验组各30名.对照组采用传统带教方法,按实习大纲要求学习、传授知识;实验组按ICU临床教学路径表进行带教并及时评估.出科时考核比较两组带教效果.结果:实验组护生在明确实习目标、护理理论及操作考核成绩、发现及解决问题能力、带教满意度、团结协作能力等方面高于对照组(P＜0.05),焦虑者少于对照组(P＜0.05).结论:实施临床教学路径带教能提高ICU实习护生的带教质量及带教满意度.     

临床护理带教资格认定的设想与实施

目的探讨在临床护理教学中老师资格认证的方法。方法将64名护生随机分为对照组和实验组，对照组采用传统教学法，实验组予以“资格认定”的老师进行固定带教，于实习18周后评价教学效果。结果2组护生实习结束后综合能力的差异有统计学意义（p〈0．05，p〈0．01）；2组老师的教学能力、知识水平及工作能力差异有统计学意义（p〈0.01），自身素质方面差异无统计学意义；护生对2组老师满意度测评差异有统计学意义（p〈0．05）。结论通过对老师的资格认定，有利于提高师资层次，提高护生的综合能力，提高带教质量。     

PBL教学法在临床护理带教中的应用研究

目的探索PBL教学法在临床护理带教中的教学效果,提高临床带教水平。方法选取2010年11月至2011年11月在本院实习的应届护生120名,随机分为试验组和对照组,每组各60名。试验组实施PBL教学法,对照组实施传统讲授法。在出科前实施理论考试,同时对两组护生进行问卷调查,比较两组教学效果。结果两组护生基础知识考试成绩无明显差异（P〉O．05）,试验组病例分析题成绩高于对照组,差异有统计学意义（P〈0．01）;调查问卷显示PBL教学组护生对学习方法在护生学习积极主动性、自我学习能力、综合分析能力等方面的培养效果评价均高于对照组。结论PBL教学法与传统讲授教学法相比,有助于提高护生运用理论知识分析问题、解决实际问题的能力,可以有效提高临床带教水平。     

中专护生带教模式的改革

目的：进一步完善培养护生综合能力的临床带教模式。方法：采用数字表随机分组，将护生分为试验组和对照组。实验组实施“专人带教”、“程序带教”与培养护生综合能力融为一体的带教方案，严格监控带教过程。对照组用传统的带教方案，实施整体护理目标实习带教。结果：护生综合能力（理论、技能）考核成绩，病人对护生护理质量的满意率，护生对带教质量的评价，实验组均高于对照组。结论：课题实施的带教方案在培养护生综合能力方面明显优于传统带教方案。     

本科护生由专科护士带教的效果评价

目的：探讨本科护生由专科护士带教的效果。方法采用随机分组法,分为实验组和对照组。实验组由专科资质护士带教,对照组由普通护士带教。结果6个月后,由专科护士带教护生的考核成绩、整体护理能力、满意度调查测试均高于对照组( P<0.05)。结论在临床工作中应加强专科护士对护生的带教。     

健康教育实践对提高护生职业能力的效果评价

目的：探讨实施新型的以护生为主体、将健康教育实践作为护生实习的核心内容的横纵联合教学模式,对护生职业能力的效果。方法：将110名护生随机分成实验组和对照组各55名。实验组实施新型的以护生为主体、将健康教育实践作为护生实习的核心内容的横纵联合教学模式．对照组实施传统的以带教老师为主体的垂直单向教学模式。结果：两组护生的“三基”考核、护士职业能力考评的比较有显著性的统计学意义（P〈0．01）,实验组病人满意度高于对照组。结论：将健康教育实践作为护生实习的核心内容的教学模式可大大提高护生的职业能力。为社会、医疗机构培养高素质的护理人才。     

日目标教学法在心胸外科临床护理教学中的应用

目的：探讨日目标教学法在心胸外科临床护理教学中的应用和效果。方法选择2009年12月至2010年11月来我科实习的护生36人为对照组,采用传统周目标教学法;2010年12月至2011年11月来我科实习的护生36人为观察组,实施日目标教学法。观察并比较两组实习护生专科理论和操作技能的考试成绩及其对带教老师、临床教学的满意度。结果实施日目标教学法的护生考试成绩及对带教老师、临床教学的满意度方面均优于采用传统周目标教学法的护生,两组比较差异有统计学意义（P＜0.05）。结论日教学目标的制定和实施遵循由易到难、循序渐进、基础与提高相结合的原则,对师生均提出了细化、具体的目标要求,使护生学习更有侧重点,提高了护生的自主学习能力,也强化了带教老师的带教意识,因材施教,满足了不同层次护生对心胸外科专科知识的学习需求,提高了护生对带教老师、临床教学的满意度,提高了临床教学质量。     

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.