护理人员预防术中获得性压力性损伤最佳证据应用障碍的质性研究

目的 深入了解护士应用预防术中获得性压力性损伤最佳证据的障碍因素,为实施压力性损伤干预提供参考。 方法 采用描述性质性研究方法,选取西部地区6所三级甲等医院手术室11名护士为研究对象,基于理论域框架制定访谈提纲,进行半结构式深度访谈,采用定向内容分析法对访谈资料进行分析。 结果 护士应用最佳证据的障碍因素分别为知识（最佳证据相关知识不足）;环境因素（特殊手术体位辅助工具不足、医院信息系统智能性欠佳）;动力和目标（患者及家属对预防压力性损伤的重视度较低,影响手术室护士积极性）;行为规范（工作流程有待完善）;结果的期望（手术室护士对实施最佳证据的效果缺乏信心）。 结论 影响术中获得性压力性损伤最佳证据在临床应用的障碍因素较多,需要科室在明确障碍因素的基础上,推进术中获得性压力性损伤最佳证据的临床应用。     

脊髓损伤伴神经源性肠功能障碍患者肠道管理最佳证据总结

目的 总结脊髓损伤伴神经源性肠功能障碍患者肠道管理的最佳证据,为改善患者肠道功能提供依据。方法 检索国内外相关循证资源网站及数据库中关于脊髓损伤肠道功能障碍患者肠道管理证据。对纳入文献进行方法学质量评价和证据提取。结果 共纳入17篇文献,其中指南7篇、专家共识5篇、系统评价3篇、随机对照试验2篇。总结了关于肠道功能评估方法、评估量表、健康教育、饮食干预、药物干预、行为干预及手术干预7个方面的26条证据。结论 脊髓损伤伴神经源性肠功能障碍患者最佳证据可为临床医护人员评估患者肠道功能及采取干预措施提供依据,实际应用中应结合临床实际情况和患者需求选择证据。     

脊髓损伤后神经源性膀胱患者容量管理最佳证据总结

目的 全面检索并总结脊髓损伤后神经源性膀胱患者容量管理的最佳证据。方法 依据证据金字塔模型,系统检索国内外数据库及官方网站,检索时限为建库至2023年11月10日,进行文献质量评价后,对证据进行提取和整合。结果 最终纳入20篇文献,形成评估、排尿管理、饮食护理、药物护理、康复护理、观察指标、健康教育7个方面20条证据。结论 形成的脊髓损伤后神经源性膀胱患者容量管理最佳证据可以为护理实践提供循证依据。 关键词：脊髓损伤;神经源性膀胱;尿潴留;容量管理;排尿管理;证据总结;康复护理;循证护理     

证据应用障碍因素和促进因素评定量表的编制及信效度检验

目的 编制证据应用障碍因素和促进因素评定量表,并检验其信效度。方法 通过对45项证据应用项目参与人员进行访谈形成测评框架和量表初稿,然后通过2轮专家函询形成初试量表,经过215名证据应用项目护理人员的初测形成正式测评量表,最终通过1 604名护士的调查对评定量表信效度进行检验。结果 证据应用障碍因素和促进因素评定量表包含6个维度共40个条目。总问卷的Cronbach′sα系数为0.931,各维度的Cronbach′sα系数为0.922～0.966,内容效度为0.904。探索性因子分析共提取6个公因子,累积方差贡献率为77.012%。验证性因子分析显示,模型拟合度良好。结论 证据应用障碍因素和促进因素评定量表具有良好的信效度,可用于证据应用过程中的障碍因素和促进因素的分析和预测。     

血液透析患者液体管理影响因素的质性研究

目的分析影响血液透析患者液体管理的因素,为制定干预措施提供参考。方法对21例血液透析患者进行半结构式焦点小组访谈,采用Colaizzi现象学研究法分析资料。结果提炼出影响血液透析患者液体管理的5个主题:知识、自我病情监测、心理因素、社会支持和身体状况。结论医务人员提升患者液体管理知识、加强心理疏导、提高社会支持等,可促进患者进行有效的液体管理。     

养老院护士压力性损伤评估影响因素的质性研究

目的深入了解养老院护士对老年人实施压力性损伤评估的影响因素,为制定针对性管理措施提供参考。方法选取上海市5所养老机构的10名护士进行半结构式深入访谈,对资料进行整理分析,提炼主题。结果提炼出"人员配置不足,知识及设施欠缺,评估信息掌握不准确,评估与临床工作结合度差,评估认知欠缺或存在利益驱动,支持力度缺乏,对Braden量表评估存在质疑"7个主题。结论针对养老院护士对老年人压力性损伤评估的影响因素,实施专业团队管理,加强培训,完善信息化及制度建设等措施,有望促进规范化压力性损伤风险评估及相应防护,避免老年人发生压力性损伤。     

2型糖尿病患者饮食行为影响因素的质性研究

目的探讨2型糖尿病患者饮食行为改变的影响因素。方法采用扎根理论研究法对19例2型糖尿病患者进行深入访谈,进行编码、归属及分析,提炼主题。结果提炼出重视饮食控制、获得饮食知识和技能、意志力坚定和家庭纽带作用4个因子的促进因素,饮食知识与实际需求脱节、家庭文化、习俗文化、忽略饮食控制和压力增加5个因子的阻碍因素。结论 2型糖尿病患者饮食行为受医务人员、患者、家属和社会文化等多种因素的影响,针对个体的综合饮食管理方案应为研究重点。     

脊髓损伤患者对居家康复环境因素体验的质性研究

目的 了解脊髓损伤患者对居家康复环境因素的真实体验,为构建针对性干预策略提供参考。方法 基于《国际功能、残疾和健康分类》核心组合的环境因素条目,采用现象学研究方法,选择12例脊髓损伤居家康复患者进行半结构式深入访谈,运用Colaizzi 7步分析法归纳并提炼主题。结果 提炼出2个主题：环境促进因素体验(支持氛围良好、护理服务模式温馨)和环境障碍因素体验(居家环境适应困难、缺少适宜的辅助器具、夫妻关系紧张、重新融入社会困难、社会服务可及性有限)。结论 脊髓损伤患者居家康复环境障碍因素居多,应重视患者居家康复环境因素评估,完善居家康复环境管理体系,借助人工智能实现居家康复管理,以推动患者康复进程,改善临床结局。     

肩袖损伤患者围术期疼痛管理困境的质性研究

目的 探讨导致肩袖损伤患者围术期疼痛管理困境的主题因素,为制定合理化的疼痛护理方案提供参考。方法 采用目的抽样方法,以2020年3月～2021年2月在安徽省某三甲医院骨关节外科行关节镜肩袖损伤修复手术的15例患者为研究对象,依据扎根理论进行情境观察,并对患者进行半结构式深入访谈,对访谈内容采用Colaizzi七步分析法分析总结,提炼主题。结果 肩袖损伤围术期疼痛管理困境的主题因素包括五个方面：手术后的负面情绪、对功能锻炼存在矛盾心理、对止痛药物副作用的担心、对家庭和医护支持的认知不足以及不正确的自我管理现象。结论 加强肩袖损伤患者围术期宣教,树立对疾病的正确认知,消除负面情绪,注重疼痛过程的管理,实施正确的自我管理措施,对围术期疼痛管理具有重要作用。     

社区医护人员实施居家安宁疗护促进及阻碍因素的质性研究

目的 了解社区医护人员实施居家安宁疗护的促进及阻碍因素,为有效推进居家安宁疗护提供依据。方法 采用描述性质性研究方法,以目的抽样法选取昆明市2所社区卫生服务中心的13名医护人员进行半结构访谈,采用内容分析法整理、分析资料。结果 提炼出社区医护人员实施居家安宁疗护促进及阻碍因素2个主题,促进因素主题的3个亚主题包括意识到居家安宁疗护的重要性、容易与居民取得联系、患者有居家安宁疗护的需求;阻碍因素主题的4个亚主题包括政策支持因素、医护人员因素、患方因素、风险因素。结论 社区医护人员实施居家安宁疗护的促进及阻碍因素是多维度的,应重视政府、社区医护人员、患者和家属共同参与居家安宁疗护的重要性,构建符合我国国情的居家安宁疗护服务模式。     

Classification of traumatic brain injury for targeted therapies

The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barriers to finding effective therapeutic interventions. In October, 2007, the National Institute of Neurological Disorders and Stroke, with support from the Brain Injury Association of America, the Defense and Veterans Brain Injury Center, and the National Institute of Disability and Rehabilitation Research, convened a workshop to outline the steps needed to develop a reliable, efficient and valid classification system for TBI that could be used to link specific patterns of brain and neurovascular injury with appropriate therapeutic interventions. Currently, the Glasgow Coma Scale (GCS) is the primary selection criterion for inclusion in most TBI clinical trials. While the GCS is extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms which are responsible for neurological deficits and targeted by interventions. On the premise that brain injuries with similar pathoanatomic features are likely to share common pathophysiologic mechanisms, participants proposed that a new, multidimensional classification system should be developed for TBI clinical trials. It was agreed that preclinical models were vital in establishing pathophysiologic mechanisms relevant to specific pathoanatomic types of TBI and verifying that a given therapeutic approach improves outcome in these targeted TBI types. In a clinical trial, patients with the targeted pathoanatomic injury type would be selected using an initial diagnostic entry criterion, including their severity of injury. Coexisting brain injury types would be identified and multivariate prognostic modeling used for refinement of inclusion/exclusion criteria and patient stratification. Outcome assessment would utilize endpoints relevant to the targeted injury type. Advantages and disadvantages of currently available diagnostic, monitoring, and assessment tools were discussed. Recommendations were made for enhancing the utility of available or emerging tools in order to facilitate implementation of a pathoanatomic classification approach for clinical trials.     

专科护士岗位胜任力提升促进和阻碍因素的质性研究

目的 探讨专科护士岗位胜任力提升的影响因素。方法 采用描述性质性研究方法,对15名不同专科方向的专科护士进行半结构式面对面深度访谈,运用内容分析法分析并归纳主题。结果 提炼出2个主题7个亚主题：促进因素包括领导能力强化,内驱力,认可角色意义,医院文化的正向作用;阻碍因素包括实际性专科岗位缺乏,培训架构与使用准则未成熟,专科能力转化困境。结论 专科护士岗位胜任力的影响因素较多,管理者应重视专科护士的使用,根据影响因素制定相应策略以推动专科护士岗位胜任力提升。     

Protocolised thromboelastometric-guided haemostatic management in patients with traumatic brain injury: a pilot study

Coagulopathy in patients with traumatic brain injury is associated with an increase in morbidity and mortality. Although timely and aggressive treatment of coagulopathy is of paramount importance, excessive transfusion of blood products has been linked with poor long-term outcomes in patients with traumatic brain injury. A point-of-care thromboelastometric-guided algorithm could assist in creating a more individually tailored approach to each patient. The aim of this study was to evaluate the feasibility of implementing a thromboelastometric-guided algorithm in centres that were formerly naïve to thromboelastometry. Hence, we developed such an algorithm and provided training to four centres across Europe to direct the haemostatic management of patients with severe traumatic brain injury. The primary outcome was adherence to the algorithm and timing of the availability of relevant results. Thirty-two patients were included in the study. Complete adherence to the algorithm was observed in 20 out of 32 cases. The availability of thromboelastometric results after hospital admission was reported significantly earlier than conventional coagulation tests (median (IQR [range]) 33 (20–40 [14–250]) min vs. 71 (51–101 [32–290]) min; p = 0.037). Although only 5 out of 32 patients had abnormalities of conventional coagulation tests, 21 out of 32 patients had a coagulopathic baseline thromboelastometric trace. Implementing a thromboelastometric-guided algorithm for the haemostatic therapy of traumatic brain injury is feasible in centres formerly naïve to this technology and may lead to more rapid and precise coagulation management. Further large-scale studies are warranted to confirm the results of this pilot trial and evaluate clinical outcomes.     

Evaluation and management of spastic gait in patients with traumatic brain injury

Damage to the corticospinal system after brain injury interferes with activities of daily living, mobility, and communication. The chief cause of this interference has to do with impairment to produce and regulate voluntary movement accompanied by the presence of spasticity. This review advocates that the evaluation of "spasticity" should focus on 3 issues: (1) identifying the clinical pattern of motor dysfunction and its source; (2) identifying the patient's ability to control muscles involved in the clinical pattern; and (3) the differential role of muscle stiffness and contracture as it relates to the functional problem. We have identified and described 6 clinical patterns of motor dysfunction affecting the lower limbs during gait, found in patients with traumatic brain injury and residual from upper motor neuron lesions. We have presented the use of dynamic electromyography to identify the voluntary and spastic characteristics of individual muscles in gait and the use of anesthetic nerve blocks to identify properties of stiffness and contracture in particular muscle groups. Treatment algorithms for these problems include identification of the muscles that contribute to the deformity across a joint; the stage of patient recovery; and most important, the clinical goals applicable to the patient. The treatment strategies based on the algorithm included in this article were focused on the use of chemodenervation of targeted muscles, neuro-orthopedic surgery, and other therapeutic strategies.     

脑外伤患者围手术期液体及代谢管理

背景 在创伤性患者中,脑外伤(traumatic brain injury,TBI)逐渐成为致残甚至致死的主要因素.快速而有效的治疗,是该类患者取得良好预后的关键. 目的 对于TBI患者,围术期治疗的关键是维持患者生命体征平稳,避免血氧不足、低血压、贫血、低(高)碳酸血症、发热、低血糖等变化,也需关注颅内血肿、颅内高压、癫痫、感染、血管痉挛等引起继发性神经损伤的因素. 内容 TBI患者围术期液体和代谢管理包括维持脑灌注压、避免血糖较大波动及控制体温,是TBI患者预后的关键.维持脑灌注压的策略在于液体的选择类型及其输注量.维持良好的血糖范围,有利于患者预后.低体温对TBI患者的影响尚存在争议. 趋向 关注液体及代谢管理,逐渐成为TBI患者围术期管理的主要内容.     

An Internet training intervention for people with traumatic brain injury: barriers and outcomes

Primary objective: To test whether people with cognitive-linguistic impairments following traumatic brain injury could learn to use the Internet using specialized training materials.

Research design: Pre-post test design.

Methods and procedures: Seven participants were each matched with a volunteer tutor. Basic Internet skills were taught over six lessons using a tutor's manual and a student manual. Instructions used simple text and graphics based on Microsoft Internet Explorer 5.5. Students underwent Internet skills assessments and interviews pre- and post-training. Tutors completed a post-training questionnaire.

Main outcomes and results: Six of seven participants reached moderate-to-high degrees of independence. Literacy impairment was an expected training barrier; however, cognitive impairments affecting concentration, memory and motivation were more significant.

Conclusions: Findings suggest that people with cognitive-linguistic impairments can learn Internet skills using specialized training materials. Participants and their carers also reported positive outcomes beyond the acquisition of Internet skills.     

Current controversies in the management of patients with severe traumatic brain injury

BACKGROUND: Traumatic brain injury is a major cause of mortality and morbidity, particularly among young men. The efficacy and safety of most of the interventions used in the management of patients with traumatic brain injury remain unproven. Examples include the 'cerebral perfusion pressure-targeted' and 'volume-targeted' management strategies for optimizing cerebrovascular haemodynamics and specific interventions, such as hyperventilation, osmotherapy, cerebrospinal fluid drainage, barbiturates, decompressive craniectomy, therapeutic hypothermia, normobaric hyperoxia and hyperbaric oxygen therapy. METHODS: A review of the literature was performed to examine the evidence base behind each intervention. RESULTS: There is no class I evidence to support the routine use of any of the therapies examined. CONCLUSION: Well-designed, large, randomized controlled trials are needed to determine therapies that are safe and effective from those that are ineffective or harmful.     

Indicators for tracheostomy in patients with traumatic brain injury

Our objective was to develop criteria to identify patients with traumatic brain injury (TBI) who require a tracheostomy (TR). From January 1994 to May 2000 all TBI patients requiring intubation on presentation and who survived >7 days were identified from our trauma registry. Demographics, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and ventilator days, ICU days, hospital days, need for TR, and development of pneumonia were statistically analyzed. Of 246 patients with TBI 211 without TR and 35 with TR were identified (mean time to TR 13.3+/-7.0 days). Logistic regression analysis identified presenting GCS < or =8, ISS > or =25, and ventilator days >7 as significant predictors for TR. Applying these three predictors to our population identified 48 patients (21 with TR, 18 without TR, and nine who died on the ventilator without TR) with a sensitivity of 60 per cent, a specificity of 87 per cent, a positive predictive value of 44 per cent, and a negative predictive value of 93 per cent. Patients with TR had lower presenting GCS and higher ventilator, ICU, and hospital days (P < 0.05). Pneumonia rates were similar. Time to neurologic recovery (GCS > or =9) was longer for the TR patients as compared with the patients without TR. We conclude that patients with TBI presenting with a GCS < or =8, an ISS > or =25, and ventilator days >7 are more likely to require TR. Performing TR late did not reduce pneumonia rates or ventilator, ICU, or hospital days. By identifying the at-risk population early TR could be performed in an attempt to decrease morbidity and length of stay.