手术患者围术期核查表的设计与使用

围术期患者因手术、术后复苏的需要,会经历多环节的转运,如由病房至手术室、手术室到麻醉复苏室、麻醉复苏室到病房或ICU等,中间经过多环节、多人员、多物品的交接。2009年6月开始,我院设计并使用了《患者术前准备单》、《手术患者交接记录单》、《巡回护士交换班记录表》、《手术安全核对表》,收到良好的效果,现报道如下。     

手术病人交接核查表的制定和应用

详细介绍手术病人交接核查表的制定和实施。手术病人交接核查表的制定和应用规范了围术期每个环节的内容、方法和步骤,让病房护士、手术室护士等医务人员明确了各自职责,为手术病人交接和术后护理提高了安全度,提高了护理质量,提高了病人的满意度。     

基于JCI标准的手术患者护理交接单的应用

正手术室是一个高风险的科室,潜在的不安全因素较多,其中手术患者交接涉及科室多,交接内容繁杂,影响患者安全和护士工作效率,患者的交接包括患者术前从病房到手术室,术后从手术室到复苏室及从复苏室再回到病房的整个过程~([1-2])。我院通过总结原有的数据,结合现实情况,设计了"手术患者交接护理记录单",为降低手术患者交接错误率提供了很好的保障。在2012年我院通过了医疗机构评审国际     

《手术患者皮肤管理记录单》在术后皮肤康复护理中的应用

目的探讨《手术患者皮肤管理记录单》在术后皮肤康复护理中的应用情况。方法选取2015年1~6月于本院行择期手术的患者2438例为对照组,对照组按常规实施皮肤护理,手术结束患者离开手术室前,手术室护士与手术医生共同查看和记录患者皮肤压疮和完整性,并与病房护士进行交接。另选取2015年7~12月择期手术的患者2358例为干预组,干预组在常规护理基础上,使用自行设计的《手术患者皮肤管理记录单》,包括患者基本信息、术中受压部位以及记录术后患者皮肤存在压之褪色的局限性红斑的具体部位和面积、手术室护士的术后随访。与病房护士共同管理手术患者围手术期皮肤安全。结果术后6 d内,对照组发生压疮23例,干预组发生6例(χ~2=9.471,P=0.002)。结论使用《手术患者皮肤管理记录单》可有效降低手术压疮的发生。     

肾移植术后患者复苏后转运交接单的应用

为了提高交接的准确性、保证患者的安全,我科主任医生及全体护士与麻醉科全体人员经讨论并制定出肾移植术后患者离开麻醉恢复室与病房交接单。2009-07使用后,收到良好的效果。现报告如下。1交接单的设计1.1设计理念本着确保患者安全,交接直观、实用,操作便利的原则。     

老年患者全麻手术复苏并发症的护理进展

随着现代＂手术全期护理＂（perioperative nursing,PN）和麻醉后恢复室（post-anaesthesia-care unit,PACU）等新理念的提出与发展,手术室护士的角色和功能也不断扩展和完善,手术室麻醉复苏护士-这种新型角色和岗位应运而生,由其完成的麻醉恢复期护理已成为手术室围术期护理的重要内容之一[1].     

麻醉复苏专科护士的构建

麻醉恢复室又称为麻醉后监测治疗室,重要意义就在于利用配备的各种设备和监测仪器,观察病人麻醉恢复过程,预防并早期发现手术、麻醉后并发症,确保术后病人安全返回病房。由麻醉复苏护士完成的麻醉恢复期护理已成为手术病患围术期护理的重要内容之一。而我国麻醉复苏专科护士在准入、人数、职责、培养等方面存在一些差距,还需要重新构建,强化准入门槛,加强培训教育,更需要国家主管部门加快制度建设,加快麻醉复苏护理人员的培养,从而有利于麻醉复苏专科护士的健康发展。     

麻醉恢复室护理风险因素的分析及对策

麻醉恢复室是对全身麻醉术后患者进行短时间严密观察和监护的场所[1]。随着医院管理年的深入,围术期的麻醉护理逐步被护理领域和麻醉领域的医护人员所关注[2],麻醉恢复室的护理质量管理也越来越受到重视。怎样有效提高麻醉恢复室的护理质量,确保患者围术期的安全,减少护理不安全事件发生。2009年1月起,上海交通大学医学院附属第九人民医院对麻醉恢复室护理质量管理进行调研分析,了解麻醉恢复室存在的护理风险,并提出了相应的对策,以期推动和促进麻醉恢复室护理质量的不断提升,现报道如下。     

围术期患者访视应用现状及展望

随着现代手术全期护理理念的提出与发展,手术室护士的角色与功能在不断扩展与完善,手术室护士对患者进行围术期访视已经成为手术全期护理和整体护理的重要内容。通过围术期患者访视将病房护理和手术室护理有机连接起来,可有效地帮助患者解决围术期存在的各种心理问题,提高机体的应激能力,促使患者平稳度过围术期,同时也为手术室     

手术患者身份识别交接表的设计及应用

目的 探讨手术室与病房交接患者时身份识别的内容及应用.方法 设计出表格的形式,采取填空的方式,除患者基本信息(姓名、住院号、科室床号、性别、年龄、影像资料等)外,将腕带、手术部位体表标识作为手术患者身份识别标志的重要信息如实记录,并在患者入手术室前、麻醉前、手术前和回病房后分别由手术室护士、病房护士、麻醉医生、手术医生认真查对签字.结果 使用该交接表后所施行的9850例手术均未发生手术患者、部位和术式错误.结论 手术患者身份识别交接表的临床应用,对保障手术室护理安全,减少差错事故,提高护理质量有极其重要的作用.     

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.