99年度急重症臨床案例教學暨實證護理研討會

北區補充講義

99/08/10

現今個案報告• 著重個系統or各問題之追蹤(longitudinal),

• 輕忽對病情之掌握, 著重心理支持

• 不重視檢查意義之討論與運用

• 未設定護理時輕重緩急問題的排序

• 個案選擇偏重罕見與特殊, 忽略實用性與教育性

• 更應重視同一時間(cross section)得相關數據的收集

• 重症病人首重生理穩定

• 了解檢查意義才知醫師照顧方向與進入病情掌握

• 應重要問題先提出

• 實用性與教育性更重要

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建議報告個案的呈現方式• 以照護期間挑一個最主要的問題，來完成案例分析，此時間點的選擇及問題可以由罕見、難纏(可分享)或普遍(表現處理的特殊點)，其目的為知識教育的經驗分享且精進分析及處理臨床問題的能力。

• 取一段有重大變化及特殊意義的照護時間點，觀察此時間點病人的現象，透過生理評估，臨床數據判讀來發現病人在此時間點出現的各系統的問題，並做深入探討及採取適當的實證照護措施，使病人紊亂的生理得到穩定。

• 加護病房病人的處置，重點是先處理生命威脅的問題，讓病人生命徵象穩定。照護著重在氧合、灌流、營養、感染及家屬心理支持。

3

Evidence-based and theory-deriven• To collect relative and related evidence(s) to triangulate

the problem focus— focused problem identification– Focused history taking– Focused PE– Focused Lab/test– Focused description of patient’s condition

• SBAR(situation, background, assessment, response)

• Based on the judged problem to – Predict /uncover hidden problems at the guidance of

patho-physiological process, confirmed by collect more evidence/follow-up lab tests

– Deliver effect intervention guided by pathophysiological theory

4

腸胃道出血GASTROINTESTINAL TRACT BLEEDING

個案介紹

急診時處理

入ICU

處理經過

結果

Systemic inflammatory response syndrome (SIRS)

The patient must have two or more of these symptoms:

• core temperature < 96.8° F (36° C) or > 100.4° F (38° C)

• elevated heart rate (> 90 beats/minute)

• respiratory rate > 20 breaths/minute or PaCO2 < 32 mm Hg

• white blood cell count < 4,000 cells/mm3 or > 12,000 cells/mm3

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DIC diagnosis criteria

1.有無誘發急性DIC疾病的背景:Severe infection,

injury, burn, tissues ecrosis,Tumor,ALL,Amniotic

fluid embolism,ABO 血型不合,出血性蛇毒

計分 0 1 2 3

Platelet

FDP D-D

3P’s test

PT

fibrinogen

>10萬

正常

延長不足3秒

大於100mgdl

<10萬

延長3~6秒

小於100mgdl

<5萬

相當增加

延長超過6秒

嚴重增加

總分大於5分:顯然的DIC

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Acute ventilation failure

• PH<7.3

• PaCO2>50

• HCO3-(偏低)

• AaDO2>350 mmHg

• AaDO2=(713*0.8)-76.4-62=432 mmHg

PH PCO2

PO2

HCO3-

BE SaO2

7.076 (7.35-7.45)62.0 (35-45mmHg)76.4(83-108mmHg)17.8 (21-28meq/L )-12.2 (±2 meq/L)91 (95-98﹪)

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Shunt

• Shunt(％): AaDO2/ 20

＝ 432/20

＝ 21.6 (6~7 ％)

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Acute lung injury

• PaO2/FiO2 <200

=76.4/0.8

=95.5 9 (<200)

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CaO2

• CaO2=1.34 ×Hb ×SaO2 ＋0.003 ×PaO2

1.34*13.3*0.91+0.0003*76.4=16.2(15~20mg/dl)

normal

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• Renal dysfunction– Serum creatinine>2.0mg/dl– Urine output<500ml/24hrs or 180ml/8hrs– Need for hemodialysis or perioneal dialysis

Renal failure– Urine output<479ml/24hrs or 159ml/8hrs– Serum BUN>100mg/dl– Serum creatinine>3.5mg/dl

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Shock differential diagnosis

CVP BP CO SvO2

Hypovolemia

Obstructive

Cardiogenic

Sepsis (early)

(late)

or N

or N or

or N

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1. Formulate an answerable question. ~ Ask (PICO)

提問: 由個案的臨床資料提出可回答的臨床問題

2. Track down the best evidence. ~ Acquire

尋找最佳的實證文獻﹝各種文獻資料庫，包括發表及未發表的資料﹞

3. Critically appraise the evidence for validity, impact, and applicability. ~ Appraisal (VIP)

評估最佳實證醫學文獻的可信度、臨床重要性，以及可應用性

4. Integrate with our clinical expertise and patient values.

整合並應用於實際患者的治療決策~ 告知﹝臨床應用﹞~ Apply

5. Evaluate our effectiveness and efficacy. 效果評估 ~ Audit溝通: 用簡單且病人可以聽懂的語言，對病患告知診療的決策

進行實證醫學討論的五大步驟5As: Ask, Acquire, Appraisal, Apply, and Audit

Ask :提問-由個案的臨床資料提出可回答的臨床問題

吃益生菌Intervention 介入處置

減少嬰兒日後氣喘的發生率Outcomes 臨床結果

Placebo安慰劑，或沒有吃益生菌Comparison intervention

對照的處置

有過敏家族史懷孕的母親Patient and/or problem

病人或問題

PICO

哪一篇是Best evidence ?

練習題

• 88歲男性，OHCA送往急診於急救室急救！家人抵達急診欲留在急救室，被護理人員請出去，家屬表示為何不能留在病人旁，美國都可以!

• 護理人員表示因避免阻礙急救過程，故無法讓家屬留在急救室，家屬無法接受！

家屬於CPR過程可否在旁?Family Presence During CPR

• PICO?

• P: patients with CPR

• I: Family Presence During CPR

• C: Not Allow Family Present During CPR

• O: Benefits for family

Benefits for the FDPR

• Decreased anxiety and hopelessness• Increased understranding of the seriousness of the

patient’s illness• The ability to provide a comforting presence to the

patient• facilitation of the grieving process（York, 2004）• Help to remove family doubts about what is

happening to the patient and provides them with th satisfaction and knowledge tha teverything possible is being done for their relative（Clark et al.,2001）

Concerns from healthcare staff

• Fear that familes may interrupt their performance

• Fear that their emotions may be evoked

• Fear of legal ramifications

• Fear of giing up control

Belanger & Reed, 1997

參考文獻

• AACN practice Dep（2007 May）Family Presence During CPR and Invasive Procedures. AJCC, 16(3) 283.

• Fallis, W.M.; McClements, S & Pereira, A. （2008 Fall）Family presence during resuscitation: A survey of Canadian critical care nurses’ practices and perceptions. CACCN, 22-28.

• Moons, P; Norekvai, T.M. （2008, Summer）European Nursing Organizations Stand Up for Family Presence Duing Cardiopulmonary Resuscitation: A Joint statement. Progressin Cardiovascular Nursing, 136-139.

• Sanford, M; Pugh, D.& Warren, N.A. （2002）. Family Presence during CPR: New Decisions in the Twenty-First Century, Crit Care Nurs Q, 25(2) 61-66.