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同学们好
今天我们要学习的内容是
《临终老年人疼痛的护理》
我们先来看这样一个案例
患者 女 64岁
胰腺癌Ⅳ期
以下是她腹部增强CT以及腹部立位拍片的结果
那么该患者主诉恶心 腹部胀痛
无排气 排便 尿少
查体显示
患者消瘦 恶液质
腹部膨隆 双下肢水肿
假如你是这个患者的责任护士
针对患者疼痛这个护理问题
你该做些什么
面对疼痛我们首先应该做什么呢
我想很多同学都想到了
首先我们应该要进行疼痛的评估
目前常用的癌痛评估的工具有很多
包括数字分级法
面部表情评分法
视觉模拟评分
和疼痛简明评估量表等
我这里就介绍两种最常见的方法
数字分级法和面部表情评分法
首先是数字分级法
大家看这个尺子
将疼痛程度用0-10十个数字依次表示
0表示无疼痛
10表示最剧烈的疼痛
交由患者自己
选择一个最能代表自身疼痛程度的数字
或由医护人员询问患者
你的疼痛有多严重
由医护人员根据患者
对疼痛的描述选择相应的数字
按照疼痛对应的数字
将疼痛程度分为
轻度疼痛
中度疼痛
和重度疼痛
还有一种常见的评估方法是
面部表情评分法
它是由医护人员
根据患者疼痛时的面部表情状态
对照《面部表情疼痛评分量表》
进行疼痛评估
这个适用于表达困难的患者
例如老年人
以及存在语言或文化差异
或其他交流障碍的患者
当然
疼痛评估工具
可以根据患者的情况进行具体选择
在完成疼痛评分后
我们要根据疼痛的级别
采取不同的干预措施
疼痛的干预措施主要包括两大块
即药物干预和非药物干预
究竟是选择药物干预还是非药物干预呢
需要根据患者的疼痛程度进行选择
经评估
案例中这位患者的疼痛评分为6分
接下来应该如何进行止痛呢
很显然非药物止痛法并非首选
此时
我们应当选择药物镇痛
药物镇痛应该遵医嘱
按照WHO的三阶梯镇痛疗法进行
大家看这张图
这就是三阶梯镇痛疗法
第一阶梯
轻度疼痛时给予非阿片类
加辅助止痛药
常用药物包括扑热息痛
阿司匹林 芬必得等
第二阶梯
针对中度疼痛应给予弱阿片类
加非阿片类和辅助止痛药
常用药物有可待因 强痛定
曲马多等
第三阶梯
重度疼痛时
给予阿片类加非阿片类和辅助止痛药
强阿片类药物无天花板效应
但可产生耐受
需适当增加剂量以克服耐受现象
以往认为用吗啡止痛会成瘾
所以不愿给患者用吗啡
现在证明这个观点是错误的
使用吗啡的患者极少产生成瘾性
此阶梯常用药物有
吗啡片 美菲康
美施康定等
但是
杜冷丁这一以往常用的止痛药
由于其代谢产物毒性大等原因
未被推荐用于控制慢性疼痛
这里值得注意的是
在给予患者止痛药时应规律 足量
对持续存在的疼痛
预防性地定时给予止痛药
很多患者家属对止痛药的使用
都存在着一定的误区
怕成瘾
认为能不用就不用
事实上
应当把关注点放在缓解疼痛上
而不必担心长期使用
可能会带来药物依赖
或者药物滥用的问题
药物止痛还要注意
不是必要时才用
等到疼痛发生时
再控制比预防疼痛发生更困难
此外
我们要取得老年人的合作
要为老年人和家属写出服药方法
服药时间 药物名称
使用的理由和剂量
如现在的药物或剂量
不能达到解除或减轻症状
应及时告诉医护人员
及时增加剂量或更换其他药物
动态评估止痛药的效果
询问老年人有无恶心 呕吐
便秘等不良行为
对无法口服止痛药
造成不安与痛苦者
可使用如皮肤贴片
舌下含化
静脉或肌内注射等
各种方式给予止痛药
回头看这个案例
患者疼痛评分为6分
根据WHO的用药推荐
我们应该用第三阶段的药物
如芬太尼等
刚才介绍的是
应对临终疼痛中的药物止痛法
如果老年人的疼痛程度较轻的情况下
我们还可以考虑非药物止痛法
非药物止痛方法很多
在这里我就介绍几种常用的
如松弛疗法 皮肤刺激止痛
毫米波生物治疗 分散注意力止痛等
我们首先来看松弛疗法
应用松弛疗法可使全身肌肉充分放松
这不仅是缓解疼痛
防止疼痛加剧的好方法
对有效地消除焦虑
帮助病人改善睡眠质量
充分休息
尽快恢复体力
都起着非常重要的作用
松弛疗法的具体方法包括
呼吸松弛法
节律按摩法
我们来看一个研究实例
田利等探讨松弛疗法
足反射区按摩加音乐疗法
在癌症病人疼痛控制中的疗效
该研究将符合纳入标准的病人
随机分为常规治疗组
足反射区按摩组
和足反射区按摩加音乐疗法组
研究结果显示松弛疗法
能在一定程度上缓解癌症病人的疼痛
改善其生活质量
皮肤刺激止痛法是利用按摩
冷 热 压力等手段刺激皮肤
使其止痛或减轻疼痛
广泛应用于医学各专科领域
按摩止痛
是根据疼痛的部位
病人可以自己也可以由他人
在腰 背及脚进行缓慢
稳定的环形按摩
压力止痛
是通过手腕 手指尖
指节或全手
进行按压病人疼痛部位
或其附近区域10秒钟左右
让病人体会一下有没有止痛作用
如果止痛不明显
再寻找最佳的压力止痛点
找到后给予大约1～2分钟的固定压力
有时缓解疼痛的时间
可以达到几分钟甚至几小时
温度刺激止痛
是指癌痛发生时
如果想采用温度刺激止痛
那么建议用冷敷的方法
冷敷是通过造成局部区域麻木
而达到减轻疼痛的
冷敷时使用毛巾包裹
冰囊袋或冰水袋
进行局部冷敷
注意局部反应
以皮肤变白为宜
但不可发生冻伤
毫米波生物治疗
是指自由空间波长为1mm～10mm的电磁波
经体表穴位将仿声信息能量导入体内
治疗各种疼痛
包括骨 关节疼痛
癌性疼痛
尤其对癌性疼痛效果较佳
并协同放疗 化疗
达到增效 增敏的治疗效果
此外
还有我们常用的分散患者的注意力
以达到暂时缓解疼痛的方法
今天我们介绍了临终老年人疼痛的护理
推荐大家课后可以阅读一些相关的杂志文献
例如The Journal of Pain
Journal of Pain and Symptom Management
好
今天我们的课就讲到这里
谢谢
-1.1 Human Life Expectancy and Age Classification of the Elderly
--Human Life Expectancy and Age Classification of the Elderly
--【Vedio Recommendation】 How do we measure life expectancy ?
-1.2 Population Aging
--【Literature Recommendation】World Report on Ageing and Health: 2015
-1.3 Influence and Countermeasures of Population Aging
--Influence and Countermeasures of Population Aging
--【Literature Recommendation】World Population Ageing Highlights：2019
-1.4 Goals and Principles of Elderly Care
--Goals and Principles of Elderly Care
--【Book Recommendation】Evidence-Based Geriatric Nursing Protocols for Best Practice
-1.5 Theories Related to Elderly Care
--1.5.1 Personality Development Theory and Life Review
--1.5.2 Disengagement Theory and Activity Theory
--1.5.3 Self-efficacy and Chronic Disease Management
--【Vedio Recommendation】8 Stages of Development by Erik Erikson
--【Literature Recommendation】Activity Theory, Disengagement Theory, and Successful Aging
--【Book Recommendation】Self-Efficacy in Changing Societies
-1.6 Elderly Support and Elderly Care
--1.6.1 Concepts of Elderly Healthcare, Elderly Support and Elderly Care
--1.6.2 Home-based Elderly Care Model
--1.6.3 Institutional Elderly Care Model
--1.6.4 Integrated Medical and Nursing Care Model
--【Vedio Recommendation】Day in the Life of Home Care
--【Website Recommendation】Official Website of the National Institutes of Health
-Concept Map
--【Concept Map】General Introduction to Geronological Nursing
-【Test】CHAPTER 1
-2.1 Aging Changes in the Elderly
--2.1.1 Aging of the Respiratory System
--2.1.2 Aging of the Cardiovascular System
--2.1.3 Aging of the Digestive System
--2.1.4 Aging of the Urinary System
--2.1.5 Aging of the Endocrine System
--2.1.6 Aging of the Motor System
--2.1.7 Aging of the Nervous System
--2.1.8 Aging of the Sensory System
--【Literature Recommendation】Exercise Attenuates the Major Hallmarks of Aging
--【Book Recommendation】Hazzard's Geriatric Medicine and Gerontology
-2.2 Comprehensive Health Assessment of the Elderly
--Comprehensive Health Assessment of the Elderly
--【Literature Recommendation】Instruments to evaluate mental well-being in old age: a systematic review
-2.3 Principles of Elderly Health Assessment
--Principles of Elderly Health Assessment
-2.4 Assessment of the Functional Status of the Elderly
--Assessment of the Functional Status of the Elderly
--【Literature Recommendation】The Lawton Instrumental Activities of Daily Living (IADL) Scale
-2.5 Assessment of Cognitive Function in the Elderly
--Assessment of Cognitive Function in the Elderly
-2.6 Assessment and Adjustment of the Living Environment for the Elderly
--Assessment and Adjustment of the Living Environment for the Elderly
-Concept Map
--【Concept Map】Elderly Health Assessment(1)
--【Concept Map】Elderly Health Assessment(2)
-【Test】CHAPTER 2
-3.1 Overview of the Psychological Characteristics of the Elderly
--Overview of the Psychological Characteristics of the Elderly
-3.2 Influencing Factors of Psychological Changes in the Elderly
--Influencing Factors of Psychological Changes in the Elderly
-3.3 Common Psychological Issues and Their Management in the Elderly
--3.3.1 Common Psychological Issues and Their Management in the Elderly (1)
--3.3.2 Common Psychological Issues and Their Management in the Elderly (2)
--【Book Recommendation】Development Through the Lifespan
-3.4 Depression in the Elderly
--3.4.1 Overview of Depression in the Elderly
--3.4.2 Clinical Symptoms of Depression in the Elderly
--3.4.3 Caring for Elderly Patients with Depression
--【Documentary Recommendation】Depression：Out of the Shadows
-3.5 Elderly Patients with Dementia
--3.5.1 Identification of Dementia Symptoms in the Elderly
--3.5.2 Intelligence Rehabilitation of Elderly Patients with Dementia
--3.5.3 Safety Care of Elderly Patients with Dementia
--【Website Recommendation】The Global Voice on Demaentia
-Concept Map
--【Concept Map】Elderly Mental Health and Mental Health Care
-【Test】CHAPTER 3
-4.1 Precautions for Daily Care of the Elderly
--Precautions for Daily Care of the Elderly
-4.2 General Care of Elderly Skin
--4.2.1 Characteristics and General Care of Elderly Skin
--4.2.2 Skin Itching and Its Management in the Elderly
--【Website Recommendation】American Academy of Dermatology
-4.3 Clothing Hygiene for the Elderly
--Clothing Hygiene for the Elderly
--【Literature Recommendation】The Design Methods of Functional Clothing for the Elderly
-4.4 Dietary Care for the Elderly
--4.4.1 Nutritional Needs of the Elderly and Influencing Factors of these Needs
--4.4.2 Dietary Care for the Elderly
--【Book Recommendation】Nutrition Care of the Older Adult: a Handbook for Dietetics
--【Website Recommendation】Nutrition for older persons
-4.5 Sleep Guidance for the Elderly
--4.5.1 Sleep Characteristics of the Elderly
--4.5.2 Sleep Guidance for the Elderly
--【Book Recommendation】An Occupational Therapist's Guide to Sleep and Sleep Problems
--【Website Recommendation】American Academy of Sleep Medicine
-4.6 Exercises Guidance for the Elderly
--4.6.1 Evaluation of Exercise Intensity in the Elderly
--4.6.2 Precautions Elderly Undertaking Exercises
--【Website Recommendation】American College of Sport Medicine
--【Book Recommendation】Handbook of Activities for the Elderly
-Concept Map
--【Concept Map】Elderly Daily Care
-【Test】CHAPTER 4
-5.1 Characteristics of Drug Metabolism and Pharmacodynamics in the Elderly
--Characteristics of Drug Metabolism and Pharmacodynamics in the Elderly
--【Website Recommendation】How Drugs Work In the Elderly
-5.2 Common Adverse Drug Reactions and Their Causes in the Elderly
--Common Adverse Drug Reactions and Their Causes in the Elderly
-5.3 The Principles of the Use of Medications in the Elderly
--The Principles of the Use of Medications in the Elderly
-5.4 Prevention of Adverse Drug Reactions in the Elderly
--Prevention of Adverse Drug Reactions in the Elderly
-5.5 Medication Compliance in the Elderly
--Medication Compliance in the Elderly
-Concept Map
--【Concept Map】Medication Safety and Care for the Elderly
-【Test】CHAPTER 5
-6.1 Falls in the Elderly
--6.1.1 Epidemiological Characteristics of Elderly Falls
--6.1.2 Risk Factors for Falls in the Elderly
--6.1.3 Prevention of Falls in the Elderly
--【Website Recommendation】CDC STEADI(Stopping Elderly Accidents, Deaths & Injuries Tool Kit)
-6.2 Dysphagia in the Elderly
-6.3 Urinary Incontinence in the Elderly
--Urinary Incontinence in the Elderly
-6.4 Constipation in the Elderly
-6.5 Dry Mouth in the Elderly
--【Website Recommendation】Academy of Nutrition and Dietetics
-6.6 Elderly Nutritional Deficiencies
--Elderly Nutritional Deficiencies - emaciation
-6.7 Visual Impairment in the Elderly
--Visual Impairment in the Elderly
--【Website Recommendation】Senior Eye Exams
-6.8 Senile Deafness
-6.9 Elderly Delirium
-6.10 Elderly Frailty
--【Literature Recommendation】Frailty in elderly people/Frailty in older people
-6.11 Pneumonia in the Elderly
-6.12 Hypertension in the Elderly
--【Literature Recommendation】2018 Chinese Guidelines for Prevention and Treatment of Hypertension
-6.13 Stroke in the Elderly
-6.14 Stable Angina in the Elderly
--Stable Angina in the Elderly
-Concept Map
--【Concept Map】Nursing Care for the Elderly with Common Health Problems and Diseases
-【Test】CHAPTER 6
-7.1 Concept of Hospice Care
--【Website Recommendation】 Definition of Palliative Care，WHO
-7.2 Death Education
--【Book Recommendation】The Meaning of Death by Herman Feife
-7.3 Nursing for Pain in the Dying Elderly
--Nursing for Pain in the Dying Elderly
-7.4 Nursing for Major Bleeding in the Dying Elderly
--Nursing for Major Bleeding in the Dying Elderly
-7.5 Nursing for Delirium in the Dying Elderly
--Nursing for Delirium in the Dying Elderly
-7.6 Nursing for Dyspnea in the Dying Elderly
--Nursing for Dyspnea in the Dying Elderly
--【Website Recommendation】The Hospice and Palliative Nurses Association,HPNA
-7.7 Psychological Problems and Nursing in the Dying Elderly
--Psychological Problems and Nursing in the Dying Elderly
--【Book Recommendation】On Death and Dying ，by Elisabeth Kübler-Ross
-7.8 Grief Counseling for the Widowed Elderly
--Grief Counseling for the Widowed Elderly
--【Book Recommendation】I Wasn't Ready to Say Goodbye，by Noel·Brook,Blair·Pamela
-Concept Map
--【Concept Map】Hospice Care for the Elderly
-【Test】CHAPTER 7