早產兒疼痛評估修訂量表之觀察者間信度檢測

The observer’s inter-rater reliability of the Premature Infant Pain Profile-Revised

王筱華(Sheau-Hwa Wang)

指導教授 ： 郭碧照 ； 汪秀怜

中山醫學大學/護理學院/護理研究所/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00094

摘要

疼痛是一種主觀又難以描述的感受，由於早產兒無法用言語表達疼痛，缺乏「自我陳述」的黃金標準，要評估疼痛僅能由間接方式測量。本研究目的即是在測試「早產兒疼痛評估修訂量表」(Premature Infant Pain Profile - Revised, PIPP-R)之評估者間信度，了解使用上的問題，做為教育訓練計畫的參考。用早產兒接受足跟採血時，與血壓測量時、及臥位改變時之三個不同程度刺激下的生理指標、行為變化的影像，和早產兒疼痛評估修訂量表(以下簡稱PIPP-R)為工具，觀察評估者對三個不同程度刺激下的PIPP-R評分一致性。結果：(一)、27位初次使用PIPP-R的評估者對早產兒三個不同程度刺激下之總評分一致性：臥位改變最好(63%)、其次是足跟扎血(44%)，最差是血壓測量(37%)。(二)、各項指標一致性，1.心跳指標信度：臥位改變最好為63%、血壓測量與足跟扎血均為52%；2. 血氧指標信度：臥位改變100%、血壓測量與足跟扎血均為63%；3. 皺眉指標信度：臥位改變100%、其次是足跟扎血為63%，最差是血壓測量為52%；4. 閉眼指標信度：臥位改變最好為96%、其次是足跟扎血為63%，最差是血壓測量為52%；5. 鼻唇溝紋指標信度：臥位改變100%、其次是足跟扎血為70%，最差是血壓測量為48%；6. 行為狀態指標信度：臥位改變與血壓測量均為41%，足跟扎血最差為20%。(三)、觀察者間信度分析：三個不同的情境，任何單一測量的觀察者間一致性差、平均測量的觀察者間一致性可，未達顯著水準(單一IRR: .20、95% CI: - .02~ .47, p= .04；平均IRR: .43、95% CI:- .07~ .72、p= .04)。結論：早產兒遭受疼痛刺激的PIPP-R評估，尤其心跳指標及行為狀態指標的一致性是未來教育訓練最可待加強的地方，針對PIPP-R使用教育訓練重點，先了解早產兒的行為線索及對刺激的反應，PIPP-R量表各指標項目的定義清楚以及基準點的擷取，充分了解評分的準則，觀察順序及視線停留點等，改善計時器的可近性，均能提高PIPP-R臨床使用的便利性，未來建議對於PIPP-R評估者使用進行教育訓練後，再與本研究做比較。

關鍵字

早產兒疼痛評估 ； 早產兒疼痛評估修訂量表 ； 觀察者間信度

並列摘要

Pain is a subjective feeling and self-describe is the most important way to assess it. Premature infants could not express their pain perception by languages; heath care providers could only assess their pain through objective measurements. The purpose of this study was to assess the inter-rater reliability (IRR) of the Premature Infant Pain Profile- Revised (PIPP-R) score by the direct care nurses. For understand the problem of the PIPP-R clinical utility to plan the education programs. We recruited 27 observers from neonatal intensive care units into this study. Three different situations of the pain sources of premature were obtained and recorded as videos: (1) during the heel stick, (2) measuring blood pressure, (3) changing the body position. The participants were invited to assess premature physiological and behavior change indicators by the PIPP-R score consistency after watching the videos. Results: The total score consistency of the PIPP-R observers were (1) 63% > (3) 44% > (2) 37%. The uni-indicator score consistency of the PIPP-R observers at the Heart Rate was (1) 63% > (2) 52%= (3) 52%; at the O2 Saturation was (1) 100% > (2) 63% = (3) 63%; at the Brow Bulge was (1)100% > (3) 63% > (2) 52%; at the Eye Squeeze was (1) 96% > (3) 63% > (2) 52%; at the Nasolabial furrow was (1)100% > (3) 70% > (2) 48%; at the Behavioral State was (1) 41%=(2) 41% > (3) 20%. The Inter-rater reliability was poor near to fair, measured by intra-class coefficients (ICC) with the two-way mixed model; the ICC estimates IRR of the pain score under three situations were .20 (95% CI: - .02~ .47) and .43 (95% CI: - .07~ .72) for a single rating and average ratings, respectively (p= .04). Conclusion: The consistency of the PIPP-R assessed the Preterm infant suffer from painful stimuli, and uni-indicator of Heart Rate and Behavioral Status were the best point to be strengthened on the future education and training programs. The education and training projects included understanding the behavior of the preterm infant cues and response to stimuli, the definition of each PIPP-R indicator, as well as fully understand the principle to capture the maximum variable data, and the observation step by step, then improving the accessibility of the timer, could be improve the convenience of PIPP-R clinical utility. Future recommendations are using above plans might be reducing the bias and to comparison with the present study.

並列關鍵字

Premature pain assessment ； Premature Infant Pain Profile – Revised ； inter-rater reliability

參考文獻

劉美芳、李慈音(2006)•早產兒和新生兒之疼痛處置與護理評估•護理雜誌，53(6)，65-72。

American Academy of Pediatrics, Committee on Fetus Newborn Section on Surgery; Canadian Paediatric Society, Fetus and Newborn Committee. (2006). Prevention and Management of Pain in the Neonate: An Update. Pediatrics, 118(5), 2231-2241. doi: 10.1542/peds.2006-2277

Anand, K. J., & Carr, D. B. (1989). The neuroanatomy, neurophysiology, and neurochemistry of pain, stress, and analgesia in newborns and children. Pediatric clinics of North America, 36(4), 795-822.

Anand, K. J., & Craig, K. D. (1996). New perspectives on the definition of pain. Pain, 67(1), 3-6; discussion 209-211.

Anand, K. J., & Hickey, P. R. (1987). Pain and its effects in the human neonate and fetus. New England Journal of Medicine, 317(21), 1321-1329. doi: 10.1056/nejm198711193172105