Title

探討外科加護病房環境改善於預防譫妄及睡眠品質之成效

Translated Titles

Effects of environmental modification on delirium and sleep in SICU patients

Authors

朱卉愉

Key Words

瞻妄 ; 睡眠品質 ; delirium ; sleep quality

PublicationName

中山醫學大學護理學系學位論文

Volume or Term/Year and Month of Publication

2017年

Academic Degree Category

碩士

Advisor

黃正宜;廖玟君

Content Language

繁體中文

Chinese Abstract

譫妄(Delirium)是加護病房常見之合併症,為急性短時間認知損傷症狀。睡眠障礙是譫妄病患的共同感受,其中以環境聲音與光照為主要誘發原因。本研究目的為探討外科加護病房環境改善於預防譫妄及睡眠品質之成效。本研究採時間前後對照研究設計,研究場所為中部某醫學中心外科加護病房,選取20歲以上成人、昏迷指數15分及在加護病房待超過24小時之病患。樣本數各39位,措施介入前為對照組(平均年齡54.31 ± 15.1),措施介入後再收集實驗組(平均年齡56.51 ± 16.1),實驗組的介入措施於每天晚上11點至隔日早上6點依據譫妄照護指引進行照護,包括:降低環境噪音分貝、調整周圍環境照度與放置時鐘等,二組連續第一天至第三天期間,以基本資料表及VSH品質問卷收集資料,再由白班及小夜班主護填寫中文版CAM-ICU,並收集第一天至第三天11PM-6AM期間亮度及音量每10分鐘之變化且於第二、三、四天早上填寫VSH品質問卷收集資料。使用SPSS統計軟體進行卡方、t檢定、重複測量及迴歸分析了解加護病房內譫妄發生率與環境因素與睡眠品質之相關性。研究結果得知對照組介入前音量為54.7~70.5(dB),介入後為40.6~44.1(dB);介入前光線變化為208~230(Lux),介入後為44~53(Lux);介入前對照組譫妄發生率(25.6%),介入後實驗組譫妄發生率(2.6%);睡眠品質部分,介入前對照組睡眠總分(平均451分),介入後實驗組睡眠總分(平均945分);採邏輯斯迴歸分析得知睡眠量表每增加100分,可降低58%發生譫妄的風險(p<.05,CI:.212∼.827)。由以上結果顯示譫妄照護指引介入可降低加護病房音量及光線變化,病患整體睡眠品質高於對照組,睡眠是譫妄發生的重要因子。希望經此結果能提供重症單位改善環境因素提升病患睡眠品質以達到預防譫妄發生,並期望能將此結果平行推展至其他醫療院所進而提升護理品質。

English Abstract

The most common complication in ICU patients is acute delirium alone with sleep disturbance. Environmental noise and light could be the major causes on delirium and sleep disturbance in ICU. The purpose of this study was to investigate the effect of an Environmental Modification Program (EMP) on delirium and sleep in SICU patients. A pre-post comparison study design was performed at the ICUs of a medical center in Taichung. Patients who were adults (20 years old or older), with a Glasgow Coma Scale of 15, and stayed in ICU more than 24 hours were recruited (n=39 before and after program implementation, respectively). The EMP includes decreasing sound and light level during night time and placing clocks in each room for orientation. Delirium was assessed twice per day by using the CAM-ICU(Confusion Assessment Method for use in intensive care unit patients). Sleep perception was assessed in the 2nd to 4th day morning by using the Chinese version of the Verran and Snyder-Halpern Sleep Scale (VSH). Data of sound and light measures from 23:00 pm to 6:00 am for three nights were collected every 10 minutes. Chi-square, t test and regression analysis were used to analyze delirium incidence and relevant environmental factors on delirium and quality of sleep in patients in the ICUs. Results show that sound and light level were decreased from 54.7~70.5 dB and 208~230 lux to 40.6~44.1 dB and 44~53 lux after EMP implantation, respectively. Sleep quality were improved (VSH 451 vs. 945) and delirium incidence was decreased (25.6% vs 2.6%) after EMP. The risk of delirium was decreased 58% if sleep can be improved every 100 VSH score (p<.05,CI:.212∼.827). Implantation of EMP to lower down light and noise level in ICU has effects on improving sleep quality and decreasing delirium risk. Improving environmental factors in ICUs can reduce the incidence of delirium and poor sleep and hence to enhance the quality of care in patients in ICUs.

Topic Category 醫藥衛生 > 社會醫學
醫學院 > 護理學系
Reference
  1. Adamis, D., Treloar, A., Martin, F. C., & Macdonald, A. J. (2007). A brief review of the history of delirium as a mental disorder. History of psychiatry, 18(4), 459-469.
    連結:
  2. Breitbart, W., Rosenfeld, B., Roth, A., Smith, M. J., Cohen, K., & Passik, S. (1997). The memorial delirium assessment scale. Journal of pain and symptom management, 13(3), 128-137.
    連結:
  3. Brummel, N. E., & Girard, T. D. (2013). Preventing delirium in the intensive care unit. Crit Care Clin, 29(1), 51-65. doi: 10.1016/j.ccc.2012.10.007
    連結:
  4. Carno, M.-A., & Connolly, H. V. (2005). Sleep and sedation in the pediatric intensive care unit. Critical care nursing clinics of North America, 17(3), 239-244.
    連結:
  5. Darbyshire, J. L., & Young, J. D. (2013). An investigation of sound levels on intensive care units with reference to the WHO guidelines. Crit Care, 17(5), R187.
    連結:
  6. de Rooij, S. E., Schuurmans, M. J., Van Der Mast, R., & Levi, M. (2005). Clinical subtypes of delirium and their relevance for daily clinical practice: a systematic review. International Journal of Geriatric Psychiatry, 20(7), 609-615.
    連結:
  7. Dyson, M. (1999). Intensive care unit psychosis, the therapeutic nurse–patient relationship and the influence of the intensive care setting: analyses of interrelating factors. Journal of Clinical Nursing, 8(3), 284-290.
    連結:
  8. Ely, E. W., Margolin, R., Francis, J., May, L., Truman, B., Dittus, R., . . . Inouye, S. K. (2001). Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Critical care medicine, 29(7), 1370-1379.
    連結:
  9. Francis, J., Martin, D., & Kapoor, W. N. (1990). A prospective study of delirium in hospitalized elderly. Jama, 263(8), 1097-1101.
    連結:
  10. Frisk, U., & Nordström, G. (2003). Patients’ sleep in an intensive care unit—patients’ and nurses’ perception. Intensive and Critical Care Nursing, 19(6), 342-349.
    連結:
  11. Gabor, J. Y., Cooper, A. B., Crombach, S. A., Lee, B., Kadikar, N., Bettger, H. E., & Hanly, P. J. (2003). Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. American Journal of Respiratory and Critical Care Medicine, 167(5), 708-715.
    連結:
  12. Inouye, S. K., & Charpentier, P. A. (1996). Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. Jama, 275(11), 852-857.
    連結:
  13. Inouye, S. K., Van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Annals of internal medicine, 113(12), 941-948.
    連結:
  14. Kress, J. P., & Hall, J. B. (2006). Sedation in the mechanically ventilated patient. Critical care medicine, 34(10), 2541-2546.
    連結:
  15. Milbrandt, E. B., Deppen, S., Harrison, P. L., Shintani, A. K., Speroff, T., Stiles, R. A., . . . Ely, E. W. (2004). Costs associated with delirium in mechanically ventilated patients*. Critical care medicine, 32(4), 955-962.
    連結:
  16. Molter, N. C. (2003). Creating a healing environment for critical care. Crit Care Nurs Clin North Am, 15(3), 295-304.
    連結:
  17. Pandharipande, P. P., Patel, M. B., & Barr, J. (2014). Management of pain, agitation, and delirium in critically ill patients. Pol Arch Med Wewn, 124(3), 114-123.
    連結:
  18. Patel, J., Baldwin, J., Bunting, P., & Laha, S. (2014). The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia, 69(6), 540-549. doi: 10.1111/anae.12638
    連結:
  19. Pattison, N. (2005). Psychological implications of admission to critical care. British journal of Nursing, 14(13), 708-715.
    連結:
  20. Richards, K., Nagel, C., Markie, M., Elwell, J., & Barone, C. (2003). Use of complementary and alternative therapies to promote sleep in critically ill patients. Crit Care Nurs Clin North Am, 15(3), 329-340.
    連結:
  21. Roberts, B. L. (2001). Managing delirium in adult intensive care patients. Crit Care Nurse, 21(1), 48-55.
    連結:
  22. Truman, B., & Ely, E. W. (2003). Monitoring delirium in critically ill patients using the confusion assessment method for the intensive care unit. Critical Care Nurse, 23(2), 25-35.
    連結:
  23. Tullmann, D. F. (2001). Assessment of delirium: another step forward. Crit Care Med, 29(7), 1481-1483.
    連結:
  24. Van Rompaey, B., Elseviers, M. M., Van Drom, W., Fromont, V., & Jorens, P. G. (2012). The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Crit Care, 16(3), R73. doi: 10.1186/cc11330
    連結:
  25. Walder, B., Francioli, D., Meyer, J.-J., Lançon, M., & Romand, J.-A. (2000). Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Critical care medicine, 28(7), 2242-2247.
    連結:
  26. 方楸淑、王瑞霞(2007)•外科加護病房病患睡眠品質及其相關因素探討•[Sleep Quality and Its Associated Factors among Surgical Intensive Care Unit Patients]•實證護理,3(1), 54-63。 doi: 10.6225/jebn.3.1.54
    連結:
  27. 王玉女(2002)•老人急性混亂的概念與護理•長庚護理,13,258-263。.
    連結:
  28. 吳少玲、郭斐如、明勇(2007).重症單位急性混亂患者之評估與護理.[Assessment and Nursing Care of Patients in Acute Confusion in Intensive Care Units]•護理雜誌,54(6),67-72。doi: 10.6224/jn.54.6.67
    連結:
  29. 吳麗芬(2001)•老年住院手術病人急性混亂發生率及其相關因素研究•榮總護理,18(3),234-244。
    連結:
  30. 李秀卿(2011)•冠狀動脈繞道術病患譫妄發生率及認知功能變化之探討•臺灣大學。 Available from Airiti AiritiLibrary database.
    連結:
  31. 李秀卿、蕭淑代、陳佳慧(2012)•心臟術後的譫妄• [Delirium after Cardiac Surgery]•臺灣醫學, 16(6),676-681。
    連結:
  32. 李欣南、潘志泉(2003)•譫妄及其治療• [Delirium and Its Therapy]•臺灣醫學,7(4),611-617。
    連結:
  33. 林小玲、蔡欣玲(2003)•維辛式睡眠量表中文版之信效度•[The Reliability and Validity of the VSH Sleep Scale Chinese Version]•榮總護理,20(1),105-106。 doi: 10.6142/vghn.20.1.105
    連結:
  34. 徐愬美(2006)•噪音對心臟手術後加護單位病人身心影響,臺灣大學。Available from Airiti AiritiLibrary database. (2006年)
    連結:
  35. 符芳蕙(2004)•加護病房急性混亂發生率相關因素及預後之探討,台北: 國防醫學院。
    連結:
  36. 符芳蕙、徐淑芬、張玉坤、吳麗芬、林健群(2007)•加護病房病人急性混亂發生率及相關因素之探討• [Acute Confusion among Intensive Care Unit Patients]•源遠護理,1(2), 52-63。
    連結:
  37. 莊玟玲、林健禾、許雯琪、丁郁茹、林高章、馬淑清(2007)•加護病房混亂評估量表中文版信效度測試•[Evaluation of the Reliability and Validity of the Chinese Version of the Confusion Assessment Method for the Intensive Care Unit]•護理雜誌, 54(4),45-52。doi: 10.6224/jn.54.4.45
    連結:
  38. 陳依鈴、孫守涓、黃采薇(2012)•外科加護病房病人譫妄發生率及相關因素探討•[Delirium among Surgical Intensive Care Unit Patients]•彰化護理,19(4),33-40。
    連結:
  39. 黃瓊鶯(2011)•兒童譫妄量表臨床適用性之先驅性研究•台灣大學碩士論文。
    連結:
  40. 黃麗玉、黃珊、蕭世槐、王美文(2004)•南部某醫學中心急診加護病房噪音改善方案. [Noise Reduction at an Emergency Intensive Care Unit of Medical Center in Southern Taiwan]•護理雜誌, 51(1), 58-69。doi: 10.6224/jn.51.1.58
    連結:
  41. 楊鎮嘉、詹鼎正、溫瓊容(2014)•老人手術後譫妄症•台北市醫師公會會刊,58(3),35-39。
    連結:
  42. 廖士程、李明濱、李宇宙(2000)•睡眠的生物學基礎及臨床的意義•[Biology of Sleep and Its Clinical Implications]•臺灣醫學, 4(6), 652-664。
    連結:
  43. 熊道芬、邱曉彥、邱艶芬(2007)•加護單位病患睡眠問題的護理挑戰• [Nursing Challenge to Sleeping Problems of Patients in ICU]•源遠護理, 1(3),15-25。
    連結:
  44. 熊道芬、張怡媛、周幸生、邱艶芬(2009)•重症病人睡眠品質及其影響因素之探討•[An Exploration on the Related Factors of Sleep Quality in the Intensive Care Unit]•榮總護理,26(3), 274-281。 doi: 10.6142/vghn.26.3.274
    連結:
  45. 劉引玉、周桂如、謝佳容(2009)•老人睡眠品質與相關測量問題之探討•[Measurement for Sleep Quality in the Elderly]•長期照護雜誌,13(2), 231-242。
    連結:
  46. 劉建良、陳亮恭(2011)•老年譫妄症•台灣老年醫學暨老年學雜誌, 6(1),1-14。
    連結:
  47. 賴玟苑、王韵宜、田秀娟、蘇美蘭、林淑媛(2011)•譫妄實證照護之應用•護理雜誌, 58(2),75-80。
    連結:
  48. 顏兆熊(2009)•老人之譫妄•當代醫學(434), 925-931。
    連結:
  49. Devlin, J. W., Fong, J. J., Howard, E. P., Skrobik, Y., McCoy, N., Yasuda, C., & Marshall, J. (2008). Assessment of delirium in the intensive care unit: nursing practices and perceptions. American Journal of Critical Care, 17(6), 555-565.
  50. Onen, S. H., Onen, F., Courpron, P., & Dubray, C. (2005). How pain and analgesics disturb sleep. The Clinical journal of pain, 21(5), 422-431.
  51. Williamson, S. N. (2002). Sleep deprivation in patients in critical care unit. Nurs J India, 93(12), 267-270.
  52. 李淑燕(2008)•睡眠臨床照護指引對改善外科重症加護病房夜間睡眠環境與病人睡眠品質之成效探討•國立台北護理學院碩士論文。