名老中医江育仁临床经验.doc

1、疼痛評估及處理(Pain Assessment and Intervention)一、前言： 吳麗彬二、疼痛的生理觀：(一)Pain transduction (疼痛傳導)1.Fast pain (快速痛)2.Slow pain (慢速痛)(二)Pain transmission (疼痛傳遞)1.A-delta fibers (A-delta 纖維)2.C fibers (C 纖維)(三)Pain modulation (疼痛調節) 1.Modulation via the dorsal horn (經由脊髓神經角調節)2.Modulation via descending pathways

2、(經由抑制疼痛路徑調節):如Endorphin3.Modulation via endogenous chemicals(經由內生性化學物質調節)三、疼痛的理論：(一)Specificity theory (二)Gate-control theory四、疼痛型態(Types of pain)(一)Acute pain (急性疼痛)(二)Chronic pain (慢性疼痛)(三)Cutaneous or superficial pain (皮膚或表皮痛)(四)Deep somatic pain (深部驅幹痛)(五)Visceral pain (內臟痛)(六)Referres pain (反射痛

3、)五、疼痛的評估及處理：(一)評估：1.影響疼痛的因素：(1) Perception of pain (對疼痛的認知)(2) Response to pain (對疼痛的反應)(3) Therapeutic implications of the pain process (疼痛過程的治療情形)2.評估之基本原則：(見表)(1) History (病史)* Pain of location (疼痛部位)* Extension or radiation (範圍或輻射大小)* Onset and pattern (開始時間和疼痛型態)* Duration (疼痛期間多久)* Character o

4、r quality (特性或性質)* Precipitation, aggravating, and alleviating factors (加強或減輕因素)* Intensity (增強情形)* Associated symptoms (相關症狀)* Effect on activities of daily living (對日常生活影響)* Methods of pain relief (減輕疼痛方法)(2) Physical examination (身體檢查)* Sympathetic responses (交感神經反應)：Vital signs 變化等* Parasympathe

5、tic responses (副交感神經反應)：腸胃症狀等* Behavioral responses (行為表現)：呻吟、嘆氣、退縮等(3) Tools used to assess pain (疼痛評估工具)：10分法、直線法等(二)處理：1.Basic principles (基本原則)(1) Alleviating anxiety (減輕焦慮) (2) Distraction or diversion (轉移或分散注意力)(3) Combatting anticipatory fears (處理預期性害怕)(4) Providing physical care (提供身體照護)(5)

6、Administration of pain-relieving medication (給減輕疼痛藥物)(6) Managing chronic interatable pain (處理慢性棘手的疼痛)(7) Managing progressive pain (處理進行性的疼痛)2.Invasive interventions (侵入性治療)(1) Local anesthesia (局部麻醉)(2) Topical local anesthesia (全身麻醉)*(3) Analgesia (止痛劑). Mechanisms of analgesia (使用機轉). Types of a

7、nalgesics (種類)A. 非Opioids (麻醉性)止痛劑：NSAIDB. 弱Opioids (麻醉性)止痛劑：Codeine，DemerolC. 強Opioids (麻醉性)止痛劑：Morphine. Complications of opiate analgesics (止痛劑之副作用)A. Respiratory depression (呼吸抑制)B. Constipation (便祕)-最常見C. Paresthesias (感覺異常)D. Tolerance (抗藥性)E. Addiction (成癮性). Factors influencing the effective

8、ness of analgesics(影響止痛劑效果之因素)A. Relative analgesic potency (各藥物本身效能)B. Time action (給予時間)C. Oral potency (口服效果)D. Principles and methods of analgesic administration(止痛劑給藥原則及方法)(A)Preadministration assessment (給藥前評估)a.Drug allergies or sensitivities (藥物過敏及感受情形)b.Other medications the client is takin

9、g (其他藥物使用情況)c.Body weight (體重)d.Individual pain experience (個人疼痛經驗)e.Other individual characteristics (個人體質)：age，general state of health，mental status，probableduration of pain，and probable life expectancyf.Body system assessment (身體系統評估)g.Previous response to analgesics (過去對止痛劑的反應)(B)Methods of admi

10、nistration (給藥方法)a.Nurse-Administered (Demand) (護理人員給予)b.Patient-Controlled analgesic (病人自控式給藥)c.Intraspinal analgesia (經脊髓給予)d.Nerve bolcks (神經阻斷) (4)Neurosurgery for pain relief (外科去神經疼痛減輕)(5)Stimulation therapy (刺激治療)：如 Transcutaneous electric nerve stimulation (TENS) (經皮電神經刺激) (6)Radiation thera

11、py (放射線治療)(7)Placebos (安慰劑)3.Noninvasive interventions (其他非侵入性治療)(1)Meditation (藥物)：如鎮定劑等(2)Autogenic training (自體免疫加強)(3)Progressive relaxation training (進行性放鬆訓練)(4)Guided imagery (冥想法)(5)Rhythmic breathing (呼吸節律控制法)(6)Operant conditioning (由心而起的反應)(7)Biofeedback (生物迴饋法). Establishing a therapeutic

12、 relationship (建立治療性關係). Cutaneous stimulation (表皮刺激)：如按摩. Hypnosis (催眠). Music (音樂). Acupressure (針灸)六、總結 參考資料：Black, J. M. & Matassarin-Jacobs, E. (1993). Luckmann and Sorensens medical-surgical nursing: a psychophysiologic approach. Philadelphia: W. B. Saunders Co.Kaye, P. (1996). Symmptom control in hospice & palliative care.Hospice education institute.黃愛娟。(民國71)。病人疼痛的處理。護理雜誌，29(3)，53-64。藍先元 & 李明濱。 (民國81)。癌症疼痛的治療。當代醫學，19(2)，162-166。