第五章 討論
第三節 研究結果應用
第三節 研究結果應用
CPOT 是一個適合大部分重症單位的疼痛觀察評估工具，依據研究結果，
在護理應用上有下列建議：
一、護理疼痛教育層面
傳統的疼痛評估方式，是由病患說出疼痛感受並由醫護人員評估疼痛強 度，病患自評疼痛也被視為「黃金標準」，如果病患表達疼痛，那麼他確實是處 於疼痛。對於無法表達疼痛的病患而言，可藉由觀察其疼痛行為來推測病患是 否疼痛(Herr et al., 2006)。本研究也支持相較於觀察生理指標的變化，觀察疼痛
行為更能代表病患的疼痛強度。但是，觀察哪些疼痛行為才能代表病患的疼痛？
CPOT 提供一個具效度的評估項目。在疼痛教育上，可以舉 CPOT 為例，教導 疼痛行為的觀察重點，以做為將來疼痛評估上的輔具及依據。
二、護理實務層面
本研究發展中文版CPOT 的初衷，是為了提升病患疼痛控制的品質，以下 有幾項建議：
(一)以 CPOT 做為意識不清及無法溝通病患的疼痛觀察工具：完整疼痛控
制的前提在於良好的疼痛評估，有研究指出，疼痛評估障礙在於受限於時間壓 力，並缺乏一個完整有系統的評估工具(Puntillo et al., 2001, Shannon & Bucknall, 2003)。據本研究結果，CPOT 是一個具效度，並能輕易於臨床運用的工具。它
包含四個疼痛行為指標，均可偵測病患的疼痛反應，臨床醫護人員可運用之，
以了解重症病患的疼痛控制是否適宜。
(二) 以 CPOT 建立疼痛評估的標準程序：疼痛評估不是一時的事，病患剛 入院後即必須進行完整疼痛評估，並每日規則評估、記錄。CPOT 因為其內容
簡單，定義性特徵明確，很容易施測於臨床上，完成完整評估只需要1 分鐘，
因為施測容易，利於臨床醫護人員每日規則使用。
(三) 以 CPOT 建立藥物調整的 protocol：臨床上可利用 CPOT 作為病患的
疼痛控制的指引，建立一個完整protocol，透過每日規律的觀察、記錄病患疼痛 分數及強度，並依據疼痛強度調整適合病患的藥物劑量，以避免止痛藥物不足 或過量對病患的傷害。特別是病患在接受會引起疼痛的醫護常規前後，如翻身、
氣管內抽痰、移除傷口引流管、移除股靜脈導管、放置中心靜脈導管及傷口換 藥(Puntillo et al., 2004)，醫護人員都必須重視到病患疼痛問題，並利用 CPOT 給予疼痛評估。
三、護理研究層面
目前國內相當缺乏對重症病患的疼痛評估之相關研究，CPOT 可做未來相
關研究之工具。而疼痛評估是為了能夠做好病患疼痛處理，將來本工具可應用 於重症單位，測試不同介入性措施下病患的疼痛處理結果，還可以測試 CPOT 其與止痛藥物劑量之關係。
參考資料
Aissaoui, Y., Zeggwagh, A. A., Zekraoui, A., Abidi, K., & Abouqal, R. (2005).
Validation of a behavioral pain scale in critically ill, sedated, and
mechanically ventilated patients. Anesthesia Analgesia, 101(5), 1470-1476.
Ahles, T., Blanchard, E., & Ruckdeschel, J. (1983). The multidimensional nature of cancer-related pain. Pain, 17(3), 277-288.
Ambuel, B., Hamlett, K., Marx, C., & Blumer, J. (1992). Assessing distress in pediatric intensive care environments: The COMFORT scale. Journal of
Pediatric Psychology, 17(1), 95-109.
Aslan, F. E., Badir, A., & Selimen, D. (2003). How do intensive care nurses assess patients’ pain? Nursing in Critical Care, 8(2), 62-69.
Aubrun, F., Salvi, N., Coriat, P., & Riou, B. (2005). Sex and age related differences in morphine requirements for postoperative pain relief. Anesthesiology, 103(1), 156-160.
Badia-Castelló, M., Trujillano-Cabello, J., Serviá-Goixart, L., March-Llanes, J., &
Rodríguez-Pozo, A. (2006). Recall and memory after intensive care unit stay.
Development of posttraumatic stress disorder. Medicina clínica, 126(15), 561-566.
Bair, M. J., Wu, J., Damush, T. M., Sutherland, J. M., & Kroenke, K. (2008).
Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosomatic Medicine, 70(8), 890 - 897.
Benaim, J. Froger, C. Cazottes, D. Gueben, M. Porte & Desnuelle, C. et al.(2007) Use of the faces pain scale by left and right hemispheric stroke patients, Pain,
128, 52–58.
Beattie, W. S., Badner, N. H., & Choi, P. (2001). Epidural analgesia reduces
postoperative myocardial infarction: A meta-analysis. Anesthesia Analgesia
93(4), 853-858.
Bijur, P., Latimer, C., & Gallagher, E. (2003). Validation of a verbally administered
Academic Emergency Medicine(4), 39-32.
Bieri, D., Reeves, R., Champion, G., Addicoat, L. & Ziegler, J.B. (1990). The faces pain scale for the self-assessment of the severity of pain experienced by children: Development, initial validation, and preliminary investigation for ratio scale properties. Pain, 41, 39–150.
Blakely, W., & Page, G. (2001). Pathophysiology of pain in critically ill patients.
Critical care nursing clinics of North America, 13(2), 167.
Brockopp, D. Y., Downey, E., Powers, P., Vanderveer, B., Warden, S., Ryan, P., et al.
(2004). Nurses' clinical decision-making regarding the management of pain.
International Journal of Nursing Studies, 41(6), 631-636.
Brodner, G., Mertes, N., Buerkle, H., Marcus, M. A. E., & Van Aken, H. (2000). Acute pain management: Analysis, implications and consequences after prospective experience with 6349 surgical patients. European Journal of Anaesthesiology,
17(9), 566-575.
Brunier, G., Carson, G., & Harrison, D. E. (1995). What do nurses know and believe about patients with pain? Results of a hospital survey. Journal of Pain and
Symptom Management, 10(6), 436-445.
Buffum, M. D., Hutt, E., Chang, V. T., Craine, M. H., & Snow, A. L. (2007).
Cognitive impairment and pain management: Review of issues and challenges.
Journal of Rehabilitation Research and Development, 44(2), 315-329.
Carroll, K., Atkins, P., Herold, G., Mlcek, C., Shively, M., Clopton, P., et al. (1999).
Pain assessment and management in critically ill postoperative and trauma patients: A multisite study. American Journal Critical Care, 8(2), 105-117.
Carpenter J.S. & Brockopp D. (1995) Comparison of patients’ ratings and examination of nurses’ responses to pain intensity ratingscales. Cancer
Cashman, J. N., & Dolin, S. J. (2004). Respiratory and haemodynamic effects of acute postoperative pain management: Evidence from published data. British
Journal of Anaesthesia, 93(2), 212-223.
Chanques, G., Jaber, S., Barbotte, E., Violet, S., Sebbane, M., Perrigault, P. F., et al.
(2006). Impact of systematic evaluation of pain and agitation in an intensive care unit. Critical Care Medicine, 34(6), 1691-1699
Choinière, M., Melzackb, R., Girarda, N., Rondeauc, J., & Paquin, M. J. (1990).
Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries. Pain, 40(2), 143-152.
Clarke, E. B., French, B., Bilodeau, M. L., Capasso, V. C., Edwards, A., & Empoliti, J.
(1996). Pain management knowledge, attitudes and clinical practice: The impact of nurses' characteristics and education. Journal of Pain and Symptom
Management, 11(1), 18-31.
Coulling, S. (2005). Nurses' and doctors' knowledge of pain after surgery. Nursing
Stander, 19(34), 41-49.
Craig, K. D.(2006). Emotion and psychobiology. In McMahon, S. B.,&
Koltzenburg, M. Wall and Melzack's textbook of pain (5th ed. pp. 231-239).
Philadelphia : Elsevier.
De Jonghe, B., Cook, D., Appere-De-Vecchi, C., Guyatt, G., Meade, M., & Outin, H.
(2000). Using and understanding sedation scoring systems: A systematic review. Intensive Care Medicine, 26(3), 275-285.
Devlin, J., Boleski, G., Mlynarek, M., Nerenz, D., Peterson, E., Jankowski, M., et al.
(1999). Motor activity assessment scale: A valid and reliable sedation scale for use with mechanically ventilated patients in an adult surgical intensive care unit. Critical Care Medicine, 27(7), 1271.
in hospitalized patients. Journal of Pain and Symptom Management, 17(6), 434-440.
Eid, T., & Bucknall, T. (2008). Documenting and implementing evidence based post-operative pain management in older patients with hip fractures. Journal
of Orthopaedic Nursing, 12, 90-98.
Erkes, E. B., Parker, V. G., Carr, R. L., & Mayo, R. M. (2001). An examination of critical care nurses' knowledge and attitudes regarding pain management in hospitalized patients. Pain Management Nursing, 2(2), 47-53.
Ferguson, J., Gilroy, D., & Puntillo, K. A. (1997). Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Australian intensive care unit. Journal of Advanced Nursing, 26(6), 1065-1072.
Gelinas, C., Harel, F., Fillion, L., Puntillo, K. A., Johnston, C. C. (2009). Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. Journal Pain Symptom and
Management, 37(1), 58-67.
Ge´linas, C. ,Fillion, L., & Puntillo, K. A. (2008). Item selection and content validity of the critical-care pain observation tool for non-verbal adults. Journal of
Advanced Nursing, 65(1), 203-216.
Gelinas, C., Fillion, L., Puntillo, K., Viens, C., & Fortier, M. (2006). Validation of the critical-care pain observation tool in adult patients. American Journal of
Critical Care, 15(4), 420.
Gélinas, C., Viens, M. F. C., Fillion, L., & Puntillo, K. (2004). Pain assessment and management in critically ill intubated patients: A retrospective study.
American Journal of Critical Care, 13, 126-135.
Hall-Lord, M. L., Larsson, G., & Steen, B. (1998). Pain and distress among elderly
assessments. Heart & Lung: Journal of Acute & Critical Care.
27(2), 123-132.
Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., et al.
(2006). Pain Assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44-52.
Herr, K.A., & Mobily, P. R.(1991) Comparison of selected pain assessment tools for use to elderly. Applied nursing research, 6(1), 39-46.
Hulley, SB, & Cummings, SR (Eds.).(1988). Designing Clinical Research. Baltimore, MD: Williams & Wilkins.
Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. (2002).
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30(1), 119-141.
Kim, E. J.,& Buschmann, M. T.(2006). Reliability and validity of the faces pain scale with older adults. International Journal of Nursing Studies, 43(3), 447-456.
Kehlet, H., & Holte, K. (2001). Effect of postoperative analgesia on surgical outcome.
British Journal of Anaesthesia, 87(1), 62-72.
Labus, J. S., Keefe, F. J., & Jensen, M. P. (2003). Self-reports of pain intensity and direct observations of pain behavior: When are they correlated? Pain, 102(1-2), 109-124.
Lebovits, A. H., Florence, I., Bathina, R., Hunko, V., Fox, M. T., & Bramble, C. Y.
(1997). Pain knowledge and attitudes of healthcare providers: Practice characteristic differences. The Clinical Journal of Pain, 13(3), 237-243.
Li, D., Puntillo, K., & Miaskowski, C. (2008). A review of objective pain measures for use with critical care adult patients unable to self-report. The Journal of
Pain, 9(1), 2-10.
management: Novel concepts. Current Opinion in Critical Care, 11(4), 295-299.
Lynn, M. R. (1986). Determination and quantification of content validity. Nursing
Research, 35(6). 382-385.
Mann, E., & Carr, E. (2007). Pain Management (essential Clinical Skills For Nurses).
New Jersey, NJ: Blackwell.
Mateo, O., & Krenzischek, D. (1992). A pilot study to assess the relationship between behavioral manifestations and self-report of pain in post anesthesia care unit patients. Journal of Post Anesthesia Nursing, 7(1), 15-21.
McCaffery, M., Ferrell, B. R., & Pasero, C. (2000). Nurses' personal opinions about patients' pain and their effect on recorded assessments and titration of opioid doses. Pain Management Nursing, 1(3), 79-87.
McCaffrey, M., & Ferrell, B. R. (1997). Nurses' knowledge of pain assessment and management: How much progress have we made. Journal of Pain and
Symptom Management, 14(3), 175-188.
McCall, M., Jeejeebhoy, K., Pencharz, P., & Moulton, R. (2003). Effect of
neuromuscular blockade on energy expenditure in patients with severe head injury. Journal of Parenteral and Enteral Nutrition, 27(1), 27.
McWilliams, L. A., Goodwin, R. D., & Cox, B. J. (2004). Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain, 111(1-2), 77-83.
Michaelene, P. J. (2008). Pain in older adult. In Michaelene P. J.(Ed.), Management
Pain in The Older Adult (pp.3-13). New York: Springer.
Milgrom, L. B., Brooks, J. A., Qi, R., Bunnell, K., Wuestefeld, S., & Beckman, D.
(2004). Pain levels experienced with activities after cardiac surgery. American
Mularski, R., Heine, C., Osborne, M., Ganzini, L., & Curtis, J. (2005). Quality of dying in the ICU: Ratings by family members. Chest, 128(1), 280-287.
Murray, M., Cowen, J., DeBlock, H., Erstad, B., Gray Jr., A., Tescher, A., et al. (2002).
Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Critical Care Medicine, 30(1), 142-156.
Nelson, J., Meier, D., Oei, E., Nierman, D., Senzel, R., Manfredi, P., et al. (2001).
Self-reported symptom experience of critically ill cancer patients receiving intensive care. Critical Care Medicine, 29(2), 277-282.
Odhner, M., Wegman, D., Freeland, N., Steinmetz, A., & Ingersoll, G. (2003).
Assessing pain control in nonverbal critically ill adults. Dimensions of Critical
Care Nursing, 22(6), 260-267.
Paice, J. A., & Cohen, F. L. (1997). Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nursing, 20(2), 88-93.
Payen, J., Bru, O., Bosson, J., Lagrasta, A., Novel, E., Deschaux, I., et al. (2001).
Assessing pain in critically ill sedated patients by using a behavioral pain scale.
Critical Care Medicine, 29(12), 2258-2263.
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods.
Philadelphis: Lippincott.
Prkachin, K. M. (1992). The consistency of facial expressions of pain: A comparison across modalities. Pain, 51(3), 297-306.
Prkachin, K. M., Hughes, E., Schultz, I., Joy, P., & Hunt, D. (2002). Real-time assessment of pain behavior during clinical assessment of low back pain patients. Pain, 95(1-2), 23-30.
Puntillo, K. (1988). The phenomenon of pain and critical care nursing. Heart & Lung:
The Journal of Critical Care, 17(3), 262.
critically ill surgical patients. American Jounial of Critical Care, 3(2), 116-122.
Puntillo, K., White, C., Morris, A., Perdue, S., Stanik-Hutt, J., Thompson, C., et al.
(2001). Patients' perceptions and responses to procedural pain: Results from Thunder Project II. American Journal of Critical Care, 10(4), 238-251.
Puntillo, K. A. (1990). Pain experiences of intensive care unit patients. Heart & Lung,
19(5), 526-533.
Puntillo, K. A., Miaskowski, C., Kehrle, K., Stannard, D., Gleeson, S., & Nye, P.
(1997). Relationship between behavioral and physiological indicators of pain, critical care patients' self-reports of pain, and opioid administration. Critical
Care Medicine, 25(7), 1159-1166.
Puntillo, K. A., Morris, A. B., Thompson, C. L., Stanik-Hut, J., White, C. A., & Wild, L. R. (2004). Pain behaviors observed during six common procedures: Results from Thunder Project II. Critical Care Medicine 32(2), 421-427.
Robinson, M. E., & Wise, E. A. (2003). Gender bias in the observation of experimental pain. Pain, 104(1-2), 259-264.
Rodgers, A., Walker, N., Schug, S., McKee, A., Kehlet, H., van Zundert, A., et al.
(2000). Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised. British Medicine
Journal, 321(7275), 1493-1496.
Rosenfeld, B. A., Faraday, N., Campbell, D., Dise, K., Bell, W., & Goldschmidt, P.
(1994). Hemostatic effects of stress hormone infusion. Anesthesiology, 81(5), 1116-1126.
Rotondi, A., Chelluri, L., Sirio, C., Mendelsohn, A., Schulz, R., Belle, S., et al. (2002).
Patients' recollections of stressful experiences while receiving prolonged
746-752.
Rotondi, A. J., Chelluri, L., Sirio, C., Mendelsohn, A., Schulz, R., Belle, S., et al.
(2002). Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. Critical Care
Medicine, 30(4), 746-752.
Sabatowski, R., Schafer, D., Kasper, S., Brunsch, H., & Radbruch, L. (2004). Pain treatment: A historical overview. Current Pharmaceutical Design, 10(7), 701-716.
Sarantopoulos, C., (2006). Pain pathway and mechanisms. In Abram, S. E., (Ed.), Pain medicine: The requisites in anesthesiology(pp. 1-9). Philadelphia:
Mosby/Elsevier.
Schelling, G., Richter, M., Roozendaal, B., Rothenhusler, H.-B., Krauseneck, T., Stoll, C., et al. (2003). Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery.
Critical Care Medicine, 31(7), 1971-1980.
Schulte-Tamburen, A., Scheier, J., Briegel, J., Schwender, D., & Peter, K. (1999).
Comparison of five sedation scoring systems by means of auditory evoked potentials. Intensive Care Medicine, 25(4), 377-382.
Shannon, K., & Bucknall, T. (2003). Pain assessment in critical care: What have we learnt from research. Intensive and Critical Care Nursing, 19, 154-162.
Siffleet, J., Young, J., Nikoletti, S., & Shaw, T. (2007). Patients' self-report of
procedural pain in the intensive care unit. Journal of Clinical Nursing, 16(11), 2142-2148.
Soh, K., Soh, K., Ahmad, Z., Raman, R., & Japar, S. (2008). Perception of intensive care unit stressors by patients in Malaysian federal territory hospitals.
Spacek, A. (2006). Modern concepts of acute and chronic pain management.
Biomedecine & Pharmacotherapy, 60(7), 329-335.
Sydow, M., & Neumann, P. (1999). Sedation for the critically ill. Intensive Care
Medicine, 25(6), 634-636.
The American Pain Society. (2003). Principle of Analgesic Use in the Treatment of
Acute Pain and Cancer Pain (5th ed.), Glenview: IL.
Terai, T., Yukioka, H., & Asada, A. (1998). Pain evaluation in the intensive care unit:
observer-reported faces scale compared with self-reported visual analog scale.
Regional Anesthesia and Pain Medicine, 23(2), 147-151.
Valdix, S. W., & Puntillo, K. A. (1995). Pain, pain relief and accuracy of their recall after cardiac surgery. Progress in Cardiovascular Nursing, 10(3), 3-11.
Von Roenn, J. H., Cleeland, C. S., Gonin, R., Hatfield, A. K., & Pandya, K. J. (1993).
Physician attitudes and practice in cancer pain management: A survey from the eastern cooperative oncology group. Annals of Internal Medicine, 119(2), 121-126.
Watt-Watson, J., Stevens, B., Garfinkel, P., Streiner, D., & Gallop, R. (2002).
Relationship between nurses' pain knowledge and pain management outcomes for their postoperative cardiac patients. Journal of Advanced Nursing, 36(4), 535 - 545.
Webb M., & Kennedy M. (1994). Behavioral responses and self reported pain in postoperative patients. Journal of post anesthesia nursing, 9, 91-95.
Young, J., Siffleet, J., Nikoletti, S., & Shaw, T. (2006). Use of a behavioural pain scale to assess pain in ventilated, unconscious and/or sedated patients.
Intensive Critical Care Nursing, 22(1), 32-39.
Zalon, M. L. (1993). Nurses' assessment of postoperative patients' pain. Pain, 54(3),
附錄一 重症照護疼痛觀察工具原作者書面同意書
LETTER OF AGREEMENT
This is a letter of agreement between the author Céline Gélinas who developed the Critical-Care Pain Observation Tool (CPOT), and Huei- Jiun, Chen who wish to use the CPOT for clinical or research purposes. By signing this letter of agreement the author Céline Gélinas gives permission to Huei- Jiun, Chen to use the CPOT for clinical or research purposes.To obtain permission to use the CPOT, Huei- Jiun, Chen commits to clearly identify the CPOT’s source in the text and in the reference list of any document naming the CPOT as follows:
Gélinas, C., Fillion, L., Puntillo, K. A., Viens, C., & Fortier, M. (2006). Validation of the Critical-Care Pain Observation Tool in adult patients. American Journal of Critical Care, 15 (4), 420-427.
Any reproduction of the description of the CPOT (Gélinas et al., 2006, Table 1, p.421) in a manuscript to be published will require permission from the American Journal of Critical Care (see http:/ /ajcc.aacnjournals.org/).
By signing this letter of agreement, Huei- Jiun, Chen also commits to share results from his or her research or from trial in clinical practice with the author Céline Gélinas and to inform her of the journal in which results will be published.
This agreement should not be deemed as a copyright transfer.
Signatures:
Montreal (Quebec) Canada, July 21, 2009: Taichung, Taiwan ROC, July 31, 2009
________________________________________________
(signature)
Céline Gélinas, RN, PhD
Assistant Professor School of Nursing McGill University 3506, University Street, Wilson Hall, Room 420
Montreal, Quebec H3A 2A7, Canada
Huei- Jiun, Chen
Address
School of Nursing China Medical University, 91 Hsush- shuh Rd. Taichung, 40402, Taiwan R.O.C
Fax: (514) 398-8455
To complete if the CPOT is used for a research purpose :
Validation of any newly developed tool like the CPOT is a long process. Any research using the CPOT could include interesting data which may result in some modifications in the CPOT in order to improve its content for better patient’s pain assessment in the non-verbal critically ill population. By sharing your research data, the CPOT could be revised or modified, and the validation could be enhanced.
By accepting to share your data, the author Céline Gélinas commits to clearly identify the source of the data in any published document.
Refusing to share your data doesn’t interfere with the permission for you to use the CPOT as agreed above.
附錄二 英文版重症照護疼痛觀察工具
Indicator Score Description
Relaxed, neutral 0 No muscle tension observed
Tense 1 Presence of frowning, brow lowering, orbit tightening and levator contraction
or any other change (e.g. opening eyes or tearing during nociceptive procedures)
Facial expression
Grimacing 2 All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube) Absence of movements 0
or normal position
Does not move at all (doesn’t necessarily mean absence of pain) or normal position
(movements not aimed toward the pain site or not made for the purpose of protection) Protection 1 Slow, cautious movements, touching or rubbing
the pain site, seeking attention through movements
Body movements
(Puntillo et al., 1997 ; Devlin et al., 1999)
Restlessness 2 Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Tolerating ventilator or movement
Restlessness 2 Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Tolerating ventilator or movement