第五章 討論
第二節 研究限制
本研究的限制有四：一、缺乏前測；二、僅對生理指標作觀察無法全 面了解包裹對早產兒能量保存的效益；三、無法完全控制臨床的研究情境；
四、樣本數較少；分別敘述如下：
一、缺乏前測
本實驗屬兩組後測設計，在抽痰前 5 分鐘就執行包裹，缺乏前測造成 沒有包裹前的生理指標作介入前後的比較，若能加上包裹前 5 分鐘的生理 指標當前測，在研究設計上會更完美；但臨床上，抽痰屬較急迫的措施，
有時間上的限制，此外要控制前測均無任何護理措施的干擾，在繁忙的加 護單位在執行上較困難。
二、僅對生理指標作觀察無法全面了解包裹對早產兒能量保存的效 益：由於人力與經費的限制無法作行為指標的觀察，如抽痰時早產兒臉部 的表情與動作等，且包裹對早產兒抽痰措施的影響，以心跳指標來當做能 量保存的效益評估，只能看出立即性的影響，可能不够客觀；若能加上長 期的能量保存指標如早產兒體重增加的情形與發展預後，可能更具說服力。
三、無法完全控制臨床的研究情境：因收案時間較久，護理人員見包 裹的確讓早產兒比較舒適，抽痰過程較順利，在研究進行期間已逐漸採用，
理人員已經有了寧握的概念，當沒有包裹的早產兒出現四肢揮動時，會以 寧握或給予棉花棒吸吮來安撫早產兒，研究者在倫理衝突與研究設計嚴謹 度的矛盾中掙扎，最後仍決定不阻止適度的寧握及吸吮安撫，臨床的研究 情境受到污染，會影響包裹措施的介入效果。
四、樣本數較少
本研究因收案時間的壓力及收案條件的限制下，樣本數只有17 個，可 能無法看出介入的真正效果。
比較樣本估算與本研究中實際收集生理指的標準差和平均數資料發 現 ，推估的標準差比本研究實際結果的標準差數值小，即本研究資料的離 散程度較大，如心跳、血壓等指標；而實驗組與對照組生理指標的平均數 差距較推估的小，當樣本離散程度較大，兩組的平均數差距較小時，所需 的樣本數較大。
王(1997)以寧握護理作為抽痰後的安撫措施，個案數為 12 個，其研究 除了個案數較少之外，執行方法上其介入措施於抽痰後才執行，以及選擇 血氧濃度為指標等因素，因此無足夠證據顯示寧握護理對早產兒抽痰後的 血氧濃度有幫助；而 Chou 等(2000)比較音樂治療對接受抽痰護理之早產兒 其生理指標之影響之研究，收集 30 個樣本；黃(2002)探討抽痰後提供有計
劃性的皮膚觸摸對其生理指標之影響，樣本數為30；Ward-Larson 等( 2004) 比較寧握與否對低體重兒氣管內管抽痰時的止痛效果，收了 40 位個案，後 三篇均呈現統計上顯著的差異，因此樣本數愈大，檢力愈大。
第三節 應用與建議
根據研究之結果與發現，就護理實務與研究的應用與建議說明如下：
一、護理實務方面：
包裹雖不能使早產兒在抽痰過程的生理指標較為穩定，但是仍可使早 產兒的心跳較為平緩而促進能量獲得保存，又可以使抽痰過程較為順利並 且節省人力，因此建議包裹措施仍可應用於早產兒的抽痰過程。
二、護理研究方面：
本研究僅以心跳速率及 Chessex, et al.(1981)的能量消耗公式來估計能
量保存，未來應以更客觀的方式，如用耗氧量、活動度及行為狀態等指標 來檢測能量保存的具體成效；此外，以包裹介入措施來促進早產兒能量的 保存，只驗證「李文能量保存護理模式」之一部份，將來應設計或發展其 他的介入措施來驗證其他的保存原則如結構完整性保存、個人完整性保 存、社會完整性保存等，使早產兒照護的理論、研究和實務能相互配合，也因為以實證為基礎的臨床照護使早產兒能有更好的發展與預後。
每一個嬰兒只有一個腦部,每件事情都會有影響
每個嬰兒都有父母,是父母最珍愛的人
每一個嬰兒都提供父母再生的機會
想像未來,你可以塑造嬰兒,你對他/她會有影響！
(Als)。
我們對早產兒的照護就如同打高爾夫球一樣，若失 之毫厘，將差之千里！(蔣，2006)。
參考資料
一、中文部份：
王銘賢、顧小明 (1997) ·寧握護理對早產兒抽痰的效益評估·榮總護理，
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吳浚明 (2005) ·序言· 於行政院衛生署國民健康局、財團法人中華民國早產 兒基金會共同印製「早產兒居家照護手冊」(p.3) ·優仕盟企業有限公司。
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附錄一 早產兒抽痰觀察記錄表 編號：
一、早產兒基本資料 觀察日期：
出生日期:__年__月__日； 入院日期:__年__月__日； on endo 日期:__年__月__ 日 放置氣管內管的天數：__天；
生產史：G:__ P:___ ；生產方式：_________；產前給藥:_________________________
侵入性措施：1( )on A-line：
APGAR score 1'：____分； APGAR score 5'：____分 出生後年齡：______（天）； 目前體重：_________ gm
二、觀察紀錄.1 1□包裹 2□未包裹
時間 抽痰活動 行為狀態 活動度 備註
備註: 行為狀態:1=深睡, 2=淺睡, 3=半睡半醒, 4=安靜清醒, 5=活動清醒, 6=哭鬧 活動度:1=活動範圍限制在臉部或頭部, 2=活動範圍限制在頸部或單一肢體, 3=兩肢體 同時活動, 4=3-4 肢體同時活動, 5=哭及全身活動
觀察紀錄.2 1□包裹 2□未包裹
時間 護理活動 行為狀態 活動度 備註
備註: 行為狀態:1=深睡, 2=淺睡, 3=半睡半醒, 4=安靜清醒, 5=活動清醒, 6=哭鬧 活動度:1=活動範圍限制在臉部或頭部, 2=活動範圍限制在頸部或單一肢體, 3=兩肢體 同時活動, 4=3-4 肢體同時活動, 5=哭及全身活動
三、觀察摘記
附錄二 抽痰技術標準
大人80-150mmHg，小孩 60-120mmHg，嬰兒 40-100mmHg。
(6)抽吸時持續壓住抽吸控制口並回抽。 (1)每次抽吸時間不可超過 15 秒，小孩以 5-8 秒
(8)將呼吸器軟管與氣管內管接頭接上。若一次未將分泌物完全抽出時，抽痰之間應待病 hyperinflation(給 3-6 次 1.5 倍的潮氣量)的適用對象要謹慎選擇，以免造成氣胸等合併症。
5.目前使用的氣管內管內囊屬於 high volume、low pressure 的 cuff，現已不用常規執行氣囊 放氣(cuff deflation)，以下情況應重新評估氣囊的空氣量：氣囊漏氣時、急救後。
6.為了預防氣囊過度充氣導致氣管咽喉損傷，氣囊壓力(cuff pressure)應維持在 20-25 mmHg(25-30 cmH2O)。
7.清水瓶應每日清洗並更換乾淨的水，病患出院或轉出應將清水瓶丟棄不重複使用。
8.抽吸引流瓶應於液面為八分滿時更換。