臺灣博碩士論文加值系統

本研究的目的在探討寧握護理於早產兒接受侵入性治療後，對體重，心跳，呼吸次數，血氧濃度變化影響。採類實驗性設計，以北部某區域教學醫院新生兒加護病房之早產兒為研究對象，立意取樣符合收案條件者。將研究對象分為控制組與實驗組。控制組15位，依加護病房常規護理照護模式提供照護，實驗組16位，除提供常規性照護外，並於每次接受侵入性治療後，給予寧握護理措施。所得資料以描述性統計，平均數，95％信賴區間，卡方檢定，t檢定，Wilcoxon Signed Ranks Test、repeated measures進行統計分析。
研究結果顯示：（一）體重方面：收案時，控制組比實驗組平均體重重239公克，但實驗組至研究第5天，體重即呈現穩定成長，控制組至第8天才趨於平穩。到第18天，實驗組之平均體重曲線圖斜率已超過控制組。（二）在照護活動次數方面：最頻繁照護活動依序為抽痰，腳跟採血，裝置鼻胃管，經皮中央靜脈導管（PCVC）。（三）對心跳次數影響：1.無論是抽痰，腳跟採血，裝置鼻胃管或是PCVC，對心跳的影響其速率皆會增加。其中以PCVC及腳跟採血影響最甚，其次是裝置鼻胃管與抽痰。2.在抽痰治療後，實驗組較控制組在心跳影響變異性小。3.接受腳跟採血治療，實驗組於腳跟採血後第9分鐘心跳趨於平穩，控制組則至第16分鐘才穩定，因此，實驗組回復基準值的時間比控制組快。（四）對呼吸次數影響：1.裝置鼻胃管與腳跟採血，PCVC及抽痰在呼吸次數影響上，皆達到統計上顯著差異。2.在PCVC、採腳跟血、抽痰皆會使呼吸下降，而裝置鼻胃管會使呼吸速率增加。3.實驗組在接受腳跟採血治療後呼吸次數達统計上顯著差異。（五）對血氧濃度之影響：1.在侵入性治療後，血氧濃度會明顯降低，影響程度以裝置鼻胃管最小，其次為腳跟採血，之後是PCVC，而抽痰影響最大。2.在抽痰治療後，血氧濃度控制組比實驗組低，變異性大，各時間變化皆達統計上顯著差異。3.腳跟採血實驗組較控制組平均值為高，且實驗組在扎針後第8分鐘即恢復採血前之血氧濃度，而控制組至扎針後第16分鐘才恢復。4.在PCVC侵入性治療實驗組並無明顯變化，而控制組血氧濃度下降至88％，治療後第11分鐘，血氧濃度才恢復平穩。變異數分析中，顯示控制組與實驗組交互作用達顯著水準。
整體而言，寧握護理可以達到穩定生理性的反應，特別是在血氧濃度的變化。同時，寧握護理提供一個簡單，無須醫囑，護理人員可獨立執行的一項非侵入性照護活動，不僅發揮護理獨特功能，亦能在加護病房之早產兒在最不穩定情況下，以維持生理上穩定，達到改善護理品質的目的。

The purpose of this research is to study Containment affect on those taken Invasive Treatment premature infant, the affects including baby weight, heart beat, frequency of taking breath, SpaO2. The experiment was taken premature infant of one local hospital in the north of Taiwan. The experimental cases were been set in two groups one was called Control group the other one called Experimental group. Control group has 15 people and follow the regular procedure of nursing, The experimental group has 16 people beside the regular nursing procedure taking, but also, taking Invasive Treatment like suction, heel stick,Percutaneous Central Venous Catheter(PCV),on-nasogastric tube etc. All data were analyzed using: Descriptive Statistics, Mean, 95% confidence interval, chi-square, t-tes, Wilcoxon signed-ranks test,repeated measures statistics analysis。
The research results indicate : 1.Body Weight：at beginning of data collect the body weight of premature infant of control group compare to experiment group was heavier around 239g in average, however, the experiment group at 5th day their weight show steady increase rate ,but the control group show steady increase rate after 8th day, more interesting data show on 18th day the experimental group their slew rate of average weight curve is higher than control group.2.Nursing activities count: The most often nursing activities taken is suction, coming next is heel stick, and then on-nasogastric tube installed, coming last is PCVC.3.Heart beat: (1) No matter what suction，heel stick，on-nasogastric tube installed or PCVC, they all will increase the heart beat pulse rate. Among that PCVC and heel stick are mostly affect, and then on-nasogastric tube installed and suction.(2) After taking suction treatment, the experimental group their heart beat pulse change rate is small than control group.(3) for the data of heel stick affect on heart beat the experimental group their average heart beat pulse get in stable at 9th minutes, but control group get in stable till 16th minutes, so that, with containment treatment experimental group they get stable more quickly. 4.Breath taking times : (1)On-nasogastric tube installed, heel stick, PCVC and suction relation to breath taking times, they all meet the statistically significant difference.(2) Invasive treatment taken like PCVC, heel stick and suction they all caused breath taking times slow down, but On-nasogastric tube installed will increase the rate of breath taking。(3) with containment experimental group after taking the heel stick their breath taking time figure are meet statistically significant. 5. SpaO2:(1)After taking invasive treatment ,the SpaO2 will drop obviously, their are ranking from suction, PCVC, heel stick then on-nasogastric tube.(2) during taking the suction no matter what control group or experimental group their blood oxygen rate will drop but control group is lower than experimental group, with bigger difference vs. time scale their difference was significant.(3) heel stick, experimental group its average blood oxygen value is higher than control group, with containment treatment heel stick experimental group, their heel oxygen come back to before punched level at 8th minutes ,but control group come back to original level after 16th minutes .(4)For PCVC with containment its blood oxygen does not much change in experimental group, But control group its blood oxygen drop down to 88％, After execute PCVC invasive treatment till 11th minutes its blood oxygen come back stable, indicate control group and experimental group cross reacted to meet statistically significant.
In general to say, containment taken can help to reach stable physical reaction, especially on blood oxygen. In the mean time, containment provide a simple way, without doctor instruction, nurses can taking their own to execute the invasive treatment or nursing, not only devote nursing unique function but also provide nursing quality and keep physiology stable at the condition of premature infant at intensive care unique in unstable condition.

目 錄
頁次
目 錄----------------------------------------------------------------------------- I
表 次----------------------------------------------------------------------------IV
圖 次---------------------------------------------------------------------------VII
摘 要------------------------------------------------------------------------- VIII

第壹章 緒論---------------------------------------------------------- 01
第一節 研究動機與重要性------------------------------------------ 01
第二節 研究目的------------------------------------------------------ 03
第三節 研究問題------------------------------------------------------ 04
第四節 研究流程------------------------------------------------------ 04
第五節 研究假設------------------------------------------------------ 04
第六節 名詞界定------------------------------------------------------ 05

第貳章 文獻探討---------------------------------------------------- 08
第一節 Apgar scoring評分系統-------------------------------------08
第二節 早產兒生理與病理-------------------------------------------09
第三節 侵入性治療對早產兒影響相關研究----------------------12
第四節 寧握護理之應用----------------------------------------------13

第叁章 研究方法-----------------------------------------------------17
第一節 概念架構-------------------------------------------------------17
第二節 研究設計-------------------------------------------------------18
第三節 研究對象及場所----------------------------------------------18
第四節 研究工具-------------------------------------------------------19
第五節 研究步驟-------------------------------------------------------20
第六節 資料分析-------------------------------------------------------21
第七節 研究倫理考量-------------------------------------------------21

第肆章 研究結果-----------------------------------------------------23
第一節 研究對象基本資料屬性-------------------------------------23
第二節 研究期間一般狀況分析-------------------------------------26
第三節 早產兒接受侵入性治療生理反應-------------------------27
第四節 寧握護理措施介入對早產兒接受侵入性治療後體重，
心跳次數，呼吸次數與血氧濃度之影響----------------34
第五節 不同侵入性治療對早產兒其生理性心跳次數，呼吸
次數，血氧濃度影響----------------------------------------57

第伍章 討論-----------------------------------------------------------64
第一節 寧握護理措施的介入對早產兒接受侵入性治療體重
增加之效--------------------------------------------------------64
第二節 寧握護理措施的介入對早產兒奶量攝取之影響--------65
第三節 寧握護理措施的介入對早產兒接受侵入性治療心跳次 數之影響--------------------------------------------------------65
第四節 寧握護理措施的介入對早產兒接受侵入性治療呼吸次 數之影響--------------------------------------------------------67
第五節 寧握護理措施的介入對早產兒接受侵入性治療血氧濃度之影響--------------------------------------------------------67

第陸章 結論與建議--------------------------------------------------69
第一節 結論-------------------------------------------------------------69
第二節 護理上運用----------------------------------------------------70
第三節 研究限制及建議----------------------------------------------71
參考文獻----------------------------------------------------------72
中文部分-------------------------------------------------------------------------72
英文部分-------------------------------------------------------------------------74

附錄：
一、 早產兒抽痰技術作業標準
二、 腳跟血抽血作業標準
三、 早產兒裝置鼻胃管作業標準
四、 早產兒寧握護理操作標準
五、 早產兒侵入性治療後寧握護理措施紀錄量表
六、 早產兒測量體重操作標準
七、 研究計劃同意書

附表：
一、抽痰－平均心跳次數變化表
二、抽痰－平均呼吸次數變化表
三、抽痰－平均血氧濃度變化表
四、腳跟採血－平均心跳次數變化表
五、腳跟採血－平均呼吸次數變化表
六、腳跟採血－平均血氧濃度變化表
七、PCVC－平均心跳次數變化表
八、PCVC－平均呼吸次數變化表
九、PCVC－平均血氧濃度變化表
十、裝置鼻胃管－平均心跳次數變化表
十一、裝置鼻胃管－平均呼吸次數變化表
十二、裝置鼻胃管－平均血氧濃度變化表

参考文獻
一、中文部份
王國恭（2001）．早產兒發生的原因與預防．於楊育正校閱，他很小他是我寶貝（五版，6-10頁）．台北：財團法人早產兒基金會。
王俊禾、鄭玫枝（2005，12月）．早產兒常見的合併症．2005年12月19日取自http://www.vghtpe.gov.tw/ped/new_page_84.htm
林其和（2003，12）．早產兒成長與營養．2005年12月19日取自http://140.116.58.191/chinese/neonate/homecare_02.htm
周利娜（2000）．兒童胸腔技術抽痰法．於張淑文等合著，產兒科護理技術（初版，266-269頁）．台北：匯華出版社。
洪漢陽（1999）． 壞死性腸炎．於洪漢陽主編，臨床新生兒科學（三版，573-580頁）．台北：嘉洲出版社。
洪漢陽（1999）．新生嬰兒的檢查、生理特徵與護理．於洪漢陽主編，臨床新生兒科學（第三版，48-49頁）．台北：嘉洲出版社。
洪漢陽（2001）．早產兒出生一週以後所遭遇的問題．他很小他是我寶貝（五版，24-27頁）．台北：早產兒基金會。
徐麗華（1995）．早產兒護理面面觀．護理雜誌，42（3），37-42。
陳銘仁（1999）．開放性動脈導管．於洪漢陽主編，臨床新生兒科學（三版，272-276頁）．台北：嘉洲出版社。
陳美津（1996）．加護病房新生兒之感覺刺激．護理新象，6（3），16-27。
陳永娟、 張和美、陳昭惠（2005）．新生兒個別化發展性照護之應用．榮總護理，22（2），204-210。
張淑文（2000）．新生兒腳跟採血法．於張淑文等合著，產兒科護理技術（初版，163-165頁）．台北：匯華出版社。
梁幸如（1999）．寧握護理對早產兒扎足跟血疼痛減輕之成效探討．未發表的碩士論文．台北：國防大學國防醫學院護理研究所。
黃惠滿（2002）．觸摸對早產兒抽痰後生理指標影響之探討．未發表
的碩士論文．台北：國防大學國防醫學院護理研究所。
葉為釗、楊黛芬（2002）．協助插入鼻胃管照護標準．於張澤芸總編，早產兒照護標準護理手冊（初版，74-77頁）台北：馬偕紀念醫院。
葉為釗、楊黛芬（2002）．沐浴照護標準．於張澤芸總編，早產兒照護標準護理手冊（初版，34頁）台北：馬偕紀念醫院。
彭鑲慧（1999）．早產兒發展性照護．台北：合記圖書出版社。
彭純芝、洪漢陽（1999）．呼吸窘迫症候群．於洪漢陽主編，臨床新生兒科學（三版，119-132頁）．台北：嘉洲出版社。
劉小瑜（1999）．早產兒的開放性動脈導管．於洪漢陽主編，臨床新生兒科學（三版，316-325頁）． 台北：嘉洲出版社。
潘依林、黃淑英、陳珮臻（2002）．發展照護．於張澤芸總編，早產兒照護標準護理手冊（初版，158-159頁）台北：馬偕紀念醫院。
滕儒錚（2001）．台灣地區早產兒發生率與存活率．於楊育正校閱，
他很小他是我寶貝（五版，12-13頁）．台北：財團法人早產兒基
金會。
蘇益美（2003）．什麼是早產．於王國恭校閱，早產防治教戰手冊（初版，1-2 頁）．台北：馬偕紀念醫院。








二、英文部分
Als, H., (1986). A synactive model of neonatal behavioral organization： Framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment. Physical ＆ Occupational Therapy in Pediatrics, 6(3), 3-55.
Anand, K. J. S. (2001). Consensus statement for the prevention and management of pain in the newborn. Arch Pediatrics & Adolescent Medicine, 155(2), 173-180.
Brazelton, T. B. (1983). Precursors for the development of emotions in early infancy. In R. Plutchik and H. Kellerman (Eds), Emotion : Theory research and experience, vol. 2 (pp.35~55). New York : Academic Press.
Barnes, C. A. and Kichhoff, K. T. (1986). Minimising hypoxaemia due to endotracheal suctioning：a review of the literature. Heart and Lung：The Journal of Critical Care, 15(2), 164-177.
Campos, R. G. (1989). Smoothing pain-elicited distess in infants with swadding and pacifier. Child Development, 60(4), 781-792.
Casey, B. M., McIntire, D. D. and Leveno, K. J. (2000). The Continuing Value of Apgar Score for the Assessment of Newborn Infants. New England Journal of Medicine 344(2), 467-471.
Cordero, L. and Hon, E. H. (1971). Neonatal bradycardia following nasopharyngeal stimulation. The Journal of Pediatrics, 78(3), 41-447.
Cooper, E. J. (1991). Incidence of hypoxaemia associated with caregiving in premature infants. Neonatal Netword , 10(2), 17-24.
Cordero, L. and Hon, H. E. (1971). Neonatal bradycardia following nasopharyngeal stimulation. The Journal of Pediatrics 78(3), 441-447
Craig, K. D., Whitfield, M. F., Grunau, R. V. E., Linton, J., and Hadjistavropoulos, H. (1993). Pain in the preterm neonate : behavioral and physiological indices. Pain 52, 287-300.
Dieter, J. N. I., and Emory, E. K. (1997). Supplemental stimulation of premature infants: A treatment mold. Journal of Pediatric Psychology 22(3), 281-295.
Ellison, R. C., (1983). Evaluation of the preterm infant for patent ductus arterios. Pediatrics, 71, 364.
Evans, J. C. (1992). Reducing the hypoxemia bradycardia, and apnea associated with suctioning in low birthweight infants. Journal of Perinatology, 12, (2), 137-142.
Fanconi, S. and Duc, G. (1987). Intratracheal suctioning in sick preterm infants：prevention of intracracial hypertension and cerebral hypoperfusion by muscle paralysis, Pediatrics, 79(4), 538-543
Gorski, P. A. , Hale, W. and Leonard, C. (1983). Direct computer recording of premature infants and nursing care：distress following two intervention. Pediatrics, 72, 198.
Gardner Cole, J. G., Begish-Duddy, A. , Judas, M. L. and Jorgensen, K. M.(1990). Changing the NICU environment：the Boston City Hospital model. Neonatal Network , 9(2), 15-23.
Harrison, L. L., Leeper, J. D., and Yoon, M, (1990). Effects if early parent touch on preterm infants' heart rates and arterial oxygen saturation levels. Journal Advanced Nursing , 15(8), 877-885.
Huang, C. M., Tung, W.S., Kuo, L.L. and Chang. Y.J. (2004). Comparison of Pain Response Between Containment and Swaddling . Journal of Nursing Research , 12(1),31-40.
Johnston, C. C., Stevens, B., Yang, F., and Horton, L. (1996). Development changes in response to heel stick in preterm infants : a prospective cohort study. Development Medicine and Child Neurology, 38, 438-445.
Jorgensen, K. M. (1993). Developmental Care of the Premature Infant: A Concise Overview.S.Weymouth, USA: Developmental Care Division of Children’s Medical Ventures.
Kraybill, E. N. (1989). Risk factors for chronic lung disease in infants with birth weight of 751 to 1000 grams. Journal of pediatr 115.
McIntosh, N., Veen, L. V., and Brameyer, H. (1993). The pain off heel prick and its measurement in preterm infants. Pain 52, 71- 74.
Murdoch, D. R. and Darlow, B. A. (1984). Handing during neonatal intensive care. Archives of Disease in Childhood, 59, 957-961.
Norris, S., Campbell, and Brenkert, S. (1982). Nursing Procedures and alterations in transcutaneous oxygen tension in preterm infants. Nursing Research, 31(6), 330-336
Oehler, J. M. (1993). Developmental care of low birth weight infants. Nursing Chnics of North America , 28(2), 289-301.
Oehler, J. M ., Strictland , M. and Nordlund, C. (1991). Beyond technology：meeting developmental needs of infants in NICUsMCN；American Journal of Maternal Child Nursing, 16(3), 148-151.
Peters, K. L. (1992). Does routine nursing care complicate the physiologic status of the premature neonate with respiratory disease sysdrome？Journal of Perinatal-Neonatal Nursing, 6(2), 67-84.
Perlman, J. M. and Volpe, J. J. (1983). Suctioning in the preterm infant：effects on cerebral Blood flow velocity, intracranial pressure and arterial blood pressure. Pediatrics, 72(3), 329-334.
Sizun, J. and Westrup, B. (2004). Early developmental care for preterm neonates: a call for more research . Archive Disease of Child Fetal Neonatal, 89, 384–389
Stevens, B., Johnson, C. C. and Horton, L. (1994). Factors that influence the behavioral pain responses of premature infants. Pain, 59, 101-109.
Stevens, B., Johnson, C. C., Petryshen, P., and Taddio, A. (1996). Premature infant pain profile: development and initial validation. Clinical Journal of Pain, 12, 13-22.
Speidel, B. D. (1978). Adverse effects of routine procedures on preterm infants. Lancet, 1, 864-866
Tucker, Catlett, A. and Holditch-Davis, D. (1990). Environmental stimulation of the acutely ill preterm infant：physiological effects and nursing implications. Neonatal Network , 8 (6), 19-25.
Taquino, L., and Blackburn, S. (1994). The effects of containment during suctioning and heelstick on physiological and behavioral responses of preterm infants. Neonatal Network , 13(7) , 55.
Wolke, D. (1987). Environmental neonatology. Archives of Disease in Childhood, 62, 987-988.
White-Traut, R. C., Nelosn, M. N., and Silvestri, J. M. (1997). Responses of preterm infants to unimodal and multimodal sensory intervention. Pediatric Nursing, 23