臺灣博碩士論文加值系統

對於譫妄發生相關因素的研究，在國外的文獻中多有著墨，但在本土的文獻中則較少被提及。本研究的目的為探討內科加護病房譫妄(ICU delirium) 的發生率及相關因素。此研究為描述性、相關性及前瞻性 (prospective) 之研究設計，依方便取樣方式選取符合收案條件的內科加護病房病人，收案期間使用加護病房混亂評估量表(Confusion Assessment Method for Intensive Care Unit；CAM-ICU ) 偵測病人，共收案102位病人，有效樣本數為96位病人。
研究結果顯示，譫妄的發生率為25%。譫妄主要發生於入住加護病房第2天(50%)，平均是第2.96天發生譫妄。譫妄持續的時間以2天為最多(25%)；其次是持續1天(20.8%)，譫妄的持續時間平均為2.31天。譫妄發生的型態以低活動型為最多(41.7%)；其次是高活動型(33.3%)。經過卡方與t檢定的單變項分析後發現，「年齡」、「Bun/Cr ratio」、「APACHEⅡ」、「管路總數」、「第1天鉀離子濃度 (D1K)」、「感染」、「約束」、「約束時間」、藥物中的「抗生素」、「心血管藥物」、「抗血小板製劑」、「非巴比妥類鎮靜安眠藥」等與譫妄的發生有相關性。此外，有譫妄的病人，其「入住加護病房天數」和「呼吸器使用時間」會越長。
期望本研究結果能做為臨床照護病人的參考，透過適當的教育訓練及適時
應用加護病房混亂評估量表 (Confusion Assessment Method
for Intensive Care Unit；CAM-ICU ) 測試病人，以能儘早偵測出病人有無譫妄的發生，並及時給予相關的醫療護理措施。亦期許未來的研究能建置一個高危的評估表，做為病人入住加護房時的篩選標準，除可在事前給予有效的早期介入措施外，也可進一步的探討早期介入措施是否能降低譫妄的發生率及相關合併症的發生，並希望譫妄的照護準則能建置於國內的加護病房常規中，進而預防譫妄的發生。

Factors associated with delirium have been widely discussed in western literature but rarely explored in Taiwan. This paper aims to discuss the occurrence rate and factors associated with ICU delirium in the department of internal medicine. This is a descriptive, correlative, and prospective study. Convenient sampling with selection criteria was conducted in a medical ICU, a total of 96 subjects was valid for analysis. The Confusion Assessment Method for Intensive Care Unit (CAM-ICU) was instrument to verify if confusion occurred.
The result showed that the occurrence rate of delirium is 25% and 50% of the delirium occurred on the second day in ICU. In average, delirium occurred on the 2.96 day in ICU. The majority (25%) of delirium lasted for two days and 20.8% of the delirium lasted for one day only. The average duration of delirium was 2.31 days. Hypoactive delirium accounted for the vast majority of the occurrence (41.7%) whereas the hyperactive delirium accounted for 33.3% only. Based on the uni-variate analysis of chi-square test and t-test, the result of this study identified factors related to the occurrence of delirium as follows: age, Bun/Cr ratio, APACHE II, total number of tubes, concentration of potassium ion on the first day (D1K), infection, restriction, restriction time, antibiotics in drugs, cardiovascular drugs, anti-platelet agents in drugs, non-barbiturate sedatives. In addition, delirious patients spent more days in ICU and relied on respirators longer.
The result of this study can serve as references for clinical care. The occurrence of delirium will be identified as soon as possible through proper education and training as well as the use of the CAM-ICU. Thus, delirious patients can receive timely medical care and treatment. In future studies, an assessment table to identify highly dangerous status is expected. This assessment table serves as the criteria of patient eligibility for ICU hospitalization and the determinant for effective early intervention prior to delirium occurrence. Whether early intervention decreases the occurrence rate of delirium and its complications can also be explored accordingly. This study hopes to incorporate the care principles of delirium into the customary practices in domestic ICUs to prevent the occurrence of delirium.

論文指導教授推薦書·········································
論文口試委員會審定書·······································
授權書···················································ⅲ
致謝·····················································ⅳ
中文摘要·················································ⅴ
英文摘要·················································ⅶ
目錄·····················································ⅸ
圖表目錄················································xii
第一章緒論··············································1
第一節研究動機與重要性··································1
第二節研究目的··········································4
第三節名詞界定··········································4
第二章文獻查證··········································6
第一節譫妄的概念········································6
第二節影響加護病房譫妄的相關因素························9
第三章研究方法·········································22
第一節研究概念架構·····································22
第二節研究問題·········································23
第三節研究假設·········································23
第四節研究設計·········································23
第五節研究場所與對象···································24
第六節研究工具·········································25
第七節測試者間一致性···································41
第八節資料的收集過程···································42
第九節資料分析與統計方法·······························43
第十節倫理考量·········································45
第四章研究結果 ········································46
第一節研究樣本的基本屬性·······························46
第二節樣本發生譫妄的情形·······························48
第三節易感因素中個案基本資料、疾病與病患是否發生譫妄之
關係·············································50
第四節促發因素中病理生理狀態、實驗室檢驗、藥物、環境與
病患是否發生譫妄之關係···························51
第五章討論 ············································63
第一節內科加護病房重症病人譫妄發生情形·················63
第二節探討易感因素中個案基本資料、疾病對重症病人於內科
加護病房住院期間譫妄發生的影響···················65
第三節促發因素中病理生理狀態、實驗室檢驗、藥物、環境對
重症病人於內科加護病房住院期間譫妄發生的影響·····67
第六章結論與建議 ········································72
第一節結論·············································72
第二節護理上的應用·····································74
第三節研究限制與建議···································76
參考文獻·················································78
附錄·····················································94

圖表目錄
圖3-1發生譫妄相關因素之概念架構··························22
圖4-1體溫趨勢圖··········································53
圖4-2心跳趨勢圖··········································54
圖4-3收縮壓趨勢圖········································54
圖4-4舒張壓趨勢圖········································55
圖4-5平均血壓趨勢圖······································55
表3-1 CAM-ICU量表之效度檢定····························41
表3-2 推論性統計分析方法·································45
表4-1 樣本基本類別資料分佈情形···························47
表4-2 樣本基本連續資料分佈情形···························47
表4-3 樣本主診斷資料分佈情形·····························48
表4-4 樣本發生譫妄的情形·································49
表4-5 病患疾病嚴重度連續資料與譫妄發生之關係·············50
表4-6 病患病理生理狀態類別資料與譫妄發生之關係···········51
表4-7 病患病理生理狀態連續資料與譫妄發生之關係···········52
表4-8 病患實驗室檢驗相關變項類別資料與譫妄發生之關係·····56
表4-9 病患藥物類別資料與譫妄發生之關係···················58
表4-10 病患藥物連續資料與譫妄發生之關係··················60
表4-11 病患環境類別資料與譫妄發生之關係··················61
表4-12 病患環境連續資料與譫妄發生之關係··················61
表4-13 以Logistic regression探討相關變項對譫妄發生的影響····62

附錄
附錄一、病人基本資料表····································94
附錄二之1~3、疾病嚴重度量表 (APACHEⅡ) ··············95~97
附錄三、意識程度量表 (GCS) ······························98
附錄四、體溫、心跳、血壓、Pulse oximetry、呼吸器設定模式登錄表
·················································99
附錄五、各項實驗室檢驗及APACHEⅡ登錄表················100
附錄六、各種檢體細菌培養登錄表···························101
附錄七之1~3、加護病房譫妄常見相關用藥表·············102~104
附錄七之4、加護病房譫妄常見相關用藥查檢表···············105
附錄八、環境因素每日查檢項目·····························106
附錄九之1、譫妄評估表之鎮靜評估 (RASS) ·················107
附錄九之2、譫妄評估表之譫妄評估 (CAM-ICU) ··············108
附錄九之3~9、視覺圖片認知測試·······················109~115
附錄九之10、RASS 和CAM-ICU每日評核表·················116
附錄十、資料收集流程圖···································117
附錄十一之1~2、參與研究同意書························118~119

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