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研究生:張玲華
研究生(外文):Chang, Ling-Hua
論文名稱:耳穴貼壓按摩對膝關節置換術病人手術後疼痛、焦慮及生理指標之成效探討
論文名稱(外文):The effects of auricular acupressure on pain, anxiety and physiological indicators for patients with total knee replacement
指導教授:蔡秀鸞蔡秀鸞引用關係
指導教授(外文):Tsay, Shiow-Luan
口試委員:許中華鍾國屏何善台林寬佳
口試委員(外文):Hsu, Chung-HuaJong, Gwo-PingHo, ShungtaiLin, Kuan-Chia
口試日期:2012-06-05
學位類別:博士
校院名稱:國立臺北護理健康大學
系所名稱:護理研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2012
畢業學年度:100
語文別:中文
論文頁數:172
中文關鍵詞:耳穴貼壓按摩手術後疼痛焦慮生理指標膝關節被動性彎曲角度
外文關鍵詞:auricular acupressurepostoperative painanxietyphysiological indicatorspassive knee bending angles
相關次數:
  • 被引用被引用:8
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  • 下載下載:100
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摘  要
儘管止痛方式與藥物有了新的發展、許多醫院也採用疼痛照護指引,手術後疼痛仍是膝關節置換術病人在手術後常面臨的最大挑戰。未緩解的疼痛影響病人手術後生理和心理之健康,延遲下床活動與肢體復建,因而增加住院天數及醫療費用。
本研究採輪後名單控制組方式進行雙盲實驗設計,探討膝關節置換術病人手術後疼痛程度、焦慮程度、與病人之血液動力學、自律神經反應及組織氧合狀態之現況,以及耳穴貼壓按摩療法對膝關節置換術病人手術後疼痛、焦慮及生理指標之影響。於臺中市某區域教學醫院之骨科病房進行收案,合乎選案條件之研究對象隨機分派至實驗組或控制組,實驗組病人(n=31)接受常規照護、疼痛治療及耳穴貼壓方案,控制組病人(n=31)接受常規照護及疼痛治療。研究測量工具包括視覺類比尺度量表(疼痛與焦慮狀態)、簡易麥克吉爾疼痛量表、醫院焦慮量表、生理指標測量(血液動力學、自律神經反應及組織氧合狀態)、膝關節連續性被動運動(CPM)角度及術後止痛藥使用總量。以皮爾森相關(Pearson’s correlation)檢定個案手術後疼痛、焦慮及生理指標間之相關性。以概似化估計方程式(Generalized Estimating Equation, GEE)或一般線性多層次分析(General linear Mixed Models, GLMM)模式檢定不同測量時間點與介入措施對兩組研究對象手術後疼痛、焦慮、生理指標與止痛藥使用總計量之影響。
結果顯示:膝關節置換術病人手術後第一天前測資料中,(一)、膝關節置換術手術後第一天病人雖接受自控式止痛處置,仍經歷著中等程度的疼痛,且其自覺焦慮程度亦屬中等程度,且手術後疼痛與焦慮互為正相關。(二)、膝關節置換術手術後第一天病人接受自控式止痛處置下,其自律神經(交感及副交感)反應較健康人正常值低,且自律神經之低高頻比值在正常值範圍內,即交感神經、副交感神經二者處平衡狀態。(三)、膝關節置換術手術後第一天病人疼痛強度(VAS-pain),與病人周邊血氧濃度(SPO2)呈負相關;若控制病人年齡、身高體重指數後,則發現病人之疼痛強度、心跳速率與手術後第一天周邊血氧飽和濃度間,呈顯著性負相關,病人疼痛強度每增加一分,其周邊血氧飽和濃度則下降 .038,心跳速率每增加一下,其周邊血氧飽和濃度則下降 .078,疼痛強度與心跳速率對周邊血氧濃度(SPO2)之解釋變異量為28.7%。
耳穴貼壓按摩介入措施之成效有(一)、實驗組與對照組二組病人之手術後疼痛強度無顯著差異,且病人手術後疼痛狀態隨著時間出現呈遞減趨勢。(二)、實驗組與對照組二組病人之手術後焦慮狀態隨著時間出現呈遞減趨勢。(三)、對照組病人之交感神經活性與副交感神經活性都較實驗組病人興奮,但仍處於平衡狀態,且二組病人之自律神經,不論是交感神經或副交感神經活性,都較健康人正常值低。(四)、實驗組與對照組二組病人之手術後周邊血氧飽和數值隨著時間出現呈遞增趨勢。(五)、耳穴貼壓按摩可降低膝關節置換手術後病人自控式止痛嗎啡之使用劑量( p < .01)。(六)、耳穴貼壓按摩可降低膝關節置換手術後病人之自覺焦慮程度( p < .05)。(七)、耳穴貼壓按摩有可提升膝關節置換術手術後第三天膝關節被動性彎曲角度的趨勢(p = .074)。
總而言之,本研究結果可作為護理人員於膝關節置換術病人手術後急性照護的參考,耳穴貼壓按摩可減少膝關節置換術手術後病人止痛藥的使用劑量,減緩手術後焦慮的感受及增加手術後第三天膝關節被動性彎曲角度,進而提升照護品質。

ABSTRACT
Despite the development of new pain control methods and medication, and the adoption of guidelines for pain care by many hospitals, postoperative pain is still a problem for many patients. Improper pain control not only increases the burden of many organs, but also limits the patient’s activity, increases postoperative morbidity, affects physical recovery and the patient’s emotional state after surgery, and is more likely to extend the length of stay and medical costs.
A randomized, sham controlled trial was conducted to investigate the correlation among post- operative pain intensity, anxiety, hemodynamic status, autonomic nervous system response, and the tissue oxygenation concentration; and to examine the adjuvant effects of auricular acupressure in relieving postoperative pain, reliving anxiety, and improving physiological indicators and knee bending angles in postoperative patients with total knee replacement. The study was conducted at a regional teaching hospital Taiwan. A randomization list was used to divide subjects into the experimental group (n=31), in which auricular acupressure (3 times daily, 6 minutes each time) was given in addition to regular care. Patients of control group (n=31) received regular care, and without magnetic beads and pressing at the same accupoints. The measurement tools of the study were included the Visual Analogue Scale (pain and anxiety state), the short-form McGill Pain Questionnaire, the Hospital Anxiety Scale, physiologic indicators (hemodynamic, autonomic nervous reaction and tissue oxygenation status), the knee bending angles (CPM) and postoperative analgesics consumption. The correlation between the postoperative pain intensity, anxiety, physiological indicators (hemodynamic status, autonomic nervous system response, and the tissue oxygenation concentration) and knee bending angles (CPM) was determined by means of Pearson’s correlation analysis. The effects of auricular acupressure on pain, anxiety, physiological indicators and analgesic drug usage for patients after total knee replacement were examined by means of generalized estimating equation models (GEE) or general linear mixed models (GLMM).
The study yield that on the first day of post-surgery: (1) The patients experienced moderate pain and anxiety while receiving patient-controlled analgesia, additionally, the postoperative pain and anxiety mutually positively correlated. (2) The response of autonomic nervous system (sympathetic and parasympathetic) compared with healthy people were low, and the sympathetic activity and parasympathetic activity were in a state of equilibrium. (3) The pain intensity (VAS-pain) and the peripheral arterial oxygen saturation (SpO2) were negatively correlated. (4) After the age and body mass index were controlled, the pain intensity, heart rate and the SpO2 were significantly negatively correlated; patients’ SpO2 decreased .038 as pain intensity increased one point; patients’ SpO2 decreased .078 as heart rate increased one beat. Pain intensity and heart rate could explain 28.7% of the variance.
The effects of auricular acupressure include: (1) there was no significant differences between two groups in the average pain intensities, and postoperative pain intensity showed a decreasing trend over time. (2) State anxiety in the two groups both decreased over time. (3) The sympathetic activity and parasympathetic activity of control group was higher than experimental group, and lower than healthy people. It was in a state of equilibrium. (4) Patients’ peripheral arterial oxygen saturation in both groups showed an increasing trend over time. (5) The analgesic drug usage in experimental group was significant lower than control group (p < .05). (6) Auricular acupressure could reduce the level of anxiety (p < .05). (7) There was an increasing trend that the passive knee bending angles in experimental group was higher than control group (p= .074) on the third day after surgery.
In summary, the results of this study could be used as a recommendation for the postoperative care of total knee replacement. Auricular acupressure was effective on reducing postoperative analgesia consumption, relieving anxiety, increasing the patient’s knee rehabilitation of bending angles, and then to improve the quality of care.

目  次
中文摘要 …………………………………………………………………………… i-ii
英文摘要 …………………………………………………………………………… iii-v
目次 …………………………………………………………………………………… vi-viii
表次 ………………………………………………………………………………… ix-x
圖次 …………………………………………………………………………………… xi
第一章 緒論
第一節 研究動機及重要性 …………………………………………… 1-4
第二節 研究目的 ……………………………………………………… 5-6
第二章 文獻查證
第一節 膝關節炎及人工關節置換術 ………………………………… 7-9
第二節 手術後疼痛及其相關理論與處置 …………………………… 10-21
第三節 人工膝關節置換術病人手術後疼痛及其影響 ……………… 22-24
第四節 手術後病人焦慮 ……………………………………………… 25-28
第五節 耳穴療法及其機轉 …………………………………………… 29-35
第六節 耳穴療法與關節手術病人手術後疼痛 ……………………… 36-38
第三章 研究方法
第一節 研究架構 ………………………………………………………. 39-40
第二節 研究假設 ………………………………………………………. 41
第三節 名詞界定 ………………………………………………………. 42-44
第四節 研究設計 ………………………………………………….…… 45-48
第五節 研究場所與對象 ……………………………………….……… 49-50
第六節 耳穴貼壓方案 ……………………………………….………… 51-52
第七節 研究工具及信效度 …………………………………….……… 53-59
第八節 研究步驟 ………………………………………………………. 60
第九節 資料處理與分析 …………………………………..……...…… 61
第四章 研究結果
膝關節置換術病人手術後第一天前測資料描述
第一節 研究對象之基本屬性資料 ……………………………………. 62-66
第二節 手術後第一天的疼痛、焦慮及生理指標狀況 ………….…… 67-70
第三節 手術後第一天疼痛、焦慮及生理指標間關係 ………….…… 71-79
耳穴貼壓按摩介入措施之成效
第一節 手術後疼痛、焦慮及生理指標狀況 …………………………. 79-95
第二節 耳穴貼壓按摩介入措施之成效 ………………………………. 96-119
第三節 研究對象接受耳穴按摩前後之主觀感受 ……………………. 120
第五章 討論
膝關節置換術病人手術後第一天前測資料討論
第一節 手術後第一天的疼痛、焦慮及生理指標狀況 ……………… 121-124
第二節 手術後第一天疼痛、焦慮及生理指標間關係 ……………… 125-128
耳穴貼壓按摩介入措施之成效討論
第一節 手術後疼痛、焦慮及生理指標狀況 ………………………………… 129-130
第二節 耳穴貼壓按摩介入措施之成效 ……………………………………… 131-138
第六章 結論與建議
第一節 結論 …………………………………………………………………… 139-140
第二節 研究限制 ……………………………………………………………… 141
第三節 應用與建議 …………………………………………………………… 142-143
參考文獻
中文部分 ………………………………………………………………………… 144-145
英文部分 ………………………………………………………………………… 146-160
附錄
附錄一 人體試驗計畫同意函 ………………………………………………… 161-162
附錄二 受訪同意書 …………………………………………………. 163-165
附錄三 簡易麥克吉爾疼痛量表(SF-MPQ)中文版使用同意書 …………………… 166
附錄四 研究評量工具 ………………………………………………. 167-172

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