臺灣博碩士論文加值系統

本研究目的在探討腦部損傷病人執行胸腔震顫物理治療對腦組織灌流包含：顱內壓、平均動脈壓、腦灌流壓、血氧飽和度之影響，採縱貫性研究並以立意取樣共收集40位病人，依研究設計由研究者進行床邊胸腔震顫物理治療、實際收集病歷資料及下載生理數據，並將所得資料以配對t檢定、重複測量變異數分析、皮爾森積差相關、多元線性迴歸分析，進行統計分析，所得結果分述如下：
一、腦部損傷病人執行胸腔震顫物理治療過程之顱內壓以治療前最低、治療中最高，隨著治療時間增加顱內壓呈現逐漸上升的趨勢，於治療結束後顱內壓逐漸回復。胸腔震顫物理治療前、中、後之顱內壓具有高度正相關，且昏迷指數、手術日數及顱骨切除術於執行胸腔震顫物理治療過程之顱內壓呈顯著差異，故預測模型為：胸腔震顫物理治療前顱內壓=12.11-3.57×手術日數(0,1)+4.63×顱骨切除術(0,1)；胸腔震顫物理治療中顱內壓=18.07-3.99×手術日數(0,1)+3.43×顱骨切除術(0,1)；胸腔震顫物理治療後顱內壓=17.02-5.46×手術日數(0,1)。
二、腦部損傷病人執行胸腔震顫物理治療過程之平均動脈壓以治療前最低、治療中最高，平均動脈壓隨著顱內壓上升而增加，而影響平均動脈壓的因素則較不明確。
三、腦部損傷病人執行胸腔震顫物理治療過程之腦灌流壓以治療後最低、治療前最高，治療過程腦灌流壓呈現逐步下降的趨勢但仍能維持足夠的腦組織灌流，手術日數於執行胸腔震顫物理治療之腦灌流壓呈顯著差異。
四、腦部損傷病人執行胸腔震顫物理治療時血氧飽和度會下降，雖未達顯著差異，亦表示執行胸腔震顫物理治療過程未造成病人腦組織缺氧。
本研究結果可提供神經外科加護病房醫護人員對於腦部損傷病人執行胸腔震顫物理治療時之照護指引，治療前審慎評估及確認病人之顱內壓，治療時維持頭頸一直線且配合改良式姿位引流，密切監控顱內壓及腦灌流壓，並將胸腔震顫物理治療流程標準化，透過預測模型估計影響顱內壓的幅度，減少二度腦損傷情形，建立安全的處置照護。

The purpose of this study was to investigate the effects and the related factors of the chest vibration physiotherapy on the cerebral perfusion procedure, including intracranial pressure, mean arterial pressure, cerebral perfusion pressure, oxygen saturation of influence brain injury patients. This study utilized a longitudinal study to collect a total of 40 patients. These patients were treated according to the study design by conducting bedside chest vibration physiotherapy, collecting patients’ medical information, and analyzing their physiological data. The results were analyzed statistically with paired-t test, ANOVA, Pearson’s Correlation, and multivariate linear regression. The result of this study includes:
(1) The intracranial pressure of the brain injury patients receiving the chest vibration physiotherapy were the lowest before the treatment, and were the highest during the treatment. The intracranial pressure was increasing along with the time of treatment, and was gradually recovered after the treatment. The intracranial pressure is significantly positive correlation with the chest vibration physiotherapy. The intracranial pressure after chest physical processes were significant differences and associated with the Glasgow Coma Scale (GCS), the days after surgery, and surgical resection of the skull. Therefore, our predicting model is as follow: The intracranial pressure before the chest vibration physiotherapy =12.11-3.57× days of surgery (0,1) + 4.63 × craniectomy (0,1); The intracranial pressure during the chest vibration physiotherapy = 18.07-3.99 × days of surgery ( 0,1) + 3.43 × craniectomy (0,1); The intracranial pressure after the chest vibration physiotherapy = 17.02-5.46 × days of surgery (0,1).
(2) The mean arterial pressure of the brain injury patients receiving the chest vibration physiotherapy process were the lowest before the treatment, and were the highest during the treatment. The mean arterial blood pressure positively associated with the increased intracranial pressure. However, the factors influencing mean arterial pressure remain to be further investigated.
(3) The cerebral perfusion pressure in the brain injury patients receiving the chest vibration physiotherapy were the lowest after the treatment, and were the highest before the treatment. Although showing a gradual decrease during treatment, the cerebral perfusion pressure was still sufficiently high to maintain an adequate tissue perfusion in brain. The days of surgery significantly affected the cerebral perfusion pressure to the patients receiving the chest vibration physiotherapy.
(4) The brain injury patients receiving the chest vibration physiotherapy showed decrease oxygen saturation in blood. Although not of significant differences, the results also suggested that the chest vibration physiotherapy does not cause the hypoxia in the patient’s brain tissue.
The results of this study provides a preliminary patient care guideline for the neuro-surgical intensive care unit on brain injury patients who receive chest vibration physiotherapy. The pre-treatment assessment and the reassurance of the intracranial pressure, keeping head and neck in a straight line, maintaining a modified postural drainage, closely monitoring the intracranial and the cerebral perfusion pressure, standardizing the chest physical tremor therapy, and estimating the degree of potential changes of the intracranial pressure using our proposed model, can reduce a repeated brain injury and establish a safer patient care.

目　　次
中文摘要 …………………………………………………………………………… ⅰ
英文摘要 …………………………………………………………………………… ⅲ
目次 ………………………………………………………………………………… ⅴ
表次 ………………………………………………………………………………… ⅶ
圖次 ………………………………………………………………………………… ⅸ
第一章 緒論
第一節 研究背景與動機 ……………………………………………………… 1
第二節 研究目的、研究問題與研究假設……………………………………… 2
第三節 名詞定義………………………………………………………………… 3
第二章 文獻探討
第一節 腦部損傷與腦組織灌流………………………………………………… 4
第二節 腦部損傷病人之肺部護理……………………………………………… 7
第三節 胸腔震顫物理治療……………………………………………………… 9
第四節 腦部損傷病人胸腔震顫物理治療對腦組織灌流之影響……………… 11
第三章 研究方法
第一節 研究架構………………………………………………………………… 14
第二節 研究設計………………………………………………………………… 14
第三節 研究對象及場所………………………………………………………… 15
第四節 研究測量方法…………………………………………………………… 15
第五節 資料收集步驟…………………………………………………………… 18
第六節 資料分析………………………………………………………………… 20
第七節 研究對象之權益保護…………………………………………………… 22
第四章 研究結果與討論
第一節 研究對象基本資料……………………………………………………… 23
第二節 胸腔震顫物理治療時腦部損傷病人顱內壓之影響…………………… 25
第三節 胸腔震顫物理治療時腦部損傷病人平均動脈壓之影響……………… 33
第四節 胸腔震顫物理治療時腦部損傷病人腦灌流壓之影響………………… 40
第五節 胸腔震顫物理治療時腦部損傷病人血氧飽和度之影響……………… 47
第六節 胸腔震顫物理治療過程對於顱內壓改變之關係……………………… 54
第七節 討論……………………………………………………………………… 61
第五章 結論與建議
第一節 結論……………………………………………………………………… 68
第二節 護理上的應用…………………………………………………………… 70
第三節 研究限制與建議………………………………………………………… 71
參考文獻
中文部分 ………………………………………………………………………… 72
外文部分 ………………………………………………………………………… 75
附錄
附錄一 資料收集表…………………………………………………………… 80
附錄二　人體試驗委員會通過證明…………………………………………… 81


表　　次
表4-1-1 個案基本資料 …………………………………………………………24
表4-2-1 胸腔震顫物理治療時顱內壓之變化………………………………… 26
表4-2-2 胸腔震顫物理治療過程顱內壓與基準值之變化…………………… 27
表4-2-3 昏迷指數對胸腔震顫物理治療過程顱內壓之影響………………… 28
表4-2-4 手術日數對胸腔震顫物理治療過程顱內壓之影響………………… 29
表4-2-5 鎮靜劑對胸腔震顫物理治療過程顱內壓之影響…………………… 30
表4-2-6 呼吸器對胸腔震顫物理治療過程顱內壓之影響…………………… 31
表4-2-7 顱骨切除術對胸腔震顫物理治療過程顱內壓之影響……………… 32
表4-3-1 胸腔震顫物理治療時平均動脈壓之變化…………………………… 33
表4-3-2 胸腔震顫物理治療過程平均動脈壓與基準值之變化……………… 34
表4-3-3 昏迷指數對胸腔震顫物理治療過程平均動脈壓之影響…………… 35
表4-3-4 手術日數對胸腔震顫物理治療過程平均動脈壓之影響…………… 36
表4-3-5 鎮靜劑對胸腔震顫物理治療過程平均動脈壓之影響……………… 37
表4-3-6 呼吸器對胸腔震顫物理治療過程平均動脈壓之影響……………… 38
表4-3-7 顱骨切除術對胸腔震顫物理治療過程平均動脈壓之影響………… 39
表4-4-1 胸腔震顫物理治療時腦灌流壓之變化……………………………… 40
表4-4-2 胸腔震顫物理治療過程腦灌流壓與基準值之變化………………… 41
表4-4-3 昏迷指數對胸腔震顫物理治療過程腦灌流壓之影響……………… 42
表4-4-4 手術日數對胸腔震顫物理治療過程腦灌流壓之影響……………… 43
表4-4-5 鎮靜劑對胸腔震顫物理治療過程腦灌流壓之影響………………… 44
表4-4-6 呼吸器對胸腔震顫物理治療過程腦灌流壓之影響………………… 45
表4-4-7 顱骨切除術對胸腔震顫物理治療過程腦灌流壓之影響…………… 46
表4-5-1 胸腔震顫物理治療時血氧飽和度之變化…………………………… 47
表4-5-2 胸腔震顫物理治療過程血氧飽和度與基準值之變化……………… 48
表4-5-3 昏迷指數對胸腔震顫物理治療過程血氧飽和度之影響…………… 49
表4-5-4 手術日數對胸腔震顫物理治療過程血氧飽和度之影響…………… 50
表4-5-5 鎮靜劑對胸腔震顫物理治療過程血氧飽和度之影響……………… 51
表4-5-6 呼吸器對胸腔震顫物理治療過程血氧飽和度之影響……………… 52
表4-5-7 顱骨切除術對胸腔震顫物理治療過程血氧飽和度之影響………… 53
表4-6-1 胸腔震顫物理治療前、中、後顱內壓相關性……………………… 59
表4-6-2 胸腔震顫物理治療過程顱內壓預測模型…………………………… 60
表4-7-1 研究假設與研究結果彙總表………………………………………… 61


圖　　次
圖4-2-1 胸腔震顫物理治療過程顱內壓趨勢圖……………………………… 27
圖4-3-1 胸腔震顫物理治療過程平均動脈壓趨勢圖………………………… 34
圖4-4-1 胸腔震顫物理治療過程腦灌流壓趨勢圖…………………………… 41
圖4-5-1 胸腔震顫物理治療過程血氧飽和度趨勢圖………………………… 49
圖4-6-1 治療前與治療中右側臥10分鐘顱內壓散佈圖……………………… 55
圖4-6-2 治療前與治療中左側臥10分鐘顱內壓散佈圖……………………… 55
圖4-6-3 治療前與治療中20分鐘顱內壓散佈圖……………………………… 56
圖4-6-4 治療前與治療後顱內壓散佈圖……………………………………… 56

中文部份
王立葳、高啟雯（2012）．顱內調適能力降低病人的臨床評估及護理處置．護理雜誌，59（5），91-96。[Wang, L. W., & Kao, C. W. (2012). Clinical Evaluation and Nursing Management of a Patient With Decreased Intracranial Adaptive Capacity. The Journal of Nursing, 59(5), 91-96.]doi:10.6224/JN.59.5.91
江盛君、江玲玲、林乾閔、李俊年、蘇芋玲（2008）．神經外科術後病患呼吸器策略之應用．呼吸治療雜誌，7(2)，71-78。[Chun, C. H., Chiang, L. L., Lin, C. M., Lee, C. N., & Su, C. L. (2008). Ventilator Strategy in Neurosurgery Patients , Journal of Respiratory Therapy, 7(2), 71-78.] doi:10.6269/JRT.2008.7.2.06
李芳珊（2005）．腦部傷患在急性期抽痰對腦血流變化之影響(未發表論文)．台北：國立台灣大學護理研究所。[ Li, F. S. (2005). Intracranial Effects of Endotracheal Suctioning in Acute Phase of Head Injury (Unpublished master’s thesis). National Taiwan University, Taiwan, ROC.]
吳英黛（2007）．長期使用呼吸器個案之物理治療．物理治療，32（2），59-71。[Wu, Y. T. (2007).Physical Therapy in Patients with Prolonged Mechanical Ventilation. Journal of Physical Therapy, 32(2). 59-71.]
邱豔芬（2000）．從腦灌流與腦組織的存活談頭部外傷病人的護理．護理雜誌，47（3），59-64。[Chao, Y. F.(2000). Nursing Care of Head Injured Patients from the Perspective of Maintaining Cerebral Perfusion and Preservation of Brain Tissue. The Journal of Nursing, 47(3), 59-64.]doi:10.6224/JN.47.3.59
林秀節、張文珠（2007）．提升護理人員執行胸腔物理治療之衛教正確率．領導護理，8（1），18-26。[Lin, S. C., & Chang, W.C. (2007). Elevating the Accuracy Rate for Nurses' Chest Physical Therapy, Leardship Nursing, 8(1)，18-26.]
林乾閔（2006）．嚴重頭部外傷病患最適當腦灌流壓之臨床研究(未發表論文)．台北：台北醫學大學傷害防治學研究所。[Lin, C. M. (2006). Clinical research for evaluation of optimal cerebral perfusion ressure in severe traumatic brain injury (Unpublished master’s thesis). Taipei Medical University, Taiwan, ROC.]
高僖黛、李愛誠（2011）．照顧一位腦動脈瘤破裂出血患者術後的加護病房護理經驗．中山醫學雜誌，22（2），205-214。[Kao,H. T.,& Li,A. C.(2011). Post Surgical Nursing Experiences of Caring for a Patient with Bleeding due to Cerebral Aneurysmal Rupture in ICU. Chung Shan Medical Journal, 22(2), 205-214.]
許宜芳（2014）．探討呼吸末期正壓對腦神經損傷病患之腦壓的影響相關因素(未發表論文)．台中：中臺科技大學護理研究所。[Fang, H. Y. (2014). Effects of Positive End-Expiratory Pressure (PEEP) on Intracranial Pressure in Acute Brain Injury Patients (Unpublished master’s thesis). Central Taiwan University of Science and Technology, Taiwan, ROC.]
陳佩珊、吳晏慈、王儷穎、鄭素芳（2003）．早產兒的慢性肺疾病：呼吸評估與物理治療．物理治療，28（5），258-268。[Chen,P. S., Wu, Y. T., Wang, L. Y.,& Jeng, S. F.(2003). Chronic Lung Disease in Premature Infants: Respiratory Assessment and Physical Therapy Intervention. Journal of Physical Therapy, 28(5), 258-268.]
陳寶貝、林碧華、李俊德(2011)．住院中低氧合病患使用侵襲性正壓呼吸器的成效．呼吸治療，10（2），1-11。[Chen, P. P., Lin, P. H.,& Lee, J. D.(2011). Outcome of in-patient with Poor Oxygenation Using Invasive Positive Mechanical Ventilator. Journal of Respiratory Therapy, 10(2), 1-11.]doi:10.6269/JRT.2011.10.2.01
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邊苗瑛（2004）．人工氣道留置病患呼吸道分泌物的處理．呼吸治療，3（1），78-90。[Bien, M. Y. (2004).Secretion Management in Patients with Artificial Airways. Journal of Respiratory Therapy, 3(1).78-90.] doi:10.6269/JRT.2003.3.1.09

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