臺灣博碩士論文加值系統

本研究的主要目的是在探討新生兒進行靜脈穿刺前給予葡萄糖液或母乳乳汁對減輕疼痛的成效。以臺大醫院嬰兒室足月健康之新生兒為研究對象，靜脈穿刺取得的血液檢體用於例行性新生兒篩檢及黃疸檢測。
本研究採實驗性研究設計，隨機取樣符合選樣條件者，並隨機分派到實驗組及控制組，共收得有效樣本93人（平均週數：38.55 ± 0.9726週；平均體重：3242.8 ± 362.5公克；平均年齡：2.85 ± 0.27天）。實驗處置為靜脈穿刺前2分鐘以空針經口滴注方式給予實驗溶液2 ml，第一實驗組（30人）給予20 ﹪葡萄糖液、第二實驗組（32人）給予母乳乳汁、對照組（31人）給予開水。疼痛反應的測量參數分為生理及行為狀態：生理狀態為疼痛刺激期間以三導程心電圖測得之心跳及呼吸速率（次數/分），行為狀態方面以全程錄影方式紀錄哭泣行為及臉部表情變化。
所蒐集的資料以SPSS 8.0 for Window、SAS 6.12版及StatXact統計套裝軟體進行描述性分析（次數、百分比、平均值、標準差）、配對t檢定、ANOVA、薛費法（Scheffe）事後多重比較及邏輯式迴歸分析（Logistic Regression）。研究結果如下：
（一） 生理狀態：三組研究對象在疼痛刺激期間心跳及呼吸速率的平均變異量（mean of difference），及穿刺後心跳、呼吸速率恢復到基準值的時間上無統計上的差異。
（二） 行為狀態：（1）未出現哭泣行為者比率：葡萄糖液組在疼痛刺激期間未出現哭泣行為的人次（76.67 ﹪）較母乳乳汁組（37.5 ﹪）及對照組（35.48 ﹪）多（p =.002, p =.001）。（2）哭泣時間比率：葡萄糖液的哭泣時間比率（18.07 ﹪）較母乳乳汁組（51.86 ﹪）及對照組（65.04 ﹪）短，與對照組比較時達統計上的差異（p =.01）。
（三） 新生兒臉部影像疼痛評分系統（NFISS）計分：將NFISS計分重新分類定義，計分0~4分為低分組（臉部表情平靜），計分10~14分為高分組（出現鬼臉）。靜脈穿刺期間，葡萄糖溶液組有86.6~100 ﹪屬低分組，高分組僅佔10 ﹪以下。給予母乳乳汁組56.6~78.2 ﹪屬低分組，高分組佔18.7~37.6 ﹪。對照組與母乳乳汁組類似，有42.8~67.7 ﹪屬低分組，高分組佔16.2~42.8 ﹪。
其它研究發現：
（一）葡萄糖液組在給液期間心跳速率的增加較其他兩組多，推測是因為用力吸吮造成。
（二）靜脈穿刺期間，以扎針開始10秒期間及拔針點的心跳、呼吸速率最快且NFISS計分最高，表示疼痛程度較其它時間點高。
（三）本研究中影響新生兒接受靜脈穿刺時是否出現哭泣行為的因素包括：實驗組別（葡萄糖液組較對照組不易出現哭泣行為） （p =.0014）、出生後餵食配方奶的次數（餵食次數越多，較容易出現哭泣行為）（p =.0137）及穿刺前的行為狀態（淺眠/瞌睡期較安靜警覺期不易出現哭泣行為）（p =.0014）。
由以上研究結果可知，靜脈穿刺前給予20 ﹪葡萄糖液可減少疼痛時的哭泣行為及臉部表情變化，其安全、不具副作用，臨床上可用於減輕新生兒經歷輕度疼痛時的行為反應，但對於生理方面的影響則不顯著。而給予母乳乳汁卻無相似的效果。

The aim of this study is to investigate the efficacy of oral glucose or human milk to reduce venipuncture pain in neonates. The subjects were normal health newborn infants in National Taiwan University Hospital in north Taiwan. The blood samples were collected for routine metabolic screening and serum bilirubin test by venipuncture.
Experimental research design was adopted in this study. Ninety-three newborn infants ( mean gestation week: 38.55 ± 0.9726 wks, mean birth body weight: 3242.8 ± 362.5 gm, mean age: 2.85 ± 0.27 days ) were recruited to the study. Subjects were randomly sampled and allocated into one of three groups: that fed with 20 % glucose water (n=30), human milk (n=32) or water ( control ) (n=31). The 2 ml of designed solution instilled into mouth with a syringe without a needle prior to venipuncture for 2 minutes.
Pain response was measured by physiological and behavioral parameters. A mounted digital camera continuously recorded the crying and facial expression. The heart rate and the respiratory rate ( beat per minute ) were read aloud off EKG monitor.
The data were analyzed with SPSS 8.0 for window, SAS 6.12 and StatXact statistics package, using descriptive analysis ( count, percentage, mean, standard deviation )、paired t-test、ANOVA、multiple comparisons ( Scheffe ) and logistic regression. The major results were summarized as the follows:
(1). Physiological state: The mean difference in the heart rate and the respiratory rate during the period of venipuncture had no statistically significant difference. Either the time return to baseline. ( There are no significantly statistical difference in the mean of the heart rate and the respiratory rate during the treatment and in the mean of time that the heart and respiratory rate returned to the baseline after the venipuncture. )
(2). Behavioral state: (a). In glucose group, 76.67 % of infants did not cry during the period of venipuncture. The percentage in glucose group is significantly higher than that in human milk group ( 37.5 %, p = 0.002 ) and in water group ( 35.48 %, p = 0.001 ). (b). The proportion of crying time in glucose group was 18.07 %, compared to 51.86 % in human milk group and 65.04 % in water group. The crying time of the glucose group was significantly shorter than that in glucose group ( p = 0.01 ); however, there is no statistically significant difference between human milk group and water group. (c). Neonatal Facial Image Scoring System ( NFISS ) score: The score was redefined as follows: the scale of NFISS between 0~4 represented low score group ( LSG ) ( smooth facial expression ), and 10~14 was high score group ( HSG ) ( facial grimacing ). In the percentage of infants in glucose group scored in LSG was 86.6~100 %, and that scored in HSG was less than 10 %. In contrast, the percentage of infants in human milk group scored in LSG was 56.6~78.2 %, and that scored in HSG increased to 18.7~37.6 %. The water group showed the similar results compared to human milk group, the percentage scored in LSG was 42.8~67.7 %, and that in HSG increased to 16.2~42.8 %.
Other findings:
(1). The heart rate increased in the glucose group more than other groups during the period of intervention. This phenomenon might result from their intensive suckling.
(2). During the period of venipuncture, the heart rate, the breath rate and the score of NFISS reached the peak in two particular time points. One is the first 10 seconds after the needle injected into skin, and the other is the moment when the needle was removed.
(3). Several factors affected the crying behaviors of infants when they received a venipuncture. The infants in control group were easier to cry than those fed with glucose ( p = 0.0014 ). In addition, the more frequency subjects fed with infant formula, the more easier they cried. Furthermore, the infants in quiet alert state were easier to cry than those in light sleep/drowsy state prior to venipuncture.
In summary, the oral administration of 20 % glucose water prior to venipuncture is effective in diminishing the proportion of time crying and facial grimacing. It is safe, no side effects and well accepted by newborn infants. It can be probably used to alleviate the behavior response of pain when the infants undergo mild pain. Unexpectedly, human milk is not effective as glucose water.

論文摘要（中文）---------------------------------------------------------------------------------I
論文摘要（英文）--------------------------------------------------------------------------------III
論文目錄-----------------------------------------------------------------------------------------V
圖表目次----------------------------------------------------------------------------------------VII
（項目） （頁次）
第壹章、緒論--------------------------------------------------01
第一節 研究動機及重要性--------------------------------------01
第二節 研究目的----------------------------------------------03
第三節 研究問題----------------------------------------------04
第四節 名詞界定----------------------------------------------05
第貳章、文獻查證----------------------------------------------15
第一節 新生兒疼痛--------------------------------------------15
一、 痛覺的發展------------------------------------------16
二、 新生兒的疼痛反應------------------------------------18
三、 新生兒疼痛評估--------------------------------------20
四、 影響新生兒疼痛反應的因素----------------------------25
第二節 減輕新生兒疼痛的甜味劑及乳汁措施--------------------30
一、 歷史背景及生理基礎----------------------------------30
二、 甜味劑及乳汁用於減輕新生兒疼痛的臨床研究------------33
第參章、研究架構與假說----------------------------------------45
第一節 研究架構--------------------------------------------45
第二節 研究假設--------------------------------------------48
第肆章、研究方法---------------------------------------------49
第一節 研究設計--------------------------------------------49
第二節 研究對象及場所--------------------------------------51
第三節 研究工具及信效度------------------------------------53
第四節 研究步驟--------------------------------------------59
第一階段 前趨前研究（pre-pilot study）----------------------59
第二階段 前趨研究（pilot study）----------------------------60
第三階段 正式研究-------------------------------------------62
一、 收集資料流程----------------------------------------62
二、 研究資料記錄----------------------------------------67
第五節 資料分析方法----------------------------------------69
第六節 倫理考量--------------------------------------------70
第伍章、研究結果---------------------------------------------71
第一節 資料收集狀況分析------------------------------------71
第二節 研究對象基本特性------------------------------------75
第三節 研究對象於研究前及研究期間一般狀況分析--------------80
第四節 新生兒接受靜脈穿刺時的疼痛反應----------------------86
第五節 實驗處置對新生兒靜脈穿刺時疼痛反應之影響------------94
第六節 影響新生兒靜脈穿刺期間是否出現哭泣行為之因素探討---121
第陸章、討論------------------------------------------------125
第一節 研究方法部份-------------------------------------126
第二節 有關研究處置部份---------------------------------127
第三節 研究對象基本特性及研究期間一般狀況探討-----------129
第四節 新生兒接受靜脈穿刺的疼痛反應探討-----------------131
第五節 研究處置對減輕新生兒疼痛的成效-------------------133
第六節 影響新生兒靜脈穿刺期間是否出現哭泣行為之因素探討-142
第七節 「新生兒臉部影像疼痛評分系統」（NFISS）
用於新生兒疼痛評估指標之探討--------------------------------145
第柒章、結論與建議------------------------------------------148
第一節 結論------------------------------------------------148
第二節 護理上的應用----------------------------------------152
第三節 研究限制、建議及未來發展方向------------------------155
參考文獻----------------------------------------------------159
附錄--------------------------------------------------------166
附錄（一）新生兒影像圖片使用授權書--------------------------166
附錄（二）研究對象基本資料記錄表----------------------------167
附錄（三）阿帕嘉分數（Apgar score）計分表-------------------168
附錄（四）新生兒疼痛反應記錄表------------------------------169
附錄（五）「新生兒臉部影像疼痛評分系統（NFISS）」評分表-----171
附錄（六）研究同意書----------------------------------------172
附錄（七）研究對象隨機順序一覽表----------------------------174
圖 表 目 次
（項目） （頁次）
圖（1~1）新生兒臉部影像疼痛評分系統（NFISS）評分圖------------13
圖（3~1）研究架構圖-------------------------------------------46
圖（4~1）研究設計圖示-----------------------------------------50
圖（4~2）收集資料流程圖---------------------------------------66
圖（5~1）研究對象各階段心跳速率平均值-------------------------87
圖（5~2）研究對象於研究期間各時間點心跳速率變化趨勢圖---------88
圖（5~3）研究對象各階段呼吸速率平均值-------------------------90
圖（5~4）研究對象於研究期間各時間點呼吸速率變化趨勢圖---------91
圖（5~5）對照組新生兒研究期間NFISS計分變化趨勢圖--------------93
圖（5~6）各組研究對象研究期間心跳速率( 95﹪CI )變化趨勢圖-----96
圖（5~7）各組研究對象研究期間呼吸速率( 95﹪CI )變化趨勢圖----102
圖（5~8）研究對象於疼痛刺激期間哭泣行為比較圖----------------106
圖（5~9）疼痛刺激期間出現哭泣行為者「哭泣時間比率」比較圖----108
圖（5~10）各組研究對象研究期間NFISS ( 95﹪CI )變化趨勢圖-----111
圖（5~11）各組研究對象NFISS計分高分組及低分組人次百分比隨時間變化趨勢圖-----------------------------------------------------120
表（1~1）新生兒行為狀態表-------------------------------------08
表（1~2）新生兒臉部影像疼痛評分系統
（Neonatal Facial Image Scoring System，NFISS）---------------12
表（4~1）研究過程中實驗參數觀測紀錄時間點---------------------65
表（4~2）資料分析方法一覽表-----------------------------------69
表（5~1）研究對象收集情況一覽表-------------------------------72
表（5~2）各組未能完成資料收集原因一覽表-----------------------74
表（5~3）研究對象基本資料（一）-------------------------------77
表（5~4）研究對象基本資料（二）-------------------------------79
表（5~5）研究期間新生兒行為狀態分析表-------------------------81
表（5~6）研究對象於研究前及研究期間一般狀況分析---------------83
表（5~7）三組研究對象「實驗措施給液期間」變異數分析表---------84
表（5~8）三組研究對象「實驗措施給液期間」事後比較分析表-------84
表（5~9）三組研究對象「黃疸值」變異數分析表-------------------85
表（5~10）三組研究對象「黃疸值」事後比較分析表----------------85
表（5~11）各階段心跳速率平均值一覽表--------------------------87
表（5~12）各階段呼吸速率平均值一覽表--------------------------90
表（5~13）研究對象各觀察時間點平均心跳速率比較表--------------95
表（5~14）實驗處置期間各組心跳速率與基準值比較表--------------97
表（5~15）研究對象疼痛刺激期間心跳速率平均變異量分析表--------98
表（5~16）各組研究對象恢復期心跳次數變化表（與基準值比較）----99
表（5~17）研究對象各觀察時間點平均呼吸速率比較表-------------101
表（5~18）研究對象疼痛刺激期間呼吸速率平均變異量分析表-------103
表（5~19）各組研究對象恢復期呼吸次數變化表（與基準值比較）---104
表（5~20）研究對象於疼痛刺激期間哭泣行為比較表（三組比較）---106
表（5~21）研究對象於疼痛刺激期間哭泣行為比較表（兩組比較）---107
表（5~22）疼痛刺激期間出現哭泣行為者「哭泣時間比率」比較表---108
表（5~23）研究對象「哭泣時間比率」變異數分析表---------------109
表（5~24）研究對象「哭泣時間比率」事後比較分析表-------------109
表（5~25）新生兒臉部影像疼痛評分系統（NFISS）計分次數分布表--115
表（5~26）新生兒臉部影像疼痛評分系統（NFISS）計分分組次數分布表-117
表（5~27）影響新生兒靜脈穿刺期間是否出現哭泣行為之相關因素分析------124
表（6~1）葡萄糖液及母乳乳汁相關研究中，研究對象、疼痛刺激來源
及給予實驗處置方式一覽表-------------------------------------128
表（6~2）本研究與其它研究在疼痛刺激期間生理狀態評估比較------136
表（6~3）本研究與其它研究在疼痛時哭泣行為之評估結果比較------138
表（6~4）疼痛刺激期間NFISS計分高、低分組出現人次百分比-------141
表（6~5）新生兒面部編碼系統（NFCS）及新生兒臉部影像疼痛評分系統（NFISS）評分項目比較表--------------------------------------147

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