【作者】 王敏；

【导师】 张彩云； 张志刚；

【作者基本信息】 兰州大学 ， 护理（专业学位）， 2024， 硕士

【摘要】 研究目的本研究旨在通过循证护理的方法,系统地检索、筛选、评价鼻肠管置管相关文献,提取和综合证据,构建机械通气患者盲视下鼻肠管主动置管的具体方案并将其应用于临床,评估该方案的效果,以期为护理人员提供科学规范、易于临床实践、安全有效的鼻肠管置管方案,减少并发症和安全隐患的发生,提升临床护理质量,为早期营养支持创造条件。研究方法(1)证据总结:成立研究小组,系统、全面检索国内外数据库和指南网站中关于机械通气患者鼻肠管置管的指南、专家共识、系统评价及原始文献,使用相应的质量评价工具对纳入的研究进行质量评价,筛选证据条目后梳理和整合所有证据,采用Joanna Briggs Institute的证据分级系统评定推荐级别,形成最佳证据总结。(2)方案构建:成立方案制定小组,结合证据总结初步形成机械通气患者盲视下鼻肠管主动置管方案初稿,通过召开专家会议,结合国内三甲医院临床护理管理者和置管实践者的意见,对初稿进行修订,确立置管方案终稿。(3)临床应用:将方案应用于临床。采取类试验研究,选择甘肃省兰州市某三级甲等医院的两个重症监护病房,2022年12月1日至2023年6月30日进行鼻肠管留置的机械通气患者40例为对照组,接受科室常规置管方式;2023年8月1日至2024年2月28日期间进行鼻肠管留置的机械通气患者39例为试验组,严格按照前期构建的方案进行鼻肠管置管操作。比较两组鼻肠管置管成功率,首次置管成功率,置管时长,不良事件发生率以及置管前后的血压、脉搏、呼吸、血氧饱和度等生命体征,采用SPSS 26.0软件进行统计学分析,P<0.05为差异具有统计学意义。研究结果(1)证据总结:初步检索共获得有关机械通气患者盲视下鼻肠管主动置管的指南及文献8670篇,根据文献纳入和排除标准筛选,最终纳入21篇文献,其中临床决策2篇,指南8篇,专家共识2篇,系统评价3篇,证据总结1篇,随机对照试验4篇,类实验1篇。通过课题小组对证据进行整理汇合,围绕置管前评估、置管前准备、置管过程、鼻肠管位置确认、注意事项和拔管6个维度共形成了37条机械通气患者盲视下鼻肠管主动置管最佳证据。(2)方案构建:在前期证据总结的基础上,通过专家会议最终形成机械通气患者盲视下鼻肠管主动置管方案,方案内容包括置管指证、操作前评估、操作前准备、床旁置管、操作后处理、拔管、注意事项等7个方面。专家会议后,删除2个条目、修改8个条目、增加1个条目,最终确立了3个维度61个条目的置管方案。专家会议的专家权威系数为0.855。(3)临床应用:两组患者在年龄、性别、BMI、支付方式、疾病类型、药物使用情况、疾病严重程度等方面的差异无统计学意义(P>0.05)。统计分析结果显示:试验组和对照组的置管成功率分别为92.3%和80.0%,差异无统计学意义(P>0.05)。首次置管成功率方面,试验组为61.5%,对照组为37.5%,差异有统计学意义(P<0.05)。在置管时长方面,试验组和对照组分别为19.69±4.75分钟和22.35±4.29分钟,差异有统计学意义(P<0.05)。在置管次数方面,试验组和对照组分别为1.54±0.76次和1.93±0.83次,差异有统计学意义(P<0.05)。置管安全事件方面,两组均出现鼻黏膜出血的并发症(试验组vs对照组:10.3%vs17.5%),但差异无统计学意义(P>0.05),均未出现其他并发症;置管前后生命体征均保持稳定,同组患者置管前后差异、试验组与对照组间差异均无统计学意义(P>0.05)。研究结论(1)本研究构建的机械通气患者盲视下鼻肠管主动置管方案基于最佳证据,充分考虑我国临床实际情境,充分考察了具体的患者群体特点,并根据专家会议修订、完善,具有科学性、可行性、安全性,操作性强,可为临床护理实践提供理论指导。(2)本研究对机械通气患者盲视下鼻肠管主动置管方案的临床效果进行了初步验证,具有较好的应用效果和安全性,能够在护士群体中使用,有效推动了证据向实践转化,切实为鼻肠管置管在临床上进一步规范开展提供了有价值的参考。更多还原

【Abstract】 ObjectivesThe purpose of this study is to systematically search,screen,and evaluate relevant literature,extract and synthesize evidence,develop a specific program for active nasoenteric tube placement under blind vision in mechanically ventilated patients through an evidence-based nursing approach and apply it to the clinic,evaluating the effect of the program,with the aim of providing nurses with a scientifically standardized,easy-to-use,safe,and effective nasoenteric tube placement program to promote the enhancement of the quality of clinical nursing care,reduce complications and safety risks,achieve early nutritional support.Methods(1)Evidence synthesis: A research team was set up to systematically and comprehensively search domestic and international guidelines,expert consensus,systematic reviews,and original literature related to nasoenteric tube placement in mechanically ventilated patients,evaluate the quality of the included studies using the appropriate quality evaluation tools,screen the evidence,sort and integrate all the evidence,and use the JBI evidence grading system to assess the level of recommendation and form the best evidence summary.(2)Evidence-based program: A protocol development group was set up to form a preliminary draft of the protocol for active nasoenteric tube placement under blind vision in mechanically ventilated patients based on the summary of the evidence,and then revise the preliminary draft to establish the final draft of the protocol by convening an expert meeting and combining the opinions of clinical nursing managers and tube placement practitioners from tertiary hospitals in China.(3)Clinical trials: A clinical trial was conducted.Two intensive care wards of a tertiary hospital in Lanzhou city,Gansu Province,were selected,and 40 cases of mechanical ventilation patients who underwent nasointestinal tube placement between December 1,2022 and June 30,2023 were taken as the control group,and received the conventional tube placement method in the department;and 39 cases of mechanical ventilation patients who underwent nasointestinal tube placement between August 1,2023 and February 28,2024 were taken as the experimental group,and the operation of nasoenteric tube placement was carried out strictly according to the preconstructed program.The success rate of nasoenteric tube placement,the success rate of first-time tube placement,the time of tube placement,the incidence of adverse events,and vital signs such as blood pressure,pulse rate,respiration,and oxygen saturation before and after tube placement were compared between the two groups,and were statistically analyzed using SPSS 26.0,with P<0.05 as the difference being statistically significant.Results(1)Evidence synthesis: A total of 21 literatures were finally included,including2 clinical decision-making articles,8 guidelines,2 expert consensus articles,3systematic reviews,1 summary of evidence,4 randomized controlled trials,and 1 quasiexperimental study.By organizing and converging the evidence by the panel,a total of37 best evidence for active nasoenteric tube placement under blind vision in mechanically ventilated patients were formed around the 6 dimensions of preplacement assessment,preplacement preparation,placement process,nasoenteric tube position confirmation,precautions,and extubation.(2)Evidence-based program: Based on the summary of the previous evidence,an active nasoenteric tube placement program for mechanically ventilated patients under blind vision was finally formed through the expert meeting,which included 7dimensions,including indications for tube placement,preoperative assessment,preoperative preparation,bedside tube placement,postoperative treatment,extubation,and precautions.After the expert meeting,2 entries were deleted,8 entries were modified,and 1 entry was added,and the nasoenteric tube placement program was finally established with 61 entries in 3 dimensions.The authority coefficient of experts was 0.855.(3)Clinical trials: The differences between the two groups in terms of age,gender,BMI,payment method,disease type,drug use,and disease severity were not statistically significant(P>0.05).Statistical analysis showed that the success rates of tube placement in the experimental group and the control group were 92.3% and 80.0%,respectively,and the differences were not statistically significant(P>0.05).In terms of the success rate of first-time tube placement,61.5% in the experimental group and 37.5% in the control group,the difference was statistically significant(P<0.05).In terms of the duration of tube placement,it was 19.69±4.75 minutes and 22.35±4.29 minutes in the experimental group and the control group,respectively,and the difference was statistically significant(P<0.05).In terms of the number of tube placement,the experimental and control groups were 1.54±0.76 and 1.93±0.83 times,respectively,with statistically significant differences(P<0.05).Regarding the complications of tube placement,the adverse events of nasal mucous membrane bleeding occurred in both groups(experimental group vs.control group: 10.3% vs.17.5%),but the difference was not statistically significant(P>0.05),and there were no other adverse events;the vital signs before and after the tube placement were stable,and the differences between before and after the tube placement,and the experimental group and control group were not statistically significant(P>0.05).Conclusion(1)The active placement of nasoenteric tube under blind vision for mechanically ventilated patients constructed in this study is based on the best evidence,fully considers the actual clinical situation in China,fully examines the specific characteristics of the patient group,and is revised and improved according to the expert meeting,which is scientific,feasible,safe,and highly operational,and can provide theoretical guidance for clinical nursing practice.(2)This study conducted a preliminary validation of the clinical effectiveness of the active nasoenteric tube placement program under blind vision in mechanically ventilated patients,and the results show great application effect and safety,and it can be used in the nurse population,effectively promoting the transformation of evidence into practice,and effectively providing valuable reference for the further standardization of nasoenteric tube placement in the clinic.更多还原