癌痛的评估与护理(汉译英).doc

癌痛的评估与护理疼痛是癌症病人普遍存在的症状。尽管在止痛方面取得了巨大进展，但仍有三分之二的癌症病人到晚期都要忍受癌痛的折磨。因此，需要护士具备处理癌痛的多方知识，掌握正确评估方法和治疗技术及恰当的护理。现就其综述如下。 1癌性疼痛的护理评估 1.1视觉模拟评分法(Viraal Aualort Scale，简称VAS)：该法比较灵敏，有可比性。具体做法是：在纸上面划一条10 cm的横线，横线的一端为0，表示无痛；另一端为10，表示剧痛；中间部分表示不同程度的疼痛。让病人根据自我感觉在横线上划一记号，表示疼痛的程度。轻度疼痛平均值为2.571.04；中度疼痛平均值为5.181.41；重度疼痛平均值为8.411.35。 1.2评估表法：它是由美国的McmilLan设计的疼痛估计表。即0等于无痛，1等于有疼痛感，但不严重；2等于轻微疼痛，病人不舒服；3等于疼痛，病人痛苦；4等于疼痛较剧烈，有恐惧感；5等于剧痛。通过问答形式由病人做出具体描述。内容包括：疼痛程度、部位、性质、发作情况及伴发症状等。据报道此表设计合理，实用性强。 1.3口述评估法(Verbal Report)：Melzack拟定了1份形容疼痛程度词汇，如轻度疼痛、重度疼痛、阵痛、可怕的痛及无法忍受的疼痛等来帮助病人描述自己的疼痛，使病人更好地把疼痛加以表达，按010分次序报告，0分表示无痛，10分表示剧痛。此法简单，但不易发觉细微变化。 2癌痛的止痛治疗 2.1药物治疗：世界卫生组织(WHO)提出2000年消除癌症患者疼痛的奋斗目标。其提出的三级止痛方案是目前世界各地都在大力推行的癌前药物治疗准则。也称“按需给药”，即一级止痛：轻度疼痛使用非麻醉性镇痛药。如阿斯匹林、扑热息痛等。二级止痛：中度持续性疼痛或加重，使用弱麻醉剂。如强痛定、可待因、美散痛等。三级止痛：强烈持续性疼痛，使用强麻醉剂，直到疼痛消失。如吗啡、杜冷丁等。其主要给药途径有以下几种： 2.1.1消化道给药：药物给药近来提倡口服为主，对慢性癌痛采用布罗芬与美散痛合用取得了良好效果，用布罗芬600 mg与美散痛2.55 mg合用，效果优于单独应用美散痛，而不增加副作用。且对骨转移癌痛也有较好的止痛效果。研究中未发现布罗芬对十二指肠粘膜有损伤，认为布罗芬的安全性和较低的副作用是可取的。近年来开发的盐酸双氢吗啡控释片，克服了吗啡的某些副反应，又增加了镇痛效果。已成为需要麻醉止痛时的首选药物。不能口服者也可直肠给药。芬太尼、buprenophine也可舌下给药。 2.1.2连续皮下或静脉给药：当大量口服止痛药不能控制疼痛时，或有严重的胃肠道反应如恶心、呕吐等副作用时，需采用连续皮下或静脉内输入麻醉剂：Sheider评估了这种方法，肯定了其给药的安全性和效能，现已普遍应用。 2.1.3皮肤给药：近年来由于皮肤生理研究和制药技术的发展，皮肤与粘膜已经作为给药的新途径。有报道，一次芬太尼贴敷止痛可达72 h。虽使用方便，但价格昂贵。另外，中药外治法能使药物经皮肤吸收，起效快、安全、方便、毒副作用小。用药10 min即可见效，总有效率79.2%。 2.1.4病人控制的止痛(Patient Controleel Analgesir，简称PCA)：PCA方法1984年在美国被有效地应用。其方法是患者拥有一个用计数电子仪控制的注药泵。它可提供麻醉剂的剂量、剂量增减范围和估计2次剂量的间隔最短时间，以及提供一个稳定的注药间隔周期。能更好地取得疼痛控制效果，减少麻醉剂用量，减少副作用。但其缺点是必须有一定设备，且价格昂贵。并可引起药物外渗、静脉炎及感染等。目前已研制出新型控制止病人的痛药泵，分家庭用、护士用及防止用药过量的PCA 3种类型。不仅可防止病人用药过量，还可通过电脑程序控制持续输液中的止痛药浓度，以维持稳定的止痛效果，防止病人出现剧痛。 2.1.5麻醉技术控制癌痛：神经阻滞在晚期癌痛病人中已应用了多年，近年来提倡在早期癌痛患者中应用。通过导管或泵，连续或间断将药物输入硬膜外或鞘内。此法避免了口服给药和其他方法给药的副作用，同时还减少了辅助药物的应用。但也有人报道，全身先用阿片类药物治疗的病人，脊柱内再给阿片类药物则无治疗效果。 2.1.6神经外科技术控制癌痛：手术治疗的目的是在周围神经与中枢神经之间某一点切断产生疼痛的途径。 3癌痛的护理 3.1护理观念的更新：迅速有效地减轻癌痛是护理的基本要求，也是护士基本的责任。因此，护士应尽力发展提高癌痛的护理水平。癌痛的控制往往受病人、护士、药物组合多种因素的综合影响，而护士的密切观察和及时提供适应的止痛方法是控制癌痛重要因素。这就需要护理教育计划从基础和临床上对药物的药理学和用药方式进一步加强，树立果断采取各种治疗手段，设法解除病人痛苦，提高病人生存质量延长生命的新观念，严格遵守有效控制疼痛的指导原则。 3.2护士的作用 3.2.1准确评估：在对癌痛控制过程中，疼痛的评估是第一重要环节。护士不仅要客观地判断疼痛是否存在，还要确定疼痛的程度。在用药前护士必须根据个体疼痛作出准确的判断，采取相应措施，才能有效地减轻病人的痛苦。通过对1 400名注册护士问卷调查表明，最佳处理疼痛的主要障碍是对疼痛估计不足，处理疼痛的知识不够及病人不愿报告疼痛。因此，对护士而言更重要的是有关疼痛的处理和用以解除癌痛的标准教育。 3.2.2准确及时给药：观察效果及副作用。包括了解治疗的基本原则，向病人说明接受治疗的效果及帮助病人正确用药，评估治疗效果，向医生报告以及副作用的防治等。 3.2.3心理护理：要帮助病人树立信心。因势利导，调动病人积极的心理因素，帮助克服其消极的心理因素。争取病人信任，增强病人的安全感，稳定情绪，解除焦虑。注意分散病人注意力。建立“舒适家庭病房”，因为舒适可使心理生理异常减轻到最低程度。Assessment and care of cancer painPain is common symptom of cancer patients. Despite the pain has made tremendous progress, but there are still two-thirds of cancer patients to have to put up with advanced cancer pain of torture. Therefore, nurses have the knowledge of handling multi-cancer pain, to master the correct assessment and treatment techniques and appropriate care. Is on its review as follows. 1A nursing assessment of cancer pain 1.1 Visual analogue scale (Viraal Aualort Scale, referred to as VAS): The more sensitive method, there are comparable. Specifically: In the paper, draw a 10 cm above the horizontal line, horizontal line of the end of 0, indicating no pain; the other side of 10, said the pain; the middle part of the varying degrees of pain. Feel the patient according to a uniform mark on the horizontal line, indicating the degree of pain. Mild pain, mean 2.57 1.04; moderate pain an average of 5.18 1.41; moderate to severe pain, average 8.41 1.35.1.2 Evaluation form method: It was designed by the American Pain McmilLan estimated table. That 0 equals no pain, 1 is equal to a pain, but not serious; 2 equals mild pain, patient discomfort; 3 is equal to the pain, the patient suffering; 4 is equal to more severe pain, there is fear; 5 equal to severe pain. Made through the Q & A specific description of the patient. Include: pain intensity, location, nature, and the concomitant onset of symptoms. It is reported that this table design is reasonable, practical. 1.3 Oral Assessment Act (Verbal Report):Melzack 1 developed vocabulary to describe the degree of pain, such as mild pain, severe pain, pain, terrible pain and could not bear the pain to help patients describe their pain, so be patient to better express the pain, according to 0 the order of 10 reports, 0 points indicating no pain and 10 points indicating severe pain. This method is simple, but difficult to notice subtle changes. 2 Analgesic treatment of cancer pain 2.1 Drug treatment: World Health Organization (WHO) proposed in 2000 to eliminate pain in patients with the goal of cancer. The proposed three-tier program is pain all over the world promoting the use of pre-cancerous drug treatment guidelines. Also called on-demand delivery, that is a pain: mild pain, use of non-narcotic analgesics. Such as aspirin, paracetamol and so on. Second pain: moderate persistent pain or increase, the use of weak anesthetic. If given strong pain, codeine, methadone pain. Three levels of pain: a strong persistent pain, with a strong anesthetic, until the pain disappears. Such as morphine, pethidine and so on. The main route of administration are the following: 2.1.1 Gastrointestinal drug delivery: Recently, the main advocate of oral drug delivery, chronic cancer pain using Bu Luofen methadone combined with the United States and achieved good results, with the United States with Bu Luofen 600 mg methadone 2.5 5 mg combination, more effective than methadone alone pain, without increased side effects. And the pain of bone metastasis has a better analgesic effect. Study found no Bu Luofen duodenal mucosa injury, that the Bu Luofen security and lower side effects is desirable. In recent years the development of controlled-release morphine hydrochloride tablets hydrochlorothiazide and overcome some of the side effects of morphine, increased the analgesic effect. Has become the first choice when the need for narcotic pain drugs. Those who can not be oral or rectal administration. Fentanyl, buprenophine also sublingual administration. 2.1.2 Continuous subcutaneous or intravenous injection: When a large number of oral pain medication can not control the pain, or have serious gastrointestinal reactions such as nausea, vomiting and other side effects, requires the use of continuous subcutaneous or intravenous anesthetic input: Sheider assessment of this approach, confirmed the safety of its administration and performance, is now widely used. 2.1.3 Skin dose: In recent years, the physiology of the skin and pharmaceutical technology, drug delivery skin and mucous membranes have been used as a new way. It has been reported, a fentanyl pain patching up to 72 h. Although easy to use, but expensive. In addition, the Chinese external treatment to make drugs absorbed through the skin, rapid onset, safety, convenience, drug side effects. 10 min treatment to be effective, total effective rate 79.2%. 2.1.4 Patient-controlled analgesia (Patient Controleel Analgesir, referred to as PCA): 1984 PCA method was applied effectively in the United States. The method is that the patient has an electronic instrument controlled by counter drug infusion pump. It provides ane sthetic dose, dose range and the estimated increase or decrease the interval between 2 doses of the shortest time, and provide a stable interval between injection cycles. Better access to effective pain control, reduce the amount of anesthetic agents, reduce side effects. But its drawback is that there must be some equipment, and expensive. And can cause drug extravasation, phlebitis and infection. Has developed a new type of control only the patients pain medication pumps, domestic use, the nurse and to prevent overdose PCA 3 types. Not only prevent overdose patients, but also sustained by the computer program control pain infusion drug concentration in order to maintain a stable analgesic effect, prevent the patient developed severe pain. 2.1.5 Anesthesia control cancer pain: Nerve block in patients with advanced cancer has been in use for many years, in recent years to promote the application of early cancer pain. Through the catheter or pump, continuous or intermittent epidural or intrathecal drug importation. This method avoids the administration of oral medication and side effects of other methods, but also reduce the application of adjuvants. However, some reports, the body first with opioid therapy in patients with spinal opioids to give no treatment. 2.1.6 Neural control of cancer pain surgical techniques: The purpose of surgical treatment of peripheral nerve and central nervous system is a point between the way off to pain. 3 Cancer Pain Care 3.1 Renewing care: Quickly and effectively to reduce pain is the basic requirement of care is a basic responsibility of nurses. Therefore, nurses should try to develop standards to improve the care of cancer pain. Cancer pain control are often affected by patients, nurses, drug combinations combined effects of many factors, and nurses to provide close observation and timely adaptation to pain is an important factor in controlling cancer pain. This requires that nursing education programs from basic and clinical pharmacology of drugs and drug use means to further strengthen and establish a firm to take a variety of treatments to try to relieve the suffering of patients and improve the quality of life in patients with life-prolonging new ideas, strict compliance with effective control of pain guidelines. 3.2 The role of nurses 3.2.1 Accurate assessment of: In the course of pain control, pain assessment is the first important part. Nurses not only to objectively determine whether there is pain, but also to determine the degree of pain. Former nurse in the treatment of pain must be based on the individual to make accurate judgments, to take corresponding measures, can effectively reduce the pain. By 1 400 registered