名老中医江育仁临床经验

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疼痛評估及處理(PainAssessmentandIntervention)一、前言：吳麗彬二、疼痛的生理觀：(一)Paintransduction(疼痛傳導)1.Fastpain(快速痛)2.Slowpain(慢速痛)(二)Paintransmission(疼痛傳遞)1.A-deltafibers(A-delta纖維)2.Cfibers(C纖維)(三)Painmodulation(疼痛調節)1.Modulationviathedorsalhorn(經由脊髓神經角調節)2.Modulationviadescendingpathways(經由抑制疼痛路徑調節):如Endorphin3.Modulationviaendogenouschemicals(經由內生性化學物質調節)三、疼痛的理論：(一)Specificitytheory(二)Gate-controltheory四、疼痛型態(Typesofpain)(一)Acutepain(急性疼痛)(二)Chronicpain(慢性疼痛)(三)Cutaneousorsuperficialpain(皮膚或表皮痛)(四)Deepsomaticpain(深部驅幹痛)(五)Visceralpain(內臟痛)(六)Referrespain(反射痛)五、疼痛的評估及處理：(一)評估：1.影響疼痛的因素：(1)Perceptionofpain(對疼痛的認知)(2)Responsetopain(對疼痛的反應)(3)Therapeuticimplicationsofthepainprocess(疼痛過程的治療情形) 2.評估之基本原則：(見表)(1)History(病史)*Painoflocation(疼痛部位)*Extensionorradiation(範圍或輻射大小)*Onsetandpattern(開始時間和疼痛型態)*Duration(疼痛期間多久)*Characterorquality(特性或性質)*Precipitation,aggravating,andalleviatingfactors(加強或減輕因素)*Intensity(增強情形)*Associatedsymptoms(相關症狀)*Effectonactivitiesofdailyliving(對日常生活影響)*Methodsofpainrelief(減輕疼痛方法)(2)Physicalexamination(身體檢查)*Sympatheticresponses(交感神經反應)：Vitalsigns變化等*Parasympatheticresponses(副交感神經反應)：腸胃症狀等*Behavioralresponses(行為表現)：呻吟、嘆氣、退縮等(3)Toolsusedtoassesspain(疼痛評估工具)：10分法、直線法等(二)處理：1.Basicprinciples(基本原則)(1)Alleviatinganxiety(減輕焦慮)(2)Distractionordiversion(轉移或分散注意力)(3)Combattinganticipatoryfears(處理預期性害怕)(4)Providingphysicalcare(提供身體照護)(5)Administrationofpain-relievingmedication(給減輕疼痛藥物)(6)Managingchronicinteratablepain(處理慢性棘手的疼痛)(7)Managingprogressivepain(處理進行性的疼痛)2.Invasiveinterventions(侵入性治療)(1)Localanesthesia(局部麻醉)(2)Topicallocalanesthesia(全身麻醉)*(3)Analgesia(止痛劑).Mechanismsofanalgesia(使用機轉).Typesofanalgesics(種類)A.非Opioids(麻醉性)止痛劑：NSAIDB.弱Opioids(麻醉性)止痛劑：Codeine，Demerol C.強Opioids(麻醉性)止痛劑：Morphine.Complicationsofopiateanalgesics(止痛劑之副作用)A.Respiratorydepression(呼吸抑制)B.Constipation(便祕)----最常見C.Paresthesias(感覺異常)D.Tolerance(抗藥性)E.Addiction(成癮性).Factorsinfluencingtheeffectivenessofanalgesics(影響止痛劑效果之因素)A.Relativeanalgesicpotency(各藥物本身效能)B.Timeaction(給予時間)C.Oralpotency(口服效果)D.Principlesandmethodsofanalgesicadministration(止痛劑給藥原則及方法)(A)Preadministrationassessment(給藥前評估)a.Drugallergiesorsensitivities(藥物過敏及感受情形)b.Othermedicationstheclientistaking(其他藥物使用情況)c.Bodyweight(體重)d.Individualpainexperience(個人疼痛經驗)e.Otherindividualcharacteristics(個人體質)：age，generalstateofhealth，mentalstatus，probabledurationofpain，andprobablelifeexpectancyf.Bodysystemassessment(身體系統評估)g.Previousresponsetoanalgesics(過去對止痛劑的反應)(B)Methodsofadministration(給藥方法)a.Nurse-Administered(Demand)(護理人員給予)b.Patient-Controlledanalgesic(病人自控式給藥)c.Intraspinalanalgesia(經脊髓給予)d.Nervebolcks(神經阻斷)(4)Neurosurgeryforpainrelief(外科去神經疼痛減輕)(5)Stimulationtherapy(刺激治療)：如Transcutaneouselectricnervestimulation(TENS)(經皮電神經刺激)(6)Radiationtherapy(放射線治療)(7)Placebos(安慰劑)3.Noninvasiveinterventions(其他非侵入性治療) (1)Meditation(藥物)：如鎮定劑等(2)Autogenictraining(自體免疫加強)(3)Progressiverelaxationtraining(進行性放鬆訓練)(4)Guidedimagery(冥想法)(5)Rhythmicbreathing(呼吸節律控制法)(6)Operantconditioning(由心而起的反應)(7)Biofeedback(生物迴饋法).Establishingatherapeuticrelationship(建立治療性關係).Cutaneousstimulation(表皮刺激)：如按摩.Hypnosis(催眠).Music(音樂).Acupressure(針灸)六、總結參考資料：Black,J.M.&Matassarin-Jacobs,E.(1993).LuckmannandSorensen’smedical-surgicalnursing:apsychophysiologicapproach.Philadelphia:W.B.SaundersCo.Kaye,P.(1996).Symmptomcontrolinhospice&palliativecare.Hospiceeducationinstitute.黃愛娟。(民國71)。病人疼痛的處理。護理雜誌，29(3)，53-64。藍先元&李明濱。(民國81)。癌症疼痛的治療。當代醫學，19(2)，162-166。