Evidence-Based Nursing

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Evidence-Based Nursing

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• Step 1 ???????
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• Step 2 ??????
• Step 3 ??????
• Step 4 ???????
• Step 5 ???????

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??????

• ??????????????????(gt 50 )
• ?????????
• ??????? / ?????? / ??????
• ?????????????????(gt 80 )
• ??????(Aerosol Therapy) (???,2002 )
• ?????,????????????,????????
• ????,??????
• ???????

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???????????

• ????, ??????,?????
• ????????, ??????
• O2 flow 6-8 l/min,??????
• ???????, ?????
• ??45-90?, ????????,??,???
• ??????15??
• ??????, ?????, ????????????,??????
• ??????, ?????

Inhalation ??
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?????????

• Evidence-Based Clinical Practice Guidelines
• ??Brochiolitis????????
• ??????
• ????????? (level D)
• suction(level D)
• ?????????
• CPT(level Ib / Level D)
• Cool mist therapy (level D)
• Saline aerosol therapy.. (level Ib)

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??EBN????

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• ??????? / ??
• O2 flow??
• flow??, ??????????,???????
• ???????
• ?????,????????

??????? / ??
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??????????

• Step 1 ????????????
• Step 2 ??????
• Step 3 ??????
• Step 4 ???????
• Step 5 ???????

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Step 1 ????

• ?????????????????????????

Intervention
Comparision
Patient
Outcome
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???? 1

• ???? (next)
• ????
• ??? V.S 0.9 ?????
• ???????
• ???pneumonia, Bronchopneumonia(?????)
• ???7??????
• ????
• ?????/ ?? (????/ ??????)
• ????? (?????????)

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???? 2

• ??????(???) ( Jet Nebulizer )
• ?? (???,2002 )
• ??????(Bernoullis priniciple),????????????????????
  ??, ??????, ????????????????, ?25 ?????????
• ??? (?, 2001 Uma Maheswari, 2001 )

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???? 3

• ??????

????
????
???
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???? (1)

• ????????? (???,2002 )
• ?????????, ????????????????
• ???????????
• ???????
• ?????????????????????????????

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???? (2)

• ???? (Aerosol Therapy) 2
• ???(???,2002 )
• ?????????????????
• ??????????????????????, ?????????
• ????????, ?????????????
• ????????????,???????

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???? (3)

• ???? (Aerosol Therapy) 3
• ??? (???,2002 Uma Maheswari, 2001 )
• ??????,???????, ???????(Aiwway obstruction)
• ?????????????????(Bronchospasm)
• ??????????????????(Over hydration) ,????
• ??(Infection)
• ??????????,????(Thermal injury)

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???? (4)
(???,2002 )

• ??????????????
• ???????????????
• ??????? lt 3um ,??????????,????????????
• ?????????????
• ??????(jet nebulizer) vs. ??????
• ????????? ?????????? ????????? (??????) ???????
  ????????
• ??????????????
• ??????????????,??????

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???? (5)

• ???????????????
• ????????? gt 2um?????????
• ???,??????????,???O2 mask ,?????????????????
• ??????????,?????,?????????????
• ???????35 ??????15

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???? (6)

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• ?????????,???????? ????? ??????????
• ?????????????????????,???????????
• ?? lt ?? lt ??
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• ????????,??????????, ????????,????????????

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Step 2 ??????
http//www.wanfang.gov.tw/EBM/
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????????? 1

• ??? aerosol therapy (1?)
• ????? 0 ?
• nebulizer ( ?)
• ????? 0 ?
• steam inhalation (6?)
• ????? 0 ?

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????????? 2

• ??? aerosol therapy (40?)
• ????? 1 ?
• nebulizer (40?)
• ????? 1 ?
• steam inhalation (1?)
• ????? 1 ?

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????????? 3
MEDLINE

• ??? aerosol therapy (18?)
• ????? 3 ?
• nebulizer (77?)
• ????? 2?
• steam inhalation (1?)
• ????? 0 ?

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????????? 4

• ??? aerosol therapy (1268?)
• ???2? ( 451?)
• inhalation (6?)
• ????? 0 ?

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Step 3 ??????

• ????????????????
• ??????????,???????????????????????

The Evidence Pyramid????????
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???????(????????????)--US Agency for Health
Care Policy and Research Classification (AHCPR,
1992)
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?????? (Grades of Recommendation of
Effectiveness )
Develop by JBI
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?????? (1-1)

• ????
• ?????????
• ??
• ???
• ??
• ???? (2001), 42, 50-55

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?????? (1-2)

• ????
• ?????????(???, 2001)
• Gas flow rate 68 l /min
• Nebulizing volume 45 c.c.
• Slow and deep breathing pattern
• Mouth breathing better than nose breathing
• ?????IV?

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?????? (2-1)

• ????
• ???? (Aerosol Therapy)
• ??
• ??? ???
• ??
• ???? (2002), 1(1), 81-101

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?????? (2-2)

• ????
• ??????????, ?????????, ?????????
• ?????IV?

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?????? (3-1)

• ????
• AEROSOL THERAPY
• ??
• Uma Maheswari
• ??
• Pulmonary Critical Care Bulletin
• Vol. VII, No. 3, July 15, 2001

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?????? (3-2)

• ????
• Bland aerosols include heated or cooled sterile
  water and saline.These aerosols are mainly used
  in treatment of upper airway disease,
  humidification of the bypassed airway and sputum
  induction.

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?????? (3-3)

• Higher flow rates cause turbulent flow, aerosol
  fragmentation and failure of deposition.
• Higher respiratory rates are associated with
  higher flow rates and poor aerosol delivery
• Hence a slow, deep breath with an end inspiratory
  breath - hold of 5-10 seconds is optimal for
  aerosol impaction in the bronchi and bronchioles.

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?????? (3-4)

• Gas flow rates of 6-8 lpm
• Optimal volume of nebulising solution 4-5 ml
• Particle size 1-5 u
• 10 of aerosol reaches its site of action
• Evidence Grade D

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?????? (4-1)

• ????
• Evidence based clinical practice guidelines for
  the infant with bronchiolitis.
• ??
• Cincinnati Children's Hospital Medical Center.
• ??
• Evidence based clinical practice guideline for
  infant with bronchiolitis. Cincinnati (OH)
  Cincinnati Children's Hospital Medical Center
  2001 Nov 28. 9 p.

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?????? (4-2)

• ????
• Scheduled or serial use of bronchodilator aerosol
  therapies is not recommended unless there is a
  documented clinical improvement response from a
  given patient
• Inhalations using epinephrine as a trial therapy
  may be considered
• if, between 15-30 minutes after a trial
  inhalation therapy, there is no significant
  improvement in clinical appearance, it is
  recommended that the therapy not be continued nor
  be repeated.

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?????? (4-3)

• It is recommended the infant be suctioned before
  feeding, PRN and prior to each inhalation therapy
  (Evidence Grade E).
• Suctioning itself may improve respiratory status
  such that inhalation therapy is not necessary.
  Thus, it is important to document the pre-and
  post-suction score.
• Suctioning may improve the delivery of the
  inhalation treatment (Evidence Grade E ).
• Normal saline nose drops may be used prior to
  suctioning (Evidence Grade E ).

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?????? (4-4)

• Other routine respiratory care therapies are not
  helpful and are not generally recommended.
• Chest physiotherapy (CPT) is not recommended
  (Nicholas et al., 1999 B Webb et al., 1985
  E).
• Cool mist therapy is not recommended (Gibson,
  1974 E).
• Aerosol therapy with saline is not recommended
  (Chowdhury et al., 1995 A Gadomski et al.,
  1994 A Ho et al., 1991 B).

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?????? (5-1)

• ????
• Guidelines for preventing health-care--associated
  pneumonia, 2003 recommendations of CDC and the
  Healthcare Infection Control Practices Advisory
  Committee.
• ??
• Tablan OC, Anderson LJ, Besser R, Bridges C,
  Hajjeh R.
• ??
• MMWR Recomm Rep 2004 Mar 2653(RR-3)1-36.

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?????? (5-2)

• ????
• Between treatments on the same patient clean,
  disinfect, rinse with sterile water (if rinsing
  is needed), and dry small-volume in-line or
  hand-held medication nebulizers (IB) .
• Use only sterile fluid for nebulization, and
  dispense the fluid into the nebulizer aseptically
  (IA).
• Whenever possible, use aerosolized medications in
  single-dose vials. If multidose medication vials
  are used, follow manufacturers instructions for
  handling, storing, and dispensing the medications
  (IB).

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?????? (6-1)

• ????
• Nebuliser hood compared to mask in wheezy
  infants aerosol therapy without tears!
• ??
• I Amirav, I Balanov, M Gorenberg, D Groshar and A
  S Luder
• ??
• Archives of Disease in Childhood. 88(8)719-23,
  2003 Aug.

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?????? (6-2)

• ????
• Both treatments provided similar clinical benefit
  and side effects as reflected in improved oxygen
  saturation, reduced respiratory frequency, and
  increased heart rate.
• It is much better tolerated by infants and
  preferred by parents.
• Hood nebulisation is a simple and patient
  friendly mode of aerosol therapy in wheezy
  infants.
• ?????Ib?

42
?????? (7)

• ????
• Effect of ipratropium bromide and/or sodium
  cromoglycate pretreatment on water-induced
  bronchoconstriction in asthma.
• ??
• Tranfa CM. Vatrella A. Parrella R. Bariffi F.
• ??
• European Respiratory Journal. 8(4)600-4, 1995
  Apr.

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?????? (7)

• ????
• ??ipratropium bromide (80 ug)?sodium cromoglycate
  (20 mg)?distilled water? bronchospasm??????
• Rrandomized, placebo-controlled, double-blind
  study (N15).
• measured by change in specific airways
  conductance (sGaw)
• These results suggest that water-induced
  bronchoconstriction is deterimined by more than
  one mechanism
• ?????Ib?

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?????

• ?????????????, ????
• Flow
• Diluents
• ????????, ????????.
• ???????
• ??????????

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??Diluents 1

• 0.9 NaCl
• ???bronchospasm, ??asthma attack
• 0.45 NaCl
• ???????
• 3 NaCl
• ???????????
• Distill Water
• ???bronchospasm

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??Diluents 2

• 0.9 NaCl
• ?????bronchospasm
• ???bronchodilator?????
• Distill Water
• ???bronchospasm
• ???bronchodilator?????

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?????????

• ????
• ???????
• 2005.03.???????0.45 Normal Saline
  Solution??inhalation solu.
• ????
• ??0.45 N.S. Solution?, ??????????
• ?????????????

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???????

• ????????????lt 5 u????
• ???????????????????
• O2 mask vs O2 hood / tent ?
• O2 hood / tent ??????, ??????, ????
• ??, ???

Atrauma care!

• Aerosol Medication Delivery

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???? ?????? http//www.wanfang.gov.tw/EBM/ebn/visi
on.htm
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