農(nóng)玉荷，莫新少，聶 峰，李壯江，熊 妮，陳寶玉

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腎移植病人睡眠質(zhì)量影響因素及護(hù)理干預(yù)研究

農(nóng)玉荷，莫新少，聶 峰，李壯江，熊 妮，陳寶玉

對(duì)腎移植術(shù)后病人的睡眠質(zhì)量現(xiàn)狀、影響因素及危害、相關(guān)的干預(yù)進(jìn)行綜述,為尋求便捷、簡單的臨床干預(yù)提供更多依據(jù),提高臨床護(hù)理質(zhì)量。

腎移植;睡眠障礙;影響因素;危害;護(hù)理干預(yù)

腎移植是目前治療終末期腎病最有效的方法之一。根據(jù)國內(nèi)外研究顯示，睡眠障礙在ICU病人當(dāng)中普遍存在,在腎移植術(shù)后監(jiān)護(hù)期的病人當(dāng)中可高達(dá)86%[1]。因此，本研究擬通過文獻(xiàn)回顧,對(duì)腎移植病人睡眠質(zhì)量及干預(yù)研究進(jìn)行綜述,以期引起醫(yī)護(hù)人員對(duì)腎移植術(shù)后病人睡眠質(zhì)量足夠的重視。

1 腎移植病人睡眠質(zhì)量現(xiàn)狀

睡眠質(zhì)量評(píng)估方法包括多導(dǎo)睡眠描記法(PSG)、體動(dòng)記錄儀(actigraphy)、腦電雙頻指數(shù)(BIS)、Richards Campbell 睡眠量表(RCSQ)、匹茲堡睡眠質(zhì)量指數(shù)(PSQI)等,臨床研究結(jié)果發(fā)現(xiàn)腎病終末期病人睡眠問題普遍存在,但腎移植術(shù)后病人睡眠問題研究甚少,國內(nèi)更是罕見。國外部分研究顯示:腎移植病人的睡眠質(zhì)量較術(shù)前有所改善,但相對(duì)于一般人群仍然很差[2-3]。Mallamaci等[4]用大樣本對(duì)301例腎移植病人,245例血液透析病人及169例健康對(duì)照人員進(jìn)行匹茲堡睡眠質(zhì)量問卷調(diào)查,結(jié)果發(fā)現(xiàn)相對(duì)于血液透析病人而言,雖然腎移植病人的睡眠障礙得到較明顯改善,但仍差于健康人群。 Sabbatini等[5]也證明了這個(gè)觀點(diǎn),報(bào)告有52%腎移植病人存在睡眠紊亂。Pourfarziani等[6]研究也顯示：腎移植病人中有67%睡眠質(zhì)量差。國內(nèi)張玲等[1]對(duì)監(jiān)護(hù)期的腎移植病人進(jìn)行調(diào)查顯示：存在睡眠障礙高達(dá)86%。目前大部分研究都是對(duì)移植病人睡眠質(zhì)量進(jìn)行橫向比較,較少學(xué)者對(duì)移植后病人的睡眠質(zhì)量變化進(jìn)行縱向?qū)Ρ?通過文獻(xiàn)檢索發(fā)現(xiàn)僅有Silva等[7]作了這方面的研究,研究顯示成功移植后1年內(nèi)病人睡眠模式無變化,睡眠質(zhì)量仍很差,但此研究對(duì)病人進(jìn)行觀察的持續(xù)時(shí)間較短,對(duì)于腎移植后遠(yuǎn)期的睡眠質(zhì)量問題廣大醫(yī)護(hù)人員應(yīng)當(dāng)充分重視,將其作為隨訪的一項(xiàng)常規(guī)調(diào)查內(nèi)容并根據(jù)結(jié)果采取一定干預(yù)措施。

2 腎移植病人睡眠質(zhì)量的影響因素

2.1 內(nèi)在因素 影響腎移植術(shù)后病人睡眠內(nèi)在因素主要分為生理因素和心理因素。①生理因素:主要包括自身疾病及疼痛,Reillyspong等[8]研究表明：疼痛移植病人睡眠障礙的相關(guān)因素中占17%(n=143),夜間上廁所高達(dá)67%。也有研究指出腰背部疼痛在影響腎移植病人睡眠占33%[9]。張玲等[1]調(diào)查也指出腎移植監(jiān)護(hù)期睡眠障礙者因身體上的不適(活動(dòng)受限、腹瀉、腹脹等)影響睡眠質(zhì)量的達(dá)66%。而術(shù)前存在的眾多影響睡眠因素(如高血壓、貧血、皮膚瘙癢、安眠藥依賴、阻塞性睡眠呼吸暫停等),術(shù)后仍對(duì)病人造成一定的影響[10-11]。②心理因素:主要為擔(dān)心醫(yī)療費(fèi)用、移植腎功能、就業(yè)問題、藥物的副作用等造成的焦慮和壓力[1,8,12-13]。

2.2 外在因素 影響腎移植術(shù)后外在因素主要作用于住院圍術(shù)期病人,包括環(huán)境[1]和醫(yī)療護(hù)理操作。①環(huán)境因素:包括光線和噪聲。周瑜利等[14]調(diào)查顯示,在各種聲音中,機(jī)器噪聲是最嚴(yán)重的影響因素,占39.66%。國際噪聲協(xié)會(huì)建議ICU的噪聲白天不超過45 dB,傍晚不超過40 dB,夜晚低于20 dB[15]。而現(xiàn)有研究顯示重癥監(jiān)護(hù)室的噪聲遠(yuǎn)遠(yuǎn)高于這一標(biāo)準(zhǔn)。陳嫄[16]研究發(fā)現(xiàn)重癥監(jiān)護(hù)室大多數(shù)機(jī)械報(bào)警聲為60 dB～70 dB,有的超過80 dB。②醫(yī)療護(hù)理操作:護(hù)士執(zhí)行夜間護(hù)理操作必然會(huì)驚醒病人,降低病人的睡眠質(zhì)量。Ugras等[17]研究發(fā)現(xiàn)43.9%的病人認(rèn)為變換體位干擾睡眠,40.9%的病人表示護(hù)士定時(shí)向其提問以判斷意識(shí),這一行為也嚴(yán)重?cái)_亂了睡眠。在夜間干擾睡眠前3位的護(hù)理操作是護(hù)士為病人進(jìn)行定時(shí)的翻身、生命體征的監(jiān)測(cè)和交接班時(shí)查體[18]。③睡眠障礙對(duì)腎移植病人的影響：腎移植病人常見睡眠障礙主要有睡眠剝奪、睡眠性呼吸暫停、失眠等[3，19],而這些對(duì)病人的生理和心理產(chǎn)生一定的影響。Molnar等[19]研究顯示:腎移植術(shù)后病人存在較高的阻塞性睡眠呼吸暫停綜合征(OSA),而OSA顯著增加了心血管和腦血管發(fā)病率。Dinges等[20]在研究睡眠剝奪和免疫細(xì)胞之間關(guān)系時(shí)發(fā)現(xiàn),睡眠剝奪和T輔助細(xì)胞的減少及白細(xì)胞、單核細(xì)胞、自然殺傷細(xì)胞的活動(dòng)性增強(qiáng)呈線性關(guān)系。睡眠剝奪可使病人的免疫力降低,增加了病人的感染概率,也可對(duì)病人的代謝產(chǎn)生影響,其增加病人的能量消耗、氧耗量和二氧化碳的產(chǎn)生量[21]。Parker等[22]又發(fā)現(xiàn)免疫功能與代謝的改變是睡眠不佳的危險(xiǎn)因素,可見睡眠剝奪與免疫功能和代謝改變互為因果,形成惡性循環(huán)的過程。在腎移植病人當(dāng)中約1/5的存在抑郁癥[23],而抑郁癥的危險(xiǎn)因素有睡眠剝奪、譫妄、過度鎮(zhèn)靜等[24]。雖然睡眠剝奪和譫妄的關(guān)系尚不清楚,但兩者具有相同的發(fā)病機(jī)制、危險(xiǎn)因素和體征[25],所以病人的睡眠狀況與心理狀態(tài)是相互影響的。睡眠障礙通過改變和影響病人的生理及心理活動(dòng),影響病人的身體健康,延長了病人住院時(shí)間,也增加其經(jīng)濟(jì)負(fù)擔(dān)。

3 腎移植病人睡眠障礙的干預(yù)措施

4 小結(jié)

綜上所述,腎移植病人的睡眠影響因素復(fù)雜,需運(yùn)用各種手段加以改善和促進(jìn)。通過改善周圍環(huán)境,減少不必要的噪音、調(diào)低光照強(qiáng)度、醫(yī)務(wù)人員進(jìn)行各項(xiàng)操作應(yīng)集中進(jìn)行。慎重使用藥物并重視其不良反應(yīng),對(duì)于疼痛病人給予持續(xù)鎮(zhèn)痛措施。盡量避免使用直接干擾病人睡眠的藥物,如苯海拉明、嗎啡、巴比妥類和鎮(zhèn)靜催眠藥等。建議首選非藥物干預(yù)法如簡短的放松按摩療法可促進(jìn)睡眠,同時(shí)減輕病人的焦慮、降低心率、呼吸頻率和氧消耗量。音樂療法可促進(jìn)病人的睡眠尤其對(duì)慢性失眠的病人。中醫(yī)療法如足浴、針灸推拿等均可促進(jìn)睡眠。睡眠質(zhì)量差對(duì)病人疾病恢復(fù)、住院時(shí)間及生活質(zhì)量產(chǎn)生嚴(yán)重影響,應(yīng)給予足夠的重視。目前國內(nèi)外對(duì)移植病人睡眠問題的干預(yù)研究很少,且方法較為復(fù)雜,所以為尋求一項(xiàng)簡單、方便易行的干預(yù)措施仍需醫(yī)務(wù)人員付出不懈的努力。

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(本文編輯孫玉梅)

Influencing factors of sleep quality in renal transplant patients and its nursing intervention research

Nong Yuhe,Mo Xinshao,Nie Feng,etal

(No.303 Hospital of Chinese People’s Liberation Army,Guangxi 530021 China)

農(nóng)玉荷,護(hù)師,碩士研究生,單位:530021,中國人民解放軍第三O三醫(yī)院;莫新少單位：530021，廣西醫(yī)科大學(xué)第一附屬醫(yī)院；聶峰、李壯江、熊妮、陳寶玉單位:530021,中國人民解放軍第三O三醫(yī)院。

信息 農(nóng)玉荷，莫新少，聶峰，等.腎移植病人睡眠質(zhì)量影響因素及護(hù)理干預(yù)研究[J].護(hù)理研究，2017，31(16)：1938-1940.

R473.6

A

10.3969/j.issn.1009-6493.2017.16.007

1009-6493(2017)16-1938-03

2016-05-01;

2017-05-05)