使用條列式動靜脈廔管身體評估表提升診斷動靜脈廔管阻塞的精確度Using listed physical examination form to increase the accuracy of physical examination of arteriovenous fistula (AVF) by nursing staffs

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2018-06-19 已刊登
新刊登 綜 整 診斷類型

作  者

張家瑜*

實證知識類別

A 類:實證健康照護綜整

PICO

診斷性問題

治療/介入措施

腎臟與高血壓 Nephrology and Hypertension

科別

  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

末期腎臟病 動靜脈瘻管 血液透析 通暢度 功能異常 堵塞 身體評估 診斷

英文關鍵詞

End Stage Renal Disease (ESRD) Arteriovenous fistula(AVF) hemodialysis Patency dysfunction stenosis physical examination diagnosis

機構名稱

三軍總醫院

申請單位

護理部

中文摘要

形成臨床提問:
維持腎透析通路的功能和通暢性對於長期血液透析患者非常重要。 動靜脈瘺(AVF)仍然是長期血液透析患者的首選血管通路,因為它提供了最長的壽命和最低的並發症發生率。狹窄和血栓形成是導致AVF阻塞的主要原因。因此,常規監測對維持AVF的通暢性至關重要。身體評估(Physical examination : PE)目前仍是指引當中評估AVF最基本且必要的技術之ㄧ。觀察現行AVF評估表格,內容過於簡短,使得評估結果不精確且過於主觀。因此,設計一新式PE表格,列出評估細項,評估的準確性有望得到改善。我們期望能夠藉此使用此評估表,早期診斷AVF狹窄而進行早期處置,以降低AVF阻塞發生。
文獻搜尋的方法與分析:
本研究以實證手法,設定PICO關鍵字,將關鍵字以照布林邏輯AND及OR的方式做聯集及交集,搜尋Uptodate、Cochrane、PubMed、Embase以及華藝(CEPS)等資料庫,適當調整搜尋設定,並選擇文章等級較高、年代較新,且符合PICO之文章進行嚴格評讀。本文採用CEBM之「Diagnostic Study Critical Appraisal Sheet中文版」進行兩篇前瞻性的斷面性研究文章之嚴格評讀。評讀的主要三大面向即VIP:V(Validity/Reliability)效度/信度、I(Importance/Impact)重要性,以及P(Practice/Applicability)臨床適用性。
文獻的品質評讀:
依照PICO問題類型選擇合適的文獻,因此次PICO乃為診斷型問題,故最後選出年代最新、等級最高的兩篇斷代性研究(cross-sectional study)文章進行嚴格評讀,依照以Oxford CEBM 2011 Levels of Evidence將文章做分級,評析文章皆屬於Level 2。評讀的兩篇文獻所使用自體動靜脈廔管身體評估方法具一致性。
結論與建議:
AVF的身體評估是重要的評估工具,是洗腎護理師需要具備的專業技術,不需特殊儀器,用雙手即可執行,且可以正確診斷出自體動靜脈廔管狹窄狀況。故臨床上建議每周至少一次使用新式的身體評估量表進行AVF洗腎病人廔管功能評估,依照表中條列的項目仔細進行一次AVF的評估,可早期診斷AVF功能異常並進行早期處理,降低AVF的堵塞率。

英文摘要

Ask an answerable question (PICO):
Maintaining the function and patency of the renal dialysis pathway is very important for patients with long-term hemodialysis. Arteriovenous fistulas (AVF) are still the preferred vascular access for long-term hemodialysis patients for it provides the longest lifetime and the lowest rate of complications. Stenosis and thrombosis formation are the main causes of AVF obstruction. Therefore, routine monitoring is essential to maintain the patency of AVF. Physical examination is the most basic and necessary technique in the guidelines. Observe that the currently used physical assessment forms are too brief to be accurately assessed and that the assessment results are inconsistent. Therefore, a new evaluation form is designed, evaluation items are listed, the accuracy of assessment is expected to be improved. We expect that we can use this assessment form to early diagnosis of AVF stenosis and do the early treatment to reduce the occurrence of AVF occlusion.
The Method and Analysis of Literature Review:
This study uses Evidence-based methods to set PICO keywords and uses Boolean logic AND and OR to search for databases such as Uptodate, Cochrane, PubMed, Embase, and CEPS, and selects the articles with higher levels to do the critical appraisal. We use CEBM's "Diagnostic Study Critical Appraisal Sheet Chinese Version" to conduct two cross-sectional research articles. The three main orientations of the review are V( Validity) /I(Impactity )/P (Practice).
Critical Appraisal:
According to the type of PICO problem, the appropriate literature was selected. Therefore, the second PICO was a diagnostic problem. Therefore, the most recent and highest grade cross-sectional study was selected for rigorous evaluation. According to Oxford CEBM 2011 Levels Of Evidence graded the articles, and the evaluation articles belonged to Level 2. The two literature reviewed were consistent with the physical assessment methods used for autologous arteriovenous fistulas.
Conclusions and Recommendations:
AVF's physical assessment is an important assessment tool. It is a professional technique required by a kidney douche care professional. It requires no special instruments, can be performed with both hands, and can accurately diagnose autologous arteriovenous fistula stenosis. Therefore, it is recommended to use the new physical assessment scale to evaluate the fistula function of AVF dialysis patients at least once a week. Carefully perform an AVF assessment according to the items listed in the form to early diagnose AVF abnormalities and perform early treatment, and reduce the AVF occlusion rate.