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手术室护理人员电外科烟雾防护中格林模式的应用

来源:山西医科大学 作者:苏娜
发布于:2020-07-01 共7288字

  格林模式促进手术室护士防护电外科烟雾的效果研究
  
  摘 要

 

  
  目的:
  

  根据格林模式评估手术室护士防护电外科烟雾的知信行现状和防护教育现状。针对问卷结果中影响手术室护士防护行为执行的问题和环节,进行干预教育及效果评价。提高手术室护士对电外科烟雾相关知识的掌握率和防护依从性,降低电外科烟雾对人体的危害,保障手术室护士身心健康,为烟雾防护教育提供依据。


手术室护理人员电外科烟雾防护中格林模式的应用

  
  方法:
  
  本研究共3个部分。

  
  第一部分是设计问卷。以“手术烟雾”为关键词,搜索国内外文献并总结,评估手术室护士的行为环境特征、流行病学特征、社会学特征、管理政策特征及教育组织特征等,设计问卷初稿;然后通过专家咨询和预调查,完成问卷设计。
  
  第二部分是描述性研究。随机抽取我省在职手术室护士240名,调查其一般特征、烟雾防护的知-信-行现状及防护教育现状。其中,调查内容包括手术室护士的年龄(岁)、职称级别、参加烟雾防护培训的次数、工作年限/年、烟雾知识、防护态度、防护行为得分和烟雾影响自评得分等数十项。
  
  第三部分是干预性研究。研究方法为类实验研究法,对我省某三甲医院54名手术室护士进行培训,统计干预前后手术室护士的知-信-行得分和烟雾影响自评得分等。使用SPSS23.0软件处理数据,同时,采用t检验、重复测量方差分析等比较干预前后效果。
  
  结果:
  
  1、基线调查结果①手术室护士的知识部分最低2分,最高18分,平均(8.70±3.31)分,合格率20.4%;其中物理性质、化学性质和权威防护标准等部分的得分偏低,分别为(2.42±1.18)分、(0.98±0.61)分和(1.39±0.96)分。防护电外科烟雾的态度平均得分为(62.87±6.95)分;防护烟雾的行为平均得分为(42.41±7.46)分;手术室护士受烟雾影响的自评得分为(5.29±1.88)分。②9.1%的护士从无参加过电外科烟雾防护的培训;16.7%参加过一次烟雾防护培训;59.2%参加过2次;参加3次及以上仅有15%。值得庆幸的是,有96.3%的护士表示有意愿参加烟雾防护培训,另外3.7%的人认为没有必要参加此类培训。
  
  2、干预的实施及效果①干预一个月后,手术室护士防护电外科烟雾的知识成绩显着提高,差异明显(P<0.05);有关概念、物理性质、化学性质和权威防护标准等部分得分提高明显(P<0.05),烟雾危害部分得分无明显提高(P>0.05);烟雾防护的态度增强明显,有统计学意义(P<0.05);烟雾防护的行为依从性明显上升,有统计学意义(P<0.05)。干预一个月后,手术室护士的烟雾影响自评得分明显下降,其差异有统计学意义(P<0.05)。②数据采用重复测量方差分析,干预前、干预一个月、三个月手术室护士防护电外科烟雾的知识、态度与行为得分逐步提高(F=65.570, P<0.001; F=78.307, P<0.001;F=403.015, P<0.001)。
  
  结论:
  
  1、手术室护士对烟雾的理论知识缺乏,主要是烟雾的物理性质、化学性质及权威防护标准等得分低;烟雾防护态度处于中等水平,主要表现在不重视烟雾的危害及防护意识不强等两方面;而烟雾防护的行为执行性较差,表现为个人防护措施不到位,且术中烟雾未及时处理。
  
  2、在格林模式的指导下,对手术室护士进行干预教育后,有效地提高了手术室护士的理论知识和态度水平,规范其安全防护操作,降低烟雾影响自评得分,提高手术室安全水平,有力地保障了护理人员的健康。
  
  3、电外科烟雾的危害及防护问题日益受到广大医务人员的重视,加强烟雾防护措施实施,减轻烟雾对人体造成的危害,保障手术室护士健康,是手术室护理工作的关键。
  
  关键词:   格林模式;手术室护士;防护;电外科烟雾;知-信-行。
  

  Effect Study on Green Model Promotes OR Nurses to Protect Electrical Surgery Smoke。
 

  Abstract

  
  Objective:
  

  According to Green's model, the current status of knowledge ,attitude and practice and protection education of nurses in operating room were assessed. Aiming at the problems and links that affect the implementation of protective behavior of nurses in operating room, intervention education and effect evaluation were carried out. To improve the mastery rate and protection compliance of nurses in operating room, reduce the harm of electrical surgical smoke to human body, ensure the physical and mental health of nurses in operating room, and provide basis for smoke protection education.
  
  Methods:
  
  There are three parts in this study.The first part is to design the questionnaire. With the keyword of "surgical smoke",we searched the literature at home and abroad and summarized it. We evaluated the characteristics of the operating room nurses' behavior environment, epidemiology,sociology, management policy and educational organization, and designed the preliminary draft of the questionnaire. Then we conducted a preliminary survey of 30 operating room nurses through five expert inquiries, and completed the questionnaire design.
  
  The second part is descriptive research. 240 nurses in operation room were randomly selected to investigate their general characteristics, smoke protection knowledge-letter-practice status and protection education status. Among them, the survey included the age (age), working years/years, professional titles, number of smoke prevention training, smoke knowledge, attitude and scores of smoke-affected self-assessment of operating room nurses.
  
  The third part is the intervention study. The research method is similar to the experimental research method. 54 operating room nurses in a third-class A hospital in ourprovince were trained. The scores of knowledge, belief and behavior of operating room nurses before and after intervention were counted. The scores of self-assessment and thefrequency of adverse reactions caused by smoke were also counted. The data were processed by SPSS23.0 software, and t-test, 2-test and repeated measurement analysis ofvariance were used to compare the effects before and after intervention.
  
  Results:
  
  1. Baseline survey results。

  
  (1) The knowledge part of nurses in operating room had the lowest score of 2 and the highest score of 18, with an average of (8.70 ± 3.31) and a qualified rate of 20.4%.
  
  The scores of physical, chemical and authority protection standards were lower (2.42±1.18), (0.98 ± 0.61) and (1.39 ± 0.96) respectively. The average score of attitude toprotect surgical smoke department was (62.87±6.95), the average score of behavior toprotect smoke was (42.41±7.46), and the self-rating score of nurses in operating roomaffected by smoke was (5.29±1.88).
  
  (2) 9.1% of nurses had never participated in training about protecting surgicalsmoke ; 16.7% had participated in once protection training; 59.2% had participated in twice training; only 15% had participated in three or more training. Fortunately, 96.3% of nurses expressed willingness to participate in smoke protection training, while 3.7% didnot think it necessary to participate in such training.
  
  2. Implementation and effect of intervention。
  
  (1) After one month of intervention, the knowledge of smoke protection of nurses in operating room was significantly improved (P<0.05); the scores of related concepts,physical properties, chemical properties and authoritative protection standards were significantly improved (P<0.05), while the scores of smoke hazards were not significantly improved (P>0.05); the attitude of smoke protection was significantly enhanced, with statistical significance (P<0.05); Compliance increased significantly (P<0.05). After one month of intervention, the scores of self-assessment affected by smoke were significantly reduced (P<0.05).
  
  (2) Data were analyzed by repeated measures of variance. Before intervention, one month and three months after intervention, the knowledge, attitude and behavior scores of nurses in operating room for the protection of electrical surgical smoke increased gradually (F=65.570, P<0.001; F=78.307, P<0.001; F=403.015, P<0.001).
  
  Conclusion:
  
  1. Operating room nurses lack theoretical knowledge of smoke, and the items with lower scores are mainly the physical properties, chemical properties and authoritative protection standards of smoke; the attitude of smoke protection is at a medium level,mainly in two aspects: neglecting the hazards of smoke and lack of protection consciousness; and the behavior of smoke protection is poorly executed, which is manifested by inadequate personal protection measures and intraoperative smoke. The fog was not handled in time.
  
  2. Under the guidance of Green's model, the intervention education for nurses in operating room has effectively improved the theoretical knowledge and attitude level of nurses in operating room, standardized their safe and protective operation, reduced the incidence of adverse reactions and self-assessment scores affected by smoke, improved the safety level of operating room, and effectively guaranteed the health of nurses.
  
  3. The hazards and protective problems of smoke in electrical surgical department have been paid more and more attention by medical staff. Strengthening the implementation of smoke protection measures, reducing the hazards of smoke to human body and ensuring the health level of nurses in operating room are the keys to nursing work in operating room.
  
  Key words :   Green Model; Operating Room Nurse; Protection; Electrical Surgery Smoke; Knowledge-Credit-Practice。
  

  前 言
 

  
  1、研究背景。

  
  职业危害,指从事某职业的工作人员因工作关系而可能出现的亚健康或疾病,有可能危害健康,更甚者危及生命[1]。护士工作内容和环境的特殊性,决定了要经常接触患者和执行各种诊疗护理操作,其工作性质决定了护理人员暴露在各种危害因素中[2],因此,护士容易遭受职业危害,常见的职业危害有腰椎间盘突出、静脉曲张、针刺伤等。
  
  手术室,是一个节奏快、独立封闭、风险高的特殊科室,是实施手术和抢救生命的关键场所。手术中被使用的超声刀、高频电刀和激光刀等器械,由于具有止血速度快、效果好的特点,在现代外科手术中被广大医生使用[3]。但是,使用这些器械和设备为广大患者造福的同时,也会有烟雾、气体和颗粒等产物产生,不仅使手术视野变得模糊,还含有各种毒害物质,对手术室工作人员造成一定程度的危害[4]。然而,目前广大医务人员对手术产生的烟雾不够重视,杨坤明等[5]经研究后发现:手术室间充斥着各种危险因素,其中电外科烟雾作为危险因素的一种,已对手术室医务人员的健康产生了危害。因此,有必要对手术室护理人员关于手术烟雾的知-信-行进行系统研究,并采取相关措施提高其防护意识,减少职业危害。
  
  1.1、外科手术中烟雾的产生。
  
  随着时代的发展,外科手术领域出现了越来越多创伤小、出血少、不损伤正常组织的精细电设备,如高频电刀、激光、超声刀和骨锯、骨钻等。①高频电刀,通过电极前端的高频高压电流造成高温来切割组织,会使细胞液气化,组织脱水、发生碳化,蛋白质结构破坏,细胞残骸分散到环境中[6、7],形成电外科烟雾。②激光通过受激辐射式光频放大器来产生聚集于光束中的光能进行照射,组织的损伤程度由时间的长短决定,其可致高温100°C-1000°C,同时产生易吸入物、苯等致癌物及甲醛等刺激性气味的烟雾,不同程度地刺激人体的皮肤和眼睛。③超声手术刀,通过坚硬的刀头端用55千赫兹的频率进行机械振动,超声能量聚集在一点,此处温度骤然升高,利用极高温来破坏肿瘤组织,在不损伤正常周边组织细胞的前提下,消除肿瘤细胞。具有切割精准,不伤及正常组织,止血效果好等优点[8]。但使用超刀时产生的副带产物“烟雾”有致癌和感染的风险。④骨锯、骨钻等器械,通过锯齿或钻头高速运转破坏组织。这些器械运转时常伴有生理盐水进行冲洗,会形成含血液成分的雾状气体,喷溅到医务人员的眼睛、皮肤或者进入呼吸道,造成血源性暴露。
  
  1.2、烟雾的危害。
  
  烟雾中含有活性的细菌病毒、刺激性成分、致癌物和微小的有害颗粒[9],会在人体中形成各种慢性不良反应、肺部损害、肿瘤细胞种植转移和细菌病毒传播[10-13]。会导致:①人体出现疲劳乏力、头晕头疼;呛咳咽干、喉咙疼痛;流泪畏光、结膜充血;食欲不振、恶心呕吐等症状[15]。②肺部损害:烟雾中直径在0.007~6.5微米之间的颗粒吸入呼吸道,易引起急慢性肺病,如哮喘、肺炎、肺气肿、支气管炎、肺泡充血等[15]。③细菌病毒传播:有报道[11]称,1名外科医生用激光刀做完患者的生殖器尖锐湿疣手术后,感染了喉部乳头状瘤(laryngeal papillomatosis),与患者体内病毒是同一类型,并且这个医生并无其他途径感染此类病毒,这为电外科烟雾可能存在病毒细菌传播提供了依据。④肿瘤细胞的种植转移:Ishida研究发现[12],手术中的肿瘤细胞产生雾化、腹腔镜手术中气体泄漏,均可能导致肿瘤细胞发生种植转移。王灏[13]等在研究腹腔镜手术中CO2气体对肿瘤细胞戳口种植的影响中,发现当腹压是30mm Hg,腹腔冲洗液以1分钟5升的速度,冲洗时间长达1小时的话,容易发生肿瘤细胞的切口种植转移。另外,术中手术器械的多次使用和变换、肿瘤细胞悬浮在空气中等都可能引起以上情况发生。
  
  1.3、国内外防护术中电外科烟雾的现状。
  
  1.3.1、国内电外科手术烟雾的防护现状。

  
  我国卫生部于2012年4月颁布了《医院空气净化管理规定WS/T368-2012》[14],提出了紫外灯消毒装置、通风系统和安装空气净化系统等相关规定,遗憾的是,没有具体规定手术间空气更新率、电外科烟雾的危害及防护等[15]。目前,手术室医务人员基本防护措施是带一次性外科口罩,外科手术的传统方法就是用吸引器吸除烟雾,一定程度上降低了烟雾吸入,但并没有过滤掉烟雾中的颗粒和有害物。
  
  国内学者关于电外科烟雾及防护的课题还处于初步探索阶段,诸多研究表明,手术室医务人员对烟雾的认知程度不高,防护意识浅薄,防护设备落后。支慧[16]等人研究表明:电外科烟雾暴露人员完全认知率为1.19%,认知较差,且防护率仅有7.14%,防护处于低水平,并对防护措施提出了相关建议。彭红[17]等人研究表明,知识和防护两项相加得分超过61分的手术室医护人数占被调查人数的30%。潘静[18]等人研究表明:被调查的医护人员缺乏相关理论,只有30%的人员了解烟雾的物理化学性质、危害,而对于权威防护标准、烟雾的来源、成份等了解较少,并认为培训是提高手术医护人员的电外科烟雾知识和防护的有效途径之一。何研明[19]研究结果显示,90名被调查的医务人员中,有91.82%的人因工作强度大及防范依从性低缺少有效防护,同时,何研明等强调应加强管理、规范操作行为,提高防范意识,保障手术室工作人员身心健康。张海伟等[40]采用横断面调查了141名医务人员,发现认知和防护水平均低,其中得分最高的条目是烟雾危害,得分最低的条目是烟雾组成。因此提出应对医务人员进行培训,以改善其对烟雾的认知和防护。
  
  1.3.2、国外电外科手术烟雾的防护现状。
  
  在国外,很多机构和权威组织[20-23]都已经认识到电外科烟雾对人体的危害,并建议医务人员采取防护措施。ANSI[20]指出,使用电设备进行组织切割的手术和激光术都会在手术间产生有毒的环境污染物,并提出这些污染物质应被排放和过滤掉。另外,AORN[14]指出,激光术和使用电设备进行切割组织时,细胞液蒸发会产生含病毒物质。并认为接触手术烟雾有风险隐患,相关人员应采取安全防护:如佩戴高过滤性口罩、安装负压吸引设备及增加烟雾排放过滤设备。1987年,NIOSH[21]探索了电外科烟雾的成分,并得出其中含有危害性和致基因突变的化学物质和成分,之后于1996年,关于电外科烟雾危害公布了以下建议;①手术医护人员应做好人员防护,比如穿防护服、戴N95或N100口罩、眼罩等,减少高浓度烟雾暴露;②使用负压吸引设备和排烟设备;③负压吸引器的速度在254-381 cm / min以上和吸引器管头到术野距离短于5.08cm; ④手术间内正确安装烟雾抽吸系统过滤器。英国学者Spearman[22]研究发现,同意防护手术烟雾并实施保护措施的手术医生占72%,但防护措施中采用专业烟雾排吸设备的手术医生只占31%,并总结了电外科烟雾的防护标准和措施[23],包括在应用烟雾排放设施的同时应采用烟雾吸引设备:移动式负压吸引器、墙壁式负压吸引器(含过滤网)和中心负压吸引器;培训手术室医务人员:制定完善培训计划、演示仪器及设施功能、遵守法规及标准、记录保存培训活动。
  

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  2、相关概念
  3、研究意义

  第一部分  基线调查.

  1、“手术室护士防护电外科烟雾的知信行”问卷设计
  2、对象与方法
  3、结果
  4、讨论
  5、结论.

  第二部分  干预性研究

  1、对象与方法.
  2、结果
  3、讨论

  4、小 结

  长时间工作在手术室,烟雾可引起人体①有不良反应:疲乏无力、头晕头痛;呛咳咽干、喉咙疼痛;流泪畏光、结膜充血;食欲不振、恶心呕吐等症状;②导致肺部疾病:哮喘、肺炎、肺气肿、支气管炎、肺泡充血等。③细菌病毒传播;④肿瘤细胞种植转移等[3]。因此,手术室医务工作者防护电外科烟雾的任务很艰巨。本文从医院、科室、设备器械及人员防护等4个方面,概括了电外科烟雾的安全防护操作,为保证工作质量,保障医务工作者的健康提供了理论前提。

  参考文献

作者单位:山西医科大学
原文出处:苏娜. 格林模式促进手术室护士防护电外科烟雾的效果研究[D].山西医科大学,2019.
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