中华护理杂志 ›› 2022, Vol. 57 ›› Issue (16): 2036-2041.DOI: 10.3761/j.issn.0254-1769.2022.16.018
周璇, 郑若菲, 简钢仁, 王圣芳, 叶诚栋, 林丽娟
出版日期:
2022-08-20
发布日期:
2022-08-08
ZHOU Xuan, ZHENG Ruofei, JIAN Gangren, WANG Shengfang, YE Chengdong, LIN Lijuan
Online:
2022-08-20
Published:
2022-08-08
摘要:
急性高危胸痛可在短时间内出现病情快速变化甚至死亡,预检分诊可对患者进行快速病情评估并判定其优先级,是急性胸痛患者风险评估的关键环节。该文阐述急性胸痛患者急诊预检分诊标准、评估方法和工具,分析其相关影响因素并提出展望,旨在为急诊预检分诊胸痛管理提供参考。
周璇, 郑若菲, 简钢仁, 王圣芳, 叶诚栋, 林丽娟. 胸痛患者急诊预检分诊的研究进展[J]. 中华护理杂志, 2022, 57(16): 2036-2041.
ZHOU Xuan, ZHENG Ruofei, JIAN Gangren, WANG Shengfang, YE Chengdong, LIN Lijuan. Research progress of emergency triage in patients with acute chest pain[J]. Chinese Journal of Nursing, 2022, 57(16): 2036-2041.
[1] | Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain:a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J]. Circulation, 2021, 144(22):e368-e454. |
[2] | 李小宇, 孟岩, 魏岚, 等. 急诊胸痛患者就诊流程的分析[J]. 中国病案, 2017, 18(12):25-27. |
Li XY, Meng Y, Wei L, et al. Analysis of medical treatment process for patients with chest pain in emergency departments[J]. Chin Med Rec, 2017, 18(12):25-27. | |
[3] | 中华医学会急诊医学分会, 中国医疗保健国际交流促进会胸痛分会. 急性胸痛急诊诊疗专家共识[J]. 中华急诊医学杂志, 2019, 28(4):413-420. |
Emergency Medicine Branch of Chinese Medical Association,Chest Pain Branch of China International Exchange and Promotive Association for Medical and Health Care. Expert consensus on emergency diagnosis and treatment of acute chest pain[J]. Chin J Emerg Med, 2019, 28(4):413-420. | |
[4] | 郑若菲, 林羽, 简钢仁. 急诊预检分诊信息系统对危重患者病情分级的效果研究[J]. 护理学杂志, 2015, 30(24):5-7. |
Zheng RF, Lin Y, Jian GR. Effectiveness of emergency triage information system on disease severity grading for critically ill patients[J]. J Nurs Sci, 2015, 30(24):5-7. | |
[5] | Frisch SO, Faramand Z, Leverknight B, et al. The association between patient outcomes and the initial emergency severity index triage score in patients with suspected acute coronary syndrome[J]. J Cardiovasc Nurs, 2020, 35(6):550-557. |
[6] | 管穗丽, 谢凤如, 张兴连. 校正改良早期预警评分系统在急性胸痛预检分诊中的应用[J]. 中华护理教育, 2016, 13(11):852-855. |
Guan SL, Xie FR, Zhang XL. Application of the modified early warning scoring in the triage for patients with acute chest pain[J]. Chin J Nurs Educ, 2016, 13(11):852-855. | |
[7] | Reaney PDW, Elliott HI, Noman A, et al. Risk stratifying chest pain patients in the emergency department using HEART,GRACE and TIMI scores,with a single contemporary troponin result,to predict major adverse cardiac events[J]. Emerg Med J, 2018, 35(7):420-427. |
[8] | Leung YK, Cheng NM, Chan CPY, et al. Early exclusion of major adverse cardiac events in emergency department chest pain patients:a prospective observational study[J]. J Emerg Med, 2017, 53(3):287-294. |
[9] | 金静芬. 急诊预检分诊标准解读[J]. 中华急危重症护理杂志, 2020, 1(1):49-52. |
Jin JF. Interpretation for emergency triage sale[J]. Chin J Emerg Crit Care Nurs, 2020, 1(1):49-52. | |
[10] | Australasian College for Emergency Medicine. Guidelines on the implementation of the australasian triage scale in emergency departments[EB/OL].[2021-10-11]. https://ed-areyoupre-pared.com/wp-content/uploads/2018/11/Australasian-Triage-Sca-le-in-Emergency-Departments. |
[11] | Bullard MJ, Musgrave E, Warren D, et al. Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) guidelines 2016[J]. Canadian J Emerg, 2017, 19(S2):S18-S27. |
[12] | Chang W, Liu HE, Goopy S, et al. Using the Five-level Taiwan triage and Acuity Scale computerized system:factors in decision making by emergency department triage nurses[J]. Clin Nurs Res, 2017, 26(5):651-666. |
[13] | Jassin M, Jouria MD. The emergency severity index:guidelines for triage[EB/OL].[2021-10-11]. https://nursece4less.com/Account/Login?returnUrl=Default. |
[14] | 史冬雷, 刘晓颖, 周瑛. 急诊预检分诊专家共识[J]. 中华急诊医学杂志, 2018, 27(6):599-604. |
Shi DL, Liu XY, Zhou Y. Expert consensus on emergency triage[J]. Chin J Emerg Med, 2018, 27(6):599-604. | |
[15] | Lee JH, Park YS, Park IC, et al. Over-triage occurs when considering the patient’s pain in Korean Triage and Acuity Scale(KTAS)[J]. PLoS One, 2019, 14(5):e0216519. |
[16] | 李杰, 张培莉, 童宇平, 等. PQRST联合改良早期预警评分快速分诊记录表在急性上腹痛患者分诊中的应用[J]. 护理学报, 2019, 26(3):70-72. |
Li J, Zhang PL, Tong YP, et al. Application of PQRST combined with modified early warning score rapid triage record table in triage of patients with acute epigastric pain[J]. J Nurs Chin, 2019, 26(3):70-72. | |
[17] | Lanham DA, Taylor AN, Chessell SJ, et al. Non-cardiac chest pain:a clinical assessment tool[J]. Br J Hosp Med(Lond), 2015, 76(5):296-300. |
[18] | Glanville D, Kiddell J, Lau R, et al. Evaluation of the effectiveness of an eLearning program in the nursing observation and assessment of acute surgical patients:a naturalistic observational study[J]. Nurse Educ Pract, 2021, 55:103152. |
[19] | Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial:identifying emergency department patients with acute chest pain for early discharge[J]. Circ Cardiovasc Qual Outcomes, 2015, 8(2):195-203. |
[20] | Than M, Flaws D, Sanders S, et al. Development and validation of the Emergency Department Assessment of Chest Pain Score and 2 h accelerated diagnostic protocol[J]. Emerg Med Australas, 2014, 26(1):34-44. |
[21] | Otsuka Y, Takeda S. Validation study of the modified HEART and HEAR scores in patients with chest pain who visit the emergency department[J]. Acute Med Surg, 2020, 7(1):e591. |
[22] | Peng LY, Hu H, He YR, et al. KTS and CRAMS were useful trauma scores in a resource-limited settings[J]. Am J Emerg Med, 2017, 35(9):1372-1373. |
[23] | 聂洪鑫, 孟辉. 创伤评分在胸部损伤中的应用[J]. 解放军医学杂志, 2019, 44(10):887-895. |
Nie HX, Meng H. Application of trauma scoring in thoracic trauma[J]. Med J Chin PLA, 2019, 44(10):887-895. | |
[24] | McKee G, Mooney M, O’Donnell S, et al. A cluster and inferential analysis of myocardial infarction symptom presentation by age[J]. Eur J Cardiovasc Nurs, 2018, 17(7):637-644. |
[25] | Groepenhoff F, Eikendal ALM, Onland-Moret NC, et al. Coronary artery disease prediction in women and men using chest pain characteristics and risk factors:an observational study in outpatient clinics[J]. BMJ Open, 2020, 10(4):e035928. |
[26] | El Hajj MC, Litwin SE. Echocardiography in the era of obesity[J]. J Am Soc Echocardiogr, 2020, 33(7):779-787. |
[27] | Sanders SF, DeVon HA. Accuracy in ED triage for symptoms of acute myocardial infarction[J]. J Emerg Nurs, 2016, 42(4):331-337. |
[28] | Kanani AN, Hartshorn S. NICE clinical guideline NG39:major trauma:assessment and initial management[J]. Arch Dis Child Educ Pract Ed, 2017, 102(1):20-23. |
[29] | 黄辉, 安文红, 刘欢, 等. 五级分诊标准信息系统用于急诊患者的信效度研究[J]. 护理学杂志, 2020, 35(13):23-26. |
Huang H, An WH, Liu H, et al. Reliability and validity of an electronic five-level triage system for emergency patients[J]. J Nurs Sci, 2020, 35(13):23-26. | |
[30] | 吴琪, 包招兰, 冯国和, 等. 急性胸痛护理分诊工具的应用进展[J]. 中国护理管理, 2018, 18(7):991-995. |
Wu Q, Bao ZL, Feng GH, et al. Current status analysis of nursing triage of patients with acute chest pain[J]. Chin Nurs Manag, 2018, 18(7):991-995. | |
[31] | 张晓庆, 沈小玲, 黄赣英, 等. 急诊预检分诊护士岗位胜任力评价指标体系的构建[J]. 中华急危重症护理杂志, 2021, 2(3):205-210. |
Zhang XQ, Shen XL, Huang GY, et al. The construction of eva-luation index system of post competency among emergency triage nurses[J]. Chin J Emerg Crit Care Nurs, 2021, 2(3):205-210. | |
[32] | 王国英, 赫晓慈, 李彩霞, 等. LBL和PBL双轨教学模式在急性胸痛分诊培训中的应用效果[J]. 中华现代护理杂志, 2015, 21(35):4318-4320. |
Wang GY, He XC, Li CX, et al. Effects of LBL and PBL teaching mode on emergency triage of acute chest pain[J]. Chin J Mod Nurs, 2015, 21(35):4318-4320. | |
[33] | 郭金玉, 杨洁, 孙红, 等. 胸痛中心模式下急诊护理流程的情景模拟演练设计与初步应用[J]. 中国急救复苏与灾害医学杂志, 2018, 13(10):1006-1009. |
Guo JY, Yang J, Sun H, et al. Scenario simulation exercise design and preliminary application of emergency nursing process in chest pain center mode[J]. Chin J Emerg Resusc Di-saster Med, 2018, 13(10):1006-1009. | |
[34] | 赵震, 杨洪华, 曹晓霞, 等. 新型冠状病毒肺炎疫情防控期间急诊科管理策略[J]. 中华护理杂志, 2020, 55(增刊2):576-577. |
Zhao Z, Yang HH, Cao XX, et al. Management strategies of the emergency department during the coronavirus disease 2019 outbreak[J]. Chin J Nurs, 2020, 55(z2):576-577. | |
[35] | Zuin G, Parato VM, Groff P, et al. ANMCO-SIMEU consensus document:in-hospital management of patients presenting with chest pain[J]. Eur Heart J Suppl, 2017, 19(Suppl D):D212-D228. |
[36] | Silcock DJ, Corfield AR, Gowens PA, et al. Validation of the National Early Warning Score in the prehospital setting[J]. Resuscitation, 2015, 89:31-35. |
[37] | 欧竹君, 范玉梅, 陈楚云. 急诊预检分诊护士的分诊能力调查及影响因素分析[J]. 护理实践与研究, 2021, 18(10):1462-1465. |
Ou ZJ, Fan YM, Chen CY, et al. Investigation on the triage ability of the nurses in emergency pre-inspection and analysis of influencing factors[J]. Nurs Prac Res, 2021, 18(10):1462-1465. | |
[38] | 陈玉国, 张敏, 王文君, 等. 护士在胸痛中心建设与发展中的作用[J]. 中华急危重症护理杂志, 2020, 1(1):7-10. |
Chen YG, Zhang M, Wang WJ, et al. The role of nurses in the construction and development of chest pain centers[J]. Chin J Emerg Crit Care Nurs, 2020, 1(1):7-10. | |
[39] | 蒋伟, 朱聚. 急诊科分级分区管理模式在胸痛患者分流中的应用研究[J]. 实用临床医药杂志, 2017, 21(14):173-175. |
Jiang W, Zhu J. Application of emergency department graded and partitioned management mode in the shunting of chest pain patients[J]. J Clin Med Pract, 2017, 21(14):173-175. |
[1] | 刘梦媛, 田凌云, 蒋敬, 冯心语, 李卫娟, 罗慧, 李映兰. 护士在跨专业合作中伦理冲突的范围综述[J]. 中华护理杂志, 2024, 59(9): 1138-1144. |
[2] | 崔怡爽, 何细飞, 王昭昭, 程捷, 杨伟梅, 陆丽娟. 共享决策在急性冠脉综合征患者中应用的范围综述[J]. 中华护理杂志, 2024, 59(9): 1145-1152. |
[3] | 张小艳, 李学靖, 杨丹, 孟美琪, 郝玉芳. 老年人久坐行为干预策略的范围综述[J]. 中华护理杂志, 2024, 59(8): 1012-1020. |
[4] | 余良梦, 俞小玲, 李佳镁, 阮晓芬. 证据图谱在护理学领域的应用进展[J]. 中华护理杂志, 2024, 59(8): 1021-1025. |
[5] | 房钰, 郝媛媛, 张晨, 董莹, 吴赢鑫, 姜桂春. 癌症患者决策疲劳的研究进展及护理启示[J]. 中华护理杂志, 2024, 59(8): 941-946. |
[6] | 周樊华, 甘霖, 梅艳丽, 杜芬, 严冶, 熊莉娟. 中西医结合病房患者入院护理评估单的研制及信效度检验[J]. 中华护理杂志, 2024, 59(7): 802-807. |
[7] | 叶磊, 夏广惠, 陈方梅, 田宇燕, 祁玮. 虚拟现实技术在癌症相关认知障碍患者中应用的范围综述[J]. 中华护理杂志, 2024, 59(7): 882-889. |
[8] | 熊桃, 谭雪梅, 罗静, 李阳, 郑予希, 李奉玲, 魏雪梅, 崔丽君, 罗澜峻. 脑卒中患者康复动机评估工具的研究进展[J]. 中华护理杂志, 2024, 59(7): 890-896. |
[9] | 陈钰妹, 赵惠芬, 赵晓珊, 赵梅晶, 彭玉美, 沈丽琴. 妊娠期糖尿病孕妇风险感知量表的编制及信效度检验[J]. 中华护理杂志, 2024, 59(6): 677-684. |
[10] | 颜钰, 龚姝, 段棣飞, 马登艳. 知识图谱在慢性病患者饮食管理中的应用进展[J]. 中华护理杂志, 2024, 59(6): 753-757. |
[11] | 邓艺帆, 王建宁, 彭梦婷, 洪杜. 决策辅助工具在失智症患者照护中应用的范围综述[J]. 中华护理杂志, 2024, 59(6): 758-763. |
[12] | 张淼淼, 张丽, 闫荣, 丁敏, 孟祥敏, 徐萍. 网络哀伤辅导在安宁疗护中的应用进展[J]. 中华护理杂志, 2024, 59(5): 556-561. |
[13] | 徐榕璟, 贺旭妍, 贾守梅. 骨科老年患者术后运动恐惧的范围综述[J]. 中华护理杂志, 2024, 59(5): 626-633. |
[14] | 王思琦, 范玲. 护士出勤主义行为的研究进展[J]. 中华护理杂志, 2024, 59(5): 634-640. |
[15] | 王晴, 黄晓婷, 唐四元, 黄重梅. 即时适配干预在护理领域中的应用进展[J]. 中华护理杂志, 2024, 59(4): 490-495. |
阅读次数 | ||||||
全文 |
|
|||||
摘要 |
|
|||||