神经重症患者阶梯式身体约束方案的最佳证据转化及效果评价

doi:10.3761/j.issn.2096-7446.2025.12.002

摘要/Abstract

摘要：

目的基于人文关怀模式，将神经重症患者阶梯式身体约束最佳证据应用于临床，并进行效果评价。方法筛选神经重症患者阶梯式身体约束的最佳证据，制订循证护理实践方法，进行基线审查以及障碍因素分析，构建最佳应用策略，融入人文关怀理念，制订阶梯式身体约束方案。在江苏省某三级甲等医院神经外科ICU实施，比较证据应用前后各项审查指标的执行率、患者身体约束时长以及相关并发症发生率。结果证据应用前后26项审查指标的执行情况差异均具有统计学意义；两组患者身体约束率、总约束时长、一二级约束时长及因约束导致的负性体验，差异均具有统计学意义（P<0.05）；约束减少后，未发生非计划性拔管。结论应用神经重症患者阶梯式身体约束的最佳证据有利于缩短患者身体约束时间、降低身体约束率，保障患者安全。

关键词: 人文关怀, 神经重症, 阶梯式身体约束, 证据应用, 循证护理学

Abstract:

Objective To apply the best evidence of stepwise physical restraint protocol for critically ill neurological patients in clinical practice，guided by a humanistic care model，and to evaluate its effectiveness. Methods The best evidence regarding stepwise physical restraint for critically ill neurological patients was systematically reviewed. Evidence-based nursing protocols were developed，baseline assessments were conducted to identify potential barriers，and a best implementation strategy was formulated. A stepwise physical restraint program incorporating the principles of humanistic care was designed. This program was implemented in the neurosurgical intensive care unit（ICU） of a Class Ⅲ Grade A hospital in Jiangsu Province. The compliance rates of various audit indicators，the duration of physical restraint，and the incidence of related complications were compared before and after the implementation of the evidence. Results There were statistically significant improvements in the implementation of 26 indicators following the application of the evidence. Statistically significant differences were observed in the physical restraint rate，total restraint time，first and second restraint durations，and negative patient experiences associated with restraint between the two groups（P<0.05）. The reduction in physical restraint did not lead to an increase in unplanned extubation. Conclusion The application of best evidence of stepwise physical restraint for critically ill neurological patients can effectively shorten restraint duration，reduce restraint rates，and ensure patient safety.

Key words: Humanistic Care, Severe Neurological Disease, Stepwise Physical Restraint, Application of Evidence, Evidence-based Nursing

张颖, 季翠玲, 梁海娟, 徐博, 狄恒丹. 神经重症患者阶梯式身体约束方案的最佳证据转化及效果评价[J]. 中华急危重症护理杂志, 2025, 6(12): 1421-1430.

ZHANG Ying, JI Cuiling, LIANG Haijuan, XU Bo, DI Hengdan. Transformation of the best evidence and effect evaluation of stepwise physical restraint in neurocritical care patients[J]. Chinese Journal of Emergency and Critical Care Nursing, 2025, 6(12): 1421-1430.

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参考文献 30

[1]	张帅, 陈娟红, 全殷殷, 等. ICU患者身体约束管理系统的构建与应用[J]. 中华护理杂志, 2023, 58(1):55-59. doi: 10.3761/j.issn.0254-1769.2023.01.007
	Zhang S, Chen JH, Quan YY, et al. Construction and application of a physical restraint management system for ICU patients[J]. Chin J Nurs, 2023, 58(1):55-59. doi: 10.3761/j.issn.0254-1769.2023.01.007
[2]	赵宝生, 张晓曼, 伊默, 等. ICU患者身体约束体验的Meta整合[J]. 中华急危重症护理杂志, 2021, 2(5):442-447.
	Zhao BS, Zhang XM, Yi M, et al. Meta-synthesis of ICU patients’ physical restraint experience[J]. Chin J Emerg Crit Care Nurs, 2021, 2(5):442-447.
[3]	Rudolph K. Ethical considerations in trauma-informed care[J]. Psychiatr Clin North Am, 2021, 44(4):521-535. doi: 10.1016/j.psc.2021.07.001
[4]	Funayama M, Takata T. Psychiatric inpatients subjected to physical restraint have a higher risk of deep vein thrombosis and aspiration pneumonia[J]. Gen Hosp Psychiatry, 2020,62:1-5.
[5]	陈巧玲, 林如玉, 朱宣静, 等. ICU身体约束患者心理弹性水平及影响因素的路径分析[J]. 中华急危重症护理杂志, 2024, 5(1):10-15.
	Chen QL, Lin RY, Zhu XJ, et al. The levels of psychological resilience and influencing factors path analysis in ICU patients with physical restrain[J]. Chin J Emerg Crit Care Nurs, 2024, 5(1):10-15.
[6]	Anis A, Patel R, Tanios MA. Analytical review of unplanned extubation in intensive care units and recommendation on multidisciplinary preventive approaches[J]. J Intensive Care Med, 2024, 39(6):507-513. doi: 10.1177/08850666231199055
[7]	国家卫生健康委办公厅, 教育部办公厅, 国家中医药局综合司, 等. 医学人文关怀提升行动方案(2024-2027年)(第一部分)[J]. 中国病毒病杂志, 2024, 14(5):474,481,487.
	Office of the National Health Commission,Office of the Ministry of Education, Office of the Ministry of Education, Comprehensive Department of the National Administration of Traditional Chinese Medicine, et al. Action plan for improving medical humanistic care(2024-2027)(Part I)[J]. Chin J Viral Dis, 2024, 14(5):474,481,487.
[8]	Registered Nurses’ Association of Ontario. Promoting safety:alternative approaches to the use of restraints[J]. Toronto, ON:Registered Nurses’ Association of Ontario(RNAO), 2012.
[9]	崔念奇, 张玉萍, 周英凤, 等. 成人ICU患者身体约束临床实践指南[J]. 中华急危重症护理杂志, 2023, 4(10):909-912.
	Cui NQ, Zhang YP, Zhou YF, et al. Clinical practice guidelines for physical restraints among adults patients in intensive care units[J]. Chin J Emerg Crit Care Nurs, 2023, 4(10):909-912.
[10]	Ekim M, Ekim H. Use of physical restraints in intensive care unit:a systematic review study[J]. Bozok Tip Derg, 2018, 8(1):38-44.
[11]	Perez D, Peters K, Wilkes L, et al. Physical restraints in intensive care:an integrative review[J]. Aust Crit Care, 2019, 32(2):165-174. doi: S1036-7314(17)30075-9 pmid: 29559190
[12]	Smithard D, Randhawa R. Physical restraint in the critical care unit:a narrative review[J]. New Bioeth, 2022, 28(1):68-82. doi: 10.1080/20502877.2021.2019979
[13]	Lei RB, Li YH, Zhou D, et al. Quality appraisal of clinical practice guidelines on physical restraints in ICU:a systematic review[J]. Ann Palliat Med, 2022, 11(2):774-783. doi: 10.21037/apm
[14]	许妮娜, 杨中善, 詹昱新, 等. 神经外科身体约束管理的系统评价[J]. 中国临床神经外科杂志, 2020, 25(2):113-117.
	Xu NN, Yang ZS, Zhan YX, et al. Systematic review of physical restraint management in neurosurgery[J]. Chin J Clin Neurosurg, 2020, 25(2):113-117.
[15]	曹锐, 胡芬, 朱小平, 等. ICU成人患者规范化身体约束证据总结[J]. 中国护理管理, 2018, 18(12):1600-1607.
	Cao R, Hu F, Zhu XP, et al. Evidence summary for standardized physical restraint for adult patients in Intensive Care Unit[J]. Chin Nurs Manag, 2018, 18(12):1600-1607.
[16]	雷若冰, 蒋小平, 林楠, 等. ICU患者身体约束替代措施的证据总结[J]. 护理学杂志, 2019, 34(14):101-104,108.
	Lei RB, Jiang XP, Lin N, et al. Evidence summary:alternatives to physical restraint in ICU[J]. J Nurs Sci, 2019, 34(14):101-104,108.
[17]	杨中善, 许妮娜, 詹昱新, 等. 住院患者规范化身体约束管理最佳证据总结[J]. 护理学报, 2019, 26(4):31-36. doi: 10.16460/j.issn1008-9969.2019.04.031
	Yang ZS, Xu NN, Zhan YX, et al. Summary of best evidence for standardized management of physical restraint in inpatients[J]. J Nurs China, 2019, 26(4):31-36.
[18]	JBI. Evidence summary. Acute mental health care: physical restraint(effectiveness and use)[EB/OL].(2022-09-03)[2023-05-16]. http://ovidsp.dc2.ovid.com/ovid-b/ovidweb.cgi.
[19]	刘凡, 王芳, 何满兰, 等. 神经外科重症患者身体约束管理的最佳证据总结[J]. 护士进修杂志, 2023, 38(16):1478-1483.
	Liu F, Wang F, He ML, et al. Summary of best evidence for the management of physical restraint in critically ill neurosurgical patients[J]. J Nurses Train, 2023, 38(16):1478-1483.
[20]	姚秋近, 张一, 张瑜, 等. 定向力评定在神经外科重症监护病房患者解除身体约束中的应用[J]. 中华护理杂志, 2017, 52(11):1327-1329.
	Yao QJ, Zhang Y, Zhang Y, et al. Application of assessment of orientation in judging patients for removing physical constraints in Neurosurgical Intensive Care Units[J]. Chin J Nurs, 2017, 52(11):1327-1329.
[21]	许妮娜, 杨中善, 刘宁, 等. 神经外科患者规范化身体约束管理的循证护理实践[J]. 护理学报, 2020, 27(19):41-46. doi: 10.16460/j.issn1008-9969.2020.19.041
	Xu NN, Yang ZS, Liu N, et al. Evidence-based nursing practice of standardized physical restraint management in neurosurgery patients[J]. Chin J Nurs, 2020, 27(19):41-46.
[22]	纪媛媛, 王军, 俞洁, 等. 神经外科ICU患者身体约束分级管理方案的构建及应用[J]. 中华护理杂志, 2021, 56(3):342-346. doi: 10.3761/j.issn.0254-1769.2021.03.004
	Ji YY, Wang J, Yu J, et al. Construction and application of a hierarchical management scheme of physical restraint for ICU patients in neurosurgery[J]. Chin J Nurs, 2021, 56(3):342-346. doi: 10.3761/j.issn.0254-1769.2021.03.004
[23]	葛娟, 柏慧华, 王德生, 等. 两种约束评估工具在神经外科重症监护病房病人身体约束中的应用效果比较[J]. 护理研究, 2022, 36(7):1293-1296.
	Ge J, Bai HH, Wang DS, et al. A comparative study of two restraint assessment tools in the application of physical restraint in neurosurgical intensive care unit[J]. Chin Nurs Res, 2022, 36(7):1293-1296.
[24]	中华护理学会. 住院患者身体约束护理[EB/OL]. (2020-02-03)[2023-09-08]. http://www.zhhlxh.org.cn/cnaWebbcn/upFilesCenter/upload/file/20200622/1592816676128083099.pdf .
	Chinese Nursing Association. Physical restraint nursing for inpatients[EB/OL]. (2020-02-03)[2023-09-08]. http://www.zhhlxh.org.cn/cnaWebbcn/upFilesCenter/upload/file/20200622/1592816676128083099.pdf .
[25]	JBI. Recommended practice. Restraint: nursing practice[EB/OL]. (2022-09-03)[2023-05-16]. http://ovidsp.ovid.com/ovid-b/ovidweb.cgi.
[26]	许娟, 莫蓓蓉, 胡玉娜, 等. 重症监护病房成人患者护理人文关怀专家共识[J]. 护理学杂志, 2022, 37(18):1-4.
	Xu J, Mo BR, Hu YN, et al. Expert consensus on nursing human caring for ICU adult patients[J]. J Nurs Sci, 2022, 37(18):1-4.
[27]	蔡壮, 许冬梅, 高静, 等. 精神科保护性约束实施及解除专家共识[J]. 中华护理杂志, 2022, 57(2):146-151. doi: 10.3761/j.issn.0254-1769.2022.02.003
	Cai Z, Xu DM, Gao J, et al. Expert consensus on the implementation and removal of protective restraints in psychiatry[J]. Chin J Nurs, 2022, 57(2):146-151. doi: 10.3761/j.issn.0254-1769.2022.02.003
[28]	王芳, 何敏, 沈雁蓉. 基于关键点控制原理的SPORT管理方案在神经外科重症患者身体约束中的应用[J]. 军事护理, 2023, 40(10):13-16.
	Wang F, He M, Shen YR. Application of SPORT management program based on key point control principle in severe neurosurgical patients with physical constraint[J]. Mil Nurs, 2023, 40(10):13-16.
[29]	Delmonico RL, Tucker LY, Theodore BR, et al. Mild traumatic brain injuries and risk for affective and behavioral disorders[J]. Pediatrics, 2024, 153(2):e2023062340. doi: 10.1542/peds.2023-062340
[30]	林婵告, 潘燕彬, 林小兰, 等. 重症患者身体约束现状的调查研究[J]. 基层医学论坛, 2023, 27(30):7-10.
	Lin CG, Pan YB, Lin XL, et al. The current status of physical restraint usage in intensive care unit patients[J]. Med Forum, 2023, 27(30):7-10.