| Summary: | 碩士 === 國立成功大學 === 護理學系 === 103 === Background: Retinopathy of prematurity (ROP) is a common complication affecting premature infants. Except for the local anesthetic eye drops proved by empirical studies, there is no consensus among the pain/stress managements from initial of mydriasis until after the examination and discussing associated factors rarely. It is essential to explore the clinical fact thoroughly to understand the pain/stress performances under ROP exams and to investigate the associated factors.
Method: A natural observation method was used. Period from twenty minutes before administration of mydriatic eye drops until one hour after ROP exam was digital videotaped and described qualitatively. A semi-structured coding instruction was developed and the content validity index was 0.97, and the intra-rater and inter-rater reliability was 88% and 85% respectively. The potential associated items contained characteristics of participants and context, smoothness level of the administration, developmental care quantified by Evaluation of Intervention (EVIN), and other possible factors. Meanwhile, except for crying and bradycardia, pain and stress performances were measured by Premature Infant Pain Profile-Revised (PIPP-R) and Behavioral Evaluation (BE) respectively. Convenient sampling was used in a neonatal intensive care unit in a tertiary hospital in southern Taiwan. Each participant was observed four times maximally. Each recording of exam was sampled at 12 event/time points.
Results: Between August 2014 to April 2015, 23 preterm infants were enrolled and 43 ROP exams were recorded. In average, the participants were 27.6 weeks gestational age (GA) with body weight (BW) 1025 gm at birth and 33.7 weeks postmenstrual age (PMA) with 1612 gm when they received the exam. Approximately, the mean period of each administration of mydriatic eye drops was 36 seconds while the ROP exam was 3 minutes. The trends of pain/stress performances are similar. Scores at event/time points were statistically significantly higher than baseline from the initial of administration of mydriatic eye drops until ten minutes after the exam. The top pain/stress scores were measured at scleral indention, insertion of eye lid speculum, and first dosage of mydratic eye drops (p〈0.001) and usually accompanied with crying or bradycardia. Instead of crying, participants with lower BW tended to show bradycardia. Most of the participants took about 12.4 minutes (742.2 ± 764.5 seconds) to get back to the baseline heart rate, respiratory rate and oxygen saturation level, and BE and PIPP-R scores decreased to baseline at the point of 10 minutes after exam. We also found Apgar scores at 1st and 5th minute (Apgar 1’ and 5’), CRIB scores at birth, sex, the EVIN scores, mode of ventilation, environmental housing care, PMA and BW on exam day (RBW) and the latest hematocrit (lHct) level were associated with PIPP-R or BE scores at part event/time points, or recovery time (p〈0.05). Qualitative analysis revealed that containment directly by hands and non-nutritive sucking may make the participants relax, self-integration, and adjust their infant state. In addition, some participants showed unstable vital signs after the immediate cease of the extra oxygen providing during examination determined by SpO2 recovery or after the routine care activities right after the completion of examination, such as changing diapers or oral gastric tube care.
Conclusion: The premature infants showed pain/stress performances from the initial of administration of mydriatic eye drops until ten minutes and physiologically recovered until around 13 minutes after the exam. Severity of the condition at birth, sex, severity of the condition on exam day, growth characteristics of the preterm infants, developmental care, containment directly by hands, non-nutritive sucking, extend the duration of extra oxygen supply, and enough time to recover were correlated to pain/stress responses. Further studies with larger sample size were needed to identify the influences of sex and RBW. We suggested considering these measuring points, outcome variables, and associated factors when developing intervention program or clinical guideline of providing effective care for ROP exam.
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