第六章 結論與建議
第三節 應用與建議
綜合研究結果對未來研究方向、護理實務與教育方面提出以下建議與應用：
一、未來研究方向
本研究對象皆為膝關節置換手術患者，手術後病人常經歷著中至重度的疼 痛，加上止痛藥使用後的噁心、頭暈、昏睡等不適症狀，使病人徘徊在用藥與不 用藥的兩難困境中，加上手術後復健執行的刻不容緩，因此病人深感焦慮不安。
本研究運用耳穴貼壓按摩方式在不增加疼痛感受下，有效減輕手術後嗎啡使用劑 量與降低焦慮程度，並且增加病人手術後被動膝關節彎曲復健的角度。但礙於樣 本數及單一醫院收案，建議未來研究能增加收案醫院，擴大樣本數，以利研究結 果的推論。另建議未來研究能延長追蹤病人的時間，以了解耳穴貼壓按摩之長期 效益。
目前查閱許多有關耳穴按摩之臨床應用資料，發現常用於神經痛、慢性疼 痛、戒菸、減肥、減輕焦慮及促進睡眠品質等等，應用於手術後減緩疼痛者結果 並不一致，建議增加運用於其他手術治療之病人，希望能獲得相同的效果，增進 手術後病人疼痛管理之成效。
二、護理實務
本研究運用耳穴貼壓按摩方式減輕膝關節置換術手術後病人疼痛及焦慮困 擾，具有顯著效果，結果再度說明結合藥物性與非藥物性處置的多元化止痛方法 的重要性。因此，若能於現有之臨床照護中增加耳穴貼壓按摩措施，經由學習後 的臨床護理人員執行，減少疼痛控制藥物的使用量及因止痛藥物產生之副作用，
如噁心、嘔吐、頭暈等現象。其次改善病人焦慮程度，讓病人能有充足的休息睡 眠，增加住院期間復健運動的配合，實為良方。
三、護理教育
耳穴按摩是一種無侵入性及方便、安全、無副作用措施，目前廣泛運用於中 西醫學治療領域。在西醫方面，運用耳穴按摩於手術前減輕焦慮、疼痛、失眠、
經痛及減重，且對疼痛疾病都具有明顯的療效(黃，2005a；劉、陳、黃，2006)。
此外，經由研究結果得知耳穴貼壓按摩的可能機轉，耳穴的刺激按壓會對人體內 自律神經造成影響，降低自律神經反應的活性。穴位按摩法是國內法定中醫護理 業務範圍，護理人員藉由學習後可自行操作，臨床推廣性與實行性高，且病人易 於接受，建議可於專業老師指導有興趣之護理人員，瞭解耳穴按摩原理與學習執 行方法，將有助於膝關節置換手術後病人疼痛與焦慮之緩解，提昇手術後的照護 品質。
參考文獻
中文文獻
中央健康保險局 (2005, October 21)．全民健康保險專業醫療服務品質報告-人工 髖關節及膝關節置換術品質．取自
http://www.nhi.gov.tw/webdata/AttachFiles/Attach_5353_2_。
呂素英 (1998)．中醫護理學．台北: 知音。
印會河 (1997)．經絡．於印會河、張伯納編著，中醫基礎理論 (pp.75-87，
pp.116-118，pp.142-166)．台北: 知音。
印會河、張伯納 (2003)．中醫基礎理論．台北: 知音。
何菊修、陳宗鷹 (2005)．急性術後疼痛，慈濟醫學，17(Suppl 6)，43-49。
林麗英 (2002)．術前疼痛護理對腹部手術個案術前焦慮、認知與術後疼痛之成
效．未發表之碩士論文，高雄: 高雄醫學大學護理研究所。
李淑綺等合著 (1998)．心理學和心理衛生學．台北: 華杏。
林碧珠、張蘇鈺、莊琴英 (2000)．人工關節置換術患者生活品質及其相關因素之 探討．護理雜誌，8(2)，165-176。
許崇明、張立貴 (2005)．現代綜合耳廓耳穴圖譜．山東: 青島。
柳更新 (2003)．中西醫結合臨床疼痛治療學．遼寧: 科學技術出版社。
姜文、李勇、孫軍 (2002)．耳穴貼壓治療經前期緊張綜合症臨床研究．中國針灸，
22(3)，165-167.
莊凱迪、王署君、林正修、傅中玲 (1999)．中文版醫院焦慮憂鬱量表在頭痛病人 之應用．中華醫學雜誌，62(11)，749-755。
張成國、孔傑、江潤次、潘隆森、林昭庚、陳宏哲、王璧矚 (1982)．中西針灸 科學．台中: 中國醫藥學院針灸研究中心。
陳佩英、史麗珠、王正旭、賴裕和、張獻崑、陳美伶 (1999)．疼痛對癌症病人焦 慮與憂鬱之影響．台灣醫學，3(4)，373-382。
陳淑如、林佳靜、鄭綺、何善台 (1998)．探討手術後病人對疼痛護理及疼痛控制 的滿意度及其影響因素．護理研究，6(6)，475-487。
陳素賢 (1998)．姿位護理方案對分娩婦女疼痛感受及自我效能之效果．未發表 之碩士論文，高雄: 高雄醫學大學護理研究所。
陳國瀚 (1992)．手術後疼痛控制．臨床醫學，30 (1)，1-6。
陳筱玲 (2005)．足部按摩對消化道癌症手術後患者之成效探討．未發表的碩士論 文，台北: 國立台北護理學院護理學研究所。
黃光琪、吳興盛、梁挋、蔡高宗 (2005)．骨科患者手術前後焦慮程度與不確定感 之相性研究．台灣復健醫誌，33(1)，1-10。
黃采薇、賴裕和、鄭安理、史麗珠、張正雄、向肇英 (2001)．背部按摩對化學治 療期間疲倦及焦慮之成效．台灣醫學，5(4)，369-378。
黃麗春 (2005 a)．耳穴治療學．台南: 豐聖。
黃麗春 (2005 b)．耳穴療效與治療手法的體會．台灣中醫臨床醫學雜誌，11(3)，
226-230。
葉海濤、李良松 (1994)．針灸英傑-林昭庚博士．福建: 廈門大學。
梁鶴秀 (2003)．圖解耳穴按摩療法．台北: 世潮。
楊淑雅、馬素華、許光宏、吳基銓 (2001)．膝部骨性關節炎醫療照護成效量表之 發展．護理雜誌，48(3)，44-53。
楊曜臨、張淑珍、陳宗鷹 (2005)．病人術後自控式疼痛控制，慈濟醫學，17(6)，
51-55。
劉吉勝、陳薇莉、黃麗春 (2006)．耳穴診斷法簡介．中華推拿與現代康復科學雜 誌，13(1)，66-69。
蔡欣玲、邱淑芬、林惠蘭、周凌瀛 (1996)．系統性護理指導對緩解手術病人焦慮 之成效．榮總護理，13(4)，379-389。
閻麗萍、李恆 (2001)．耳神門的臨床運用淺析．上海中醫藥雜誌，35(9)，28-29。
謝霖芬、陳文珊、莊志誠 (2004)．關節炎之復健．輔仁醫學期刊，2(1)，17-42。
英文文獻
Acello, B. (2000). Meeting JCAHO standards for pain control. Nursing, 30(3), 52-54.
Ahles, T. A., Tope, D. M., Pinkson, B., Walch, S., Hann, D., & Whedon, M., et al., (1999). Massage therapy for patients undergoing autologous bone marrow transplantation. Journal of Pain and Symptom Management, 18(3), 157-163.
American Pain Society Quality of Care Committee (1995). Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of American Medical Association, 274(23), 1874-1880.
Apfelbaum, J. L., Chen, C., Mehta, S.S., & Gan, T. J. (2003). Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia, 97(2), 534-540.
Arellano, R., Cruise, C., & Chung, F. (1989). Timing of the anesthetist’s preoperative outpatient interview. Anesthesia & Analgesia, 68(5), 645-648.
Ashburn, M. A., & Lipman, A. G. (2004). Pain in society. In: Lipman, A. G. & FASHP, P. D. (Eds.), Pain management for primary care clinicians. Bethesda, MD:
American Society of Health-System Pharmacists, Inc.
Ashburn, M. A., & Ready, L. B. (2001). Postoperative pain. In: Loeser, J. D., Butler, S.H., Chapman, C. R., & Turk, D. C. (Eds.), Bonica’s management of pain. (3rd ed. pp.765-779). Baltimore: Lippincott Williams & Wilkins.
Authers. (2008). Auricular points- subcortex, antitragic aex, middle border, brain stem.
Journal of Chinese herbal medicine and accupuncture, October 16th.
Barker, R., Kober, A., Hoerauf, K., Latzke, A. S., Kain, Z. N., & Wang, S. M. (2006).
Out-of-hospital auricular acupressure in elder patients with hip fracture: A randomized double-blinded trail. Academic Emergency Medicine, 13(1), 19-23.
doi: 10.1197/j.aem.2005.07.014
Bell, L., & Duffy, A. (2009). A concept analysis of nurse-patient trust. British
journal of Nursing, 18(1), 46-51.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the hospital anxiety and depression scale. An updated literature review. Journal of Psychosomatic Research, 52(2), 69-77. doi: http://dx.doi.org/10.1016/
S0022-3999(01)00296-3
Bonica, J. J., & Loeser, J. D. (2001). History of pain concepts and therapies. In:
Loeser, J. D., Butler, S. H., Chapman, C. R., & Turk, D. C. (Eds.), Bonica’s management of pain. (3rd ed. pp.3-16). Baltimore: Lippincott Williams &
Wilkins.
Brander, V. A., Stulberg, S. D., Adams, A. D., Harden, R. N., Bruehl, S., & Stanos, S.
P., et al. (2003). Predicting total knee replacement pain: A prospective,
observational study. Clinical Orthopaedics and Related Research, 416, 27-36.
doi: 10.1097/01.blo.0000092983.12414.e9
Brown, A. K., Christo, P. J., & Wu, C. L. (2004). Strategies for postoperative pain management. Best Practice & Research Clinical Anaesthesiology, 18(4), 703-717. doi:10.1016/j.bpa.2004.05.004
Buckley, H. (2000). Nurse management of postoperative pain. Contemporary Nurse, 9(2), 148-154.
Canadian Institute for Health Information (2005). Total hip and total knee replace- ments in Canada. Canadian Joint Replacement Registry(CJRR) 2005 report.
Carpenito -Moyet, L. J. (2004). Nursing diagnosis: Application to clinical practice.
(10th ed.). Philadelphia: Lippincott Williams & Wilkins.
Carr, E. C. (1990). Postoperative pain: Patients' expectations and experiences. Journal of Advanced Nursing, 15(1), 89-100.
Carr, E. C., Nicky, T.V., & Wilson-Barnet, J. (2005). Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective. International
Journal of Nursing Studies, 42(5), 521-530. doi:10.1016/j.ijnurstu.2004.09.014 Carr, E. C. & Thomas, V. J. (1997). Anticipating and experiencing post-operative pain:
the patients' perspective. The Journal of Nursing, 6(3), 191-201. doi: 10.1111/j.
1365-2702.1997.tb00304.x
Chang, F. C., Tsai, H. Y., Yu, M. C., Yi, P. L., & Lin, J. G. (2004). The central serotonergic system mediates the analgesic effect of electroacupuncture on Zusanli(ST36) acupoints. The Journal of Biomed Science, 11, 179-185.
doi: 10.1007/BF02256561
Chang, L. H., Ma, T. C., Tsay, S. L., & Jong, G. P. (2012). Relationships between pain intensity and heart rate variability in patients after abdominal surgery: a pilot study. Chinese Medical Journal,125(11), 1964-1969. doi: 10.3760/cma.j.issn.
0366-6999.2012.11.023
Chang, M. Y., Chen, C. H., & Huang, K. F. (2006). A comparison of massage effects on labor pain using the McGill pain questionnaire. Journal of Nursing Research, 14(3), 190-197. doi: 10.1097/01.JNR.0000387577.51350.5f
Carr, D. B., & Goudas, L. C. (1999). Acute pain. Lancet, 353(9169), 2051-2058.
Cheng, S., Foster, R. L., & Huang, C. ( 2003). Concept analysis of pain. 慈濟護理雜 誌，2(3)，20-30。
Cicuttini, F. M., Wluka, A. E., & Stuckey, S. L. (2001). Tibia and femoral cartilage change in knee osteoarthritis. Annals of the Rheumatic Disease, 60(10), 977-980.
doi:10.1136/ard.60.10.977
Coda, B. A. & Bonica, J. J. (2001). General considerations of acute pain. In: Loeser, J.
D., Butler, S. H., Chapman, C. R., & Turk, D. C. (Eds.), Bonica’s management of pain. (3rd ed. pp.3-16). Baltimore: Lippincott Williams & Wilkins.
Dahlen, L., Zimmerman, L., & Barron, C. (2006). Pain perception and its relation to functional status post total knee arthroplasty: A pilot study. Orthopaedic Nursing,
25(4), 264-270.
Deleo, (2006). Basic science of pain [Graph]. The Journal of Bone & Joint Surgery (American), 88(2), 58-62.
Dijk, M., Boer, J. B., Koot, H. M., Duivenvoorden, H. J., Passchier, J., & Bouwm eester, N., et al. (2001). The association between physiological and behavioral pain measures in 0 to 3-year-old infants after major surgery. Journal of Pain and Symptom Management, 22(1), 600-609.
Di Rienzo, M., Parati, G., Castiglioni, P., Tordi, R., Mancia, G., & Pedotti, A. (2001).
Baroreflex effectiveness index: An additional measure of baroreflex control of heart rate in daily life. American Journal of Physiology - Regulatory, Integrative and Comparative Physiology, 280(3), 744-751.
Dolin, S. J., Cashman, J. N., & Bland, J. M. (2002). Effectiveness of acute post- operative pain management: I. Evidence from published data. British Journal of Anaesthesia, 89(3), 409-23. doi: 10.1093/bja/89.3.409
Dossey, B. (1996). Help your patient break free anxiety. Nursing, 60(10), 52-54.
Duschek, S., & Del Paso, G. A. R. (2007). Quantification of cardiac baroreflex function at rest and during autonomic stimulation. The Journal of Physiological Sciences, 57(5), 259-267. doi: 10.2170/physiolsci.RP008807
Feeney, S. L. (2004). The relationship between pain and negative affect in older adults:
anxiety as a predictor of pain. Journal of Anxiety Disorders, 18(6), 733-744. doi:
10.1016/j.janxdis.2001.04.001
Felson, D. T., Lawrence, R. C., Dieppe, P. A., Hirsch, R., Helmick, C. G., & Jordan, J.
M., et al., (2000). Osteoarthritis: new insights. Part 1: the disease and its risk factors. Annals of Internal Medicine, 133, 635-646.
Frank, B. L., & Soliman, N. E. (2006). Auricular therapy: A comprehensive text:
Auricular phases, frequencies, and blockages. The Journal of Alterative and
Complementary Medicine, 12(6), 585-586. doi:10.1089/acm.2006.12.585 Freeman, L. W. (2001). Massage therapy. In Freeman, L. W., & Lawlis, G. F. (Eds.), Complementary & Alternative Medicine a research: Based approach (pp.361- 385). St. Louis: Mosby Co.
Goldman, B. M., Cullinan, J., & Roger, T. (2001). Neuro-cardiovascular regulation:
From molecules to man. Annals of the New York Academy of Sciences, 940, xiii-xxii. doi: 10.1111/j.1749-6632.2001.tb03661.x
Grella, R. (2008). Continuous passive motion following total knee arthroplasty: A useful adjunct to early mobilisation? Physical Therapy Reviews, 13(4), 269-279.
doi: 10.1179/174328808X309197
Grinstein-Cohen, O., Sarid, O., Attar, D., Pilpel, D., & Elhayany, A. (2009).
Improvements and difficulties in postoperative pain management. Orhtopaedic Nursing, 28(5), 232-239. doi: 10.1097/NOR.0b013e3181b99c26
Han, J. S. (2010). Acupucture analgesia: Areas of consensus and controversy. Pain, doi: 10.1016/j. pain.2010.10.012.
Hobbs, G. J., & Hodgkinson, V. (2003). Assessmsnt, measurement, history, and examination. In: Rowbotham, D. J., & Macintyre, P. E. (Eds.), Clinical pain management: Acute pain. (pp.93-111). London: ARNOLD.
Hsieh, C. L. (1998). Modulation of cerebral corted in acupuncture stimulation: A study using sympathetic skin response and somatosensory evoke potentials.
American Journal of Chinese Medicine, 26(1), 1-11. doi: 10.1142/
S0192415X98000026
Hutchison, R. W. (2007). Challenges in acute post-operative pain management.
American Journal of Health-System Pharmacy. 64: S2-S5. doi: 10.2146/
ajhp060679
International Association for the Study of Pain: Sub-committee on taxonomy. (1979).
Pain term: A list with definitions and notes on usage. Pain 6(3), 249-252. doi:
http://dx.doi.org/10.1016/0304-3959(79)90046-0
Jain, S., & Datta, S. (1997). Postoperative pain management . Chest surgery clinics North America. 7(4), 773-99.
Jensen, M. P., & Karoly, P. (2001). Self-report scales and procedures for assessing pain in adult. In: Turk, D. C., & Melzack, R. (Eds.), Handbook of pain measurement. (2nd ed. pp.35-52). New York: Guilford Press.
Jin, F., & Chung, F. (2001). Multimodal analgesia for postoperative pain control.
Journal of Clinical Anesthesia, 13(7), 524-539. doi: http://dx.doi.org/10.1016/
S0952-8180(01)00320-8
Joint Commission on Accreditation of Healthcare Organization. (2001, May 22). Joint Commission focuses on pain management. Retrieved December 28, 2008, from http://www.jcaho.org/news+room/health+care+issue/jcaho+focuses+on+pain +management.htm
Karpen, J., Ortiz, R., & Shoemaker, W. C. (2010). Parasympathetic and sympathetic monitoring in pain management. Retrieved December 28, 2010, from
http://pain.com/library/
Katz, J., Poleshuck, E. L., Andrus, C. H., Hogan, L. A., Jung, B. F., Kulick, D.I., &
Dworkin, R. H. (2005). Risk factors for acute pain and its persistence following breast cancer surgery. Pain, 119(1-3), 16-25.
Karst, M., Winterhalter, M., Münte, S., Fracki, B., Hondronikos, A., & Eckardt, A.
et al. (2007). Auricular acupuncture for dental anxiety: A randomized controlled trial. Anesthesia & Analgesia, 104(2), 295-300. doi: 10.1213/01.ane.
0000242531.12722.fd
Kee, C. C., Harris, S., Booth, L. A., Rouser, G., & McCoy, S. (1998). Perspective on
the nursing management of osteoarthritis. Geriatric Nursing, 19(1), 19-28.
Kerr, D. R., & Kohan, L. (2008). Local infiltration analgesia: A technique for the control of acute postoperative pain following knee and hip surgery : A case study
of 325 patients. Acta Orthopaedica, 79(2), 174-183. doi: http://dx.doi.org/
10.1080/17453670710014950
Kim, M. J., McFarland, G. K., & McLane, A. M. (Eds.). (1995). Pocket guide to nursing diagnosis. (pp.57). St. Louis: Mosby Co.
Kindler, C. H., Harms, C., Amsler, F., Ihde-Scholl, T., & Scheidegger, D. (2000). The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesthesia & Analgesia, 90, 706-712.
Kober, A., Scheck, T., Schubert, B., Strasser, H., Gustorff, B., & Bertalanffy, P., et al.
(2003). Auricular acupuncture as a treatment for anxiety in prehospital transport setting. Anesthesiology, 98(6), 1328-1332.
Kurtz, S., Ong, K., Lau, E., Mowat, F., & Halpern, M. (2007). Projections of primary and revision hip and knee arthroplaty in the United States from 2005 to 2030.
The Journal of Bone and Joint Surgery (American,), 89, 780-785. doi:10.2106 /JBJS.F.00222
Levick, J. R. (2003). Cardiovascular reports, reflexes and central control. In An introduction to cardiovascular physiology. (4th ed. pp.278-297). London:
Edward Arnold.
Lewis, G. B. (1987). An alternative approach to premedication: Comparing diazepam with auriculotherapy and a relaxation method. American Journal of Acupucture, 15(3), 205-214.
Lin, J. G., & Chen, W. L. (2008). Acupuncture analgesia: A review of its mechanisms of actions. The American Journal of Chinese Medicine, 36(4), 635-645. doi:
10.1142/S0192415X08006107
Lohmander, L.S., Gerhardsson, M., Rollof, J., Nilsson, P. M., & Engstrom, G. (2009).
Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass. A population-based prospective cohort study. Ann Rheum Dis, 49(8), 490-496.
Macintyre, P. E., & Schug, S. A. (2007). Acute pain management: a practical guide.
(3rd ed. pp1-7). New York: Saunders.
Mantle, F. (1996). Safe practice. Nursing Times, 92(6), 36-38.
Manheimer, E., Eaton, K., Lao, L., White, A. R., & Morozova, O. (2009).
Acupuncture for the treatment of post-operative pain. The Cochrane Library, Published Online: 21 JAN. doi: 10.1002/14651858.CD006042
McCaffery, M., & Beebe, A. (1989). Pain: Clinical manual for nursing practice. St.
Louis: Mosby Co.
McFarland, G.. K., & McFarlane, E. A. (1997). Nursing diagnosis & intervention.
(3rd ed.). Louise: Mosby Co.
Melzack, R. (1975). The McGill pain questionnaire: Major properties and scoring methods. Pain, 1(3), 277-299. doi: http://dx.doi.org/10.1016/0304-3959
(75)90044-5
Melzack, R. (1987). The short-form McGill pain questionnaire. Pain, 30(2), 191-197.
doi: http://dx.doi.org/10.1016/0304-3959(87)91074-8
Melzack, R., & Casey, K. L.(1968). Sensory, motivational and central control
determinants of chronic pain: A new conceptual model. In: Kenshalo, D. R. The skin senses: Proceedings of the first International Symposium on the Skin Senses.
Florida: State University in Tallahassee.
Melzack, R., & Katz, J. (2001). The McGill pain questionnaire: Appraisal and current