基于阶梯式护理模式的睡眠管理方案在NICU早产儿中的应用

黄小夏; 高萍; 胡思思; 郑冰清; 陈霜; 徐小群

doi:10.16766/j.cnki.issn.1674-4152.004351

基于阶梯式护理模式的睡眠管理方案在NICU早产儿中的应用

doi: 10.16766/j.cnki.issn.1674-4152.004351

温州医科大学附属第一医院新生儿监护室，浙江温州 325015

基金项目:

浙江省医药卫生科技计划项目 2023KY144

详细信息

通讯作者:
徐小群，E-mail：xuxiaoqun1@wzhospital.cn

中图分类号: R473.72 R722.6
计量
- 文章访问数: 8
- HTML全文浏览量: 3
- PDF下载量: 0
- 被引次数: 0
出版历程
- 收稿日期: 2025-01-27
- 网络出版日期: 2026-04-01

Application of a sleep management program based on the stepwise nursing model in premature infants in the NICU

Neonatal Intensive Care Unit, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325015, China

摘要

摘要: 目的基于阶梯式护理模式构建早产儿睡眠管理方案并评价其应用效果，为临床上早产儿睡眠的保护和干预提供借鉴。方法选取2023年9—12月于温州医科大学附属第一医院新生儿科住院的60例早产儿作为研究对象，按照入院先后顺序分为观察组和对照组，各30例，对照组采用常规护理，观察组在对照组的基础上应用早产儿睡眠管理方案进行护理。比较2组早产儿24 h平均睡眠时长、日间平均睡眠时长、夜间平均睡眠时长、平均体质量增长速度、平均心率、平均住院时间及平均血氧饱和度。结果观察组24 h平均睡眠时长[(18.40±1.87)h]、日间平均睡眠时长[9.00(8.75, 10.00)h]均长于对照组[(16.00±2.45)h、7.00(6.00, 8.00)h，P < 0.001]；2组夜间平均睡眠时长差异无统计学意义[9.00(8.00, 10.00)h vs. 9.00(8.00, 10.00) h, P>0.05]。观察组平均体质量增长速度为(20.50±0.43)g/(kg·d)，快于对照组[(16.37±0.50)g/(kg·d)]，平均心率为(135.83±13.91)次/min，慢于对照组[(145.07±12.25)次/min]，差异均有统计学意义(P < 0.05)。2组平均住院时间、平均血氧饱和度比较差异均无统计学意义[25.50(20.00, 32.00)d vs. 30.00(25.00, 37.00)d、(95.13±3.15)% vs.(96.20±2.80)%，P>0.05]。结论基于阶梯式护理模式的早产儿睡眠管理方案能增加早产儿睡眠时长、降低早产儿心率、提高体质量增长速度，值得在临床推广。
- 早产儿 /
- 阶梯式护理模式 /
- 睡眠 /
- 管理方案
Abstract: Objective To develop and evaluate a stepped-care-based sleep protocol for preterm infants, with a view to guiding clinical sleep protection and intervention. Methods From September to December of 2023, a total of 60 infants born preterm (as defined by a gestational age of less than 37 weeks) were enrolled in the study. These infants were recruited from a designated neonatal unit and were subsequently divided into two groups comprising 30 individuals each. The control group received routine care, while the intervention group received the sleep protocol in addition to routine care. The outcomes encompassed a range of metrics, including 24 h/daytime/nighttime sleep duration, weight gain velocity, heart rate, number of days spent in hospital, and oxygen saturation levels. Results The intervention group exhibited a greater duration of average sleep over a 24-h period [(18.40±1.87) hours] and during daytime [9.00 (8.75, 10.00) hours] vs. control group [(16.00±2.45) hours and 7.00 (6.00, 8.00) hours, both P < 0.001]. Nighttime sleep showed no difference [9.00(8.00, 10.00)h vs. 9.00(8.00, 10.00) h, P>0.05]. A significant difference was observed in weight gain velocity [(20.50±0.43) g/(kg·d) vs. (16.37±0.50) g/(kg·d)] and heart rate [(135.83±13.91) times/min vs. (145.07±12.25) times/min] (P < 0.05). Hospitalization days [25.50 (20.00, 32.00) d vs. 30.00 (25.00, 37.00) d] and oxygen saturation [(95.13±3.15) % vs. (96.20±2.80) %] were comparable (P>0.05). Conclusion The stepped-care protocol has been demonstrated to enhance sleep duration, heart rate, and weight gain in preterm infants, thus offering significant clinical benefits in terms of promotion..
- Premature infants /
- Stepped care models /
- Sleep /
- Management plan

HTML全文

图 1 医疗护理活动与睡眠得分关系图

Figure 1. Correlation diagram of healthcare interventions and sleep quality scores

下载: 全尺寸图片幻灯片

表 1 2组早产儿一般资料比较

Table 1. Baseline characteristics of 2 groups of preterm infants

项目	对照组(n=30)	观察组(n=30)	统计量	P值
性别[例(%)]			0.268^a	0.605
男	15(50.00)	13(43.33)
女	15(50.00)	17(56.67)
胎龄(x±s, 周)	32.46±2.81	31.51±2.87	1.299^b	0.199
出生体重(x±s, g)	1 621.83±381.19	1 537.50±412.44	0.822^b	0.414
1 min Apgar评分[M(P₂₅, P₇₅), 分]	9(7, 10)	9(8, 10)	-1.127^c	0.260
分娩方式[例(%)]				0.792^d
剖宫产	19(63.33)	17(56.67)
顺产	11(36.67)	12(40.00)
顺产+侧切	0	1(3.33)
生后喂养情况[例(%)]			1.498^a	0.221
禁食	28(93.33)	25(83.33)
开奶	2(6.67)	5(16.67)
生后吸氧方式[例(%)]				0.275^d
头罩吸氧	0	3(10.00)
箱式吸氧	3(10.00)	0
鼻旁吸氧	2(6.67)	3(10.00)
无吸氧	7(23.33)	7(23.33)
有创呼吸机	8(26.67)	10(33.34)
无创呼吸机	10(33.33)	7(23.33)
注：^a为χ²值，^b为t值，^c为Z值，^d为采用Fisher精确检验。

下载: 导出CSV

表 2 早产儿睡眠管理方案

Table 2. Sleep management plan for premature infants

睡眠管理方案	具体内容
1睡眠评估	1.1睡眠评估时机
	1.1.1每小时评估
	1.1.2医疗护理操作前后评估
	1.1.3睡眠中断后评估
	1.2睡眠评估工具：新生儿睡眠-觉醒评估量表
	1.3睡眠状况判定
	1.3.1判定依据：早产儿1 d的睡眠需求为17~24 h(折算8 h一个班的睡眠需求为5~8 h)
	1.3.2睡眠不足：早产儿1 d睡眠期<17 h或一个班睡眠<5 h
2睡眠时间节点管理	2.1医疗护理活动分级
	2.1.1 A级别为不可暂缓的医疗急救活动，不管睡眠得分多少，必须立即展开医疗活动
	2.1.2 B级别为可有条件进行的医疗护理活动，如输液更换尽量不接触及不打扰患儿的活动
	2.1.3 C级别为可暂缓的医疗护理活动，如更换尿布、整理床单位以及可以暂缓的常规血液检查等活动
	2.2睡眠时间节点与医疗活动
	2.2.1觉醒期：可以进行任何医疗活动
	2.2.2睡眠期：建议除A级医疗活动外暂停打扰，不建议进行B级医疗活动，禁止C级医疗活动
3睡眠干预措施	3.1睡眠干预措施实施时机
	3.1.1早产儿睡眠不足时
	3.1.2睡眠中断后
	3.2睡眠干预措施层级分级
	3.2.1基础保护措施(第1层级)(1)病房环境温湿度适宜，温度控制在24~26 ℃，湿度为55%~65%，暖箱的温度以维持早产儿的中性温度为准；(2)医护人员日常工作做到“四轻”，减少不必要的噪声，暖箱内声音分贝控制：白天< 45 dB，夜间<35 dB；(3)体位支持：根据早产儿睡眠-觉醒周期改变体位，早产儿日常护理抬高床头15°~30°，头正中或偏向一侧，四肢自然摆放；(4)早产儿暖箱盖有暖箱罩，白天半盖至暖箱箱门处及以上，夜间常规全部遮盖；(5)早产儿“鸟巢”式襁褓包裹
	3.2.2促进措施(第2层级)(1)音乐疗法，采用MP4播放摇篮曲等轻音乐，将MP4音量设置为35~45 dB，每次15~30 min；(2)安抚，将早产儿双手放置腹部，轻轻安抚，每次10~15 min；(3)袋鼠式护理，将早产儿袋鼠抱至胸前进行安抚，每次10~15 min；(4)非营养性吸吮，将安抚奶嘴放入早产儿嘴巴进行吸吮，每次5~15 min
	3.2.3矫正行为(第3层级)(1)评估以上措施落实的有效性；(2)评估医疗护理活动是否过于频繁等
	3.3睡眠干预措施实施顺序
	3.3.1当患儿需要进行睡眠干预时，先从第1层级常规措施落实情况开始(此层级的成本最低)
	3.3.2第1层级无效后进入第2层级，根据患儿自身特点选择一种或多种措施
	3.3.3第2层级措施无效后，进入第3层级，评估措施执行方法的正确性及干扰因素，矫正不当的睡眠干预行为
	3.4睡眠干预措施选择
	3.4.1睡眠干预措施的选择应根据早产儿的情况进行选择，不是所有措施都适合所有早产儿
	3.4.2根据早产儿当时的治疗护理环境选择，如腰穿治疗后的早产儿不能采用袋鼠式护理安抚等
	3.4.3根据早产儿疾病特点进行选择，如缺氧缺血兴奋易激惹早产儿不能采用音乐安抚，吸吮-呼吸功能不协调的早产儿不宜采用非营养性吸吮等

下载: 导出CSV

表 3 2组早产儿睡眠时长比较

Table 3. Comparison of average sleep duration between two groups of premature infants

组别	例数	24 h平均睡眠时长(x±s, h)	日间平均睡眠时长[M(P₂₅, P₇₅), h]	夜间平均睡眠时长[M(P₂₅, P₇₅), h]
对照组	30	16.00±2.45	7.00(6.00, 8.00)	9.00(8.00, 10.00)^c
观察组	30	18.40±1.87	9.00(8.75, 10.00)	9.00(8.00, 10.00)
统计量		4.267^a	-5.620^b	-0.460^b
P值		< 0.001	< 0.001	0. 646
注：^a为t值，^b为Z值。与同组日间平均睡眠时长比较，^cP < 0.001。

下载: 导出CSV

参考文献(21)

[1]	MATRICCIANI L, PAQUET C, GALLAND B, et al. Children's sleep and health: a meta-review[J]. Sleep Med Rev, 2019, 46: 136-150. doi: 10.1016/j.smrv.2019.04.011
[2]	慎斐, 罗飞翔, 徐红贞. 新生儿重症监护室早产儿睡眠促进的研究进展[J]. 护理学杂志, 2024, 39(12): 125-129. SHEN F, LUO F X, XU H Z, et al. Sleep promotion for preterm infants in the nonatal intensive care unit[J]. Journal of Nursing Science, 2024, 39(12): 125-129.
[3]	MEHTA B, WATERS K, FITZGERALD D, et al. Sleep disordered breathing (SDB) in neonates and implications for its long-term impact[J]. Paediatr Respir Rev, 2020, 34: 3-8.
[4]	VISSER S S M, VAN DIEMEN W J M, KERVEZEE L, et al. The relationship between preterm birth and sleep in children at schoolage: a systematic review[J]. Sleep Med Rev, 2021, 57: 101447. DOI: 10.1016/j.smrv.2021.101447.
[5]	李翰. NICU早产儿睡眠评估及干预措施的研究进展[J]. 齐鲁护理杂志, 2024, 30(20): 100-102. LI H. Research progress on sleep assessment and interventions for premature infants in NICU[J]. Qilu Journal of Nursing, 2024, 30(20): 100-102.
[6]	聂玲, 孙小玲, 蒋玲, 等. NICU早产儿睡眠保护的最佳证据总结[J]. 中华护理杂志, 2023, 58(12): 1449-1455. NIE L, SUN X L, JING L, et al. Summary of best evidence of sleep protection for premature infants in NICU[J]. Chinese Journal of Nursing, 2023, 58(12): 1449-1455.
[7]	ABRAMS D B. Treatment issues: towards a stepped-care model[J]. Tobacco Control, 1993, 2: 17-29.
[8]	朱政, 胡雁, 周英凤, 等. 推动证据向临床转化(五)证据临床转化研究中的文献质量评价[J]. 护士进修杂志, 2020, 35(11): 996-1000. ZHU Z, HU Y, ZHOU Y F, et al. Promotion evidence to clinical transformation: Evidence resource retrieval for the purpose of clinical transformation[J]. Journal of Nurses Training, 2020, 35(11): 996-1000.
[9]	沈琛, 李丽莎, 傅建英, 等. 肝移植术后代谢病患者标准化非药物管理方案的构建及应用[J]. 中华全科医学, 2024, 22(3): 428-432. doi: 10.16766/j.cnki.issn.1674-4152.003418 SHEN C, LI L S, FU J Y, et al. Construction and application of standardized non-drug management scheme for progeny patients with degenerative diseases after liver transplantation[J]. Chinese Journal of General Practice, 2024, 22(3): 428-432. doi: 10.16766/j.cnki.issn.1674-4152.003418
[10]	廖金花, 苏丽静, 侯婉玲, 等. 非药物干预对新生儿重症监护室早产儿睡眠影响的Meta分析[J]. 循证医学, 2018, 18(3): 150-159. LIAO J H, SU L J, HOU W L, et al. Non-pharmacological interventions for NICU preterm infants' sleep promotion: a meta-anal ysis[J]. Journal of Evidence-Based Medicine, 2018, 18(3): 150-159.
[11]	JINHEE P. Sleep promotion for preterm infants in the NICU[J]. Nurs Womens Health, 2020, 24(1): 24-35. doi: 10.1016/j.nwh.2019.11.004
[12]	KOBUS S, DIEZEL M, DEWAN M V, et al. Music therapy is effective during sleep in preterm infants[J]. Int J Environ Res Public Health, 2021, 18(16): 2-10.
[13]	慎斐, 罗飞翔, 商祯茹, 等. 吊床体位促进早产儿生长发育效果的研究[J]. 中华护理杂志, 2022, 57(3): 301-305. SHEN F, LUO F X, SHANG Z R, et al. Study on the effect of hammock positioning in promoting the growth and development of premature infants[J]. Chinese Journal of Nursing, 2022, 57(3): 301-305.
[14]	ALMADHOOB A, OHLSSON A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants[J]. Cochrane Database Syst Rev, 2020, 1(1): CD010333. DOI: 10.1002/14651858.CD010333.
[15]	林楠, 诸纪华, 徐红贞, 等. 早产儿体位管理的最佳证据总结[J]. 中华护理杂志, 2022, 57(4): 486-492. LIN N, ZHU J H, XU H Z, et al. Best evidence summary of positioning management for preterm infants[J]. 中华护理杂志, 2022, 57(4): 486-492.
[16]	杨茹, 陈琼, 李颖馨, 等. 我国医院早产儿发育支持护理实施现状调查[J]. 中华现代护理杂志, 2022, 28(17): 2360-2364. YANG R, CHEN Q, LI Y X, et al. Investigation on implementation status of developmental supportive care for premature infants in Chinese hospitals[J]. Chinese Journal of Modern Nursing, 2022, 28(17): 2360-2364.
[17]	COSTA V S, BUNDCHEN D C, SOUSA H, et al. Clinical benefits of music-based intervention-s on preterm infants' health: a systematic review of randomised trials[J]. Acta Paediatr, 2022, 111(3): 478-489. doi: 10.1111/apa.16222
[18]	李颖馨, 陈琼, 范玲, 等. 新生儿重症监护室住院早产儿发育支持护理的最佳证据总结[J]. 护理学报, 2024, 31(11): 28-34. LI Y X, CHEN Q, FAN L, et al. Best evidence summary for developmental supportive care in premature infants in neonatal intensive care units[J]. Journal of Nursing, 2024, 31(11): 28-34.
[19]	Watson Nursing Science Institute. Neo SWAT Sleep-Wake Assessment Tool[EB/OL]. (2022-02-10)[2023-08-25]. https://neonatalcertification.com/site/wp-content/uploads/2020/10/NeoSWAT_ENGLISH-2019-2.pdf.
[20]	李倩, 涂素华, 李雨昕, 等. 母亲心音联合话音刺激对NICU早产儿心率及行为状态的影响[J]. 护理学报, 2019, 26(22): 6-10. LI Q, TU S H, LI Y X, et al. Effects of maternal heart sound combined with voice stimulation on heart rate and behavior status of premature infants in NICU[J]. Journal of Nursing, 2019, 26(22): 6-10.
[21]	SAJJADIAN N, MOHAMMADZADEH M, ALIZADEH TAHERI P, et al. Positive effects of low intensity recorded maternal voice on physiologic reactions in premature infants[J]. Infant Behav Dev, 2017, 46: 59-66. doi: 10.1016/j.infbeh.2016.11.009