三种行为观察量表在评估烧伤婴幼儿患者疼痛中的应用研究
|
摘要
研究目的：
检验三种行为观察量表在评估烧伤婴幼儿患者创面换药过程中疼痛的信度和效度，探讨量表在临床应用中的影响因素。
研究方法：
将临床上符合纳入标准的烧伤婴幼儿患者创面换药过程进行录像记录，从中选取24段视频，分为A、B、C三组，分别为打开敷料至创面处理前组、创面处理过程组和处理后的包扎过程组，每组8段视频，每段时长2分钟。采用便利抽样的方法选取广州市某三甲医院55名护理本科实习生，首先对他们进行三种行为观察量表即COMFORT行为量表、FLACC量表和POCIS量表的应用培训，然后对24段视频中患儿的疼痛情况进行评分。第一次评分两个月后再进行第二次评分。对评分结果进行信度和效度分析。
结果：
(1).COMFORT行为量表的测量者间信度为0.82-0.85，克朗巴赫α系数为0.869-0.873，前后两次评分结果间的相关系数为0.597；FLACC量表的测量者间信度为0.79-0.82，克朗巴赫α系数为0.709-0.799，前后两次评分结果间的相关系数为0.645；POCIS量表的测量者间信度为0.78-0.80，克朗巴赫α系数为0.846-0.856，前后两次评分结果间的相关系数为0.657。三个量表间的Pearson相关系数均大于0.822，且P=0.000。(2).COMFORT行为量表和FLACC量表各组间的疼痛评分结果有差异，前后两次评分的P值分别为0.013、0.023和0.019、0.007，POCIS量表各组间的评分结果没有显著差异（P值分别为0.102、0.099）。(3).COMFORT行为量表中得分最高的项目是“警觉状态”（4.16、4.12），最低的是“肌肉张力”（3.32、3.35）；FLACC量表中得分最高的项目是“哭闹”和“可安抚程度”（1.45、1.38），最低的是“身体情况”（1.12、1.19）；POCIS量表中得分最高的项目是“面部”（0.94、0.94），最低的是“呼吸”（0.81、0.79）。
结论：
(1).三种量表的测量者间信度、重测信度和克朗巴赫α系数均较好，量表间的评分结果一致性较高。(2).COMFORT行为量表和FLACC量表能够区分评估对象烧伤创面换药过程中不同阶段的疼痛程度，而POCIS量表不能有效区分不同阶段的疼痛情况。(3).由于研究方法的局限性，各量表的效度有待进一步的研究。
Objective:
This study was to assess if the COMFORT behavioral scale, FLACC scale and POCISscale are reliable and valid instruments to measure burns pain in young children, and todiscuss the factors of affecting the clinical application.
Methods:
The process of dressing change for those young children with burns of meeting theinclusion criteria in clinical was recorded on video. The24segments of videos wereselected from the recorded, which were divided into three groups: A. the process ofopening dressing until the moment of being ready to treating burn wound, B. the processof treating the burn wound, C. the process of binding up after the treatment. Each groupconsists of eight segments videos with two minutes for each segment video. Byconvenience sampling,55nursing undergraduate interns were selected from a3-A-gradehospital of Guangzhou. At first, they were trained to learn about application of the threescales, then conditions of pain related to the young children with burns were gradedamong24segments videos. Besides, the second time for grading were conducted aftertwo months of the first time for that. And the reliability and validity of assessment resultswere analyzed.
Results:
(1).The inter-raters reliability of COMFORT behavioral scale is0.82-0.85, Cronbach’salpha is0.869-0.873, and the related coefficient is0.597between the first time and secondtime assessment. The inter-raters reliability of FLACC scale is0.79-0.82, Cronbach’salpha is0.709-0.799, and the related coefficient is0.645between two assessments. Theinter-raters reliability of POCIS scale is0.78-0.80, Cronbach’s alpha is0.846-0.856, andthe related coefficient is0.657between two assessments. The Pearson Correlation amongthe three scales are all above0.822, and P=0.000.(2).The pain assessment results varyamong each group of COMFORT behavioral scale and FLACC scale (P-value is0.013,0.023and0.019,0.007respectively). There is no significant difference for the assessment results among each groups of POCIS scale.(P-value is0.102,0.099).(3).The item withthe highest score is “alertness”（4.16,4.12）in the COMFORT behavior scale, and theitem with the lowest score is “muscle tone”（3.32,3.35）; the items with the highest scorein the FLACC scale are “cry” and “consolability”（1.45,1.38）and the item with thelowest score is “activity”（1.12,1.19）; the item with the highest score in the POCIS scaleis “facial”（0.94,0.94）and the item with the lowest score is “breath”（0.81,0.79）.
Conclusion:
From the above research, we can conclude that the inter-raters reliability, test-retestreliability as well as the Cronbach’s alpha are preferably among the three scales. What’smore, it has a higher consistency of assessment results among the scales, and theCOMFORT behavior scale and the FLACC scale are able to distinguish the various stagesof pain degree of assessment objects while the POCIS scale can’t distinguish the variousstages of pain condition effectively. Due to the limitation of research methods, the validityof each scale needs to be further researched.
检验三种行为观察量表在评估烧伤婴幼儿患者创面换药过程中疼痛的信度和效度，探讨量表在临床应用中的影响因素。
研究方法：
将临床上符合纳入标准的烧伤婴幼儿患者创面换药过程进行录像记录，从中选取24段视频，分为A、B、C三组，分别为打开敷料至创面处理前组、创面处理过程组和处理后的包扎过程组，每组8段视频，每段时长2分钟。采用便利抽样的方法选取广州市某三甲医院55名护理本科实习生，首先对他们进行三种行为观察量表即COMFORT行为量表、FLACC量表和POCIS量表的应用培训，然后对24段视频中患儿的疼痛情况进行评分。第一次评分两个月后再进行第二次评分。对评分结果进行信度和效度分析。
结果：
(1).COMFORT行为量表的测量者间信度为0.82-0.85，克朗巴赫α系数为0.869-0.873，前后两次评分结果间的相关系数为0.597；FLACC量表的测量者间信度为0.79-0.82，克朗巴赫α系数为0.709-0.799，前后两次评分结果间的相关系数为0.645；POCIS量表的测量者间信度为0.78-0.80，克朗巴赫α系数为0.846-0.856，前后两次评分结果间的相关系数为0.657。三个量表间的Pearson相关系数均大于0.822，且P=0.000。(2).COMFORT行为量表和FLACC量表各组间的疼痛评分结果有差异，前后两次评分的P值分别为0.013、0.023和0.019、0.007，POCIS量表各组间的评分结果没有显著差异（P值分别为0.102、0.099）。(3).COMFORT行为量表中得分最高的项目是“警觉状态”（4.16、4.12），最低的是“肌肉张力”（3.32、3.35）；FLACC量表中得分最高的项目是“哭闹”和“可安抚程度”（1.45、1.38），最低的是“身体情况”（1.12、1.19）；POCIS量表中得分最高的项目是“面部”（0.94、0.94），最低的是“呼吸”（0.81、0.79）。
结论：
(1).三种量表的测量者间信度、重测信度和克朗巴赫α系数均较好，量表间的评分结果一致性较高。(2).COMFORT行为量表和FLACC量表能够区分评估对象烧伤创面换药过程中不同阶段的疼痛程度，而POCIS量表不能有效区分不同阶段的疼痛情况。(3).由于研究方法的局限性，各量表的效度有待进一步的研究。
Objective:
This study was to assess if the COMFORT behavioral scale, FLACC scale and POCISscale are reliable and valid instruments to measure burns pain in young children, and todiscuss the factors of affecting the clinical application.
Methods:
The process of dressing change for those young children with burns of meeting theinclusion criteria in clinical was recorded on video. The24segments of videos wereselected from the recorded, which were divided into three groups: A. the process ofopening dressing until the moment of being ready to treating burn wound, B. the processof treating the burn wound, C. the process of binding up after the treatment. Each groupconsists of eight segments videos with two minutes for each segment video. Byconvenience sampling,55nursing undergraduate interns were selected from a3-A-gradehospital of Guangzhou. At first, they were trained to learn about application of the threescales, then conditions of pain related to the young children with burns were gradedamong24segments videos. Besides, the second time for grading were conducted aftertwo months of the first time for that. And the reliability and validity of assessment resultswere analyzed.
Results:
(1).The inter-raters reliability of COMFORT behavioral scale is0.82-0.85, Cronbach’salpha is0.869-0.873, and the related coefficient is0.597between the first time and secondtime assessment. The inter-raters reliability of FLACC scale is0.79-0.82, Cronbach’salpha is0.709-0.799, and the related coefficient is0.645between two assessments. Theinter-raters reliability of POCIS scale is0.78-0.80, Cronbach’s alpha is0.846-0.856, andthe related coefficient is0.657between two assessments. The Pearson Correlation amongthe three scales are all above0.822, and P=0.000.(2).The pain assessment results varyamong each group of COMFORT behavioral scale and FLACC scale (P-value is0.013,0.023and0.019,0.007respectively). There is no significant difference for the assessment results among each groups of POCIS scale.(P-value is0.102,0.099).(3).The item withthe highest score is “alertness”（4.16,4.12）in the COMFORT behavior scale, and theitem with the lowest score is “muscle tone”（3.32,3.35）; the items with the highest scorein the FLACC scale are “cry” and “consolability”（1.45,1.38）and the item with thelowest score is “activity”（1.12,1.19）; the item with the highest score in the POCIS scaleis “facial”（0.94,0.94）and the item with the lowest score is “breath”（0.81,0.79）.
Conclusion:
From the above research, we can conclude that the inter-raters reliability, test-retestreliability as well as the Cronbach’s alpha are preferably among the three scales. What’smore, it has a higher consistency of assessment results among the scales, and theCOMFORT behavior scale and the FLACC scale are able to distinguish the various stagesof pain degree of assessment objects while the POCIS scale can’t distinguish the variousstages of pain condition effectively. Due to the limitation of research methods, the validityof each scale needs to be further researched.
引文
[1] Burd A, Yuen C. A global study of hospitalized paediatric burn patients[J]. Burns.2005,31(4):432-438.
[2]杨宗城,盛志勇.烧伤治疗学[M].第3版.北京:人民卫生出版社,2006:391-394.
[3] Kai-Yang L, Zhao-Fan X, Luo-Man Z, et al. Epidemiology of pediatric burnsrequiring hospitalization in China: a literature review of retrospective studies[J].Pediatrics.2008,122(1):132-142.
[4] Hanafiah Z, Potparic O, Fernandez T. Addressing pain in burn injury[J]. CurrentAnaesthesia& Critical Care.2008,19(5–6):287-292.
[5] Fitzgerald M. The development of nociceptive circuits[J]. Nat Rev Neurosci.2005,6(7):507-520.
[6] Lidow M S. Long-term effects of neonatal pain on nociceptive systems[J]. Pain.2002,99(3):377-383.
[7] Stoddard F J, Ronfeldt H, Kagan J, et al. Young burned children: the course of acutestress and physiological and behavioral responses[J]. Am J Psychiatry.2006,163(6):1084-1090.
[8] Howard R F. Current status of pain management in children[J]. JAMA.2003,290(18):2464-2469.
[9] Ramelet A S, Abu-Saad H H, Rees N, et al. The challenges of pain measurement incritically ill young children: a comprehensive review[J]. Aust Crit Care.2004,17(1):33-45.
[10] Walker S M. Pain in children: recent advances and ongoing challenges[J]. Br JAnaesth.2008,101(1):101-110.
[11] The assessment and management of acute pain in infants, children, andadolescents[J]. Pediatrics.2001,108(3):793-797.
[12] Crellin D, Sullivan T P, Babl F E, et al. Analysis of the validation of existingbehavioral pain and distress scales for use in the procedural setting[J]. PaediatrAnaesth.2007,17(8):720-733.
[13] Blount R L, Loiselle K A. Behavioural assessment of pediatric pain[J]. Pain ResManag.2009,14(1):47-52.
[14] Chen Y Y, Lai Y H, Shun S C, et al. The Chinese Behavior Pain Scale for criticallyill patients: translation and psychometric testing[J]. Int J Nurs Stud.2011,48(4):438-448.
[15] Bai J, Hsu L, Tang Y, et al. Validation of the COMFORT Behavior Scale and theFLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery[J].Pain Manag Nurs.2012,13(1):18-26.
[16]温惠娟.护理干预在小儿静脉输液中的应用及效果观察[J].当代医学.2011(15).
[17]林艳，马敬香，刘润梅，等.危重症患儿疼痛状况评估及护理[J].护理学报.2008(4):61-62.
[18]涂亚杰，熊玉珍.非药物疗法在小儿烧伤疼痛管理中的应用[J].护理学杂志.2009(10).
[19]郑敏惠，丁娜，钟玉娥.分散注意力在减轻患儿静脉穿刺疼痛中的应用[J].齐鲁护理杂志.2011(10):71-72.
[20] de Jong A E, Bremer M, Schouten M, et al. Reliability and validity of the painobservation scale for young children and the visual analogue scale in children withburns[J]. Burns.2005,31(2):198-204.
[21] de Jong A, Baartmans M, Bremer M, et al. Reliability, validity and clinical utility ofthree types of pain behavioural observation scales for young children with burnsaged0-5years[J]. Pain.2010,150(3):561-567.
[22] Casey G. Pain--the fifth vital sign[J]. Nurs N Z.2011,17(5):24-29.
[23] Harold Merskey N B. Classification of Chronic Pain[M]. New York：IASP Press,1994,2nd Edition,p209-214
[24] Dennis L. Kasper, Eugene Braunwald, Anthony S. Fauci, et al. Harrison's Principlesof Internal Medicine[M]. McGraw-Hill Professional,2004,16th Edition,p71-76.
[25]吴在德,吴肇汉.外科学[M].北京：人民卫生出版社,2008,第7版.p179.
[26] Esfahlan A J, Lotfi M, Zamanzadeh V, et al. Burn pain and patients' responses[J].Burns.2010,36(7):1129-1133.
[27] Richardson P, Mustard L. The management of pain in the burns unit[J]. Burns.2009,35(7):921-936.
[28] Summer G J, Puntillo K A, Miaskowski C, et al. Burn injury pain: the continuingchallenge[J]. J Pain.2007,8(7):533-548.
[29] Byers J F, Bridges S, Kijek J, et al. Burn patients' pain and anxiety experiences[J]. JBurn Care Rehabil.2001,22(2):144-149.
[30] Walco G A, Conte P M, Labay L E, et al. Procedural distress in children with cancer:self-report, behavioral observations, and physiological parameters[J]. Clin J Pain.2005,21(6):484-490.
[31] Stinson J N, Kavanagh T, Yamada J, et al. Systematic review of the psychometricproperties, interpretability and feasibility of self-report pain intensity measures foruse in clinical trials in children and adolescents[J]. Pain.2006,125(1-2):143-157.
[32]赵继军，陆小英，赵存凤，等.数字疼痛量表和描述疼痛量表的相关性研究和改进[J].现代护理.2002(9):660-661.
[33] Dowman R, Rissacher D, Schuckers S. EEG indices of tonic pain-related activity inthe somatosensory cortices[J]. Clin Neurophysiol.2008,119(5):1201-1212.
[34] Apkarian A V, Bushnell M C, Treede R D, et al. Human brain mechanisms of painperception and regulation in health and disease[J]. Eur J Pain.2005,9(4):463-484.
[35] Owen D G, Bureau Y, Thomas A W, et al. Quantification of pain-induced changes incerebral blood flow by perfusion MRI[J]. Pain.2008,136(1-2):85-96.
[36] Wolf K, Raedler T, Henke K, et al. The face of pain--a pilot study to validate themeasurement of facial pain expression with an improved electromyogram method[J].Pain Res Manag.2005,10(1):15-19.
[37] Rittner H L, Brack A, Stein C. Pain and the immune system[J]. Br J Anaesth.2008,101(1):40-44.
[38] Abbadie C. Chemokines, chemokine receptors and pain[J]. Trends Immunol.2005,26(10):529-534.
[39] Mousa S A, Straub R H, Schafer M, et al. Beta-endorphin, Met-enkephalin andcorresponding opioid receptors within synovium of patients with joint trauma,osteoarthritis and rheumatoid arthritis[J]. Ann Rheum Dis.2007,66(7):871-879.
[40] van Dijk M, de Boer J B, Koot H M, et al. The association between physiological andbehavioral pain measures in0-to3-year-old infants after major surgery[J]. J PainSymptom Manage.2001,22(1):600-609.
[41] Katz E R, Kellerman J, Siegel S E. Behavioral distress in children with cancerundergoing medical procedures: developmental considerations[J]. J Consult ClinPsychol.1980,48(3):356-365.
[42] Katz E R, Kellerman J, Ellenberg L. Hypnosis in the reduction of acute pain anddistress in children with cancer[J]. J Pediatr Psychol.1987,12(3):379-394.
[43] von Baeyer C L, Spagrud L J. Systematic review of observational (behavioral)measures of pain for children and adolescents aged3to18years[J]. Pain.2007,127(1-2):140-150.
[44] Cohen L L, Lemanek K, Blount R L, et al. Evidence-based assessment of pediatricpain[J]. J Pediatr Psychol.2008,33(9):939-957.
[45] Ambuel B, Hamlett K W, Marx C M, et al. Assessing distress in pediatric intensivecare environments: the COMFORT scale[J]. J Pediatr Psychol.1992,17(1):95-109.
[46] van Dijk M, Roofthooft D W, Anand K J, et al. Taking up the challenge of measuringprolonged pain in (premature) neonates: the COMFORTneo scale seemspromising[J]. Clin J Pain.2009,25(7):607-616.
[47] Johansson M, Kokinsky E. The COMFORT behavioural scale and the modifiedFLACC scale in paediatric intensive care[J]. Nurs Crit Care.2009,14(3):122-130.
[48] van Dijk M, de Boer J B, Koot H M, et al. The reliability and validity of theCOMFORT scale as a postoperative pain instrument in0to3-year-old infants[J].Pain.2000,84(2-3):367-377.
[49] Ista E, van Dijk M, Tibboel D, et al. Assessment of sedation levels in pediatricintensive care patients can be improved by using the COMFORT "behavior" scale[J].Pediatr Crit Care Med.2005,6(1):58-63.
[50] Bear L A, Ward-Smith P. Interrater reliability of the COMFORT Scale[J]. PediatrNurs.2006,32(5):427-434.
[51] Franck L S, Ridout D, Howard R, et al. A comparison of pain measures in newborninfants after cardiac surgery[J]. Pain.2011,152(8):1758-1765.
[52] Valkenburg A J, Boerlage A A, Ista E, et al. The COMFORT-Behavior scale isuseful to assess pain and distress in0-to3-year-old children with Down syndrome[J].Pain.2011,152(9):2059-2064.
[53] Merkel S I, Voepel-Lewis T, Shayevitz J R, et al. The FLACC: a behavioral scale forscoring postoperative pain in young children[J]. Pediatr Nurs.1997,23(3):293-297.
[54] Voepel-Lewis T, Zanotti J, Dammeyer J A, et al. Reliability and validity of the face,legs, activity, cry, consolability behavioral tool in assessing acute pain in critically illpatients[J]. Am J Crit Care.2010,19(1):55-61,62.
[55] Taddio A, Hogan M E, Moyer P, et al. Evaluation of the reliability, validity andpracticality of3measures of acute pain in infants undergoing immunizationinjections[J]. Vaccine.2011,29(7):1390-1394.
[56] Voepel-Lewis T, Merkel S, Tait A R, et al. The reliability and validity of the Face,Legs, Activity, Cry, Consolability observational tool as a measure of pain in childrenwith cognitive impairment[J]. Anesth Analg.2002,95(5):1224-1229.
[57] Nilsson S, Finnstrom B, Kokinsky E. The FLACC behavioral scale for proceduralpain assessment in children aged5-16years[J]. Paediatr Anaesth.2008,18(8):767-774.
[58] Malviya S, Voepel-Lewis T, Burke C, et al. The revised FLACC observational paintool: improved reliability and validity for pain assessment in children withcognitive impairment[J]. Paediatr Anaesth.2006,16(3):258-265.
[59]陈梅芳.婴儿和儿童疼痛评估的FLACC量表法[J].国外医学.护理学分册.2003(6):289-290.
[60]黄俊梅，雷小平，卢佑英.不同方式口服葡萄糖水对减轻婴儿静脉穿刺疼痛的效果观察[J].现代医药卫生.2010(2).
[61] Boelen-Van D L W, Scheffer E, de Haan R J, et al. Clinimetric evaluation of the painobservation scale for young children in children aged between1and4years after ear,nose, and throat surgery[J]. J Dev Behav Pediatr.1999,20(4):222-227.
[62] Polit D F, Beck C T. The content validity index: are you sure you know what's beingreported? Critique and recommendations[J]. Res Nurs Health.2006,29(5):489-497.
[63] Polit D F, Beck C T, Owen S V. Is the CVI an acceptable indicator of contentvalidity? Appraisal and recommendations[J]. Res Nurs Health.2007,30(4):459-467.
[2]杨宗城,盛志勇.烧伤治疗学[M].第3版.北京:人民卫生出版社,2006:391-394.
[3] Kai-Yang L, Zhao-Fan X, Luo-Man Z, et al. Epidemiology of pediatric burnsrequiring hospitalization in China: a literature review of retrospective studies[J].Pediatrics.2008,122(1):132-142.
[4] Hanafiah Z, Potparic O, Fernandez T. Addressing pain in burn injury[J]. CurrentAnaesthesia& Critical Care.2008,19(5–6):287-292.
[5] Fitzgerald M. The development of nociceptive circuits[J]. Nat Rev Neurosci.2005,6(7):507-520.
[6] Lidow M S. Long-term effects of neonatal pain on nociceptive systems[J]. Pain.2002,99(3):377-383.
[7] Stoddard F J, Ronfeldt H, Kagan J, et al. Young burned children: the course of acutestress and physiological and behavioral responses[J]. Am J Psychiatry.2006,163(6):1084-1090.
[8] Howard R F. Current status of pain management in children[J]. JAMA.2003,290(18):2464-2469.
[9] Ramelet A S, Abu-Saad H H, Rees N, et al. The challenges of pain measurement incritically ill young children: a comprehensive review[J]. Aust Crit Care.2004,17(1):33-45.
[10] Walker S M. Pain in children: recent advances and ongoing challenges[J]. Br JAnaesth.2008,101(1):101-110.
[11] The assessment and management of acute pain in infants, children, andadolescents[J]. Pediatrics.2001,108(3):793-797.
[12] Crellin D, Sullivan T P, Babl F E, et al. Analysis of the validation of existingbehavioral pain and distress scales for use in the procedural setting[J]. PaediatrAnaesth.2007,17(8):720-733.
[13] Blount R L, Loiselle K A. Behavioural assessment of pediatric pain[J]. Pain ResManag.2009,14(1):47-52.
[14] Chen Y Y, Lai Y H, Shun S C, et al. The Chinese Behavior Pain Scale for criticallyill patients: translation and psychometric testing[J]. Int J Nurs Stud.2011,48(4):438-448.
[15] Bai J, Hsu L, Tang Y, et al. Validation of the COMFORT Behavior Scale and theFLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery[J].Pain Manag Nurs.2012,13(1):18-26.
[16]温惠娟.护理干预在小儿静脉输液中的应用及效果观察[J].当代医学.2011(15).
[17]林艳，马敬香，刘润梅，等.危重症患儿疼痛状况评估及护理[J].护理学报.2008(4):61-62.
[18]涂亚杰，熊玉珍.非药物疗法在小儿烧伤疼痛管理中的应用[J].护理学杂志.2009(10).
[19]郑敏惠，丁娜，钟玉娥.分散注意力在减轻患儿静脉穿刺疼痛中的应用[J].齐鲁护理杂志.2011(10):71-72.
[20] de Jong A E, Bremer M, Schouten M, et al. Reliability and validity of the painobservation scale for young children and the visual analogue scale in children withburns[J]. Burns.2005,31(2):198-204.
[21] de Jong A, Baartmans M, Bremer M, et al. Reliability, validity and clinical utility ofthree types of pain behavioural observation scales for young children with burnsaged0-5years[J]. Pain.2010,150(3):561-567.
[22] Casey G. Pain--the fifth vital sign[J]. Nurs N Z.2011,17(5):24-29.
[23] Harold Merskey N B. Classification of Chronic Pain[M]. New York：IASP Press,1994,2nd Edition,p209-214
[24] Dennis L. Kasper, Eugene Braunwald, Anthony S. Fauci, et al. Harrison's Principlesof Internal Medicine[M]. McGraw-Hill Professional,2004,16th Edition,p71-76.
[25]吴在德,吴肇汉.外科学[M].北京：人民卫生出版社,2008,第7版.p179.
[26] Esfahlan A J, Lotfi M, Zamanzadeh V, et al. Burn pain and patients' responses[J].Burns.2010,36(7):1129-1133.
[27] Richardson P, Mustard L. The management of pain in the burns unit[J]. Burns.2009,35(7):921-936.
[28] Summer G J, Puntillo K A, Miaskowski C, et al. Burn injury pain: the continuingchallenge[J]. J Pain.2007,8(7):533-548.
[29] Byers J F, Bridges S, Kijek J, et al. Burn patients' pain and anxiety experiences[J]. JBurn Care Rehabil.2001,22(2):144-149.
[30] Walco G A, Conte P M, Labay L E, et al. Procedural distress in children with cancer:self-report, behavioral observations, and physiological parameters[J]. Clin J Pain.2005,21(6):484-490.
[31] Stinson J N, Kavanagh T, Yamada J, et al. Systematic review of the psychometricproperties, interpretability and feasibility of self-report pain intensity measures foruse in clinical trials in children and adolescents[J]. Pain.2006,125(1-2):143-157.
[32]赵继军，陆小英，赵存凤，等.数字疼痛量表和描述疼痛量表的相关性研究和改进[J].现代护理.2002(9):660-661.
[33] Dowman R, Rissacher D, Schuckers S. EEG indices of tonic pain-related activity inthe somatosensory cortices[J]. Clin Neurophysiol.2008,119(5):1201-1212.
[34] Apkarian A V, Bushnell M C, Treede R D, et al. Human brain mechanisms of painperception and regulation in health and disease[J]. Eur J Pain.2005,9(4):463-484.
[35] Owen D G, Bureau Y, Thomas A W, et al. Quantification of pain-induced changes incerebral blood flow by perfusion MRI[J]. Pain.2008,136(1-2):85-96.
[36] Wolf K, Raedler T, Henke K, et al. The face of pain--a pilot study to validate themeasurement of facial pain expression with an improved electromyogram method[J].Pain Res Manag.2005,10(1):15-19.
[37] Rittner H L, Brack A, Stein C. Pain and the immune system[J]. Br J Anaesth.2008,101(1):40-44.
[38] Abbadie C. Chemokines, chemokine receptors and pain[J]. Trends Immunol.2005,26(10):529-534.
[39] Mousa S A, Straub R H, Schafer M, et al. Beta-endorphin, Met-enkephalin andcorresponding opioid receptors within synovium of patients with joint trauma,osteoarthritis and rheumatoid arthritis[J]. Ann Rheum Dis.2007,66(7):871-879.
[40] van Dijk M, de Boer J B, Koot H M, et al. The association between physiological andbehavioral pain measures in0-to3-year-old infants after major surgery[J]. J PainSymptom Manage.2001,22(1):600-609.
[41] Katz E R, Kellerman J, Siegel S E. Behavioral distress in children with cancerundergoing medical procedures: developmental considerations[J]. J Consult ClinPsychol.1980,48(3):356-365.
[42] Katz E R, Kellerman J, Ellenberg L. Hypnosis in the reduction of acute pain anddistress in children with cancer[J]. J Pediatr Psychol.1987,12(3):379-394.
[43] von Baeyer C L, Spagrud L J. Systematic review of observational (behavioral)measures of pain for children and adolescents aged3to18years[J]. Pain.2007,127(1-2):140-150.
[44] Cohen L L, Lemanek K, Blount R L, et al. Evidence-based assessment of pediatricpain[J]. J Pediatr Psychol.2008,33(9):939-957.
[45] Ambuel B, Hamlett K W, Marx C M, et al. Assessing distress in pediatric intensivecare environments: the COMFORT scale[J]. J Pediatr Psychol.1992,17(1):95-109.
[46] van Dijk M, Roofthooft D W, Anand K J, et al. Taking up the challenge of measuringprolonged pain in (premature) neonates: the COMFORTneo scale seemspromising[J]. Clin J Pain.2009,25(7):607-616.
[47] Johansson M, Kokinsky E. The COMFORT behavioural scale and the modifiedFLACC scale in paediatric intensive care[J]. Nurs Crit Care.2009,14(3):122-130.
[48] van Dijk M, de Boer J B, Koot H M, et al. The reliability and validity of theCOMFORT scale as a postoperative pain instrument in0to3-year-old infants[J].Pain.2000,84(2-3):367-377.
[49] Ista E, van Dijk M, Tibboel D, et al. Assessment of sedation levels in pediatricintensive care patients can be improved by using the COMFORT "behavior" scale[J].Pediatr Crit Care Med.2005,6(1):58-63.
[50] Bear L A, Ward-Smith P. Interrater reliability of the COMFORT Scale[J]. PediatrNurs.2006,32(5):427-434.
[51] Franck L S, Ridout D, Howard R, et al. A comparison of pain measures in newborninfants after cardiac surgery[J]. Pain.2011,152(8):1758-1765.
[52] Valkenburg A J, Boerlage A A, Ista E, et al. The COMFORT-Behavior scale isuseful to assess pain and distress in0-to3-year-old children with Down syndrome[J].Pain.2011,152(9):2059-2064.
[53] Merkel S I, Voepel-Lewis T, Shayevitz J R, et al. The FLACC: a behavioral scale forscoring postoperative pain in young children[J]. Pediatr Nurs.1997,23(3):293-297.
[54] Voepel-Lewis T, Zanotti J, Dammeyer J A, et al. Reliability and validity of the face,legs, activity, cry, consolability behavioral tool in assessing acute pain in critically illpatients[J]. Am J Crit Care.2010,19(1):55-61,62.
[55] Taddio A, Hogan M E, Moyer P, et al. Evaluation of the reliability, validity andpracticality of3measures of acute pain in infants undergoing immunizationinjections[J]. Vaccine.2011,29(7):1390-1394.
[56] Voepel-Lewis T, Merkel S, Tait A R, et al. The reliability and validity of the Face,Legs, Activity, Cry, Consolability observational tool as a measure of pain in childrenwith cognitive impairment[J]. Anesth Analg.2002,95(5):1224-1229.
[57] Nilsson S, Finnstrom B, Kokinsky E. The FLACC behavioral scale for proceduralpain assessment in children aged5-16years[J]. Paediatr Anaesth.2008,18(8):767-774.
[58] Malviya S, Voepel-Lewis T, Burke C, et al. The revised FLACC observational paintool: improved reliability and validity for pain assessment in children withcognitive impairment[J]. Paediatr Anaesth.2006,16(3):258-265.
[59]陈梅芳.婴儿和儿童疼痛评估的FLACC量表法[J].国外医学.护理学分册.2003(6):289-290.
[60]黄俊梅，雷小平，卢佑英.不同方式口服葡萄糖水对减轻婴儿静脉穿刺疼痛的效果观察[J].现代医药卫生.2010(2).
[61] Boelen-Van D L W, Scheffer E, de Haan R J, et al. Clinimetric evaluation of the painobservation scale for young children in children aged between1and4years after ear,nose, and throat surgery[J]. J Dev Behav Pediatr.1999,20(4):222-227.
[62] Polit D F, Beck C T. The content validity index: are you sure you know what's beingreported? Critique and recommendations[J]. Res Nurs Health.2006,29(5):489-497.
[63] Polit D F, Beck C T, Owen S V. Is the CVI an acceptable indicator of contentvalidity? Appraisal and recommendations[J]. Res Nurs Health.2007,30(4):459-467.