三浦 由佳

＜文献概要＞排泄とは,物質代謝の結果生じた不要になった老廃物を体外に排出することであり,排泄物には尿や便,汗などがある.排泄は人が生きていくために必要不可欠な行為であり,人としての尊厳や自己実現にかかわるため,大変重要である.現在日本は超高齢社会の到来に伴い,運動機能や認知機能が低下した高齢者の自立を支援するケアへの取り組みが進められている.排泄ケアにおいても,高齢者が残された能力で良好かつ最大限自立した排泄ができるような支援が求められており,その1つとして2016年に診療報酬として「排尿自立指導料」が新設された.その後,排尿自立指導料を申請する病院数が増加し,2020年度の改定では,入院中の患者に対する包括的排尿ケアの評価は,基本診療料のなかの「入院基本料等加算」として,「排尿自立支援加算」が新設された.これまでの「排尿自立指導料」は,入院中の患者以外を対象とした包括的排尿ケアの評価に対する「外来排尿自立指導料」に変更となった.また「排尿自立支援加算」となったことで,算定可能な入院料が拡大され,「地域包括ケア病棟入院料」,「回復期リハビリテーション病棟入院料」,「精神科救急入院料」,「精神療養病棟入院料」などで新たに算定可能となった.このように病棟と外来を通して,患者の排尿自立を支援することの重要性の理解が進んでいる.

超高齢社会に突入したわが国では,2025年を目処に地域包括ケアシステムの構築が推進され,高齢者の尊厳の保持と自立生活の支援を目的として,可能なかぎり,住み慣れた地域で自分らしい生活を送れるための準備が進められている。医療が病院から在宅にシフトし,地域の高齢者が「時々入院,ほぼ在宅」と言われるようになっていく中,在宅医療のキーパーソンとなる看護師に求められる役割はますます重要になっている。特に重要なのは,必ずしも現場に医師がいない中で,看護師が患者の身体状態を正しく観察,アセスメントする能力である。近年,看護師が在宅やベッドサイドで,体内を可視化し観察するためのモダリティとして,携帯型超音波診断装置(ポータブルエコー)が注目されている。エコーは,従来から非侵襲,リアルタイムに体内の可視化画像を得られる検査であるが,小型で高性能な装置の登場によって,看護師がポイントオブケア検査として使いやすいものとなり,「第6のフィジカルアセスメント」可視化のツールと呼ばれるようになった。体内を可視化できるだけでなく,画像情報を医療者間で共有でき,さらには療養者,家族とも共有できることで,迅速な治療・ケア方針や意思決定につながる。エコーというモダリティが看護の観察,アセスメントに新しい価値を生み出し,まさにケアイノベーションを起こしたと言える。(著者抄録)

■便秘は本来,体外に排出すべき糞便を十分量かつ快適に排出できない状態と定義されており,加齢に伴い有訴者は増加する.評価には自覚症状の聴取が重要となるが,認知症などで意思疎通が困難な高齢者では聴取が困難であり,看護師は便秘のアセスメントや排便ケア方法選択に難渋してきた.■看護師による携帯型超音波画像診断装置(エコー)を利用した可視化は,これまでの診断のための検査として行われている大腸エコーとは異なり,エコーで便貯留をアセスメントしその場の排便ケアを選択するというPoint-of-Care Ultrasound(POCUS)を行うという視点であり,新しい.■エコーの導入は便秘症状の下剤量の減少につながり,看護師が短時間で学ぶことのできる教育プログラム,AI(Artificial Intelligence)によるアシスト機能を備えたデバイスも市販されており,老年看護の新しいアセスメントツールとして今後ますますの活用が期待される.(著者抄録)

AIM: This clinical practice guideline aims to provide and recommend methods of assessing aspiration and pharyngeal residue during eating and swallowing and methods of selecting and implementing nursing care for adults to prevent the development of aspiration pneumonia through early and appropriate management of oropharyngeal dysphagia. METHODS: In April 2018, the Japan Academy of Nursing Science established the Supervisory Committee in Nursing Care Development/Standardization Committee to develop clinical practice guidelines for aspiration and pharyngeal residual assessment during eating and swallowing for nursing care. This clinical practice guideline was developed according to the Minds Manual for Guideline Development 2017, with the aim of providing a specific pathway for nurses to determine the policy for selecting management for oropharyngeal dysphagia based on research evidence and multifaceted factors including the balance of benefits and harms and patients' values. RESULTS: Based on the 10 clinical questions related to assessment by physical assessment, the Repetitive Saliva Swallowing Test, Modified Water Swallowing Test, Food Test, cervical auscultation, observation using an ultrasound diagnostic device, and an endoscope, 10 recommendations have been developed. Eight recommendations have been evaluated as the Grading of Recommendations Assessment, Development and Evaluation (GRADE) 2C, and the other two have been evaluated as no GRADE. CONCLUSION: The first reliable clinical practice guideline has been produced from an academic nursing organization that focuses on assessment for nursing care and incorporates the latest findings.

The classification of ultrasound (US) findings of pressure injury is important to select the appropriate treatment and care based on the state of the deep tissue, but it depends on the operator’s skill in image interpretation. Therefore, US for pressure injury is a procedure that can only be performed by a limited number of highly trained medical professionals. This study aimed to develop an automatic US image classification system for pressure injury based on deep learning that can be used by non-specialists who do not have a high skill in image interpretation. A total 787 training data were collected at two hospitals in Japan. The US images of pressure injuries were assessed using the deep learning-based classification tool according to the following visual evidence: unclear layer structure, cobblestone-like pattern, cloud-like pattern, and anechoic pattern. Thereafter, accuracy was assessed using two parameters: detection performance, and the value of the intersection over union (IoU) and DICE score. A total of 73 images were analyzed as test data. Of all 73 images with an unclear layer structure, 7 showed a cobblestone-like pattern, 14 showed a cloud-like pattern, and 15 showed an anechoic area. All four US findings showed a detection performance of 71.4–100%, with a mean value of 0.38–0.80 for IoU and 0.51–0.89 for the DICE score. The results show that US findings and deep learning-based classification can be used to detect deep tissue pressure injuries.

BACKGROUND: The effectiveness of point-of-care ultrasound (POCUS) for nurses has been demonstrated; however, only a limited number of nurses have been trained to perform POCUS. This article reports on a POCUS train-the-trainer program for nurse educators that targets lower urinary track dysfunction. METHOD: Nurse educators (n = 38) were invited to participate in a POCUS train-the-trainer program, which comprised an e-learning module and a hands-on seminar. Acquisition of knowledge and skills were assessed after the module and seminar, respectively. RESULTS: Questions from the "Basic Knowledge of Ultrasonography" test were answered correctly at a rate of 93.0% (SD, 8.5%). Measured values of bladder urinary volume using ultrasonography were in close agreement with actual values. All of the participants indicated that the program covered the content necessary to use in practice. CONCLUSION: The POCUS train-the-trainer program equips nurse educators with the knowledge and skills needed for training nurses at their institutions. [J Contin Educ Nurs. 2021;52(8):375-381.].

AIMS: While bowel preparation for colonoscopy is the key to successful examination, taking laxatives and showing stools to others causes both physical and mental distress to the patient. Thus, an alternative method to evaluation bowel preparation is necessary. In the current study, we studied the colonic fecal retention by ultrasonography (US) and examined the US finding which reflected completion of BP. MATERIAL AND METHODS: The subjects were outpatients who underwent colonoscopy. This report summarizes the ultrasonographic images of patients who underwent multiple US examinations for all five sites of the colon just before, during, and immediately after bowel preparation. According to the standard protocol, the patients took 2 L of polyethylene glycol-ascorbic acid as a laxative, which was discontinued when the nurse visually judged the stool to be clear. RESULTS: Seven patients in their 50s-80s, none of whom were unable to complete a colonoscopy due to residual feces were included in study. Following bowel preparation, the US images showed anechoic areas with haustration in four or all five areas of the colon. Three of the seven patients received low-dose laxatives (1.1-1.2 L); all three had watery stools in three or more colon areas and none of them were constipated at the time of taking 1 L of laxatives. CONCLUSIONS: Completion of bowel preparation can be assessed by the observation of anechoic areas with haustration in multiple colonic sites by ultrasonography.

AIM: To estimate diagnostic accuracy of ultrasonography for detecting aspiration and pharyngeal residue in patients with dysphagia. METHODS: A systematic search was conducted in MEDLINE (via PubMed), CINAHL, EMBASE, Ichushi-Web, and Cochrane Library databases to identify articles that showed diagnostic accuracy of ultrasonography for detecting aspiration and residue published in English and Japanese until August 2019. Cross-sectional studies, case-control studies, and cohort studies were included. The diagnostic accuracy results were extracted and the pooled estimated sensitivity and specificity were calculated. The risk of bias of the studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies 2. The certainty of the evidence was assessed using the Grades of Recommendation Assessment, Development, and Evaluation methodology. RESULTS: Five studies were included in this review. The pooled estimated sensitivity and specificity for detecting aspiration were 0.82 (95% CI: 0.72-0.89) and 0.87 (95% CI: 0.81-0.92), respectively. One study was included that evaluated ultrasound assessments of pharyngeal residue. The sensitivity and specificity were 0.62 (95% CI: 0.32-0.86) and 0.67 (95% CI: 0.22-0.96), respectively. The certainty of the evidence was low and very low for the diagnostic accuracy of aspiration and pharyngeal residue, respectively. CONCLUSION: Ultrasound is a non-invasive method with good sensitivity and specificity in detecting aspiration as well as reference standards. While risk of bias and small number of studies limited the strength of this systematic review, our results suggested that ultrasound examination was useful as a bedside screening tool for detecting aspiration.

訪問看護師が撮影した直腸エコー動画を用いて，既存のArtificial Intelligenceに基づく読影支援アプリケーションによる便貯留評価をより高い精度で行うことのできる手法の考案を目的とした．訪問看護ステーション1施設の診療記録を対象とし，撮影された直腸エコー動画から静止画を出力した．各静止画に対し，エコーのエキスパートによる読影，および直腸便貯留を示す高エコー域を抽出しカラー表示するアプリケーションによる便貯留の有無の判定を行った．前者を正解とし，アプリケーションの判定精度を評価した．アプリケーションの判定で偽陽性であった画像において，直腸以外の便やガスの貯留と区別するために抽出領域の深度が体表面から50 mm 未満であった画像，さらに，便貯留以外の高エコー域と区別するために長径が14.5 mm未満となる抽出領域を除外したところ，感度81.1％，特異度87.8％，正解率83.7 であった．アプリケーションの判定精度を高めるための手段として，抽出領域の深度および長径を調整する手法が考案された．<br><br>【キーメッセージ】<br>1．今回の研究は看護・介護のどのような問題をテーマにしているのか？<br> 研究を行うきっかけとなったことはどのようなことか？<br>&rarr;訪問看護では便秘，具体的には大腸便貯留のアセスメントに難渋しており，超音波検査（エコー）による便の可視化が有用である．先行研究より，便秘をアセスメントするうえでは特に直腸の観察が重要であることが明らかになっている．エコーの撮影技術は教育プログラムで解決できるものの，画像の読影のむずかしさに対する解決策は立っていなかったため，今回の研究に着手した．<br><br>2．この研究成果が看護・介護にどのように貢献できるのか？あるいは，将来的に貢献できることは何か？<br>&rarr; 簡便で迅速・正確な大腸便貯留観察と便秘のアセスメントにつながる．看護師だけでなく将来的には介護職，家族，患者など，誰もが便秘の評価に使えるような技術になることが期待される．<br><br>3．今後どのような技術が必要になるのか？<br>&rarr; 現時点ではパソコンあるいはスマーフォン上で起動するアプリケーションのため，今回の研究のような機能を搭載した携帯型エコー装置が開発されることが期待される．

AIM: Nurses have difficulty assessing the type of constipation by ordinal assessment methods and may therefore struggle to select an appropriate defecation care. Although previous studies described the safety and effectiveness of defecation care based on ultrasonographic observations in the colorectum, no standardized educational program has been established. This study aimed to determine the feasibility of the constipation point-of-care ultrasound (POCUS) educational program regarding the use of ultrasonography as an assessment tool to determine different types of constipation. METHODS: This descriptive study was conducted for visiting nurses working in Japan. The constipation POCUS educational program that nurses can learn in as short as 7 days comprised four elements: E-learning, a hands-on seminar, self-learning, and objective structured clinical examinations (OSCEs). The nurses were asked to complete a questionnaire regarding the education materials. OSCEs were used to assess the participants' skills in assessing patients based on the use of ultrasound observation in the colorectum. RESULTS: Of the 44 participants who enrolled, 40 were able to complete the program. All the 40 participants (100.0%) who took the OSCEs were able to pass at the first attempt. Moreover, 94.9% of the trainees indicated that this program was able to cover the content necessary to use ultrasonography in home care settings. CONCLUSIONS: The results of this study suggest that the 7-day constipation POCUS educational program provided trainees with a foundational knowledge and skills to observe fecal retention in the colorectum. Thus, further educational program enhancements and clinical skill evaluations are needed to maximize the program's effectiveness in the future.

AIM: The present study aimed to analyze the use of machine learning in ultrasound (US)-based fecal retention assessment. METHODS: The accuracy of deep learning techniques and conventional US methods for the evaluation of fecal properties was compared. The presence or absence of rectal feces was analyzed in 42 patients. Eleven patients without rectal fecal retention on US images were excluded from the analysis; thus, fecal properties were analyzed in 31 patients. Deep learning was used to classify the transverse US images into three types: absence of feces, hyperechoic area, and strong hyperechoic area in the rectum. RESULTS: Of the 42 patients, 31 tested positive for the presence of rectal feces, zero were false positive, zero were false negative, and 11 were negative, indicating a sensitivity of 100% and a specificity of 100% for the detection of rectal feces in the rectum. Of the 31 positive patients, 14 had hard stools and 17 had other types. Hard stool was detected by US findings in 100% of the patients (14/14), whereas deep learning-based classification detected hard stool in 85.7% of the patients (12/14). Other stool types were detected by US findings in 88.2% of the patients (15/17), while deep learning-based classification also detected other stool types in 88.2% of the patients (15/17). CONCLUSIONS: The results showed that US findings and deep learning-based classification can detect rectal fecal retention in older adult patients and distinguish between the types of fecal retention.

BACKGROUND: Assessing the presence of pharyngeal residue in the pyriform sinus and epiglottic vallecula is important because insufficient pharyngeal clearance is a risk factor for aspiration pneumonia. Improvements in the performance of ultrasound to visualize the pyriform sinus and epiglottic vallecula are needed. The aim of this study was to establish a method to visualize the pyriform sinus and epiglottic vallecula with ultrasound to detect pharyngeal residue. METHODS: We used real-time virtual sonography (ie, a fusion of magnetic resonance imaging and ultrasound imaging) as the scanning method to visualize the pyriform sinus and epiglottic vallecula without residue in 4 healthy individuals. Using established ultrasound methodology and fiberoptic endoscopic evaluation of swallowing, 35 subjects with dysphagia were studied to investigate the performance of ultrasound to detect pharyngeal residue. RESULTS: The fusion ultrasound images showed that transverse scans at the level of the laryngeal prominence and above the hyoid bone using a linear array transducer can be used to visualize the pyriform sinus and the epiglottic vallecula, respectively. We obtained 238 ultrasound images of the pyriform sinus from 35 subjects and 82 images of epiglottic vallecula from 26 of 35 subjects. The ultrasound images with fiberoptic endoscopic evaluation of swallowing showed that areas of high echogenicity in the pyriform sinus and epiglottic vallecula are related to the presence of pharyngeal residue. The presence of high-echogenicity areas resulted in a sensitivity of 92.0% and specificity of 71.9% for detecting pharyngeal residue in the pyriform sinus and a sensitivity of 86.7% and specificity of 63.6% for detecting pharyngeal residue in the epiglottic vallecula. CONCLUSIONS: Transverse ultrasound scans at the level of the laryngeal prominence and above the hyoid bone enable the visualization of the pyriform sinus, epiglottic vallecula, and pharyngeal residue.

BACKGROUND: For nurses to provide swallowing care that is appropriate to individual patients' swallowing functions, techniques for using ultrasound to monitor for aspiration and pharyngeal post-swallow residue would be helpful. OBJECTIVES: This study seeks to clarify the effectiveness of an education program concerning the use of ultrasound to assess swallowing function (the "Swallowing Point-of-Care Ultrasound Education Program"). This assessment is based on a comparison of the observation skills of general nurses' and certified nurses in dysphagia nursing in this regard; both groups underwent the education program, but dysphagia nurses have greater knowledge of swallowing functions as a result of their training. METHODS: This prospective descriptive study was conducted as a post-graduate education program in two locations in Japan. The swallowing point-of-care ultrasound education program comprised four elements: e-learning, practical seminar, self-learning, and objective structured clinical examination. The objective structured clinical examination was used after the program to assess whether the participants had obtained the necessary skills. The general nurses were then asked to report the ease-of-use of the education materials. RESULTS: Of the 32 participants enrolled in the program, 22 general nurses and nine dysphagia nurses completed the program. In the objective structured clinical examination concerning monitoring for aspiration, the dysphagia-nurses group had a higher proportion of participants evaluated as "excellent" (p = 0.007); this group had a significantly higher ability to maintain adequate images during the swallowing process than did the general-nurse group (p = 0.034). However, there was no difference between the two groups regarding monitoring for post-swallowing residue. Further, over 70% of the nurses gave a positive evaluation of the user-friendliness of the e-learning and practical seminar. CONCLUSIONS: Our results suggest that the swallowing point-of-care ultrasound education program provides both general nurses and dysphagia nurses with sufficient knowledge and skill to monitor for aspiration and post-swallowing residue.

The demand for methods to ensure safe oral consumption of food and liquids in order to prevent aspiration pneumonia has increased over the last decade. This study investigated the safety of swallowing care selected by adding ultrasound-based observation, evaluated its efficacy, and determined effective content of selected swallowing care. The study employed a pragmatic quasi-experimental research design. Participants were 12 community-dwelling adult patients (age: 44–91 years) who had experienced choking within 1 month prior to the study. After the control phase, in which conventional swallowing care was provided, trained nurses provided ultrasound observation-based swallowing care for a minimum period of 2 weeks. Outcome measurements were compared across three points, namely T1—beginning of the control phase, T2 and T3—before and end of the intervention phase. The mean durations of intervention were 30.8 days in the control phase and 36.5 days in the intervention phase. Pneumonia and suffocation did not occur in the control phase or the intervention phase. The safe intake food level and the food intake level score significantly improved during the intervention phase (p = 0.032 and 0.017, respectively) by adding eating training based on the ultrasound observation. However, there was no significant improvement in the strength of the muscle related to swallowing by the selected basic training. Our results suggest that swallowing care selected based on the ultrasound observation, especially eating training, safely improved safe oral intake among community-dwelling adults with swallowing dysfunction.

AIM: To verify the efficacy of defecation care based on handheld ultrasonographic observations for functional constipation by visiting nurses skilled in bowel ultrasonography. METHODS: Home-care patients with suspected functional constipation receiving nursing visits were recruited in this multiple-baseline, single-case experiment with intervention points shifted by 1 week. A total of 15 older adults were categorized into 3-, 4-, 5- or 6-week intervention phases. Ultrasonographic observations of fecal retention in the colorectum and defecation care based on observations during the ordinal physical assessment were reviewed. Tau-U was used for confirming the efficacy of the intervention by measuring the number of non-artificial and artificial defecations, as well as hard stools per week, and the amount of non-stimulant and stimulant laxatives, enemas and suppositories per week. For evaluating safety, adverse events, such as bowel obstruction and incontinence-associated dermatitis, were confirmed. RESULTS: No adverse events were observed. Statistical analysis showed that hard stools and artificial defecation reduced, and that their effect sizes were significant (Tau = -0.48, P < 0.01; Tau = -0.53, P < 0.01). Even the amounts of stimulant laxative and glycerin enema reduced, and their effect sizes were significant (Tau = -0.56, P < 0.01; Tau = -0.34, P = 0.04). CONCLUSIONS: Thus, defecation care based on ultrasonographic assessment by nurses in home-care settings is safe and effective for improving constipation symptoms and reducing laxative use. Geriatr Gerontol Int 2020; ••: ••-••.