【作者】 钱春荣；

【导师】 朱京慈；

【作者基本信息】 第三军医大学 ， 护理学， 2011， 博士

【摘要】 脑卒中是导致中老年人致残、致死、生活依赖的常见病,疾病发作后1～6个月内患者独立生活能力和生存质量显著下降。从医院返回家庭的转移期内,患者常面临脑卒中相关知识不足、出院依从性偏低、康复技能缺乏等健康问题。为了协助患者从医院安全转移至家庭,提升患者的自我护理能力、降低再次返院率,国内外护理学者开展了多种护理干预的探索,目前研究常将住院护理和出院护理分开进行探讨,且干预活动缺乏对既往护理循证证据的参考。本研究采用延续护理模式,参考循证护理的实证推荐,建立本土化的脑卒中患者延续护理方案,并采用随机对照临床试验测试该方案的临床效果。第一部分:脑卒中患者延续护理方案的建立一、方法通过文献复习和临床试验的研究方法建立脑卒中患者的延续护理方案。主要步骤如下:1.复习脑卒中护理干预的循证指南相关文献,提炼出推荐级别高的护理实证证据;2.复习脑卒中患者延续护理干预的国内外研究进展,建立干预方案的框架结构;3.建立相关的4个子方案:①脑卒中患者住院期健康教育方案,并进行临床试验验证其效果;②脑卒中患者出院依从性日记指导方案;③脑卒中患者居家康复训练指导方案;④脑卒中患者综合性护理评估表的建立。二、结果1.建立了5周4次系列护理活动的脑卒中延续护理方案,分出院前和出院后2个阶段实施:①出院前的小群体式健康教育、出院患者依从性指导以及奥马哈问题分类系统为框架的综合性护理评估;②出院后提高患者依从性和指导居家康复训练的电话随访和家庭访视。除了干预者发起的护理活动,方案还提供患者在需要时可以自由发起的电话咨询。方案由受过培训的专科护士按照案例管理程序执行,并组成由神经科医生、专科护士、康复治疗师和心理治疗师组成的团队提供治疗建议和转诊指导。三、结论1.干预方案以延续护理模式为理论指导,紧密衔接住院护理和出院护理,较好的体现了护理服务的全面性、协调性、延续性和协作性,重点增强了出院护理干预剂量。2.干预内容以循证护理指南的高级别推荐意见为依据,护理活动包括健康教育提高知识水平、患者日记提高出院指导依从性、综合性评估患者的健康问题、上肢及手指的居家康复训练促进上肢功能。第二部分:脑卒中患者延续护理方案的效果评价一、方法通过随机对照临床试验测试前期建立的延续护理方案的干预效果。有效纳入初次发作的缺血性脑卒中患者72例,采取抛硬币法随机分成干预组(35例)和对照组(37例)。对照组接受常规护理方案,干预组除接受常规护理外增加延续护理方案干预。效果评价分4个方面:①患者依从性,包括对出院指导遵从行为的5个项目:康复训练、均衡饮食、正常作息、正规服药和复诊随访;②生存质量,包括反映日常生活活动能力的BI指数、反映手活动能力的九孔柱试验、患者的主观健康感受3个观察指标;③卫生服务利用,包括再次返院次数、访问急诊次数、访问门诊次数3个观察指标;④护理满意度,分住院护理满意度和出院护理满意度2个指标。数据收集员分别于出院前3天、出院后12周2个时间点收集数据。SPSS13.0软件包分析数据,独立样本t检验用于两组定量数据的比较,卡方检验用于两组率的比较,显著性水平定于P<0.05。二、结果1.患者依从性:出院指导依从性总分(t=6.011, P=0.000<0.05)及其中的3个单项依从性康复训练(t=5.255, P=0.000<0.05)、生活作息(t=5.156, P=0.000<0.05)、复诊随访(t=3.476, P=0.010<0.05)显著高于对照组;均衡饮食(t=0.967, P=0.337>0.05)和正规服药(t=0.845, P=0.401>0.05)2个单项无显著差异。2.生存质量:干预组主观健康感受(t=2.716, P=0.008<0.05)和九孔柱试验时间(t=2.185, P=0.033<0.05)的提高幅度均显著高于对照组;BI指数提高无显著差异(t=0.823, P=0.414>0.05)。3.卫生服务利用:干预组门诊访问率显著高于对照组(χ~2=9.053, P=0.029<0.05);两组的再次住院率(χ~2=0.278, P=0.870>0.05)和急诊访问率(χ~2=1.036, P=0.596>0.05)无显著差异。4.护理满意度:干预组住院护理满意度(t=4.135, P=0.000<0.010)和出院护理的满意度(t=10.010, P=0.000<0.01)均显著高于对照组,其中以出院护理满意度最为显著。三、结论1.脑卒中延续护理干预能显著提高患者对出院指导的依从性。2.脑卒中延续护理干预能显著改善患者的主观健康感受、促进手活动能力、提升住院及出院护理满意度。3.脑卒中延续护理干预能显著提高门诊复诊率。4.脑卒中延续护理干预未能显示出提高BI指数的显著效应。5.脑卒中延续护理干预未能显示出减少再次返院率和急诊访问率的显著效应。综上所述,本研究建立了脑卒中患者延续护理方案,经临床试验验证在提高患者知识水平、出院指导依从性、护理满意度以及改善主观健康感受和手活动能力5个指标中显示出积极效果,基本达到方案设计目的。该研究是对我国脑卒中患者延续护理模式的积极探索,其研究结果为提升脑卒中患者院内和/或院外护理质量提供了新的干预思路和实践依据。更多还原

【Abstract】 Stroke is a common disease causing disability, death and dependent living in mid-aged and elderly people. Most of stroke survivors experience a significant decline in quality of life 1 to 6 months after stroke. In the transitional period from hospital to home, patients will face some problems such as lack of stroke knowledge, low discharge compliance, and lack of home rehabilitation skills. Accordingly, nursing scholars have carried out a variety of care intervention to deal with patients’health problems occurring in the transition. But the domestic researches were still existed the following deficiencies:①lack of evidence-base for intervention programme;②lack of nursing theory or model for framework. This study will develop a transitional care programme for stroke patients guided by transiontal care model (TCM) and referred by evidence-based care recommendations. In addition, this study will evaluate the effects of the programme by a randomized controlled clinical trail.Part A: Developing a Transional Care Programme for Stroke Patients1. MethodsThe aim of this part was to develop a transitional care programme for stroke patients by literature reviewing and clinical trial. Main procedures are follows.1) Review literatures of evidence-based guidelines in stroke care intervention, and summarize some nursing evidence with high level recommendation.2) Review literatures of the progression in transional care model and stroke care, and establish a constructive framework of the programme.3) Develop the 4 sub-programmes:①health education programme in hospital,②discharge recommendation in patient compliance,③home rehabilitation guidance,④comprehensive nursing assessment.2. Results The transitional care programme for stroke patients was a 5-week series of 4 nursing activities containing 2 stages of hospital care and discharge care. The pre-discharge stage is the small-based health education, the discharge recommendation of patient diary and the comprehensive nursing assessment guided by Omaha problem classification system. The post-discharge stage is the telephone follow-up and the home visit in promoting patient compliance and guiding home rehabilitation. Besides provider-initiated events, the programme accommodated patient-initiated call if patients need immediate advice. The intervener was leaded by the trained nurse specialist, and assisted by the multi-disciplinary team including neurologist, nurses, rehabilitation therapists and psychological therapists.3. Conclusion1) The intervention model was guided by TCM as a theoretical framework. And the intervention programme reflected four features of comprehensiveness, continuity, coordination, and collaboration.2) The intervention activities were embedded in the best available nursing evidence. And the nursing activities included that health education improving knowledge level, discharge diary guidance in improving patient compliance, comprehensive nursing assessment in finding and dealing with health problems, upper limbs and fingers rehabilitation training in promoting hand function.Part B: Evaluating the Transitional Care Programme for Stroke PatientsThe aim of second part was to evaluate the effects of the developed programme by a randomized controlled clinical trial.1. MethodsSeventy-two patients on first confirmation of ischemic stroke in the acute stroke department from 2 large general hospitals were effectively enrolled and randomized to the intervention group (n=35) and the control group (n=37). The control group received conventional care, whereas the interventional group received the conventional care plus the transitional care. The outcome fell into 4 domains:①patient compliance with discharge recommendation;②Quality of Life (QOL): Barthel Index (BI) reflecting activities of daily living, Nine Hole Peg Test (NHPT)reflecting hand operation ability, and the self-reported subjective quality of life (SQOL);③health service utility: the number of hospital readmission, emergency visits, and outpatient visits;④patient satisfaction: patient satisfaction separately with hospital care and discharge care. The data were collected at two time-points, at 3 days pre-discharge and 12 weeks post-discharge. The analysis was conducted by SPSS13.0 software. The independent sample t test was used in comparison of quantitative data between the two groups, and chi-square test used in comparison of rates. The significance level was set at P<0.05.2. Results1) Patients Compliance: The total score of compliance with discharge recommendation (t= 6.011, P= 0.000<0.05) and the three single compliance items of rehabilitation training (t=5.255, P=0.000<0.05), lifestyle (t=5.156, P=0.000 <0.05), and referral follow-up (t=3.476, P=0.010<0.05) in the intervention group were significantly higher than in the control. But the two single items of balanced diet (t=0.967, P=0.337>0.05) and regular medication (t = 0.845, P = 0.401> 0.05) were no significant difference.2) Quality of Life: The increased range in subjective quality of life (t=2.716, P=0.008<0.05) and NHPT time (t=2.185, P=0.033<0.05) in the intervention group was significantly higher than in the control. The increased range of Barthel Index was no significant difference (t=0.823, P=0.414>0.05).3) Health Service Utility: The outpatient visits in the intervention group was higher than in the control (χ~2=9.053, P=0.029<0.05). The readmission hospital (χ~2=0.278, P=0.870>0.05) and the emergency visits (χ~2=1.036, P=0.596>0.05) were no significant difference.4) Patient Satisfaction: The patient satisfaction with hospital care (t=4.135, P= 0.000 <0.010) and discharge care (t=10.010, P=0.000 <0.01) in the intervention group were separately higher than in the control.3. Conclusion1) The stroke transitional care programme may significantly improve the patient compliance with discharge recommention.2) The stroke transitional care programme may significantly improve the patients’perception of quality of life.3) The stroke transitional care programme may significantly improve the hand ability. 4) The stroke transitional care programme may significantly improve the patient satisfaction with hospital care and discharge care.5) The stroke transitional care programme may significantly promote the visits to hospital clinic.6) The stroke transitional care programme may be non-effective in increasing Barthel Index and reducing hospital readmission and emergence visits.In summary, this study developed the stroke transitional care programme and evaluated the effects of it. The results presented that the developed programme showed the positive effects in stroke knowledge, discharge compliance, subjective quality of life, hand operation ability and nursing satisfaction. The conclusion showed that the developed programme was mostly consistent with the design purpose. This study is a preliminary exploration of the domestic transitional care for the stroke survivors. The results can be referred in promoting stroke hospital care and discharge care, and be presented some new interventional ideas in promoting the domestic stroke nursing practice.更多还原