【作者】 曹虹；

【导师】 赵岳；

【作者基本信息】 天津医科大学 ， 护理学， 2014， 硕士

【摘要】 目的应用连续护理模式对老年髋部骨折术后患者实施综合干预,分析老年髋部骨折患者术后康复的特点,评价对患者术后亚急性期实施综合干预的效果。方法本研究采用临床随机对照实验设计,于2013年1月至2013年12月在天津医院某老年骨科方便抽取符合纳入标准的老年髋部骨折患者82例(剔除失访的18例患者),将患者随机分为干预组(39例)和对照组(43例),两组在年龄、性别、文化程度、婚姻状况、骨折部位、手术方式、合并症等方面差别无统计学意义(P>0.05)。对照组患者术后接受常规护理。干预组在接受常规护理的基础上,实施多学科协作、连续的综合干预,干预时间从患者围手术期至出院后3个月。干预内容包括：老年患者综合评估、内科与骨科的联合诊治、抗骨质疏松治疗、个性化的健康教育、编写并发放康复指导手册、康复评定、为患者量身定制康复计划、指导功能锻炼、制订出院计划,进行为期3个月的电话随访及家庭访视；出院随访内容包括健康教育、心理支持、并发症预防、康复训练指导、骨质疏松二级预防、跌倒危险因素评估及防范。应用Harris髋关节评分表、功能独立性测量量表(Functional Independence Measure, FIM)于患者出院时、出院后1个月、出院后3个月对患者的髋关节功能和功能独立性进行评价。于患者出院后3个月,应用Berg平衡量表(Berg balance scale, BBS)、计时起立—步行测验(Timed Up and Go Test, TUGT)评价患者的平衡能力,应用骨质疏松二级预防问卷调查并评价患者抗骨质疏松药物治疗的依从性,应用欧洲五维健康量表(EQ-5D)的健康状况自评问卷对患者的生活质量进行评价。结果1.干预组Harris髋关节总评分在出院时、出院后1个月、3个月均高于对照组(P<0.05),两组在出院时、出院后1个月、3个月的Harris髋关节总评分均呈上升的趋势,干预组在出院1个月及3个月Harris髋关节总评分明显高于对照组(P<0.01)。干预组Harris髋关节疼痛、功能和关节活动度3个维度的评分在出院时、出院后1个月、出院后3个月均高于对照组(P<0.05)。2干预组F1M功能独立性总评分在出院时、出院后1个月、出院后3个月均高于对照组(P<0.05),两组在出院时、出院后1个月、3个月的FIM总评分均呈上升的趋势,干预组在出院1个月及3个月FIM总评分明显高于对照组(P<0.01)。干预组FIM的自理、括约肌控制、转移、行走、交流及社会认知各维度评分在出院时、出院后1个月、出院后3个月均高于对照组(P<0.05)。3两组出院后3个月BBS平衡能力测试结果：干预组与对照组测试评分>40分的患者分别占43.59%、18.60%,平衡能力良好；测试评分<40分的患者分别占56.41%、81.40%,平衡功能较差,有跌倒的危险。两组患者的构成比具有统计学差异(P<0.05)。两组患者出院后3个月TUGT测试结果：干预组与对照组完成指令动作测试时间<30秒的患者分别占33.33%、13.95%,平衡功能良好；完成指令动作测试时间>30秒的患者分别占66.67%、86.05%,平衡功能较差,有跌倒的危险。两组患者的构成比具有统计学差异(P<0.05)。4干预组与对照组出院后坚持持续服用双磷酸盐药物的患者分别为53.84%、16.28%,间断服药或服药时间小于3个月的患者分别占30.77%、20.93%,未服药的患者分别占15.39%、62.79%；两组出院后每日补钙≥600mg的患者分别为64.10%、23.26%,间断补钙的患者占28.20%、48.84%,未补钙的患者分别占7.70%、27.90%；两组出院后每日补充维生素D≥4001U的患者分别占48.72%、20.93%,间断补充维生素D的分别占35.90%、23.26%,未补充维生素D的分别占15.38%、55.81%。两组患者出院后抗骨质疏松药物治疗的依从性有统计学差异(P<0.01)。5两组EQ-5D自评健康状况问卷调查结果：干预组和对照组活动能力没有困难的患者分别占38.46%、6.98%,有些困难的患者分别占53.85%、65.12%,极度困难的患者分别占7.69%、27.90%；自理能力没有困难的患者分别占20.51%、2.33%,有些困难的患者分别占61.54%、44.19%,极度困难的患者分别占17.95%、53.48%;日常生活没有问题的患者分别为17.95%、2.33%,有些问题的患者分别为51.28%、39.53%,无法进行的患者分别为30.77%、58.14%；没有疼痛及不舒适的患者分别占71.79%、44.19%；存在中度疼痛/不舒适的患者分别占23.08%、39.53%；存在极度疼痛的患者分别占5.13%、16.28%。没有焦虑/抑郁症状的患者分别为58.97%、25.58%：存在轻度焦虑/抑郁症状的患者分别占28.21%、39.54%;有中度焦虑/抑郁症状的患者占12.82%、34.88%；两组患者EQ-5D自评问卷中5个维度3个水平的构成比均有统计学差异(P<0.05)。结论1老年髋部骨折患者是一个特殊而复杂的群体,不仅存在身体虚弱、功能残缺、合并多种内科疾病等医学问题,而且还伴有许多心理和社会问题,患者术后亚急性期康复面临重大的挑战。2应用连续护理模式,对老年髋部骨折患者实施综合干预不仅能够促进患者髋关节功能的恢复,还能够提高患者日常生活功能的独立性,提高平衡能力和抗骨质疏松药物治疗的依从性,从而使患者的生活质量得到全面的改善。更多还原

【Abstract】 ObjectivesTo analyze the postoperative characteristics of the elderly patients with hip fracture and verify the effect of comprehensive intervention on the elderly patients with hip fracture based on continuity of care model.MethodsA randomized controlled clinical trial design was used. From January2013to December2013in Tianjin Orthopedic hospital,82cases of elderly hip fracture patients (18patients were lost when follow-up) enrolled by convenience sampling, and randomly divided into intervention group (39cases) and control group (43cases) based on the inclusive criteria. There were no significant differences between patients of two groups in age, gender, educational level, marital status, fracture position, surgical procedure, complication etc (P>0.05). The control group received routine postoperative care. The intervention group received continuity of care and comprehensive intervention. The comprehensive intervention program included the implementation of the multidisciplinary collaboration care, comprehensive assessment, personalized health education, professional rehabilitation evaluation, tailor rehabilitation program for patients, discharge plan, telephone follow-up and family visits for three months. Discharge follow-up including health education, psychological support, complications prevention, rehabilitation training, osteoporosis secondary prevention, fall risk factors assessment and prevention. The Harris Hip Scale and the Functional and Independence Measure (FIM) were used to evaluate hip joint function and Functional Independence of patients at discharge，1month and3months post-discharge. At the3months post-discharge, patient’s balance ability was measured by the Berg Balance Scale (BBS) and the Timed Up and Go Test (TUGT). Patient’s drug treatment adherence was evaluated by the osteoporosis secondary prevention questionnaire survey. The health-related quality of life (HRQOL) of patients was measured by European five-dimensional health scale (EQ-5D) health self-evaluation questionnaire. Results1. The total score of Harris Hip Score were higher in the intervention group than in the control group at discharge,1month and3months post-discharge (P<0.05). Both of the two groups are on the rise trend.The total score of Harris Hip Score were significantly higher in the intervention group than in the control group at1month and3months post-discharge (P<0.01). The range of the total score change gradually increase over time. The three dimensions score of the Harris Hip Score(pain, function and joint mobility) in the intervention group were higher than the control group at discharge,1month,3months post-discharge (P<0.05).2. The total score of FIM were higher in the intervention group than in the control group at discharge,1month and3months post-discharge (P<0.05). Both of the two groups are on the rise trend.The total score of FIM were significantly higher in the intervention group than in the control group at1month and3months post-discharge (P<0.01). The range of the total score change gradually increase over time. The five dimensions score of the FIM(self-care, muscle control, transfer, walking, communication and social cognitive) in the intervention group were higher than the control group at discharge,1month,3months post-discharge (P<0.05).3. The results of balance test of the two groups at3months post-discharge:43.59%and18.60%of patients showed good balance ability respectively, BBS score>40points;56.41%and81.40%of patients in the intervention group and the control group respectively were in danger of falling, BBS score<40points. The proportion in two groups were statistical difference (P<0.05).33.33%,and13.95%of patients in the intervention group and control group respectively showed good balance function, TUGT test<30seconds;66.67%and86.05%of patients in the intervention group and control group respectively with poor balance functionwere in in danger of falling, TUGT test>30seconds. The proportion of two groups were statistical difference (P <0.05).4. The results of the adherence to osteoporosis drug:53.84%and16.28%of patients in the intervention group and the control group respectively kept taking bisphosphonates for3months post-discharge.30.77%and20.93%of patients respectively were taking bisphosphonates with interruption;15.39%and62.79%respectively did not take bisphosphonates.64.10%and23.26%of patients respectively kept daily calcium supplement≥600mg,28.20%,and48.84%of patients respectively were taking calcium with interruption,7.70%and27.90%of patients respectively did not taking calcium.48.72%and20.93%of patients respectively kept daily vitamin D of supplement≥400iu,35.90%and23.26%of patients respectively were taking vitamin D with interruption,15.38%and55.81%of patients respectively did not taking vitamin D. The adherence to osteoporosis drug of two groups were statistically significant (P<0.01).5. The results of EQ-5D in the two groups:accounted for38.46%and6.98%patients in the intervention group and control group respectively, whose activities ability had not difficult,53.85%and65.12%respectively had some difficult,7.69%and27.90%respectively had extremely difficult.20.51%and2.33%of patients respectively had ability of self-care with no difficult,61.54%and44.19%of patients respectively,with some difficult,17.95%and53.48%of patients, with extremely difficult.17.95%and2.33%of patients respectively had no problem in Daily life;51.28%and39.53%of patients respectively had some problem,30.77%and58.14%of patients respectively could not care.71.79%and44.19%of patients respectively had no pain and uncomfortable,23.08%and39.53%of patients respectively felt moderate pain/discomfort,5.13%and16.28%of patients respectively felt extremely pain.58.97%and25.58%of patients respectively were no anxiety/depression,28.21%and39.54%of patients respectively were mild anxiety/depression,12.82%and34.88%of patients respectively were moderate anxiety/depression.The EQ-5D of the two groups in the composition of the five dimensions of three level were statistically significant (P<0.05).Conclusion1. The elderly patients with hip fracture is a special and complex group, they are not only weak, functional disability, combined with variety of medical problems, but also have a lot of psychological and social problems, postoperative patients with subacute recovery faces significant challenges.2. Apply continuum care model and implement comprehensive intervention for elderly patients with hip fracture can not only promote the recovery of patients with hip function, also also improve the functional independence, balance ability, osteoporosis drug compliance and adherence of patients, thereby improving the patient’s quality of life.更多还原