【作者】 高飞；

【导师】 张卫青；

【作者基本信息】 郑州大学 ， 护理学， 2017， 硕士

【摘要】 研究目的(1)在了解慢加急性肝功能衰竭患者的营养风险的基础上给予夜间加餐,观察对患者营养状态、肝功能恢复、营养风险、并发症发生率的影响,以期减少患者并发症,提高生活质量,改善临床结局和预后;(2)为慢加急肝功能衰竭患者寻找一种价格低廉并有效的加餐模式;(3)为临床实践中实施有效的护理措施、促进慢加急肝功能衰竭患者的康复提供理论依据。研究方法本研究选取2015年12月到2016年6月进入郑州市某三级综合医院感染科就诊的101例慢加急性肝功能衰竭患者,分为夜间加餐研究组和对照组。用抛硬币法随机将感染一病区患者分为对照组,接受一般内科综合治疗+日间营养干预;感染二病区患者为研究组,在一般内科综合治疗+日间营养干预的基础上加夜间加餐,加餐内容:小面包40g+酸奶100ml。加餐时间为睡前半小时或晚9-10点加餐,观察周期为入院24小时后至住院一个月。两组均在入院48小时内,入院一周后,入院一月后记录营养相关指标。包括一般情况调查表、NRS-2002评分、实验室指标:肝功能(白蛋白、前白蛋白);特种蛋白(转铁蛋白)、人体测量学指标:体重、体重指数(BMI)、上臂肌围(MAMC)、肱三头肌皮褶厚度(TSF)、入院和出院时患者Child-Pugh评分、两组患者并发症、住院时间、住院期间输注白蛋白量以及患者疾病转归情况。本研究所有数据资料进行统计学分析均使用SPSS 21.0,其中检验水准定为α=0.05。统计分析结果均用x±s表示。主要运用包括独立样本t检验、重复测量的方差分析、χ2检验及稚和检验等统计学方法来完成数据的统计分析。结果1.本研究入组病例共120例,其中干预组及对照组均为60例,研究过程中,因肝移植手术、病情加重、死亡等原因脱落19例,样本流失率为15.8%。共有101例患者完成整个干预过程,干预组50例,对照组51例。干预前两组患者干预前一般情况资料处于均衡状态,统计学分析显示两组差异无统计学意义(P>0.05);2.两组患者干预前后营养风险NRS-2002评分的比较:干预组患者干预前的NRS-2002评分为(1.60±0.81)分,对照组评分为(1.75±0.74)分,统计学分析显示两组间差异没有统计学意义(P>0.05)。干预一个月后,干预组的NRS-2002评分较对照组低,两组相比差异有统计学意义(P<0.05)。3.干预前后两组患者Child-Pugh评分的比较:干预前干预组患者ChildPugh评分为(9.54±0.76)分,对照组为(9.73±1.02)分,统计学分析显示两组间差异没有统计学意义(P>0.05)。干预一个月后,干预组的Child-Pugh评分较对照组低,两组相比差异有统计学意义(P<0.05);4.干预前后两组患者营养相关的身体测量指标的比较:两组患者的皮褶厚度值在干预前,干预一周、干预一个月相比均没有统计学差异(P>0.05);两组患者的上臂围值在干预前,干预一周、相比均没有统计学差异(P>0.05),干预一个月后,两组相比差异有统计学意义(P<0.05);两组患者的体重值在干预前,干预一周、相比均没有统计学差异(P>0.05),随着时间的延长,在干预一个月后干预组的体重值要明显高于对照组,有统计学差异(P<0.05);BMI值在干预前,干预一周、干预一个月相比差异无统计学意义(P>0.05)。5.两组患者干预前后营养相关的生化指标的比较:两组患者的血清白蛋白值在干预前,干预一周后相比均没有统计学差异(P>0.05),随着时间的延长,在干预一个月后干预组的血清白蛋白值要明显高于对照组,有统计学差异(P<0.05);两组患者的前白蛋白值在干预前,干预一周后相比没有统计学差异(P>0.05),干预一个月后两组前白蛋白值有统计学差异(P<0.05);两组患者的转铁蛋白值在干预前,干预一周后相比均没有统计学差异(P>0.05),干预一个月后两组转铁蛋白值有统计学差异(P<0.05)。6.两组患者住院期间临床结局指标的比较:干预后发现:住院期间两组患者的并发症发生率有统计学差异(P<0.05);感染性相关并发症的差异没有统计学意义(P>0.05);非感染性相关并发症的发生率有统计学差异(P<0.05)。干预后对两组患者住院期间输注白蛋白量和住院时间进行组间比较,两组患者住院期间输注白蛋白的量没有统计学意义(P>0.05),两组患者住院时间有统计学差异(P<0.05);干预后对两组患者的临床结局进行两两比较,两组患者临床转归,差异没有统计学意义(P>0.05)。结论1.本研究证明营养风险在慢加急性肝功能衰竭患者中广泛存在,需要在临床工作中引起关注并及时给予治疗;2.在常规治疗护理的基础上,夜间加餐可以有效降低慢加急性肝功能衰竭患者的NRS-2002评分、Child-Pugh评分;3.夜间加餐在短期内改善患者BMI、皮褶厚度等方面效果不明显,但在干预一月后改善血清白蛋白、前白蛋白、转铁蛋白等方面效果明显;4.夜间加餐对于住院期间两组患者的并发症发生率有影响,尤其体现在非感染性相关并发症方面;夜间加餐对两组患者住院期间输注白蛋白的量没有影响;住院期间短期的夜间加餐对患者临床转归并不能带来明显积极的影响。更多还原

【Abstract】 Objective(1)In order to reduce the incidence of complications,improve the quality of life,and improve clinical outcome and prognosis,We observe the effects of Night extra meal on nutritional status,recovery of liver function,nutritional risk and incidence rate of complication,on the basis of the overall nutritional status and nutritional risk of the ACLF patients.(2)To find a cheap and effective extra meal model for the ACLF patients;(3)To provide a theoretical basis for the implementation of effective nursing intervention in clinical practice and to promote the rehabilitation of the ACLF patients;.MethodsIn this study,we randomly selected 101 ACLF patients who were enrolled in the Department of Infectious Diseases from a general hospital in Zhengzhou from December 2015 to June 2016.They were divided into two groups: the study group and the control group.The patients in first ward were treated with general internal medicine combined with daytime nutrition intervention as the control group,and the patients in another ward were the experimental group,who accepted night extra meal on the same basis.Night extra meal content: bread 40g+ yogurt 100 ml.Meal time for half an hour before going to bed or 9 to 10 p.m to give the extra meal,the observation period is within 24 hours after admission into hospital for a month.the baseline of both groups was recorded within 48 hours,a week and four week after admission,Including general condition questionnaire,NRS-2002 score,laboratory indicators: liver function(albumin,prealbumin);special protein(transferrin),anthropometric indicators: weight,body mass index(BMI),arm muscle circumference(MAMC),triceps skinfold thickness(TSF),Child-Pugh score at admission and discharge,two groups of patients’ complications,hospital stay,human serum albumin infusion during hospitalization,and patient disease outcome.All data were analyzed by SPSS20.0,and the test level was α = 0.05.The results are expressed as ± s.Statistical methods were performed using two independent samples t test,χ2test,repeated measurement of variance analysis.ResultThis study included 104 patients,52 patients in intervention group,52 patients in the control group,In the process of the intervention,3 cases were lost due to liver transplantation,infection,exacerbation,death and automatic withdrawal.the Sample attrition rates was 2.9%.To complete a total of 101 patients with the whole process of intervention,50 in the intervention group and 51 in the control group.The baseline data of the two groups before intervention were balanced,and there was no statistical significance between the two groups(P> 0.05).The scores of NRS-2002 in the intervention group were(1.60 ± 0.81)and(1.75 ± 0.74)in the control group before intervention.The statistical analysis showed no significant difference between the two groups(P>0.05).The scores of NRS-2002 in the intervention group were lower than those in the control group after one month of intervention,the difference was statistically significant(P <0.05);The Child-Pugh score of the intervention group was(9.54± 0.76)and the control group was(9.73 ± 1.02).The statistical analysis showed that there was no significant difference between the two groups(P>0.05).The Child-Pugh score of the intervention group was lower than that of the control group after one month of intervention,and the difference was statistically significant(P<0.05).The thickness of the skin fold were no significant difference(P>0.05)between the two groups before and after intervention in one week after the intervention the skin fold thickness in the intervention group was higher than that of control group,there was statistical the difference(P<0.05);The weight value is the same.The upper arm circumference and BMI value of the two groups had no significant difference between the two groups before and after the intervention,and there was not statistically significant difference(P>0.05).The biochemical indexes of two groups of patients were compared: There were no significant differences in the serum albumin values between the two groups before and after the intervention after a week(P>0.05).The serum albumin value of the intervention group was significantly higher than that of the control group after one month of intervention(P<0.05).The prealbumin and transferrin were the same.There was significant difference in the complication rate between the two groups during hospitalization(P<0.05).the difference of infectious complications was not statistically significant(P>0.05);non infectious complications related to the incidence of significant difference(P<0.05).There was no significant difference in human serum albumin infusion between the two groups(P>0.05),and two groups of patients hospitalization time had significant difference(P<0.05);The clinical outcome of the two groups was compared after the intervention.The clinical outcome was not statistically significant(P>0.05).Conclusion1.This study proves that nutritional risk is widely found in ACLF patients,and in the clinical it needs attention and give timely treatment.2.On the basis of routine treatment and nursing,night extra meal can effectively reduce the NRS-2002 score and Child-Pugh score of ACLF patients;3.The effect of night meal on improving the BMI,upper arm circumference and skinfold thickness index in the short term was not obvious,but the effect of improving serum albumin,prealbumin and transferrin was significant after one month of intervention.4.Night extra meal have an effect on the incidence of complications in both groups during hospitalization,especially in noninflammatory related complications;Night extra meal have no effect on human serum albumin infusion during hospitalization;There was a positive impact on the clinical outcome in the intervention group.更多还原