Chinese Journal of Antituberculosis ›› 2023, Vol. 45 ›› Issue (10): 940-948.doi: 10.19982/j.issn.1000-6621.20230125
• Original Articles • Previous Articles Next Articles
Gao Dan, Wang Linghua(), Huang Jinpeng, Zhang Yue, Mao Xiaoxiao
Received:
2023-04-19
Online:
2023-10-10
Published:
2023-10-07
Contact:
Wang Linghua, Email: Supported by:
CLC Number:
Gao Dan, Wang Linghua, Huang Jinpeng, Zhang Yue, Mao Xiaoxiao. Analysis of the application effect of integrated traditional Chinese and Western medicine pulmonary rehabilitation nursing program for patients with tuberculous empyema undergoing thoracoscopic clearance[J]. Chinese Journal of Antituberculosis, 2023, 45(10): 940-948. doi: 10.19982/j.issn.1000-6621.20230125
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URL: http://www.zgflzz.cn/EN/10.19982/j.issn.1000-6621.20230125
干预时机 | 干预要点 | 干预内容 | 干预时点及频率 | 实施者 | |||||
---|---|---|---|---|---|---|---|---|---|
术前 | 1.健康教育 | (1)介绍病房环境,包括六字诀、八段锦锻练的场地 | 入院时 | ①② | |||||
(2)围手术期注意事项 | |||||||||
(3)戒烟酒 | |||||||||
(4)抗结核药物的不良反应,告知早期、联合、适量、规律、全程服用抗结核药物的重要性,做好照顾者宣传教育,积极支持治疗 | |||||||||
(5)介绍中西医结合肺康复过程 | |||||||||
(6)向患者及家属解释中医在围手术期中应用的特点及优势 | |||||||||
(7)练习“六字诀”及“八段锦”时的注意事项 | |||||||||
2.患者评估 | (1)患者年龄、体质量指数 | 入院当天 | ①② | ||||||
(2)用力肺活量(FVC)和第1秒用力呼气容积(FEV1) | |||||||||
(3)术前6min步行距离 | |||||||||
(4)日常活动能力[巴氏指数评分(Barthel index)] | |||||||||
(5)营养评估:评估6个月内体质量指数减少>10%、体质量指数<18.5、血清白蛋白<30g/L(与肝肾功能异常无关)中符合1项及以上的患者,进行营养干预 | |||||||||
(6)焦虑(焦虑自评量表评分) | |||||||||
(7)运动强度:运动期间,用遥测心电监护监测血氧饱和度、心率,出现脸色苍白、步态不稳、头晕胸闷、难以忍受的气促、大汗淋漓、收缩压≥180mmHg或下降≥20mmHg、血氧饱和度≤90%等应终止锻炼 | 六字诀、八段锦锻炼及6min步行试验时 | ③④ | |||||||
(8)制作患者肺康复床边执行单,挂于患者床尾,进行质量控制 | 入院时制作,每日评估反馈 | ②③⑤ | |||||||
3.营养支持 | (1)结核病患者应进食高蛋白、高热量和高维生素饮食,如鸡蛋、牛奶等 | 入院时 | ①② | ||||||
(2)营养失调者进行肠内或肠外营养 | |||||||||
4.肺部管理 | (1)进行吸氧 | 12h/d | ①② | ||||||
(2)雾化吸入治疗 | 2次/d,15~20min/次 | ||||||||
(3)有效咳嗽 | 雾化后,2次/d | ||||||||
(4)穴位贴敷贴于肺俞穴滋阴润肺 | 贴6h/d,按摩2次/d,3~4min/次 | ||||||||
5.运动训练 | (1)呼吸训练:六字诀 | 2次/d,10min/次 | ①② | ||||||
(2)有氧运动:文式八段锦 | 1次/d,30min/次 | ||||||||
6.心理 | (1)运用中药安神助眠香囊挂于床头,舒缓情志 | 手术前1晚 | ①② | ||||||
(2)情感支持,指导患者放松技巧 | 入院当天 | ||||||||
(3)鼓励表达,病友交流,树立治疗信心 | |||||||||
术后 | 1.健康教育 | (1)做好术后早期运动训练对手术恢复的优势 | 术后6h床上运动,术后1d下床活动 | ①② | |||||
(2)对患者及照顾者进行治疗、服药依从性的重要性宣传教育 | 术后当天 | ||||||||
2.患者评估 | (1)生命体征评估 | 1次/h | |||||||
(2)胸腔引流管评估:导管是否在位,观察引流液的量、性质;运动训练前再次评估导管固定情况 | 6次/d(2次/班) | ||||||||
(3)安全性评估:运动前评估患者体能,生命体征,出现脸色苍白、步态不稳、头晕胸闷、胸痛、难以忍受的气促、大汗淋漓、收缩压≥180mmHg或下降≥20mmHg、血氧饱和度≤90%等应终止锻炼 | 六字诀、八段锦锻炼及6min步行试验时 | ||||||||
(4)运动效果评估:制定结核性脓胸行胸腔镜清除术患者中西医结合肺康复训练健康教育执行单、肺康复护理评估表,对护理方案实施质量控制 | 入院时、术后2d、出院前、出院后1个月 | ③④⑤ | |||||||
3.营养 | (1)术后6h进清淡易消化食物,术后第1天高蛋白、高热量、高维生素饮食 | 适时 | ①② | ||||||
(2)营养失调者根据医嘱进行肠内或肠外营养 | 术后 | ||||||||
4.肺部管理 | (1)进行吸氧 | 术后1~2d,23h/d,3d后12h/d | |||||||
(2)雾化吸入治疗 | 2次/d,15~20min/次; | ||||||||
(3)有效咳嗽 | 3次/d,晨间护理和2次雾化吸入治疗后 | ||||||||
5.运动训练 | (1)六字诀发音;文式八段锦法第1段浴手、浴臂,第3~5段 | 术后第6~24小时,10min/次 | ② | ||||||
(2)六字诀发音;文式八段锦第1段浴手、浴臂,第3~5段 | 术后第1~2d,1次/d,15min/次 | ||||||||
(3)六字诀发音;文式八段锦法第1段浴手、浴臂、浴鼻、浴膝,第3~5段 | 术后第3~6天引流管保留期间,六字诀2次/d,10min/次,八段锦1次/d,20min/次 | ||||||||
(4)六字诀发音;文式八段锦法第1段浴手、浴臂、浴鼻、浴腿、浴膝,第3~5段 | 术后第7~10天引流管拔除至拆除切口缝线前,六字诀2次/d,10min/次,八段锦1次/d,25min/次 | ||||||||
(5)六字诀,文八段锦全套 | 术后第11~14天拆除切口缝合线至出院前1d,六字诀2次/d,10min/次,八段锦1次/d,30min/次 | ||||||||
6.症状管理 | (1)胃肠道反应:穴位贴敷贴于神阙、气海、关元 | 术后当天至出院 | ③④ | ||||||
(2)疼痛:使用麻醉镇痛泵(3d),运用数字评分法评估术后疼痛,遵医嘱使用止痛药 | |||||||||
(3)药物反应:抗结核药物的不良反应、服药依从性观察 | |||||||||
(4)并发症管理:胸腔出血、气胸、肺部感染、心律失常、肺栓塞、呼吸衰竭 | 术后当天至出院后1个月 | ③④⑤ | |||||||
出院 | 1.出院指导 | (1)研究组制作六字诀、文式八段锦锻炼视频二维码,患者根据视频练习 | 六字诀2次/d,10min/次,文式八段锦全套1次/d,30min/次 | ②③⑤ | |||||
(2)依从性:出院时发放每周训练依从性表,研究组成员每周日督促患者将表格拍照发送至微信群,根据表格填写内容及时调整训练方式及健康宣传教育 | 出院后的每周日 | ①② | |||||||
2.随访 | (1)进行微信随访,包括运动训练、服药依从性,以及锻炼过程中是否出现不适 | 出院后的每周日 | ② | ||||||
(2)提醒患者门诊复查时间,术后1个月进行门诊复查时评估患者肺康复指标 | 术后1个月 | ②④ |
基线资料 | 对照组(28例) | 观察组(31例) | 统计检验值 | P值 |
---|---|---|---|---|
性别[例,构成比(%)] | χ2=0.094 | 0.759 | ||
男性 | 20(71.43) | 21(67.74) | ||
女性 | 8(28.57) | 10(32.26) | ||
年龄[岁,M(Q1,Q3)] | 29.5(25.0,47.0) | 35.0(25.0,50.0) | Z=-0.441 | 0.659 |
职业[例,构成比(%)] | χ2=0.775 | 0.679 | ||
职员 | 14(50.00) | 13(41.94) | ||
务农 | 7(25.00) | 7(22.58) | ||
其他 | 7(25.00) | 11(35.48) | ||
婚姻状态[例,构成比(%)] | χ2=0.005 | 0.943 | ||
已婚 | 21(75.00) | 23(74.19) | ||
未婚/离异/丧偶 | 7(25.00) | 8(25.81) | ||
医疗保险[例,构成比(%)] | χ2=1.002 | 0.606 | ||
自费 | 4(14.29) | 7(22.58) | ||
农村合作医疗 | 11(39.29) | 13(41.94) | ||
城镇医疗保险 | 13(46.42) | 11(35.48) | ||
文化程度[例,构成比(%)] | χ2=3.390 | 0.184 | ||
初中及以下 | 8(28.57) | 7(22.58) | ||
高中及中专 | 8(28.57) | 16(51.61) | ||
大专及以上 | 12(42.86) | 8(25.81) | ||
吸烟状态[例,构成比(%)] | χ2=1.417 | 0.234 | ||
是 | 6(21.43) | 11(35.48) | ||
否 | 22(78.57) | 20(64.52) | ||
耐药[例,构成比(%)] | χ2=0.121 | 0.728 | ||
是 | 7(25.00) | 9(29.03) | ||
否 | 21(75.00) | 22(70.97) | ||
术中转开胸[例,构成比(%)] | χ2=0.021 | 0.886 | ||
是 | 4(14.29) | 3(9.68) | ||
否 | 24(85.71) | 28(90.32) | ||
体质量指数[M(Q1,Q3)] | 23.8(21.9,24.4) | 23.1(20.3,23.9) | Z=-1.518 | 0.129 |
抗结核治疗时长[月,M(Q1,Q3)] | 8.5(4.3,12.0) | 7.0(4.0,12.0) | Z=-0.483 | 0.629 |
手术时长[min,M(Q1,Q3)] | 3.4(2.0,4.5) | 2.8(3.0,7.5) | Z=-1.397 | 0.162 |
术中出血量[ml,M(Q1,Q3)] | 85.0(50.0,200.0) | 50.0(30.0,100.0) | Z=-0.610 | 0.542 |
第1秒用力呼气容积[L,M(Q1,Q3)] | 1.93(1.75,2.14) | 1.94(1.67,2.36) | Z=0.215 | 0.643 |
用力肺活量[L,M(Q1,Q3)] | 2.80(2.60,2.94) | 2.80(2.59,2.94) | Z=1.123 | 0.289 |
焦虑评分(分,$\bar{x} \pm s$) | 60.54±5.18 | 60.32±5.35 | t=0.155 | 0.877 |
巴氏指数评分[分, M(Q1,Q3)] | 100.0(95.0,100.0) | 95.0(95.0,100.0) | Z=-0.932 | 0.351 |
肺功能指标 | 入院时 | 出院前 | 出院后 1个月 | 时间效应 | 组间效应 | 交互效应 | |||
---|---|---|---|---|---|---|---|---|---|
Wald χ2值 | P值 | Wald χ2值 | P值 | Wald χ2值 | P值 | ||||
FEV1[L,M(Q1,Q3)] | 140.035 | <0.001 | 4.851 | 0.028 | 28.304 | <0.001 | |||
对照组 | 1.93 (1.75,2.14) | 1.58 (1.43,1.83)a | 1.91 (1.88,2.04)bc | ||||||
观察组 | 1.94 (1.67,2.36) | 1.83 (1.60,2.29)d | 2.20 (2.00,2.32)ef | ||||||
Wald χ2值 | 0.215 | 8.947 | 7.285 | ||||||
P值 | 0.643 | 0.003 | 0.007 | ||||||
FVC[L,M(Q1,Q3)] | 666.426 | <0.001 | 5.640 | 0.018 | 16.192 | <0.001 | |||
对照组 | 2.8 (2.60,2.94) | 2.21 (2.20,2.49)a | 2.55 (2.35,2.69)bc | ||||||
观察组 | 2.80 (2.59,2.94) | 2.50 (2.30,2.64)d | 2.65 (2.45,2.79)ef | ||||||
Wald χ2值 | 1.123 | 10.072 | 5.708 | ||||||
P值 | 0.289 | 0.002 | 0.017 |
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