Value of clinical pathway table of enhanced recovery cluster nursing in patients with spinal tuberculosis during perioperative period

doi:10.3969/j.issn.1000-6621.2020.09.017

Abstract

Abstract:

Objective To investigate the application effect of clinical pathway table of enhanced recovery cluster nursing in patients with spinal tuberculosis during perioperative period. Methods Forty-two patients who met the inclusion criteria and underwent surgery for spinal tuberculosis from Zhejiang Integrated Traditional and Western Medicine Hospital, between July 2018 and December 2018, were selected as the control group. Forty patients who met the inclusion criteria and underwent surgery for spinal tuberculosis from the same hospital between July 2018 and December 2018 were selected as the observation group. Patients in the control group were treated with traditional perioperative nursing measures, and those in the observation group were treated with clinical pathway table of enhanced recovery cluster nursing designed by ourselves. The postoperative Numerical Rating Scale (NRS score), occurrence of breakthrough pain, recovery time of gastrointestinal function, time of first getting out of bed and eating, occurrence of adverse reactions, satisfaction with hospitalization, cost of hospitalization and so on, were compared between the two groups. Results The NRS score of 24, 48 and 72 hours after operation were 3.75±0.81, 3.48±0.93 and 2.63±0.74, respectively in the observation group. All of them were significantly lower than those in the control group (4.26±1.06, 4.12±0.83 and 3.26±0.83, respectively). The differences were statistically significant (t=2.449, 3.301 and 3.665, respectively; P=0.017, 0.001 and 0.000, respectively). In the observation group, 1 patient (2.4%) experienced breakthrough pain, the rate was significantly lower than the control group (6 patients (14.3%)) (χ²=4.178, P=0.041). In the observation group, the times of first passing gas, getting out of bed and eating after operation were significantly earlier than those in the control group ((23.65±7.76) h vs. (32.38±11.50) h, t=4.008, P=0.000; (10.20±2.87) d vs. (13.90±1.45) d, t=7.444, P=0.000; (19.58±10.43) h vs. (30.81±9.81) h, t=5.024, P=0.000). The incidence rate of nausea and vomiting in the observation group (20.0%, 8/40) was significantly lower than that in the control group (64.3%, 27/42) (χ²=16.424, P=0.000). The postoperative satisfaction rate of the observation group was 100.0% (40/40), which was significantly higher than that of the control group (88.1%, 37/42) (χ²=6.531, P=0.038). The hospitalization expense in the observation group was RMB (90.2±14) thousand yuan, which was significantly lower than that in the control group (RMB (101.8±16) thousand yuan) (t=3.486, P=0.001). Conclusion The clinical pathway table of enhanced recovery cluster nursing for spinal tuberculosis patients could promote recovery of the patients, reduce the cost of hospitalization, improve satisfaction, and improve the overall efficacy, it is worthy of promotion in clinic.

Key words: Tuberculosis,spinal, Perioperative care, Critical pathways, Comparative study, Data interpretation,statistical

ZHANG Li-juan, TAO Xiao, XIA Li-li, WEI Fen-fen, ZHENG Qi. Value of clinical pathway table of enhanced recovery cluster nursing in patients with spinal tuberculosis during perioperative period[J]. Chinese Journal of Antituberculosis, 2020, 42(9): 981-986. doi: 10.3969/j.issn.1000-6621.2020.09.017

Figures/Tables 3

临床资料	对照组(42例)	观察组(40例)	统计检验值	P值
年龄[岁,M(Q₁,Q₃)]	43.50(24.75,66.25)	39.00(26.50,66.00)	Z=-0.028	0.978
性别[例(构成比,%)]			χ²=0.003	0.956
男	26(61.9)	25(62.5)
女	16(38.1)	15(37.5)
病变节段[例(构成比,%)]			χ²=0.152	0.927
颈椎	7(16.7)	8(20.0)
胸椎	12(28.6)	11(27.5)
腰椎	23(54.7)	21(52.5)
术前疼痛数字评价量表评分(分, $x ˉ$ ±s)	5.24±0.93	4.80±0.46	t=3.273	0.052
手术方式[例(施行率,%)]			χ²=0.152	0.927
颈椎手术	7(16.7)	8(20.0)
胸椎手术	12(28.6)	11(27.5)
腰椎手术	23(54.7)	21(52.5)

时间	项目	内容	完成情况	观察指标
入院日	健康教育	评估患者应激能力,认知评价及应对方式,通过面对面、书面、视频等方式介绍疾病相关知识、治疗手段、目的和效果	□完成 □变异	能复述疾病相关知识 □是□否
	营养评估	根据营养风险筛查表(NRS2002)做好营养评估,总分值≥3分者需要营养支持,将常用食物及食物等价交换表、简易膳食摄入的计算方法等制成宣教手册,进行面对面宣教,结合临床,制定营养治疗计划,首选肠内营养	□完成 □变异	有营养计划并实施 □是□否
	疼痛管理	进行疼痛的神经生理学知识宣传教育、指导采用数字评分法评估疼痛分值	□完成 □变异	学会疼痛评估方法,疼痛时能主动寻求干预 □是□否
	体位管理	通过多模式宣传教育方法向患者说明绝对卧床的重要性和必要性,轴位翻身,搬动患者使用“过床易”,保持脊柱水平位置,颈椎结核佩戴颈托,避免头颈的突然或快速转动	□完成 □变异	知晓绝对卧床重要性和必要性,卧床依从性好 □是□否
	截瘫平面观察	观察患者双下肢肌力、感觉及括约肌功能,有无刺激性疼痛、感觉异常,如麻木、蚁走感,感觉错乱症状及感觉缺失表现,排便排尿情况;已经出现截瘫患者,每日关注截瘫平面	□完成 □变异	每日关注双下肢肌力、感觉及截瘫平面 □是□否
入院第2天至术前2d	呼吸功能训练	戒烟、指导腹式呼吸和缩唇呼吸,训练吹气球活动或使用呼吸训练器	□完成 □变异	学会有效咳嗽,正确使用呼吸训练器 □是□否
	二便训练	指导床上排便及排尿训练	□完成 □变异	能卧床排二便 □是□否
	脓肿观察	咽后壁脓肿,观察呼吸及吞咽情况,做好饮食宣传教育;流注脓肿,观察局部皮肤防止破溃,做好皮肤护理	□完成 □变异	呼吸及吞咽困难 □是□否皮肤清洁完整 □是□否
	用药护理	告知药品作用、不良反应、疗程及注意事项	□完成 □变异	知晓药品不良反应 □是□否
术前1d	术前训练	颈椎结核患者,气管食管推移训练,每天训练3次,每次间隔2~3h(医生协助下完成);胸腰椎结核患者,俯卧位训练,每天训练2次,每次30min,以患者能耐受为宜	□完成 □变异	完成相关训练 □是□否
	健康教育	通过多模式宣传教育方法强化术前准备及术后配合的加速康复外科项目	□完成 □变异	知晓术前准备及术后配合项目 □是□否
	禁食禁饮	禁食6h,禁水和清流质饮食2h	□完成 □变异	禁食6h,禁水和清流质饮食2h □是□否
	肠道准备	晚餐饮食清淡易消化,常规肠道准备	□完成 □变异	术前肠道准备 □是□否
	皮肤准备	皮肤清洁,手术部位附近窦道换药	□完成 □变异	术前皮肤准备 □是□否
术后0~1d	体位管理	颈椎结核术后颈托及米袋间歇固定;腰椎结核术后6h轴位翻身;胸椎结核术后6h取30°半卧位	□完成 □变异	卧位符合要求 □是□否
	疼痛管理	采用自控镇痛技术联合足量规律使用非甾体抗炎药品超前镇痛模式	□完成 □变异	镇痛不全发生 □是□否爆发痛发生次数:
	液体管理	根据医嘱,遵循个体化目标导向的限制性输液,合理应用胶体及晶胶结合的输液方案,维持每小时尿量在30ml以上	□完成 □变异	每小时尿量在30ml以上 □是□否
	生命体征监测	监测心率、心律、血压、呼吸、血氧饱和度和尿量的变化,每小时巡视1次,颈椎手术观察切口周围及颈部有无肿胀、渗血,气管是否居中及软组织张力有无增大	□完成 □变异	生命体征稳定 □是□否
	呼吸道管理	吸氧,维持血氧饱和度在95%以上,雾化吸入,2次/d,指导患者深呼吸,有效咳嗽,吹气球或使用呼吸训练器协助肺复张,咳痰无力者使用振动排痰仪	□完成 □变异	血氧饱和度正常 □是□否
	神经功能监测	颈椎手术检查上、下肢肌力感觉,胸腰椎手术检查下肢肌力感觉,分别在术后6h内每小时观察1次,术后7~48h内每4h观察评估1次,术后48h以后每8h评估1次并记录。观察有无脊髓损伤,脊髓前动脉综合征,周围神经损伤,喉返、喉上神经损伤及其他交感神经损伤	□完成 □变异	神经功能正常 □是□否
	引流管管理	观察引流液的量、颜色及性状;胸腔闭式引流管的患者,注意水柱波动情况,保持管路密闭,随时检查引流装置	□完成 □变异	引流管通畅,无不良并发症发生 □是□否
	经皮内镜清除灌洗引流管护理	冲洗液选用生理盐水3000ml加入异烟肼0.6g,术后前3d用间断快速冲洗法,每2h快冲(滴速为直线流注)1次,每次2~3min,间隔时间内常规冲洗(40滴/min),3d后根据实际情况调整。灌洗2~3d后,冲洗量改为2000ml/d。冲洗时间10~14d	□完成 □变异	经皮内镜清除灌洗引流管通畅 □是□否
	预防胃肠道反应	做咀嚼动作;选用大黄、芒硝打粉后神阙穴外敷,2次/d,每次持续4h;腹结、天枢、足三里穴位揿针治疗,每3d治疗1次,每次持续48~72h	□完成 □变异	恶心呕吐发生 □是□否腹胀便秘发生 □是□否
	早期进食	麻醉清醒饮少量温开水,约50ml(腰椎手术者肠鸣音恢复后),逐渐增量,防止误吸	□完成 □变异	首次进食时间
术后2~3d	早期进食	术后2~3d,鼓励患者口服进食稀饭、小米粥、面条等(腰椎手术者待肠鸣音恢复后),少量多餐,逐步过渡到正常饮食,主张肠内营养,防止误吸	□完成 □变异
	功能锻练	颈椎、胸椎术后30~60°半卧位休息。适应性训练,包括:双下肢直腿抬高和膝、髋关节的伸屈运动,以及双足背伸和跖屈、踝泵运动;截瘫者指导家属协助患者行被动运动,每天累积≥1h。遵循安全而不加重疼痛,主动运动为主,被动运动为辅的原则	□完成 □变异	按要求进行功能锻练,无不良反应发生 □是□否
	预防深静脉血栓	血栓风险评估量表(Caprini)评分≥5分,气压治疗,2次/d,30min/次。术后24~36h遵医嘱予以低分子肝素钠(排除禁忌证)。肢体主动及被动活动,避免膝下垫枕、过度屈髋	□完成 □变异	深静脉血栓发生 □是□否
	早期拔管	各种引流管引流液≤50ml/d,予以拔管	□完成 □变异	早期拔管 □是□否
术后4~7d	早期拔管	各种引流管引流液≤50ml/d予以拔管,观察有无不适	□完成 □变异	早期拔管 □是□否
	疼痛控制	非甾体抗炎药物每12h 1次,对于神经根性疼痛,在使用非甾体抗炎药物的基础上加用神经修复剂、肌肉松驰剂等	□完成 □变异	镇痛不全发生 □是□否爆发痛发生次数:
	功能锻练	半卧位休息,关节活动度训练,踝泵运动,双下肢直腿抬高动作,腰背肌锻炼,每天累积≥1h。遵循安全而不加重疼痛,主动运动为主,被动运动为辅的原则	□完成 □变异	按要求进行功能锻练,无不良反应发生 □是□否
术后8~12d	功能锻练	颈椎手术佩戴颈托或头颈胸支具下床活动,借助步行器行走,每天累积≥1h;胸腰椎手术除加强床上训练的强度外,在胸腰椎支具固定下起床,借助步行器进行负重站立训练并室内行走,每天累积≥1h。遵循安全而不加重疼痛,主动运动为主,被动运动为辅的原则	□完成 □变异	首次离床活动时间:
术后13~14d	健康教育	出院指导,告知随访相关注意事项	□完成 □变异	掌握出院指导内容: □是□否
	出院	评估是否达到出院标准:患者生活基本自理,体温、肝功能、白细胞计数及炎性指标正常,抗结核药品口服能耐受,疼痛评分≤2分,能正常进食,切口愈合良好,能自行佩戴支具在室内行走	□完成 □变异	患者满意度: 住院费用: 并发症:

组别	例数	肛门排气时间 (h, $x ˉ$ ±s)	首次下床时间 (d, $x ˉ$ ±s)	首次进食时间 (h, $x ˉ$ ±s)	恶心呕吐 [例(发生率,%)]
观察组	40	23.65±7.76	10.20±2.87	19.58±10.43	8(20.0)
对照组	42	32.38±11.50	13.90±1.45	30.81±9.81	27(64.3)
统计检验值		t=4.008	t=7.444	t=5.024	χ²=16.424
P值		0.000	0.000	0.000	0.000

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