護理措施對腹部手術老年病患胃腸活動的影響

Abstract

目的：神經反射及發炎反應是術後胃腸活動延後恢復的兩大機制，本研究分析新型照護模式(Modified Hospital Elder Life Program, mHELP)中所包含的口腔護理及早期下床活動是否可藉由增加迷走神經刺激，強化抗發炎機制，而促進腹部手術老年病患的胃腸活動恢復。 方法：採用台大護理研究所陳佳慧副教授的單盲、分層、叢集隨機臨床試驗-新型照護模式(Modified Hospital Elder Life Program, mHELP)的研究資料，分析此照護模式在排氣、排便、進食固體食物未有噁心嘔吐時間、及住院天數的成效。分析採兩步驟驗證，第一步驟為全樣本(n=297)分析，分析實驗組與控制組在胃腸活動恢復的成效。第二步驟為術式配對樣本分析(採全胃/次全胃切除術、右側結腸切除術、左側結腸/低/前位切除術、胰頭十二指腸切除術1:1配對；配對數為99對)，藉此進一步了解介入措施成效是否因術式而異。資料以SAS 9.3套裝軟體分析，採線性迴歸(linear regression model) 分析全樣本及以廣義估計方程式(Generalized estimating equation)分析配對樣本。結果變項為第一次排氣時間、第一次排便時間、第一次進食固體食物而未有噁心嘔吐症狀時間、及住院天數。 結果：配對樣本分析顯示，新型照護模式(mHELP)可有效(1)提早右側結腸切除術後排氣時間(p=0.022)；(2) 提早腹部手術後排便時間 (p=0.049)；(3) 提早胃部手術後進食固體食物時間(p=0.010) ；及(4) 縮短胃部手術後住院時間(p=0.000)。控制了年齡、性別、查爾森共病症嚴重度、腫瘤分期、手術時間、造口術及行腹腔鏡術等變項後，全樣本分析顯示mHELP可顯著提早排便時間，雖可縮短排氣、進食固體食物時間、及住院天數，但未達統計差異。 結論：研究結果顯示，結合口腔護理、早期下床活動及定向溝通的新型照護模式，尤在某些特定的腸胃道術式上，可顯著促進老年病患的胃腸道活動恢復，並有效降低住院天數。

Purpose: Neuroreflex and inflammation are two main mechanisms of gastrointestinal dysmotility after abdominal surgery. Nursing interventions such as oral care and early mobilization might have effects on the mechanisms of neuroreflex and inflammation. The purpose of this study was to analyze the effects of a nursing intervention program including oral care and early mobilization on alleviating gastrointestinal dysmotility in a sample of elderly patients undergoing abdominal surgery. Method: As part of a randomized controlled trial (RCT) examining effects of a modified Hospital Elder Life Program (mHELP) on patient outcomes, we analyzed effect of the mHELP on the first time of flatus, first time of defecation, first time of taking solid food without nausea or vomiting, and length of hospital stay for elderly patients (65 years and older) undergoing elective major abdominal surgery. Matched n=99 pairs) and unmatch analyses (n=279) of data from the RCT were conducted using SAS program. Individuals were matched 1:1, on type of their surgical procedures (i.e., total /subtotal gastrectomy, right hemicolectomy, left hemicolectomy, and pancreaticoduodenectomy) to specify whether the effects were various by surgical procedures. Result: In matched pairs, participants who received the mHELP interventions were significantly more likely to have (1) shorter time to first flatus, particularly for those underwent right hemicolectomy(p=0.022); (2) shorter time to first defecation (p=0.049); (3) shorter time for taking solid food without nausea and vomiting, particularly for those who underwent gastrectomy(p =0.010); and (4) shorter length of stay, particularly for those underwent gastrectomy(p <0.001). For unmatch analysis, individuals who received the mHELP had significantly shorter time to defecation, adjusting for age, sex, Charlson comorbidity scores, tumor stage, duration of surgery, having ostomy, and laparoscopic procedures. Conclusion: The mHELP comprised of oral care, early mobilization, and orienting communication is effective in alleviating gastrointestinal dysmotility after abdominal surgery but the benefit is various among different surgical procedures. Thus, the mHELP provides a usual approach to promote the recovery of gastrointestinal motility for the elderly who undergoing elective major abdominal surgery.