冠狀動脈心臟手術病人對手術前護理指導內容瞭解程度之相關因素

Abstract

背景：冠狀動脈繞道手術為冠狀動脈心臟疾病病人當症狀無法經由內科療法獲得改善時的唯一治療方式，手術前護理指導介入對病人知識、技能的成效及影響護理指導內容瞭解程度有所不同。 目的：瞭解冠狀動脈心臟手術病人手術前焦慮感及護理指導過程互動情形、冠狀動脈心臟手術病人特性與手術前護理指導暸解程度之差異與相關、呼吸訓練器(Triflow)使用技能與手術後胸部X光影像攝影之變化，以及手術前護理指導之感受、評價及給予時機。 方法：採橫斷式研究設計，於2012年2月至2012年10月在北部某醫學中心心臟外科病房，採立意取樣收案因冠狀動脈心臟疾病預接受手術的住院病人，於護理指導前後完成問卷包括基本資料表、醫院焦慮和憂鬱量表－焦慮次量表、護理指導互動過程量表、護理指導內容知識量表、護理指導內容技能量表（腹式深呼吸、有效的深呼吸咳嗽方法及呼吸訓練器(Triflow)使用）、訪談，及追蹤術後四日的呼吸訓練器(Triflow)使用頻率與手術後胸部X光影像攝影之變化，研究資料以SPSS 20.0進行統計分析。 結果：共有70位病人完成資料收集，研究結果顯示（1）護理指導後病人對護理指導內容知識（paired t=-12.41，p＜0.01）及護理指導技能包括腹式深呼吸（paired t=-9.01，p＜0.01）、有效的深呼吸咳嗽（paired t=-17.20，p＜0.01）、呼吸訓練器(Triflow)使用（paired t=-13.28，p＜0.01）有顯著提升，（2）「護理指導互動過程」愈好時「呼吸訓練器(Triflow)使用」（r=0.30，p=0.01）得分會愈高、「焦慮」程度愈高時腹式深呼吸（r=-0.34，p＜0.01)及有效的深呼吸咳嗽（r=-0.37，p＜0.01）技能得分會愈低、「術前不適症狀數」愈多時，「腹式深呼吸」（r=-0.25，p=0.03）、「有效的深呼吸咳嗽」（r=-0.32，p＜0.01）及「呼吸訓練器(Triflow)使用」（r=-0.52，p＜0.01）得分會愈低，（3）單變項邏輯斯迴歸分析發現性別（O.R.=19.9，95%C.I. =1.70~233.0，p=0.02）、術前有效的深呼吸咳嗽技能得分（O.R.=4.08，95% C.I. = 1.27~13.09，p=0.02）、術後三天呼吸訓練器(Triflow)練習總數（O.R.=1.68，95%C.I.=1.00~2.82，p=0.05）及術後三天呼吸訓練器(Triflow)平均吸球量（O.R. =2.72，95% C.I.=1.08~6.83，p=0.03）為術後第三天胸部X光影像攝影正常與否顯著之預測因子。（4）護理指導的效果為「對手術相關事項比較了解」、覺得「比較踏實、減少心理緊張感」。 結論/實務運用：手術前護理指導使病人更瞭解手術準備相關知識及技能的學習，可是護理指導前若病人處於高度焦慮的情緒，則會影響病人的學習狀況，手術後呼吸訓練器(Triflow)練習次數，有助於術後肺部復原，應列入護理計畫並主動督促及鼓勵病人呼吸訓練，依本研究結果建議（1）病人入院前能透過諮詢管道、護理指導手冊、DVD光碟瞭解手術相關知識，且能在門診就給予腹式深呼吸，有效的深呼吸咳嗽及呼吸訓練(Triflow)使用技能指導，使病人能提早練習，（2）護理人員可運用焦慮評估工具評估病人焦慮程度，並協助處理焦慮情緒，（3）鼓勵家屬一起參與護理指導過程，（4）將疼痛程度、呼吸訓練器(Triflow)吸球量及練習次數，列為每日護理常規記錄，以便能清楚瞭解病人練習狀況。

Background: Coronary artery bypass graft (CABG) surgery is recommended for patients who have coronary artery heart disease but show no health improvement after medical treatment. The effects of pre-surgical nurse-led education on the acquisition of surgery-related knowledge and skills vary from patient to patient. Objective: The purposes of this study were to understand (1) the level of pre-surgical anxiety and nurse–patient interaction during pre-surgical nurse-led education in patients undergoing CABG surgery; (2) factors related to surgery-related knowledge and skills obtained by patients from nurse-led education; (3) frequency in practicing incentive spirometry (Triflow) and differences in chest X-ray findings after surgery; and (4) patient’s perception and timing of pre-surgical nurse-led education. Methods: A cross-sectional approach was adopted. The research participants were selected based on purposive sampling from hospitalized patients scheduled to undergo CABG surgery in a medical center in northern Taiwan during February 2012 to October 2012. Patients completed a questionnaire series consisting of demographic information, the anxiety subscale of Hospital Anxiety and Depression Scale, nurse–patient interaction questionnaire, surgery-related knowledge questionnaire and skills checklists, and semi-structured questions related to their perception of pre-surgical nurse-led education. In addition, the frequency in practicing incentive spirometry (Triflow) as well as that of post-surgical chest X-ray imaging was recorded on days 1, 2, 3, and 6 after surgery. The collected data were analyzed using SPSS 20.0. Results: A total of 70 patients completed the questionnaire. The findings were as follows: (1) after nurse-led education, patients showed significant improvement in surgery-related knowledge (paired t = −12.41, p＜0.01), diaphragmatic breathing technique (paired t = −9.01, p＜0.01), effective deep breathing and coughing technique (paired t = −17.20, p＜0.01), and usage of incentive spirometry (Triflow) skill (paired t = −13.28, p＜0.01); (2) improved nurse–patient interaction during nurse-led education led to higher scores on usage of spirometry (Triflow) skill (r = 0.30, p = 0.01); higher anxiety led to lower scores on diaphragmatic breathing technique (r = −0.34, p＜0.01) and effective deep breathing and coughing technique (r = −0.37, p＜0.01); scores on diaphragmatic breathing technique (r = −0.25, p = 0.03), effective deep breathing and coughing technique (r = −0.32, p＜0.01), and usage of spirometry (Triflow) skill (r = −0.52, p＜0.01) were lower in the presence of more pre-operative symptoms; (3) The univariate logistic regression analysis showed gender (O.R.= 19.9, 95% C.I.= 1.70~ 233.0, p = 0.02）, pre operation effective deep breathing and coughing technique (O.R. =4.08, 95% C.I.= 1.27~13.09,p= 0.02) , total times of incentive spirometry (Triflow) practice in post operation three days（O.R.=1.68, 95% C.I.=1.00~2.82, p=0.05）and average amount of inhaled incentive spirometry (Triflow) in post operation three days（O.R.=2.72, 95% C.I.= 1.08~6.83, p=0.03）were significant predictors of normal chest X-ray on the third days after surgery; (4) the main effects of nurse-led education were “better knowledge of preoperative routines” and “reduced anxiety” in patients. Conclusion/ Implications: Pre-surgical nurse-led education can improve surgery-related knowledge and skills of patients. However, it adversely affects learning if the patients are highly anxious before surgery. Frequency in practicing incentive spirometry (Triflow) is helpful for pulmonary function after surgery. It should be listed in the nursing care plan and encouraged among patients. Based on the research findings, nurses are highly recommended to provide patients sufficient information about the procedure through various channels such as consultation, pamphlets, DVDs, videos and also teach them with necessary post-operative skills, including diaphragmatic breathing technique, deep breathing and coughing technique, and usage of incentive spirometry (Triflow), during their out-patient visits. Nurses can use instruments/tools to assess the level of anxiety in patients and assist them to cope with their anxiety. The patients’ family should also be encouraged to take part in pre-surgical nurse-led education. In addition, the level of pain and frequency in practicing incentive spirometry (Triflow) should be documented daily for better tracking of the status of patients.