方 霞，汪 燕，劉 斌，劉 燕，顧 群

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·臨床醫(yī)學(xué)·

·論著·

專業(yè)護(hù)理干預(yù)對(duì)院內(nèi)缺血性卒中患者從發(fā)現(xiàn)至靜脈溶栓用藥時(shí)間的影響

方 霞，汪 燕，劉 斌，劉 燕，顧 群

目的 探討專業(yè)護(hù)理對(duì)院內(nèi)缺血性卒中患者從發(fā)現(xiàn)至靜脈溶栓用藥時(shí)間的影響。方法 選取我院2010-2016年發(fā)生缺血性卒中并實(shí)施重組人組織纖維蛋白溶酶原激活劑(recombinant tissue plasminogen activator，rt-PA)靜脈溶栓的住院患者19例。將其中8例由急診科和神經(jīng)科經(jīng)過溶栓專業(yè)培訓(xùn)護(hù)士實(shí)施靜脈溶栓的患者歸為專業(yè)組，將其余11例在其他科室住院期間發(fā)生缺血性卒中，由未經(jīng)過溶栓培訓(xùn)護(hù)士實(shí)施rt-PA靜脈溶栓的患者歸為對(duì)照組。分別統(tǒng)計(jì)從發(fā)現(xiàn)至溶栓治療時(shí)間(find to needle time，F(xiàn)NT)、下達(dá)醫(yī)囑到溶栓開始時(shí)間(preparation to needle time，PNT)以及患者溶栓后90 d的改良Rankin量表(modified Rankin scale，mRS)評(píng)分，分別對(duì)上述指標(biāo)進(jìn)行單因素分析，并通過問卷調(diào)查方式分別評(píng)估經(jīng)過溶栓專業(yè)培訓(xùn)護(hù)士和未經(jīng)過溶栓培訓(xùn)護(hù)士對(duì)院內(nèi)卒中的認(rèn)知情況。結(jié)果 單因素分析結(jié)果顯示，專業(yè)組FNT明顯短于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；專業(yè)組PNT明顯短于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；2組患者溶栓治療后90 d的mRS評(píng)分無明顯差異(P>0.05)；經(jīng)過溶栓專業(yè)培訓(xùn)的護(hù)士對(duì)院內(nèi)卒中的認(rèn)知程度明顯高于未經(jīng)過溶栓培訓(xùn)的護(hù)士。結(jié)論 急診和神經(jīng)科病區(qū)院內(nèi)卒中的FNT明顯短于其他科室；經(jīng)過正規(guī)溶栓培訓(xùn)的護(hù)士可以縮短院內(nèi)卒中FNT。

靜脈溶栓；院內(nèi)卒中；溶栓護(hù)理

院內(nèi)卒中(in-hospital stroke，IHS)是指非卒中原因住院患者在住院期間發(fā)生的卒中，占急性卒中的4%～17%，其中手術(shù)和實(shí)施有創(chuàng)操作患者發(fā)生率高[1]。我院缺血性卒中靜脈溶栓工作主要在急診與神經(jīng)內(nèi)科進(jìn)行，護(hù)理人員均受過溶栓專業(yè)培訓(xùn)，IHS患者可以及時(shí)行溶栓治療，而其他科室IHS患者的靜脈溶栓率偏低，與非溶栓專業(yè)科室缺乏急性卒中處置的相關(guān)培訓(xùn)有關(guān)，因此本研究試圖分析并探討不同護(hù)理人員對(duì)院內(nèi)缺血性卒中靜脈溶栓用藥時(shí)間的影響，為進(jìn)一步優(yōu)化IHS靜脈溶栓流程提供依據(jù)。

1 對(duì)象與方法

1.1 研究對(duì)象

選取2010-2016年在我院實(shí)施重組人組織纖維蛋白溶酶原激活劑(recombinant tissue plasminogen activator，rt-PA)靜脈溶栓的IHS患者共19例作為研究對(duì)象。其中男13例，女6例，年齡65～90歲，平均(80.26±8.35)歲。納入對(duì)象符合《中國急性缺血性腦卒中診治指南2014》診斷標(biāo)準(zhǔn)[2]，均經(jīng)頭顱磁共振確診，有詳細(xì)的溶栓記錄。將以上患者分為2組，(1)專業(yè)護(hù)理組：由經(jīng)過溶栓專業(yè)護(hù)理培訓(xùn)護(hù)士進(jìn)行靜脈溶栓的急診科和神經(jīng)科住院患者8例，其中男性5例，女性3例，年齡65～89歲，平均(77.75±9.80)歲；(2)對(duì)照組：由未經(jīng)過溶栓護(hù)理培訓(xùn)護(hù)士進(jìn)行靜脈溶栓的其他科室住院患者11例，其中男性7例，女性4例，年齡66～90歲，平均(78.09±8.71)歲。2組患者一般資料比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。分別選取經(jīng)過溶栓專業(yè)培訓(xùn)的急診和神經(jīng)科護(hù)士，以及未經(jīng)過溶栓培訓(xùn)的其他科室護(hù)士各25名作為問卷調(diào)查對(duì)象。

1.2 方法

1.2.1 數(shù)據(jù)采集 通過回顧溶栓記錄和醫(yī)囑記錄對(duì)IHS靜脈溶栓患者的救治過程進(jìn)行還原。統(tǒng)計(jì)護(hù)士發(fā)現(xiàn)患者出現(xiàn)癥狀至靜脈開始注射藥物的時(shí)間(find to needle time，F(xiàn)NT)。醫(yī)生下達(dá)靜脈溶栓醫(yī)囑至溶栓開始的時(shí)間(preparation to needle time，PNT)。溶栓治療90 d后隨訪，對(duì)患者進(jìn)行改良的Rankin量表(modified Rankin scale，mRS)評(píng)分。

1.2.2 問卷調(diào)查 問卷由神經(jīng)科醫(yī)師自行設(shè)計(jì)，采用現(xiàn)場(chǎng)填寫的方式進(jìn)行，20 min內(nèi)完成。共發(fā)放問卷50份，回收有效問卷46份，有效回收率為92%。按是否接受過rt-PA靜脈溶栓培訓(xùn)將參加問卷調(diào)查的護(hù)士分為受訓(xùn)組和對(duì)照組，并分別計(jì)算各組回答的正確率。

1.3 統(tǒng)計(jì)學(xué)處理

運(yùn)用SPSS 20.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)數(shù)資料組間比較采用χ2檢驗(yàn)，計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示，進(jìn)行方差齊性檢驗(yàn)，組間比較采用兩獨(dú)立樣本t檢驗(yàn)，P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 計(jì)量資料單因素分析

2組間IHS患者年齡差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，F(xiàn)NT、PNT差異有統(tǒng)計(jì)學(xué)意義(P<0.05或P<0.01)?；颊呷芩ê?0dmRS評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表1。

表1 2組患者FNT、PNT及mRS評(píng)分的比較(x±s)

注：FNT：發(fā)現(xiàn)至溶栓時(shí)間，PNT：下達(dá)醫(yī)囑至溶栓開始時(shí)間，mRS：改良Rankin量表

2.2 問卷調(diào)查結(jié)果分析

問卷調(diào)查結(jié)果顯示，受訓(xùn)組護(hù)理人員在對(duì)IHS患者的識(shí)別、rt-PA靜脈溶栓流程、配藥方法和并發(fā)癥認(rèn)知方面，回答正確率均高于對(duì)照組。見表2。

表2 2組護(hù)理人員對(duì)IHS靜脈溶栓的認(rèn)知程度比較[例(%)]

注：a使用Fisher確切概率法。IHS：院內(nèi)卒中

3 討論

急性缺血性卒中是急診科和神經(jīng)科的常見病，而rt-PA靜脈溶栓是目前公認(rèn)最有效的治療方法之一[3]。患者發(fā)病后如能及時(shí)給予靜脈溶栓治療，使閉塞的血管再通，可改善缺血半暗帶的供血，縮小腦梗死面積，從而減輕腦組織的損傷程度[4]。我院自2009年開始急性腦梗死rt-PA靜脈溶栓以來，致力于開展急診和神經(jīng)科醫(yī)護(hù)人員的溶栓培訓(xùn)、簡(jiǎn)化診治流程、加強(qiáng)部門協(xié)作，力爭(zhēng)縮短急診患者到院至溶栓的時(shí)間。而發(fā)生在院內(nèi)非卒中治療科室的急性腦梗死常由于醫(yī)務(wù)人員缺乏相關(guān)培訓(xùn)及知識(shí)，無法及時(shí)識(shí)別，加上重視程度不夠、會(huì)診延誤、檢查耗時(shí)等問題，錯(cuò)過了溶栓治療的最佳時(shí)機(jī)。護(hù)士往往是IHS患者的第一發(fā)現(xiàn)人，護(hù)士對(duì)急性腦卒中認(rèn)知和判斷存在差異，經(jīng)過溶栓培訓(xùn)的護(hù)士能夠更快地識(shí)別并報(bào)告責(zé)任醫(yī)師，配合醫(yī)師完成溶栓前的各項(xiàng)化驗(yàn)檢查并及時(shí)給予患者溶栓藥物，從而縮短FNT[5]。本研究問卷調(diào)查結(jié)果顯示，受訓(xùn)組護(hù)士在癥狀識(shí)別、溶栓流程、溶栓藥物使用以及溶栓并發(fā)癥的認(rèn)識(shí)方面均高于對(duì)照組，溶栓前的準(zhǔn)備時(shí)間也短于對(duì)照組。理論上IHS患者發(fā)病時(shí)已在院內(nèi)，其FNT應(yīng)明顯短于院外卒中患者。但事實(shí)并非如此，非專業(yè)科室的IHS患者在院內(nèi)診治過程中耽擱了大量時(shí)間，在早期識(shí)別、科室協(xié)作、檢查化驗(yàn)、談話溝通，護(hù)理工作方面的問題也較為突出，例如溶栓前靜脈通道的建立、心電監(jiān)護(hù)儀和注射泵的安裝、導(dǎo)尿和胃管置入等操作延誤都會(huì)增加FNT。以上問題共同導(dǎo)致了IHS患者發(fā)病至溶栓時(shí)間的延長(zhǎng)，同時(shí)也提示院內(nèi)卒中溶栓流程仍有很大的優(yōu)化空間。與患者接觸最多的護(hù)理人員，是靜脈溶栓的關(guān)鍵一環(huán)，對(duì)待急性卒中應(yīng)有警惕性和時(shí)間緊迫感，并熟知靜脈溶栓的流程和溶栓藥物的使用方法，為減少IHS患者的死亡率和致殘率做出努力。此外，筆者觀察到2組IHS溶栓患者溶栓后90 d的mRS評(píng)分無統(tǒng)計(jì)學(xué)差異，可能與樣本量的限制有關(guān)。筆者初步探討了護(hù)理工作對(duì)院內(nèi)卒中靜脈溶栓的影響，下一步將對(duì)護(hù)理工作在靜脈溶栓過程中的各環(huán)節(jié)和步驟進(jìn)行深入分析和研究。

[1] Saltman AP, Silver FL, Fang J, et al. Care and outcomes of patients with in-hospital stroke[J].JAMA Neurol, 2015, 72(7): 749-755. DOI:10.1001/jamaneurol.2015.0284.

[2] 中華醫(yī)學(xué)會(huì)神經(jīng)病學(xué)分會(huì). 中國急性缺血性腦卒中診治指南(2014)[J]. 中華神經(jīng)科雜志, 2015, 48(4):246-257.

[3] Gumbinger C, Reuter B, Stock C, et al. Time to treatment with recombinant tissue plasminogen activator and outcome of stroke in clinical practice: retrospective analysis of hospital quality assurance data with comparison with results from randomised clinical trials[J]. BMJ, 2014, 348: g3429. DOI:10.1136/bmj.g3429.

[4] 肖靜，江思德，唐明山. 急性腦梗死患者阿替普酶靜脈溶栓預(yù)后相關(guān)危險(xiǎn)因素初步研究[J]. 河北醫(yī)學(xué), 2015, 21(1): 30-32. DOI:10.3969/j.issn.1006-6233.2015.01.010.

[5] 何霞婷，褚安紅. 急診專業(yè)組護(hù)士對(duì)急性腦卒中患者診療時(shí)間的影響[C]. 中華醫(yī)學(xué)會(huì)急診醫(yī)學(xué)分會(huì)第十六次全國急診醫(yī)學(xué)學(xué)術(shù)年會(huì)論文集, 2013: 353.

(本文編輯：彭潤(rùn)松)

Effect of professional nursing intervention on the medication time of intravenous thrombolytic therapy in inpatients with ischemic stroke

Fang Xia, Wang Yan, Liu Bin, Liu Yan, Gu Qun

(Department of Neurology, No. 411 Hospital of CPLA, Shanghai 200081, China)

Objective To investigate the effect of professional nursing intervention on the medication time of intravenous thrombolytic therapy in inpatients with ischemic stroke.Methods Selected for the study were 19 cases of ischemic stroke that occurred during their stay in the hospital from 2010 to 2016, and they were treated with intravenous thrombolysis of recombinant human tissue plasminogen activator (rt-PA). Of the 19 cases, 8 cases treated with intravenous thrombolysis implemented by trained professional nurses in the emergency and the neurology departments were assigned as the professional nursing group, the other 11 cases treated with intravenous thrombolysis of rt-PA implemented by non-professional nurses in other medical departments were assigned as the control group. Statistical analyses were made on the scores of from perceiving to needle time (PNT), find to needle time (FNT) and the scores of Modified Rankin Scale(MRS)90 days after thrombolytic therapy, and single-factor analyses were also made on the above indicators. Then, awareness of ischemic stroke perceived respectively by trained professional nurses and non-professional nurses was assessed by the approach of questionnaire.Results Single-factor analyses indicated that PNT of the trained professional nursing group was significantly shorter than that of the control group, and statistical significance could be noticed when comparisons were made between them(P<0.01). The FNT of the trained professional nursing group was also significantly shorter than that of the control group, and there was no statistical significance when comparisons were made between them(P<0.05). And there were neither significant differences in mRS scores 90 days after intravenous thrombolytic therapy, when comparisons were made between the 2 groups(P<0.05). The awareness of in-hospital stroke by the professional nursing group was significantly higher than that of the non-professional nursing group.Conclusion The PNT of the in-hospital stroke patients in the emergency and neurological wards was significantly shorter than that of the other departments of the hospital. Nurses with regular thrombolytic therapy training could obviously shorten the time from stroke onset to thrombolytic therapy.

Intravenous thrombolysis; In-hospital stroke; Thrombolytic nursing

200081 上海，解放軍第四一一醫(yī)院神經(jīng)內(nèi)科(方霞、汪燕、劉燕、顧群)；海軍上海東體育會(huì)路離職干部休養(yǎng)所(劉斌)

顧群，電子信箱：gq1975@soho.com

R473.74

A [DOI] 10.3969/j.issn.1009-0754.2016.05.018

2016-06-16)