李成香 楊萌 周蘭島 覃花桃 麻新靈 陸美嬌 羅琳雪
【摘要】目的探索疼理干預(yù)模式對(duì)社區(qū)老年性骨質(zhì)疏松患者疼痛管理的應(yīng)用效果。方法將108例在百色市東合社區(qū)衛(wèi)生服務(wù)中心門診確診的老年骨質(zhì)疏松癥患者隨機(jī)分為干預(yù)組與對(duì)照組,每組54例。對(duì)照組給予傳統(tǒng)治療方法,干預(yù)組按預(yù)定的干預(yù)模式實(shí)施,即在傳統(tǒng)治療方法的基礎(chǔ)上,給予疼痛評(píng)估并結(jié)合有效的疼痛護(hù)理干預(yù)措施。分別比較干預(yù)前、干預(yù)后6個(gè)月患者骨密度(BMD)、血堿性磷酸酶(AKP)及血鈣(Ca)值,以及干預(yù)前、干預(yù)后3個(gè)月、干預(yù)后6個(gè)月患者疼痛程度及生活質(zhì)量。結(jié)果通過疼痛干預(yù)模式實(shí)施6個(gè)月后,(1)干預(yù)組的踝關(guān)節(jié)與膝關(guān)節(jié)BMD值較干預(yù)前顯著升高,且明顯高于對(duì)照組(P<0.001);干預(yù)后6個(gè)月干預(yù)組AKP明顯升高,血Ca值明顯下降,與對(duì)照組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。(2)兩組患者在干預(yù)后3個(gè)月、干預(yù)后6個(gè)月的VAS評(píng)分呈下降趨勢(shì)(P<0.01),但觀察組各時(shí)間點(diǎn)均低于對(duì)照組,疼痛改善更為明顯,差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。(3)兩組患者干預(yù)后的WHOQOL-BRLEF評(píng)分均比干預(yù)前升高(P<0.001),但干預(yù)組升高更明顯,差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。結(jié)果表明,干預(yù)組患者骨密度含量明顯增加,疼痛癥狀明顯減輕或消失,骨代謝生化指標(biāo)明顯下降,生活質(zhì)量明顯提高。結(jié)論疼痛護(hù)理干預(yù)模式的構(gòu)建在社區(qū)老年性骨質(zhì)疏松患者疼痛管理中應(yīng)用切實(shí)可行,為各地社區(qū)護(hù)理服務(wù)中心開展病人疼痛健康教育提供有益的借鑒。
【關(guān)鍵詞】社區(qū);老年;骨質(zhì)疏松癥;疼痛干預(yù)
中圖分類號(hào):R473文獻(xiàn)標(biāo)識(shí)碼:ADOI:10.3969/j.issn.1003-1383.2018.05.008
【Abstract】ObjectiveTo explore the application effect of pain nursing intervention mode for elderly patients with osteoporosis in community.Methods108 elderly patients with osteoporosis diagnosed in Donghe Community Health Service Center of Baise City were randomly divided into intervention group and control group,with 54 cases in each group.The control group were treated with traditional therapy.However,the intervention group were treated with predetermined mode of intervention,that was,on the basis of traditional therapy,pain evaluation and effective pain nursing intervention were carried out.Bone mineral density(BMD),serum alkaline phosphatase(AKP) and serum calcium(Ca) before intervention and 6 months after intervention as well as pain degree and quality of life(QOL) before intervention,3 months after intervention and 6 months after intervention were compared between the two groups.Results(1)After 6 months of pain intervention,the BMD values of ankle joint and knee joint in the intervention group were significantly higher than those before the intervention,and significantly higher than those in the control group(P<0.001).And the AKP of the intervention group increased significantly,and the Ca value of the blood decreased significantly while comparing with the control group,difference was statistically significant(P<0.001).(2) The VAS scores of the two groups decreased at 3 months and 6 months after intervention(P<0.01),but those of the observation group were lower than those of the control at all time points,and the improvement of pain of the observation group was more obvious,so difference was statistically significant(P<0.001).(3) After intervention,the WHOQOL-BRLEF scores of the two groups increased while comparing with those before intervention(P<0.001),but the increase was more obvious in the intervention group,difference was statistically significant(P<0.001).The results showed that the content of BMD in the intervention group obviously increased,the symptoms of pain statistically alleviated or disappeared,the biochemical indexes of bone metabolism obviously decreased,and the quality of life obviously improved in the intervention group.ConclusionThe construction of pain nursing intervention mode is feasible in the pain management of elderly patients with osteoporosis in the community.It provides a useful reference for community nursing service centers to carry out patients pain health education.
【Key words】community;the elderly;osteoporosis;pain intervention
骨質(zhì)疏松癥(Osteoprosis,OP)是一種骨強(qiáng)度下降導(dǎo)致骨脆性增加和骨折危險(xiǎn)性升高的全身代謝障礙性骨骼疾病,伴有不同程度的腰背疼痛癥狀,嚴(yán)重影響中老年人的健康和生活質(zhì)量。合理、有效的疼痛干預(yù)措施可以降低或防止疼痛對(duì)機(jī)體生理、心理的一系列不良影響,促進(jìn)康復(fù)[1]。本研究在借鑒國(guó)內(nèi)外成功經(jīng)驗(yàn)的基礎(chǔ)上,設(shè)計(jì)針對(duì)OP疼痛干預(yù)模式,以骨量低下和骨質(zhì)疏松癥患者為對(duì)象,進(jìn)行隨機(jī)對(duì)照干預(yù)研究,評(píng)析其效果,為各地社區(qū)開展病人疼痛健康教育提供更有效的方法,為社區(qū)護(hù)理服務(wù)管理者提供有益的借鑒。
1資料與方法
1.1一般資料選取2014年8月至2016年4月百色市東合社區(qū)流行病學(xué)調(diào)查時(shí)發(fā)現(xiàn)的老年骨質(zhì)疏松癥患者108例為調(diào)查對(duì)象,隨機(jī)分為干預(yù)組和對(duì)照組各54例。所有患者均按照《骨質(zhì)疏松癥診斷標(biāo)準(zhǔn)》中相關(guān)標(biāo)準(zhǔn)進(jìn)行診斷,行腰椎第1~4節(jié)(L1~4)及左股骨骨密度(BMD)檢查,至少有一個(gè)部位骨密度低于同性別骨量峰值2.5個(gè)標(biāo)準(zhǔn)差或以上,均出現(xiàn)自發(fā)性疼痛,排除繼發(fā)性骨質(zhì)疏松、風(fēng)濕、腫瘤、有精神病史患者或合并其他嚴(yán)重疾病者。所有患者均意識(shí)清楚,對(duì)健康教育相關(guān)內(nèi)容能夠正確理解,并且知情同意。兩組患者的一般情況(性別、年齡、體重指數(shù)、骨密度、疼痛程度、病程等情況)比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。見表1。
1.2干預(yù)方法兩組患者每天均口服鈣劑600 mg+維生素D 800 IU,療程12個(gè)月。干預(yù)組在此基礎(chǔ)上構(gòu)建疼痛護(hù)理干預(yù)模式:(1)建立健康檔案,患者均建立家庭和個(gè)人健康檔案及骨質(zhì)疏松疾病管理檔案,定期對(duì)患者進(jìn)行隨訪和個(gè)性化指導(dǎo),親屬積極配合治療,實(shí)施社區(qū)疼痛護(hù)理干預(yù)后進(jìn)行對(duì)照。(2)疼痛曲線識(shí)別[2],目的是讓患者了解并準(zhǔn)確描述自己的疼痛,有意識(shí)讓患者主動(dòng)參與,內(nèi)容包括:①指導(dǎo)患者自我敘述疼痛的部位和范圍;②指導(dǎo)患者按視覺模擬評(píng)分法(Visual Analogue Scale,VAS)[3]對(duì)疼痛程度進(jìn)行評(píng)分,根據(jù)每天的分?jǐn)?shù)描繪整個(gè)疼痛曲線。(3)對(duì)患者及家屬同步實(shí)施疼痛知識(shí)健康教育,健康教育采取知識(shí)講座、宣傳板報(bào)、宣傳畫冊(cè)或小處方、視頻錄像等形式,使患者了解疼痛評(píng)估方法,對(duì)疼痛及止痛藥有所認(rèn)識(shí),消除對(duì)疼痛的焦慮、恐懼情緒,有利于緩解疼痛。(4)分別對(duì)患者實(shí)施心理干預(yù)、飲食干預(yù)、運(yùn)動(dòng)干預(yù)、疼痛干預(yù)。(5)藥物治療護(hù)理干預(yù),科學(xué)合理指導(dǎo)用藥,定期進(jìn)行電話隨訪或家庭訪視,提高患者服藥的依從性。
1.3觀察指標(biāo)分別比較干預(yù)前、干預(yù)后3個(gè)月、干預(yù)后6個(gè)月患者骨密度、骨代謝生化指標(biāo)、疼痛程度及生活質(zhì)量。① 疼痛程度:采用VAS尺評(píng)價(jià),0分表示無痛,10分表示難以忍受的劇烈疼痛。②BMD:用美國(guó)Hologic-2000雙能X線骨礦含量測(cè)定儀測(cè)定踝關(guān)節(jié)和膝關(guān)節(jié)的BMD值(以g/cm2表示)。③骨代謝生化指標(biāo):禁食12 h以上清晨空腹抽取靜脈血檢測(cè)堿性磷酸酶(AKP)及血鈣(Ca)。④生活質(zhì)量:干預(yù)前、干預(yù)后6個(gè)月采用世界衛(wèi)生組織生活質(zhì)量測(cè)定量表(WHO Quality of Scale,WHOQOL-BRLEF)評(píng)定兩組病人的生活質(zhì)量,包含心理領(lǐng)域、生理領(lǐng)域、社會(huì)領(lǐng)域、環(huán)境領(lǐng)域4個(gè)維度10個(gè)條目,每個(gè)維度均為100分,得分越高表明生活質(zhì)量越好。
1.4統(tǒng)計(jì)學(xué)方法使用SPSS 11.0軟件進(jìn)行數(shù)據(jù)處理,數(shù)據(jù)以均數(shù)±標(biāo)準(zhǔn)差(±s)表示,組間數(shù)據(jù)比較采用兩獨(dú)立樣本均數(shù)t檢驗(yàn),治療前后比較采用配對(duì)t檢驗(yàn),檢驗(yàn)水準(zhǔn):α=0.05,雙側(cè)檢驗(yàn)。
2結(jié)果
2.1兩組干預(yù)前后骨密度、骨代謝相關(guān)生化指標(biāo)比較結(jié)果顯示,干預(yù)后6個(gè)月,干預(yù)組的踝關(guān)節(jié)與膝關(guān)節(jié)BMD值較干預(yù)前顯著升高,差異有統(tǒng)計(jì)學(xué)意義(P<0.001),而對(duì)照組分值差異無統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后6個(gè)月干預(yù)組AKP明顯升高,與干預(yù)前比較差異有統(tǒng)計(jì)學(xué)意義( P<0.001) ,而對(duì)照組稍有改善,但前后比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05);干預(yù)后6個(gè)月兩組血Ca值均有下降(P<0.05或0.01),但干預(yù)組下降更明顯(P<0.001)。見表2。
2.2兩組患者干預(yù)前后腰背部的VAS評(píng)分改善情況比較結(jié)果顯示,兩組患者在干預(yù)后3個(gè)月、干預(yù)后6個(gè)月的VAS評(píng)分呈下降趨勢(shì)(P<0.01),但觀察組各時(shí)間點(diǎn)均低于對(duì)照組,疼痛改善更為明顯,差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。見表3。
2.3兩組患者干預(yù)前后WHOQOL-BRLEF評(píng)分比較兩組患者干預(yù)后的WHOQOL-BRLEF評(píng)分均比干預(yù)前升高(P<0.001),但干預(yù)組升高更明顯,差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。見表4。
3討論
隨著人口老齡化,骨質(zhì)疏松的患病率也日益增加,成為一個(gè)全球性的公共健康問題[4],相關(guān)數(shù)據(jù)顯示,95%以上老年骨折患者均有不同程度骨質(zhì)疏松或骨密度降低等基礎(chǔ)疾病,由此引發(fā)的疼痛、駝背、脆性骨折等癥狀可導(dǎo)致病人殘疾、失能,降低生活質(zhì)量[5]。隨著對(duì)常見慢性疾病防治的重視,社區(qū)衛(wèi)生服務(wù)在慢性病的管理模式方面進(jìn)行了越來越多的研究[6]。探索符合我國(guó)國(guó)情的社區(qū)疼痛護(hù)理干預(yù)模式,更好地推廣社區(qū)護(hù)理服務(wù)工作,將是今后社區(qū)工作的重點(diǎn)。
研究結(jié)果顯示,通過心理護(hù)理、飲食指導(dǎo)、運(yùn)動(dòng)指導(dǎo)、疼痛評(píng)估與干預(yù)、藥物治療等干預(yù)模式的實(shí)施,干預(yù)組患者骨密度含量及骨代謝相關(guān)生化指標(biāo)較干預(yù)前明顯增加(P<0.001),實(shí)施骨質(zhì)疏松疼痛護(hù)理干預(yù)后,干預(yù)組VAS評(píng)分顯著低于對(duì)照組及干預(yù)前,WHOQOL-BRLEF評(píng)分較干預(yù)前明顯提高,表明該干預(yù)措施對(duì)降低骨質(zhì)疏松患者疼痛和提高生活質(zhì)量具有重要意義,對(duì)患者康復(fù)有較大幫助。通過對(duì)社區(qū)老年性骨質(zhì)疏松患者進(jìn)行疼痛干預(yù),讓患者主動(dòng)參與健康教育,指導(dǎo)其如何進(jìn)行自我評(píng)估疼痛程度,掌握疼痛知識(shí)與技能,提高其自護(hù)能力,并減少鎮(zhèn)痛與止痛劑的應(yīng)用,在一定程度上緩解患者的精神壓力與經(jīng)濟(jì)負(fù)擔(dān)。
目前我國(guó)康復(fù)治療的開展范圍相對(duì)較少,特別是對(duì)于長(zhǎng)期腰背疼痛者康復(fù)治療尚未普及[7~8],所以本研究的開展具有廣闊的運(yùn)用前景,同時(shí)具有重要的現(xiàn)實(shí)意義。上述針對(duì)OP實(shí)施的疼痛干預(yù)模式,骨質(zhì)疏松帶給患者的疼痛程度得到了有效緩解,骨密度增加,能有效消除患者不良情緒,生活質(zhì)量明顯提高,效果良好,可為OP的疼痛防治提供借鑒和參考。應(yīng)有效動(dòng)員社區(qū)內(nèi)更多的老年OP患者參與到項(xiàng)目中來,使他們也能從項(xiàng)目中獲益。此外,骨質(zhì)疏松腰背部疼痛因治療困難、療程長(zhǎng)、容易復(fù)發(fā)的特點(diǎn),已成為現(xiàn)代社會(huì)難以醫(yī)治的痼疾,疼痛的改善過程較漫長(zhǎng),并且受到許多因素的影響,隨訪追蹤尚有待于進(jìn)一步研究。
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(收稿日期:2018-08-29修回日期:2018-10-16)
(編輯:潘明志)