四肢肢體活動介入方案對長期呼吸器依賴病人之成效

Effectiveness of the Extremities Activities Program for Patients with Prolonged Use of Mechanical Ventilation

刁于純(Yu-Chun Diao)

指導教授 ： 羅美芳

國立臺灣大學/醫學院/護理學研究所/碩士(2019年)

https://doi.org/10.6342/NTU201903619

摘要

研究背景：長期呼吸器使用是高度資源耗用及高成本的照護方式，國內長期呼吸器使用病人逐年成長，對家庭、社會及醫療資源之分配造成相當大的衝擊。呼吸器病人長期臥床後，活動量減少，肌力減退導致日常生活活動功能受到影響，復健運動能增加活動量，使病人生活品質不論在身體功能或心理層面都獲得改善。
研究目的：本研究目的在探討四肢肢體活動介入方案對長期呼吸器依賴病人之呼吸器脫離指標、四肢肌力、日常生活活動功能和心理情緒之成效。
研究方法：本研究收案對象為北部某醫學中心之長期呼吸器依賴病人，採兩組前、後測之類實驗重複測量設計，收案期間自2017年1月至12月，以立意取樣，1月至6月先進行對照組收案，7月至12月再進行實驗組收案，取得病人同意後，對照組為維持病房常規復健活動；實驗組為接受常規復健活動和四肢肢體活動介入方案，介入措施為每天一次，每次約5~20分鐘(根據病人當時活動狀況而定)，總共10天之四肢主動活動、上肢手搖車和下肢踩腳踏車活動。兩組個案於收案當天(觀察或介入措施前一天)(T0)、收案第11天(T1) (觀察或介入措施結束後第一天)、收案第18天(T2)(觀察或介入措施結束後一週)三個時間點進行呼吸器脫離指標、四肢肌力、日常生活活動功能和心理情緒等成效指標資料收集。研究所得資料以SPSS 22.0套裝軟體進行建檔與統計分析，以描述性統計、卡方檢定(Chi-square test)及獨立t檢定(Independent t test)進行檢定，並以廣義估計方程式(generalized estimating equation, GEE)檢定兩組不同時間點之各項指標成效。
研究結果：本研究共收案53位個案，對照組25位個案，實驗組28位個案。結果顯示(1)本研究對象年齡偏大(平均¬¬¬68.96歲)，慢性病史數多(3.40個)，教育程度高中及以下程度居多，呼吸器使用天數長(29.43天)；(2)兩組個案基本屬性無顯著差異；(3)實驗組在呼吸器脫離指標得分差異皆大於對照組，然而在統計上未達顯著差異；(4)實驗組在四肢肌力得分差異皆大於對照組，在統計上達顯著差異；(5)實驗組在日常生活活動功能(整體部分、運動部分、認知部分)得分差異皆大於對照組，在統計上達顯著差異；(6)兩組於訓練結果有顯著差異，實驗組有更多個案達到坐床邊及以上的能力；(7)實驗組在心理情緒得分差異皆大於對照組，然而在統計上未達顯著差異；(8)實驗組在情緒困擾程度個案數變化之於對照組，在統計上未達顯著差異。
結論：整體而言，10天四肢肢體活動介入能提升病人的四肢肌力、日常生活活動功能及復健訓練結果，且成效在介入方案結束一週後仍能繼續維持，但在呼吸脫離指標及心理情緒則無。建議臨床護理師可將四肢肢體活動列入常規護理或於會客時間邀請家屬一同參與病人之肢體活動，除了能透過肢體接觸，增進家屬與病人間的情感交流，也能讓病人獲得實質的幫助。

關鍵字

長期呼吸器使用 ； 復健運動 ； 日常生活活動功能 ； 心理情緒

並列摘要

Background. Prolonged use of mechanical ventilation is a care mode involving high energy consumption and costs. In Taiwan, the number of patients requiring prolonged mechanical ventilation increases every year, leading to a rather high impact on families, the society, and medical resource allocations. Patients who are supported by mechanical ventilation have reduced physical activity and compromised muscle strength after staying in bed for a prolonged period, which impacts their daily activities. Rehabilitation exercises help increase physical activities, bringing improvements to the quality of life, physical functions, and psychological aspects of patients.
Objectives. This study aims to understand the effectiveness of the extremities activities program in relation to the weaning parameter, extremity muscle strength, activities of daily living functions, and psychological-emotional status of patients with prolonged use of mechanical ventilation.
Methods. The study subjects were patients from a medical center in Northern Taiwan relying on mechanical ventilators. A quasi-experimental with repeated measures design was developed and implemented with a study period ranging from January to December, 2017. The study applied purposive sampling, which was first carried out with a control group between January and June and then with an experimental group between July and December. After acquiring consent from patients, the study led the control group to continue their regular rehabilitation exercises and the experimental group to undergo regular rehabilitation exercises plus the extremities activity intervention. The intervention program consisting of active extremities exercises, upper-extremity rowing exercises, and lower-extremity biking exercises, was 5 to 20 minutes at a time and once a day. These were implemented for a total of 10 days. The outcome indicators, including the weaning parameter, extremity muscle strength, activities of daily living functions, and psychological-emotional status of the subjects of each study group, were collected at three time points: before the first day (T0), on day 11 (T1), and day 18 (T2) of starting the observation or implementing the intervention program. The data were analyzed by SPSS 22.0 software. Data were analyzed through descriptive statistics using Chi-square test and Independent t test. The effectiveness of each indicator was tested using generalized estimating equation (GEE) on the two groups at different time points.
Results. The study collected a total of 53 cases comprised of 25 from the control group and 28 from the experimental group. The results showed that (1) the study subjects were elderly (aged 68.96 years old on average) with many chronic conditions (3.40 on average); most had a high school education or less and their use of mechanical ventilation was long (29.43 days); (2) the basic characteristics of the subjects between the two groups were not significantly different; (3) the differences in the weaning parameter scores were all greater in the experimental group compared to those in the control group; yet, the difference between the two groups was not statistically significant; (4) the differences in the muscle strength scores were all greater in the experimental group compared to those in the control group; the difference between the two groups was statistically significant; (5) the differences in the activities of daily living functions (overall function, physical function, and cognitive function) scores were all greater in the experimental group compared to those in the control group; the difference between the two groups was statistically significant; (6) the outcomes of the two groups were significantly different, with the experimental group showing more cases in which subjects were able to sit up on the edge of the bed; (7) the differences in the psychological-emotional status scores were all greater in the experimental group compared to those in the control group; yet, the difference between the two groups was not statistically significant; and (8) the number of cases experiencing psychological-emotional changes was not significantly different between the experimental group and the control group.
Conclusion. In summary, 10 days of extremities activity intervention could increase patients’ extremity muscle strength, activities of daily living functions, and rehabilitation outcomes. The effects persisted one week after the end of the intervention program. However, no statistical differences were observed for the weaning parameter and psychological-emotional status. It is recommended that nurses include extremities activities as a regular nursing activity or invite family members to participate together with the patient during the activities, which, through body contact, not only facilitates psychological-emotional exchanges between the family member and patient but also offer substantial aid to the patient.

並列關鍵字

prolonged use of mechanical ventilation ； rehabilitation exercises ； activities of daily living functions ； psychological-emotional status

參考文獻

Lee, M. B., Liao, S. C., Lee, Y. J., Wu, C. H., Tseng, M. C., Gau, S. F., & Rau, C. L. (2003). Development and verification of validity and reliability of a short screening instrument to identify psychiatric morbidity. Journal of the Formosan Medical Association, 102(10), 687-694.

Chen, Y. H., Lin, H. L., Hsiao, H. F., Chou, L. T., Kao, K. C., Huang, C. C., & Tsai, Y. H. (2012). Effects of exercise training on pulmonary mechanics and functional status in patients with prolonged mechanical ventilation. Respiratory Care, 57(5), 727-734. doi:10.4187/respcare.01341

中文文獻

2016年度全民健康保險醫療統計摘要‧取自https://www.mohw.gov.tw/dl-41030-48dcbe17-223a-474d-8f1c-e33d88e28ff2.html

吳清平、楊式興（2012年11月）・臺灣呼吸器長期使用概況・醫療爭議審議報導:系列51取自http://www.mohw.gov.tw/dmc/admin/UpFile/Period51/1_%E5%8F%B0%E7%81%A3%E5%91%BC%E5%90%B8%E5%99%A8%E9%95%B7%E6%9C%9F%E4%BD%BF%E7%94%A8%E6%A6%82%E6%B3%81.pdf