| BackgroundStroke, also known as cerebrovascular accident, is a chronic non-communicable disease with high rate of prevalence, morbidity, mortality and recurrence. According to the China2011report of cardiovascular disease, only1million patients diagnosis with stroke discharged in1980, which more than200million patients in2008, and nearly increased at an annual rate of9%.Constipation is one of the most common and severe complications after stroke. In recent years, domestic and international researches have showed that incidence of post-stroke constipation was up to30%to60%.Causes of post-stroke constipation are diverse and complex, while constipation occurring, intracranial pressure will increase due to excessive force defecation, which aggravates illness and affect the patient’s recovery and prognosis, in addition, which affect the patients’ quality of life, for serious patient and even life-threatening illness. Post-stroke constipation is a major cause of death in the elderly, for their family and society which bring heavy burden. Post-stroke Cognitive Dysfunction (PSCD) is fairly common, according to statistics, more than half of stroke patients with cognitive dysfunction. The so-called cognitive dysfunction, including the following aspects:memory impairment, aphasia, loss of use, agnosia, visual-spatial perception syndrome, etc. PSCD will seriously influence the orderly’s health, is also the important factors influencing the recovery. At present most of the research that the occurrence of post-stroke constipation is associated with brain injury factors and cognitive function, but there is less research on the correlation. On the nursing of post-stroke constipation patients, nurses are reliance on individual experience. Although individual research report that for patients with post-stroke constipation are adopted behavior intervention, while the content is not comprehensive, the operation process is not standard and evaluation index is not clear.Based on the current research situation, this study is to investigate the incidence of post-stroke constipation, to explore the relationship of post-stroke constipation and cognitive function, to improve the attention of medical workers and guide the rehabilitation of patients, which has important clinical significance. Then according to the result of the investigation and related literature review, we formulate three intervention methods, and evaluate the influence of different intervention in patients with defecation situation, cognitive function and ADL. That provide reference basis for clinical nursing.Objectives1. To know about defecation situation cognitive function in patients with post-stroke constipation, and further analysis the relationship between post-stroke constipation and cognitive function.2. Evaluate the influence of different intervention in patients with defecation situation, cognitive function and ADL. MethodsThe study is divided into two parts:Part ⅠThe research adopts the cross-sectional survey research design method, through self-designed questionnaire,764cases of stroke patients was investigated. To know about basic information, defecation situation, medical history, stroke condition, as well as cognition of patients with post-stroke constipation. To explore constipation and cognitive function in patients with post-stroke constipation, further analysis their relationship. To improve the attention of medical workers and guide the rehabilitation of patients, which has important clinical significance.1.1Study population:Take the convenience sampling method, in December2010to July2011764patients with stroke was collected in10hospitals of Guangzhou.1.1.1Inclusion criteria(1)Patients who conforms to the diagnosis of stroke (Stroke was defined according to the World Health Organization criteria and confirmed by CT scan or MR image);(2) Patients whose cognitive impairment must occur after stroke;(3) Patients who is conscious;(4) Patients who can cooperate with the investigators.1.1.2Exclusion criteria(1) History of structural diseases in the rectum or colon;(2) History of severe liver or kidney diseases, and malignant tumor;(3) Personal or family history of mental disorders;(4)Suffering from other brain diseases and spinal cord diseases such as Parkinson’s disease, multiple system degeneration, senile dementia, etc;(5) Failed to cooperate. 1.2Research methods:questionnaire and interview method. The questionnaire included:(1)General data Including gender, age, country of origin, education background, marital status, medical expenses, long-term caregivers, etc.(2)Past history Including diabetes, hypertension, coronary heart disease, hyperlipidemia, TIA history, smoking history and drinking history.(3)Stroke condition Including stroke type, stroke frequency, stroke period, lesions number, lesion location.(4)Defecation situation According to the Roman Ⅲ standards.(5)The cognitive function Mini-mental state examination.Part Ⅱ2.1Research objects:Different nursing interventions were given to90patients with post-stroke constipation that was enrolled in August2012to March2013from two stroke unit of tertiary general hospital in Guangzhou City.2.1.1Inclusion criteria:(1) Aged from18to80, male or female;(2) Diagnosis of stroke;(Stroke was defined according to the World Health Organization criteria and confirmed by CT scan or MR image.)(3) Diagnosis of constipation (According to the Roman III standards);(4) First attack of stroke and admission within7days of stroke onset;(5) Stable vital signs, no severe mental retardation;(6) All patients informed consent, and voluntarily joined this research project.2.1.2Exclusion criteria:(1) History of structural diseases in the rectum or colon or constipation;(2) History of severe liver or kidney diseases, and malignant tumor;(3) Suffering from other brain diseases and spinal cord diseases such as Parkinson’s disease, multiple system degeneration, senile dementia, etc;(4)Indwelling stomach tube, liquid diet;(5)Selected before other clinical trials may affect the results of those;(6)Pregnant women;(7)Who does not meet the inclusion criteria, not according to stipulations method treatment, unable to judge the curative effect or information is not complete.2.2The research contentThe research object were randomly divided into three groups by using random number table, respectively was control group (conventional nursing), behavior group (behavior intervention, conventional nursing) and cognitive behavior group (cognitive therapy, behavior intervention and conventional nursing).Even five days were a treatment course, between two treatment courses is separated on2nd,altogether observes two treatment courses. The changes of constipation symptoms, cognitive function and ADL, the improvement of clinical results in patients before and after intervention are observed.2.2.1Intervention method(1) The control groupAccording to the latest clinical nursing practice guide that the national ministry of health and the general logistics department of the ministry of health issued,the routine nursing care were implemented in patients with constipation on the basis of the clinical routine treatment, mainly through the health education guidance form, such as guide patients to increase crude fiber food intake, appropriately increase water quantity, encourage the appropriate movement and abdominal massage, regular bowel movement everyday, provide bowel movement environment and plenty of defecation time.If patients didn’t have to defecate within2-3days after illness, glycerine enema injection was given according to nursing routine.While patients still no defecate for more than3days and the above measures were invalid, if condition to allow and that may solve by hand.Generally didn’t use a laxative or enema treatment. But because of the lack of follow-up evaluation and tracking, health education became a mere formality, the effect was poor, the majority of patients still rely on glycerine enema injection.(2) The behavior groupOn the basis of routine nursing, first of all, we changed the way of diet guide and bowel movement behavior. Secondly, we made the systematic behavior intervention, such as the early rehabilitation exercise guidance, abdominal breathing training, and crissum massage abdomen, psychological intervention, etc. these were more operability for patients, and improved patients’ compliance.(3) The cognitive behavior therapy groupProphase survey found that cognitive impairment had a certain impact on the occurrence of constipation after stroke, especially in the directional power, memory, attention, and speech communication. Therefore, on the basis of behavior intervention and conventional nursing we made personalized guidance on cognitive function training for patients and made them focus on gastrointestinal function.2.3The evaluation method2.3.1Main evaluation index(1) Constipation symptom integral(2) Effect assessment2.3.2Secondary evaluation index(1) Mini-mental State Examination (MMSE)(2) Barthel index (BI)Part ⅢData analysis All statistical data were analyzed by using statistical software SPSS13.0. Measurement Data was expressed as Mean±S.D. Statistical significance was determined in a multiple comparisons among different groups of data if homogeneity of variance using One-way ANOVA, group multiple comparisons using the LSD method. Among the three groups after the intervention of the constipation symptom integral, MMSE and BI in scores were compared by using repeated measurements factor analysis of variance, determine the efficacy of rank conversion of non-parametric tests (the Kruskal-Wallis H test). Using correlation analysis to discusses the correlation between constipation symptom integral, MMSE score and BI score. P value<0.05was considered to be significant.Results1. Based on convenience sampling in this research. We sent764questionnaires. The valid questionnaires were723and the effective rate reached94.63%. Data of723patients were analyzed using method of statistics. The incidence of post-stroke constipation was34.6%,during31.0%in ischemic stroke,44.8%in hemorrhagic stroke,47.4%in cerebral hemorrhage and infarction, there was statistics significance between stroke type (X2=12.369, P=0.002),and ischemic stroke had statistical significance compared to other two types(P<0.05).Compared with ischemic stroke, the incidence of the hemorrhagic, mixed stroke is2.289,3.003times respectively. During the acute phase reached41.6%, the recovery phase31.5%and the sequelae phase22.6%,there is statistically significant among them.(X2=24.421, P<0.001).In terms of stroke position, the incidence of constipation in patients with thalamus lesion is higher than without thalamus lesion. Compared with normal, the incidence of constipation in patients with basal ganglia lesion is2.148times (OR=2.418,95%CI1.7363.369). Compared with single lesion, multiple lesions was2.017times (OR=2.017,95%CI1.4082.890). 2. The incidence of PSCD after stroke was62.4%.during60.4%in ischemic stroke,65.2%in hemorrhagic stroke,76.6%in cerebral hemorrhage and infarction, a difference that was not statistically significant (X2=5.459, P=0.065). During the acute phase reached63.4%, the recovery phase57.0%and the sequelae phase65.1%, which was not statistically significant(X2=2.803, P=0.246). A statistical difference was found in age, educated level, caregivers, hyperlipidemia and history of TIA.3. the rates of constipation patients with cognitive dysfunction (74%) were higher than patients without cognitive dysfunction (56.24%), there was statistics significance between two groups (P<0.05).And the difference especially in directional force (P<0.001), memory (P=0.001), attention and calculation force (P<0.001), reading (P<0.001) and expression (P<0.001) was statistically significant respectively (P<0.001), during expression was the most relevant. The difference in the incidence of constipation among different cognitive dysfunction groups was statistically significant (P<0.001), and them are were positive correlation, compared with normal cognitive function, the light, medium and severe cognitive dysfunction is1.519,2.879,3.064times respectively.4. The influence of nursing intervention in patients with post-stroke constipationThere are90patients whereas78finished the whole research and12lost. Results of78patients were involved in the result analysis. Before the intervention, there were no difference among age, gender, disease duration, type of stroke and clinical symptoms before treatment in the three groups of patients selected (P>0.05) and it was compatible.(1) Comparison of constipation symptom integral and effect evaluation among three groups1) After the intervention, based on the analysis of the variance on constipation symptom integral of three groups, the control group, behavior group and cognitive behavior group were significantly different(P<0.05);behavior group and cognitive behavior group were significantly different(P<0.05).The behavior group and cognitive behavior group have obvious curative effect on improving of costive symptoms after the stroke, and the curative effects of cognitive behavior group are clearly superior to the behavior group.2) Compared to its total curative effect respectively after one course of treatment and two courses of treatment, the curative effect of two courses of treatment is better than one course of treatment; The behavior group and cognitive behavior group are more effective than the control group(P<0.05).The behavior group and cognitive behavior group have not significantly difference in effective rate(P>0.05),and their effective rate were higher than the control group (P<0.05).The efficacy of the behavior group and cognitive behavior group is better than control group in the short term. The behavior group and cognitive behavior group can shorten the overall treatment time of patients. Of course, these results may not reflect the whole because our sample size is too small.(2) Comparison of patients’ MMSE among three groupsBefore the intervention, there are no difference in MMSE before treatment among the three groups of patients selected (F=0.004, P=0.996).After the intervention, based on the repeated measurements factor analysis of the variance on MMSE of three groups, the comparison difference of MMSE score on different time points within each group has statistical significance(F=117.712,P<0.001),and the MMSE score of two courses of treatment is better than one course of treatment (P<0.05). It presents the three groups have certain curative effect on improving of MMSE for patients with PSCD. But the comparison difference of MMSE score between three groups there was no statistically significant difference(F=0.128, P=0.880); There is not interaction effect.Which may be associated with follow-up time, so the longer follow-up study is worthy of further doing.(3) Comparison of patients’ BI among three groupsBefore the intervention, there are no difference in BI before treatment among the three groups of patients selected (F=0.016, P=0.984). After the intervention, based on the repeated measurements factor analysis of the variance on BI of three groups, the comparison difference of MMSE score between three groups there was no statistically significant difference(F=0.352, P=0.704). But the comparison difference of BI score on different time points within each group has statistical significance(F=357.014, P<0.001).And the MMSE score of two courses of treatment is better than one course of treatment (P<0.05).There is not interaction effect.(4) The correlation analysis among the change of constipation symptom integral, MMSE scores and BI scoresThe correlation analysis results show that before and after treatment the relevant indicators score difference of the patients is relevant (P<0.05). While improving patient’s cognitive function, relieve constipation symptoms and improves their ADL.Conclusions1. The total incidence of post-stroke constipation is higher, the constipation rate in the acute phase was highest, and recovery period and sequelae period declined. Cerebral hemorrhage, bleeding merge infarction group had a significantly higher rate of constipation comparing with cerebral infarction group. That implied constipation caused by stroke may be temporary, not long-term impact on intestinal function. The more serious the illness, the more prone to constipation; Medical workers should pay close attention to patient’s intestinal function in the acute phase of stroke.2. The total incidence of PSCD is higher. The PSCD rates among different stroke types were very close, among different stroke period as well. Patient’s age, educated level, caregivers, hyperlipidemia and history of TIA were the risk factors of the PSCD.3. Constipation patients often have cognitive dysfunction, especially in patient’s orientation force, memory, attention problems and computing power, reading and expression; Incidence of constipation between different degree of cognitive impairment was statistically significant, That suggests that the more serious in cognitive impairment, the greater the occurrence risk of constipation. Medical staffs need to be alerted to the possibility that patients with impaired cognitive function may be at greater risk of constipation. The preventive and treatment measures should be emphasized in to improve patient’s cognitive function.4. To some extent, pure behavior intervention and cognitive behavior therapy in combination with behavioral interventions can improve the symptoms of post-stroke constipation compared with routine nursing methods, and the curative effect of the latter is superior to the former. The improvement of cognitive function and recovery of ADL play a promoting role in easing constipation symptoms.5. The three interventions have certain effect on improving of BI and MMSE, cognitive behavior group slightly higher than the behavior group and the control group, but the synergies of behavior with cognitive is to be observed by large sample research, the next step is still need to increase the sample size to explore. |
PDF Full Text Request