| BACKGROUNDChronic non-communicable diseases have been a major public issue, currently85%of the deaths are caused by chronic diseases in our country. The morbidity of Chronic non-communicable diseases in the elderly population is91.7%, and mortality of the total mortality accounted for it is84.3%. High incidence of chronic diseases are closely related with irrational dietary structure, poor physical activity, smoking, alcohol and other bad habits. Nutrition plays an important role in the development of chronic diseases, malnutrition is an important factor in high mortality in elderly patients with chronic diseases, but because of poor nutrition focus on elderly patients with chronic diseases in clinical, nutrition risk screening mechanisms are inadequate, there are no clear evidence-based evidences for malnutrition of intervention, intervention timing and effectiveness of the intervention, resulting in elderly patients with chronic diseases during hospitalization can not accepted effective nutritional assessment and scientific nursing intervention. Elderly patients with chronic diseases or their families usually arrange empirically unrestricted diet after discharge, they can not guarantee a balanced nutritional intake for elderly patients, coupled with characteristics of such restrictions as a longer duration of chronic illness, easily repeated, comorbidities and more vulnerable to economic conditions, health care,and so on. The risk of deterioration of nutritional status could be further increased. Nutritional problems in elderly patients with chronic diseases throughout the whole period of the ill, the place extends from the hospital to the community.How to continue the care and guide patients to improve malnutrition is a new topic for nursing.In order to meet the growing medical needs and reduce health care burden of the elderly (chronic) patients, the study on the transitional care began in the1980s. In recent decades, with a lot of researches and promotion of many countries and regions, the transitional care model has been extended from the hospital to home or community, by emphasizing the continuity and coordination of the patient’s care planning, which has been proven to play a positive effect on satisfaction with nursing care, the compliance of treatment after discharge, quality of life, etc, and fully reflects the importance of care for patients discharged home after rehabilitation.China mainland expert Professor Huang Jinyue from Hong Kong began to extend this model in studies on several chronic diseases from2002, we can see that the model shows its general applicability of elderly patients with chronic conditions.With the increasing number of the world’s elderly population, elderly patients with chronic diseases is growing, when a comprehensive, systematic, sustained, effective transitional care model is also becoming more and more attractived. The Omaha system which was applied on studies constructing the transitional care model that can connect the community with hospital patients care achieved positive results. Omaha system is one of the American Nurses Association recognized12standard nursing language, which concludes three parts that are the problem classification scheme, the intervention system scheme and evaluation scheme. Problem classification scheme is composed of four areas that includes environmental domain, social psychology domain, physiology domain and health-related behaviors domain. The intervention scheme formed by four areas that are health education, guidance and counseling, treatment and procedures, case management and monitoring. Effectiveness evaluation scheme includes cognitive (Knowledge), behavior (Behavior), status (Status), referred to KBS.OBJECTIVESTo establish transitional care model for elderly malnourished patients with chronic diseases from admission to the period after discharge through using Omaha system as a framework,being conducted by the KAP model, Maslow’s hierarchy of basic needs and self-efficacy theory. To explore patients’main nutrition-related problems in hospital and after discharge and nutrition demands from elderly patients with chronic diseases, discuss the personalized and continuous care that provided by nurses, and evaluate the improvement of their self-care abilities. To explore the affect of the transitional care model on the malnutrition-related problems, demands of nutrition and the nursing outcomes of the main problems in the elderly malnourished patients with chronic diseases.METHODS1To establish a transitional care model framed by Omaha System undergoing on elderly malnutrition patients with chronic malnutrition1.1MethodsBy using Omaha system as the framework, the basis of literature, guided by the KAP theory, Maslow’s hierarchy and self-efficacy theory as the theoretical basis, combined with the physiological and nutritional care needs of elderly patients with chronic diseases, and then perfected through expert advice and preliminary experiments, we established an initial formulation of transitional care models for elderly malnourished patients with chronic diseases.1.2ResultsIn this study, through reviewing literature, analyzing adverse factors related the nutritional status of elderly patients, we found the issues related to malnutrition,and categorized them into physiological domain, psychosocial domain, health-related behaviors domain and environment domain by the classification scheme,26health problems and70performance-related symptoms or signs included. Intervention system based on literature reviews and pre-experiments, consulted Omaha System intervention system, the nutritional status and disease characteristics of elderly patients, including the forms of education, counseling and guidance, treatment and procedures, case management and monitoring. we executed the education on nutrition-related knowledge, evaluation of malnutrition-related care issues and monitor of status. Effectiveness evaluation reference Omaha outcome evaluation system, we evaluate the improvement by ways of knowledge on malnutrition-related problems,behavior and status. We used the knowledge about arrangement dietary questionnaire to evaluated the improvement in patients’knowledge. We evaluated the behavior changes with Cardiac diet self-efficacy scale, used the Mini Nutritional Assessment and World Health Organization Quality of Life-Brief version to reflect the malnutrition status and living conditions change. By compared the outcome trends of knowledge, dietary self-efficacy and quality of life, we could see differences between the experimental group and the control group. The transitional care model for elderly patients with chronic diseases was divided into two parts, including hospitalization and after discharge. Each part includes malnutrition-related nursing problems, intervention plans and effectiveness evaluation of the problems. In part1of the study, we focused on a standardized assessment for elderly patients with chronic diseases on admission, and developed a nutritional assessment intervention evaluation record sheets, the effectiveness of nursing care and nutritional evaluation sample flowchart for elderly patients with chronic malnutrition.2To investigate the application of the transitional model framed by Omaha System in elderly malnourished patients with chronic diseases.Chinese Health Service survey(2008) showed that among29,634elderly (≥60years) population, the prevalence of cerebrovascular disease and COPD separately ranked No.2and No.4, and the proportion of hospitalized patients with cerebrovascular disease and COPD, separately ranked No.l and No.3. Elderly stroke and COPD patients are characterized with longer duration, higher risk of relapse, illness complicated, dependent on caregivers and other characteristics, the impact of the body showed a acute high metabolic state and chronic wasting state alternately, the body state is closely with heart, brain, lung and other organ functions. Domestic and foreign research data show that the prevalence of malnutrition in elderly patients with chronic ranged from37%to78%. Studies have shown that malnutrition is an independent risk factor of poor prognosis for patients with Stroke, COPD and other chronic diseases. This study selected elderly patients with Stroke and COPD as the research object, aims to establish a viable model of care which can be applied not only the two diseases, but can be promoted into elderly patients with other chronic diseases, in order to improve the nutrition outcome.2.1MethodsConvenient sampling was used in elderly patients who undergoing Stroke and COPD were chose from one-A grade hospital from April2013to September2013. According to the result of MNA,the one who met MNA<17, with weight losing were chosen. Then the chosen patients were randomly divided into intervention group and control group, each group contents45patients with stroke and45patients with COPD. Control group patients in the hospital was implemented conventional nutrition care and health education by the responsible nurse, and accept subsequent follow-up after discharge from hospital nurses.The control group patients were implemented the transitional care model framed by Omaha System. With a comprehensive knowledge of nutrition education, guidance and counseling, meeting the dietary needs of different individuals,improving adverse symptoms/signs of nursing management. And by dynamically monitoring and evaluation the patients’ and caregivers’knowledge, behavior and status of malnutrition-related problems,we perfected the intervention content. By using diet arrange knowledge questionnaire, CDSE, MNA, WHOQOL-BREF, their nutrition knowledge, behavioral and status data were collected when they were in hospital, one week after discharge,1month after discharge, three months after discharge, six months after discharge. All data were analyzed by SPSS13.0, Descriptive statistical analysis was used to analyze baseline and nursing problems. The results of score made known the effectiveness improvement were analyzed with repeated measures ANOVA. The data of evaluation index between the two groups was analyzed by Nonparametric Test, T-test and repeated measures ANOVA.2.2Results184cases included the study,5cases of experimental group remote medical research can not continue the experiment, then turn the control group,87cases finalized in the experimental group and97cases in the control group, There have no significant differences in age, gender, marital status, educational level, comorbidities, disease diagnosis time, dental function, the primary caregiver and psychological conditions between two groups (P>0.05).Knowledge (K):There was significant differences in Food Arrangement Knowledge Questionnaire between the two group, and no significant differences at admission and the1st month after discharge(P>0.05), significant differences existed at the3rd month and the6th month after discharge(P<0.05).Behavior(B):There was significant differences between the two groups in total score of CDSE, and no significant differences at admission and the lth month(P>0.05), significant differences existed at the3rd month and the6th month after discharge(P<0.05).There was significant differences between the two groups in total score of MNA, and no significant differences at admission and the lth month(P>0.05), significant differences existed at the3rd month and the6th month after discharge(P<0.05).The total score of the quality of life and its other areas compare significant differences between the two groups, and which had significant differences at the first month after discharge, the third month after discharge and the6th month after discharge (P<0.05).There are633malnutrition-related nursing problems about patients in experimental group during hospitalization, and each patient with7.28nursing problems on average, the physiological nursing problems are the most(488,70.77%), then are the health-related behavior nursing problems(104,16.43%), social psychological nursing problems(17,10.11%) and environmental nursing problems(10,2.69%). There are629malnutrition-related nursing problems about patients in experimental group after discharge, and each patient with7.23nursing problems on average, the physiological nursing problems are the most(319,50.72%), then are the health-related behavior nursing problems(172,27.34%), social psychological nursing problems(76,12.08%) and environmental nursing problems(62,9.86%).There are9nursing problems which occurred more than30%of the COPD patients during hospitalization, digestion-hydration(100%), respiration (100%), infection(100.00%),psychological health(71.42%), oral Health(64.29%), bowel function(54.76%), nerve-muscle-skeletal function (50.00%), physical activity(40.48%), cognitive(35.71%).Analyzing the problems,we can see that there were significant differences in all nursing outcomes (knowledge、behavior、status)(p<0.05) except the status of nerve-muscle-skeletal function. There are8nursing problems which occurred more than30%of the COPD patients after discharge, digestion-hydration(100%), respiration (100%), self-care(69.05%), physical activity(52.38%), psychological health(45.24%), nerve-muscle-skeletal function (40.48%), cognitive(35.71%), clean(35.71%).Analyzing the problems,we can see that there were significant differences in all nursing outcomes (knowledge, behavior, status)(p<0.05) except the status of self-care and psychological health.There are9nursing problems which occurred more than30%of the Stroke patients during hospitalization, digestion-hydration(100%), respiration (100%), circulation100.00%), cognitive(71.11%), nerve-muscle-skeletal function (62.22%), bowel function(55.56%), oral Health(53.33%), psychological health(50.57%), physical activity(46.67%), Poor glycemic control(31.11%). Analyzing the problems, we can see that there were significant differences in all nursing outcomes (knowledge、behavior、status)(p<0.05) except the status of nerve-muscle-skeletal function and physical activity. There are9nursing problems which occurred more than30%of the Stroke patients after discharge, digestion-hydration(100%), respiration (100%), physical activity(68.89%), psychological health(57.78%), cognitive(57.78%), nerve-muscle-skeletal function (51.11%), self-care(44.45%), dwelling(37.78%), bowel function(35.56%). Analyzing the problems,we can see that there were significant differences in all nursing outcomes (knowledge, behavior, status)(p<0.05) except the status of cognitive, self-care and dwelling. CONCLUSIONS1. The research proved that the transitional care model based on Omaha system can analysed the main nursing problems of elderly malnourished patients during hospitalization and after discharge. Assessing nursing problems, cognition behavior and conditions dynamically can reflect the effectiveness of nursing intervention. It proves that the transitional care model was scientific and clinical feasibility.2. In this study, We compared the proportion of the malnourished patients among the first onset with the non-first onset, and found that the incidence of malnutrition in patients with COPD among the first onset was8.60%, and that among the non-first onset one was91.40%. Elderly malnourished patients with Stroke in the first onset patients accounted for4.96%, the proportion of patients with non-first onset of95.04%. It confirmed that the transitional care and the monitoring of nutritional status after discharge was necessary for preventing the relapse of the diseases and deterioration of the nutritional status.3. The main nutrition-related problems of the patients during hospital and after discharge were concentrated in the domain of physiology, followed by the domain of health-related behavior. During hospitalization and after discharge, the total number of nutrition-related patient care issues were633and629, but the difference of the proportion distributed in four major domains was obvious. Problems of physical domain during hospitalization decreased from70.77%to50.72%after discharge, the problems in the health-related behavior domain increased from16.43%to27.34%, one question after discharge added. Problems in the domain of social psychology increased from10.11%to12.08%, one question after discharge added. Problems in environmental domain after discharge were significantly increased from2.69%to10.65%,2new questions added. It confirmed the necessity of design of transitional care model for elderly patients with chronic diseases. 4. Compared with conventional methods, the transitional care model based on Omaha system can improve the nutrition station, and the quality of life of elderly patients with chronic diseases. |
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