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研究生:黎小娟
研究生(外文):Hsiao Juan Li
論文名稱:整合型跨專業介入措施對髖骨骨折老年病患術後蛋白質營養狀況及功能恢復狀況之成效
論文名稱(外文):The effects of a comprehensive interdisciplinary intervention program on protein nutritional status and functional recovery among the elders with hip fracture during postoperative period
指導教授:徐亞瑛徐亞瑛引用關係
指導教授(外文):Y. I. Shyu
學位類別:博士
校院名稱:長庚大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
論文頁數:170
中文關鍵詞:髖骨骨折老人蛋白質營養狀況功能恢復狀況
外文關鍵詞:hip fractureelderlyprotein nutritional statusfunctional recovery
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營養不良在老年族群是常見的現象。過去的研究結果顯示髖骨骨折病患於術後期間補充蛋白質,可以減少合併症及住院天數。而本研究主要的目的是在探討整合型跨專業介入措施對髖骨骨折老年病患術後三個月蛋白質營養狀況及功能恢復狀況的影響。原始研究為縱貫式前瞻性的單盲隨機控制試驗,於北臺灣一所醫學中心的外傷科、骨科病房中選取符合選樣標準的髖骨骨折老年病患來作為研究對象。本研究依研究目的選取152位完成三個月追蹤的整合組(n = 79)與控制組(n = 73)髖骨骨折老年病患的資料加以分析。整合組個案乃接受「整合型跨專業介入措施」及醫院常規照護,而控制組個案則僅接受醫院常規照護。資料收集的時間點分別為出院前、出院後一個月及出院後三個月。以廣義估計方程式分析資料後,研究結果發現:(一)整合組髖骨骨折老年病患的「三頭肌皮層厚度」、「上臂肌肉中點環圍」、「血清白蛋白」、「全淋巴球計數」及「迷你營養評估量表」等蛋白質營養狀況顯著較控制組髖骨骨折老年病患為佳;(二)當髖骨骨折老年病患的蛋白質營養狀況改善時,其「日常活動」、「工具性日常活動」、「平地行走能力恢復率」及「標準化股四頭肌最大肌耐力比率」亦有顯著改善的趨勢;(三)整合組髖骨骨折老年病患與控制組髖骨骨折老年病患的功能恢復狀況無顯著差異;(四)當「營養指導方案」遵從度越高時,整合組髖骨骨折老年病患的「日常活動」、「工具性日常活動」、「平地行走能力恢復率」及「標準化股四頭肌最大肌耐力比率」有顯著增加的趨勢;(五)當「復健方案」遵從度越高時,髖骨骨折老年病患的「日常活動」、「工具性日常活動」、「平地行走能力恢復率」、「標準化股四頭肌最大肌力比率」及「標準化股四頭肌最大肌耐力比率」亦有顯著增加的趨勢。本研究的結果有助於醫療專業人員瞭解整合型跨專業介入措施對髖骨骨折老年病患術後三個月蛋白質營養狀況及功能恢復狀況的影響,以及介入措施的遵從度對髖骨骨折老年病患功能恢復狀況的重要性。建議未來的研究進一步探討蛋白質營養狀況的長期變化與介入措施成效之間的關係。
Malnutrition is a common phenomenon among elderly patients. Previous studies have shown a reduction in the medical complication rate and length of hospital stay for hip fracture patients who received protein supplementation during postoperative period. The main purpose of this study was to explore the effects of a comprehensive interdisciplinary intervention program on protein nutritional status and functional recovery among elder patients with hip fracture 3 months after surgery. The original study was a single-blind randomized controlled trial using a longitudinal prospective research design. The elderly with hip fracture were recruited from the trauma and orthopedics wards of a medical center in northern Taiwan. For the purpose of the present study, we selected 152 elderly patients with hip fracture and completed a 3-month follow-up study to the original study. Subjects in the experimental group (n = 79) received our comprehensive interdisciplinary intervention program as well as the routine care from the hospital, while subjects in the control group (n = 73) received only routine care from the hospital. The data were collected from 3 time points, the pre-discharge period, 1 month after discharge, and 3 months after discharge. These data were then analyzed using the generalized estimating equations (GEE). The findings of this study were (1) the protein nutritional status of the subjects in the experimental group, including triceps skin fold (TSF), mid-arm muscle circumference (MAMC) , serum albumin, total lymphocyte count (TLC), and mini nutritional assessment (MNA), was significantly better than from those in the control group. (2) Activities daily living (ADL), instrumental activities daily living (IADL), walking recovery rate (WR), and standardized ratio of maximum muscle endurance of quadriceps (SMEQ) among the elderly with hip fracture was significantly improved when their protein nutritional status was improved. (3) The functional recovery of the subjects in the experimental group was not significantly different from those in the control group. (4) When the adherence to the nutrition program increased, the ADL, IADL, WR, and SMEQ of the subjects in the experimental group increased significantly. (5) When the adherence to the rehabilitation program increased, the ADL, IADL, WR, SMPQ (standardized ratio of maximum muscle power of quadriceps), and SMEQ of the subjects in the experimental group also increased significantly. These findings will help health care providers to understand the effects of a comprehensive interdisciplinary intervention program on the protein nutritional status and the functional recovery of elderly patients with hip fracture 3 months after surgery. In addition, it helps us to understand the importance of adhering to the proposed comprehensive interdisciplinary intervention program for the functional recovery of the elderly with hip fracture. Further study to explore the relationship between the long-term trend of protein nutritional status and the effects of the proposed intervention is suggested.
目 錄
指導教授推薦書
口試委員會審定書
長庚大學授權書………………………………………………………… iii
誌謝……………………………………………………………………… iv
中文摘要………………………………………………………………… vi
英文摘要………………………………………………………………… viii
目錄……………………………………………………………………… xi
第一章 緒論
第一節 研究背景及重要性……………………………………………1
第二節 研究動機………………………………………………………3
第三節 研究目的………………………………………………………5
第四節 研究假設………………………………………………………6
第五節 名詞界定………………………………………………………7
第二章 文獻查證
第一節 老年人蛋白質營養不良………………………………………10
第二節 蛋白質營養狀況的評估………………………………………20
第三節 老年髖骨骨折術後的蛋白質攝取及相關研究………………26
第三章 研究方法
第一節 研究設計………………………………………………………39
第二節 概念架構………………………………………………………43
第三節 研究場所及對象………………………………………………46
第四節 整合型跨專業介入措施………………………………………47
第五節 研究工具………………………………………………………52
第六節 資料收集過程…………………………………………………60
第七節 資料分析………………………………………………………66
第八節 研究倫理的考量………………………………………………68
第四章 研究結果
第一節 研究對象之基本屬性…………………………………………70
第二節 介入措施對髖骨骨折老年病患蛋白質營養狀況之影響……76
第三節 蛋白質營養狀況對髖骨骨折老年病患功能恢復狀況之
影響……………………………………………………………83
第四節 介入措施對髖骨骨折老年病患功能恢復狀況之影響………90
第五節 介入措施的遵從度對髖骨骨折老年病患功能恢復狀況
的影響…………………………………………………………92
第五章 討論
第一節 介入措施對髖骨骨折老年病患蛋白質營養狀況之影響……99
第二節 蛋白質營養狀況對髖骨骨折老年病患功能恢復狀況之
影響……………………………………………………………101
第三節 介入措施對髖骨骨折老年病患功能恢復狀況之影響………103
第四節 介入措施的遵從度對髖骨骨折老年病患功能恢復狀況
的影響…………………………………………………………107
第六章 結論與建議
第一節 結論與護理應用………………………………………………110
第二節 研究限制與建議………………………………………………112
參考文獻
一、中文部分……………………………………………………………115
二、英文部分……………………………………………………………116

表次目錄
表2-1 老年髖骨骨折術後蛋白質補充療法介入性試驗一覽表………………33
表3-1 原始研究之介入措施方案內容的比較…………………………………40
表3-2 整合組與控制組介入措施內容之比較…………………………………50
表3-3 測量時間點及測量項目…………………………………………………65
表3-4 統計方式一覽表…………………………………………………………67
表4-1 髖骨骨折老年病患之社會人口學特性…………………………………72
表4-2 髖骨骨折老年病患之生心理特性………………………………………75
表4-3 介入措施對髖骨骨折老年病患的蛋白質營養狀況之影響……………81
表4-4 整合組和控制組的蛋白質營養狀況在不同時間點之比較……………82
表4-5 蛋白質營養狀況及介入措施對髖骨骨折老年病患的功能恢復
狀況之影響………………………………………………………………89
表4-6 整合組和控制組的功能恢復狀況在不同時間點之比較………………91
表4-7 營養指導方案的遵從度對髖骨骨折老年病患功能恢復狀況之
影響………………………………………………………………………96
表4-8 復健方案的遵從度對髖骨骨折老年病患功能恢復狀況之影響………97

圖次目錄
圖3-1 研究概念架構……………………………………………………………45
圖3-2 整合組營養評估及指導方案執行的流程………………………………51
圖3-3 原始研究流程……………………………………………………………63
圖3-4 本研究之收案流程………………………………………………………64
圖4-1 研究流程圖………………………………………………………………71
圖4-2 髖骨骨折老年病患出院後三個月內體重變化之趨勢…………………77
圖4-3 髖骨骨折老年病患出院後三個月內三頭肌皮層厚度變化之趨勢……77
圖4-4 髖骨骨折老年病患出院後三個月內上臂肌肉中點環圍變化之趨勢…78
圖4-5 髖骨骨折老年病患出院後三個月內血清白蛋白值變化之趨勢………78
圖4-6 髖骨骨折老年病患出院後三個月內血清類胰島素生長因子-1值
變化之趨勢………………………………………………………………79
圖4-7 髖骨骨折老年病患出院後三個月內全淋巴球計數變化之趨勢………79
圖4-8 髖骨骨折老年病患出院後三個月內迷你營養評估量表變化之趨勢…80
圖4-9 髖骨骨折老年病患出院後三個月內日常活動變化之趨勢……………85
圖4-10 髖骨骨折老年病患出院後三個月內工具性日常生活活動變化之
趨勢………………………………………………………………………85
圖4-11 髖骨骨折老年病患出院後三個月內平地行走能力恢復率變化之
趨勢………………………………………………………………………86
圖4-12 髖骨骨折老年病患出院後三個月內坐姿體前彎變化之趨勢…………86
圖4-13 髖骨骨折老年病患出院後三個月內標準化髖關節屈曲比率變化
之趨勢……………………………………………………………………87
圖4-14 髖骨骨折老年病患出院後三個月內標準化股四頭肌最大肌力
比率變化之趨勢…………………………………………………………87
圖4-15 髖骨骨折老年病患出院後三個月內標準化股四頭肌外展最大
肌力比率變化之趨勢……………………………………………………88
圖4-16 髖骨骨折老年病患出院後三個月內標準化股四頭肌最大肌耐
力比率變化之趨勢………………………………………………………88
圖4-17 髖骨骨折老年病患出院後三個月內「營養指導方案」及「復
健運動方案」遵從度變化之趨勢………………………………………95
附錄目錄
附錄一 基本資料問卷表………………………………………………………132
附錄二 老人憂鬱量表…………………………………………………………134
附錄三 巴氏量表………………………………………………………………135
附錄四 工具性日常活動量表…………………………………………………136
附錄五 迷你營養評估量表……………………………………………………138
附錄六 MNA使用者指引………………………………………………………139
附錄七 24小時飲食回憶表…………………………………………………144
附錄八 飲食評估及指導記錄表………………………………………………145
附錄九 復健評估表……………………………………………………………147
附錄十 復健測量項目標準手冊………………………………………………148
附錄十一 復健運動記錄表………………………………………………………151
附錄十二 同意書…………………………………………………………………152
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