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研究生:賴詩怡
研究生(外文):Shih-Yi Lai
論文名稱:急性腦損傷重症病患移除氣管內管後進行重複性吞嚥障礙護理篩檢處置之成效研究
論文名稱(外文):Repeated dysphagia nursing screening among acquired brain injury patients with post-extubation in the neurological intensive care unit
指導教授:林麗禪林麗禪引用關係
指導教授(外文):Li-Chen Lin
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:臨床暨社區護理研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2014
畢業學年度:102
語文別:中文
論文頁數:187
中文關鍵詞:吞嚥障礙護理篩檢
外文關鍵詞:DysphagiaNursing Screening
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研究目的:探討移除氣管內管成功之急性重症腦損傷病患,接受「重複性吞嚥障礙護理篩檢處置」後,其練習口腔進食率、鼻胃管移除率、肺炎發生率、住院日數、醫療成本之影響。
研究方法:採類實驗設計(Quasi-experimental design),以配對取樣(Paired selection sampling design)方式於台北市某醫學中心神經重症加護單位選取研究對象,收案條件為:1.病歷記載之醫學診斷及影像學符合腦中風、或創傷性腦損傷其中之ㄧ的病患。2.已計劃性成功移除氣管內管路24小時,呼吸功能穩定者。3. GCS≧13分,並且可遵從簡單指令,能維持警醒狀態至少20分鐘、能在輔助物協助下坐直坐正身軀者。4.大於20歲,能以國台客語溝通,且願意參加本研究者。5.無口腔、鼻咽、頸部、食道等解剖部位有結構異常或癌症者。6. 此次住院期間未發生中樞神經感染、或次發性腦出血、或胰臟炎、偽膜性腸炎之合併症。實驗組共收案7個月,收案數32人;對照組則以回溯病歷方法,蒐集於實驗處置開始前的前10個月的病歷資料,配對收案數32人。實驗組「重複性吞嚥障礙護理篩檢處置」依篩檢結果將病患分為三組:「灌食組」、「部分口腔進食組」、「正常口腔進食組」,而給予不同的護理處置,包含管灌飲食的補充、特殊吞嚥姿勢、特殊吞嚥法、特殊食物質第之教導,直至研究對象出院。
研究結果:「吞嚥障礙護理篩檢及處置」能使實驗組於成功移除氣管內管後,當日之口腔進食率由對照組之24%提升至58.6%,共提升34.6%,早期有效率的介入措施,也有效將實驗組鼻胃管留置日數比對照組縮短20.65天,在移除氣管內管30日內,移除鼻胃管成功率亦可由45%提升至84.21%。移除氣管內管後3~60日內肺炎發生率顯著下降21.8%。死亡率未達統計上顯著差異。住院天數方面,實驗組吞嚥障礙病患於成功移除氣管內管後的住院天數也可比對照組縮短12.75天,總住院天數更可縮短15.91天。而在成本方面:總鼻胃管灌食相關總成本每人顯著下降6511元新台幣,移除氣管內管後鼻胃管灌食相關總成本每人顯著下降4777元新台幣,移除氣管內管後醫療總成本每人顯著下降143555元新台幣。
討論與建議:「吞嚥障礙護理篩檢及處置」對病患進食吞嚥功能之評估及指導,有直接幫助吞嚥功能改善、降低醫療成本之成效,建議納入醫療常規處置。後續研究可再增加樣本數,並針對嚴重吞嚥障礙病患加強吞嚥障礙復健護理指導,以提升出院前鼻胃管移除率,以及降低進住慢性機構發生率。
Background and Purpose: Acute-onset dysphagia after acquired brain injury and post-extubatin is frequently associated with an increased risk of aspiration pneumonia. This study aims to evaluate repeated dysphagia nursing screening for prevention of pneumonia and comparison of medical cost-reduction and the length of hospital stay shortening in acquired brain injury patients in the neurological intensive care unit.

Method: Repeated dysphagia nursing screening was introduced since November 2013 and therefore acquired brain injury patients were divided into pre-screen(32) and post-screen(32) groups. The way of sampling is paired selection. The factors of paired selection were diagnosis(stroke or traumatic brain injury) and medicine (decadron or epinephrine or hydrocortisone) for laryngeal swelling.

Result: Within 30 days post-extubation, removal rate of nasogastric tube in the post-screen group elevated up to 84% than the 45% of the pre-screen group. Within 3~60 days post-extubation, pneumonia rate reduced from 28% down to 6% significantly. No statistically significance was found in mortality. The average medical cost of each post-screen patient reduced 143555 nt than the pre-screen patient significantly. Furthermore, The medical cost of enteral feeding reduced 6511 nt/1 patient during whole hospital stay and 4777 nt/1 patient post-extubation, respectively. In the last, the length of stay of each post-screen patient shortened 12.75 days than the , and 15.91 days after post-extubation, respectively.

Conclusion and discussion: Repeated dysphagia nursing screening can improve swallowing function directly, which could be used widely in the neurological intensive unit.
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中文摘要…………………………………………………………………i
英文摘要…………………………………………………….…….……iii
目錄……………………………………………………………..………iv
第一章 緒論……………………………………………………………1
第一節 研究背景與動機…………………………………………3
第二節 研究重要性………………………………………………9
第二章 文獻查證…………………………………………………...…15
第一節 急性重症腦損傷病患之氣管內管插管治療………...…18
第二節 急性重症腦損傷相關之吞嚥障礙流行病學……………25
第三節 急性重症腦損傷吞嚥神經病理變化……..……..………29
第四節 氣管內管插管治療之吞嚥障礙流行病學及合併症……37
第五節 急性重症腦損傷吞嚥障礙症狀及管路相關吞嚥障礙合併症狀綜合比較………………….……………………..…40
第六節 吞嚥神經、器官之進展變化及鼻胃管的不當延長滯留44
第七節 口咽期吞嚥障礙之臨床評估……………………………49
第八節 移除氣管內管後之急性腦損傷重症口咽期吞嚥障礙臨床護理處置…..……………………………………………60
第九節 研究架構………………………..…………….……….…79
第十節 研究假設…………………………………………………81
第十一節 名詞定義………………………………………………82
第三章 研究方法
第一節 研究設計…………………………………………………85
第二節 受試對象與場所…….…..………………….……………90
第三節 研究工具與信效度檢定…………………………………92
第四節 資料收集過程………………………………………..…101
第五節 研究步驟………………………………………………..106
第六節 研究變項之操作型定義……………………………..…107
第七節 資料分析方法………………………………………..…108
第八節 研究倫理考量………………………………………..…112
第四章 研究結果
第一節 急性重症腦損傷病患之基本屬性………………….….113
第二節 研究介入對練習由口腔進食現象之影響……………117
第三節 研究介入對鼻胃管留置之影響………………………..120
第四節 研究介入對肺炎發生率之差異………………………124
第五節 研究介入對死亡率之差異……………………………127
第六節 研究介入對住院日數之影響…………………………128
第七節 研究介入對成本效益之影響…………………………130
第八節 研究介入對病患出院後進住慢性機構之影響………132
第九節 住院天數、醫療成本之預測因子分析………………134
第五章 討論
第一節 研究結果摘要…………………………………………146
第二節 研究結果之討論………………………………………147
第三節 研究之限制……………………………………………158
第四節 研究之貢獻及應用……………………………………159
第六章 結論和建議…………………………………………………161
參考文獻
中文部分………………………………………...…….…………163
英文部分…………………………………………….…...………164
附錄
附錄一. 吞嚥檢查問卷表………….……………………………183
附錄二. 吞嚥生理檢查…………………………………..…...…186
圖目錄
圖一 呼吸協調運動………………………………………………63
圖二 聲帶內轉運動………………………………………………64
圖三 下巴內縮姿勢………………………………………………67
圖四 研究架構………………………………..…………………80
圖五 吞嚥障礙篩檢流程圖……………………………..………88
圖六 研究資料收集流程………………………………………106
圖七 兩組吞嚥障礙病患練習口腔進食起始差異日數比較…119
圖八 兩組於移除氣管內管30日內移除鼻胃管發生率比較..122
圖九 移除氣管內管後鼻胃管放置日數比較…………………123
表目錄
表一 與吞嚥生理機制直接相關的Brodmann氏大腦皮質功能區.........................................................................................30
表二 Stroke、TBI、以及氣管內管(ENDO)合併症相關之吞嚥障礙症狀發生率比較﹙單位:%﹚………………………40
表三 移除氣管內管後急性腦損傷重症口咽期吞嚥障礙之臨床護理處置比較表.………………….…………..………………73
表四 研究設計………………………..…….…………………….86
表五 資料分析的目的與統計方法……………………………109
表六 兩組研究對象基本資料屬性……………………………114
表七 兩組研究對象生理功能概況屬性比較…………………116
表八 兩組研究對象口腔進食率比較…………………………117
表九 兩組練習口腔進食起始差異日數比較…………………118
表十 兩組練習口腔進食起始差異日平均天數比較…………118
表十一 兩組吞嚥障礙病患練習由口腔進食起始差異日平均天數
比較……………………………………………………119
表十二 兩組移除鼻胃管發生率比較…………………………120
表十三 兩組於加護病房內移除鼻胃管發生率比較………….121
表十四 兩組於移除氣管內管30日內移除鼻胃管發生率比較122
表十五 兩組移除氣管內管後30日內肺炎發生率比較………124
表十六 兩組移除氣管內管後60日內肺炎發生率比較………124
表十七 肺炎相關危險因子分析………………………………126
表十八 兩組移除氣管內管後死亡率比較……………………127
表十九 兩組住院日數比較……………………………………128
表二十 兩組吞嚥障礙個案移除氣管內管後住院日數比較…129
表二十一 兩組成本比較………………………………………130
表二十二 兩組診斷吞嚥障礙曾放置鼻胃管的病人成本比較131
表二十三 兩組出院後安置處比較……………………………132
表二十四 進住機構相關危險因子……………………………133
表二十五 類別變項之基本屬性因子與總住院日數之相關性134
表二十六 總住院日數之預測因子分析………………………135
表二十七 類別變項之基本屬性因子與移除氣管內管後住院日數之相關性……………………………………………136
表二十八 移除氣管內管後住院日數之預測因子分析………137
表二十九 類別變項之基本屬性因子與普通病房住院日數之相關性……………………………………………………138
表三十 普通病房住院日數之預測因子分析………………139
表三十一 類別變項之基本屬性因子與住院期間總鼻胃管灌食相關總成本之相關性…………………………………140
表三十二 住院期間總鼻胃管灌食相關總成本之預測因子分析……………………………………………………141
表三十三 類別變項之基本屬性因子與移除氣管內管後住院期間鼻胃管灌食相關總成本之相關性…………………142
表三十四 移除氣管內管後住院期間鼻胃管灌食相關總成本之預測因子分析…………………………………………143
表三十五 類別變項之基本屬性因子與移除氣管內管後醫療總成本之相關性…………………………………………144
表三十六 移除氣管內管後醫療總成本之預測因子分析……145
表三十七 住院日數與預測因子綜合比較……………………154
表三十八 醫療成本與預測因子綜合比較………………157
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