专科护士主导的多学科团队在卒中急性期吞咽障碍分级管理护理实践中的应用研究

Application research of a multidisciplinary team led by specialist nurses in nursing practice of graded management of dysphagia in the acute stage of stroke

目的:探索吞咽专科护士为主导的多学科团队(MDT)在卒中急性期吞咽障碍识别和管理中的应用,并观察临床效果。方法:将符合纳入标准的急性脑卒中吞咽障碍病人共103例按便利抽样法抽取后分为对照组52例和观察组51例,所有入组病人都给予急性脑卒中常规治疗,对照组由护士在入院后进行改良洼田饮水试验,发现有吞咽障碍风险的病人给予常规饮食护理、健康教育指导及康复治疗;观察组由以专科护士为主导的MDT,团队成员包括吞咽专科护士、神经内科医师、呼吸内科医师、吞咽康复治疗师、责任护士、营养师、心理咨询师等,实施脑卒中急性期基于评估的吞咽障碍分级管理。比较两组病人吞咽障碍筛查评估落实率、吞咽功能疗效改善情况、吸入性肺炎发生率及留置胃管发生率。结果:观察组入院后首次进食进饮前(24 h)吞咽障碍风险筛查评估率为85.47%,显著高于对照组51.56%;干预14 d后,观察组病人吞咽功能显效13例,有效28例,总有效率80.39%,对照组病人吞咽功能显效9例,有效22例,总有效率59.61%;住院期间观察组病人发生2例吸入性肺炎,吸入性肺炎发生率3.92%,对照组发生8例吸入性肺炎,吸入性肺炎发生率15.38%;观察组病人留置胃管17例(33.33%),对照组留置胃管27例(51.92%)。4项指标组间比较差异均具有统计学意义(P<0.05)。结论:由专科护士主导的多学科团队对急性期卒中吞咽障碍病人实施吞咽障碍分级管理是可行的,能有效弥补临床康复治疗师短缺的问题,有利于改善卒中早期吞咽障碍病人的临床症状,同时也扩大了专科护士的工作实践范围并丰富了团队协作工作模式,推动和促进了护理专业的整体发展。

Objective:To explore the application of a multidisciplinary team(MDT)led by swallowing specialist nurses in the dysphagia identification and management in the acute phase of stroke and to observe the clinical effect.Methods:A total of 103 patients with acute stroke dysphagia who met the inclusion criteria were divided into control group with 52 cases and observation group with 51 cases according to the convenience sampling method.All patients received routine treatment for the acute phase of stroke.Patients in the control group received modified water drinking test after admission,and patients at risk of swallowing disorders received routine dietary care,health education guidance,and rehabilitation treatment.Patients in the observation group received assessment-based classification management of swallowing disorders in the acute phase of stroke by specialist nurses-led MDT,including swallowing specialist nurses,neurologists,respiratory physicians,swallowing rehabilitation therapists,responsible nurses,nutritionists,and psychological consultants,etc.The implementation rate of screening assessment for swallowing disorders,the improvement of the efficacy of swallowing function,the incidence of aspiration pneumonia,and the incidence of the indwelling gastric tube were compared between the two groups.Results:The risk screening and assessment rate of swallowing disorders in the observation group before the first eating and drinking(24 hours)after admission was 85.47%,significantly higher than that of the control group(51.56%).After 14 days of intervention,in the observation group,13 cases showed effective significantly and 28 cases showed effective in swallowing function,with a total effective rate of 80.39%.In the control group,9 cases showed effective significantly and 22 cases were effective in swallowing function,with a total effective rate of 59.61%.A total of 2 cases of aspiration pneumonia occurred in the observation group during hospitalization,with an incidence of 3.92%;8 cases with aspiration pneumonia in the control group,with an incidence of 15.38%.A total of 17 cases of gastric tube indwelling occurred in the observation group,with an incidence of 33.33%;27 cases of gastric tube indwelling in the control group,with an incidence of 51.92%.There were statistically significant differences in the four indexes between the groups(P<0.05).Conclusions:It is feasible for a MDT led by specialist nurses to implement dysphagia grading management for patients with dysphagia in acute stroke.It can effectively make up for the shortage of clinical rehabilitation therapists,help to improve the clinical outcome of patients with dysphagia in the early stage of stroke,expand the scope of work practice of specialist nurses and enrich the working mode of team cooperation,promote and promote the overall development of nursing profession.