Abstract
Objective: This study aimed at exploring the effects of early rehabilitation nursing (ERN) on the neurological functions, the incidence of lower extremity deep venous thrombosis (LEDVT) and the quality of life (QOL) of patients with ischemic stroke hemiplegia (ISH). Methods: Admitted to our hospital from January 2018 to February 2019, 123 patients with ISH were enrolled, among which 70 cases received routine nursing (a control group) and 53 cases received ERN (a study group). The patients in the two groups were compared with respect to the scores of the European Stroke Scale (ESS), the Barthel Index (BI) and the Fugl-Meyer Assessment (FMA), the incidences of complications and LEDVT, QOL and nursing satisfaction. Results: After intervention, the ESS, BI and FMA scores rose in both groups, but they were remarkably higher in the study group (P < 0.05). Compared with those in the control group, patients in the study group had remarkably lower incidences of complications and LEDVT (P < 0.05), remarkably better indicators of QOL (P < 0.05), and higher nursing satisfaction (P < 0.05). Conclusion: For patients with ISH, ERN can improve neurological functions, reduce the incidence of LEDVT, and improve their QOL, so this safe and effective nursing method is worthy of clinical application.
Keywords: Early rehabilitation nursing, ischemic stroke hemiplegia, neurological functions, incidence of lower extremity deep venous thrombosis, quality of life
Introduction
Stroke is classified into ischemic stroke (IS) and hemorrhagic stroke, among which the former is the more common type and patients with it account for 60-80% of stroke patients [1]. IS, also considered as cerebral infarction, occurs more commonly among the elderly, and has a high incidence, mortality rate, disability rate and recurrence rate [2,3]. Because of the disturbance of blood circulation, local brain tissues are necrotic after ischemia and hypoxia, and limbs suffer from different degrees of antagonistic muscle spasm [4]. Clinically, IS is manifested as a series of clinical syndromes such as unilateral or bilateral paralysis and numbness of upper and lower limbs, neurological defects, balance disturbance, facial distortion or expressive language disorders [5]. IS complicated with hemiplegia (ischemic stroke hemiplegia; ISH) is the most common complication, usually characterized by dyskinesia, balance disturbance, language disorders and dysphagia [6,7]. Due to sudden changes in physiological functions, ISH is easily complicated with negative psychology, and then patients with ISH lose confidence in life, resist treatment, and subsequently develop the psychology of anxiety, depression and suicide [8]. According to modern medicine, the central nervous system of the brain has strong plasticity, and rehabilitation exercises can promote the recovery of hemiplegic limbs, especially during the first 1-3 months of the exercises, so the untimely treatment of ISH greatly reduces the patients’ quality of daily life and abilities of activities [9].
Early rehabilitation nursing (ERN) is very important for ISH patients. On the basis of mastering the plasticity of cranial nerves tissues, through scientific and standardized rehabilitation exercises, active and effective ERN can restore and reconnect damaged neurons, and make them plasticized, thus strengthening the functional rehabilitation of nerve tissues and improving the prognosis of patients [10]. As reported by a previous study, after their vital signs are stabilized, patients with ISH are suggested to receive ERN to improve physiological functions, reverse negative psychology, and promote the recovery of neurological functions [11]. Therefore, in this study, the effects of ERN on patients with ISH were discussed. Specific reports are as follows.
Materials and methods
General information
Admitted to The First Affiliated Hospital of Chongqing Medical University from January 2018 to February 2019, 123 patients with ISH were enrolled, among which 70 cases received routine nursing (the control group) and 53 cases received ERN (the study group). The patients consisted of 59 males and 64 females with an average age of 55.72 ± 18.38 years. There were 35 cases of grade I, 63 cases of grade II, and 25 cases of grade III muscle tension in total. Inclusion criteria: (1) All included patients were diagnosed with ISH by clinical manifestations and imaging examinations. (2) The included patients were aged over 50, and their vital signs were stable and their estimated survival time was over one month. Exclusion criteria: (1) Those who were complicated with severe systemic or local infection and severe hepatic, renal, cardiac and pulmonary insufficiencies. (2) Those who suffered from coagulation disorders and psychological or mental diseases. (3) Those who were complicated with diseases related to the neuromuscular junction of the motor system. Before enrollment, the patients or their authorized persons signed the consent form. This study was approved by the ethics committee of our hospital.
Nursing methods
Within two weeks after the onset of ISH, the patients in the control group received routine nursing from the aspects of diet and life. The nursing staff strengthened psychological guidance and health education on the patients, and explained and implemented active and passive postoperative rehabilitation exercises when their symptoms were effectively relieved. Within 24 hours after the onset of the disease, the patients in the study group received the training of ERN, and were intervened when their vital signs were initially stable. (1) Psychological nursing: The generally sudden attacks of stroke and the factors such as prognosis and economic pressure easily lead to desperateness, stress, anxiety and other different degrees of negative psychology and emotions, which affect the therapeutic effects of ERN. Medical staff accurately assessed the patients’ postoperative conditions, strengthened their understanding of stroke and hemiplegia, and perfected the research on their personal characteristics and psychological states, so as to strengthen psychological support. For instance, the patients’ attention could be diverted via music, language environment, bedside education and family care. The medical staff also regularly communicated and interacted with the patients and their families, understood their true feelings, and carefully answered their questions about various diseases, so that their early negative emotions could be eliminated. After hemiplegia, effective early rehabilitation training could enhance the courage and self-confidence of the patients in treatment and rehabilitation. Besides, the most comfortable and quiet wards could be created and nursing operation could be scientifically arranged, so as to minimize the negative effects of external environment on the patients. (2) Limb function training: After the individualized plans of ERN were formulated, the nursing staff formulated scientific and feasible nursing plans and training targets according to the patients’ daily life. During the recovery period, the patients were guided to conduct isometric, standing, and walking training. They were also guided to adjust their sitting and prone positions, in order to keep the correct physiological position of the lumbar spine. During the rehabilitation training, it was suggested that the patients should be placed in a position on the unaffected side and develop the habit of turning over once every 2 hours. The nursing staff also assisted the patients to change positions intermittently. Active and passive exercises were implemented after the affected limb was fully extended. As for the hemiplegic limbs, the time of the isometric training was appropriately prolonged to avoid strephenopodia, ankylosis and foot drop. The focus of the guidance was to improve the muscle strength of the hemiplegic limbs. The nursing staff informed the patients and their families of the importance of passive massage, explained the detailed knowledge and precautions of massage action, and kept the effective local blood circulation of the affected limbs through the passive massage, thereby avoiding joint stiffness and muscular atrophy and helping the patients restore the functions of the affected limbs faster. Additionally, the correct use of toilets was explained. (3) Diet guidance: The patients were instructed to eat more food with high proteins and cellulose, and strengthen the supply of appropriate vitamins and calcium.
Outcome measures
(1) The European Stroke Scale (ESS) was used for scoring the patients’ neurological functions, with a total score of 100 points; the ESS scores are directly proportional to the neurological functions [12]. (2) Activities of daily living: Before and after discharge, the scores of the modified Barthel Index (BI) were assessed by the primary nurses; higher BI scores indicate better self-care ability [13]. (3) The Fugl-Meyer Assessment (FMA) was used to assess the motor function of limbs, and the FMA scores are directly proportional to the motor function [14]. (4) Incidence of complications: After intervention, the incidence of complications (pulmonary infection, joint stiffness, muscular atrophy, bedsore) was compared between the two groups. (5) The incidence of lower extremity deep venous thrombosis (LEDVT) was counted and compared between the two groups. (6) The World Health Organization Quality of Life: Brief Version (WHOQOL-BREF) was used to assess the patients’ quality of life (QOL), which consisted of social, environmental, physiological and psychological fields. Higher QOL scores indicate better QOL [15]. (7) Nursing satisfaction: The self-made satisfaction questionnaires of our hospital were applied to assessment from the items of hospital environment, doctor-patient communication, medical ethics, technical levels and medical expenses. Nursing satisfaction = (very satisfied + satisfied cases)/total number of cases ×100%.
Statistical processing
SPSS 20.0 was applied to data processing. Measurement data with normal distribution or approximate normal distribution were expressed as mean ± standard deviation, and compared by the two independent samples t-test. Measurement data with non-normal distribution were expressed as M (QR), and compared by the Mann-Whitney U test. The χ2 test was used for analyzing counting data. P < 0.05 was considered as statistically significant difference.
Results
Comparison of general information
There were no significant differences between the study and control groups in gender, age, course of disease and other aspects (P > 0.05) (Table 1).
Table 1.
Comparison of general information
| Groups | Control group (n=70) | Study group (n=53) | t/X2 | P |
|---|---|---|---|---|
| Gender (Cases) | 0.080 | 0.777 | ||
| Male | 33 (47.14) | 26 (49.06) | ||
| Female | 37 (52.86) | 27 (50.94) | ||
| Age (Years) | 55.56 ± 18.32 | 55.78 ± 18.39 | 0.066 | 0.948 |
| Course of stroke (Days) | 18.72 ± 3.63 | 18.38 ± 3.52 | 0.521 | 0.603 |
| Educational backgrounds (Cases) | 1.034 | 0.596 | ||
| Primary school | 17 (24.29) | 14 (26.42) | ||
| Junior and senior high schools | 42 (60.00) | 33 (62.26) | ||
| University and above | 11 (15.71) | 6 (11.32) | ||
| Hemiplegic sites (Cases) | 0.080 | 0.777 | ||
| Left | 34 (48.57) | 25 (47.17) | ||
| Right | 36 (51.43) | 28 (52.83) | ||
| Muscle tension (Cases) | 0.398 | 0.820 | ||
| Grade I | 21 (30.00) | 14 (26.42) | ||
| Grade II | 35 (50.00) | 28 (52.83) | ||
| Grade III | 14 (20.00) | 11 (20.75) | ||
| Complications (Cases) | 3.480 | 0.176 | ||
| Hypertension | 38 (54.29) | 34 (64.15) | ||
| Diabetes | 18 (25.71) | 13 (24.53) | ||
| Heart disease | 14 (20.00) | 6 (11.32) | ||
| Stroke sites (Cases) | 1.454 | 0.835 | ||
| Basal ganglia | 33 (47.14) | 26 (49.06) | ||
| Thalamus | 13 (18.57) | 11 (20.75) | ||
| Temporal lobe | 8 (11.43) | 7 (13.21) | ||
| Frontal lobe | 10 (14.29) | 5 (9.43) | ||
| Pons | 6 (8.57) | 4 (7.55) |
Comparison of ESS scores
Before intervention, there were no statistically significant differences in the ESS scores between the control group (50.93 ± 6.79) and the study group (51.31 ± 6.83) (P > 0.05). After intervention, the ESS scores in both groups rose, but those in the study group (84.34 ± 11.31) were remarkably higher than those in the control group (69.93 ± 8.19) (P < 0.05) (Table 2).
Table 2.
Comparison of ESS scores (Points)
| Groups | Control group (n=70) | Study group (n=53) | t | P |
|---|---|---|---|---|
| Before intervention | 50.93 ± 6.79 | 51.31 ± 6.83 | 0.307 | 0.760 |
| After intervention | 69.93 ± 8.19 | 84.34 ± 11.31 | 8.197 | < 0.001 |
| t | 14.940 | 18.200 | ||
| P | < 0.001 | < 0.001 |
Comparison of BI scores
Before intervention, there were no statistically significant differences in the BI scores between the control group (61.03 ± 7.97) and the study group (61.22 ± 7.93) (P > 0.05). After intervention, the BI scores in both groups rose, but those in the study group (83.23 ± 11.13) were remarkably higher than those in the control group (70.36 ± 9.38) (P < 0.05) (Table 3).
Table 3.
Comparison of BI scores (Points)
| Groups | Control group (n=70) | Study group (n=53) | t | P |
|---|---|---|---|---|
| Before intervention | 61.03 ± 7.97 | 61.22 ± 7.93 | 0.131 | 0.896 |
| After intervention | 70.36 ± 9.38 | 83.23 ± 11.13 | 6.951 | < 0.001 |
| t | 6.342 | 11.730 | ||
| P | < 0.001 | < 0.001 |
Comparison of FMA scores
Before intervention, there were no statistically significant differences in the FMA scores between the control group (43.23 ± 5.34) and the study group (43.62 ± 5.42) (P > 0.05). After intervention, the FMA scores in both groups rose, but those in the study group (71.42 ± 6.92) were remarkably higher than those in the control group (62.42 ± 6.73) (P < 0.05) (Table 4).
Table 4.
Comparison of FMA scores (Points)
| Groups | Control group (n=70) | Study group (n=53) | t | P |
|---|---|---|---|---|
| Before intervention | 43.23 ± 5.34 | 43.62 ± 5.42 | 0.399 | 0.691 |
| After intervention | 62.42 ± 6.73 | 71.42 ± 6.92 | 7.256 | < 0.001 |
| t | 18.690 | 24.990 | ||
| P | < 0.001 | < 0.001 |
Comparison of incidence of complications
The incidence of complications in the study group was 3.77% (2/53), which was remarkably lower than 14.29% (10/70) in the control group (P < 0.05) (Table 5).
Table 5.
Comparison of incidence of complications [n (%)]
| Groups | Control group (n=70) | Study group (n=53) | X2 | P |
|---|---|---|---|---|
| Pulmonary infection | 3 (4.29) | 1 (1.89) | - | - |
| Joint stiffness | 4 (5.71) | 0 | - | - |
| Muscular atrophy | 1 (1.43) | 0 | - | - |
| Bedsore | 2 (2.86) | 1 (1.89) | - | - |
| Incidence of complications | 10 (14.29) | 2 (3.77) | 6.105 | 0.014 |
Comparison of incidence of LEDVT
The incidence of LEDVT was 1.89% (1/53) in the study group and 18.57% (13/70) in the control group. The incidence of LEDVT was remarkably lower in the study group (P < 0.05) (Table 6).
Table 6.
Comparison of incidence of LEDVT
| Groups | Control group (n=70) | Study group (n=53) | X2 | P |
|---|---|---|---|---|
| incidence of LEDVT | 13 (18.57) | 1 (1.89) | 15.381 | 0.05 |
Comparison of QOL
The scores of each indicator in the WHOQOL-BREF and the total QOL scores were remarkably better in the study group than those in the control group. The QOL scores were 58.39 ± 10.28 in the study group and 44.23 ± 8.93 in the control group (P < 0.05) (Table 7).
Table 7.
Comparison of QOL (Points)
| Groups | Control group (n=70) | Study group (n=53) | t | P |
|---|---|---|---|---|
| Physiological field | 10.37 ± 2.34 | 14.23 ± 2.79 | 8.336 | < 0.001 |
| Psychological field | 11.15 ± 2.73 | 14.12 ± 2.68 | 6.022 | < 0.001 |
| Social field | 11.09 ± 2.69 | 13.92 ± 3.02 | 5.479 | < 0.001 |
| Environmental field | 11.62 ± 2.10 | 13.99 ± 3.04 | 5.111 | < 0.001 |
| Total scores | 44.23 ± 8.93 | 58.39 ± 10.28 | 8.157 | < 0.001 |
Comparison of nursing satisfaction
The nursing satisfaction of the patients was 98.11% (52/53) in the study group and 87.14% (61/70) in the control group. The nursing satisfaction was remarkably higher in the study group (P < 0.05) (Table 8).
Table 8.
Comparison of nursing satisfaction [n (%)]
| Groups | Control group (n=70) | Study group (n=53) | X2 | P |
|---|---|---|---|---|
| Very satisfied | 37 (52.86) | 42 (79.25) | - | - |
| Satisfied | 24 (34.29) | 10 (18.87) | - | - |
| Dissatisfied | 9 (12.86) | 1 (1.89) | - | - |
| Nursing satisfaction | 61 (87.14) | 52 (98.11) | 8.721 | 0.003 |
Discussion
Surgery and drugs are mostly used to treat stroke. After the onset of IS, patients with the disease may suffer from dyskinesia and expressive language disorders, and most patients who have undergone surgery still experience the dysfunction of consciousness, language and movement, which seriously affects their daily life [16]. Hemiplegia is a common complication of IS. ISH may be greatly related to the fact that the ischemia or hypoxia of the central nervous system after the onset softens brain tissues and then causes damage to the cerebral nervous system. Additionally, the long-term bedridden induced by hemiplegia may result in the reduced ability of muscle protein synthesis and even different degrees of bone loss, which is considered to affect the prognosis of patients [17,18]. According to related research, nervous compensation promotes the regeneration of neurons and the recovery of limb functions, thus reducing negative emotions [19]. Early rehabilitation training can avoid muscular atrophy and joint stiffness that are caused by the hemiplegia-induced long-term bedridden, so it is a scientific and reasonable nursing model [20]. Therefore, in this study, patients with ISH were included, and given routine nursing and ERN for comparison, in order to observe their prognoses after interventions.
The recovery of neurological functions is crucial to patients with hemiplegia that is caused by cranial nerve injury. Therefore, we counted the ESS scores of the patients after intervention, and found that the scores were higher in the study group compared with the control group. As reported by previous studies, hemiplegic patients can conduct early rehabilitation training based on the plasticity of the central nervous system, which promotes the formation of new synapses and stimulate the repair and regeneration of cells. The rehabilitation nursing of limb movement, physiology and language can contribute to the recovery of brain functions. The repeated activities of affected limbs can stimulate cerebral cortex, promote the recovery of reflex function, and shorten the recovery time of consciousness, language and motor functions. Additionally, the combination with nervous compensation can repair and regenerate some damaged tissues, cells and neurons, alleviate the hypoxia and ischemia that is caused by the long-term damage to the microcirculation of the central nervous system, and promote the recovery of cell functions, eventually completing the functional reconstruction of non-damaged areas [21,22]. These findings suggest that on the basis of the regeneration ability and high plasticity of central nervous system tissues, rehabilitation training in the early stage of ISH contributes to the recovery of neurological functions. Furthermore, it is of positive significance for promoting the recovery of nervous system functions in stroke patients to strengthen health education, conduct ERN based on the patients’ characteristics, and relieve their pessimistic and negative psychology, as well as improve their confidence in rehabilitation and training cooperation [23]. The activity of daily living of hemiplegic patients is affected by the damage severity of their neurological and motor functions and by their later recovery. In our study, the BI scores were better and the FMA scores were remarkably higher in the study group, compared with those in the control group. ERN is performed on patients after their postoperative physical conditions are basically stabilized, to evaluate various aspects of them and formulate individualized exercise rehabilitation programs, which are instructed and implemented by rehabilitation therapists; the therapists should keep on observing ECG monitors to ensure the safety of rehabilitation training, which amount should be gradually increased within the patients’ tolerance range [24]. Accordingly, the implementation of scientific exercise plans is helpful in restoring the motor capacity of patients with ISH.
After intervention, the incidence of complications in the study group was lower than that in the control group, which reveals that ERN prevents the occurrence of avoidable complications. Clinical attention is highly paid to the incidence of LEDVT in patients with ISH, and the occurrence of thrombosis largely determines the prognosis of the patients. In this study, the incidence of LEDVT was lower in the study group compared with the control group. The implementation of each rehabilitation plan, which is formulated based on early rehabilitation training, can accelerate the blood flow velocity of heart, restore myocardial blood supply in time, and dilute blood. Moreover, these effects promote blood circulation, balance endothelium-derived contracting and relaxing factors, and improve cardiac and body functions rapidly, as well as effectively avoid the occurrence of venous thrombosis [25]. This is quite consistent with the conclusions of this study. Finally, in our study, the QOL and the nursing satisfaction in the study group were better than those in the control group. This suggests that postoperative ERN is markedly effective for patients with ISH, and that it can promote the improvement of the two indicators, so it is worthy of clinical promotion.
In summary, for patients with ISH, safe and effective ERN can improve neurological functions, reduce the incidence of LEDVT, and improve QOL. In this research, we focused on the way of ERN to restore and improve the neurological functions of the patients, and on the preventive measures for LEDVT. Studies have shown that from the aspects of proprioception and cognitive methods, the rehabilitation of patients with ISH has improved after ERN [26]. Our experiments have further validated relevant views. However, there are still shortcomings in this study. For example, the activity of daily living was investigated only from the aspects of neurological and motor functions. Besides, we did not carry out analyses from psychological and other factors, and explain the improvement of QOL from the aspect of implementing rehabilitation methods. These will be the focuses and directions of subsequent studies, in order to provide better prognostic nursing for patients with ISH.
Disclosure of conflict of interest
None.
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