护士主导的肠内营养喂养策略在神经重症患者中的应用

范小宁; 孙盼盼; 靳玉萍; 姚乐; 许闯呼; 汤睿; 方翔

doi:10.16766/j.cnki.issn.1674-4152.002791

护士主导的肠内营养喂养策略在神经重症患者中的应用

doi: 10.16766/j.cnki.issn.1674-4152.002791

中国科学技术大学附属第一医院神经重症科，安徽合肥 230036

基金项目:

国家自然科学基金项目 81870060

安徽省自然科学基金项目 2108085QH327

详细信息

通讯作者:
靳玉萍，E-mail：1077289983@qq.com

中图分类号: R473 R651
计量
- 文章访问数: 205
- HTML全文浏览量: 111
- PDF下载量: 15
- 被引次数: 0
出版历程
- 收稿日期: 2022-05-11
- 网络出版日期: 2023-02-07

Application of nurse-led enteral nutritional feeding strategies in neurological intensive care unit patients

Department of Neurocritical Care Unit, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui 230036, China

摘要

摘要: 目的通过组建肠内营养管理小组等一系列措施，探讨以护士为主导的肠内营养喂养策略在神经重症患者肠内营养中的应用效果。方法选取2021年1—8月中国科学技术大学附属第一医院神经重症科住院的130例患者作为研究对象，根据入院先后顺序分为对照组62例和观察组68例。对照组患者采用传统肠内营养方法，观察组采用护士主导的肠内营养喂养策略，护士独立进行胃肠功能评估、EN耐受性评估、床旁超声胃残余量监测以及喂养速度、剂量的调整，增加监测频率等干预措施，保障肠内营养顺利进行。比较2组患者肠内营养喂养不耐受、肠内营养目标达成情况、白蛋白等营养指标以及肠内营养速度、速度的调整次数等。结果对照组患者喂养不耐受发生率为33.9%，观察组为17.6%，2组比较差异有统计学意义(χ²=4.507，P=0.034)；观察组患者血清蛋白、前白蛋白及血红蛋白指标较对照组明显升高(均P＜0.05)；观察组患者肠内营养速度调整次数[(13.28±3.57)次]明显多于对照组[(7.42±1.17)次]，差异有统计学意义(t=12.210，P＜0.001)；对照组患者肠内营养目标达成率为72.6%，观察组为82.4%，观察组高于对照组，但差异无统计学意义(P＞0.05)。结论护士主导的肠内营养喂养策略可减少患者肠内营养喂养不耐受的发生率，改善患者的营养指标，但同时也增加了护士肠内营养速度的调整次数。在临床护理工作中，护士应加强肠内营养相关知识的学习，动态评估，积极进行护理干预，预见性地处理肠内营养并发症，改善患者的营养指标。
- 重症监护病房 /
- 肠内营养 /
- 护士主导 /
- 喂养不耐受 /
- 并发症
Abstract: Objective To explore the effect of nurse-led enteral nutrition feeding strategy on enteral nutrition (EN) in neurological intensive care unit patients through the establishment of an EN management group. Methods A total of 130 patients hospitalised in the Department of Neurointensive Care Unit at the First Affiliated Hospital of University of Science and Technology of China from January 2021 to August 2021 were selected as research objects. Based on the order of admission, the patients were divided into the control (62 cases) and observation (68 cases) groups. The traditional EN method was used in the control group, whereas the nurse-led EN feeding strategy was implemented in the observation group. The nurses independently conducted interventions, such as gastrointestinal function assessment, EN tolerance assessment, bedside ultrasound gastric residual amount monitoring, feeding speed and dose adjustment and increased monitoring frequency to ensure the smooth progress of EN. Comparison of feeding intolerance, EN target achievement, albumin and other nutritional indicators and the number of adjustments of EN speed was conducted. Results The incidence of feeding intolerance was 33.9% in the control group and 17.6% in the observation group (χ²=4.507, P=0.034). The value-added values of serum protein, prealbumin and haemoglobin index significantly increased compared with those in the control group (P < 0.05). The number of EN speed adjustments [(13.28±3.57) times] was significantly higher than that in the control group [(7.42±1.17) times, t=12.210, P < 0.001]. The achievement rate of EN goal in the control group was 72.6%, while that in the observation group was 82.4%, which was higher than that in the control group, but the difference was not statistically significant (P>0.05). Conclusion Nurse-led EN feeding strategy can reduce the incidence of feeding intolerance, improve nutritional indicators, but also increase the number of adjustments for nurse EN speed. In the clinical nursing work, nurses should strengthen the study of EN knowledge, dynamic evaluation, actively carry out nursing intervention, predictably deal with EN complications, and improve the nutritional indicators of patients.
- Intensive care unit /
- Enteral nutrition /
- Nurse-led program /
- Feeding intolerance /
- Complication

HTML全文

表 1 肠内营养耐受性评估

Table 1. Assessment of enteral nutrition tolerance

分值	腹胀/腹痛	恶心/呕吐	腹泻
0	无	无恶心呕吐或持续胃肠减压时无症状	无
1	轻微腹胀无腹痛	有恶心呕吐	稀便3~4次/d，且量＜500 mL/d
2	明显腹胀或腹内压15~20 mm Hg或能够自行缓解的腹痛	恶心呕吐但不需胃肠减压或150 mL≤胃残留＜250 mL	稀便≥5次/d，且量在500~1 500 mL/d
5	严重腹胀或腹内压＞20 mm Hg或不能自行缓解的腹痛	呕吐且需胃肠减压或胃残留≥250 mL	稀便≥5次/d，且量≥1 500 mL/d

下载: 导出CSV

表 2 2组神经重症科住院患者基本资料比较

Table 2. Comparison of basic data of inpatients in the Department of Neurointensive Care between the two groups

组别	例数	性别(例)		年龄(x±s，岁)	机械通气(例)		RASS评分(例)					疾病类型(例)					AGI分级(例)		肠内营养耐受性评分(例)
组别	例数	男性	女性	年龄(x±s，岁)	是	否	1分	-1分	-2分	-3分	-4分	脑出血	脑梗死	颅脑损伤	脑血管性疾病	其他	一级	二级	0分	1分	4分	5分
对照组	62	39	23	57.61±12.04	50	12	1	5	3	52	1	29	7	15	8	3	59	3	43	17	2	0
观察组	68	45	23	57.07±14.33	48	20	1	4	2	59	2	24	13	24	6	1	66	2	49	18	0	1
统计量		0.152^a		0.231^b	1.768^a		0.811^a					5.369^a
P值		0.697		0.818	0.184		0.935					0.261					0.669^c		0.493^c
注：^a为χ²值，^b为t值, ^c为采用Fisher精确检验。

下载: 导出CSV

表 3 2组神经重症科住院患者喂养不耐受及喂养目标达成情况比较[例(%)]

Table 3. Comparison of FI of inpatients in the Department of Neurointensive Care and the number of feeding goal achieved between the two groups [case (%)]

组别	例数	喂养不耐受		目标达成
组别	例数	是	否	是	否
对照组	62	21(33.9)	41(66.1)	45(72.6)	17(27.4)
观察组	68	12(17.6)	56(82.4)	56(82.4)	12(17.6)
χ²值		4.507		1.787
P值		0.034		0.210

下载: 导出CSV

表 4 2组神经重症科住院患者营养指标情况比较(x±s)

Table 4. Comparison of nutritional index increments of inpatients in the Department of Neurointensive Care between the two groups(x±s)

组别	例数	血清蛋白(g/L)		血红蛋白(g/L)		前白蛋白(mg/L)		白蛋白(g/L)
组别	例数	EN前	EN后	EN前	EN后	EN前	EN后	EN前	EN后
对照组	62	58.94±11.64	60.77±10.30	102.13±20.39	121.80±22.16	188.97±78.70	214.44±59.32	33.76±4.45	39.26±4.55
观察组	68	61.39±7.34	66.09±9.23	105.18±30.51	134.10±41.60	186.68±81.77	249.18±74.31	34.15±4.27	41.10±5.05
t值		1.419	3.102	0.660	2.075	0.163	2.928	0.511	2.169
P值		0.158	0.002	0.506	0.040	0.871	0.004	0.610	0.032
注：与同组肠内营养前比较，^aP＜0.001。

下载: 导出CSV

表 5 2组神经重症科住院患者肠内营养速度及调整次数情况比较

Table 5. Comparison of enteral nutrition speed and adjustment times of inpatients in the Department of Neurointensive Care between the two groups

组别	例数	EN速度[M(P₂₅, P₇₅), mL/h]	EN速度调整次数(x±s, 次)
对照组	62	56(53, 61)	7.42±1.17
观察组	68	55(52, 60)	13.28±3.57
统计量		1.733^a	12.210^b
P值		0.083	< 0.001
注：^a为Z值，^b为t值。

下载: 导出CSV

参考文献(25)

[1]	MCCLAVE S A, TAYLOR B E, MARTINDALER G, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N. )[J]. J Parenter Enteral Nutr, 2016, 40(2): 159-211. doi: 10.1177/0148607115621863
[2]	LEE Z Y, IBRAHIM N A, MOHD-YUSOF B N. Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit[J]. Nutrition, 2018, 9(53): 26-33.
[3]	潘莉. 肠内营养在重症急性胰腺炎临床治疗中的效果及护理方法探讨[J]. 河北医学, 2016, 22(12): 2111-2112. doi: 10.3969/j.issn.1006-6233.2016.12.074 PAN L. The effect and nursing method of enteral nutrition in the clinical treatment of severe acute pancreatitis[J]. Hebei Medicine, 2016, 22(12): 2111-2112. doi: 10.3969/j.issn.1006-6233.2016.12.074
[4]	TAYLOR B E, MCCLAVE S A, MARTINDALE R G, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N. )[J]. Crit Care Med, 2016, 44(2): 390-438. doi: 10.1097/CCM.0000000000001525
[5]	马红雅, 姚彦蓉, 李晓银, 等. 以护士为主导的肠内营养支持在胃癌患者围术期护理中的应用[J]. 护理实践与研究, 2021, 18(23): 3568-3573. doi: 10.3969/j.issn.1672-9676.2021.23.022 MA H Y, YAO Y R, LI X Y, et al. Clinical application of nurse-guided enteral nutrition support on perioperative gastric cancer patients[J]. Nursing Practice and Research, 2021, 18(23): 3568-3573. doi: 10.3969/j.issn.1672-9676.2021.23.022
[6]	MCCLAVE S A, DIBAISE J K, MULLIN G E, et al. ACG clinical guideline: Nutrition therapy in the adult hospitalized patient[J]. Am J Gastroenterol, 2016, 111(3): 315-335. doi: 10.1038/ajg.2016.28
[7]	高辉, 李君, 陈鑫, 等. 护士为主导的多学科团队协作营养管理模式在神经重症患者中的应用[J]. 国际神经病学神经外科学杂志, 2019, 46(6): 657-661. doi: 10.16636/j.cnki.jinn.2019.06.016 GAO H, LI J, CHEN X, et al. Nutritional management by a nurse-led multidisciplinary team in neurocritical care patients[J]. Journal of International Neurology and Neurosurgery, 2019, 46(6): 657-661. doi: 10.16636/j.cnki.jinn.2019.06.016
[8]	ARZOLA C, CARVALHO J C, CUBILLOS J, et al. Anesthesiologists ' learning curves for bedside qualitative ultrasound assessment of gastric content: A cohort study[J]. Can J Anaesth, 2013, 60(8): 771-779. doi: 10.1007/s12630-013-9974-y
[9]	赵庆华, 皮红英, 周颖. 危重患者持续肠内营养治疗期间胃残余量变化趋势研究[J]. 中华现代护理杂志, 2018, 24(22): 2629-2632. doi: 10.3760/cma.j.issn.1674-2907.2018.22.007 ZHAO Q H, PI H Y, ZHOU Y. Variation trend of gastric residual volume during continuous enteral nutrition in critical patients[J]. Chinese Journal of Modern Nursing, 2018, 24(22): 2629-2632. doi: 10.3760/cma.j.issn.1674-2907.2018.22.007
[10]	陈闯, 徐杰丰, 刘少云, 等. 超声监测ICU危重患者胃残余量和预测肠内营养不耐受研究[J]. 中华急诊医学杂志, 2020, 29(10): 1291-1295. doi: 10.3760/cma.j.issn.1671-0282.2020.10.005 CHEN C, XU J F, LIU S Y, et al. A study on the monitor of gastric residual volume by ultrasound and its prediction on feeding intolerance during enteral nutrition in critically ill patients in intensive care unit[J]. Chinese Journal of Emergency Medicine, 2020, 29(10): 1291-1295. doi: 10.3760/cma.j.issn.1671-0282.2020.10.005
[11]	刘新平, 赵新英, 丁梅, 等. NRS2002评分预测ICU成人重症患者预后的临床研究[J]. 中华全科医学, 2018, 16(10): 1629-1631, 1666. doi: 10.16766/j.cnki.issn.1674-4152.000443 LIU X P, ZHAO X Y, DING M, et al. Clinical study of predicted the prognosis use NRS2002 score in ICU adult critically ill patients[J]. Chinese Journal of General Practice, 2018, 16(10): 1629-1631, 1666. doi: 10.16766/j.cnki.issn.1674-4152.000443
[12]	李琳, 李纯, 陈静. 基于肠内营养耐受性评分的俯卧位通气患者早期肠内营养实施[J]. 护理学杂志, 2020, 35(22): 11-14. doi: 10.3870/j.issn.1001-4152.2020.22.011 LI L, LI C, CHEN J. Practice of administering early enteral nutrition therapy based on enteral nutrition tolerance assessment score to patients receiving mechanical ventilation in the prone position[J]. Journal of Nursing Science, 2020, 35(22): 11-14. doi: 10.3870/j.issn.1001-4152.2020.22.011
[13]	REINTAM B A, MALBRAIN M L, STARKOP J, et al. Gastrointestinal function in intensive care patients: Terminology, definitions and management[J]. Intens Care Med, 2012, 38(3): 384-394. doi: 10.1007/s00134-011-2459-y
[14]	傅园花, 郭莉娟, 葛国平. 酒石酸布托啡诺联合右美托咪定对机械通气患者肠内营养耐受性的影响[J]. 浙江临床医学, 2020, 23(6): 839-840. FU Y H, GUO L J, GE G P. Effects of butorphanol tartrate combined with dexmedetomidine on enteral nutrition tolerance in mechanically ventilated patients[J]. Zhejiang Clinical Medical Journal, 2020, 23(6): 839-840.
[15]	GUNGABISSOON U, HACQUOIL K, BAINS C, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness[J]. JPEN J Parenter Enteral Nutr, 2015, 39(4): 441-448. doi: 10.1177/0148607114526450
[16]	WANG K L, MCILROY K, PLANK L D, et al. Prevalence, outcomes, and management of enteral tube feeding intolerance: A retrospective cohort study in a tertiary center[J]. J Parenter Enteral Nutr, 2017, 41(6): 959-967. doi: 10.1177/0148607115627142
[17]	陈亭, 王婷, 李清, 等. 重症急性胰腺炎患者肠内营养喂养不耐受状况及影响因素研究[J]. 中华护理杂志, 2017, 52(6): 716-720. doi: 10.3761/j.issn.0254-1769.2017.06.015 CHEN T, WANG T, LI Q, et al. Current status and influencing factors of enteral feeding intolerance in patients with severe acute pancreatitis[J]. Chinese Journal of Nursing, 2017, 52(6): 716-720. doi: 10.3761/j.issn.0254-1769.2017.06.015
[18]	邹圣强, 朱小芳, 乔瑶, 等. ICU脓毒症患者肠内营养喂养不耐受的危险因素调查[J]. 中华灾害救援医学, 2017, 5(9): 498-501. https://www.cnki.com.cn/Article/CJFDTOTAL-JYZH201709008.htm ZOU S Q, ZHU X F, QIAO Y, et al. Investigation of risk factors associated with enteral feeding intolerance of septic patients in an intensive care unit[J]. Chinese Journal of Disaster Medicine, 2017, 5(9): 498-501. https://www.cnki.com.cn/Article/CJFDTOTAL-JYZH201709008.htm
[19]	贾静, 吴小梅, 王金萍. 护士主导的留置导尿管拔除模式构建与实施[J]. 护理学杂志, 2020, 35(9): 48-50. doi: 10.3870/j.issn.1001-4152.2020.09.048 JIA J, WU X M, WANG J P. Implementation of nurse-led removal of urinary catheter[J]. Journal of Nursing Science, 2020, 35(9): 48-50. doi: 10.3870/j.issn.1001-4152.2020.09.048
[20]	魏莹莹, 徐银铃, 周金阳, 等. 护士主导手术伤口管理模式的建立与实践[J]. 中国护理管理, 2021, 21(8): 1261-1266. doi: 10.3969/j.issn.1672-1756.2021.08.028 WEI Y Y, XU Y L, ZHOU J Y, et al. The establishment and clinical application of nurse-led surgical wound management model[J]. Chinese Nursing Management, 2021, 21(8): 1261-1266. doi: 10.3969/j.issn.1672-1756.2021.08.028
[21]	华美芳, 韩秋英, 梁成强, 等. 以护士为主导的营养支持团队在神经外科重症患者中的实践[J]. 中华急危重症护理杂志, 2021, 2(3): 211-215. https://www.cnki.com.cn/Article/CJFDTOTAL-HLZH202103004.htm HUA M F, HAN Q Y, LIANG C Q, et al. The practice of nurse-led nutrition support team in neurosurgical critical patients[J]. Chinese Journal of Emergency and Critical Care Nursing, 2021, 2(3): 211-215. https://www.cnki.com.cn/Article/CJFDTOTAL-HLZH202103004.htm
[22]	杨宏军, 王晓斌, 师燕. 老年普外科住院患者发生营养风险的危险因素及接受营养支持情况分析[J]. 中国医药, 2021, 16(4): 588-591. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGYG202104025.htm YANG H J, WANG X B, SHI Y. The risk factors of nutritional risk and receiving nutritional support in elderly inpatients of department of geriatric general surgery[J]. China Medicine, 2021, 16(4): 588-591. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGYG202104025.htm
[23]	王月圆, 张杨梅. 经鼻空肠管肠内营养支持对晚期胃癌患者营养状况和免疫功能及近期生活质量的影响[J]. 中国医药, 2019, 14(8): 1204-1208. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGYG201908021.htm WANG Y Y, ZHANG Y M. Effect of nasoenteric nutrition on nutritional status, immune function and short-term quality of life in patients with advanced gastric cancer[J]. China Medicine, 2019, 14(8): 1204-1208. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGYG201908021.htm
[24]	卢勇, 郭敏慧, 毕铁男, 等. 肠梗阻导管联合早期肠内营养对粘连性肠梗阻的治疗效果观察[J]. 中华全科医学, 2017, 15(5): 879-882. doi: 10.16766/j.cnki.issn.1674-4152.2017.05.046 LU Y, GUO H M, BI T N, et al. Observation on therapeutic effects of ileus tube placement combined with the early enteral nutrition on adhesive ileus[J]. Chinese Journal of General Practice, 2017, 15(5): 879-882. doi: 10.16766/j.cnki.issn.1674-4152.2017.05.046
[25]	夏莉娟, 张曦, 刘莎, 等. 护士主导的多学科协作鼻咽癌同步放化疗患者营养管理[J]. 护理学杂志, 2021, 36(4): 82-85. https://www.cnki.com.cn/Article/CJFDTOTAL-HLXZ202104026.htm XIA L J, ZHANG X, LIU S, et al. Nurse-led multidisciplinary nutritional support for patients with nasopharyngeal carcinoma undergoing concurrent radiochemotherapy[J]. Journal of Nursing Science, 2021, 36(4): 82-85. https://www.cnki.com.cn/Article/CJFDTOTAL-HLXZ202104026.htm