• 沒有找到結果。

本章依據研究結果提出結論與建議,共分為三節,第一節為結論、第二節

為研究限制與建議。

第一節 結論

脊髓損傷後,神經性腸道功能障礙為脊髓損傷病患常見的後遺症,排便困

難及不自主排便情形嚴重的困擾著患者,腸道訓練方案有助於重建規則排便。

本研究研究設計方法以「肛門括約肌刺激腸道訓練護理方案」、「肛門括約肌刺 激加腹部按摩腸道訓練護理方案」兩方案為介入措施,對改善脊髓損傷病人排 便之成效,其研究結論如下:

一、本研究人口學變項,研究對象以男性居多,男女比例約2-3:1;平均年齡

50.62±18.28歲。疾病受傷時間平均為6.15±4.96個月、受傷部位以頸椎居多、

受傷原因以創傷性為主;AIS等級在完全性損傷及不完全性損傷比例為1:1。實 驗設計採隨機分派,實驗組與對照組的人口學變項及NBD score與腸道管理滿 意度得分均未呈現差異。

二、本研究的收案對象為NBD score總分≥14分的病人,在腸道訓練前NBD

score分數平均為24.96±4.33分;最高34分、最低18分,顯示研究對象有非常

嚴重的神經性腸道狀況。研究結果顯示脊髓損傷病人每次排便花費時間以一個 多小時為最多,顯見病人排便耗時且費力。九成以上的病人除使用軟便藥物外

,還須借助肛門括約肌刺激法幫助排便。多達 85%病人有不自主排便的問題,

無法控制排氣行為的近九成,顯示病人常有腹脹情形。

三、「肛門括約肌刺激腸道訓練護理方案」於收案日的NBD score分數為 23.91±0.82分,第7天、第14天、第21天分數分別為20.49±0.97、

16.59±1.27、13.39±0.72分。滿意度前測為4.78±0.29分,於第7天、第14天、

第21天分別為6.62±0.36、6.97±0.28、7.92±0.26分。「肛門括約肌刺激加腹部

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按摩腸道訓練護理方案」於收案日的NBD score分數為25.96±0.89分,第7 天、第14天、第21天分數分別為23.38±0.89、20.03±0.88、17.58±0.90分,滿 意度前測為3.46±0.34分,於第7天、第14天、第21天分別為5.12±0.37、

6.25±0.29、6.90±0.28分,說明了兩組介入措施均能減緩脊髓損傷病人的神經性

腸道功能障礙,兩組滿意度都有慢慢提升。

四、兩腸道訓練二方案的成效之比較,在控制了年齡、性別、受傷時間、受傷 原因、受傷部位及AIS等級等人口學變項後,以GEE分析時間作用之差異,結 果顯示兩組腸道訓練護理方案介入對脊髓損傷患者NBD score總分隨訓練天數 增加都呈現總分下降趨勢,比較二組於第7天、14天、21天分別減少0.845分 (p>0.05)、減少1.391(p>0.05)、減少2.141分(p<0.05),呈現實驗組成效優於對 照組,顯示未加入腹部按摩的腸道訓練方案的方案更具成效。腸道訓練滿意度 隨著時間的推移兩組分數皆有提升,然未達顯著差異。

第二節 建議與研究限制 一、臨床實務的建議

本研究比較二種腸道訓練方案,結果顯示減省腹部按摩步驟更具成效,建

議可修改腸道訓練的護理常規,同時可以減省護理人員與病人的時間,對病人 而言更易於學習與持續執行。

二、護理研究

(一) 本研究介入後第21天兩組才顯現差異,是否與個案數不足以呈現出成

效有關,建議增加個案數以瞭解成效。

(二) 本研究顯示兩種訓練方式皆具成效,然後續成效是否能維持,建議增加

後續的追蹤。

(三) NBD的問題並不是剛受傷的病人才有,隨著時間的推移,NBD的問題仍

存在,是否會更嚴重?這些人是否曾受過腸道訓練?還是教過卻執行不徹底?

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腸道訓練的過程太複雜、不易執行?建議可進行相關研究以釐清問題本質所 在。

(四) 以往的研究中顯示腹部按摩組合方案成效不一,然在本研究的肛門括約

肌刺激加腹部按摩腸道訓練護理方案卻是有效的,這是腹部按摩手法的選擇、

按摩深度或是按摩的時間的影響?故建議未來研究可進一步探討不同的腹部按 摩手法、按摩時間長短對於改善脊髓損傷病人神經性腸道功能障礙之成效。

三、限制

本研究由處於COVID-19三級警戒時期,入院病人減少,使收案樣本數受

限,可能影響成效評估。

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附錄

附錄一 樣本數估計圖

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附錄二 樣本數隨機分派

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附錄三 腸道訓練正確性查檢表

腸道訓練正確性查檢表

受檢者:

1.能講出每日固定時間執行腸道訓練

2.能說出引發胃結腸反射方法、時間(喝溫水或三餐擇一餐飯後 30-60min)

3.能執行腹部按摩過程【平躺或坐於便盆椅(馬桶)上、順時鐘按 摩方向(升、橫、降結腸)、拳頭或掌心下壓3-5公分、按摩時間 15MIN】

4.左側臥或坐於便盆椅(馬桶)上,檢測肛門口,若有硬便予挖除

5.EVAC灌腸(EVAC使用方式、灌腸後壓住肛門口3-5MIN)

6.DIGITAL技巧

戴上手套充分潤滑食指、輕輕地插入直腸2-4cm、順時針方向輕 輕地旋轉(手指抵靠肛門括約肌壁)約20-30秒、對直腸壁輕柔拉 伸以使糞便通過、根據需要重複步驟最多不超過5次。

7.確保直腸是空的。

DIGITAL間隔10分鐘後,沒有大便流出。粘液出來沒有大便。

刺激手指周圍的直腸完全閉合。

8.紀錄大便性狀、顏色、量(布里斯托大便分類法)

稽核人員: