Observation of the clinical effectiveness of evidence-based nursing for patients with a vertebral osteoporotic fracture

2.3.1 Construction of the department’s evidence-based nursing team

The EBN team comprised four members led by the department’s head nurse who had a graduate degree, strong research skills, and extensive clinical nursing experience. The group members comprised two department nurses engaged in front-line clinical nursing practice who had bachelor’s degrees and specific research skills. All three nursing staff members had completed a two-month training course on EBN competencies delivered by the hospital, had successfully graduated, and were proficient in the concept and steps of EBN. In addition, an associate physician in the department served as a consultant who was always available for communication. The authors of this study were all members of the EBN team.

2.3.2 Evidence-based problems

Through a detailed assessment of the patient on admission, their physical condition, pain level, sleeping habits, personal history, health history, self-care, and any psychosocial support aspects were acknowledged. Based on the treatment and nursing plans, together with the department’s nursing experience and the patient’s characteristics, the influencing factors that could affect recovery were identified, and potential nursing problems were discussed through brainstorming methods. Literature databases, e.g., the CNKI, VIP, Wanfang, Springer, and PubMed databases were reviewed to derive relevant nursing evidence, and the best nursing implementation plan was selected following an assessment of the quality of the evidence. The evidence-based problems that were proposed were as follows:

(1) Pain

Newly onset vertebral fractures are often accompanied by acute lower back pain [8], which can cause sleep disturbances and adverse psychological and emotional experiences, as well as stress reactions, such as an increased heart rate, gastrointestinal dysfunction, and urinary retention. In addition, painful irritation will also often prevent patients from completing rehabilitation exercises, thus affecting their recovery process.

(2) The perioperative physical condition

This refers to a patient’s physical condition from the time they decide to undergo surgical treatment to the time of surgical treatment, and, thereafter, up to basic recovery. It covers their physical condition before, during, and after the surgery. Women aged over 65 years and men aged over 75 years are at a high risk of developing OPF. The digestive, circulatory, and respiratory systems of patients at an advanced age are in a degenerative state. It has been confirmed that patients with OPF often have accompanying problems, including excessive leanness or obesity, vitamin D deficiency, long-term administration of drugs (e.g., glucocorticoids), long-term smoking habits, and alcohol abuse [9]. Their relatively poor physical condition will increase the risk of postoperative complications, such as pressure injuries, urinary tract infections, pulmonary infections, and other surgical risks.

(3) Poor adherence to rehabilitation exercises

Older patients are often unable to persist with exercise due to pain and their psychological characteristics. When the exercise targets are too difficult to achieve, their exercise confidence will be undermined.

(4) Psychological problems

Due to sensory and motor dysfunction, older patients need to rely on family members for care and support and may feel guilty, worried, and frustrated because of their dependence on family members [10]. The lack of understanding of the disease and concerns about therapeutic costs will also add to patients’ psychological burden [11].

2.3.3 Evidence-based support

Evidence-based support was only applied to the observation group and included the following.

(1)

The standardization of pain management, including multimodal analgesia, individualized analgesia, pain education, rational assessment, and preventive analgesia. On admission, the nurse provided pain education and psychological guidance to the patient and the patient’s family and informed the patient that early and adequate analgesia was conducive to early postoperative ambulation and was a prerequisite for early postoperative nutritional supplementation. The nurse regularly scored the patient on the visual analog scale (0 points, no pain; 3 points or less, mild pain but could be tolerated; 4–6 points, pain affected sleep but could still be tolerated; 7–10 points, gradually intensifying pain that affected appetite and sleep and was unbearable). Non-pharmacological treatment was provided when the score was within the range of 1–3, including physical therapy (light therapy, cold and hot compresses), psychological relief, and relaxation therapy. When the score was 4–7, oral or intravenous administration of non-steroidal anti-inflammatory drugs was given. When the score was above 8, opioid analgesics were administered.

(2)

The physical condition of the patients was optimized by providing nutritional support to those with a poor nutritional status as early as possible to reduce postoperative morbidity and mortality [12]. For patients who could take food orally, the nutrition department was consulted to provide nutritious meals and to provide enteral and parenteral nutritional support to patients with poor gastrointestinal function. The relevant departments were consulted to regulate preoperative blood pressure and blood glucose levels, as well as respiratory system functions, to achieve an optimal status for surgery. The time of fasting from food and water before anesthesia and after surgery was reduced; food was allowed until 6 hours before surgery, and clear liquids were allowed until 2 hours before surgery. Patients were then allowed to take water orally 2 hours after surgery and rice soup 4 hours postoperatively. Pantoprazole sodium, a gastric mucosal protector, was given to prevent postoperative nausea and vomiting. For older patients with sputum that was thick and difficult to expel after surgery, postoperative ultrasonic nebulized inhalation with Mucosolvan ® was given to help expel sputum. The patients were given a Braden pressure ulcer score upon admission to prevent pressure injuries; for patients with a score lower than 18, a timed axis turn of 30 ∘ was conducted once every 2 hours with soft cushion support. A skin protectant (Sanyrene [13]) was applied and covered with a thin silicone foam dressing for decompression of bony prominences. The department’s internal health instruction manual was distributed to instruct patients to quit smoking, limit their alcohol intake, increase nutrition, drink more water daily to prevent urinary tract infections, and develop healthy living habits.

(3)

With satisfactory postoperative fixation of the fracture, patients were encouraged and instructed to actively perform early functional exercises as soon as possible to avoid continued postoperative bone loss. When returning to the ward after surgery, patients were instructed to remain in a position lying down and to perform isometric muscle contractions and passive joint exercises, such as ankle pump exercises, quadriceps isometric contractions, and straight leg-raising exercises. One day after surgery, the amount of limb movement was gradually increased under analgesics, using movements such as the five-point, three-point, and flying swallow yoga methods. The patients were required to walk as part of their rehabilitation, wearing an abdominal brace. The functional exercise plan was formulated according to the patient’s characteristics, following joint medical and nursing visits [14], based on the principle of gradual and individualized progress and supervised by the nurses to ensure regular and quantitative completion with verbal encouragement.

(4)

Patients were prone to anxiety about falling, irritability, and experiencing guilt, based on their perceived psycho-emotional state, brought on by pain and the reduced ability to care for themselves. In these cases, a nurse would take the initiative to communicate with the patient, understand their current concerns and worries, express their understanding and support in a targeted manner, and establish mutual trust and a cordial nurse-patient relationship. The nursing staff answered the patients’ questions promptly, carefully, and empathetically to help reduce patients’ stress. Cases of successful healing were described to the patients to enhance their confidence about recovery. The involvement of family and other forms of social support was encouraged to provide relief and encouragement to the patients.

2.4 Observation indicators

The following observation indicators were applied to both groups for comparison.

2.5 Statistical methods

The SPSS Statistics 19.0 software program was used to conduct data analysis. The measurement data that satisfied the normal distribution were expressed as mean ± standard deviation ( x ¯ ± s ), and a t -test was used for comparison between the groups. The countable data were expressed as a percentage (%), and the chi-square ( χ 2 ) test was adopted for a comparison between the groups; 0.05 was considered statistically significant.

3.1 Basic characteristics

There were 45 cases in the control group comprising 23 males and 22 females. Their ages ranged from 38 to 92 years (average age, 66.91 ± 9.94 years). There were 22 cases with thoracic vertebrae fracture sites and 23 with lumbar vertebrae fracture sites. The patients’ educational backgrounds were as follows: 25 cases with primary school, 15 with junior high school, 4 with senior high school and junior college, and 1 with a higher-than-junior-college-level education. There were 45 cases in the observation group comprising 22 males and 23 females. Their ages ranged from 35 to 80 years, with an average age of 65.82 ± 9.78 years. There were 24 cases with thoracic vertebrae fracture sites and 21 cases with lumbar vertebrae fracture sites. The patients’ educational backgrounds were as follows: 23 cases with primary school, 16 with junior high school, 3 with senior high school and junior college, and 3 with a higher-than-junior-college-level education. The differences in the clinical characteristics, including gender, age, fracture sites, and educational background, were not statistically significant between the two groups ( $P>$ 0.05). Accordingly, the data were comparable. The baseline characteristics of patients are shown in Table 1.

3.2 Comparison of the incidence of postoperative complications between the two groups

Compared with those in the control group, the incidences of incisional infection, pulmonary infection, pressure injury, and venous thrombosis of the lower limbs were lower in the observation group, and the differences were statistically significant ( 0.05) as shown in Table 2.

3.3 Comparison of the Barthel index scores on the first day of admission and the day before discharge between the two groups

Differences in the BI on the first day of admission were not statistically significant between the two groups ( $P>$ 0.05). In both groups, the BI score on the day before discharge was higher than those on the day of admission, and the BI score on the day before discharge in the observation group was significantly higher than in the control group ( 0.05) as shown in Table 3.

The ADLs in the observation group were significantly better than in the control group ( 0.05). The nursing satisfaction was 100.0% (45/45) and 82.2% (37/45) in the observation and control groups, respectively. The difference in nursing satisfaction was statistically significant between the two groups ( 0.05) as shown in Table 4.