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

Abstract

BACKGROUND:

An osteoporotic fracture (OPF) can significantly affect patients’ activities of daily living (ADLs).

OBJECTIVE:

This study observed the effects of evidence-based nursing (EBN) on the occurrence of postoperative complications and ADLs in patients with a vertebral OPF.

METHODS:

A total of 90 patients with vertebral OPF were divided into two groups. The conventional orthopedic nursing method was conducted for the control group, and the EBN model was delivered for the observation group.

RESULTS:

Differences in the Barthel index (BI) score on the first day of admission were not statistically significant between the two groups. The BI scores on the day before discharge, compared with the day of admission, had improved in both groups. The BI score on the day before discharge was 83.67 $\pm$ 6.94 in the observation group, and the difference was statistically significant ( $P<$ 0.05) compared with the control group (76.56 $\pm$ 6.89). The rate of satisfaction with nursing in the observation group (100.0%) was significantly higher than in the control group (82.2%) ( $P<$ 0.05). The incidence of postoperative complications in the observation group (2.2%) was significantly lower than in the control group (24.4%) ( $P<$ 0.05).

CONCLUSIONS:

The implementation of EBN in patients with vertebral OPF improved the postoperative ADLs, reduced the incidence of postoperative complications, and improved the patients’ satisfaction with nursing.

Keywords

Osteoporotic fracture evidence-based nursing activities of daily living postoperative complication observation of clinical effectiveness

1. Introduction

An osteoporotic fracture (OPF), also known as a fragility fracture, occurs in association with systemic skeletal pathologies, such as reduced bone density, the destruction of bone microstructure, and decreased bone mass [1]. As the population in China continues to age, the incidence of osteoporosis, which more commonly occurs in older adults, also increases and can result in a significant decrease in a patient’s quality of life. It has been shown that OPF of the hip and vertebrae can reduce life expectancy [2]. A vertebral fracture is a common complication of osteoporosis. The thoracolumbar vertebrae are the primary sites of fractures, which manifest primarily as lower back pain, as well as sensory and motor dysfunction of the lower limbs [3]. Pain and vertebral dysfunction caused by fractures can affect the respiratory and digestive systems, reduce the activities of daily living (ADLs) and mobility of patients, and eventually increase the risk of complications, including pulmonary infections and pressure injuries [4].

Evidence-based nursing (EBN) is a process through which staff judiciously, explicitly, and intelligently integrates scientific findings with clinical nursing experience and patient needs to develop nursing plans, thereby obtaining evidence to serve clinical nursing decision-making [5, 6, 7]. In the present study, the authors aimed to compare the effectiveness of EBN with conventional orthopedic nursing methods concerning the occurrence of postoperative complications and ADLs in patients with vertebral OPFs.

2. Materials and methods

2.1 General patient data

Patients with a vertebral OPF who had been admitted to the authors’ vertebral surgery department between June and December 2018 were recruited as the control group. The second group of patients with vertebral OPFs, who were admitted between January and June 2019, were enrolled as the observation group. The inclusion criteria of this study were the following: (1) patients older than 18 years who provided informed consent for inclusion in the present study; (2) patients diagnosed with a vertebral OPF by X-ray and magnetic resonance imaging or computed tomography examination; (3) osteoporosis was confirmed by a bone density test; (4) patients with obvious lower back pain (with a visual analog scale score of $\geqslant$ 6); (5) patients with normal cognitive function (clear consciousness and able to express themselves and communicate clearly) and the ability to cooperate with treatment and nurses; (6) patients who had undergone successful kyphoplasty (both the surgical procedure and the bone cement-filling were completed to good effect). The exclusion criteria for this study were as follows: (1) patients in poor health who could not tolerate surgery; (2) patients with significant intervertebral occupancy or metastases; (3) serious comorbidities in other organs or systems; (4) patients with mental abnormalities and who were unable to communicate normally with the medical staff; (5) patients who were unwilling to cooperate with the treatment and care. This study was approved by the ethics committee of the authors’ hospital (Approval number: sydwgzv20180617).

2.2 Methods

The control group received conventional orthopedic nursing treatment, including the following: (1) admission guidance (i.e., introduction to the ward environment and responsible doctors and nurses); (2) preoperative health education (i.e., preoperative fasting management, cleaning of the surgical area, and preparing imaging materials); (3) postoperative health education (i.e., postoperative eating management and turning methods, precautions concerning the urinary catheter and drainage tube); (4) discharge guidance (i.e., the reexamination time and instructions to take oral drugs). The observation group received both conventional orthopedic nursing and EBN. The differences in ADLs, the incidence of postoperative complications, and satisfaction with nursing were observed between the two groups.

2.3 Evidence-based nursing

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 ${}^{\@setsize{\scriptsize}{8pt}{\viipt}{\@viipt}\textregistered}$ 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 ${}^{\circ}$ 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.

(1) The occurrence of postoperative complications

Incision infection, pulmonary infection, pressure injury, and deep vein thrombosis of the lower limbs after surgery were observed in the two groups.

(2) Activities of daily living

The Barthel index (BI) self-care ordinal scale was adopted to measure the performance of ADLs. The 10 variables included in the BI are feeding, bathing, help needed with grooming, dressing, fecal control, toilet use, transfers (e.g., from chair to bed), walking, climbing stairs, and urinary control (total score, 100). Total independence corresponded to a score of 100, mild dysfunction ranged from 61 to 99, moderate dysfunction was between 41 and 60, and severe dysfunction was $\leqslant$ 40. The patients were evaluated on the first day of admission and the day before their discharge.

(3) Nursing satisfaction

Patients’ satisfaction with nursing scores were obtained from the “Nursing Satisfaction Questionnaire,” developed by the authors’ department; this evaluation form was used to survey the two patient groups on the day of their discharge. The scale was divided into five entries, i.e., admission reception, service attitude, nursing skills, health promotion, and discharge guidance) (total score, 100). The nursing satisfaction score was divided into very satisfied ( $\geqslant$ 90), satisfied (70–89), generally satisfied (60–69), and unsatisfied ( $<$ 60). Nursing satisfaction $=$ the number of very satisfied patients $+$ the number of satisfied patients/the total number of patients $\times$ 100%.

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 $\pm$ standard deviation ( $\bar{x}\pm s$ ), and a $t$ -test was used for comparison between the groups. The countable data were expressed as a percentage (%), and the chi-square ( $\chi^{2}$ ) test was adopted for a comparison between the groups; $P<$ 0.05 was considered statistically significant.

Table 1
Baseline characteristic of patients

Group	Control group	Observation group	$P$
N of all patients	45	45	$>$ 0.05
N of male patients	23	22	$>$ 0.05
Mean age (years)	66.91 $\pm$ 9.94	65.82 $\pm$ 9.78	$>$ 0.05
Fracture sites			$>$ 0.05
Thoracic vertebra	22	24
Lumbar vertebra	23	21
Educational background			$>$ 0.05
Primary school	25	23
Junior high school	15	16
Senior high school and junior college	4	3
Above junior college	1	3

Table 2

Comparison of the incidence of postoperative complications between the two groups (number of cases %)

Group	Number of cases	Incision infection	Pulmonary infection	Pressure injury	Deep vein thrombosis of the lower limb	Incidence
Control group	45	4	2	3	2	24.4%
Observation group	45	0	0	1	0	2.2%
$\chi^{2}$	10.282
$P$	0.036 ${}^{\ast}$

Note: ${}^{*}P<$ 0.05 between the control and observations groups.

3. Results

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 $\pm$ 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 $\pm$ 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 ( $P<$ 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 ( $P<$ 0.05) as shown in Table 3.

Table 3
Comparison of the Barthel index on the first day of admission and the day before discharge between the two groups ( $\bar{X}\pm s$ , scores)

Group	Number of cases	The first day of admission	The day before discharge	$t$	${P}_{2}$
Control group	45	35.44 $\pm$ 9.40	83.67 $\pm$ 6.94	$-$ 34.547	0.000 ${}^{*}$
Observation group	45	35.00 $\pm$ 9.41	76.56 $\pm$ 6.89	$-$ 27.747	0.000 ${}^{*}$
$t$		0.224	4.876
$P_{1}$		0.444	0.000 ${}^{*}$

Note: $P_{1}$ : Comparison between each group; $P_{2}$ : Comparison within the group. ${}^{*}P<$ 0.05. Barthel: The self-case index ordinal scale.

3.4 Comparison of the activities of daily life and nursing satisfaction between the two groups

The ADLs in the observation group were significantly better than in the control group ( $P<$ 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 ( $P<$ 0.05) as shown in Table 4.

Table 4
Comparison of the nursing satisfaction on the day of discharge between the two groups

Group	Number of cases	Very satisfied	Satisfied	Generally satisfied	Unsatisfied	The nursing satisfaction
Control group	45	32	5	7	1	82.2%
Observation group	45	42	3	0	0	100.0%
$\chi^{2}$	9.851
$P$	0.020 ${}^{*}$

Note: ${}^{*}P<$ 0.05 between the control and observations groups.

4. Discussion

As the Chinese population continues to age, the incidence of osteoporotic vertebral compression fracture, primarily among seniors, increases annually. Vertebral OPF is a common complication in patients with osteoporosis that primarily manifests as lower back pain and causes varying degrees of sensory and motor dysfunction, affecting the vertebral function and the respiratory, cardiovascular, and digestive systems, reducing the ADLs, and affecting the physical and mental health of the patient. Complications such as kyphoscoliosis, pressure injuries, and pulmonary infections can develop in patients with vertebral OPF who are not treated promptly and effectively, causing lifelong disability; in severe instances, these may even be life-threatening. Therefore, it is essential to enhance the clinical treatment and care for patients with vertebral OPF [15, 16].

Although traditional clinical nursing does meet patients’ basic needs, it is primarily based on symptomatic treatment, and patients are primarily in a state of passive care acceptance [17]. Measures are generally conducted for patients to remedy their pain and reduce pressure injuries, infection, and other uncomfortable symptoms only once they have already occurred. This results in high incidences of postoperative complications, inadequate postoperative nutrient intake, decreased body resistance, poor compliance with postoperative functional exercises, the extreme dependence of patients on medical care, and poor self-care ADLs among some patients [18]. These complications increase patients’ pain and can affect their prognosis. It has been suggested that improving the ADLs of patients with OPF, and having them participate in their own care can help them adjust their mindset, build confidence in overcoming the disease, and exert positive effects on recovery [19]. Therefore, helping patients with vertebral OPF to recover quickly, safely, and effectively, and reducing the incidence of postoperative complications has become a worthy research topic for the nursing staff in the department that was involved in this study. Evidence-based nursing requires the caregiver to apply a theoretical foundation, combined with clinical and nursing experience, to develop an optimal nursing plan with full consideration of the patient’s individual requirements and needs [20].

The limitations of the present study are as follows: (1) the sample size was small; (2) the educational background of patients varied; (3) the study was performed in the department where the authors worked, which may have introduced bias to the results.

5. Conclusion

This study showed that the incidence of postoperative complications was significantly lower in the observation than the control group, and the ADLs and nursing satisfaction were significantly better in the observation compared with the control group. These results confirmed that implementing EBN for patients with vertebral OPF could significantly reduce the incidence of postoperative complications, promote early recovery and a return to ADLs, achieve fast and optimal postoperative recovery, and improve nursing satisfaction, all of which make EBN worthy of promoting clinically.

Ethics approval

This study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Harbin Medical University (Approval no. sydwgzv20180617) and was conducted in accordance with the Declaration of Helsinki.

Funding

The study was supported by the WeiGao Science Foundation of Heilongjiang Provice Nursing Association (No. 201851101002).

Informed consent

Written informed consent was obtained from all participants.

Author contributions

Conception and design of the research: LH, HY; Acquisition of data: LH, WYX; Analysis and interpretation of the data: LH, HY; Statistical analysis: LH, GL; Obtaining financing: LH; Writing of the manuscript: LH, GL; Critical revision of the manuscript for intellectual content: LH, HY, GL; All authors read and approved the final draft.

Footnotes

Acknowledgments

The authors would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

Conflict of interest

The authors declare that they have no conflict of interest.

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

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Materials and methods

2.1 General patient data

2.2 Methods

2.3 Evidence-based nursing

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

2.3.2 Evidence-based problems

(1) Pain

(2) The perioperative physical condition

(3) Poor adherence to rehabilitation exercises

(4) Psychological problems

2.3.3 Evidence-based support

(1) The occurrence of postoperative complications

(2) Activities of daily living

(3) Nursing satisfaction

2.5 Statistical methods

Table 1 Baseline characteristic of patients

3.1 Basic characteristics

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

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

Table 3 Comparison of the Barthel index on the first day of admission and the day before discharge between the two groups ( X ¯ ± s , scores)

Table 4 Comparison of the nursing satisfaction on the day of discharge between the two groups

5. Conclusion

Ethics approval

Funding

Informed consent

Author contributions

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Baseline characteristic of patients

Table 3
Comparison of the Barthel index on the first day of admission and the day before discharge between the two groups ( $\bar{X}\pm s$ , scores)

Table 4
Comparison of the nursing satisfaction on the day of discharge between the two groups