Effects of an evidence-based nursing intervention on neurological function and serum inflammatory cytokines in patients with acute cerebral infarction: A randomized controlled trial

Abstract

Background:

Acute cerebral infarction is a clinically common and critical disease which seriously endangers the life and safety of elderly patients. Evidence-based nursing is an effective way of nursing and has great significance in improving the neurological function and quality of life of patients. In China, evidence-based nursing has been highlighted and highly developed in recent decades.

Objectives:

This research aimed to investigate the effect of evidence-based nursing on the recovery of neurological function and serum inflammatory cytokines in patients with acute cerebral infarction.

Methods:

A total of 116 patients with acute cerebral infarction were randomly divided into two groups: the control group patients (n = 58) received conventional nursing, while the intervention group patients (n = 58) received evidence-based nursing intervention. National Institutes of Health Stroke Scale (NIHSS), Fugl-Meyer assessment (FMA) and activities of daily living (ADL) scores, as well as serum TNF-α and IL-6 levels were evaluated and compared between the two groups.

Results:

NIHSS scores in the intervention group were significantly lower than the control group. FMA and ADL scores in the intervention group were significantly higher than the control group. TNF-α and IL-6 levels in the serum of the intervention group were significantly lower than the control group.

Conclusions:

In conclusion, evidence-based nursing has a positive effect on the treatment of patients with acute cerebral infarction, which decreases the level of serum inflammatory cytokines and contributes to the recovery of neurological function, motor function and activities of daily living.

Keywords

Acute cerebral infarction evidence-based nursing IL-6 quality of life neurological function

1 Introduction

Acute cerebral infarction is a common and critical disease in clinic, which is caused by the sudden interruption of blood flow in the local blood supply artery, resulting in ischemia, hypoxia, brain tissue necrosis and softening in the blood supply area (NanZhu, AiChun, Xin, & XiangHua, 2018). In the corresponding sites, clinical symptoms of neurological deficits occur, including hemiplegia and aphasia (Choudhury & Ding, 2016). Patients with this disease are mostly elderly, showing characteristics of sudden onset, rapid development of the disease, high fatality and disability rates (Langhorne & Stott, 1995). With the aging population, the increase in life pressure, and the change of people’s living habits, the incidence rate of acute cerebral infarction has increased year by year in China, which seriously endangers the life and safety of elderly patients (Sun, Xu, Gao, Zhao, & Sun, 2019). If acute cerebral infarction is not treated timely, patients’ mortality and disability rate is high. Studies have shown that the mortality and disability rate of patients with acute cerebral infarction in developing countries is as high as 75%, which has caused heavy mental, material and economic burdens on patients’ family and the society as a whole (Zhou et al., 2018).

The in-depth study of cerebral infarction etiology and pathology has greatly advanced in recent years. The mortality rate of cerebral infarction declined significantly as a result of greatly improved therapeutic techniques, such as drugs and interventions (Jang & Kwon, 2016). While patients with cerebral infarction are treated by several therapeutic strategies in clinic, it is also necessary to cooperate with scientific and reasonable nursing methods to obtain better treatment outcomes. In recent decades, evidences have indicated that the performance of advanced specialized nursing care interventions could reduce disability, shorten length of hospital stay and improve patient outcomes (Theofanidis & Gibbon, 2016; Tulek, Poulsen, Gillis, & Jonsson, 2018). Research has also illustrated the great contribution of integrating stroke-specific rehabilitation skills in nurses’ practice in improving outcomes of stroke survivors (Clarke, 2014). In China, the demand for stroke survivors to receive rehabilitation services is strong, but the performance of rehabilitation services is unsatisfactory (Asakawa, Zong, Wang, Xia, & Namba, 2017).

Evidence-based nursing is the “the conscientious, explicit and judicious use of theory-derived, research-based information in making decisions about educational options and approaches with individuals or groups and in consideration of individual or group needs and preferences” (Ingersoll, 2000). Research has illustrated that evidence-based nursing intervention is of great significance in improving the neurological function and quality of life of patients, and reducing the rate of death and disability (Zhao et al., 2018). In China, evidence-based nursing was performed since 2001 and has flourished during recent years (Hsu, Hsieh, & Huang, 2015). Implementation of evidence-based protocols for the management of fever, hyperglycaemia and swallowing dysfunction by nurses improves the outcome of patients with stroke (Middleton et al., 2011). Stroke is classified as ischemic or hemorrhagic. Studies have suggested that evidence-based interventions for ischemic stroke are effective in reducing the morbidity and mortality associated with stroke (H. Adams et al., 2005; H. P. Adams, Jr. et al., 2003). Eight out of ten stroke cases are due to cerebral infarction (Sveinsson, Kjartansson, & Valdimarsson, 2014). The performance of evidence-based nursing may also have benefits on improving outcomes of patients with acute cerebral infarction.

Based on these results, this study conducted evidence-based nursing intervention on patients with acute cerebral infarction, explored its effects on neurological deficits, exercise capacity and serum inflammatory factors, and explained its significance in patients’ rehabilitation.

2 Methods

2.1 Patient eligibility

In this research, all the participants were patients with cerebral infarction who were admitted to Cangzhou Central Hospital from 2016 to 2018. This research was approved by the Ethics Committee of Cangzhou Central Hospital (#2016-039). Written informed consent was obtained from all participants.

Inclusion criteria included: (1) Diagnosed with cerebral infarction through transcranial CT and MRI examinations; (2) With first acute episode cerebral infarction of onset within 6 hours; (3) Treated by intravenous thrombolytic therapy; (4) Expected survival time≥3 months; (5) With no obvious complications, no coagulation dysfunction, no drug allergy, and no severe liver or kidney damage; (6) With no neurological dysfunction, no hearing impairment, and no aphasia; (7) Was literate and able to read and understand the informed consent.

Exclusion criteria were: (1) With congenital immunodeficiency; (2) With severe inflammatory or infectious diseases; (3) With cardiac, hepatic or renal insufficiency; (4) With malignant tumor; (5) Allergic to the drugs in the therapy against cerebral infarction; (6) With mental disease or family history of mental illness; (7) With language or hearing dysfunction.

2.2 Grouping and randomization

In this study, 157 patients were recruited and 41 of them were excluded. The participants were randomized into the intervention group and control group. The patient allocation sequence was generated using a complete randomization procedure. The random numbers and the associated allocated treatment were kept in sequentially numbered sealed opaque envelopes. Researchers involved in the recruitment, data collection and analyses were blind to group allocation.

2.3 Interventions

Participants in both groups were treated by conventional nursing, which included close observation of patient’s condition, health education, nutritional support, psychological counseling and rehabilitation training. On the basis of conventional nursing, the intervention group also received evidence-based nursing. An evidence-based nursing team was established, composed of the head nurse of the Department of Neurology and the nurses in charge of the department. According to the actual situation of individual patient, the pathogenesis of cerebral infarction, related nursing methods, patients’ neurological function and living ability, and prognostic factors were discussed. Relevant cerebral infarction nursing literatures were collected through resources such as CNKI and PubMed, and group discussion to obtain nursing evidence was conducted. Then an individualized patient care plan was formulated according to the needs of patients and nursing practice experience.

For each patient, the time of the onset of stroke was not the same. The performance of evidence-based nursing started when the patients were discharged from ICU to general ward. The care process of each patient was not identical but personalized, based on the characteristics of evidence-based care. The method of evidence-based nursing was as follows: (1) Psychological rehabilitation: according to the patient’s personality, family, and psychological characteristics, comprehensive psychological intervention was implemented. The needs of patients and psychological changes were understood to, answer questions raised by patients. The patient’s understanding of the disease was improved, incorrect treatment of the disease was corrected, and the patient was encouraged to fully express their feelings. To keep patients in a good state of mind, confidence was established to overcome the disease, and patient compliance was improved with treatment. (2) Health education to choose appropriate health education methods: the content of education included the cause of cerebral infarction, prevention and treatment strategies, and complications. (3) Rehabilitation intervention: implementing early rehabilitation care for patients with stable conditions. At early stage, passive movement in bed, such as turning over and massage of limbs, were performed. When the patient’s condition improved, short distances walking and exercises on stationary bike cycling were performed. The frequency of both exercises was 30 min/times, 1 time/d. Before exercise, the condition of patient was carefully assessed. During exercise, the changes in various indicators of patients were observed and exercise was stopped at appropriate time. Patients were encouraged to independently urinate, climb stairs, walk, etc., to gradually improve the patient’s ability to take care of themselves in life.

2.4 Observation indexes

Indexes were observed at three different time points: before intervention (T1), after intervention (T2), and after follow-up (T3).

Neurologic impairment was evaluated using the National Institutes of Health Stroke Scale (NIHSS). The score of NIHSS was between 0 and 42. 0-1: normal status; 2–4: mild neurologic impairment; 5–15: moderate neurologic impairment; 16–20: severe neurologic impairment; 21–42: extremely severe neurologic impairment.

The motor function of patients was evaluated by the Fugl-Meyer assessment (FMA). The items of FMA included flexion and extension cooperative movement of shoulder, elbow and wrist, small joint movement speed, and coordination ability. The assessment was composed of 33 events and the highest score of each event was 2.

The quality of life of the participants was assessed by the activities of daily living (ADL) scale. The score of ADL was between 0 and 100. Score < 20: having severe dysfunction and complete life dependency; 20–40: requiring maximum assistance; 40–60: requiring help; score≥60: having basic self-care ability.

2.5 ELISA

A fasting venous blood sample of 5 mL was collected from each patient. The levels of TNF-α and IL-6 were analyzed through Human TNF alpha ELISA Kit (ab181421) (Abcam, Cambridge, UK) and Human IL-6 ELISA kit (ab178013) (Abcam).

2.6 Statistical analysis

SPSS 21.0 was employed for data analysis. Data were shown as mean±standard deviation (SD) or n (percentage, %). The demographic characteristics between groups were assessed by either unpaired t test or Mann–Whitney test as appropriate. The observation indexes between groups were assessed by two-way ANOVA test followed by Tukey’s multiple comparisons test.

3 Results

The framework of this study was shown in Fig. 1. A total of 157 patients with acute cerebral infarction were assessed for eligibility and 116 of them were eventually recruited. Participants were randomly divided into the intervention group (n = 58) and control group (n = 58). During the 4 weeks of intervention, 5 patients in the intervention group and 6 in the control group withdrew from the study. During the 8 weeks of follow-up, another 2 participants in the intervention group and 2 in the control group were lost to follow-up. Finally, 51 participants in the intervention group and 50 in the control group completed this research and their data were recorded and analyzed.

Fig. 1

Research framework of this study.

Demographic characteristics of participants in this research were collected and shown in Table 1. These characteristics included age, sex distribution, body mass index, smoking history, drinking history, education level, diabetes history and hypertension history. Based on statistical analysis, all the baseline data were comparable in these two groups (all p > 0.05; Table 1).

Table 1

Demographic characteristics of the acute cerebral infarction study participants

	Study group
Characteristics	Intervention	Control	p
	(n = 51)	(n = 50)
Age (years)	62.3±7.9	59.6±8.7	0.153
Gender
Male	28 (54.9%)	24 (48.0%)	0.553
Female	23 (45.1%)	26 (52.0%)
BMI	23.6±4.1	22.4±5.4	0.218
Smoking history
Yes	32 (62.7%)	35 (70.0%)	0.529
No	19 (37.3%)	15 (30.0%)
Drinking history
Yes	27 (52.9%)	27 (54.0%)	1
No	24 (47.1%)	23 (46.0%)
Education level
High school and below	34 (66.7%)	38 (76.0%)	0.380
College and above	17 (33.3%)	12 (24.0%)
Diabetes history
Yes	12 (23.5%)	8 (16.0%)	0.455
No	39 (76.5%)	42 (84.0%)
Hypertension history
Yes	14 (27.5%)	17 (34.0%)	0.522
No	37 (72.5%)	33 (66.0%)

Values were expressed as n (percentage, %) or mean±SD. p values for each group were derived from either unpaired t test or Mann–Whitney test as appropriate. Chi-square test or Fisher’s exact test was used for assessing distribution of observations or phenomena between different groups. BMI: body mass index.

In this research, neurologic impairment caused by acute cerebral infarction was evaluated through NIHSS. The scores of NIHSS were shown in Fig. 2a. Before intervention, no difference was observed between the 2 groups. After the 4-week intervention, NIHSS scores in both groups were decreased, while the score of the intervention group was significantly lower than the control group. After 8 weeks of follow-up, NIHSS scores in both groups were further decreased and the score of the intervention group was also significantly lower than that of the control group.

Fig. 2

Clinical outcomes of the patients. Differences between the two groups in terms of NIHSS score (A), FMA score (B) and ADL score (C). Box plots with all data points were used to present the data. Two-way ANOVA test followed by Tukey’s multiple comparisons test. ^*p < 0.05, ^**p < 0.01, ^***p < 0.001, ns: no significance. T1: before the intervention, T2: at the end of the intervention, T3: at the end of follow-up.

The motor function of patients was evaluated by FMA. The scores of FMA were shown in Fig. 2b. FMA scores were comparable in these two groups before intervention. During intervention and follow-up, FMA scores in both groups were elevated and the intervention group exhibited significant higher FMA score than the control group.

ADL scores were evaluated to assess the quality of life (Fig. 2c). ADL scores in these two groups had no significant difference before intervention. After 4 weeks of intervention and 8 weeks of follow-up, both groups had a higher ADL score than baseline, and the score of the intervention group was dramatically higher than that of the control group.

Through the performance of ELISA, the serum levels of TNF-α and IL-6 were detected. As shown in Fig. 3a, the levels of TNF-α in both groups were decreased after 4 weeks of intervention and 8 weeks of follow-up. Meanwhile, the intervention group showed significantly lower TNF-α level than the control group during intervention and follow-up. As shown in Fig. 3b, the performance of conventional nursing and evidence-based nursing also dramatically decreased the level of IL-6 in both groups. After 8 weeks of follow-up, IL-6 level in the intervention group was significantly lower than the control group.

Fig. 3

Difference between the two groups in inflammatory cytokines of TNF-α and IL-6 Levels of inflammatory cytokines TNF-α (A) and IL-6 (B) were analyzed by ELISA. Box plots with all data points were used to present the data. Two-way ANOVA test followed by Tukey’s multiple comparisons test. ^**p < 0.01, ^***p < 0.001, ns: no significance. T1: before the intervention, T2: at the end of the intervention, T3: at the end of follow-up.

4 Discussion

Acute cerebral infarction is a common neurological emergency with serious consequences. If not treated promptly, acute cerebral infarction will cause irreversible damage to the patient’s nervous system, and even death in severe cases (Wang, 2019). Thus, acute cerebral infarction has become a threat to the life and health of middle-aged and elder individuals (Andersen et al., 2016). Cerebral atherosclerosis is the dominant cause of acute cerebral infarction, since increased risks of vascular stenosis and thrombus disturb blood circulation and oxygen supply in the brain (Wilson et al., 2016). Emergency ischemia and hypoxia in the brain lead to brain tissue necrosis and brain death (Xian et al., 2017).

With the progressively aging society and the improvement in people’s quality of life, the incidence rate of cerebral infarction in China is increasing in recent decades (Jin et al., 2019). Significant improvement has been made in the therapeutic strategy for acute cerebral infarction. In order to improve the treatment outcome, it is crucial to provide standardized nursing during the treatment period. Effective nursing methods can reduce the mortality and improve the prognosis of patients. Clinical practice has suggested that the prognosis of patients with acute cerebral infarction is mostly unsatisfactory (Lv et al., 2019). Among the survivors of acute cerebral infarction, about 75% of patients have neurological deficit symptoms (Yin, Chen, Wang, Zhang, & Huang, 2019). Evidences have shown that a part of neural stem cells can be regenerated into new nerve cells after cerebral infarction, and part of the nervous system function can be established or perfected through training (Doeppner et al., 2011). Relevant studies have demonstrated that improvement in the neurological function of patients with cerebral infarction can promote the recovery of their body functions, while nursing intervention can improve the neurological function and quality of life of patients with cerebral infarction (Chen, Han, & Gu, 2019).

Evidence-based nursing is developed on the basis of evidence-based medicine (Balakas & Smith, 2016). In view of the great success in evidence-based medicine in recent decades, researchers have focused on evidence-based nursing which is compatible with evidence-based medicine (Cheng, Feng, & Hu, 2017). Evidence-based nursing is different from conventional nursing in that, conventional nursing is a basic nursing system derived from a theoretically designed treatment plan, which cannot meet the actual needs of medical treatment and patients in actual work (Scott & McSherry, 2009). Therefore, evidence-based nursing collects, organizes, summarizes and optimizes a large number of clinically valuable and scientifically rigorous studies in various disciplines and related fields, and summarizes and proposes evidence-based points, applies them in practical work, and finally finalizes the evidence-based nursing program (Leung, Trevena, & Waters, 2016). Evidence-based nursing mainly includes three elements: the usage of suitable and available nursing research, the skills and clinical experience of the nursing staffs, and the actual situation and wishes of the patients (Hsu et al., 2015). At present, evidence-based nursing has become an important clinical nursing method. The main purpose of this research was to explore whether evidence-based nursing could promote the recovery of neurological function and the improvement in quality of life of patients with acute cerebral infarction.

This randomized controlled trial implemented evidence-based nursing intervention for patients with acute cerebral infarction. First, an evidence-based nursing team was established, and the team members’ evidence-based ability was improved through training. Then, a nursing plan was formulated by searching literature and combining the specific conditions of the patient. To improve patients’ awareness of the disease and enhance treatment compliance, health education for patients was performed. Psychological intervention was applied to improve the patient’s negative emotions, enhance the activeness of treatment and rehabilitation and early rehabilitation care.

The pathogenesis of acute cerebral infarction triggers neurologic impairment in the central nerve system, significantly influences motor function and quality of life of patients (Novotny et al., 2019). In this research, NIHSS, FMA and ADL were employed to evaluate these indexes during the process of rehabilitation intervention and follow-up. The NIHSS scores in this research showed that during the patient’s rehabilitation, the neurological impairment gradually recovered. Meanwhile, the neurological function of the intervention group recovered more obviously. Thus, evidence-based nursing accelerated the recovery of neurological impairment in patients with acute cerebral infarction. In the process of nursing, the recovery of motor function in both groups was shown by the scores of FMA. The motor function of patients treated by evidence-based nursing recovered more obviously and the effect was better. Improvingthe quality of life of patients was the focus of the evidence-based nursing. ADL score indicated that the improvement of quality of life was significantly accelerated by evidence-based nursing compared to conventional nursing during rehabilitation.

The brain tissue damage after acute cerebral infarction is closely related to elevated inflammation response. Cytokines are markers of inflammation, and their expression changes significantly after acute cerebral infarction. TNF-α is reported to be the dominant cytokine associated with apoplectic brain injury (Luo, Luo, Zeng, Reis, & Chen, 2019). Another research demonstrated that, in patients with acute cerebral ischemia, the expression of TNF-α was enhanced in the brain, and apoptosis of neurons is promoted (Sumbria, Boado, & Pardridge, 2012). The occurrence of acute cerebral infarction promotes the overexpression of IL-6 as well (Lu et al., 2018). Normally expressed low-concentration IL-6 can mediate tissue immunity and nerve repair in the central nervous system. Increased serum IL-6 level is thought to reflect poor neurological function and larger infarct volume (Kim et al., 2000). The serum levels of TNF-α and IL-6 were also analyzed in this research. It was observed that the concentrations of TNF-α and IL-6 in patients with acute cerebral infarction gradually decreased during the recovery process, but evidence-based nursing accelerated the reduction in TNF-α and IL-6 serum levels.

In recent decades, the clinical nursing practice in European countries has indicated that specialized stroke care reduces disability and improves patient prognosis. Highly specialized nursing input is critical for achieving high quality of nursing care and optimal treatment outcomes (Theofanidis & Gibbon, 2016; Tulek et al., 2018). Another research demonstrated that evidence-based protocols for fever, hyperglycaemia and swallowing dysfunction management delivered better patient outcomes after stroke (Middleton et al., 2011). This study adopted evidence-based nursing intervention, based on the actual situation of the individual patients, and established personalized nursing programs suitable for patients by establishing evidence-based nursing teams, strengthening nursing staff training, communicating and consulting, and discussing relevant literature content. Evidence-based nursing included health education to deepen patients’ understanding of cerebral infarction, which could discourage patients’ negative behaviors in their lives and encourage a positive effect on disease recovery. Evidence-based nursing used psychological nursing intervention to promptly ameliorate the negative emotions of patients, so they can actively participate in the treatment and rehabilitation process. Evidence-based nursing also promoted the reconstruction of patients’ neurological function through early rehabilitation training. At the same time, through appropriate exercise, the patient’s immunity was improved, the occurrence of complications was reduced, the patient’s recovery was promoted, and the patient’s quality of life was improved. Through a series of evidence-based nursing, the patient’s NIHSS score was significantly improved, and the ADL and FMA scores were also significantly optimized, indicating that the patient’s neurological function was significantly improved, and the life and sport ability was also significantly improved. In summary, the implementation of evidence-based care for acute cerebral infarction patients is effective in improving neurological deficits and exercise capacity, and is worthy of clinical promotion.

Evidence-based nursing is a systematic process. Evidence-based nursing is a systematic process. In China, the promotion of evidence-based nursing has been restricted by many practical conditions. First, the nurses involved in evidence-based nursing need to have certain literature reading ability and scientific research training. However, most of the existing nurses have not received good scientific research training. Secondly, evidence-based nursing requires high manpower and equipment requirements, which is current in short supply to meet the personalized care of a large number of patients across China. Rehabilitation treatment for stroke patients in China is not fully covered by medical insurance, and at the same time, there is a lack of corresponding nursing insurance. Due to the low income level in the nursing profession, the quality and quantity of well-trained nursing staff are insufficient. At the same time, China’s nursing technology is still underdeveloped, and many rehabilitation equipments have not been widely used. Finally, the importance of early rehabilitation has not been universally recognized among the Chinese population. Nursing staff’s weak foreign language skills and a small number of samples were two limitations in this research. For this reason, we will expand sample numbers, improve the level of scientific research and foreign language among nursing staffs, and carry out multi-center collaborative research to further verify the observed effects of evidence-based nursing on patients with acute cerebral infarction.

5 Conclusion

Footnotes

Acknowledgments

None.

Conflict of interest

All of the authors declare that they have no competing interests.

Funding

None.

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