Amanda, Manda
Synopsis: Write a study synopsis that includes these main points.
- how the study was conducted
explain how the data was collected
include measurement instruments and what they measured
if the study involved an intervention, how the intervention was carried out
Appraisal: Appraise the article in narrative format by answering the following questions.
- Were the measurement instruments reliable and valid? Why or why not?
- If the study was experimental, was the intervention performed consistently? Why or why not?
- Were the conclusions of the study supported by the results? Why or why not?
Include key statistical results and p-values as part of your rationale.
Consider study limitations when analyzing conclusions with respect to results.
O R I G I N A L A R T I C L E
Effect of quantitative assessment-based nursing intervention
on the bowel function and life quality of patients with
neurogenic bowel dysfunction after spinal cord
injury
Yanyan Zhang MD, RN, Superviser Nurse1 | Xiyan Xia MD, Lecturer2 | Xuewei Zhuang
MD, PhD, Associate Professor3
1Rehabilitation Center, Shandong University
Qilu
Hospital, Jinan, China
2Department of Immunology, Jinan
Vocational College of Nursing, Jinan, China
3Department of Clinical Laboratory
Medicine, Shandong University Qilu
Hospital, Jinan, China
Correspondence
Xuewei Zhuang, Department of Clinical
Laboratory Medicine, Shandong University
Qilu Hospital, Jinan, China.
Email: zhiyuan0517@163.com
Funding information
Shandong Provincial Nature Science Found,
Grant/Award Number: 2015ZRE2757
Aims and objectives: To study the effect of quantitative assessment-based nursing
intervention on the
bowel function and life quality of patients with neurogenic
bowel dysfunction after
spinal cord injury.
Background: Neurogenic bowel dysfunction after spinal cord injury was clinically
manifested by abdominal distension, intractable constipation, prolonged defecation
and faecal incontinence, which seriously affected the normal life of patients. Tradi-
tional ways of nursing for these patients focused on basic care, but lacked sufficient
recognition of disease severity and individual needs.
Design: One hundred and eighty-four patients with neurogenic bowel dysfunction
after spinal cord injury were randomly allocated into observation group (n = 92) and
control group (n = 92).
Methods: The
patients in the control group were given regular nursing, and the
patients in the observation group were given quantitative assessment-based nursing
intervention. Recovery of bowel function, quality of life and satisfaction were com-
pared between the two groups.
Results: Scores for bowel function including bloating, constipation, prolonged defeca-
tion, defecation drug dependence and faecal incontinence in the observation group
were significantly lower than those in the control group (p < .05). The scores for the
quality of life including physical function, general health, social functioning, role-
motional, mental health in the observation group were significantly higher than those in
the control group (p < .001). Finally, the satisfaction rate in the observation group was
95.56%, which was significantly higher than that in the control group (83.7%) (p < .01).
Conclusion: We concluded that quantitative assessment-based nursing intervention con-
tributed to recovery of bowel function and improvement of life quality and satisfaction.
Relevance to clinical practice: Our finding can increase the rational allocation of
nurse–patient ratio and provide personalised nursing for severe patients to reduce
complications and promote the rehabilitation of the disease. Our findings can also
serve as a reference for other coun
tries to develop the
nurse practitioner role.
K E Y W O R D S
neurogenic bowel dysfunction, nursing interventions, quantitative assessment, spinal cord
injury
Accepted: 19 November 2017
DOI: 10.1111/jocn.14198
e1146 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:e1146–e1151.
http://orcid.org/0000-0002-6819-2024
http://orcid.org/0000-0002-6819-2024
http://orcid.org/0000-0002-6819-2024
http://wileyonlinelibrary.com/journal/JOCN
http://crossmark.crossref.org/dialog/?doi=10.1111%2Fjocn.14198&domain=pdf&date_stamp=2018-03-25
1 | INTRODUCTION
Patients with spinal cord injury (SCI) is associated with autonomic
dysreflexia (Furusawa et al., 2011), serious upper and lower neuro-
genic bowel dysfunction (NBD)(Preziosi & Emmanuel, 2009; Gondim,
de Oliveira, & Thomas, 2010). NBD after SCI was clinically mani-
fested by abdominal distension, intractable constipation, prolonged
defecation and faecal incontinence, which seriously affected the nor-
mal life of patients (Zhu & Liu, 2012). Traditional ways of nursing for
these patients focused on basic care, but lacked sufficient recogni-
tion of disease severity and individual needs. Through comprehen-
sive evaluation of the patient’s symptoms, laboratory and
radiological results, quantitative assessment-based nursing interven-
tion can identify the most urgent care needs and provide person-
alised nursing
intervention to reduce complications and promote the
rehabilitation of the disease (Huang & He, 2012). In this study, we
determined the effect of quantitative assessment-based nursing
intervention on the bowel function and quality of life in patients
with neurogenic bowel dysfunction after spinal cord injury.
1.1 | Background
Spinal cord injury was associated with not only in motor and sensory
deficits but also in autonomic dysfunctions. This included compro-
mised cardiovascular, respiratory, urinary, gastrointestinal, ther-
moregulatory and sexual activities. In particularly, neurogenic bowel
dysfunction with constipation and/or incontinence was a critical con-
sequence of SCI (Hou & Rabchevsky, 2014). Faecal incontinence in
SCI is due to loss of recto-anal sensitivity and loss of voluntary con-
trol of the external anal sphincter. Constipation is due to immobilisa-
tion, abnormal recto-anal reflexes and colonic contractility (Krogh &
Christensen, 2009). Traditional methods of nursing were stereotyped
and emphasise only on the treatment of diseases and basic care,
which ignored the impact of the disease on the quality of care and
quality of treatment. Therefore, traditional nursing cannot meet the
patients’ physical and psychological needs. Management of NBD
after SCI is complicated and remains conservative (Coggrave, Norton,
& Wilson-Barnett, 2009). Many therapeutic protocols for NBD, such
as treatment with oral laxatives and abdominal massage, have been
reported (Ayas�, Leblebici, S€ozay, Bayramo�glu, & Niron, 2006; Cog-
grave & Norton, 2010). Studies have shown that quantitative assess-
ment-based nursing intervention can fully evaluate and consider the
patients’ own disease condition, and execute individualised nursing
intervention programmes, which can maximally meet the patients’
care needs, improve the care’s quality and promote the rehabilitation
of patients.
2 | METHODS
2.1 | Aim
The aim of the study was to determine the effect of quantitative
assessment-based nursing intervention on the bowel function and
life quality in patients with neuro/genic bowel dysfunction after
spinal cord injury.
2.2 | Design
Patients were randomly allocated into observation group (n = 92)
and control group (n = 92) by means of random number table. The
patients in the control group were given regular nursing, and the
patients in the observation group were given quantitative assess-
ment-based nursing intervention. Recovery of bowel function, quality
of life and satisfaction were compared between the two groups.
2.3 | Participants
Patients included 113 males and 71 females between the ages of
35–70 years. There were 73 cases of complete injury, 58 cases of
lumbosacral injury, 40 cases of cervical spinal cord injury and 13
cases of thoracic spinal cord injury. The gender, age and the type of
spinal cord injury were not significantly different between the obser-
vation group and control group.
2.4 | Data collection
2.4.1 | Nursing in the control group
The patients in the control group were provided with routine nurs-
ing, including disease health education, psychological care, guiding
patients to eat more fresh vegetables, fruits and high dietary fibre
foods, and drink sufficient water, promoting bowel patency, eating
less candy and milk that produce gas and reducing bloating. For
patients with severe constipation, senna, fruit and other drugs
catharsis were used. If necessary, artificial catharsis was performed
(Hu, 2013).
2.4.2 | Nursing in the observation group
The detailed nursing in the observation group was described below.
What does this study contribute to the wider
global clinical community?
• Through comprehensive evaluation of the patient’s symp-
toms, laboratory and radiological results, quantitative
assessment-based nursing intervention can identify the
most urgent care needs and provide personalised nursing
intervention to reduce complications and promote the
rehabilitation of the disease.
• Our finding can be used as a assessment tool for continu-
ing education of nurse practitioners.
• Our findings can also serve as a reference for other coun-
tries to develop the nurse practitioner role.
ZHANG ET AL. | e1147
Quantitative assessment: According to basic signs, clinical symp-
toms, laboratory tests and radiographic results, patients were given a
score of 0.5, 1.0 and 1.5 for mild, moderate and severe, respectively.
If patients over 55 years old, the total score was added with 0.5 for
every 5 years of the age. The total score for each patient was subse-
quently obtained.
Nurse–patient ratio: According to the quantitative evaluation, the
ratio of nurses to patients was adjusted. For patients with mild dis-
ease, the nurse–patient ratio was 1:3. For patients with moderate
disease, the nurse–patient ratio was 1:2. For patients with severe
disease, the nurse–patient ratio was 1:1. All nurses who have been
provided with organised trainings and grasped quantitative evalua-
tion method can carry out personalised nursing inter
vention.
Personalised nursing intervention: (i) Intake of high-fat and
high-protein foods was reduced. When the condition permits, daily
fluid intake was minimum of 2000 ml. (ii) Abdominal massage was
performed to speed up bowel movements. During the massage, the
patients were in supine position. The navel was used as the centre,
and a nurse used one or both hands’ fingers, massage from right
to left along the colon anatomical location of circular and lasted
for 10–15 min. Massage was performed 1 time/day, 1–2 times/day
and 2 times/day for patients with mild, moderate and severe condi-
tions, respectively. During the massage, the patient was relaxed
with calm breathing. The massage intensity should be moderate
without causing pain to the patients. (iii) Exercise the muscles
involved in defecation: the patients were guided to exercise
abdominal muscles. Patients sit on toilet or adopted a bed slope
position. The abdominal muscle was exercised through deep
breathing, abdominal breathing and actions of defecation. The
patients were taught to correctly execute anal contraction exercise.
The patients were in supine position with both legs together and
knees buckling slightly separated. The patients were instructed to
lift the buttocks and contracted the anus. During the anal contrac-
tion, perineal muscle and thigh muscle were contracted for 5s and
then relaxed for 3s. A consecutive of 10-20 contraction and relax
was considered one group and a total of 4–6 groups were exer-
cised each day. (iv) Stimulate the anus and promote the colorectal
reflection: Anal action can stimulate the peristaltic activity of intes-
tine.(Li & He, 2002). Nurses or family members wore gloves with
liquid paraffin lubrication on forefinger and middle finger, slowly
inserted into the anus and rotated in the rectum. Such mechanical
stimulation was performed at the position of 3, 6, 9 at 12 o’clock.
For patients with severe constipation and prolonged defecation,
faeces were removed before anal action. Anal action was per-
formed daily and lasted for 1 min.
2.5 |
Parameters
2.5.1 | Bowel dysfunction
After nursing intervention in both groups, bloating, constipation, pro-
longed excretion, drug-dependent defecation and bowel inconti-
nence were scored. The score for incontinence including the type
and frequency of incontinence ranged from 0–20 points. Higher
score indicated more severe incontinence.
2.5.2 | Quality of life
At the day of admittance and 1 day before discharge, the quality of
life for all patients was evaluated by SF-36 questionnaire (Sang,
Pang, Zhang, & Wang, 2014). This questionnaire has been verified to
have good reliability with a half coefficient c = 0.726~0.975, and
coefficient of internal consistency Cronbach’a=0.755~0.826. A total
of 10 items for physical function (PF), four items for role-physical
(RE), two items for bodily pain (BP), five items for general health
(GH), four items for vitality (VT), two items for social functioning
(SF), three items for role-motional (RM) and five items for mental
health (MH) were included in the questionnaire. The score for each
item ranged from 0–100. Higher score indicated better quality of
life.
2.5.3 | Satisfaction
We used our home-made questionnaire to determine the satisfaction
of the patients. The questionnaire had three levels: satisfaction, gen-
eral satisfaction and nonsatisfaction. The satisfaction rate indicates
the percentage of patients with general satisfaction or satisfaction.
2.6 | Ethical consideration
Ethical approval was granted by Ethics Committee of Qilu Hospital,
and patients voluntarily signed an informed consent.
2.7 | Data analysis
SPSS 20.0 software was used for statistical analysis of data. Student
t test was used to compare the quality-of-life scores between the
two groups. The chi-square test was used to compare the bowel
function and satisfaction. p < .05 was considered statistically signifi-
cant.
3 | RESULTS
3.1 | Comparison of bowel function between
observation and control groups
The scores for abdominal distension, prolonged defecation, drug-
dependent defecation and faecal incontinence in the observation
group were significantly lower than those in the constipation control
group (p < .05) (Table 1).
3.2 | Comparison of life quality between
observation and control groups
The scores of life quality parameters (PF, RE, BP, GH, VT, MG, RE
and MH) at the day of admittance were not significantly different
e1148 | ZHANG ET AL.
between the observation group and control group (p > .05). Com-
pared with the day of admittance, the scores of life quality parame-
ters (PF, RE, BP, GH, VT, MG, RE and MH) 1 day before discharge
were significantly increased in both observation group and control
group (p < .01) (Table 2). The scores for RE, GH, SF, RM and MH in
the observation group were significantly higher than those in the
control group (p < .001) (Table 3).
3.3 | Comparison of satisfaction rate between
observation and control groups
The satisfaction rate in the observation group was 95.56% (69 cases
of satisfaction and 19 cases of general satisfaction), which was sig-
nificantly higher than that in the control group (p < .01) (Table 4).
4 | DISCUSSION
The integrity of the nervous system in patients with spinal cord
injury is destroyed, which may lead to symptoms related to sensory
dysfunction, motor dysfunction and reflex dysfunction (Whiteneck
et al., 2011). Therefore, spinal cord injury has many complications,
mainly manifested by the local soft tissue damage, pulmonary infec-
tion and urinary retention. Bowel dysfunction after spinal cord injury
may result in constipation, bloating, prolonged defecation and faecal
incontinence. Severe cases can even have mechanical obstruction
due to faecal accumulates (Cong et al., 2012). The lack of gastrocolic
reflection after spinal cord injury slows down colon peristalsis. The
injury of nerves that control rectal defecation reflex results in the
disappearance of defecation reflex. Prolonged stay of stool in rectum
and water absorption led to the occurrence of dry stool (Ozisler,
Koklu, Ozel, & Unsal-Delialioglu, 2015). Due to the bowel dysfunc-
tion, patient diet is limited and they cannot participate in normal
work and life. Furthermore, long-term bowel dysfunction can also
TABLE 1 Comparison of bowel function between the two groups
Abdominal distensiona N (%) Constipationa N (%) Drug-dependenta N (%) Defecation timeb �X�s Faecal incontinenceb �X�s
Observation 18 (19.57) 15 (16.30) 12 (13.04) 14.06 � 3.87 9.68 � 0.61
Control 35 (38.04) 31 (33.70) 27 (29.35) 18.65 � 4.23 10.57 � 0.84
p <.05 <.05 <.05 <.05 <.05
aChi-square test.
bt test.
TABLE 2 Comparison of quality of life within groups (�X�s)
Parameters
Observation group Control group
At the day of admittance 1 day before discharge p At the day of admittance 1 day before discharge p
Physical functioning 66.18 � 6.69 74.03 � 7.15 <.01 65.79 � 6.27 73.14 � 7.41 <.01 Role-physical 44.95 � 5.34 62.56 � 6.37 <.01 45.08 � 5.16 56.32 � 5.76 <.01 Bodily pain 60.68 � 6.37 68.61 � 7.24 <.01 60.49 � 6.24 68.05 � 7.09 <.01 General health 49.43 � 5.46 67.22 � 6.63 <.01 48.97 � 5.61 63.17 � 6.15 <.01 Vitality 60.45 � 6.71 75.34 � 7.86 <.01 60.72 � 6.39 73.41 � 6.93 <.01 Social functioning 51.35 � 5.47 60.61 � 6.38 <.01 50.82 � 5.06 54.82 � 5.71 <.01 Role-motional 43.16 � 4.53 55.35 � 5.02 <.01 43.27 � 4.31 50.42 � 4.78 <.01 Mental health 40.39 � 4.28 57.09 � 6.16 <.01 40.12 � 4.78 51.17 � 5.69 <.01
Student’s t test for paired samples.
TABLE 3 Comparison of quality of life between the two groups 1
day before discharge (�X�s)
Observation group Control group
p
1 day before
discharge
1 day before
discharge
Physical functioning 74.03 � 7.15 73.14 � 7.41 >.05
Role-physical 62.56 � 6.37 56.32 � 5.76 <.001
Bodily pain 68.61 � 7.24 68.05 � 7.09 >.05
General health 67.22 � 6.63 63.17 � 6.15 <.001
Vitality 75.34 � 7.86 73.41 � 6.93 >.05
Social functioning 60.61 � 6.38 54.82 � 5.71 <.001
Role-motional 55.35 � 5.02 50.42 � 4.78 <.001
Mental health 57.09 � 6.16 51.17 � 5.69 <.001
t test for independent samples.
TABLE 4 Comparison of satisfaction between the two groups
Groups Case No.
Nonsatisfaction
N (%)
Satisfaction rate
N (%)
Observation group 92 4 (4.35) 88 (95.56)
Control group 92 15 (16.30) 77 (83.70)
Chi-square test, p < .01.
ZHANG ET AL. | e1149
increase mental stress, leading to anxiety, depression and other neg-
ative emotions, which seriously affects the quality of life (Long, Gao,
& Xu, 2015). Therefore, it is very important to implement high-qual-
ity nursing intervention to reduce related symptoms.
In this study, we developed quantitative assessment-based nurs-
ing interventions for patients with bowel dysfunction after spinal
cord injury, which makes nursing more targeted and efficient. With
the rational allocation of nurse–patient ratio and intensive care for
severe patients, we showed that scores for bloating, constipation,
prolonged defecation, defecation drug dependence and faecal incon-
tinence in the observation group were significantly decreased com-
pared to those in the control group, which is consistent with
previous reports (Hsieh et al., 2013). These results suggested that
quantitative assessment-based nursing intervention can improve the
patients’ bowel function.
Effective bowel movements and the involvement of abdominal
and pelvic muscles are important for normal defecation (Xiao et al.,
2014). Based on the severity of spinal cord injury and bowel dys-
function, we executed individualised nursing intervention. Through
abdominal massage, sit-ups, abdominal breathing and anal contrac-
tion, the muscles involved in defecation were exercised. Artificial
mechanical stimulation of the anus and other forms of nursing inter-
vention were carried out to stimulate defecation reflex, promote
smooth bowel movements and foster bowel habits of defecation and
thus reduce bloating, constipation, prolonged bowel dysfunction and
the occurrence of drug-dependent defecation stool incontinence.
After the bowel function was improved, patients can be involved in
normal work and social participation, and thus, quality of life was
improved (Liu, 2012). Based on SF-36 questionnaire, the scores for
RE, GH, SF, RM and MH were significantly higher in the observation
group than in the control group, suggesting that quantitative assess-
ment-based nursing intervention included abdominal massage and
anal stimulation can improve patients’ life quality. Similar results
have also been reported previously (Awad et al., 2013; Li, 2012). We
recommend that individualised nursing intervention should be
included in rehabilitation programmes for patients with SCI because
this therapy can relieve some clinical components of neurogenic
bowel dysfunction.
Limitations of this study include the small sample size and the
deficiency of study design. It must be noted that we need to expand
our sample size to efficiently integrate the quantitative assessment
into the nursing intervention strategies because quantitative evalua-
tion involves patients’ both physiological and psychological aspects.
Nursing intervention is one of the rehabilitation programmes for
patients with SCI, which is not appropriate for determining the
effectiveness of treatment.
4.1 | Rigour
Inclusion criteria of patients were randomly allocated into observa-
tion group (n = 92) and control group (n = 92): (i) consistent with
diagnostic criteria for spinal cord injury and neurogenic bowel dys-
function; (ii) confirmation by X-ray, CT and/or MRI examination;
however, patients with previous history of intestinal disorders or
unwilling to cooperate in the assessment were excluded. All nurses
who have been provided with organised trainings and grasped quan-
titative evaluation method can carry out personalised nursing inter-
vention.
5 | CONCLUSION
In summary, quantitative assessment-based nursing intervention can
promote the recovery of bowel function, improve the life quality of
patients with neurogenic bowel dysfunction after spinal cord injury
and improve patients’ satisfaction.
6 | RELEVANCE TO CLINICAL PRACTICE
Our finding can increase the rational allocation of nurse–patient ratio
and provide personalised nursing for severe patients to reduce com-
plications and promote the rehabilitation of the disease. Our findings
can also serve as a reference for other countries to develop the
nurse practitioner role.
ACKNOWLEDGEMENTS
This study was supported in part by grants from Shandong Provincial
Nature Science Found (2015ZRE2757).
CONFLICT OF INTEREST
No conflict of interest has been declared by the authors.
CONTRIBUTIONS
Study design: YZ, XZ; data collection and analysis: YZ, XX; and
manuscript preparation: XZ.
ORCID
Xuewei Zhuang http://orcid.org/0000-0002-6819-2024
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How to cite this article: Zhang Y, Xia X, Zhuang X. Effect of
quantitative assessment-based nursing intervention on the
bowel function and life quality of patients with neurogenic
bowel dysfunction after spinal cord injury. J Clin Nurs.
2018;27:e1146–e1151. https://doi.org/10.1111/jocn.14198
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