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เตรียมสอบป้องกัน14032014

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Education

Published on March 15, 2014

Author: aphisittamsat

Source: slideshare.net

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ป.โท
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Pol. Lt. Aphisit Tamsat No. 5436795 RAAN/M Master of Nursing Science (Adult Nursing)

Background and Significance Trend and the number of older adults at the age of over 60 years. (Bunlu Siriphanich, B.E. 2553) 2025 14.9 million 2009 7million 2030 17.8 million

Evidence of Hip Fractures Aged 65 years old and over and were mostly evident in the age group of over 80 years old. (Yarrow, & Beech, 2012)

Hip fracture ที่มา: http://bonefracturetreatment.com/blog/wp-content/uploads/2011/06/hip-fracture-types.bmp  Head of Femur 45 %  Intertrochanteric 45 %  Subtrochanteric 15 % (UCLA Division of Geriatrics, 2010 ) Fracture head of femur

• In the western countries, • the incidents of hip fractures were found in over 550,000 people every year (UCLA Division of Geriatrics, 2010). • In Asia, – Japan was 851, 906, and 1,059 patients in 2004, 2005, and 2006 respectively, and the trends in the incidence and lifetime risk of hip fracture had showed a significant increase over time among both genders (Hagino et al., 2009). • In Thailand, – 185 people out of a hundred thousand populations, and the tendency was higher in line with increasing ages. – The ratio of the incidents between women and men was 2 to 1 (Pattarawan Worathanarat, B.E. 2545). Incidence & Prevalence

Impact of Hip Fracture Disability Quality of life Mortality Socioeconomic

Cause and Risk Factors • Hip degenerative • Comorbidity • Falls • Age • Gender • History of falls and fracture • Visual impairment • Smoking • Low BMI • Sedative drugs • Menopause

Treatment of Hip Fracture • Conservative treatment • Surgical treatment Open reduction internal fixation (ORIF) Proximal Femoral Nail Antirotation (PFNA)

Surgical treatment Total Hip Arthroplasty Hemiarthroplasty

Factors Contributing to the Process of Recovery after Surgery • Gender • Age • Health Status • Perceptual Ability • Pain • Physical Ability before Having Fractures • Types of Fractures • Muscle Strength • Initial Level of Disability • Fear of Falling • Restriction of Activities • Postoperative Complications

Fear of falling  Lack of self-confidence  Low perceived self-efficacy (Evitt & Quigley, 2004; Tinetti et al., 1990) ภาพจาก http://www.thaijoints.com/content_images/hip_08_01.jpg?rand=999486918

Functional Ability • The ability or potential of an individual to perform different activities required of daily living according to the levels of ability to perform activities. • Functional ability can be divided into two levels: the ability to do fundamental daily activities and the ability to perform complex activities in daily life (Sutthichai Jitapankul, B.E. 2542, as cited in Sirirat Wichittrakultaworn, B.E. 2545).

(Hadjistavropoulo et al., 2011) Conceptual Framework Balance Confidence (Efficacy) Falls Reduced Stability Muscle Decline/ Deconditioning Avoidance of Activity FOF FA

1) Fear of falling is found low level to high level in older adults after hip fracture. 2) In Thailand, there is not examine fear of falling and functional ability in older adults undergoing hip surgery. Gap of knowledge

Research Questions 1. How about fear of falling and functional ability among older adults undergoing hip surgery? 2. Is there any correlation between fear of falling and functional ability in older adults undergoing hip surgery?

Research Objectives 1. To examine fear of falling in older adults undergoing hip surgery before rehabilitation and at 6-week follow-up. 2. To explore functional ability in older adults undergoing hip surgery before rehabilitation and at 6-week follow-up. 3. To investigate the correlation between fear of falling and functional ability in older adults undergoing hip surgery.

Definition of Variables • Fear of falling is defined as perception on a lack of confidence to perform activity of daily life. It was measured by the falls-efficacy scale (Tinetti, Richman, & Powell, 1990), • Total scores ≥ 80 points = the risk of falls, • Total scores ≥ 70 points = the fear of falling.

Definition of Variables • Functional ability is defined as the ability or potential of individuals in performing basic activities daily living. • Measured by Modified Barthel Activity of Daily Index (MBAI) (Jitapunkul, Kamolratanakul, Chandraprasert, & Bunnag, 1994). • Total scores range from 0 - 18 points. • The higher scores indicate the better functional ability.

1. General knowledge about hip fracture - Incidence of hip fracture in older adults - Cause and risk factors of hip fracture - Impact of hip fracture - Treatments of hip fracture - Postoperative complications of hip surgery - Functional abilities after hip surgery 2. Fear of Falling and Functional Ability after Hip Surgery 3. Summary of the Literature Reviews LITERATURE REVIEW

METHODOLOGY The target population • The older patients ≥ 60 years, • who were diagnosed by the orthopaedist with hip fracture, undergoing hip surgery, and • admitted in general surgery-orthopaedic wards at tertiary hospitals in Bangkok, Thailand, • From July to December 2013.

Sample Inclusion criteria: 1. Male or female aged ≥ 60 years; 2. Being able to perform activities daily living by themselves before the admission; 3. Having good consciousness, with a total score based on Thai Mental State Examination (TMSE) ≥ 24 points (Mental rehabilitation group, B.E. 2536) 4. Being able to communicate either by listening, speaking, reading, or writing Thai language; and 5. Being willing to participate in the study.

Exclusion criteria: 1. Having complications after surgery, such as joint dislocation, or re-operation during admission; 2. Being unable to be discharged according to the clinical pathway in each hospital. Sample

• the power and sample size tables by Cohen (1992) • Spearman’s rho (rs) to be equal to -.78 (Jellesmark, Herling, Egerod, & Beyer, 2012) • α = .05, power of test = .80 (Nunta Khandee, B.E. 2553) • The effect size was .50 (Cohen, 1992, 157) Sample

Police General Hospital Pramong kutklao Hospital Lerdsin Hospital Rama thibodi Hospital 126 persons 145 persons 131 persons 190 persons Tertiary Hospitals The older patients with hip surgery in 2012 Sample

(126/592) x 33 (145/592) x 33 (131/592) x 33 (190/592) x 33 7 persons 8 persons 7 persons 11 persons Proportions Sample Sample

Instruments • Instrument for screening – Thai Mental State Examination (TMSE) (Appendix A) • Instrument for data collection – Demographic and Health Information Questionnaire (Appendix B) – Fall Efficacy Scale (FES) (Appendix C) – Modified Barthel Activities of Daily Index (MBAI) (Appendix D)

Thai Mental State Examination (TMSE) • by Nipon Puangwarintr et al. (Mental Rehabilitation Group, B.E. 2536) • six aspects – Orientation - Registration – Attention - Calculation – Language - Recall • Total scores of 30 points • > 24 points had normal mental state or had no dementia.

Validity and reliability • Mean 27.38 points (SD. = 2.02) (Mental Rehabilitation Group, B.E. 2536) • In this study: (TMSE) score in the normal cognition Ranged from 25-30 scores, mean ± SD = 27.55 ± 1.62. Thai Mental State Examination (TMSE)

Fall Efficacy Scale (FES) • Developed by Tinetti et al. (1990). • ranged from 1 point (very confident) to 10 points (not confident at all). • Total scores ≥ 80 points = risk of falls • Total scores ≥ 70 points = fear of falling • Test-retest reliability revealed that Pearson’s correlation coefficient = .71 The validity showed a good internal consistency (α = .91) (Tinetti et al., 1990)

• In this study, FES was validated by 5 expertises. The content validity index = .93 10 older adults were selected to test for instrument’s reliability. The Cronbach’s alpha was .95. Fall Efficacy Scale (FES)

Fall Efficacy Scale (FES)

Modified Barthel Activities of Daily Index (MBAI) • Modified from Barthel ADL Index (Mahoney & Barthel, 1965) • Translated into Thai by Jitapunkul et al. (1994). • Total scores ranged from 0-20 points. • In this study The total activities to be measured include 9 activities. Total scores ranged from 0 to 18 points High scores indicate good functional ability and high performance in doing basic activities daily living.

• Validity and reliability • In 703 older patients. The Cronbach’s alpha reliability was .67, and its inter-rater reliability was .79 (Jitapunkul et al., 1994). • In this study, The MBAI was validated by 5 experts, and then content validity index was calculated as.78. The reliability was tested in 10 older adults, which reported the Cronbach’s alpha of .90. Modified Barthel Activities of Daily Index (MBAI)

Human Rights Protection Institutional Review Board (IRB) Star Data Collection consent form informed Explained proposed and objective

Data Collection Introduction & Clarification of purpose, and procedure Recruited based on the inclusion criteria Appointment to explain the objectives, human rights protection, and procedures of data collection.

Agreed to participate read and signed informed consent Face to Face Interviewed TMSE (10 minutes) & Demographic and Health Information Data Collection

Visited at least one time before and after surgery for maintain the relationship Before rehabilitation FES (10 minutes) & Appointment At 6-week Follow-up FES & MBAI (15-20 minutes) C H E C K E D Data Collection

Data Analysis • Statistical Package of Social Science for windows (SPSS/FW) • Descriptive statistics, percentage, mean, and standard deviation were used to analyze the demographic data and health information

How do about fear of falling and functional ability among older adults undergoing hip surgery have fear of falling? • Wilcoxon Signed Ranks Test Is there any correlation between fear of falling and functional ability in older adults undergoing hip surgery? • Spearman rank correlation coefficient Analysis for Research Question

Spearman rank correlation coefficient The interpretation of the correlation coefficient was presented as follows (Munro, 2005): .90 - 1.00 = very high correlation .70 - .89 = high correlation .59 - .69 = moderate correlation .29 - .49 = low correlation .00 - .25 = little if any correlation

RESULTS Part I The demographic characteristics of participants Part II The health information of participants Part III The research questions.

Table 4.1 Demographic Characteristics of Participants. (N=33) Variables Frequency Percentage Gender Female 22 66.7 Male 11 33.3 Age (Years) (Rang = 61-91 years,; Mean = 74.9,; SD.= 8.1 ) 60 - 74 14 42.4 75 - 84 16 48.5 ≥ 85 3 9.1 Marital status Widowed 17 51.5 Married 12 36.3 Single 2 6.1 Divorce or Separate 2 6.1

Variables Frequency Percentage Religion Buddhist 33 100.0 Educations No formal education 4 12.1 Primary school 13 39.4 Secondary school 5 15.2 Junior or High school diploma 8 24.2 Bachelor degree 3 9.1 Income Per Month sufficient 28 84.8 insufficient 5 15.2

Variables Frequency Percentage Source of Income Children/spouse 17 51.5 Pension 7 21.1 Owner business 5 15.2 Personal saving 2 6.1 Other …(welfare of elderly) 2 6.1 Payment Method for Treatment Government welfare 20 60.6 Universal coverage scheme 8 24.2 Social security scheme 3 9.1 Cash 2 6.1

Table 4.2 Health Information of Participants (N=33) Variables Frequency Percentage Body mass index (kgs/m2) (Rang = 15.57-33.30 kgs/m2,; Mean = 22.45 kgs/m2,; SD.= 5.24 kgs/m2) < 18.5 5 15.3 18.5-22.9 11 33.3 23-24.9 8 24.2 25-29.9 8 24.2 ≥ 30 1 3.0

Variables Frequency Percentage Number of Co-morbidity None 2 6.1 Yes 31 93.9 1 disease 6 18.2 2 diseases 9 27.3 3 diseases 9 27.3 > 3 diseases 7 21.1 Co-morbidities Hypertension 25 75.8 Diabetic Mellitus 16 48.5 Dyslipidemia 16 48.5 Cardiovascular disease 9 27.3

Variables Frequency Percentage Co-morbidities Bone & Joint problem 7 21.2 Respiratory problem 3 9.1 Anemia 2 6.1 Endocrine Hormone dysfunctions 2 6.1 Urinary problem 2 6.1 Cerebrovascular accident 1 3.0 Cancer 1 3.0 Cause of Hip Fracture Falls during ADL 18 54.5 Accident/Trauma 15 45.5 History of falls None 23 69.7 1 times a year 6 18.2 2 times a year 1 3.0 3 times a year 2 6.1 > 3 times a year 1 3.0

Variables Frequency Percentage Visual impairment No 10 30.3 Yes 23 69.7 Cataract 10 30.3 Blur and Myopia/Hyperopia 9 27.3 Glaucoma 4 12.1 History of Medication Use Cardiovascular & Hypertensive drugs 23 69.7 Dyslipidemia drugs 14 42.4 Bone & relief pain for bone and joint drugs 11 33.3 Diabetic drugs 9 27.3 Gastrointestinal drugs 9 27.3

Variables(Cont.) Frequency Percentage History of Medication Use Vitamin 6 18.2 Anemia 5 15.2 Diuretic drugs 3 9.1 Sedative drugs 3 9.1 Anti-histamine 1 3.0 History of Alcohol Drinking Never 29 87.8 Used to drink 2 6.1 Current Drinks 2 6.1 History of Smoking Never 28 84.8 Used to smoke 2 6.1 Current Smokes 3 9.1

Variables Frequency Percentage Functional Ability before Admission Total self-care independent 33 100.0 Living Status before Admitted Living with spouse 21 63.7 Living with spouse and children 11 33.3 Living with cousin 1 3.0 Pre-Operative Laboratory Values Hemoglobin (g/dl) (N=33) (Rang = 8.10-17.40 g/dl,; Mean = 11.50 g/dl,; SD.= 2.03 g/dl) < 10 g/dl 8 24.2 ≥ 10 g/dl 25 75.8 Hematocrit (%) (N=33) (Rang = 24.90-49.30 %,; Mean = 34.86 %,; SD.= 5.54 %) < 30 % 6 18.2 ≥ 30 % 27 81.8 Albumin (g/dl) (N=25) (Rang = 2.62-4.50 g/dl,; Mean = 3.63 g/dl,; SD.= .49 g/dl) < 3.5 g/dl 9 36.0 ≥ 3.5 g/dl 16 64.0

Variables Frequency Percentage Type of Hip Fracture Neck of femur 20 61.6 Intertrochateric 12 36.4 Subtrochanteric 1 3.0 Type of Operations Hip arthroplasty 16 48.5 Hemiarthroplasty 14 87.5 Total hip arthroplasty 2 12.5 Internal fixation 17 51.5 Proximal femoral nail antirotation (PFNA) 11 64.7 Plate and screws 6 35.3

Variables Frequency Percentage Post-Operative Pain Management None 4 12.1 Yes 29 87.9 Received continuous in 24 hr. in Day 1st 29 87.9 Received prn. for pain after 24 hr. in Day 1st 29 87.9 Received prn. for pain in Day 1st to Day 3rd 19 57.6 Other 2 6.1 Type of Walking Aids when Discharge Walker 27 81.8 Wheel chair 6 18.2 Rehabilitation after Discharge Weight as tolerate 15 45.5 Partial weight bearing 11 33.3 Non-weight bearing 7 21.2

Variables Frequency Percentage Living Status after Discharge Same before admission 33 100.0 Complications in hospital No 24 72.7 Yes 9 27.3 Anemia 3 9.1 Hyperglycemia 2 6.1 Flatulence 1 3.0 Electrolyte imbalance 1 3.0 Pulmonary embolism 1 3.0 Urinary tract infection 1 3.0

Variables N Rang Mode Mean SD. Length of Hospital Stay before Operation (day) 33 1 - 15 5 6.94 4.06 Internal fixation 17 1 - 13 5 5.59 3.57 Hip arthroplasty 16 1 - 15 9 8.37 4.16 Operative Duration (minute) 33 75 - 255 90 134.33 49.76 Internal fixation 17 75 - 230 90 122.94 43.08 Hip arthroplasty 16 90 - 255 120 146.44 54.77 Length of Hospital Stay (day) 33 3 - 38 11 16.70 9.51 Internal fixation 17 4 - 31 7 13.35 7.82 Hip arthroplasty 16 3 - 38 26 20.25 10.09

Table 4.3 Mean and Standard Deviation of Study Variables among Participants (N=33) Variables Possible Scores Actual Scores Before Rehabilitation (Mean ± SD.) At 6-Week Follow-Up (Mean ± SD.) FOF 10-100 10-100 39.59 ± 27.14 16.12 ± 12.29 FA 0-18 10-18 18.00 ± 0.00 17.09 ± 1.79

Table 4.4 Wilcoxon Signed Ranks Test for Functional Ability in Older Adults undergoing Hip Surgery (N=33) Functional ability (FA) Mean Rank Sum of Ranks Z p At 6-week follow-up Before admission Negative Rank Positive Rank Ties 10a 0b 23c 5.50 0.00 55.00 0.00 -2.831 .005* Note: FA = Functional Ability, *p < .01 (a) FA at 6-week follow-up < FA before admission (b) FA at 6-week follow-up > FA before admission (c) FA at 6-week follow-up = FA before admission

Table 4.5 Wilcoxon Signed Ranks Test for Fear of Falling in Older Adults undergoing Hip Surgery (N=33) Fear of falling (FOF) Mean Rank Sum of Ranks Z p At 6-week follow-up Before rehabilitation Negative Rank Positive Rank Ties 24a 2b 7c 14.46 2.00 347.00 4.00 -4.356 .000* Note: FOF = Fear of falling, *p < .01 (a) FOF at 6-week follow-up < FOF before rehabilitation (b) FOF at 6-week follow-up > FOF before rehabilitation (c) FOF at 6-week follow-up = FOF before rehabilitation

Table 4.6 Correlation Matrix among Study Variables. (N=33) Variables 1 2 3 1. FOF before rehabilitation 1.00 2. FOF at 6-week follow-up .41* 1.00 3. FA at 6-week follow-up -.37* -.63** 1.00 Note: FOF = Fear of falling, FA = Functional ability, *p < .05; **p < .01

Study limitations 1. The purposive sampling was used to select the participants in this study. Therefore, the results of the study could not represent all older adults undergoing hip surgery.

2. This study collected the data in 4 tertiary hospitals in Bangkok. Although these hospitals had doctors specialized in orthopedics, nursing practices, surgery, and treatment in a similar way, the data collection revealed that there had been some different protocols, such as surgery consideration, starting rehabilitation by walking practice, and discharge consideration. Study limitations

The participants in some hospitals had not been followed up after being discharged from the hospital due to their inconvenience in seeing the doctor as per the appointment. Therefore, the researcher collected the data after undergoing hip surgery for 6-week follow-up over the phone, possibly affecting the assessment on actual ability of the patients. Study limitations

Recommendations • Recommendations for nursing practices • Recommendations for nursing education • Recommendations for next studies

Recommendations for nursing practices The multidisciplinary team approach, relatives and nurses in charge of home visits should also involve in patient care during the hospitalization and after the discharge, especially during 6-week rehabilitation period when the patients required the walking aid, in order to promote confidence in walking and reduce fear of falling.

Recommendations for nursing education Assess risk factors of falling and mitigate such risk factors to prevent falling, but also assess psychological factors, especially fear of falling, in order to cover all dimensions of health promotion for older adults.

Recommendations for next studies Next studies should involve factors relating to fear of falling and factors contributing to functional ability after undergoing hip surgery in order to acquire specific factors to develop a program for purpose of reducing fear of falling and increasing functional ability in older adults after undergoing hip surgery.

• correlation between fear of falling and long-term functional ability, such as 3 months, 6 months, and 1 year after undergoing surgery, in order to follow up their rehabilitation. • Compare between fear of falling and rehabilitation, or activities of older adults with hip fractures in order to ensure more extensive study, and acquire fundamental information on specific health promotion for patients of different treatments. Recommendations for next studies

Thank you very much

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