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Objective:To establish the Chinese version of (strength, assistance with walking, rise from a chair, climb stairs and falls, SARC-F) scale using the standardized methods and to validate the reliability and validity for sarcopenia screening among elderly population.Methods:Following the recommended procedure by World Health Organization and European Union Geriatric Medicine Society Sarcopenia Special Interest Group, the translation process included forward translation, expert panel, back-translation, pre-testing and cognitive interviewing to generate the final version. In the pilot study, the test-retest reliability, inter-rater reliability, and internal consistency of the Chinese version of SARC-F scale were assessed. In the diagnostic test for clinical validation, the participants were consecutively recruited from communities and hospitals in Beijing and Tianjin between December 2021 and October 2022. The scale administration, anthropometry, and body composition measurement were conducted by trained investigators. Participants with the SARC-F score ≥ 4 were considered at risk of sarcopenia. Diagnostic tests and receiver operating characteristic curve analysis were performed against the definitions of sarcopenia according to European Working Group on Sarcopenia in Older People (EWGSOP2) and Asian Working Group for Sarcopenia (AWGS2019), and the sensitivity, specificity, positive predictive value, negative predictive value and the area under curve were displayed.Results:The Chinese version of SARC-F scale was approved by the author that the translation has expressed the original meaning correctly. The Chinese version of SARC-F had good test-retest reliability (ICC = 0.914), inter-rater reliability ( r = 0.726), and internal consistency ( α = 0.729). There were altogether 1 882 participants included in the clinical validation. According to the diagnostic criteria of EWGSOP2 and AWGS2019, the Chinese version of SARC-F scale had low sensitivity (13.6% and 16.0%) and positive predictive value (44.6% and 35.4%), high specificity (95.1% and 94.7%) and negative predictive value (79.0% and 86.2%), and moderate AUC of 0.619 and 0.616 (all P < 0.001) for sarcopenia screening. Conclusions:The Chinese version of SARC-F scale was of good reliability and validity. The application of SARC-F in the primary healthcare settings would contribute to the early diagnosis of sarcopenia.
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Object:To explore the role of personalized nutritional intervention based on nutritional assessment in long-term continuous nursing of elderly postoperative colorectal cancer patients.Methods:Elderly patients with colorectal cancer who received radical surgery in a tertiary hospital in Beijing were screened from January 2021 to January 2022 and a total of 100 patients at nutritional risk (defined as with a Nutritional Risk Screening 2002 [NRS 2002] score ≥ 3) were included in the study. Patients were stratified by age and then divided into control and intervention groups with 50 cases in each. The control group received regular health guidance and follow-up visits at postoperative outpatient clinics while the intervention group received personalized nutritional intervention based on nutritional assessment additionally. The intervention period was 12 months. Nutritional indicators including body mass index (BMI), upper arm circumference, grip strength and hemoglobin, as well as albumin and quality of life (QoL), are compared between the two groups.Results:Compared with the control group, the intervention group showed significantly better results of BMI [(18.46±0.53) vs (16.9±0.77)], upper arm circumference [(25.09±1.41)cm vs (23.49±1.45)cm], grip strength [(28.34±8.00)kg vs (23.97±7.19)kg], HGB [(135.10±9.27)g/L vs (106.40±8.73)g/L] and ALB [(41.62±3.41)g/L vs (28.62±2.38)g/L, all P < 0.01]. The intervention group also had significantly higher scores in physical [(20.96±2.03) vs (15.66±0.82)], emotional [(21.48±1.64) vs (15.76±1.00)], social [(23.44±1.67) vs (15.96±0.99)], and functional [(20.74±1.74) vs (5.46±0.97)] domains of QoL (all P<0.01). Conclusion:In elderly patients with colorectal cancer after radical resection, personalized nutritional intervention based on nutritional assessment can effectively control nutritional indicators, help reduce the incidence of malnutrition, improve postoperative quality of life, and inform the establishment of standardized process in nutrition management.
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Objective:To investigate the effects of nurse-led interRAI-based multidisciplinary team management on body composition and metabolic parameters among elderly patients with metabolic syndrome.Methods:100 elderly patients aged 60-74 with the diagnosis of metabolic syndrome were randomized into control group ( n=50) and study group ( n=50). The control group was followed up after routine physical examination. Based on interRAI assessment, the study group received nurse-led individualized intervention which integrated management regarding geriatric internal medicine, clinical nutrition, psychology and physical rehabilitation. This 12-week study measured body composition indexes body protein, body fat mass (BFM), skeletal muscle mass (SMM), body mass index (BMI), waist-to-hip ratio (WHR) and biochemical indexes [triglycerides (TG), high density lipoprotein cholesterol (HDL-C) and glycosylated hemoglobin (HbA1c)] on the first day and 12 weeks after enrollment and compared those parameters between the two groups. Results:After 12 weeks of intervention, compared with the control group, the study group showed significantly increased body protein [(10.48±2.02) kg vs (9.72±1.65) kg, P=0.043], SMM [(29.61±6.07) kg vs (27.36±4.96) kg, P=0.046], BFM [(17.86±3.42) kg vs (19.64±5.07)kg, P=0.042], WHR (0.88±0.05 vs 0.89±0.03, P=0.021) and TG [(2.31±0.42) mmol/L vs (2.95±0.52) mmol/L, P=0.014]. There was no significant difference in BMI [(25.06±3.41) kg/m 2vs (24.40±2.48) kg/m 2, P=0.272], HDL-C [(0.94±0.10) mmol/L vs (0.91±0.31) mmol/L, P=0.246] and HbA1c [(6.11±0.51)% vs (6.37±0.42)%, P=0.185]. After 12 weeks of intervention, body fat [(17.86±3.42) kg vs (20.71±5.98) kg, P=0.004], WHR (0.88±0.05 vs 0.91±0.05, P=0.001), TG [(2.30±0.42)mmol/L vs (2.75±0.37) mmol/L, P=0.032] and HbA1c [(6.11±0.51) mmol/L vs (6.35±0.63) mmol/L, P=0.015] in the study group were significantly lower compared with baseline and there was no difference in those parameters at baseline and 12 weeks after enrollment in the control group. Conclusion:The nurse-led multidisciplinary management model based on interRAI assessment can effectively improve the body composition and certain metabolic indexes of the elderly with metabolic syndrome.
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Objective:To evaluate dynamic changes of functional status in elderly emergency inpatients by using the interRAI Acute Care for Comprehensive Geriatric Assessment(interRAI AC-CGA), and to analyze whether assessment results are helpful for clinical decision-making.Methods:Elderly patients(aged 60 years and older)who were hospitalized in the Acute Care Unit of PLA General Hospital from October 2017 to March 2018 were included.Each patient received the interRAI AC-CGA instrument-based assessment at admission(day 1), on day 7 and day 28 after admission.Analysis of collected data was conducted using interRAI AC-CGA scales, geriatric syndrome screening and risk identification of adverse outcomes, in order to examine dynamic changes of functional status in patients at and after admission and to explore the relationship between functional status at admission and outcomes(at discharge).Results:Thirty-four patients were evaluated, including 26 males and 8 females, aged from 60 to 101 years, with a mean age of(84.2±10.1)years.Patients had a variety of functional abnormalities at admission and during hospitalization, in which the ability to perform activities of daily living(ADL)and instrumental activities of daily living(IADL)decreased significantly.Compared with evaluation results on day 1, the incidences of functional abnormalities on day 7 and day 28 declined, and there was improvement in transient depression, pain and falls( χ2=6.298, 6.027 and 7.766, P=0.043, 0.049 and 0.021). After evaluation on day 28, 16 patients were discharged and 18 remained hospitalized(including 2 deaths). The rate for most abnormality was lower in the discharge group than in the continued hospitalization group, and the rates for abnormal communication and falls were lower in the discharge group than in the continued hospitalization group( χ2=6.349 and 5.443, P=0.019 and 0.030). Age(≥85 years old)had no effect on discharge.There was no significant difference in hospital discharge rate between the advanced age group(≥85 years old)and the elderly group(60-84 years old)(40.0% or 8/20 vs.57.1% or 8/14, χ2=0.971, P=0.324). Conclusions:The interRAI AC-CGA instrument can systematically and dynamically estimate functional changes in elderly emergency inpatients.Functional status at admission is related to prognosis(performance at discharge)of patients.
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Objective:To determine associations between postpartum depression (PPD) and plasma neurotransmitters.Methods:We conducted a case-control study nested to a prospective cohort established in 3 comprehensive tertiary hospitals in Changsha,Hunan,China from February to September 2007.The Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) was used at 2 weeks postpartum to screen PPD,with a score of 13 or higher as the cut-off for PPD.The women with matched age but without PPD and delivery within 5 years were selected as controls.The levels of plasma monoamine neurotransmitters including serotonin (5-hydroxytryptamine,5-HT),dopamine (DA),and norepinephrine (NE),and peptide neurotransmitters including neuropeptide Y (NPY) and substance P (SP) in maternal blood samples taken at 2 weeks postpartum were measured and compared between PPD women (n=42) and controls (n=42).Results:Plasma levels of 5-HT and NPY were significantly lower while plasma levels of NE and SP were significantly higher in PPD women than those in the controls.For women with PPD,a negative correlation between NPY and NE (r=-0.36,P＜0.05) was observed.Conclusion:There are changes in plasma levels of neurotransmitters in women with PPD,and there are potential interactions between different neurotransmitters.
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Objective To compare differences among measured rest energy expenditure (REE) by using indirect calorimetry (IC) and predictive REE from predictive equations (PE) and human body component analyzer (HBCA).Methods Young and middle-aged healthy volunteers of light manual labor were recruited in this study.REEs were obtained from IC,PE (WHO-Schofield and Harris-Benedict equations) and HBCA.Results A total of 30 healthy participants were included,of whom 12 were males (25-46 years old) with an average age of (37.8±7.4) and 18 were females (26-52 years old) with an average age of (40.4±7.8).Measured REE of the males was (1 848.33± 155.01) kcal/d,which was significantly different from the predictive REE result of H-B equation (P=0.003) but not from results of WHO-Schofield equation and HBCA.In females,however,measured REE was (1 294.44± 134.23) kcal/d,which was significantly different from predictive REE results of both equations and HBCA,P=0.002 (WHO-Schofield),P=0.031 (H-B) and P=0.002 (HBCA).Results of measured REE were related to weight (P=0.033) and percentage of body fat (P=0.036) in males,and to height and muscle mass (P=0.003) in females.Conclusion In young and middle-aged healthy females of light manual labor,IC represented a more accurate way to measure REE,while in males WHO-Schofield equation and HBCA could be considered as alternative choices to predict REE.
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Objective To explore the effect of the model of comprehensive nursing interventions based on time nursing in improving therapeutic effects and prognosis of patients with schizophrenia. Methods A total of 84 cases of patients with schizophrenia were selected and were divide into two groupsby the random number table—an experimental group and a control group , both of which were 42 cases. The model of comprehensive nursing interventions based on time nursing was adopted in the experimental group and routine nursing was given to the control group until their discharge. Before and after the interventions, the Brief Psychiatric Rating Scale(BPRS) was used to evaluate the severity of the disease. The Activities of Daily Living(ADL) and the Social Disability Screening Schedule(SDSS) were used to evaluate the patients′ abilities of daily living and social skills. After the interventions, a satisfaction survey was conducted. Hospitalization time and disease recurrence of the two groups were observed. Results After the interventions,BPRS scales, ADL scales and SDSS scales were (31.50±4.23), (89.37 ± 8.16)、(6.65 ± 2.02) points in experimental group, and (45.43 ± 5.62), (81.03 ± 5.92), (8.96 ± 2.26) points in control group, the differences are statistically significant (t =2.361, 2.047, 2.206,P<0.05).The rates of satisfaction of the two groups was 95.24%(40/42) and 80.95%(34/42), and there was significant difference(χ2=6.892,P<0.05). Hospitalization time was respectively (42.86 ± 6.21)d and (67.49 ± 7.65)d in experimental group and control group, and and there was significant difference(t=2.253,P<0.05). Disease recurrence was respectively4.76%(2/42) and 23.81%(10/42),and there was significant difference(χ2=7.437, P=0.024). Conclusions The model of time nursing, with higher satisfaction level, shorter hospitalization time, and lower recurrence rate, can significantly improve the symptoms of patients with schizophrenia and enhance their self-care and social life abilities. It is worth popularizing in clinical nursing.
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Objective To preliminarily explore the level of spiritual needs from nurses in cancer patients,and to analyze its influencing factors.Methods Convenience sampling was applied to recruit 153 inpatients from a tertiary general hospital and a tumor hospital from December 2015 to April 2016.The Chinese version of the Nurse Spiritual Therapeutics Scale (NSTS) was administered to assess the level of spiritual needs from nurses in cancer patients.Results The total score of NSTS was (32.10-±7.68).Regression results showed that educational level and religion belief were influencing factors.Conclusion The level of spiritual needs from nurses in cancer patients was at middle level.With different educational level and religion status,the level of spiritual needs was different.
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Comprehensive geriatric assessment (CGA) is widely used for creating tailored individual care plans for seniors who usually are suffering from multiple diseases,frailty,disability and cognition decline.Skilled communicators are of importance for high-quality clinical data collection.Communication skills used in CGA are summarized in this article by reviewing related references and combining practical experiences in the process of applying international resident assessment instruments (interRAI).
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Objective To explore the effect of the model of comprehensive nursing interventions based on time nursing in improving therapeutic effects and prognosis of patients with schizophrenia. Methods A total of 84 cases of patients with schizophrenia were selected and were divide into two groupsby the random number table—an experimental group and a control group , both of which were 42 cases. The model of comprehensive nursing interventions based on time nursing was adopted in the experimental group and routine nursing was given to the control group until their discharge. Before and after the interventions, the Brief Psychiatric Rating Scale(BPRS) was used to evaluate the severity of the disease. The Activities of Daily Living(ADL) and the Social Disability Screening Schedule(SDSS) were used to evaluate the patients′ abilities of daily living and social skills. After the interventions, a satisfaction survey was conducted. Hospitalization time and disease recurrence of the two groups were observed. Results After the interventions,BPRS scales, ADL scales and SDSS scales were (31.50±4.23), (89.37 ± 8.16)、(6.65 ± 2.02) points in experimental group, and (45.43 ± 5.62), (81.03 ± 5.92), (8.96 ± 2.26) points in control group, the differences are statistically significant (t =2.361, 2.047, 2.206,P<0.05).The rates of satisfaction of the two groups was 95.24%(40/42) and 80.95%(34/42), and there was significant difference(χ2=6.892,P<0.05). Hospitalization time was respectively (42.86 ± 6.21)d and (67.49 ± 7.65)d in experimental group and control group, and and there was significant difference(t=2.253,P<0.05). Disease recurrence was respectively4.76%(2/42) and 23.81%(10/42),and there was significant difference(χ2=7.437, P=0.024). Conclusions The model of time nursing, with higher satisfaction level, shorter hospitalization time, and lower recurrence rate, can significantly improve the symptoms of patients with schizophrenia and enhance their self-care and social life abilities. It is worth popularizing in clinical nursing.
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<p><b>OBJECTIVE</b>To explore the high risk factors of thrombosis in paroxysmal nocturnal hemoglobinuria (PNH). It has been reported that in Chinese patients with venous thrombosis, the mutation frequency in PROC c.574_576 del (rs199469469), PROC c.565C>T (rs146922325) and THBD c.-151G>T (rs1698852) was higher than that of normal controls, indicating its importance in thrombophilia pathogenesis.</p><p><b>METHODS</b>142 patients with PNH diagnosed between 2009 and 2015 were enrolled in the study. Clinical data were analyzed and thrombophilia risk factors, such as the level of protein C, protein S, antithrombin III, APC resistance, blood fat, phospholipid antibody, were evaluated. Samples from patients and 100 normal controls were detected for the mutations of PROC c.574_576 del (rs199469469), PROC c.565C>T (rs146922325) and THBD c.-151G>T (rs1698852) by Sanger sequence.</p><p><b>RESULTS</b>Of the 142 PNH patients, 21 (14.8%) patients had at least 1 episode of thrombotic event. Only 2 patients had arterial thrombosis and 19 patients had venous thrombosis. The median age of patients with thrombosis was 35 years old, similar to those without episode (40 years old, P=0.687). The ratios of males and females were 1.33 in thrombosis group and 1.57 in non-thrombosis group (P=0.728) , respectively. Patients with thrombosis had the same disease pattern compared with those without episode. Although there was no difference in the level of hemoglobin, WBC and PLT count, and LDH level between patients with thrombosis and those without episode, patients with thrombosis showed higher RBC, higher percentage of CD59(-) granulocytes and RBC, and Flaer(-) granulocytes compared with those without episode. The routine thrombophilia screening tests did not show any difference either between PNH patients and normal controls, or between patients with or without thrombosis. There were two mutations in rs199469469 and rs16984852 sites in patients with PNH, but the mutated patients did not have any thrombosis. Mutation rs146922325 was found in PNH patients. The mutation rate was similar between PNH patients and normal controls, thrombotic PNH and non-thrombotic PNH (P>0.05).</p><p><b>CONCLUSIONS</b>Compared with non-thrombotic patients, PNH thrombotic patients have bigger PNH clone and higher RBC count. There are no differences among the routine thrombophilia factors and the three known venous eligible genes either between PNH patients and normal controls or between thrombotic and non-thrombotic PNH patients.</p>
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Adult , Female , Humans , Male , Antithrombin III , Metabolism , Case-Control Studies , Clone Cells , Cell Biology , Granulocytes , Cell Biology , Hemoglobinuria, Paroxysmal , Genetics , Leukocyte Count , Protein C , Metabolism , Protein S , Metabolism , Risk Factors , Thrombosis , GeneticsABSTRACT
With the emerging of aging society and advances of information sciences, telemedicine has gradually become a new medical model.Telemedicine can be used in health monitoring, disease diagnosis, counseling, education, chronic disease management and long-term care in elderly population;particularly in management of chronic heart failure, diabetes and other chronic diseases, as well as in referral and continuous medical care.To promote telemedicine in the elderly population can break the physical limitations of different health care settings, so that geriatrician and the allied team members are enable to maximize their values in providing corresponding health services.This article reviews the progress of telemedicine in foreign countries, which would be of reference value for development of telemedicine for elderly people in China.
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Objective To investigate the differences of four equations to estimate glomerular filtration rate (GFR) and their impacts on chronic kidney disease (CKD) prevalence in communitydwelling elderly people in Beijing.Methods A total of 489 participants aged above 70 years were enrolled.The GFR was estimated using the Cockcroft Gault (CG) equation,Chronic Kidney DiseaseEpidemiology Collaboration (CKD-EPI) equation,Modification of Diet in Renal Disease (MDRD) equation and Berlin Initiative Study (BIS) equation respectively.The internal-consistency check was made on the four equations for the GFR (ml min 1 1.73m 2) estimates.Results The mean age of participants was (81.8±7.6) years.The mean GFR estimated using the CG,CKD-EPI,MDRD and BIS equation was 58.4± 17.2,71.9± 15.3,76.7± 19.1 and 62.7± 12.7,respectively.And the prevalence of CKD was 56.2％,22.7％,17.8％ and 41.7％,respectively.The greatest differences of equations to estimate GFR were seen in elderly people aged 90 and above,and those with body mass index＜ 20.0 kg/m2 or serum creatinine concentration＜ 88.4 μmol/L.Conclusions The GFR estimated using different equations has a large difference which has a significant effect on CKD classification in elderly people.The equation to estimate GFR for the elderly is urgently needed.Until then,the eGFR and CKD classification estimated using different equations should be regarded with caution.
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Objective To summarize the progress of research on the influence of nutrition support on quality adjusted life year (QALY) in elderly patients with nutritional risk, and to evaluate the feasibility of QALY as an outcome indicator.Methods Literature in Chinese, English and Japanese relating to the feasibility of QALY and cost-utility in evaluating the influence of nutrition support on the outcomes of patients with nutritional risk published from 1980 to 2013 were searched in Wanfang, China National Knowledge Infrastructure,PubMed, Nature databases.The methodological quality of randomized controlled trials was assessed using Jadad scale combined with Schulz allocation concealment, and the quality of cohort studies with Newcastle-Ottawa scale.Results Totally 10 articles were fotnd, in which 8 were selected, including 6 randomized controlled trial and 2 cohort studies, covering 1 130 patients;the other 2 were excluded for not conforming to inclusion criteria.Four of the 6 randomized controlled trial indicate that QALY is higher and all-cost is lower in the treatment group compared with the control group (or cost-utility is higher in the treatment group).The 2 cohort studies indicate that total parenteral nutrition support at home could improve the QALY of malnourished patients and could save cost compared with nutrition support at hospital when necessary.Conclusions Nutrition support for patients with nutritional risk can improve prognosis, reduce cost, and increase QALY.More large-scale, high-quality randomized controlled trials are needed to evaluate the effect of nutrition support on the QALY of elderly patients with nutritional risk.
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Medical charts of tuberculotic patients with secondary autoimmune hemolytic anemia (AIHA) admitted to Peking Union Medical College Hospital (PUMCH)from 2006 to 2015 were retrospectively reviewed.Four cases with complete information of laboratory tests,imaging findings and bone marrow results were included.Therapy regimens and outcomes of survival were followed by phone call if needed.Ages at diagnosis of AIHA were 58-80 years old,hemoglobin levels were 31-73 g/L,Coomb tests were negative in all cascs.Thcrapy of cortical steroid did not work,while anti-TB therapy (including isoniazid,rifampicin,ethambutol) significantly improved hemoglobin to normal level in three cases during six to nine months.One case died within one week,for progressive TB to central neurological system.As one of rarc complications of TB,AIHA may be fatal.Early diagnosis and appropriately anti-TB therapy is helpful for good outcomes.
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This paper reviews the etiology , pathogenesis ,prediction and evaluation and other related aspects of motion sickness in order to contribute to further research on motion sickness and to proride the theorotic basis for prevention .
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ObjectiveTo improve an obvious postoperative man-made crease when eyes closed and to achieve the optimal cosmetic and functional results.MethodsExposing and scissoring the levator aponeurosis were performed to make it move freely.Fairly infra-incision and lower margin orbicularis oculi muscle were cut.The double eyelids were formed by fixing the palpebral dermis of the lower skin flap onto the levator aponeurosis.ResultsThe follow-up of 580 patients (1160 eyes) showed that double eyelid crease were natural and fluent,eyelashes raised slightly,there was no an obvious postoperative man-made crease when eyes closed,and there was no sausage-appearing. Conclusions The method is quick,with minor injury and fast restoration. There is no sausage appearance and an obvious man-made crease when eyes are closed,and so double eyelids are natural and nice,the postoperative results are all aesthetically and functionally pleased.
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ObjectiveTo explore the characteristic and difference of the executive function of the premeditated group and attack group of male juvenile delinquents by the Stroop test.Methods 123 male juvenile delinquents and 128 normal controls were examined by a general information questionnaire,the Stroop test of the Chinese version and impulsive premeditated aggression scale (IPAS).SPSS17.0 statistical software used to analysis the survey results.Results ( 1 ) By Stroop test the premeditated group and impulsive group of juvenile delinquents was found that correct number of test 3( 109.97 ± 1.87),errors number of test 4(4.45 ±4.84),amend number of test 1 and test 4 ( 1.18 ± 1.50 ; 1.50 ± 1.59 ),and completion time of test 4 ( 143.74 ± 28.36) had statistically significant (P ＜ 0.05 ),the others had no significant difference between the two groups.(2) The premeditated group of juvenile delinquents and normal adolescents in Stroop test comparison was statistically significant in completion time of test 1,test 2 (56.49 ± 14.90 ;88.31 ± 20.02)(P ＜ 0.05 ).The impulse group of the juvenile delinquents and normal adolescents was statistically significant in the correct number of test 2 to test 4( 107.20 ± 3.39 ; 109.97± 1.87 ; 102.47 ± 5.62 ),errors number of test 2 ( 1.86 ± 2.27 ),amends number of test 3 ( 1.50 ± 1.59 ),and completion time of test 1 to test 4 (59.96 ± 11.08 ;92.03 ± 20.87 ;62.77 ± 12.31 ; 143.74 ± 28.36) (P ＜ 0.05 ).The others of two groups were no significant difference.ConclusionIt is found that juvenile delinquents exist defects of executive function,and perform functional defects in the attack group of juvenile delinquents is more obviously.
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Objective To summarize the perioperative nursing cares for patients with coronary in-tervention by transraidal approach. Methods Retrospective analyzed the nursing cares among 42 pa-tients with coronary intervention by transraidal approach. Results Normal postoperative radial plnse were monitored in 42 patients, there were no flase aneurysm, arterio-venous fistula, median nerve injury and dysporia occurred. Conclusions Coronary intervention by transraidal aporoach can reduce perioperative hemmorrhage, avoid certain related complications and saving financial costs. Renforee preoperative psychological cares can re-lease pains of patients and then promote the nursing quality.