iii ABSTRACT Stroke due to intracerebral haemorrhage is defined as the rapidly developing clinical signs

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    Name of Candidate: Sabarisah Hashim

    Registration/Matric No: MHA 080001

    Name of Degree: Doctor of Philosophy

    Title Thesis: Factors Affecting Early and Long Term Adaptation among Post

    Primary Intracerebral Haemorrhage Patients

    Field of Study: Neuro Surgical Nursing

    I do solemnly and sincerely declare that:

    (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for

    permitted purposes and any excerpt or extract from, or reference to or reproduction of

    any copyright work has been disclosed expressly and sufficiently and the title of the

    Work and its authorship have been acknowledged in this Work;

    (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work;

    (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that

    any reproduction or use in any form or by any means whatsoever is prohibited without

    the written consent of UM having been first had and obtained;

    (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any

    other action as may be determined by UM.

    Candidate’s Signature Date

    Subscribed and solemnly declared before,

    Witness’s Signature Date



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    Stroke due to intracerebral haemorrhage is defined as the rapidly developing clinical signs

    of neurologic dysfunction related to the focal collection of blood within the brain

    parenchyma which is not attributed to trauma. A person with stroke related to primary

    intracerebral haemorrhage (PICH) may exhibit physical disabilities, cognitive deficits,

    speech problems, emotional difficulties, daily living problems and post stroke

    complications. Adaptation to achieve greater independence to function in activities is

    crucial in relation to achieved positive stroke recovery outcomes.

    This study aimed to determine the early functional adaptation, later (3 months) functional

    adaptation, improvement over time, and factors associated with achieving the functional

    recovery of PICH patients admitted at Hospital Universiti Sains Malaysia and Hospital

    Sultanah Nur Zahirah, Kuala Terengganu, Malaysia. The specific questionnaire includes

    the Functional Independence Measure (FIM score), National Institutes of Health Stroke

    Scale (NIHSS), Complication Inventory Checklist (CIC), Patient Health Questionnaire

    Nine-item Depression Scale (PHQ-9-DS), and Stroke Knowledge Checklist (SKC). A

    total of 113 subjects were included in the analysis.

    The subjects consisted of 66 (58%) men and 47 (41.6%) women. Their mean (SD) age

    were 55.0 (SD=11.8) years. The majority of participants were hypertensive (95.6%).

    Basal ganglia were the most common area (49.5 %) of bleeding, followed by bleeding in

    the lobar areas (20.3%) and thalamic (14.1%) of the brain. Fifteen patients (13%)

    underwent surgery combined with conservative treatment, whereas 98 patients (86%)

    received conservative treatment. The mean (SD) length of hospitalisation was 12.0 (SD

    =14.1) days.

    The total mean (SD) of early functional adaptation score (FIM) was 48.1(30.1), which

    indicated low functional adaptation in acute recovery phase. Later (3 months) functional

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    adaptation total mean (SD) score was expected at a significantly higher than the early

    adaptation score, the total mean difference, t (112) = -16.45, p < .05, 95% Cl [-50.6, -

    39.7]. This finding indicates that functional adaptation markedly improved at three month

    post PICH after received treatment and rehabilitation intervention.

    Multiple linear regression analysis demonstrated that five associated variables

    statistically predicted as factors affecting of the early functional adaptation score, R2 =

    .52, F = 22.7, p < .05). Females (β = 9.6, p = .023), intracerebral bleeding in the non-

    lobar area (β = -16.7, p < .001), higher neurological deficit score (β = - 1.91, p < .001),

    respiratory infection (β = -16.7, p < .001), and lower stroke knowledge score (β = 2.89, p

    = .09) were associated with lower early functional adaptation score.

    The regression analysis of later (3 months) functional adaptation accounted for, R2 = .65,

    F = 33, p < .05) of the factors affecting later (3 months) adaptation score. Six predictors

    including young age (β = - 0.82, p < .001), early functional adaptation score (β = .40, p <

    .001), high stroke knowledge (β = 2.78, p < .001), lack of exposure to urinary infection

    at three months post PICH (β = -29.1, p < .001), absence of depression at three months

    post PICH (β = - 0.98, p < .001), and appropriate ICH treatment (β = 22.5, p < .001) were

    identified as factors associated with the increase in later (3 months) adaptation outcome

    score at three months post PICH.

    A better understanding of the factors that affect the adaptation process is essential in the

    planning of specific stroke education and rehabilitation interventions with the aim of

    enhancing functional recovery process.

    Keywords: intracerebral haemorrhage, stroke, stroke related disability, adaptation, post

    stroke complications.

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    Strok yang disebabkan oleh perdarahan intraserebral primer didefinisikan sebagai

    terbentuknya tanda-tanda klinikal ketidakfungsian sistem neurologik yang disebabkan

    terdapat pengumpulan darah di dalam parenkima otak yang bukan terjadi akibat

    kecederaan. Individu yang mengalami strok akibat perdarahan intraserebral primer

    mungkin mengalami kecacatan fizikal, deficit fungsi kognitif, masalah pertuturan,

    gangguan emosi, masalah ketidakupayaan melakukan aktiviti seharian dan terdedah pada

    risiko komplikasi pos-strok. Kajian ini bertujuan untuk mengenalpasti tahap adaptasi

    awal dan lewat (3bulan) akibat kecacatan selepas perdarahan intraserebral primer, tahap

    pemulihan dan faktor-faktor yang mempengaruhi adaptasi awal di fasa pemulihan akut

    dan lewat iaitu tiga bulan selepas perdarahan intraserebral primer. Subjek adalah pesakit

    yang dimasukkan ke Hospital Universiti Sains Malaysia (Hospital USM) dan Hospital

    Sultanah Nur Zahirah (HSNZ) Terengganu, Malaysia semasa Jun 2009 dan Disember

    2010 akibat perdarahan intraserebral primer. Soalan kajian yang digunakan termasuklan

    Ukuran Tahap Kebergantungan Untuk Berfungsi (Functional Independence Measure)

    (FIM), Skala Institud Kebangsaan Kesihatan Strok (National Institutes of Health Stroke

    Scale) (NIHSS), Senarai Semak Inventori Komplikasi (Complication Inventory

    Checklist) (CIC), Soalselidik Kesihatan Pesakit 9 – jenis skala tekanan (Patient Health

    Questionnaire 9-item depression scale) (PHQ-9-DS) dan Senarai Semak Tahap

    Pengetahuan tentang Stroke (Stroke Knowledge checklist) (SKC).

    Subjek terdiri dari 66 (58%) lelaki dan 47 (41.6%) wanita. Secara purata umur adalah

    55.0 (SP = 11.8) tahun. Hampir keseluruhan subjek adalah pengidap penyakit darah

    tinggi (95.6%). Lokasi perdarahan dalam otak yang utama adalah di basal ganglia (49.5

    %) diikuti dengan dalam talamik (14.1%) dan kawasan lobar (20.3%) dalam otak. Lima

    belas pesakit (13%) menjalani rawatan pembedahan serta kombinasi dengan rawatan

    ubatan dan 98 pesakit (86 %) hanya mendapat rawatan ubatan. Secara purata jangkamasa

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    tinggal dalam hospital adalah 12 (SP = 14.1) hari. Purata (Sisihan Piawai) tahap adaptasi

    awal adalah 48.1 (30.1), bermaksud tahap adaptasi awal adalah di peringkat rendah.

    Sementata purata (Sisihan Piawai) adaptasi lewat (3 bulan) adalah lebih tinggi dari di

    peringkat awal adaptasi iaitu 93.2 (34.8) berbanding adaptasi di peringkat awal iaitu t

    (112) = -16.45, p < .05, 95% Cl [-50.6, -39.7], yang membawa maksud tahap adaptasi

    menunjukkan ada peningkatan pada tiga bulan selepas menjalani rawatan dan pemulihan.

    Analisia ujian regresi linear berganda menunjukan terdapat lima varibel secara signifikan

    menyumbang sebagai faktor yang mempengaruhi skor adaptasi awal, R2 = .52, F = 22.7,

    p < .05). Jantina wanita (β = 9.6, p = .023), perdarahan dalam otak di bahagian luar lobar

    otak (β = -16.7, p < .001), tahap keterukan defisit neurologi (β = - 1.91, p < .001), infeksi

    salur pernafasan (β = -16.7, p < .001), dan tahap pengetahuan yang rendah tentang

    penyakit strok (β = 2.89, p = .09,) adalah yang faktor berkait dengan skor tahap adaptasi

    awal yang rendah. Analisis regresi linear berganda bagi adaptasi lewat (3 bulan),

    keputusan menunjuk