慢性心力衰竭患者的延续性护理有效模式探究

　　中文摘要

    目的 了解慢性心力衰竭患者的自我护理行为和生活质量现状，出院后的护理需求及社区卫生资源的利用情况，观察基于医院的延续性护理模式对慢性心力衰竭患者自我护理能力及生活质量的影响，探讨适合我国当前医疗体制下慢性心力衰竭患者的延续性护理模式。

　　方法 研究一：采用描述性研究中的横断面调查方法，抽取 2012 年 10 月 1 日～2013 年 4 月 30 日某三级甲等医院符合研究标准的 115 例慢性心力衰竭（Chronicheart failure，CHF）患者为研究对象，失访 13 例。采用自编患者一般情况调查问卷、改良的欧洲心力衰竭自我护理行为量表（European Heart Failure Self CareBehaviour scale 9，EHFSCB-9）、明尼苏达心力衰竭生活质量问卷（Minnesota Livingwith Heart Failure Questionnaire，MLHFQ 中文版）调查心力衰竭患者的自我护理行为和生活质量状况。研究二：采用随机对照临床试验研究方法，将研究一中的研究对象运用随机数字表将患者分为试验组 51 例和对照组 51 例。两组患者在住院期间给予相同的护理措施，试验组由经过培训的专门的护士实施延续性护理干预，对照组常规护理。延续性护理是运用延续护理理论给予患者信息的延续，管理的延续，关系的延续三个方面的延续性护理干预。干预 6 周进行自我护理能力（EHFSCB-9 得分）、生活质量（MLHFQ 得分）评价。采用 SPSS17.0 统计软件进行数据分析。

　　结果 研究一：导致心力衰竭的原发疾病以冠心病最多见，占 39.2%，其次是是扩张型心肌病，占 35.3%；EHFSCB-9 得分最高的是“体重增加会就医”（3.65±1.39），最低的是“按医嘱吃药”（1.39±0.90）；MLHF 问卷得分最高的是“性生活困难”（3.27±1.87），最低的是“因为治疗出现了副作用”（0.75±1.21）；年龄、经济收入、文化程度以及心力衰竭病史对自我护理行为和生活质量均无统计学意义（p>0.05）。

　　研究二：自我护理能力方面：EHFSCB-9 总分情况：干预前对照组 23.96±7.48，试验组为 22.27±7.38，无统计学意义（p=0.080)；干预后对照组 24.14±6.08，试验组14.51±4.09，有统计学意义（p<0.000)。EHFSCB-9 各分条目得分情况：干预前两组除“每天测量体质量”外，其余各条目得分均无统计学意义（p>0.05）；干预后各条目中除“按医生医嘱吃药”、“采用低盐饮食”外，得分均具有统计学意义（p<0.000)。生活质量方面：MLHFQ 总分干预前后得分差值：对照组 5.490±2.434，试验组 21.118±2.179，有统计学意义（p<0.000)；MLHFQ 各维度得分情况：症状维度两组在干预后较干预前降低，均具有统计学意义（p<0.05)，而身体活动维度、情感维度对照组较干预前无变化，而试验组较干预前得分降低，有统计学意义（p<0.000)。卫生资源利用情况：102 例患者居住区都有社区医疗卫生资源的配置,但利用率低，只有 6 例（5.88%）到过社区就诊，3 例（2.94%）在社区医疗机构建立档案。

　　结论 合肥市社区医疗卫生资源较好，但 CHF 患者对社区卫生资源的利用较差。由医院护士主导的基于医院的延续性护理模式比较适合当前三级医院开展延续性护理工作，且能够提高 CHF 患者的自我护理能力和生活质量，同时护士的价值也得到了体现。

　　关键词 延续性护理 慢性心力衰竭 自我护理能力 生活质量

　　Abstract

　　Objective The aim was to investigate the chronic heart failure patients self-carecompetence and quality of life ，care needs after hospital and their utilization ofcommunity health resources,to observe the effects on self-care ability and quality of lifein patients with chronic heart failure (CHF)who were supplied with hospital-basedcontinuity of care，and to explore suitable continuity of care model for CHF patientsunder Chinese current medical system.

　　Methods Part 1: A cross-sectional investigation method was carried out. Byconvenience sampling, 115 sample patients were selected from 2 cardiovascular wardsof Anhui Provincial Hospital from October 1, 2012 to April 30, 2013. 13 patients lost tofollow-up. Demographic data and disease characteristics variables questionnaire wasused to investigate the characteristics of patients ，European Heart Failure Self CareBehaviour scale 9(EHFSCB-9 ) was used to measure the patients self-care competenceand Minnesota Living with Heart Failure questionnaire(MLHFQ) was used to measurethe patients quality of life .Part 2:Using a randomized controlled clinical study method,the sample patients (n = 102) were randomly assigned to intervention-group (IG, n = 51)who received hospital-based continuity of care or control-group (CG, n = 51) whoreceived care according to hospital routines. Programme effects were evaluated withMLHFQ score and EHFSCB-9 score on discharge and in 6 weeks after discharge.

　　Results Part 1:Coronary heart disease was the most common course of heartfailure(39.2%), followed by dilated cardiomyopathy(35.3%); the highest EHFSCB-9score was " seeing a doctor when weight gain " (3.65 ± 1.39), the lowest was " takingmedicine according to the doctor's advice " (1.39 ± 0.90); the highest MLHF score was"sexual life difficulties"(3.27 ± 1.87), the lowest is "side effects caused by the treatment" (0.75 ± 1.21); age, income, education level and history of heart failure had no statistical significance on self-care behavior and quality of life (p>0.05). Part 2: Self care competence: There were no statistical differences in EHFSCB-9 total score before intervention, CG was 23.96 ± 7.48 and IG was 22.27 ± 7.38 ,p=0.080. There was statistical significance after intervention between the two groups, CG was 24.14 ± 6.08 and IG was 14.51 ± 4.09, p<0.000. Result of each item of EHFSCB-9 score shows: "weigh daily "(respectively 3.90 ± 1.33, 3.33 ± 1.53) and " seeing a doctor when weight gain" (respectively 3.88 ± 1.35, 3.41 ± 1.40) were the two high score items in the two groups before intervention ; Before intervention each dimension,except" weigh daily ",of EHFSCB-9 scores had no statistical significance (p> 0.05),while after intervention were statistically significant (p < 0.000),beside " taking medicine according to doctor's advice "and " with low salt diet ". Quality of life: The difference of MLHF Questionnaire total score before and after the intervention were 5.490 ± 2.434 in CGand 21.118±2.179 in IG , p<0.000; each dimension of MLHF Questionnaire score result:" symptom dimensions "score was lower after the intervention in both groups,p<0.05;Compared with before intervention there were no changes in " physical activity dimension " and " emotional dimension " in CG, while decreased in IG, p<0.000.Utilization of health resources: All patients living area there were community health care resources, but the utilization rate was low, only 6 cases (5.88%) had been to thecommunity health care, 3 cases (2.94%)were established archives in community medical institutions.

　　Conclusion Allocation of community health care resources is appropriate in Hefeicity, but the CHF patients utilization of the resources is poor.Nurse leadinghospital-based continuity of care model is suitable to the current great hospital.It canimprove CHF patients` self-care competence and their quality of life.The nurse's valuehas been reflected.

　　Key words continuity of care/ chronic heart failure/ self-care ability/ quality of life
 

　　目 录

　　中文摘要

　　英文摘要

　　前言

　　研究一 慢性心力衰竭患者自我护理能力及生活质量的调查分析

　　前言

　　对象与方法

　　结果

　　讨论

　　结论

　　研究二 医院护士主导的延续性护理对慢性心力衰竭患者自我护

　　理能力及生活质量的干预研究

　　前言

　　对象与方法

　　结果

　　讨论

　　结论

　　参考文献

　　致谢