【作者】 张林；

【导师】 宁宁；

【作者基本信息】 四川大学 ， 护理学， 2021， 硕士

【摘要】 研究背景:原发性大隐静脉曲张是一种常见的下肢静脉血管慢性疾病(Chronic venous diseases,CVD),该病病程长达数十年,患病初期可无症状或出现下肢轻度疼痛、酸胀、沉重感,随着病情进展,出现下肢浅静脉曲张隆起、患肢肿胀、皮炎、局部皮肤色素沉着及湿疹等,严重者出现静脉性跛行、难愈性静脉溃疡,甚至可发生曲张静脉破裂出血休克,危及患者生命。外科手术仅为治疗原发性大隐静脉曲张的手段之一,尤其对于有深静脉血返流的下肢静脉曲张患者,目前并无公认的静脉瓣膜修复术式以阻止深静脉血返流,此类患者即使接受下肢浅静脉手术治疗,术后仍存在较大的疾病复发风险,使患者长期饱受身心痛苦,增加卫生经济资源耗损。医用梯度弹力袜(Graduate compression stockings,GCS)压力治疗因可促进下肢静脉血液向心回流,防治血液返流瘀滞,减轻下肢肿胀、疼痛等症状,可有效保护下肢静脉、延缓下肢CVD病情发展,被认为是治疗下肢CVD的基石。伴随深静脉血返流的大隐静脉曲张术后患者须长期配合医用梯度弹力袜压力治疗,以促进术后康复和巩固手术疗效。而GCS需患者长期居家自主穿戴,患者依从性是其疗效保障的关键。目前,国内外专门针对大隐静脉曲张术后GCS穿戴依从性的研究均较匮乏,大部分研究的关注点主要集中在术后GCS穿戴疗效及最佳穿戴时长的探索中,反而对作为下肢CVD患者GCS压力治疗研究基础和前提的患者GCS穿戴依从性研究重视不足。故本研究对原发性大隐静脉曲张术后患者的GCS穿戴依从性开展调查,并分析其影响因素,以期为下肢静脉曲张的慢病管理工作提供参考依据。目的:1.调查原发性大隐静脉曲张患者术后医用梯度弹力袜穿戴依从性现况。2.探索原发性大隐静脉曲张患者术后医用梯度弹力袜穿戴依从性的影响因素。方法:本研究为横断面调查研究,采用方便抽样法选取2020年3月～2020年11月在四川省成都市某三级甲等医院行原发性大隐静脉曲张综合手术治疗(即“大隐静脉高位结扎、曲张静脉点式剥脱联合局部曲张静脉硬化剂注射”或“曲张静脉射频消融联合曲张静脉点式剥脱、局部曲张静脉硬化剂注射”)的出院患者178例为研究对象,应用患者一般情况调查表、下肢静脉曲张术后患者医用梯度弹力袜穿戴依从性调查表、Champion健康信念模式量表、社会支持评定量表对研究对象院外医用梯度弹力袜穿戴的依从性及其影响因素进行测评。选用数据录入软件Epidata3.1双人录入数据,数据统计分析采用SPSS22.0软件。统计指标描述中,计量资料以“均数±标准差”表示;计数资料则采用频数及构成比表示。采用探索性因子分析及内部一致性系数评价下肢静脉曲张术后患者医用梯度弹力袜穿戴依从性调查表的效、信度;采用独立样本t检验、单因素方差分析分析一般情况不同的患者术后医用梯度弹力袜穿戴依从性的差异;采用相关分析分析患者健康信念、社会支持与出院后医用梯度弹力袜穿戴依从性的关系;将患者医用梯度弹力袜穿戴依从性与其一般资料、健康信念、社会支持进行多元逐步线性回归分析,探究患者医用梯度弹力袜穿戴依从性的影响因素。结果:1.本研究患者共178例,其中女性106例(59.55%),男性72例(40.45%),年龄28～80岁,45～59岁年龄段者占48.31%,≥60岁者占44.94%,原发性大隐静脉曲张病程≥10年者占79.22%,54.49%的患者术前无GCS穿戴史,74.16%的患者接受的手术方式为传统外科手术(大隐静脉高位结扎、曲张浅静脉剥脱术)联合超声引导下泡沫硬化剂曲张静脉注射术的联合术式,93.26%的患者穿戴膝上型GCS,85.96%的患者GCS穿戴知识获取来源于他人传授(医护传授者占其中95.42%),知识获取方式以他人口头告知为主(94.52%)。2.下肢静脉曲张术后患者医用梯度弹力袜穿戴依从性调查表的内容效度及结构效度良好,其内容效度为0.954,探索性因子分析结果显示该量表各条目在其从属的公因子中载荷均>0.4(0.514～0.928);该量表还具有较好的信度,其Cronbach’sα系数值0.853,量表中各维度的Cronbach’sα系数为0.789～0.934,重测信度为0.759(P<0.001)。3.研究对象医用梯度弹力袜穿戴总体依从性水平一般,69.66%的研究对象医用梯度弹力袜穿戴总体依从性得分率在50.00%～74.99%。医用梯度弹力袜穿戴方法依从性得分率及注意事项依从性得分率较高,85.96%的研究对象医用梯度弹力袜穿戴方法依从性得分率集中在75.00%～100.00%,注意事项依从性得分率50.00%～74.99%者占47.75%,主动寻求建议依从性得分率水平较低,38.76%的研究对象主动寻求建议依从性得分率低于50.00%。患者自我报告影响其穿戴医用梯度弹力袜的障碍因素主要有:医用梯度弹力袜穿着带来的不适感(14.04%)、医用梯度弹力袜穿脱困难(9.55%)、感觉病情已好转,无须再穿戴(7.30%)等。4.单因素分析结果显示,不同年龄、文化程度、居住地、医疗付费方式、随访季节、握力值、心理情绪状况患者间的医用梯度弹力袜穿戴依从性有显著差异(P<0.05),患者健康信念总分、感知到的易感性维度得分、感知到的严重性维度得分、感知到的益处维度得分、感知到的障碍维度得分、健康动力维度得分及自我效能维度得分均与其院外医用梯度弹力袜穿戴依从性呈正相关(γ=0.542,0.283,0.261,0.271,0.230,0.437,0.244;P<0.05),患者社会支持水平、客观支持水平及主观支持水平与其医用梯度弹力袜穿戴依从性呈正相关(γ=0.219,0.169,0.169;P<0.05)。多因素分析结果显示,患者年龄、文化程度、居住地、握力、健康信念中健康动力、感知到的易感性、感知到的障碍、感知到的益处、感知到的严重性及社会支持中的主观支持进入了患者医用梯度弹力袜穿戴依从性影响因素多因素分析的多元逐步线性回归方程(P<0.05),是影响患者医用梯度弹力袜穿戴依从性的主要因素。结论:1.下肢静脉曲张术后患者医用梯度弹力袜穿戴依从性调查表信、效度良好,可用于测评原发性大隐静脉曲张术后患者医用梯度弹力袜穿戴依从性。2.原发性大隐静脉曲张患者术后医用梯度弹力袜穿戴依从性一般,其中主动寻求建议依从水平最低,医护人员应对患者术后医用梯度弹力袜穿戴的依从性现况给予重视,分析原因,寻求改善策略,努力提高患者医用梯度弹力袜穿戴的依从性。3.患者年龄、文化程度、居住地、握力、健康动力、感知到的易感性、感知到的严重性、感知到的益处、感知到的障碍、主观支持是影响其术后医用梯度弹力袜穿戴依从性的主要因素。患者越年轻、文化程度越高、居住地越城市化、握力值越大、健康动力、感知到的易感性、严重性、益处及障碍越强,主观支持水平越高,其术后医用梯度弹力袜穿戴依从性越好。更多还原

【Abstract】 Background:Primary great saphenous vein varicose is a common kind of Chronic Venous Disease(CVD),which may last for decades.In the early phase of this disease,patients may not have obvious symptoms,or only with slight pain,edema,skin irritation,pigmentation,eczema in lower limbs,etc.But with the progression of this disease,patients may suffer from venous claudication,unhealed ulcers,and even hemorrhagic shock because of fracted varicose veins.Surgical procedures are only one of the means of treating primary varicose veins,Especially for patients with deep venous blood regurgitation,there is no accepted method of venous valve repair to prevent deep venous blood reflux.Even if this kind of patients receive superficial vein surgery of lower extremities,there is still a great risk of recurrence after the operation,which makes the patients suffer from physical and mental burden for a long time and increases the consumption of health and economic resources.Compression therapy using Medical Graduated Compression Stockings(GCS)can effectively protect veins in lower limbs and delay the development of CVD,because it can promote the concentric reflux of the lower extremity venous blood,prevent and cure the blood reflux stasis,relieve the swelling and pain of lower extremities,and is considered to be the cornerstone of the treatment of CVD.Postoperative Patients with deep venous blood regurgitation need Compression therapy of GCS for a long time to promote postoperative rehabilitation and consolidate the curative effect.But patients are required to wear GCS at home for a long time,so their adherence to correct GCS use is of critical importance to the treatment outcome.At present,there are few related studies on postoperative patients’ wearing compliance of GCS.Most of the studies focus on the exploration of postoperative GCS wear efficacy and optimal wear time,but pay less attention to the GCS wear compliance which is the basis and premise of GCS compression therapy.Therefore,this study investigated the GCS wear compliance of patients who received the combined varicose vein operation,and analyzed its influencing factors in order to provide a reference for this chronic disease management.Objective:1.To investigate and describe compliance status of graduated compression stockings compression therapy among postoperative primary great saphenous vein varicose patients.2.To explore and analyze the related factors of patients’ compliance and non-compliance.Methods:A cross-sectional study was conducted using a convenient sampling design.A total sample of 178 discharge patients who received combined operation(“High ligation plus Vein striping and Ultrasound-guided foam sclerotherapy” or“Radiofrequency ablation plus Vein striping and Ultrasound-guided foam sclerotherapy)for lower limb vein varicose in a Tertiary A hospital,Chengdu,Sichuan Province,China,were recruited into this study.A structured questionnaire applied to the patients collected their general information,the level of patients’ health belief and social support were assessed through the Champion Health Belief Model Scale and the Social Support Rate Score,patients’ compliance of wearing graduated compression stockings was evaluated by a self-designed questionnaire,the Graduated Compression Stockings Wearing Compliance Scale for Postoperative Lower Limb Vein Varicose Patients.Data entry was done by 2 individuals through Epidata3.1,SPSS 22.0 was used for data analysis.The counting date was described by frequency and composition ratio,and the measurement data were expressed by the mean and standard deviation.Exploratory factor analysis and Cronbach’s αcoefficient were used to test the self-designed scale’s structure and reliability.Independent t-test and One-way ANOVA were used to compare the compliance of wearing graduated compression stockings among patients with different general information.Relationships between patients’ health belief,social support and compliance of graduated compression stockings were analyzed by correlation analysis.The patients’ compliance of graduated compression stockings and their general data,social support and health beliefs were analyzed by multiple stepwise linear regression analysis to explore the influencing factors of graduated compression stockings compliance.Results:1.A total of 178 patients were included in this study,with 106(59.55%)females and 72(40.45%)males,and the age range is 28～80 years,48.31% of the patients were 45～59 years old,44.94% of them were above 60 years old,79.22% of the patients with primary great saphenous vein varicose for more than 10 years,54.49%patients didn’t have a history of wearing GCS before the operation,74.16% of them received high ligation plus vein striping and ultrasound-guided foam sclerotherapy,93.26% of them chose knee-length stockings to wear,and 85.96% patients acquired knowledge of wearing GCS from others(95.42% of them acquired GCS wearing knowledge from health care providers),and the method of knowledge acquisition is oral notification by others mainly.2.The content validity of the Graduated Compression Stockings Wearing Compliance Scale for Postoperative Lower Limb Vein Varicose Patients was 0.954,results of the exploratory factor analysis show that the factor load of each item in this scale was above 0.4(0.514～0.928).Cronbach’s α coefficient of the total scale was0.853,Cronbach’s α coefficient of each factor in this scale was 0.789～0.934,and the retested reliability coefficient of this scale was 0.759(P<0.001).3.69.66% of the patients whose compliance to wearing graduated compression stockings was within 50.00%～74.99%.85.96% of the patients whose compliance to the right methods of wearing graduated compression stockings was over 75.00%,47.75% of the patients whose compliance to the precautions of wearing graduated compression stockings was between 50.00% to 74.99%,38.76% of the patients whose compliance to searching for advices of wearing graduated compression stockings was below 50.00%.Patients’ self-reported reasons of non-compliance to wearing graduated compression stockings were: uncomfortable(14.04%),hard to put them on and take them off(9.55%),not necessary to wear(7.30%),etc.4.According to the single factor analysis results,there was a significant difference of graduated compression stockings wearing compliance among patients with different ages,educational levels,living locations,medical payment method,follow-up seasons,grip strengths,and emotional conditions(P < 0.05),patients health beliefs,and health power,self-efficacy and perceived susceptibility,perceived seriousness,perceived benefits,perceived barriers in their health beliefs were positively related to their graduated compression stockings wearing compliance(γ=0.542,0.437,0.244,0.283,0.261,0.271,0.230;P<0.01).patients social support level,their objective support and subjective support in the social support,all of them were also positively related to their graduated compression stockings wearing compliance(γ =0.219,0.169,0.169;P<0.05).Refer to the multiple stepwise linear regression analysis results,age,educational levels,living locations,grip strengths,health power,perceived susceptibility,perceived seriousness,perceived benefits,perceived barriers,subjective support entered the regressive equation of compliance(P<0.05).Conclusion:1.The Graduated Compression Stockings Wearing Compliance Scale for Postoperative Lower Limb Vein Varicose Patients had good reality and validity,which is suitable for evaluation of the graduated compression stockings wearing compliance among postoperative primary great saphenous vein varicose patients.2.The level of graduated compression stockings wearing compliance among patients in this research was medium,patients’ compliance to searching for advice was the lowest in the 3 factors of the scale.Health care professionals should pay more attention to the patients’ concordance,uncover the reasons for non-concordance,find strategies,and reach higher levels of concordance.3.The main influencing factors for the patients’ graduated compression wearing compliance were patients’ age,educational levels,living locations,grip strengths,health power,perceived susceptibility,perceived seriousness,perceived benefits,perceived barriers and subjective support.更多还原