【作者】 石岩；

【导师】 张艳；

【作者基本信息】 郑州大学 ， 护理学， 2024， 硕士

【摘要】 目的1.构建PCI术后患者居家心脏康复云督导方案。2.探讨干预方案对PCI术后患者康复依从性、心功能、疾病复发高危因素、生活质量以及3个月内再次入院率的的影响。方法本研究共分为两部分:第一部分 PCI术后患者居家心脏康复云督导方案的构建。(1)PCI术后患者居家心脏康复需求的描述性质性研究。通过访谈法,完成对不同类别患者的访谈,深入挖掘并分析PCI术后患者居家心脏康复的真实需求,为干预方案的构建提供参考。(2)通过文献研究完善PCI术后患者居家心脏康复云督导方案。制定文献检索策略,检索并分析心脏康复相关干预研究,为后期PCI术后患者居家心脏康复云督导方案的制定提供理论依据和实践指引。(3)PCI术后患者居家心脏康复云督导方案的修订。基于前期质性访谈、文献研究初步构建干预方案初稿,选择16名专家开展2轮专家咨询,形成干预方案施测稿。第二部分 PCI术后患者居家心脏康复云督导方案的应用及效果评价。选取邓州市一所三级综合医院位于两个不同楼层的心血管内科病区作为研究对象。采用抛硬币法随机将两个病区分配为干预组和对照组,每组计78名患者,合计156名。对照组予以常规治疗护理,干预组在常规治疗护理的基础上出院后予以居家心脏康复云督导方案。所有患者分别于干预前、干预后即刻、干预后1个月、干预后3个月评价康复依从性、心功能、疾病复发高危因素、生活质量及3个月内再入院情况。主要采用统计描述、独立样本t检验、Mann-WhitneyU秩和检验、广义估计方程等方法进行统计分析。检验水准a=0.05。结果第一部分(1)本阶段通过对16名经过PCI介入治疗的患者进行深入访谈,综合分析后概括出以下3大主题和16个维度的亚主题:获取知识需求(疾病管理与预防、科学的运动康复指导、健康饮食指导、有效的自我监测、急救知识与技能、合理用药的指导、科普知识的趣味性和有效性)、获取信息渠道需求(通过智能手机获取信息、通过电话随访获取信息、通过传统的健康讲座获取信息、通过多种方式结合的方式获取信息)、获取支持需求(专业医护人员的支持和督导、同伴交流、家人陪伴与指导、居家康复安全保障、医保等相关政策的支持)。(2)该阶段制定文献检索策略,严格按照文献纳排标准独立进行文献筛选和资料提取,最终纳入10篇文献,结合质性研究内容提炼出来的主题和亚主题将文献进行归纳总结,形成干预方案初稿。(3)选择16名专家开展2轮专家咨询,形成干预方案施测稿。干预方案主要内容为电子健康素养、健康知识我来答、日常监测我会做、远离睡眠障碍、规律排便、急救技能人人学、规范合理用药、助力健康饮食、阳光心“晴”,一路同行、远离不良嗜好倡导健康生活、生命不息运动不止等12个主题。干预时间为12周,每次60～90分钟;干预形式为线上方式,如:腾讯课堂、抖音、微信等途径;干预方案的质量控制是针对干预的内容进行远程督导,干预小组分工合作,宣教护士主要负责患者的心脏康复教育,督导护士主要负责干预方案质量的控制,将干预工作分层次、分职责完成。第二部分本研究共纳入患者156例,脱落13例,失访率为8.33%,有效样本数量为143例,其中干预组72例,对照组71例,两组研究对象基线均衡可比。(1)康复依从性:通过研究分析两组患者在干预前后的服药依从性差异,结果表明组间效应差异具有统计学意义(Wald χ2=7.939,P<0.05),时间效应差异具有统计学意义(Wald χ2=15.714,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.582,P<0.05)。干预前后两组患者复查依从性组间效应差异具有统计学意义(Wald χ2=6.689,P<0.05),时间效应差异具有统计学意义(Wal d χ2=15.896,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.857,P<0.05)。干预前后两组患者戒烟依从性组间效应差异具有统计学意义(Waldχ2=4.481,P<0.05),时间效应差异具有统计学意义(Wald χ2=16.561,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.967,P<0.05)。干预前后两组患者限酒依从性组间效应差异具有统计学意义(Wald χ2=12.309,P<0.05),时间效应差异有统计学意义(Wald χ2=14.608,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.529,P<0.05)。干预前后两组患者运动依从性组间效应差异有统计学意义(Wald χ2=9.508,P<0.05),时间效应差异有统计学意义(Wald χ2=15.580,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.688,P<0.05)。干预前后两组患者饮食依从性组间效应差异有统计学意义(Waldχ2=3.902,P<0.05),时间效应差异具有统计学意义(Wald χ2=21.185,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=10.989,P<0.05)。干预前后两组患者BMI达标组间效应差异具有统计学意义(Wald χ2=8.027,P<0.05),时间效应差异具有统计学意义(Wald χ2=16.357,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.403,P<0.05)。(2)心功能:通过对照实验研究两组患者在干预前后左心室射血分数(LV EF)的变化表明,组间效应差异具有统计学意义(Wald χ2=6.612,P<0.05),时间效应差异具有统计学意义(Wald χ2=32.344,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=22.063,P<0.05)。干预前后两组患者6分钟步行实验的组间效应差异具有统计学意义(Wald χ2=5.974,P<0.05),时间效应差异具有统计学意义(Wald χ2=27.112,P<0.05),干预因素与时间因素存在交互效应(Wal d χ2=9.596,P<0.05)。干预前后两组患者心输出量的组间效应差异具有统计学意义(Wald χ2=5.421,P<0.05),时间效应差异具有统计学意义(Waldχ2=16.209,P<0.05),干预因素与时间因素不存在交互效应(Wald χ2=6.623,P>0.05)。(3)疾病复发高危因素:疾病复发高危因素的评估结果显示,经过干预后两组患者的SBP的组间效应差异具有统计学意义(Wald χ2=11.126,P<0.05),时间效应差异具有统计学意义(Wald χ2=27.876,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.415,P<0.05)。两组患者的DBP的组间效应差异具有统计学意义(Wald χ2=4.498,P<0.05),时间效应差异具有统计学意义(Waldχ2=17.649,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.593,P<0.05)。两组患者空腹血糖的组间效应差异具有统计学意义(Wald χ2=8.244,P<0.05),时间效应差异具有统计学意义(Wald χ2=13.032,P<0.05),干预因素与时间因素不存在交互效应(Wald χ2=4.614,P>0.05)。两组患者总胆固醇的组间效应差异具有统计学意义(Wald χ2=5.708,P<0.05),时间效应差异具有统计学意义(Wald χ2=19.757,P<0.05),干预因素与时间因素不存在交互效应(Wald χ2=5.939,P>0.05)。两组患者甘油三酯的组间效应差异具有统计学意义(χ2=12.935,P<0.05),时间效应差异具有统计学意义(Wald χ2=18.688,P<0.05),干预因素与时间因素存在交互效应(Wald χ2=8.228,P<0.05)。(3)生活质量:干预3个月后对照组患者生活质量总分为(62.80±14.73)分,干预组患者生活质量总分为(88.46±8.85)分,两组数据组间效应差异具有统计学意义(Wald χ2=152.233,P<0.05),时间效应差异具有统计学意义(Wald χ2=156.329,P<0.05),干预因素与时间因素存在交互效应(Waldχ2=85.565,P<0.05)。(4)3个月内再次入院率:在为期三个月的观察中,干预组的再次入院率为5.6%,明显低于对照组的16.9%,经统计分析,二者间的差异具有统计学意义(P<0.05)。结论对PCI术后患者进行居家心脏康复云督导可以明显改善患者的心功能,提高患者的运动耐力,提升患者对于疾病复发高危因素的管理能力,提高患者的生活质量、治疗依从性,降低再次入院率,具有一定的临床价值。更多还原

【Abstract】 Objectives1.Construct a cloud supervision scheme for home cardiac rehabilitation of patients after PCI.2.To explore the effects of intervention programs on treatment compliance,heart function,risk factors for disease recurrence,quality of life and readmission rate within 3 months after PCI.MethodThis study is divided into two parts:Part Ⅰ:Construction of home cardiac rehabilitation cloud supervision scheme for patients after PCI.(1)Descriptive nature study of home cardiac rehabilitation needs of patients after PCI.Through interviews,different categories of patients were interviewed,and the real needs of home cardiac rehabilitation of patients after PCI were deeply explored and analyzed,providing references for the construction of intervention programs.(2)Improve the cloud supervision program of home cardiac rehabilitation for patients after PCI through literature research.Literature search strategies were developed,and intervention studies related to cardiac rehabilitation were retrieved and analyzed to provide reference for the formulation of at-home cardiac rehabilitation cloud supervision program for patients after post-PCI.(3)Revision of home cardiac rehabilitation cloud supervision scheme for patients after PCI.Following initial qualitative interviews,a thorough examination of the background,and an extensive review of relevant literature,the inaugural version of the intervention plan was crafted.Subsequently,a carefully chosen panel of 16 specialists engaged in a dual-stage consultation process,ultimately shaping the trial version of the intervention strategy.Part Ⅱ:Application and effect evaluation of home cardiac rehabilitation cloud supervision scheme for patients after PCI.In the Cardiology Department of a comprehensive tertiary hospital in Dengzhou,two separate wards situated on different levels were opportunistically chosen for a study.The allocation of these wards into an intervention group and a control group was determined by a coin flip,with each group comprising 78 individuals,summing to a collective total of 156 participants.The control group received standard care and nursing,whereas the intervention group benefited from a post-discharge cardiac rehabilitation program supported by cloud oversight,in addition to the conventional care.Parameters such as adherence to treatment,cardiac efficacy,recurrent disease risk factors,life quality,and instances of readmission were assessed at multiple points:prior to the intervention,right after its implementation,one month post-intervention,and finally,at the three-month mark following the intervention.The methods of statistical description,independent sample t test,Mann-Whitney U rank sum test and generalized estimation equation were used for statistical analysis.Test level a=0.05.ResultsPart Ⅰ:(1)In this stage,16 post-PCI patients were interviewed,and a total of 3 themes and 16 sub-themes were extracted:Demand for knowledge acquisition(disease management and prevention,scientific exercise rehabilitation guidance,healthy diet guidance,effective self-testing,first-aid knowledge and skills,guidance on rational drug use,interest and effectiveness of popular science knowledge),demand for information channels(access to information through smartphones,access to information through telephone follow-up visits,access to information through traditional health lectures,and access to information through a combination of methods),demand for support(support and supervision of professional medical staff,peer communication,family companionship and guidance,home rehabilitation security,medical insurance and other related policies).(2)In this stage,literature retrieval strategies were developed,literature screening and data extraction were carried out independently in strict accordance with the criteria of literature inclusion and ranking,and 10 literatures were finally included.The literatures were summarized according to the themes and sub-themes extracted from the qualitative research content,and the preliminary intervention plan was formed.(3)A group of 16 specialists was chosen to conduct 2 rounds of expert consultations and develop the intervention plan draft.The main content of the intervention program is health literacy,health knowledge I answer,daily monitoring I will do,away from sleep disorders,regular defecation,first-aid skills and human learning,standardized and rational drug use,help healthy diet,sunny heart ’sunny’,along the way,away from bad habits to advocate healthy life,life more than 12 themes.The duration of intervention was 60 to 90 minutes for 12 weeks.The intervention forms were online,such as Tencent Class,Tiktok,wechat,etc.The quality assurance for the intervention strategy involves overseeing the intervention’s content remotely,with the team members collaborating through a division of labor.The education nurses are mainly responsible for the cardiac rehabilitation education of patients,and the supervision nurses are mainly responsible for the quality control of the intervention plan,and the intervention work is completed by layers and responsibilities.Part two:This study encompassed 156 participants,of which 13 were identified as cases of shedding.The attrition rate stood at 8.33%,leaving 143 valid samples for analysis.Among these,72 individuals were part of the intervention cohort,while the control group consisted of 71 cases.The baseline balance of subjects in the two groups was comparable.(1)TAdherence to treatment:There was a notable difference in how well each group stuck to their medication regimens before and after the intervention,with this disparity having statistical significance(Wald χ2=7.939,P<0.05).Additionally,the variation over time in medication adherence was also statistically significant(Waldχ2=15.714,P<0.05).There was interaction effect between intervention factors and time factors(Wald χ2=8.582,P<0.05).The discrepancy in review compliance across the two groups showed a notable shift pre-and post-intervention,with robust statistical backing(Wald χ2=6.689,P<0.05),Similarly,the evolution over time was marked by a significant statistical change(Wald χ2=15.896,P<0.05),Additionally,an interactive dynamic between the intervention measures and the temporal elements was observed,further substantiated by the data(Wald χ2=8.857,P<0.05).There was a statistically significant difference in the intergroup effect of smoking cessation compliance between the two groups before and after intervention(Wald χ2=4.481,P<0.05),and a statistically significant difference in the time effect(Wald χ2=16.561,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.967,P<0.05).There was a statistically significant difference in the intergroup effect of alcohol restriction compliance between the two groups before and after intervention(Wald χ2=12.309,P<0.05),and a statistically significant difference in the time effect(Wald χ2=14.608,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.529,P<0.05).The intergroup effect difference of exercise compliance between the two groups before and after intervention was statistically significant(Wald χ2=9.508,P<0.05),and the time effect difference was statistically significant(Wald χ2=15.580,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.688,P<0.05).The intergroup effect difference of dietary compliance between the two groups before and after intervention was statistically significant(Wald χ2=3.902,P<0.05),and the time effect difference was statistically significant(Wald χ2=21.185,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=10.989,P<0.05).Before and after intervention,there was a statistically significant difference between the two groups in the effect of BMI reaching the standard(Wald χ2=8.027,P<0.05),and a statistically significant difference in the time effect(Wald χ2=16.357,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.403,P<0.05).(2)Heart function:The difference of LVEF between the two groups before and after intervention was statistically significant(Wald χ2=6.612,P<0.05),the difference of time effect was statistically significant(Wald χ2=32.344,P<0.05),and there was an interaction effect between intervention factors and time factors(Wald χ2=22.063,P<0.05).Before and after intervention,there was a statistically significant difference between the two groups in the 6-minute walking experiment(Wald χ2=5.974,P<0.05)and a statistically significant difference in the time effect(Wald χ2=27.112,P<0.05).There was an interaction effect between intervention factors and time factors(Waldχ2=9.596,P<0.05).The intergroup effect difference of cardiac output between the two groups before and after intervention was statistically significant(Wald χ2=5.421,P<0.05),the time effect difference was statistically significant(Wald χ2=16.209,P<0.05),and there was no interaction effect between intervention factors and time factors(Wald χ2=6.623,P<0.05).(3)Control of high-risk factors for disease recurrence:The intergroup effect difference of systolic blood pressure between the two groups before and after intervention was statistically significant(Wald χ2=1 1.126,P<0.05),and the time effect difference was statistically significant(Wald χ2=27.876,P<0.05).There was interaction effect between intervention factors and time factors(Wald χ2=8.415,P<0.05).The difference of diastolic blood pressure between the two groups before and after intervention was statistically significant(Wald χ2=4.498,P<0.05),and the difference of time effect was statistically significant(Wald χ2=17.649,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.593,P<0.05).Before and after intervention,the difference of fasting blood glucose between the two groups was statistically significant(Wald χ2=8.244,P<0.05),and the difference of time effect was statistically significant(Wold χ2=3.032,P<0.05).There was no interaction effect between intervention factors and time factors(Wald χ2=4.614,P<0.05).The intergroup effect difference of total cholesterol between the two groups before and after intervention was statistically significant(Wald χ2=5.708,P<0.05),the time effect difference was statistically significant(Wald χ2=19.757,P<0.05),and there was no interaction effect between intervention factors and time factors(Wald χ2=5.939,P<0.05).Before and after intervention,the difference in the intergroup effect of triglyceride between the two groups was statistically significant（Wald χ2=12.935,P<0.05),and the difference in the time effect was statistically significant(Wald 2=18.688,P<0.05).There was an interaction effect between intervention factors and time factors(Wald χ2=8.228,P<0.05).(4)Quality of life:After 3 months of intervention,the total score of quality of life in the control group was(62.80±14.73)points,and that in the intervention group was(88.46±8.85)points,and the difference between the two groups was statistically significant（Wald χ2=152.233,P<0.05).The difference of time effect was statistically significant(Wald χ2=156.329，P<0.05),and there was an interaction effect between intervention factors and time factors(Wald χ2=85.565,P<0.05).(5)Readmission rate within 3 months:The readmission rate within 3 months in the intervention group(5.6%)was lower than that in the control group(16.9%),and the difference was statistically significant(P<0.05).ConclusionsHome cardiac rehabilitation cloud supervision for patients after PCI can significantly improve patients’ heart function,improve patients’ exercise endurance,enhance patients’ management ability of high-risk factors for disease recurrence,improve patients’ quality of life,rehabilitation compliance,and reduce readmission rate,which has certain clinical value.更多还原