【作者】 隋东明；

【导师】 王伯莹；

【作者基本信息】 吉林大学 ， 护理学， 2007， 硕士

【摘要】 近年来国内外研究发现慢性丙型肝炎病毒(Chronic hepatitis C virus, HCV)感染者糖尿病发病率增多,即HCV感染可能导致糖尿病(Diabetes Mellitus, DM)特别是2型糖尿病(Type 2 diabetes)的发生,而DM反过来又可加重肝脏的损害,加速了慢性丙型肝炎(Chronic hepatitis C, CHC)患者肝硬化、肝癌进度,造成恶性循环,成为威胁生命的重要因素。特别是在治疗和护理的过程中,两种疾病之间还存在着矛盾点,如CHC患者饮食中多提倡含糖食物,特别是提倡食用果糖,利于补充肝脏代谢消耗的能量,但这对于CHC诱发DM的患者来说无疑是禁忌的。目的:希望通过护理干预有效改善HCV感染合并DM患者的生活习惯,将两者联系到一起,避开矛盾,异中求同,以加强药物治疗的效果,进一步促进疾病康复,最大限度的提高生命质量。方法:选择HCV感染合并DM的患者100例,随机分为对照组48例和干预组52例,两组患者治疗方案、治疗时间和用药均相同。对照组进行用药指导,保证药物治疗效果。干预组52例患者除用药指导外,在心理、饮食、运动等方面进行护理干预,建立健康生活习惯。干预前后采用一般自我效能感量表(General Perceived Self-Efficacy Scale,GSES)对患者进行评估以了解心理干预效果。两组患者同时进行为期6个月的随访,观察并记录干预前、干预后3个月、干预后6个月两组患者空腹血糖、糖化血红蛋白及血清HCV核糖核酸(HCV–RNA)的变化,以了解药物治疗相同情况下,护理干预能否进一步促进疾病康复。结果:在药物治疗相同情况下,护理干预效果体现在:1.干预组在干预3个月后HCV-RNA变化与干预前比较P=0.0026,差异显著,而对照组则无显著差异。两组患者在干预后6个月时HCV–RNA治疗有效性比较P=0.04,治疗效果差异显著。2.干预后3个月时,两组空腹血糖、糖化血红蛋白比较无显著差异,但二者变化差值的组间对照比较P<0.05,具有统计学意义。至干预后6个月时,两组患者空腹血糖、糖化血红蛋白比较P值均<0.05,且两者变化差值的组间对照比较P值均<0.05,具有统计学意义,说明干预组空腹血糖和糖化血红蛋白下降较对照组显著。3.干预后,干预组患者在治疗疾病的态度和自信心上较干预前具有明显改善,两组患者心理量表评分比较P<0.0001,具有统计学意义,而对照组干预前后心理量表评分无显著差异。结论:1.药物治疗相同情况下,护理干预使HCV-RNA治疗效果提早出现且显著提高治疗效果。2.护理干预强化了药物治疗效果,使空腹血糖、糖化血红蛋白下降显著。3.护理干预有助于患者正确认知疾病,增强了战胜疾病的信心。4.护理干预有助于患者建立健康的生活习惯,有效提高生命质量。更多还原

【Abstract】 Chronic hepatitis C(CHC)is a kind of chronic infectious liver disease caused by Chronic hepatitis C virus(HCV) infection. After 1989, the time hepatitis C virus was first discovered, more and more studies have been confirming that HCV can cause disfunction of extrahepatic organizations and tissues such as mixed type congealed globulinemia、thyroiditis、porphyria cutanea tarda、angitis and so on except for liver damage, like liver steatosis、hepatic cirrhosis、hepatocellular carcinoma. Owing to liver playing a very important role in saccharometabolism, approaching researches between internal and domestic all discover that HCV infection may result in Diabetes Mellitus, especially Type 2 diabetes,it is the consequence of progressing damage of insulin resistance (IR) and together with secretion. The association between CHC and DM was first discovered in patients with hepatic cirrhosis. Allison etc. reported that 50% persons suffered hepatic cirrhosis after HCV infection also have been accompanying with non-insulin dependent diabetes mellitus (NIDDM), whereas there are only 9% persons suffered hepatic cirrhosis due to other reasons accompanying with NIDDM, Logic multiple regression analysis indicates the development of DM has statistically significant associativity with HCV infection. Along with deeply investigating, more and more findings indicate that hepatic cirrhosis contributes to a significant role in CHC complicating DM, but it is not the prerequisite of DM, what important is that HCV itself concerned with the development of DM. Knobler and Mehte also reported that even though not combined with hepatic cirrhosis, the occasion CHC complicating DM is notable elevated, and the chance will be more higer in persons with hepatic cirrhosis.On the other hand, liver is the critical organ in glycometabolism, DM reverses to aggravate the impairment of hepatic function. The reason may be that the disturbance of glycometabolism and fat metabolism in DM patients leads to total lipids increasing, which caused hepar adiposum、hepatomegalia and so on. Some researches has shown serum glutamic-oxaloacetic transaminase (AST), glutamate-pyruvate transaminase (ALT), total bile acids (TBA), r-glutamate-trans- peptidase (GGT) in DM patients are all higher than non-DM, which indicates that DM is the consideration factor of liver functional lesion. Tazawa etc. did a more further study and research, he considered DM is the independence and association factor of CHC patients not with hepatic cirrhosis developed primary hepatocellular carcinoma (HCC), and handling DM may reduce the occurrence of HCC.To sum up we arrived at such a conclusion: HCV infection may result in CHC which can damage hepatic function and induce DM, DM reverses to aggravate the impairment of hepatic function, which results to vicious circle, accelerating the progress of hepatic cirrhosis、hepatoma in CHC patient, at last becoming the significant life-threatening factor. It should be especially to emphasis that many contraries exist in the treatment and nursing procedure of these two diseases, for instance, we encourage patients with CHC to take drink and foods containing sugar especially laevoglucose in order to supply metabolic exhaustion of liver, but it is undoubtedly contraindicated for CHC patients with DM. Nowadays, therapeutics to CHC or to DM are successful, however, it has been becoming the same problem to all health staffs how to integrate these two diseases, avoid contradictions in the treating and nursing procedure, and eventually try to find out interventions in common to improve life quality of patients. 【Purpose】To explore nursing interventions which were used to help HCV infection patients combined with DM to build healthy habits whether or not can avoid contradictions in the treating and nursing procedure, strengthen therapeutic efficacy of medication, and at last improve life quality of patients.【Methods】100 patients who are anti-HCV positive combined with DM were divided randomly into control group (n=48), and intervention group (n=52). Patients’therapeutic regimen and duration of medication therapy of both groups are identical. Medicine administer instruction is given to 48 patients in control group to enhance patient’s medication compliance so that to ensure drug treatment effect. Instruction not only on medication administer but on psychology、dietary and physical exercise are given to 52 patients in intervention group so that they could rebuild healthy living style. Patients’attitude and confidence of diseases was evaluated by General Perceived Self-Efficacy Scale (GSES) pre- and post-nursing intervention in two groups.Six months duration follow-up visit was given to patients of two groups at same time. FBG, HbA1c and HCV-RNA were observed and recorded relatively pre-intervention, and 3 months, 6 months after intervention in order to distinguish that nursing intervention whether or not can improve life quality except for medication effect.【Results】At the situation of identical medication, the effcativity of nursing instruction is shown in:1. HCV–RNA was significantly decreased at 3 months after nursing instruction (P=0.0026) when compared with that of pre-instruction in intervention group, whereas there was no statistically significant difference in control group. The difference of HCV-RNA therapeutic efficacy 6 months after instruction was statistically significant between two groups(P=0.04). 2. There was no statistically significant difference of FBG and HbA1c between two groups at 3 months after nursing instruction, but the variation of difference was significant (P<0.05). At 6 months after nursing instruction there was statistically significant difference of FBG and HbA1c between two groups , and the variation of difference of FBG and HbA1c was significant (P<0.05). FBG and HbA1c were reduced significantly in intervention group.3. There was statistically significant difference of the mental scale score before and after 6 months of nursing instruction (P<0.0001) between two groups. The patients’attitude and confidence to treating disease has been improved in intervention group.【Conclusion】1. Nursing intervention made the anti-HCV infection therapeutic efficacy of medication appeared to an earlier time and made it more significantly.2. Nursing intervention strengthened the results of medication, made FBG、HbA1c reduced more significantly.3. Nursing intervention helped patients to recognize their disease rationally and meanwhile enhanced their confidence to overcome diseases.4. Nursing intervention helped patients to rebuilded healthy living habits and eventually enhanced their life quality.更多还原