【作者】 陈洁；

【导师】 柏亚妹；

【作者基本信息】 南京中医药大学 ， 护理（专业学位）， 2024， 硕士

【摘要】 [目的]编制结直肠癌患者营养相关症状(Nutrition impact symptom,NIS)评估量表并进行信效度检验,调查结直肠癌患者术后NIS发生现况及影响因素,基于网络分析模型分别构建结直肠癌患者术后NIS及影响因素网络,识别核心症状及关键影响因素,为临床症状管理实践提供科学依据。[方法]1.量表编制与信效度检验:①初始量表形成:基于文献研究法检索国内外结直肠癌患者营养与症状相关文章,筛选与结直肠癌患者膳食摄入减少、体重减轻、营养不良发生密切相关的症状,在参考现有量表基础上,构建量表初始条目池;2022年9-10月邀请专业领域15名专家进行两轮德尔菲专家函询,整理汇总专家评分和意见,对量表结构与内容进行修改;2022年10月便利抽取30名结直肠癌患者,进行小样本预调查,测试量表条目设置合理性、患者理解及配合程度,以形成科学适用的结直肠癌患者NIS评估初始量表。②量表的信效度检验:2022年10-12月便利抽取127名结直肠癌患者,采用结直肠癌患者NIS评估初始量表对其进行调查;采用项目分析法对初始量表条目进行筛选,采用专家评判法、探索性因子分析检验量表效度,采用内部一致性信度、折半信度评价量表信度。2.NIS及影响因素的现况调查与网络分析:①现况调查:2022年12月-2023年8月便利抽取389名结直肠术后患者,采用编制的结直肠癌患者NIS评估量表、医学应对方式问卷(MCMQ)、心理一致感量表(SOC-13)、简易疾病感知问卷(BIPQ)、社会支持评定量表(SSRS)对其进行调查。②网络构建与分析:采用高斯图论模型构建结直肠癌患者术后NIS偏相关网络,通过估计中心性指标(强度中心性、中介中心性、接近中心性)识别核心症状;通过单因素分析、二元logistic回归筛选NIS发生的影响因素,采用混合图形模型构建影响因素与核心NIS网络,可视化影响因素与核心NIS间相关性,探究关键影响因素。[结果]1.量表编制与信效度检验部分,基于文献研究法,检索到12篇结直肠癌患者营养与症状相关文章,筛选21个症状条目,基于不悦症状理论并参考现有量表,将其分为胃肠道症状、口咽部症状、病态感症状、心理症状四个维度,并采用Likert4级评分法从严重程度、发生频率,进食干扰程度层面评价症状。两轮专家函询后,根据专家意见修改和删减条目、规范条目定义、增加问卷填写的参考标准。通过预调查和信效度检验,最终形成量表包括17个条目,5个维度。量表各条目与总量表得分相关系数为0.226-0.575(P<0.05),内容效度指数为0.83-1,平均内容效度指数为0.97,探索性因子分析提取了 5个公因子,累计方差贡献率为61.622%。量表总Cronbach’s α系数为0.708,各维度Cronbach’s α系数分别为 0.762、0.642、0.625、0.510、0.644,量表折半信度为 0.824。2.NIS及影响因素的现况调查与网络分析部分,结直肠癌患者术后NIS发生率为53.21%,疲乏(37.28%)、腹胀(23.39%)、口干(21.08%)是发生率较高的症状;疲乏强度中心性(1.49)、中介中心性(57)、紧密中心性(0.0061)最高,为核心症状,腹泻是情感心理症状与病态感症状间的桥梁症状,焦虑中心性指标数值略次于疲乏,需要重点关注;二元logistic分析结果显示,年龄、疾病分期、应对方式、心理一致感水平、社会支持程度、疾病感知能预测NIS的发生;在核心NIS与影响因素网络中,年龄(0.18)、疾病分期(0.19)与腹泻存在较强的相关性;应对方式(0.60)、疾病感知(0.15)与疲乏存在较强的相关性,客观支持(0.15)和对支持的利用度(0.14)与焦虑之间有较强的负相关性,其中疾病感知、应对方式是关键影响因素。[结论]1.本研究基于不悦症状理论,通过文献研究法、德尔菲专家函询法、预调查法编制结直肠癌患者NIS评估量表并进行信效度检验,符合量表编制规范流程,量表信效度良好,具有一定的实用性。2.结直肠癌术后NIS发生率较高,疲乏是核心NIS,腹泻是情绪心理症状群与病态感症状群间的桥梁NIS,焦虑是重要NIS。疾病感知、应对方式是NIS发生的关键影响因素。医护人员应优先关注疲乏、腹泻、焦虑,可基于关键影响因素构建较为科学的干预方案,通过缓解整体症状负担改善患者经口进食,降低营养不良的发生率。更多还原

【Abstract】 [Objective]To develop a NIS assessment scale for colorectal cancer patients,conduct reliability test,investigate the occurrence of NIS in early postoperative period of colorectal cancer patients,construct networks of NIS and influencing factors based on the network analysis model,identify the core symptoms and key influencing factors,and provide scientific basis for the practice of clinical symptom management.[Methods]1.Scale development and reliability test:①Initial scale formation:based on the literature research method to retrieve domestic and international articles related to colorectal cancer nutrition and symptoms,screen the symptoms closely related to the occurrence of malnutrition in colorectal cancer,and construct an initial pool of scale entries based on reference to existing scales;from September-October,2022,15 experts in the professional field were invited to conduct two rounds of Delphi Expert Correspondence to collate and summarize Experts’ scores and opinions were collected,and the structure and content of the scale were modified;30 colorectal cancer patients were conveniently selected in October 2022 to conduct a small-sample pre-survey to test the reasonableness of the scale’s entry settings and the degree of understanding and cooperation of the patients,in order to form the scientifically applicable Initial Scale for NIS in Colorectal Cancer Patients.②Reliability test of the scale:127 colorectal cancer patients were conveniently sampled from October to December 2022,and the initial scale of NIS of colorectal cancer patients was used to investigate them;the items of the initial scale were screened by item analysis,the validity of the scale was examined by content validity and exploratory factor analysis,and the reliability of the scale was evaluated by internal consistency reliability and folding half reliability.2.Status survey and network analysis of NIS and influencing factors:①Status survey:389 early postoperative colorectal patients were conveniently selected from November 2022 to August 2023,and the compiled Nutrition-Related Symptom Specificity Assessment Scale for Colorectal Cancer Patients(NRSSC),Medical Coping Mode Questionnaire(MCMQ),Psychological Coherence Scale(SOC-13),Brief Illness Perception Questionnaire(BIPQ),Social Support Rating Scale(SSRS),and Social Support Rating Scale(SSRS)were used to evaluate the validity of the scales.),and Social Support Rating Scale(SSRS)were used to investigate them.Network construction and analysis:Gaussian graph theory model was used to construct a transversal network of NIS in early postoperative period of colorectal cancer patients,and the core symptoms were identified by estimating centrality indexes(intensity centrality,mediated centrality,and proximity to centrality);the influencing factors of NIS occurrence were screened by univariate analysis and binary logistic regression,and a mixed graph model was used to construct the network of core influencing factors and NIS,and the network of core influencing factors and NIS was visualized correlation between influencing factors and NIS.[Results]1.In the part of scale preparation and reliability test,based on the literature research method,12 articles were retrieved,21 symptom entries were screened out,and based on the theory of unpleasant symptoms and referring to the existing scales,they were classified into four dimensions,namely gastrointestinal symptoms,oropharyngeal symptoms,symptoms of sense of morbidity,and psychological symptoms,and the Likert4 scale was used to evaluate symptoms from the level of severity,frequency of occurrence,eating interference degree dimension to evaluate the symptoms.After two rounds of expert correspondence,the entries were modified and deleted,the definitions of the entries were standardized,and the reference standards for completing the questionnaire were added according to the experts’ opinions.Through the pre-survey and reliability test,the final scale included 17 entries and 5 dimensions.The correlation coefficients of each entry of the scale and the total scale score were 0.226-0.575(P<0.05),the content validity index was 0.83-1,and the average content validity index was 0.97.The exploratory factor analysis extracted five common factors,and the cumulative variance contribution rate was 61.622%.The total Cronbach’s alpha coefficient of the scale was 0.708,and the Cronbach’s alpha coefficients of the dimensions were 0.762,0.642,0.625,0.510,and 0.644,and the folded reliability of the scale was 0.824.2.In the current investigation and network analysis section of NIS and influencing factors,the incidence of early postoperative NIS in colorectal cancer patients was 53.21%,and fatigue(37.28%),bloating(23.39%),and dry mouth(21.08%)were the symptoms with high incidence rates;fatigue had the highest strength(1.49),betweenness(57),and closeness(0.0061),and was the core symptom,diarrhoea is a bridge symptom between emotional-psychological and morbid-sense symptoms,and anxiety centrality index values are slightly lower than fatigue and need to be focused on;the results of binary logistic analyses showed that age,disease staging,coping styles,level of psychological congruence,level of social support,and disease perception predicted the occurrence of NIS;and in the network of core NIS and influencing factors,age(0.18),disease staging(0.19)and diarrhoea had a strong correlation;coping styles(0.60),illness perception(0.15)and fatigue had a strong correlation,and there was a strong negative correlation between objective support(0.15)and use of support(0.14)and anxiety,with illness perception and coping styles being the key influencing factors.[Conclusion]1.Based on the theory of unpleasant symptoms,this study compiled the nutritionrelated symptom assessment scale for colorectal cancer patients through the literature research method,Delphi expert correspondence method,and pre-survey method and carried out the reliability test,which was in line with the standardized process of scale compilation,and the scale had good reliability and validity.2.The incidence of NIS in the early postoperative period after colorectal cancer is high,and fatigue is the core NIS,diarrhoea is the bridge NIS between the cluster of emotional and psychological symptoms and the cluster of symptoms of sense of illness,and anxiety is an important NIS.Disease perception and coping styles are the key influences.Healthcare professionals should give priority attention to fatigue,diarrhoea and anxiety,and can construct a more scientific intervention programme to improve patients’ oral feeding and reduce the incidence of malnutrition by alleviating the symptom burden.更多还原