【作者】 蒋小剑；

【导师】 何国平；

【作者基本信息】 中南大学 ， 护理， 2012， 博士

【摘要】 目的：1.依据人工全髋关节置换术患者居家护理现状及相关文献资料,围绕人工全髋关节置换术患者实际需求,制定人工全髋关节置换术患者居家护理方案。包括“人工全髋关节置换术患者居家护理服务指标体系框架”和“人工全髋关节置换术患者居家护理康复训练路径及评价基本要求”。2.评价人工全髋关节置换术患者居家护理方案应用于人工全髋关节置换术患者居家护理的效果。方法：1.人工全髋关节置换术患者居家护理方案的制定：在文献回顾、专家访问和我们前期研究工作的基础上,结合患者和主要照顾者的需求调查,同时考虑我国的实际情况,初步构建人工全髋关节置换术患者居家护理方案,包括“人工全髋关节置换术患者居家护理服务指标体系框架”和“人工全髋关节置换术患者居家护理康复训练路径及评价基本要求。通过专家评估法对24名专家进行2轮问卷调查,研究居家护理服务指标体系框架的逻辑适当性和二、三级指标的必要性、可行性、风险性,问卷最后设置开放性问题,进一步了解专家对居家护理服务指标体系框架中未提及内容的意见和建议；通过专家组对“人工全髋关节置换术患者居家护理康复训练路径及评价基本要求”进行进一步讨论,使之完善。2.人工全髋关节置换术患者居家护理方案的应用和效果评价：通过制定纳入与排除标准,选择符合条件的100例首次接受单侧人工全髋关节置换术患者作为研究对象,开展随机对照试验,对照组50例,干预组50例；对照组给予常规护理,干预组在常规护理的基础上,按本研究制定的居家护理方案进行居家护理；干预组干预内容包括躯体照护、心理和精神支持、康复指导及社会支持四大内容,共干预6个月；于干预第3、6个月观察干预效果,观察指标主要分为髋关节功能Harris评分、生存质量(SF-36)评分及并发症发生情况。结果：1.2轮专家咨询的应答率均为96%、100%,充分反映了专家们对本研究的关心和支持；专家的权威系数均值为0.8,对各指标的权威系数均>0.7；2轮调查后变异系数大于25%的指标只有1个,占1.9%,其他指标变异系数均小于25%；肯德尔和谐系数统计协调性在逻辑性、必要性、技术可行性、人力可行性及风险性方面具有统计学意义(P<0.005)；形成了由4项一级指标、12项二级指标、38项三级指标组成的人工全髋关节置换术患者居家护理服务指标体系框架；制定了人工全髋关节置换术患者居家护理康复训练路径及评价基本要求,两者一起构成了一套人工全髋关节置换术患者居家护理方案。2.人工全髋关节置换术患者居家护理方案应用于人工全髋关节置换术患者居家护理(1)Harris评分：干预3、6个月后,两组患者Harris评分差异有统计学意义(P<0.05),干预组高于对照组,干预时间越长,Harris评分越高；两组患者髋关节功能优良率存差异(P<0.05)；干预6个月后,干预组髋关节功能优良率达100%,对照组优良率达82%。(2)生存质量评分：干预3、6个月后,两组患者SF-36生存质量量表的八个维度评分差异有统计学意义(P<0.05),干预组高于对照组,干预时间越长,生存质量评分趋于高。(3)并发症：干预3、6个月后,两组患者并发症发生率存有差异(P<0.05),干预组低于对照组；干预3个月,干预组并发症发生率为16%,对照组为52%；干预6个月,干预组并发症发生率为4%,对照组为28%；结论：1.本研究制定的人工全髋关节置换术患者居家护理方案具有一定实用性与可操作性；一方面制定了具体的、清晰的居家护理服务体系框架、康复训练路径及评价基本要求、相关视频图谱和手册使操作简便易行；另一方面,此方案以患者和照顾者需求为导向,选择患者和照顾者需要而又适合家庭环境实施的服务项目,使服务内容全面化、系统化、人性化、规范化。2.方案的应用研究结果证明：人工全髋关节置换术患者居家护理方案的实施能够更好的促进患者髋关节功能恢复、增进心理健康、提高生存质量；而且随着干预时间的延长,效果趋于更好。因此,人工全髋关节置换术患者居家护理方案的应用,有利于髋关节置换患者的身心健康,值得在社区护理中推广应用。更多还原

【Abstract】 Objective1. To work out the feasibility and practical home-based care programme for total hip replacement(THR) patients, including " home-based care services content index system framework for THR patients" and " home-based care rehabilitation training paths and evaluation basic contents for THR patients ", on the basis of the present state of home-based care and relevant documents and THR patients’demand.2. To evaluate the effects of home-based care programme applied to the home-based care for THR patientsMethods1. Designing home-based care programme for THR patients:Combining the demand investigation of the home-based care among THR patients and their main care-takers, considering the practical situation in our country, the primary home-based care programme for THR patient, including " home-based care services content index system framework for THR patients " and " home-based care rehabilitation training paths and evaluation scale for THR patients ", has been worked out on the basis of relevant documents, consulting experts and our initial research. With Delphi technique,24specialists have taken part in questionnaire investigations for twice to explore the logicality、 necessity、feasibility and risk of home-based care services content index system framework. Opening questions were designed in questionnaire to help collect some advice from specialists.Home-based care rehabilitation training paths and evaluation scale for THR patients were further discussed and improved by experts group so as to be more perfect.2. Applying and evaluating the effects of home-based care programme for THR patients:By establishing inclusion and exclusion standard,100patients with inicial unilateral total hip replacement were selected as research subjects, then randomized controlled trial was carried out with50cases as an intervention group and a control group respectively. Home-based care programme in this study was conducted in the intervention group, and usual care in the control group. The intervention measures include4categories:body care, psychological and spiritual support, rehabilitation guidance and social support. The intervention time lasts for6months. The effects were evaluated at the3th and6th months. The evaluation indexes consist of Harris score system, quality of life scale(SF-36) and complication occurrences. Results1. The answering rates of the experts in the two questionnaires are96%and100%respectively, which reflect the concern and support of the specialists for the study. The experts authority coefficient mean value is0.8and each index authority coefficients is over0.7. After two investigations, only one index’s variation coefficient is more than25%, accounting for1.9%, the others less than25%; Kendal harmonious coefficients play a statistically significant part in five aspects of logicality, necessity, technical feasibility, human feasibility and risk (P<0.005); Finally, the index system of home-based care services composed of4primary indexes,12second-level indexes,383-level indexes and the home-based care rehabilitation training paths and evaluation scale for THR patients are established, which compose home-based care programme for THR patients.2. Application and effect evaluation of home-based care programme for THR patients(1) Harris scores system:3months and6months after intervention, the differences of Harris scores between the two groups are statistically significant (P<0.05), the scores of intervention group are more than those of control group, moreover, the longer intervention time is, the higher Harris scores are; The excellent rate of functions between two groups is different(P<0.05).6months after intervention, the excellent rate of intervention group was100%, while that of control group 82%.(2) Quality of life scores:3months or6months after intervention, quality of life scores of eight dimensions from SF-36scale exists significance between two groups(P<0.05), the scores from intervention group are higher than those of control group, moreover, the longer intervention time is, the higher scores are.(3) Complications:3months or6months after intervention, the occurrence rate of complications between two groups is different(P<0.05), and the rate of intervention group is lower than that of control group;3months after intervention, the rates of complications of intervention group and control group are respectively16%,52%;6months after intervention, the rates are respectively4%,28%.Conclusions1. The home-based care programme for THR patients is characterized by operability and practicality. On the one hand, it includes concrete, feasible and clear home-based care services index system framework, rehabilitation training paths and evaluation scale for THR patients, and related video atlas and manual, which all make it conducted simply and easily. On the other hand, it is guided by the demand of the THA patients and the care-takers, and the service items selected are suitable to be conducted in home, which make the service comprehensive, systematic, humane and standardized. 2. Application of home-based care programme on THR patients is beneficial to promote hip function recovery and psychological health, as well as improve the quality of life. Meanwhile the intervention time is longer, the effect trends better. Therefore, the application of home-based care programme can promote physical and mental health of patients, and the programme is worthy of being applied to community caring.更多还原