【作者】 臧小英；

【导师】 赵岳；

【作者基本信息】 天津医科大学 ， 护理学， 2011， 博士

【摘要】 目的1.分析不同社会人口学特征及临床特征高血压人群动态血压监测的血压均值、血压负荷、血压变异、血压节律等指标的差异；探讨动态动脉硬化指数(AASI)及对称性动态动脉硬化指数(Sym_AASI)的相关影响因素；评定AASI、Sym_AASI与心踝血管指数(CAVI)的关系。2.以时间治疗学为指导,根据患者动态血压监测结果,制定个体化连续护理干预措施,即在行为干预的基础上调整患者服药时间,通过为期一年的干预,探讨连续护理干预措施的效果,为社区控制老年高血压患者血压提供一套操作简便、无创有效、易接受的综合干预措施。方法1.通过横断面研究的方法,自2009年5月到2010年10月,在天津市王顶堤社区采取便利抽样的方法收集符合标准的原发性高血压患者92例。通过调查其一般社会人口学资料及临床资料,进行24小时动态血压监测及动脉硬化检测,采用t检验、方差分析等比较不同特征人群动态血压各指标及动脉硬化情况的差异,采用Logistic回归的方法分析AASI及Sym_AASI的影响因素,采用相关分析探讨AASI、Syin_AASI与CAVI之间的关系。2.采用类试验研究的方法,从第一部分研究对象中,根据自愿参与的原则,选取60名,随机分入两干预组,即干预组A(行为+时间药物治疗干预组)和干预组B(行为干预组)。同时从研究对象所在社区选取30名原发性高血压患者作为对照组。根据患者动态血压监测结果,以时间治疗学为指导制定两种不同的连续护理干预措施,进行为期1年的连续护理干预,于干预后6月、12月测定干预组动态血压及CAVI,采用重复测量数据的方差分析和多元方差分析等评定干预效果。结果1.高血压患者动态血压均值、动态心率、动态脉压、血压负荷及血压变异分别受不同人口学及临床资料因素的影响,日间动态血压参数比夜间更易受人口学及临床资料的影响。2.不同血压节律患者的日间、夜间、24h收缩压均存在统计学差异(P<0.01),不同血压节律患者脉压、夜舒张压变异及24h舒张压变异之间差异也具有统计学意义(P<0.05)。是否出现晨峰患者的日间收缩压、日间脉压、24h脉压、日收缩压负荷及24h收缩压负荷之间存在统计学差异(P<0.05)。3. AASI、Sym_AASI与CAVI之间均呈显著中度正相关(P<0.01)。多因素Logistic回归分析结果显示影响AASI的因素包括胆固醇、高血压病程、糖尿病,Sym_AASI受胆固醇、性别、年龄影响较大。4.两干预组动态血压相关指标在不同时间点差异有统计学意义(P<0.01)。动态血压均值在干预6月、干预12月与干预前比较差异均有统计学意义(P<0.01),各时间点两组比较,干预6月、12月两组比较结果均有统计学差异(P<0.05,P<0.01)。干预组A动态血压负荷在干预6月、干预12月与干预前比较差异均有统计学意义(P<0.01)。5.随着护理干预的实施,干预组A杓型血压患者人数增加,反杓型血压患者人数减少,两组间统计学差异有显著性。随着干预时间进展,两组晨峰患者均减少,但干预组A减少更明显,干预后6个月两组晨峰患者比例差异有显著性。6.两干预组AASI、Sym_AASI在不同时间点差异有统计学意义。干预组A在干预6月、干预12月与干预前比较差异均有统计学意义(P<0.01)。结论1.根据患者动态血压监测结果实施以时间为指导的连续护理干预,在其血压上升前服药可进一步降低患者动态血压均值,起到更好的降压效果；可持续降低患者动态血压变异指标,从而避免及减少心血管事件的发生。2.行为干预加药物调整可增加患者夜间血压下降,使杓型血压患者人数增加,反杓型血压患者人数减少；可以显著改善患者晨起血压急骤上升的趋势。此外需要重视对血压节律、晨峰现象有影响的社会人口学及临床因素,以采取更有效的护理措施,使患者异常血压节律转为正常,减少晨峰现象的出现。3. Sym_AASI受血压波动影响小于AASI,在评估动脉硬化程度方面优于AASI,可以在社区推广应用。AASI受胆固醇、高血压病程、糖尿病的影响,Sym_AASI受胆固醇、性别、年龄影响较大。行为干预加药物调整具有降低并维持AASI及Sym_AASI的效果,可减缓动脉硬化恶化速度,对缓解血管阻塞程度具有一定的效果。更多还原

【Abstract】 Objectives1. To find the differences of the indexes of Ambulatory Blood Pressure Monitoring (ABPM) between patients with different socio-demographic and clinical characteristics; To explore the interfering factors of ambulatory arterial stiffness index (AASI) and symmetrical AASI (Sym_AASI); To determine the relationship between AASI, Sym_AASI and CAVI (Cardio-ankle vascular index).2. To explore the effectiveness of the continuous nursing interventions directed by chronotherapeutics so as to provide the easy, noninvasive, effective and acceptable interventions for hypertensive patients in the community.Methods1. The cross-sectional study was used. A convenience sample of hypertensive patients was recruited in Wangdingdi community of Tianjin, China from May 2009 to October 2010. Sociodemographic and medical data were obtained and 24h ABPM and CAVI were measured. T test and ANOVA were used to find the differences of the indexes of ABPM and arterial stiffness between patients of different characteristics. The interfering factors of AASI and Sym_AASI were found by Logistic analysis and correlation analysis was used to explore the relationship between AASI, Sym_AASI and CAVI.2. The semi-experimental study was used and 60 patients from the first part were recruited and separated into two groups randomly, which were intervention group A (Behaviour and chronotherapy intervention) and intervention group B (Behaviour intervention). Another 30 hypertensive patients were recruited in the control group from the community. At 6m and 12m after the intervention ABPM and CAVI were measured for the intervetntion groups. Repeated measures and multivariate analysis of variance were used to evaluate the effectiveness.Results1. Patients’ABPM indexes were interfered by different sociodemographic and medical data. Daytime ABPM indexes were interfered more than nighttime by patients’different characteristics.2. There were statistical differences in daytime, nighttime and 24h systolic blood pressure (SP) between patients with different rhythm of blood pressure (P<0.01). The pulse pressure (PP), nighttime diastolic blood pressure (DBP) and the coefficient of variation (CV) of 24h DBP had statistical differences between patients with different rhythm of blood pressure (P<0.05). There were statistical differences in daytime SP, daytime and 24h PP, daytime and 24h SP load between patients with or without morning surge (P<0.05).3. There was significantly moderate positive correlation between AASI, Sym_AASI and CAVI. The cholesterol, duration of hypertension and diabetes interfered AASI, and Sym_AASI was interfered by cholesterol, gender and age.4. There were statistical differences in ABPM indexes between two intervention groups at different measurement time (P<0.01). There were statistical differences in the mean of ABPM between 6m,12m after and before the intervention and between the two groups at different measurement time. BP load of intervention group A had statistical differences at 6m and 12m after and before the intervention (P<0.01).5. The number of patients with dipper increased and patients with reverse dipper decreased in group A as the interventions were applied. There were statistical differences between two groups. The number of patients with morning surge decreased in two groups but the number in group A decreased more and there were statistical differences between two groups at 6m after the intervention.6. AASI and Sym_AASI of two intervention groups had statistical differences at different measurement time. Intervention group A had statistical differences between 6m and 12m after the intervention and before the intervention (P<0.0i).Conclusions1. The continuous nursing intervention based on patients’ABPM could control BP much better and decrease the CV of BP.2. The continuous nursing intervention could increase patients’nocturnal SP drop, increase patients with dipper and decrease patients with reverse dipper. Besides the nursing intervention could control patients’morning surge significantly.3. Sym_AASI could reflect the arterial stiffness better than AASI. AASI was interfered by cholesterol, duration of hypertension and diabetes. Sym_AASI was interfered by cholesterol, gender and age. The continuous nursing intervention could decrease AASI and Sym_AASI.更多还原