【作者】 刘雯；

【导师】 卢惠娟；

【作者基本信息】 复旦大学 ， 护理学， 2011， 硕士

【摘要】 背景：急性心肌梗死(AMI)作为冠心病中的严重类型,已经对我国人民的健康构成了严重威胁。近年来我国急性心肌梗死的发病率正逐渐升高。由于AMI起病急、急性期病情重、变化快,且患者出院后原有的生活状态面临较大改变,在面对与疾病、医院环境及家庭社会等方面的压力源时,患者会有不同的压力感受。既往研究显示AMI患者在康复过程中存在不同程度的心理压力。目前国内还未见深入探讨AMI患者患病后压力感受和压力反应的质性研究和纵向研究。本研究运用“压力认知交互作用理论”作为理论框架,强调了应对方式和社会支持在心理应激中的调节作用,采用深入访谈和量性测评相结合的方法,对AMI患者康复过程中的压力感受及压力反应进行纵向研究。目的：(1)探讨AMI患者康复过程中不同时期的压力感受程度及其变化情况；(2)探讨AMI患者康复过程中不同时期的压力反应及其变化情况；(3)描述AMI患者康复过程中不同时期的应对方式及社会支持状况；(3)分析AMI患者康复过程中不同时期压力感受及压力反应的影响因素；(4)探索AMI患者康复过程中的压力体验。方法：本研究包括两部分,即量性研究中的纵向调查研究和质性研究中的现象学研究。在量性研究部分,本研究以方便抽样的方法,从2010年1月至9月,从上海市中山医院和华山医院的心内科CCU病房中,抽取符合纳入标准的AMI患者60名进行为期6个月的随访调查。采用一般资料调查表、中文版压力知觉量表(CPSS)、综合医院焦虑抑郁量表(HADS)、医学应对问卷(MCMQ)和社会支持评定量表(SSS)来评价AMI患者的一般人口社会学资料、压力感受、心理压力反应、应对方式和社会支持情况。研究分别在患者患病后7-10天、6周、3个月及6个月时发放问卷。所得数据采用SPSS15.0进行统计分析。在质性研究部分,采用质性研究中的现象学研究方法,对15名急性心肌梗死患者在其患病后7-10天、6周、3个月及6个月分别进行深度访谈,并采用现象学分析法分析资料。结果：量性研究：(1)AMI患者四个时间点的CPSS的得分为19.45±5.96、17.67±6.33、14.75±6.41、15.25±6.32,经过重复测量的方差分析,不同时间AMI患者的CPSS得分之间差异有统计学意义(P<0.05)。AMI患者四个时间点的健康危险性压力的发生率分别为20%、15%、8.3%、8.3%,且经卡方检验不同时间的健康危险性压力的发生率之间差异有统计学意义(P<0.05)。(2)四个时间AMI患者的焦虑得分分别为6.80±2.57、5.88±2.15、5.08±2.55及4.82±2.49,经重复测量的方差分析,不同时间患者的焦虑得分之间差异有统计学意义(P<0.05)。四个时间点AMI患者的抑郁得分分别为5.52±3.66、4.67±3.81、4.23±3.55、4.03±2.86,且不同时间的抑郁得分之间差异有统计学意义(P<0.05)。四个时间点AMI患者的焦虑阳性率为33.3%、20%、10%、11.7%,且焦虑阳性率之间差异有统计学意义(P<0.05)。四个时间点患者抑郁阳性率为33.3%、20%、23.3%、11.3%,且差异有统计学意义(P<0.05)。(3)将AMI患者四个时间点的三种应对方式得分分别与常模比较,除6周时面对得分与常模相比差异不显著,其余时间的面对得分均低于常模,且差异有统计学意义(P<0.05)；除6个月时回避得分与常模相比差异不显著,其余时间的回避得分均高于常模,且差异有统计学意义；仅在住院阶段患者的屈服应对得分高于常模,差异有统计学意义(P<0.05)。重复测量的方差分析示,不同时间AMI患者的面对和回避得分之间差异不显著,不同时间患者的屈服应对得分之间差异有统计学意义(P<0.05)。(4)四个时间点AMI患者的社会支持总分均高于常模(P<0.05),四个时间点AMI患者的主观支持、客观支持、对支持的利用度及社会支持总分之间差异无统计学意义(P>0.05)。(5)AMI患者患病后7-10天时,屈服应对、吸烟史、面对应对、职业和居住状态是患者压力感受的影响因素；心功能分级是患者焦虑反应的影响因素；社会支持总分和屈服应对是患者抑郁反应的影响因素。患者患病后6周时,屈服应对、锻炼习惯、年龄和社会支持总分是压力感受的影响因素；屈服应对、年龄和锻炼习惯是患者焦虑反应的影响因素；屈服应对、面对应对、锻炼习惯和年龄是患者抑郁反应的影响因素。患者患病后3个月时,屈服应对是压力感受、焦虑抑郁反应的影响因素；客观支持、职业和回避应对是患者抑郁反应的影响因素。患者患病后6个月时,屈服应对、锻炼习惯、心功能分级是压力感受的影响因素；屈服应对、锻炼习惯和客观支持是焦虑反应的影响因素；屈服应对和回避应对是患者抑郁反应的影响因素。质性研究：将AMI患者急性期的压力反应归纳为三个方面：①面对现实的打击；②适应角色改变；③准备回归与重建。将AMI患者出院后6个月内的压力反应归纳为三个方面：①关注疾病康复；②生活习惯的改变；③人际关系的重建。结论(1)AMI患者住院时的压力感受程度最重,患者的压力感受在出院后前3个月下降显著,但是仍有一定程度的压力,3个月后压力感受下降不明显。(2)在住院阶段AMI患者在面对现实打击、适应角色改变及准备回归与重建的过程中出现了压力反应。出院后AMI患者由于关注疾病康复、生活习惯的改变和人际关系的重建而出现了不同的心理压力反应。(3)AMI患者较倾向于采用回避方式应对,较少采用面对方式。(4)不同应对方式在患者患病后的不同阶段有不同的影响。(5)社会支持在AMI患者患病过程中有助于减少心理压力。(6)良好的生活习惯有助于减少患者心理压力。(7)能否重返工作是AMI患者患病过程关注的问题。更多还原

【Abstract】 Background:Acute myocardial infarction(AMI) is a serious coronary heart disease, and it has posed a health threat to people in our country. The incidence of AMI in china has been increasing these years. The onset of AMI is usually unexpected, and at the acute phase, the patients are in a very serious condition and the illness condition changes quickly. After discharging from the hospital, the patients’ lifestyle and living conditions may experience significant changes. When facing with the stressors coming from the disease,environment of the hospital, or the family and society, the patients may have different stress perceptions. Some studys showed that patients with AMI had various digrees of pressure during the rehabilitation process.In our country, there are no study investigating the change of the patients’stress perception and stress response longitudinally. This study used the theory-"interaction of cognitive and stress" as the framework, and especially considered the regulating function of coping styles and social support on patients’psychological health, conducted a longitudinal study using the qulitative method combined with the quantitative evaluation to explore the stress perception and stress response of patients with AMI.Objective:(1) To investigate the level of stress perception and its the changing trend in patients with acute myocardial infarction (AMI) during their rehabilitation process;(2)To investigate the stress response status and its changing trend in patients with AMI during their rehabilitation process;(3) To identify the coping style and the social support in patients with AMI in four periods; (4) To analyze the influential factors of stress perception and stress response status of patients with AMI in four periods during their rehabilitation process; (5) To explore the stress experiences of patients with AMI during the first 6 months after the onset of the disease.Methods:This study includes two parts:the Longitudinal survey and the qualitative study using the phenomenology method.In the Longitudinal survey study,60 AMI patients from the cardiology department of Zhongshan hospital and Huashan hospital, were investigated during the first 6 months in their rehabilitation process from January 2010 to September 2010. The Common status Questionnaire, The Chinese Perceived Stress Scale(CPSS),The Hospital Anxiety and Depression Scale(HADS), the Social Support Scale(SSS) and the Medical Coping Modes Questionnaire(MCMQ) were used respectively to investigate the common status, stress perception, psychological stress responses, social support conditions and coping styles of patients with AMI. The survey were conducted in four different times:7～10 days (time 1)、6 weeks (time 2)、3 months (time 3) and 6 months (time 4) after the onset of AMI. The SPSS15.0 was used for data analysis.In the qualitative study, the phenomenology method was adopted,15 patients with AMI participated in the semi-structure interviews which were conducted in four times:7～10 days, six weeks, three months and six months after the discharge. The data was analyzed by Claizzi’s phenomenological procedure.Results:In the Longitudinal survey study:(1) The scores of CPSS scale in four times were 19.45±5.96、17.67±6.33、14.75±6.41、15.25±6.32, The repeated measure analysis of variance indicated that the level of stress perceptions were different along with the change of time (P< 0.05).The percentages of patients with stress threating to health in the four times were:20%、15%、8.3%、8.3%. The chi-square test indicated that the difference between these four percentages was significant (P <0.05). (2)The scores of anxiety in the four times were:6.80±2.57、5.88±2.15、5.08±2.55及4.82±2.49. The repeated measure analysis of variance indicated that there were significant difference between the scores of anxiety in four time points (P<0.05). The scores of depression in the four times were:5.52±3.66、4.67±3.81、4.23±3.55、4.03±2.86. The repeated measure analysis of variance indicated that there were significant difference between the scores of anxiety in four time points(P<0.05). The incidence of anxiety in the four times were:33.3%、20%、10%、11.7%, which were significantly different (P<0.05). The incidence of depression in the four times were:33.3%、20%、23.3%、11.3%, which had significant difference (P<0.05). (3) Comparing the average scores of the confrontation coping style to the norm, except the scores measured in the 6th week, the other scores were significantly lower than the norm(P<0.05). Comparing the average scores of the avoidance coping style to the norm, except the scores measured in the 6th month, the other scores were significantly higher than the norm(P<0.05). Comparing the average scores of the resignation coping style to the norm, only the score of resignation coping style measured in hospital was significantly higher than the common model (P<0.05). The repeated measure analysis of variance showed that:At different time points, the difference of the scores of confrontation coping style had no statistics significance(P >0.05), and the difference of the scores of avoidance coping style had no statistics significance(P> 0.05), but the scores of resignation coping style significance were significant different (P<0.05). (4) The whole social support scores in four time points were all higher than the common model (P<0.05). The scores of active support, objective support, utilization of support and the whole score of support had no significant change along with time(P>0.05). (5) The stepwise regression analysis showed that:during 7～10 days after the onset of AMI, the level of stress perception was influenced by resignation coping, smoking state in the past, confrontation coping, occupation and living status;the level of cardiac function may influence the incidence of anxiety; the whole score of social support and the resignation coping might influence the incidence of depression. On the time of six weeks after the onset of AMI, the level of stress perception was influenced by resignation coping,exercising status in the past, age and the whole score of social support;the resignation coping, age and exercising status in the past might influence the incidence of anxiety; the resignation coping, age, exercising status in the past and confrontation coping might influence the incidence of depression. On the time of three months after the onset of AMI, the level of stress perception and the incidence of anxiety and depression were influenced by resignation coping;the passive support, occupation and avoidance coping may influence the incidence of depression. On the time of six months after the onset of AMI, the level of stress perception was influenced by resignation coping, exercising status and the level of cardiac function;the resignation coping, exercising status and passive support might influence the incidence of anxiety; the resignation coping and the avoidance coping mmight influence the incidence of depression.In the qualitative study:the stress response of patients at the early stage of AMI included three aspects:①facing the strike of reality;②the changing role;③preparation of going back to normal life and rebuilding. The stress response of patients with AMI when they leave hospital included three aspects:①worrying about the rehabilitation ofAMI;②changing the living habits;③rebuilding the interpersonal relationships.Conclusions:(1) The stress perception was most significant when patients were in hospital, although the level of stress perception decreased after they discharged, patients still had some stress in life. (2) According to the semi-structure interviews, patients in hospital felt stressful during the process of facing the strike of reality, changing the role and preparing for going back to normal life and rebuilding. When patients left hospital after they discharged, they felt stressful during the process of worrying about the rehabilitation, changing the living habits and rebuilding the interpersonal relationships. (3)The patients with AMI preferred to use the avoidance coping style during the rehabilitation process, and they used the confrontation coping style less frequently than the norm. (4) AMI patients should choose different coping strategies according to different phases during the disease rehabilitation. (5)The social support could decrease AMI patients’ psychological stress. (6)Healthy life habits could decrease AMI patients’ psychological stress. (7) Patients were worrying about whether they could go back to work again after the onset of AMI.更多还原