本文選題：胃腸惡性腫瘤　切入點(diǎn)：胃癌　出處：《廣州醫(yī)科大學(xué)》2017年博士論文　論文類型：學(xué)位論文

【摘要】：腹腔熱灌注化療(Hyperthermic intraperitoneal chemotherapy,HIPEC)是胃腸惡性腫瘤治療的新技術(shù)、新方法,然而HIPEC護(hù)理現(xiàn)狀存在一定局限性,需要建立一套科學(xué)、系統(tǒng)的護(hù)理模式。個(gè)案管理是新型、有效的管理型腫瘤照護(hù)模式,是構(gòu)建HIPEC護(hù)理模式的理想契入點(diǎn)。目的:1.漢化簡(jiǎn)化版癌癥患者支持性照護(hù)需求量表(The 34-item Short-Form Supportive Care Needs Survey,SCNS-SF34)與簡(jiǎn)化版癌癥患者主要照護(hù)者未能滿足的需求量表(The Support Person’s Unmet Needs Survey-Short Form,SPUNS-SF),并測(cè)量其心理學(xué)測(cè)量指標(biāo)。2.明確胃腸惡性腫瘤HIPEC患者及其主要照護(hù)者的需求。3.構(gòu)建胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式。本研究將為測(cè)量中國(guó)大陸癌癥患者的支持性照護(hù)需求、中國(guó)大陸癌癥患者主要照護(hù)者的需求提供新型、有效測(cè)評(píng)工具;為規(guī)范胃腸惡性腫瘤HIPEC臨床護(hù)理實(shí)踐與提升專科護(hù)理質(zhì)量提供參考范式與科學(xué)依據(jù);為中國(guó)大陸腫瘤照護(hù)領(lǐng)域深入研究與推進(jìn)個(gè)案管理模式的臨床應(yīng)用提供借鑒。方法:1.采用翻譯-回譯-專家討論-預(yù)實(shí)驗(yàn)的方法分別對(duì)SCNS-SF34、SPUNS-SF進(jìn)行漢化;于2015年11月至2016年5月在中山大學(xué)腫瘤防治中心、廣州醫(yī)科大學(xué)附屬腫瘤醫(yī)院便利抽取癌癥患者及主要照護(hù)者進(jìn)行大樣本橫斷面調(diào)查研究,評(píng)價(jià)簡(jiǎn)化版癌癥患者支持性照護(hù)需求量表-簡(jiǎn)體中文版(The Mandarin Chinese version of the 34-item Short-Form Supportive Care Needs Survey,SCNS-SF34-C(Mandarin))、簡(jiǎn)化版癌癥患者主要照護(hù)者未能滿足的需求量表-簡(jiǎn)體中文版(The Chinese version of the Support Person’s Unmet Needs Survey-Short Form,SPUNS-SFC)的心理學(xué)測(cè)量指標(biāo)。2.將胃腸惡性腫瘤HIPEC患者及其主要照護(hù)者的需求橫斷面調(diào)查數(shù)據(jù)分別進(jìn)行統(tǒng)計(jì)學(xué)分析,明確其各自的需求。3.采用病例回顧研究,分析胃腸惡性腫瘤HIPEC圍治療期診療護(hù)理信息特點(diǎn),在此基礎(chǔ)上,擬訂胃腸惡性腫瘤HIPEC-臨床護(hù)理路徑(Clinical nursing pathway,CNP)(HIPEC-CNP)草案;然后,基于胃腸惡性腫瘤HIPEC患者及其主要照護(hù)者的需求、胃腸惡性腫瘤HIPEC-CNP草案,采用循證證據(jù)檢索與總結(jié)、文獻(xiàn)回顧、內(nèi)容分析法,分別擬訂胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐方案草案及護(hù)理實(shí)踐成效評(píng)價(jià)指標(biāo)體系草案;從而,初步形成胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式草案;最后,采用兩輪的Delphi專家咨詢法對(duì)胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式草案進(jìn)行論證與修訂,完成胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式的構(gòu)建。結(jié)果:1.SCNS-SF34-C(Mandarin)與SPUNS-SFC的心理學(xué)測(cè)量指標(biāo):(1)SCNS-SF34-C(Mandarin)共包含33個(gè)條目,5個(gè)維度:醫(yī)療體系服務(wù)與信息需求、心理需求、患者照護(hù)與支持需求、生理與日常生活需求、性需求,累計(jì)方差貢獻(xiàn)率為69.757%;量表的聚合效度與區(qū)分效度良好;總量表Cronbach’s alpha系數(shù)為0.947,5個(gè)維度Cronbach’s alpha系數(shù)介于0.854~0.942。(2)SPUNS-SFC共包含21個(gè)條目,5個(gè)維度:信息需求、醫(yī)療服務(wù)獲取及其連續(xù)性的需求、個(gè)人與情緒的需求、應(yīng)對(duì)對(duì)未來(lái)的擔(dān)憂的需求、經(jīng)濟(jì)需求,累計(jì)方差貢獻(xiàn)率為78.47%;量表的聚合效度與區(qū)分效度良好;總量表Cronbach’s alpha系數(shù)為0.94,5個(gè)維度Cronbach’s alpha系數(shù)介于0.87~0.95。2.胃腸惡性腫瘤HIPEC患者及其主要照護(hù)者的需求:(1)胃腸惡性腫瘤HIPEC患者的心理需求程度、生理與日�；顒�(dòng)需求程度最高,且顯著高于胃腸惡性腫瘤非HIPEC患者該兩方面的需求程度(t=-4.353,P0.001;t=-5.584,P0.001)。(2)胃腸惡性腫瘤HIPEC患者的主要照護(hù)者在醫(yī)療服務(wù)獲取及其連續(xù)性的需求(t=-2.510,P0.05)、個(gè)人與情緒的需求(t=-3.727,P0.001)、經(jīng)濟(jì)需求(t=-2.757,P0.05)三個(gè)維度的得分均高于非HIPEC患者的主要照護(hù)者的得分;其對(duì)各類需求的程度由高到低依次為:應(yīng)對(duì)對(duì)未來(lái)的擔(dān)憂的需求、個(gè)人與情緒的需求、信息需求、醫(yī)療服務(wù)獲取及其連續(xù)性的需求、經(jīng)濟(jì)需求。3.胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式:兩輪Delphi專家咨詢的專家積極性系數(shù)分別為92.86%、100%,專家權(quán)威系數(shù)為0.925。條目重要性賦值均數(shù)介于3.54~4.60,變異系數(shù)介于0.10~0.24,專家咨詢協(xié)調(diào)系數(shù)為W=0.413(P0.001)。胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式包含:(1)HIPEC-CNP(含時(shí)間限定、入徑標(biāo)準(zhǔn)、出徑標(biāo)準(zhǔn)、可能出現(xiàn)的變異、9類HIPEC各單日CNP實(shí)施表格)(見附錄23);(2)七類胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐方案(含HIPEC治療中專科護(hù)理操作方案、HIPEC圍治療期營(yíng)養(yǎng)支持方案、HIPEC圍治療期VTE預(yù)防及運(yùn)動(dòng)方案、HIPEC圍治療期壓力性損傷預(yù)防管理方案、HIPEC圍治療期腸功能管理方案、HIPEC圍治療期個(gè)體化心理支持方案、HIPEC圍治療期主要照護(hù)者個(gè)體化支持性照護(hù)方案)(見附錄23)及HIPEC健康管理手冊(cè)(見附錄23);(3)質(zhì)性評(píng)價(jià)(主觀評(píng)價(jià)指標(biāo))與量性評(píng)價(jià)(衛(wèi)生經(jīng)濟(jì)學(xué)指標(biāo)、客觀評(píng)價(jià)指標(biāo))相結(jié)合的胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐成效評(píng)價(jià)指標(biāo)體系(見附錄23)。結(jié)論:1.SCNS-SF34-C(Mandarin)、SPUNS-SFC具有良好的信效度,分別是測(cè)量中國(guó)大陸癌癥患者支持性照護(hù)需求、中國(guó)大陸癌癥患者主要照護(hù)者需求的有效測(cè)評(píng)工具。2.在胃腸惡性腫瘤HIPEC圍治療期,護(hù)理人員應(yīng)注意全程、動(dòng)態(tài)評(píng)估患者的心理需求、生理與日�；顒�(dòng)需求,以及主要照護(hù)者各類需求的程度及變化。3.胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式的Delphi專家咨詢結(jié)果理想,具備科學(xué)性、可行性、實(shí)用性。該模式為HIPEC臨床護(hù)理實(shí)踐提供了初步的參考范式與科學(xué)依據(jù),也為我國(guó)大陸腫瘤照護(hù)領(lǐng)域推進(jìn)個(gè)案管理模式的研究與臨床應(yīng)用提供了參考與借鑒。然而,有待于胃腸惡性腫瘤HIPEC-臨床路徑(Clinical pathway,CP)(HIPEC-CP)建立完善后,以HIPEC-CP為支撐,開展胃腸惡性腫瘤HIPEC個(gè)案管理護(hù)理實(shí)踐模式的多中心、隨機(jī)對(duì)照研究,以進(jìn)一步論證本課題構(gòu)建模式的臨床實(shí)踐成效。
[Abstract]:Intraperitoneal hyperthermic perfusion chemotherapy (Hyperthermic intraperitoneal, chemotherapy, HIPEC) is a new technology, the new method for treatment of gastrointestinal malignant tumor, but the status of HIPEC nursing has certain limitation, need to establish a scientific and systematical nursing model. Case management is a new type of tumor, management effective care model, the ideal is to construct HIPEC nursing mode the starting point. Objective: 1. Chinese simplified version of cancer supportive care needs scale (The 34-item Short-Form Supportive Care Needs Survey, SCNS-SF34) and a simplified version of the main caregivers of cancer patients failed to meet the demand of the scale (The Support Person s Unmet Needs Survey-Short Form ', SPUNS-SF), and measure the psychological measurement index.2. clear gastrointestinal malignant tumor patients with HIPEC and its main caregivers needs.3. to construct gastrointestinal malignant tumor HIPEC case management nursing practice mode of this study. For the measurement of China, support for cancer patients, cancer patients care needs, China caregivers need to provide new and effective evaluation tool; and improve the standard for gastrointestinal cancer HIPEC clinical nursing practice to provide a reference paradigm and the scientific basis of the quality of nursing; for further study and clinical application of case management model can provide a reference for promoting care China, tumor. Methods: 1. using the translation back translation and expert discussion - Method of pre experiment of SCNS-SF34, SPUNS-SF finished in November 2015; to May 2016 at the Zhongshan University cancer center, a cross-sectional study of large sample of Cancer Hospital of Guangzhou Medical University Affiliated to a convenience sample of cancer patients and caregivers, evaluation of a simplified version of cancer patients supportive care needs scale - simplified version of Mandarin Chinese Chinese (The version of the 34-item Short-F ORM Supportive Care Needs Survey SCNS-SF34-C (Mandarin)), a simplified version of the main caregivers of cancer patients failed to meet the needs of scale - simplified version of Chinese (The Chinese version of the Support Person s Unmet Needs Survey-Short Form ", SPUNS-SFC) the psychology measurement index.2. will demand cross-sectional survey data of gastrointestinal malignant tumor patients and its main HIPEC the caregivers were analyzed statistically, identify their respective needs.3. through retrospective case study, analysis of gastrointestinal malignant tumor HIPEC perioperative nursing information characteristics, based on the development of gastrointestinal malignant tumor clinical nursing path HIPEC- (Clinical nursing pathway, CNP) (HIPEC-CNP) draft; then, gastrointestinal malignant tumor patients and HIPEC based on the needs of caregivers, gastrointestinal malignant tumor HIPEC-CNP draft, using evidence-based evidence retrieval and summary of the literature review, in The content analysis method, respectively for gastrointestinal malignant tumor HIPEC case management program of nursing practice and nursing practice effectiveness evaluation index system to draft; the initial formation of gastrointestinal malignant tumor HIPEC case management nursing practice pattern draft; finally, discussion and revision of gastrointestinal malignant tumor HIPEC case management in nursing practice mode using Delphi draft expert consultation rounds and complete the construction of gastrointestinal malignant tumor HIPEC case management in nursing practice mode. Results: 1.SCNS-SF34-C (Mandarin) and psychological measurement index of SPUNS-SFC (1): SCNS-SF34-C (Mandarin) contains a total of 33 items in 5 dimensions: the medical service system and information needs, psychological needs, patient care and support needs, physiological and daily life. Demand, demand, the cumulative variance contribution rate was 69.757%; polymerization validity and discriminant validity of the scale is good; the total scale of Cronbach 's alpha coefficient 0.947,5 Cronbach s alpha 'dimension coefficient between 0.854~0.942. (2) SPUNS-SFC contains a total of 21 items in 5 dimensions: information demand, medical service demand and obtain continuous, personal and emotional needs, respond to concerns about the future demand, economic demand, the cumulative variance contribution rate was 78.47%; convergent validity and distinguish the validity of the scale is good; the total scale of Cronbach' s alpha Cronbach 'coefficient of 0.94,5 dimensions s alpha coefficient between 0.87~0.95.2. HIPEC of gastrointestinal malignant tumor patients and their primary caregivers needs: (1) the degree of the psychological needs of patients with gastrointestinal cancer HIPEC, physiology and degree of daily activities demand the highest, and was significantly higher than that of malignant gastrointestinal the degree of tumor patients with non HIPEC needs two aspects (t=-4.353, P0.001; t=-5.584, P0.001). (2) the main care of patients with malignant gastrointestinal tumor HIPEC acquisition and continuity in medical service The demand (t=-2.510, P0.05), personal and emotional needs (t=-3.727, P0.001), (t=-2.757, P0.05) the economic needs of the three dimensions of primary care scores were higher than non HIPEC patients' score; the requirements of various degree from high to low: responding to the demand for future worries, personal and emotional needs, information needs, and the demand of medical service to obtain continuous, economic demand.3. gastrointestinal malignant tumor HIPEC case management in nursing practice mode: positive coefficient of experts and two rounds of Delphi expert consultation were 92.86%, 100%, the expert authority coefficient of 0.925. entry importance mean evaluation between 3.54~4.60, the coefficient of variation is 0.10~0.24 expert consultation, coordination coefficient of W=0.413 (P0.001). Gastrointestinal malignant tumor HIPEC case management nursing practice model includes: (1) HIPEC-CNP (including the time limit, the size of a standard size standard, the possible variation, 9 Each class HIPEC CNP implementation one-day form) (see Annex 23); (2) seven kinds of gastrointestinal malignant tumor HIPEC case management program (nursing practice nursing operation scheme, with HIPEC in the treatment of perioperative nutritional support for HIPEC, HIPEC during treatment, VTE prevention and treatment period movement period HIPEC confining pressure injury prevention management scheme, HIPEC perioperative bowel function management scheme, HIPEC perioperative individualized psychological support, HIPEC perioperative caregivers individual supportive care programme) (see Appendix 23) and the HIPEC health management manual (see Annex 23); (3) qualitative evaluation (subjective evaluation index) evaluation and quantity (objective evaluation index, health economics) the combination of gastrointestinal malignant tumor HIPEC case nursing practice management effectiveness evaluation index system (see Appendix 23). Conclusion: 1.SCNS-SF34-C (Mandarin), SPUNS-SFC has good reliability and validity, which is measured The amount of Chinese, supportive care needs of cancer patients, cancer patients, Chinese main caregivers need effective assessment tools of.2. in gastrointestinal malignant tumor HIPEC during the treatment period, the nursing staff should pay attention to the whole, dynamic assessment of patients with psychological needs, physiological and daily activities, Delphi expert consultation results and main caregivers and the degree of change of all kinds of demand the.3. of gastrointestinal malignant tumor HIPEC case management in nursing practice mode of the ideal, have the scientific nature, feasibility and practicability. This model provides a preliminary reference paradigm and scientific basis for HIPEC clinical nursing practice, also promote the case management model research and clinical application provides a reference for the care in China. However, tumor and to be malignant gastrointestinal tumor HIPEC- clinical pathway (Clinical pathway, CP) (HIPEC-CP) was established to improve, with HIPEC-CP as the support, to carry out gastrointestinal evil A multicenter, randomized controlled study of the HIPEC case management nursing practice model of sexual tumors was conducted to further demonstrate the effectiveness of the clinical practice of this model.

【學(xué)位授予單位】：廣州醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R473.73
，

本文編號(hào)：1557906