胃肠恶性肿瘤腹腔热灌注化疗个案管理护理实践模式的构建

发布时间：2018-03-02 19:36

  本文选题：胃肠恶性肿瘤　切入点：胃癌　出处：《广州医科大学》2017年博士论文　论文类型：学位论文

【摘要】：腹腔热灌注化疗(Hyperthermic intraperitoneal chemotherapy,HIPEC)是胃肠恶性肿瘤治疗的新技术、新方法,然而HIPEC护理现状存在一定局限性,需要建立一套科学、系统的护理模式。个案管理是新型、有效的管理型肿瘤照护模式,是构建HIPEC护理模式的理想契入点。目的:1.汉化简化版癌症患者支持性照护需求量表(The 34-item Short-Form Supportive Care Needs Survey,SCNS-SF34)与简化版癌症患者主要照护者未能满足的需求量表(The Support Person’s Unmet Needs Survey-Short Form,SPUNS-SF),并测量其心理学测量指标。2.明确胃肠恶性肿瘤HIPEC患者及其主要照护者的需求。3.构建胃肠恶性肿瘤HIPEC个案管理护理实践模式。本研究将为测量中国大陆癌症患者的支持性照护需求、中国大陆癌症患者主要照护者的需求提供新型、有效测评工具;为规范胃肠恶性肿瘤HIPEC临床护理实践与提升专科护理质量提供参考范式与科学依据;为中国大陆肿瘤照护领域深入研究与推进个案管理模式的临床应用提供借鉴。方法:1.采用翻译-回译-专家讨论-预实验的方法分别对SCNS-SF34、SPUNS-SF进行汉化;于2015年11月至2016年5月在中山大学肿瘤防治中心、广州医科大学附属肿瘤医院便利抽取癌症患者及主要照护者进行大样本横断面调查研究,评价简化版癌症患者支持性照护需求量表-简体中文版(The Mandarin Chinese version of the 34-item Short-Form Supportive Care Needs Survey,SCNS-SF34-C(Mandarin))、简化版癌症患者主要照护者未能满足的需求量表-简体中文版(The Chinese version of the Support Person’s Unmet Needs Survey-Short Form,SPUNS-SFC)的心理学测量指标。2.将胃肠恶性肿瘤HIPEC患者及其主要照护者的需求横断面调查数据分别进行统计学分析,明确其各自的需求。3.采用病例回顾研究,分析胃肠恶性肿瘤HIPEC围治疗期诊疗护理信息特点,在此基础上,拟订胃肠恶性肿瘤HIPEC-临床护理路径(Clinical nursing pathway,CNP)(HIPEC-CNP)草案;然后,基于胃肠恶性肿瘤HIPEC患者及其主要照护者的需求、胃肠恶性肿瘤HIPEC-CNP草案,采用循证证据检索与总结、文献回顾、内容分析法,分别拟订胃肠恶性肿瘤HIPEC个案管理护理实践方案草案及护理实践成效评价指标体系草案;从而,初步形成胃肠恶性肿瘤HIPEC个案管理护理实践模式草案;最后,采用两轮的Delphi专家咨询法对胃肠恶性肿瘤HIPEC个案管理护理实践模式草案进行论证与修订,完成胃肠恶性肿瘤HIPEC个案管理护理实践模式的构建。结果:1.SCNS-SF34-C(Mandarin)与SPUNS-SFC的心理学测量指标:(1)SCNS-SF34-C(Mandarin)共包含33个条目,5个维度:医疗体系服务与信息需求、心理需求、患者照护与支持需求、生理与日常生活需求、性需求,累计方差贡献率为69.757%;量表的聚合效度与区分效度良好;总量表Cronbach’s alpha系数为0.947,5个维度Cronbach’s alpha系数介于0.854~0.942。(2)SPUNS-SFC共包含21个条目,5个维度:信息需求、医疗服务获取及其连续性的需求、个人与情绪的需求、应对对未来的担忧的需求、经济需求,累计方差贡献率为78.47%;量表的聚合效度与区分效度良好;总量表Cronbach’s alpha系数为0.94,5个维度Cronbach’s alpha系数介于0.87~0.95。2.胃肠恶性肿瘤HIPEC患者及其主要照护者的需求:(1)胃肠恶性肿瘤HIPEC患者的心理需求程度、生理与日常活动需求程度最高,且显著高于胃肠恶性肿瘤非HIPEC患者该两方面的需求程度(t=-4.353,P0.001;t=-5.584,P0.001)。(2)胃肠恶性肿瘤HIPEC患者的主要照护者在医疗服务获取及其连续性的需求(t=-2.510,P0.05)、个人与情绪的需求(t=-3.727,P0.001)、经济需求(t=-2.757,P0.05)三个维度的得分均高于非HIPEC患者的主要照护者的得分;其对各类需求的程度由高到低依次为:应对对未来的担忧的需求、个人与情绪的需求、信息需求、医疗服务获取及其连续性的需求、经济需求。3.胃肠恶性肿瘤HIPEC个案管理护理实践模式:两轮Delphi专家咨询的专家积极性系数分别为92.86%、100%,专家权威系数为0.925。条目重要性赋值均数介于3.54~4.60,变异系数介于0.10~0.24,专家咨询协调系数为W=0.413(P0.001)。胃肠恶性肿瘤HIPEC个案管理护理实践模式包含:(1)HIPEC-CNP(含时间限定、入径标准、出径标准、可能出现的变异、9类HIPEC各单日CNP实施表格)(见附录23);(2)七类胃肠恶性肿瘤HIPEC个案管理护理实践方案(含HIPEC治疗中专科护理操作方案、HIPEC围治疗期营养支持方案、HIPEC围治疗期VTE预防及运动方案、HIPEC围治疗期压力性损伤预防管理方案、HIPEC围治疗期肠功能管理方案、HIPEC围治疗期个体化心理支持方案、HIPEC围治疗期主要照护者个体化支持性照护方案)(见附录23)及HIPEC健康管理手册(见附录23);(3)质性评价(主观评价指标)与量性评价(卫生经济学指标、客观评价指标)相结合的胃肠恶性肿瘤HIPEC个案管理护理实践成效评价指标体系(见附录23)。结论:1.SCNS-SF34-C(Mandarin)、SPUNS-SFC具有良好的信效度,分别是测量中国大陆癌症患者支持性照护需求、中国大陆癌症患者主要照护者需求的有效测评工具。2.在胃肠恶性肿瘤HIPEC围治疗期,护理人员应注意全程、动态评估患者的心理需求、生理与日常活动需求,以及主要照护者各类需求的程度及变化。3.胃肠恶性肿瘤HIPEC个案管理护理实践模式的Delphi专家咨询结果理想,具备科学性、可行性、实用性。该模式为HIPEC临床护理实践提供了初步的参考范式与科学依据,也为我国大陆肿瘤照护领域推进个案管理模式的研究与临床应用提供了参考与借鉴。然而,有待于胃肠恶性肿瘤HIPEC-临床路径(Clinical pathway,CP)(HIPEC-CP)建立完善后,以HIPEC-CP为支撑,开展胃肠恶性肿瘤HIPEC个案管理护理实践模式的多中心、随机对照研究,以进一步论证本课题构建模式的临床实践成效。
[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.

【学位授予单位】：广州医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R473.73
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本文编号：1557906