【摘要】：目的:評估妊娠期糖尿病(GDM)患者妊娠壓力水平及其影響因素;評價跨理論模型(TTM)的心理護理對GDM患者妊娠壓力、應(yīng)對方式、血糖水平和妊娠結(jié)局的干預(yù)效果,以尋求適合GDM患者壓力管理行為改變的干預(yù)模式,為完善GDM患者健康促進行為提供實踐依據(jù)。方法:本研究分兩部分進行。一部分為GDM患者妊娠壓力現(xiàn)狀及其影響因素的研究(簡稱為“研究一”),采用目的性抽樣,于2016年2月~7月對承德市某三甲醫(yī)院產(chǎn)科門診的15例GDM患者妊娠壓力的情況及原因進行半結(jié)構(gòu)式、深入訪談,收集資料后采用Colaizzi分析法進行分析并提煉主題。另一部分為TTM的心理護理干預(yù)的研究(簡稱為“研究二”),采用便利性抽樣,于2016年2月~7月在知情同意的基礎(chǔ)上,選取承德市某三甲醫(yī)院產(chǎn)科門診常規(guī)產(chǎn)檢的86例GDM患者為研究對象,按隨機數(shù)字表法分為實驗組(n=43例)和對照組(n=43例);對照組實施常規(guī)護理,實驗組在常規(guī)護理的基礎(chǔ)上實施跨理論模型的心理護理,兩組干預(yù)時間均持續(xù)3個月;分別于干預(yù)前、干預(yù)1個月后、干預(yù)3個月后,采用妊娠壓力量表、行為改變階段問卷、簡易應(yīng)對方式問卷(SCSQ)、新生兒及產(chǎn)婦觀察指標對2組患者進行數(shù)據(jù)的收集,數(shù)據(jù)采用SPSS22.0統(tǒng)計軟件進行統(tǒng)計學分析。結(jié)果:研究一Colaizzi分析法共提煉8個主題:(1)負性情緒;(2)胎兒健康方面;(3)妊娠結(jié)局方面;(4)知識獲取方面;(5)未來生活方面;(6)血糖控制方面;(7)工作、社交方面;(8)家庭方面。研究二TTM的心理護理干預(yù)結(jié)果:1.基線資料顯示:(1)2組患者在年齡、職業(yè)、居住地、文化程度、家庭人均月收入、醫(yī)療費用支付方式、孕產(chǎn)次數(shù)、有無糖尿病家族史及不良孕產(chǎn)史方面比較,差異均無統(tǒng)計學意義(p0.05);(2)gdm患者妊娠壓力總分為(47.05±5.11)分,得分指標為52.51%;(3)2組患者在妊娠壓力得分[(0.52±0.05)vs(0.53±0.06),t=-0.842]、行為變化階段(χ2=3.248)及應(yīng)對方式[積極應(yīng)對:(16.83±2.97)vs(15.51±2.68),t=-1.696;消極應(yīng)對:(9.88±1.69)vs(10.02±1.37),t=1.634]得分進行比較,差異均無統(tǒng)計學意義(p0.05),具有可比性。2.干預(yù)后結(jié)果顯示:(1)對干預(yù)前、干預(yù)1個月后、干預(yù)3個月后,2組患者的妊娠壓力總分進行重復(fù)測量方差分析,結(jié)果顯示,2組患者妊娠壓力總分在時間效應(yīng)、干預(yù)效應(yīng)及其交互效應(yīng)均有統(tǒng)計學意義(f時間效應(yīng)=930.459,f干預(yù)效應(yīng)=20.831,f交互效應(yīng)=90.086,p均0.01);干預(yù)1個月后2組患者妊娠壓力總分比較[(0.43±0.47)vs(0.48±0.06),t=-4.323],干預(yù)3個月后2組患者妊娠壓力總分比較[(0.35±0.04)vs(0.44±0.06),t=-8.403],差異均有統(tǒng)計學意義(p均0.01);在不同時間點上,實驗組妊娠壓力總分比較(f實=607.241),對照組妊娠壓力總分比較(f對=323.332),差異均有統(tǒng)計學意義(p均0.01);2組患者妊娠壓力總分在各時間點的兩兩比較差異均有統(tǒng)計學意義(p均0.05)。(2)對干預(yù)前、干預(yù)1個月后、干預(yù)3個月后,2組患者的scsq得分進行重復(fù)測量方差分析,結(jié)果顯示,2組患者的積極應(yīng)對方式得分的時間效應(yīng)、干預(yù)效應(yīng)及其交互效應(yīng)均有統(tǒng)計學意義(f時間效應(yīng)=232.522,f干預(yù)效應(yīng)=12.280,f交互效應(yīng)=4.246,p均0.01);實驗組和對照組患者在干預(yù)1個月后積極應(yīng)對方式得分比較[(18.02±2.69)vs(16.42±2.60),t=2.814]、干預(yù)3個月后積極應(yīng)對方式得分比較[(22.12±2.54)vs(19.53±2.81),t=-3.232],差異均有統(tǒng)計學意義(p均0.05);不同時間點上,實驗組患者積極應(yīng)對方式得分比較(f實=107.013),對照組患者積極應(yīng)對方式得分比較(f對=144.906),差異均有統(tǒng)計學意義(p均0.01);實驗組和對照組患者積極應(yīng)對方式得分在各時間點上的兩兩比較,差異均有統(tǒng)計學意義(p均0.01)。2組患者的消極應(yīng)對方式得分的時間效應(yīng)、干預(yù)效應(yīng)均無統(tǒng)計學意義(f時間效應(yīng)=0.584,f干預(yù)效應(yīng)=2.126,p均0.05);實驗組和對照組患者干預(yù)1個月后消極應(yīng)對方式得分比較[(9.44±1.59)VS(10.26±1.36),t=-2.545],差異有統(tǒng)計學意義(P0.05);不同時間點實驗組患者消極應(yīng)對方式得分比較(F實=5.064),對照組消極應(yīng)對方式得分比較(F對=4.226),差異均有統(tǒng)計學意義(P均0.05);實驗組和對照組患者消極應(yīng)對方式得分在各時間點上的兩兩比較,結(jié)果顯示2組患者干預(yù)前與干預(yù)1個月后比較差異有統(tǒng)計學意義(P0.05),2組患者其余時間點之間比較差異均無統(tǒng)計學意義(P均0.05)。(3)實驗組和對照組患者在不同時間點上妊娠壓力行為變化階段的組內(nèi)、組間比較結(jié)果顯示,實驗組和對照組患者在干預(yù)1個月后、干預(yù)3個月后的行為變化階段進行組間比較(χ21個月=22.928,χ23個月=24.952),差異均有統(tǒng)計學意義(P均0.01);不同時間點上實驗組和對照組患者行為變化階段進行組內(nèi)比較(χ2實=84.488,χ2對=37.360),差異均有統(tǒng)計學意義(P均0.01)。(5)實驗組和對照組患者血糖水平及妊娠結(jié)局的比較,結(jié)果顯示,實驗組患者三餐后2小時血糖值均顯著低于對照組[(5.41±0.55)VS(6.00±0.77),t早餐=-3.132;(6.31±0.29)VS(6.96±0.89),t中餐=-2.248;(6.23±0.26)VS(7.21±0.67),t晚餐=-2.030],差異均有統(tǒng)計學意義(P均0.05);實驗組患者的剖宮產(chǎn)、新生兒并發(fā)癥以及產(chǎn)婦并發(fā)癥發(fā)生率均顯著低于對照組[χ2剖=5.296,χ2新=5.780,χ2產(chǎn)=7.026],差異有統(tǒng)計學意義(P均0.05)。結(jié)論:1.GDM患者的妊娠壓力處于中等水平,需要及時評估并給予有針對性的心理護理干預(yù);2.TTM應(yīng)用于GDM患者的妊娠壓力干預(yù),能有效降低患者的壓力水平,促使患者采取積極的應(yīng)對方式,使行為變化階段明顯向前發(fā)展;3.TTM能促進GDM患者自我管理,使患者意識到行為改變對控制血糖的好處,最終改善妊娠結(jié)局。
[Abstract]:Objective: To evaluate the pregnancy stress level and its influencing factors in patients with gestational diabetes mellitus (GDM), and to evaluate the intervention effect of psychological nursing across theoretical model (TTM) on pregnancy stress, coping style, blood glucose level and pregnancy outcome in GDM patients, so as to find a suitable intervention model for the change of stress management behavior in GDM patients, and to improve the health of GDM patients. Methods: This study is divided into two parts. One part is the study on the pregnancy pressure status and its influencing factors of GDM patients (study 1). From February to July, 2016, 15 cases of GDM patients in the obstetric clinic of a third-class hospital in Chengde were selected by purposeful sampling. Colaizzi analysis method was used to analyze and refine the subject. Another part was the study of psychological nursing intervention of TTM (study 2). Based on informed consent from February to July, 2016, 86 patients with GDM were selected as subjects. The subjects were divided into experimental group (n = 43 cases) and control group (n = 43 cases) according to random number table method; the control group was given routine nursing, and the experimental group was given cross-theoretical model psychological nursing on the basis of routine nursing. The intervening time of the two groups lasted for three months; before intervention, after intervention for one month, after intervention for three months, the pregnancy pressure scale and behavior were adopted. Results: A Colaizzi analysis method was used to extract 8 topics: (1) negative emotions; (2) fetal health; (3) pregnancy outcomes; (4) knowledge acquisition. (5) Future life; (6) Blood glucose control; (7) Work, social aspects; (8) Family aspects. Study 2 TTM psychological nursing intervention results: 1. Baseline data showed: (1) 2 groups of patients in age, occupation, residence, education level, family per capita monthly income, medical expenses payment, times of pregnancy and childbirth, family history of diabetes and adverse. There was no significant difference in pregnancy and childbirth history (p0.05); (2) the total score of gestational stress in GDM patients was (47.05 + 5.11) and the score index was 52.51%; (3) the score of gestational stress in the two groups was (0.52 + 0.05) vs (0.53 + 0.06), t = - 0.842], the stage of behavior change (2 = 3.248) and coping style [positive coping: (16.83 + 2.97) vs (15.51 + 2.68), t = - 1.696; Negative coping: (9.88 + 1.69) vs (10.02 + 1.37), t = 1.634] scores were compared, the differences were not statistically significant (p0.05), with comparability. 2. After intervention, the results showed: (1) Before intervention, 1 month after intervention, 3 months after intervention, the total score of pregnancy pressure in the two groups were repeated measurement of variance analysis, the results showed that the total score of pregnancy pressure in the two groups was in Time effect, intervention effect and interaction effect were statistically significant (f-time effect = 930.459, f-intervention effect = 20.831, f-interaction effect = 90.086, P 0.01); after 1 month intervention, the total score of pregnancy pressure in the two groups was compared [(0.43 + 0.47) vs (0.48 + 0.06), t = - 4.323]; after 3 months intervention, the total score of pregnancy pressure in the two groups was compared [(0.35 + 0.04) vs (0.44 + 0.44]. 0.06, t = - 8.403], the difference was statistically significant (p 0.01); at different time points, the experimental group pregnancy pressure total score comparison (f = 607.241), the control group pregnancy pressure total score comparison (f = 323.332), the difference was statistically significant (p 0.01); two groups of pregnancy pressure total score at each time point were statistically significant (p 0.01); (2) Before intervention, one month after intervention, and three months after intervention, the SCSQ scores of the two groups were analyzed by repeated measures of variance. The results showed that the time effect, intervention effect and interaction effect of the two groups were statistically significant (f-time effect = 232.522, f-intervention effect = 12.280, f-interaction effect = 4.246, P 0). The scores of positive coping style in the experimental group and the control group were compared after 1 month of intervention [(18.02 (+ 2.69) vs (16.42 (+ 2.60), t = 2.814]. The scores of positive coping style in the experimental group were compared after 3 months of intervention [(22.12 (+ 2.54) vs (19.53 (+ 2.81), t = - 3.232], and the differences were statistically significant (all P 0.05). The scores of positive coping style in the experimental group and the control group were statistically significant (p 0.01); the scores of positive coping style in the experimental group and the control group were statistically significant (p 0.01). The time effect of negative coping style scores in the two groups was statistically significant (p 0.01). There was no significant difference in the intervention effect (f-time effect = 0.584, f-intervention effect = 2.126, P 0.05); the scores of negative coping style between the experimental group and the control group after intervention for one month [(9.44 + 1.59) VS (10.26 + 1.36), t = - 2.545], the difference was statistically significant (P 0.05); the scores of negative coping style between the experimental group and the control group at different time points were compared (F = 5.064). The scores of negative coping styles in the experimental group and the control group were compared at different time points, the results showed that there was a significant difference between the two groups before and after intervention (P 0.05), and the other time points between the two groups were compared (P 0.05). There was no significant difference between the two groups (P 0.05). (3) Comparisons between the experimental group and the control group at different stages of gestational stress behavior showed that the experimental group and the control group were compared at different stages of gestational stress behavior (21 months = 22.928, 23 months = 24.952) after one month of intervention and three months of intervention. The differences were statistically significant (P 0.01); at different time points, the experimental group and the control group were compared within the behavior change stage (_2 solid = 84.488, _2 pair = 37.360), the differences were statistically significant (P 0.01). (5) The experimental group and the control group were compared in blood glucose levels and pregnancy outcomes, the results showed that the experimental group two hours after three meals. The blood glucose values were significantly lower than those of the control group [(5.41+0.55) VS (6.00+0.77), t breakfast =-3.132; (6.31+0.29) VS (6.96+0.89), t lunch =-2.248; (6.23+0.26) VS (7.21+0.67), t dinner =-2.030], the differences were statistically significant (P 0.05); the incidence of cesarean section, neonatal complications and maternal complications in the experimental group were significantly lower than those in the control group (P 0.05). [_2 dissection = 5.296, _2 new = 5.780, _2 birth = 7.026], the difference was statistically significant (P 0.05). Conclusion: 1. GDM patients with pregnancy pressure is in the middle level, need to be timely assessment and give targeted psychological nursing intervention; 2. TTM applied to GDM patients with pregnancy pressure intervention, can effectively reduce the level of patients'pressure, prompt patients to take active measures. TTM can promote the self-management of GDM patients, make them aware of the benefits of behavior change on blood sugar control, and ultimately improve pregnancy outcomes.
【學位授予單位】：承德醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R473.71

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