臺灣博碩士論文加值系統

急性心肌梗塞病人需面對疾病引發的生理與心理不適症狀，胸痛及憂鬱是最常見的症狀，許多病人在接受治療後症狀並不如預期的完全得到緩解，進而影響病人的生活品質及生活功能，因此本研究主要探討急性心肌梗塞病人發病至6個月期間的胸痛、憂鬱、死亡焦慮等身心症狀和生活品質的復原軌跡以及影響軌跡型態的預測因子。
本研究為前瞻性縱貫性研究設計，以台灣東部二家教學醫院的心臟內科及內科病房為收案場所，資料收集共計四次，以結構性問卷分別在住院中、出院一個月、三個月以及六個月進行訪談，研究工具包括人口學資料，疾病相關屬性資料，西雅圖心絞痛問卷(SAQ)、醫院焦慮憂鬱量表(HADS)、死亡焦慮量表(DAS)、服藥遵從性量表(MMAS)以及簡版生活品質量表(SF-12)。
本研究共收案102人，完成第二次收案有79位病人，完成第四次收案為76位病人。其中男性病人80(78.4%)人，女性病人22(21.6%)，平均年齡為62.75 歲 (SD=11.71)； 疾病相關的屬性方面急性心肌梗塞的分類以NSTEMI（Non ST Elevation Myocrdial Infarction）佔52%，STEMI (ST Elevation Myocardial Infarction) 48%；個案當中86%接受冠狀動脈經皮介入手術(PCI)；心肌梗塞的疾病嚴重度(Killip classification)以Killip II, 32.4%佔多數；左心室射出率(LVEF)平均為47.97%(13.97)；個案平均住院天數為6.06天(SD=4.74)。
症狀復原軌跡方面98%的個案在急性心肌梗塞發生時經歷心絞痛之症狀、經過治療一個月至六個月後約有三分之一的個案仍舊存在間歇性的心絞痛。憂鬱的比例住院中為56.9%，在出院後有顯著的下降；死亡焦慮的程度在住院中平均分數為5.68(SD=2.62)，出院後六個月分數為2.21(SD=2.87)有顯著的改善。生活品質的復原軌跡在生理層面或心理層面都未達顯著的變化。
以廣義估計方程式(GEE)進行預測因子分析顯示年齡、住院天數、再灌流治療種類為胸痛有關的預測因子，心肌梗塞次數則與心理症狀的憂鬱復原軌跡有顯著相關；生活品質的預測因子為種族、婚姻、職業、住院天數、心肌梗塞次數以及胸痛程度等變項。
本研究的結果提供臨床在照護急性心肌梗塞病人的過程中能更加敏銳的察覺病人的需求，適時提供關懷及支持，尤其在疾病初期，身心症狀的程度較為嚴重，更需要護理人員及時察覺並減緩疼痛及害怕的情緒，另外，出院後約有三分之一的病人仍持續發生心絞痛症狀，更需要醫護人員提供足夠的衛教和資源協助病人及時處理或及時就醫。

Patients with acute myocardial infarction need to face the physiological and psychological symptoms caused by the disease. Chest pain and depression are the most common symptoms. Many patients do not fully relieve their symptoms after receiving treatment, which affects the quality of life and physical function. Thus, the purpose of this study was to investigate the level of physical and psychological symptoms such as chest pain, depression, fear of death and quality of life of patients with acute myocardial infarction from the onset to 6 months. In the meanwhile, also to detect the predict factors of recovery trajectory pattern.
This study was designed for prospective longitudinal study. The cardiac and internal medicine wards of two teaching hospitals in eastern Taiwan were used as the venues for the collection of data. The data were collected for a total of four times. The structured questionnaires were used during hospitalization and discharge for one month, three months and six months respectively. Research tools including demographic data, disease-related attributes data, Seattle Angina Questionnaire (SAQ), Hospital Anxiety and Depression Scale (HADS), Death Anxiety Scale (DAS), Morisky Medication Adherence Scale (MMAS-8) and a Short Form Life Quality (SF-12).
In this study, a total of 102 people were enrolled, 79 patients were completed for the second time, and 76 patients were completed for the fourth time. 80 (78.4%) were males and 22 (21.6%) were females, with an average age of 62.75 (SD=11.71). The type of acute myocardial infarction was NSTEMI (52%) and STEMI (48%); 86% received percutaneous coronary intervention (PCI); the disease severity of the myocardial infarction (Killip classification) was Killip II, 32.4%; the left ventricular ejection fraction (LVEF) averaged 47.97% (SD=13.97); The length of stay was 6.06 days (SD = 4.74).
98% of patients experienced angina pectoris at the time of acute myocardial infarction. There were about one-third of patients remaining intermittent angina after six months of treatment. The proportion of depression was 56.9% initially, then significantly declined after 6 months. The average score of fear of death during hospitalization was 5.68 (SD = 2.62), and decreased to 2.21 (SD = 2.87) at 6 month. The recovery trajectory of quality of life has not reached significant changes in either the physiological or psychological aspects.
The predictive factor analysis by the generalized estimating equation (GEE) showed that the age, length of stay, type of reperfusion treatment were predictors of physical symptoms, and the number of myocardial infarction was significantly related to the recovery trajectory of psychological symptoms; the predictor of quality of life was ethnicity, marriage status, occupation, length of stay, number of myocardial infarctions, and degree of initial chest pain.
The results of this study provide better clinical observation of acute myocardial infarction patients, especially in the early stages of the disease, which the degree of physical and psychological symptoms is more serious. The nurses should be more alert about patient’s symptoms and to provide comprehensive support and treatment. In addition, about one-third of patients still suffer from angina symptoms after discharge. They also need medical staff to provide adequate education and resources to assist patients and medical treatment.

目次
博士學位考試委員會考試審定書 I
誌謝 II
中文摘要 III
英文摘要 V
目次 VII
表次 X
圖次 XII
第一章 緒論
第一節 研究背景及動機 1
第二節 研究目的 4
第二章 文獻查證
第一節 急性心肌梗塞 Acute myocardial infarction (AMI) 5
第二節 胸痛 8
第三節 憂鬱 15
第四節 害怕死亡 19
第五節 健康行為依從性與急性心肌梗塞 22
第六節 生活品質與急性心肌梗塞 24
第七節 症狀相關理論 26
第八節 研究架構 35
第九節 名詞解釋 37
第三章 研究方法
第一節 研究設計 38
第二節 研究對象 40
第三節 研究工具 42
第四節 研究步驟 51
第五節 資料分析方法 53
第四章 研究結果
第一節 研究對象之基本資料分析 57
第二節 急性心肌梗塞之身心症狀、服藥遵從性及生活品質 61
第三節 身心症狀、服藥遵從性及生活品質與人口學之相關性 68
第四節 身心症狀及生活品質與疾病相關指標之相關性 82
第五節 急性心肌梗塞身心症狀及生活品質之預測因子 93
第五章 討論
第一節 胸痛程度與其預測因子 110
第二節 憂鬱程度與其預測因子 114
第三節 害怕死亡與其預測因子 116
第四節 生活品質與其預測因子 118
第六章 結論與建議
第一節 結論 122
第二節 限制與建議 123
參考文獻
中文參考文獻 124
英文參考文獻 125
附錄一 人體試驗委員會通過證明-1 135
附錄二 人體試驗委員會通過證明人體試驗委員會通過證明-2 136
附錄三 健康相關生活品質量表(SF-12) 授權書 137
附錄四 西雅圖心絞痛量表(SAQ) 授權書 138
附錄五 醫院焦慮憂鬱量表(HADS) 授權書 142
附錄六 死亡焦慮量表(DAS) 授權書 143
附錄七 藥物依從性量表(MMAS-8) 授權書 144

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