Application of natural head position in orthodontics
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摘要: 自然头位（NHP）参考系统因其稳定性及可重复性较颅内参考平面高、可克服与颅内参考线变异性有关问题以及代表着真实的生活外观，现已被越来越频繁地用于头影测量预测先天面部发育方向和正颌手术的方案设计中。正畸领域、脊柱外科领域和心理学领域等大量NHP相关研究发现，颅颌面部畸形在影响头部姿势的同时，还表现在颈椎姿势和躯体姿势上，又反映了个体对美观的要求，甚至还与个人性格有关，反之也与正畸治疗的基本目标（美观、功能、平衡、稳定）相呼应。这些发现进一步提高了NHP的研究价值，现将NHP的起源、发展及其在正畸领域的临床应用状况综述如下。Abstract: Natural head position(NHP) is increasingly being used in cephalometry to predict congenital facial development tendency and design of orthognathic surgery because its higher stability and repeatability than the intracranial reference planes. So far, extensive studies using NHP in orthodontics, spinal surgery, and psychology have found that craniofacial deformities not only affect head posture, cervical and somatic posture, but also reflect aesthetic requirements of individuals. Meanwhile, it is related to the personality of the individuals, and corresponds to the basic goals(beauty, function, balance and stability) of orthodontic treatment. These findings further enhance the value of NHP. This article reviewed the origin, development of NHP and its application in orthodontics in recent years.
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Keywords:
- natural head position /
- malocclusion /
- head posture /
- cervical posture /
- body posture /
- orthognathic surgery /
- orthodontics
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断指是手足外科常见疾病，且常合并皮肤、血管、肌腱、神经等损伤。断指再植是将完全或不完全断离的指体在光学显微镜的助视下彻底清创，将离断的血管重新吻合，进行骨、神经、肌腱及皮肤的整复术，术后进行各方面的综合治疗，以恢复其功能的精细手术[1]。但术后患者断指功能的恢复与术后护理及患者配合程度密切相关[2-3], 就需要患者在短时间内尽快掌握断指再植术后注意事项[4]。传统宣教方法以口头宣教为主, 方法单一且患者不易掌握，患者依从性差，影响教育效果[5]。本研究采用思维导图方法对断指再植术后进行健康教育，取得一定效果，现报告如下。
1. 资料与方法
1.1 一般资料
选取2020年1—12月收治的115例断指再植患者，其中男80例，女35例; 年龄18~58岁; 文化程度: 专科及以上29例，高中41例，初中及以下45例。纳入标准: 患者均为意外事故导致; 无其它基础性疾病者; 神志清醒能正常交流沟通者; 单纯1~3手指离断伤的患者。将研究对象随机分2组，对照组57例采用常规方式健康宣教，观察组58例采用思维导图式健康宣教。2组患者年龄、文化、疾病等资料比较，差异无统计学意义(P>0.05)。
1.2 护理方法
1.2.1 对照组
采用常规方法进行健康宣教，由责任护士按照常规术后断指再植护理进行健康宣教，主要以口头讲解和发放健康教育单宣教为主，讲解术后体位、饮食、疼痛知识、烤灯使用、功能锻炼等，同时将宣教单悬挂于患者床头，便于患者随时查看。根据患者接受情况连续宣教3~5 d, 每天宣教时间为20 min左右，第6天时进行宣教效果评价。
1.2.2 观察组
利用思维导图方式进行断指再植术后健康宣教。建立思维导图健康教育小组，小组成员由1名主治医生、护士长和责任护士组成，护士长和主治医生负责制订断指再植术后患者全面系统的健康教育内容，同时根据查阅的相关文献运用MindMaster思维导图软件进行具体思维设计[6]。实施健康宣教前, 护士长对所有责任护士进行统一培训，每位护士将抽象的健康宣教过程通过思维导图的结构进行展现，把各级宣教内容用相互隶属的层级图表现出来，以保证每位护士的宣教方法一致。护士长每天检查护士健康宣教实施情况，检查患者的依从性情况，发现异常情况及时处理。
1.2.3 导图制作及内容
思维导图由英国托尼. 博赞提出，又称脑图、心智地图，是表达发散性思维的有效图形思维工具，可以将大脑中抽象的思考过程通过图文并茂的结构展现在1张白纸上，把主题关键词与图像、颜色等建立记忆连接[7]。思维导图内容主要包括: 从中心思想“断指再植术后健康教育”出发建立根基，然后把与中心思想相关的信息如病房环境、患者体位、饮食生活习惯、血运观察、疼痛观察、功能锻炼等筛选出来，并有条不紊地挂在不同的树枝上，树枝可以再延伸出分枝，最后成长为一幅图文并茂的健康教育“思维大树”[8], 见图 1。
1.3 观察指标
分别对2组患者依从性进行评价，术后康复的依从性分为3个等级[9]: ①完全依从，指术后完全按照健康宣教内容和时间截点进行主动配合; ②部分依从，指术后未完全按照健康宣教内容和时间截点进行配合，偶尔需要责任护士和家属的督促; ③依从性差，指术后完全未按照健康宣教内容和时间截点进行配合，责任护士和家属督促后也不配合。
分别对2组患者的断指再植成活率、断指功能恢复优良率、术后并发症发生率进行比较。断指再植成活率是指患者5 d内血运恢复正常[10-12]; 断指功能恢复优良率根据《中华医学会手外科学会上肢部分功能评定标准》[13]对患者断指功能进行评价, 优良率=(优+良)/总例数×100%。术后并发症发生率由管床医生进行界定，主要包括血管痉挛、血管栓塞、局部感染、功能障碍等。
评价2组患者满意度。采用本病区自行设计的《断指再植出院患者满意度调查表》对患者出院前1 d的满意度情况进行问卷调查。调查表共10个条目，每个条目10分, 10分为非常满意，8为满意, 6分为一般, 4分为不满意，其中80~100分为满意, 60~ < 80为一般, < 60分为不满意，满意率与一般满意率之和为总满意度。该问卷内容在使用前进行了效度测定，邀请1名副主任护师、1名护理研究生、1名诊疗组医生共同参与效度测定, CVI为0.8, Cronabach's α系数为0.87, 表明具有良好的信效度。
1.4 统计学方法
采用SPSS 19.0进行数据处理，计数资料采用χ2检验，计量资料采用t检验，等级资料采用秩和检验, P < 0.05为差异有统计学意义。
2. 结果
2.1 2组依从性比较
观察组完全依从性达72.4%, 高于对照组的49.1%, 差异有统计学意义(P < 0.05), 见表 1。
表 1 2组患者依从性比较[n(%)]组别 n 完全依从 部分依从 不依从 观察组 58 42(72.4)* 12(20.3) 4(6.8) 对照组 57 28(49.1) 22(38.5) 7(12.2) 与对照组比较, * P < 0.05。 2.2 2组手指功能恢复情况比较
观察组患者术后手指功能恢复优良率为86.2%, 高于对照组的70.2%, 差异有统计学意义(P < 0.05), 见表 2。
表 2 2组患者手指功能恢复情况比较[n(%)]组别 n 断指再植
成活断指再植
恢复优良术后
并发症观察组 58 53(91.4) 50(86.2)* 2(3.4)* 对照组 57 50(87.7) 40(70.2) 10(17.5) 与对照组比较, * P < 0.05。 2.3 2组满意度比较
观察组总满意度高于对照组，差异有统计学意义(P < 0.05), 见表 3。
表 3 2组患者满意度比较[n(%)]时间点 n 满意 一般 不满意 总满意 观察组 58 53(91.4) 3(5.2) 2(3.4) 56(96.5)* 对照组 57 40(70.2) 8(14.0) 9(15.8) 48(84.2) 与对照组比较, * P < 0.05。 3. 讨论
思维导图简单却又极其有效, 形状往往像一颗开枝散叶的树，能够用一张图解释复杂的过程，是一种革命性的思维工具，主要运用左右脑机能，利用记忆、阅读、思维的规律，协助人们在科学与艺术、逻辑与想象之间的平衡发展，从而开启人类大脑的无限潜能。
研究[14]表明，导致断指再植患者术后康复依从性差的原因与护士宣教方式有关。提高患者依从性将有助于促进患者对断指再植术后知识的认知，主动配合康复锻炼，有利于断指功能恢复。运用思维导图进行健康宣教，能够使患者思路清晰，提高患者对术后康复的认知和自我管理能力，使患者从被动康复锻炼转化为积极主动康复锻炼，术后对体位、烤灯使用及功能锻炼等主要健康宣教内容依从性更高，进而减少术后并发症的发生[15]。本研究中, 2组患者断指再植的成活率比较, 差异无统计学意义(P>0.05), 但观察组断指再植恢复优良率高于对照组，术后并发症低于对照组。
运用思维导图与患者交流更快捷顺畅，护理人员更有耐心，能够与患者建立良好的护患关系，较短时间内满足患者对护理的需求，做到有针对性的健康宣教，在宣教中能够让患者及其家属“看到、听到、感受”到护理服务效果[16]。本研究中观察组患者满意度高于对照组，差异有统计学意义(P < 0.05)。
思维导图宣教能够提高护士评判性思维能力。掌握思维导图制作和运用，护士必须及时熟悉患者病情变化的相关信息并进行分析、归纳，这对护十的评判性思维能力有较高的要求。落实过程中，思维导图引导护理人员根据程序逐项收集、分析患者相关信息，能够快速地对患者术后康复情况进行分析和评估，做到准确宣教。
综上所述，运用思维导图对断指再植术后患者进行健康教育能有效提高患者术后康复的依从性和康复效果，减少并发症，提高断指恢复的优良率，提高患者满意度。
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