糖尿病足是糖尿病最常见的慢性并发症之一，具有高发生率、高截肢率、高住院率和高复发率的特点[1-2]。据统计，糖尿病患者一生中罹患糖尿病足的风险最高可达34%[3]。在我国，每年新确诊的糖尿病足患者约400万例[4]。糖尿病足溃疡愈合后，仍有极高的复发风险[5]。研究[6]表明，足部减压护理是降低糖尿病足复发风险、改善患者预后的关键措施。但目前，国内外糖尿病足相关指南和共识中关于溃疡愈合后足部减压护理的证据较为分散，缺乏系统、全面的证据总结，限制了其在该领域的推广和应用[7-8]。鉴于此，本研究通过对预防糖尿病足复发的足部减压护理相关证据进行评价并汇总，以期为临床护理实践提供参考。该研究已在复旦大学循证护理中心注册（ES2023-3868）。
1 资料与方法
1.1 确定循证问题
根据PIPOST模式[9]确定循证问题。①目标人群（population，P）：有糖尿病足史的患者。②干预措施（intervention，I）：足部减压护理相关措施。③实施人群（professional，P）：医护人员、患者及家属。④研究结局（outcome，O）：主要结局指标为糖尿病足复发情况，次要结局指标为足底压力、糖尿病足发生风险等级等。⑤应用场所（setting，S）：医院、社区或家庭。⑥证据类型（type of evidence，T）：临床决策支持、指南、最佳实践、证据总结、系统评价、专家共识。
1.2 检索策略
按照“6S”证据金字塔模型自上而下进行检索，检索时限为建库至2025年1月。以“diabetes mellitus/diabetes”“diabetic foot/foot ulcer/diabetic high-risk foot/foot disease/healed diabetic foot ulcer”“offloa-ding/decompression/pressure relief”“recurrence/recur-rent/re-ulceration/relapse”“prevent/prevention/prophy-laxis”等为英文检索词，检索UpToDate、BMJ Best Prac-tice、美国指南网、加拿大安大略省注册护士协会网站、苏格兰院际指南网、英国国家卫生与临床优化研究所网站、美国糖尿病学会网站、国际糖尿病足工作组网站、Cochrane Library、澳大利亚乔安娜布里格斯研究所（Joanna Briggs Institute，JBI）循证卫生保健中心数据库、CINAHL、PubMed、Embase和Web of Science；以“糖尿病”“糖尿病足/足溃疡/高危足”“减压/卸载/压力缓解”“复发/再发/再出现”“预防/防治”等为中文检索词，检索中国生物医学文献数据库、中国知网、万方数据库、维普数据库和医脉通指南网。主题词结合自由词构建检索式。
1.3 文献的纳入与排除标准
纳入标准：①研究对象为有糖尿病足病史的患者；②研究内容为预防糖尿病足复发的足部减压护理措施；③研究类型为临床实践指南、专家共识、证据总结及系统评价等；④发表语言为中文或英文。排除标准：①信息不完整；②重复发表、指南或共识解读、翻译版本。
1.4 文献质量评价标准
1.5 文献质量评价过程
所有文献由2名完成《循证护理学》研究生课程学习、接受过相关培训的研究者根据文献评价标准独立评价，如出现分歧，与1名糖尿病足领域的循证护理专家商议，决定纳入或剔除文献。
1.6 证据汇总与分级
由2名研究者逐篇阅读纳入的文献，进行内容提取，提取结果由第3名循证护理专家进行语义与内容核查。若存在因翻译导致的差异，与团队内具备专业英语学习背景的高级职称专家共同分析、讨论，直至形成共识。证据汇总原则如下。①内容一致时，采用简洁易懂的推荐意见；②内容互补时，按照语言逻辑，整合为1条推荐意见；③内容冲突时，遵循循证证据优先、高质量证据优先、最新发表文献优先的原则，选择适宜的推荐意见；④内容独立时，则保留原始的推荐意见。采用2014版JBI证据预分级系统将纳入证据的等级划分为1~5级，其中1级为最高级别，5级为最低级别[13]。
2 结果
2.1 纳入文献的基本特征
表1 纳入文献的基本特征（n=14）
Table 1
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注：NICE为英国国家卫生与临床优化研究所，ADA为美国糖尿病学会，IWGDF为国际糖尿病足工作组。
2.2 纳入研究的质量评价结果
2.2.1 指南的质量评价结果
2.2.2 专家共识的质量评价结果
2.2.3 系统评价的质量评价结果
纳入1篇系统评价[21]，条目8“系统评价作者是否详细地描述了纳人的研究?”评价结果为“部分是”，条目14“系统评价作者是否对研究结果的任何异质性进行合理的解释和讨论?”为“否”，其他10个条目均为“是”，文献整体质量较高，予以纳入。
2.3 证据汇总（表2）
表2 足部减压护理预防糖尿病足复发的最佳证据总结
Table 2
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3 讨论
3.1 足部压力评估与危险因素识别是预防糖尿病足复发的基础
第1~12条证据指出足部压力评估的实施人员、频率和内容。研究证实，足部压力异常增高是糖尿病足复发的重要独立危险因素及预测指标[6]，压力水平与复发风险呈正相关[23]。糖尿病患者足部压力异常现状不容乐观，总异常增高率达86%[24]。因而，定期评估足部压力并精确识别相关危险因素至关重要。已有证据[1,5,7,19]指出，足部畸形、胼胝、关节活动受限、步态异常以及不合适的鞋袜等均能引起足部生物力学异常，导致糖尿病足复发。提示医疗机构应将足部压力评估纳入糖尿病足常规随访项目，并加强对临床医护人员的专项培训，提升其对足部压力异常及相关危险因素的识别能力。临床医护人员在实践中应从多角度出发，全面筛查，以明确糖尿病足复发风险。然而，目前聚焦于糖尿病足愈合患者复发风险评估的相关证据仍相对匮乏[5,8]。未来研究应加强对糖尿病足复发危险因素的深入探究，构建低偏倚风险、高临床适用性的评估工具。
3.2 局部压力调适是预防糖尿病足复发的关键
3.2.1 溃疡前期病变处理技术是局部压力调适的关键手段
第13~19条证据详细阐述了溃疡前期病变的标准化处理流程、频率及注意事项。研究[5]证实，足部胼胝、过度角化增生组织及畸形趾甲等溃疡前期病变，可直接导致足部压力异常升高及分布失衡，是糖尿病足发生发展的重要危险因素。同时，不正确、不规范的处理方式还会增加足部感染、破溃及溃疡风险[25]。因此，规范化处理溃疡前期病变对预防糖尿病足复发具有重要意义。然而，病变的处理频率尚无统一标准，部分学者建议根据患者足部病变进展或压力水平进行动态调整，但缺乏量化指标和临床验证[8]。此外，病变处理后的减压护理环节常被忽视，后续若未配合有效的减压措施，足部压力极易再次升高。因此，未来研究应通过多中心、大样本随机对照试验，深入探究不同处理技术的适用人群、各种技术的最佳操作参数及联合治疗方案，为临床制订更具针对性和科学性的处理策略提供依据。
3.2.2 使用减压敷料与辅助器具是局部压力调适的核心技术
第20~25条证据指出了应用减压敷料开展足部压力转移的操作步骤，以及减压辅助器具的使用时机、类型选择及观察要点。研究[26]表明，糖尿病足发生的常见途径为失去保护性感觉的足部遭受过大的机械应力。因而，借助减压敷料和辅助器具实现足部压力重新分配已成为预防的核心策略。建议依据患者足部生物力学特征分析结果，合理选择并及时使用，以支撑足部，减少摩擦和分散转移异常增高的足部压力[19]。但目前关于减压敷料与辅助器具应用的高质量临床研究相对不足，现有证据多为理论指导或小样本观察，缺乏大规模随机对照试验验证其长期有效性和安全性。另一方面，因穿戴不适、姿势失衡导致的依从性下降可能削弱减压效果。因此，未来可系统评估不同类型减压敷料和辅助器具的临床效果及适用人群，根据患者反馈及时调整辅助器具类型或穿戴方式，提高其穿戴依从性。
3.2.3 步态训练技术是局部压力调适的重要补充
3.3 日常足部减压行为是预防糖尿病足复发的重要保障
第30~33条证据总结了日常足部减压行为的具体内容。目前，糖尿病足的发生发展仍未得到有效控制，不可回避的突出问题是患者足部的健康行为不佳，表现为日常护理不佳、遵医行为不佳以及就医行为延迟。随着“主动健康”成为慢病管理的新理念和模式[28]，帮助患者建立积极的日常足部减压行为，包括足部检查、清洁、趾甲修剪、异常步态调整及适度运动等[2,19]，是实现糖尿病足管理目标的重要保障。建议由专科护士对其实施终身监测与密切随访，及时发现患者足部问题并给予针对性护理处理[14]，并帮助寻求可利用的支持资源[18]，协助病情管理，维持足部减压护理的连续性。证据[1]指出，在实践过程中，还需考虑影响患者自我管理的身体限制，例如视力障碍患者可能无法及时察觉足部的细微损伤或溃疡早期病变。故未来研究可深入研究影响患者日常足部减压行为的躯体、心理和社会因素及其干预策略等。
3.4 减压预防健康教育是预防糖尿病足复发的必要环节
第34~36条证据总结了减压预防健康教育的实施时机、人员和内容。研究[1]表明，糖尿病患者足部减压护理知识的掌握程度与其护理行为之间存在正相关关系，即系统接受健康教育的患者更能主动落实定期复查、使用减压辅具等，有效规避因护理不当引发的足部压力异常。现有证据已形成涵盖内分泌、血管外科、护理等多学科知识的教育内容框架，为临床制订标准化教育方案奠定了基础。但多学科协作开展健康教育的具体实施路径尚不明确，各学科在教育内容整合、职责分工方面缺乏统一标准。其次，针对健康教育效果的质量评价体系尚不健全。因此，建议组建由内分泌医师、专科护士、康复治疗师等专业人员构成的多学科团队，依据患者疾病阶段、知识水平及个体需求，制订分层式健康教育方案[1,8]。同时，建立动态化效果评价机制，并根据反馈及时优化教育内容。未来多学科团队可借助大数据和远程管理技术，开展多层次的结构化教育，进行有效的复发风险预警，以及实施连续性疾病诊疗和健康管理。
4 小结
本研究从足部压力评估、局部压力调适、日常足部减压行为和减压预防健康教育4个方面总结了足部减压护理预防糖尿病足复发的最佳证据，为临床医护人员进行预防干预提供了可靠的循证依据。由于本研究在证据纳入方面，仅选取了公开发表的指南、专家共识以及系统评价类文献，且证据来源多为国外研究。因此，医护人员在应用证据时，需结合患者的主观意愿、文化背景及具体临床情境，开展本土化的最佳证据实践。
利益冲突 所有作者声明无利益冲突
作者贡献声明 万艳：确定选题、设计框架、文献检索、质量评价、证据汇总、论文撰写及修改；贾青：文献检索、质量评价、证据汇总；白姣姣：研究设计指导、研究质量控制、论文审阅
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IDF diabetes atlas:global estimates for the prevalence of diabe-tes for 2015 and 2040
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主动健康视角下养老机构失能老年人“给予式照护”困境的质性研究
[J].目的 从主动健康视角出发，探析养老机构失能老年人“给予式照护”困境的形成原因。 方法 采用目的抽样法，2022年7月—12月选取重庆某养老机构的失能老年人及照护人员为研究对象。采用一对一深入访谈、Colaizzi 7步分析法进行资料收集及分析。 结果 确定了4个主题：①“给予”照护理念主导，包括以孝为本的文化思想、被动接受的照护特征、购买服务的用尽心理；②参与照护能力不足，包括主动健康的知识缺乏、参与照护的技能弱化；③转型照护模式受阻，包括人力资源的客观限制、适老环境的匹配滞后；④利用内在能力减退，包括潜在风险的过度规避、照护人员的工作超负荷、个性照护的质量欠佳。 结论 养老机构失能老年人“给予式照护”形成原因受到社会背景、服务体系、供给资源、管理模式等多重影响。将失能老年人从“给予式被动照护”转型到“参与式主动健康”，是实现积极健康老龄化理念的重要举措。
A qualitative study on dile-mma of “Giving Care” for the disabled elderly in nursing homes from perspective of active health
[J].
