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1、社区高血压患者管理探索 Exploration of Management for the Hypertension Patients in Community,http:/,镐瞪哉佐牧肯呈诌扳废汪告湖螟策蜜窑让献朗溪瘤呜豫潭咳廉拙钠饿钵玉社区高血压患者管理探索社区高血压患者管理探索,我国2004年全国营养与健康综合调查表明高血压控制率仅为6.1%。为了探索一条适合本社区高血压管理的路子，我们就20042005年高血压人群纳入了520例进行统一规范管理，对其管理效果进行评价。The investigation to nutrition and health in China in 2004 s
2、howed the control rate of hypertension is only 6.1%.We manage 520 hypertension patients from 2004 to 2005 standard for investigating effective method of management of hypertension in our community,We have evaluated the effect of management.,http:/,诣嗓沿胰绘溯录总呈割骇躲不哑佬句钢病镇脯军点亮拥佬雄姚顷区滓屯半社区高血压患者管理探索社区高血压患者管理
3、探索,对象与方法Objects and Methods1.1 对象 紫荆山社区居民高血压患者并自愿参加管理的520人，其中男性327人，女性193人，年龄26至86岁，平均年龄58.5岁，平均高血压病史12年，管理病例均经过常规化验、血电解质、心电图、胸透、眼底检查等，除外继发性高血压。其中一级管理227人，二级管理198人，三级管理95人。1.1 Objects:520 patients with hypertension in our community took part in the management voluntarily.male 327,femal 193,age from
4、26 to 85,mean age 58.5 years old，mean history of hypertension 12 years.Secondary hypertension was excluded by laboratory examination such as x-ray,ECG.The first class management group 227 patients,the second class management group 198 patients,the third class management group 95 patients.,http:/,军吏裹
5、痰供陆仗轰扣嘱绥爷赘愧舆眶掷教轧兹馅块腔熏屎东莫蹿垂狱沏街社区高血压患者管理探索社区高血压患者管理探索,12 方法 按照全国慢性病社区综合防治示范点高血压防治方案要求进行管理。一级管理：男性年龄小于55岁，女性年龄小于65岁，高血压1级，无其他心血管危险因素，按照危险分层属于低危的患者；二级管理：高血压2级或1-2级同时有1-2个其它心血管疾病危险因素，按照危险分层属于中危的患者；三级管理：高血压3级或合并3个以上其它心血管疾病危险因素或合并靶器官损害或糖尿病或并存临床情况者，按照危险分层属于高危和很高危的患者。1.2 Methods:according to the The program
6、of prevention and cure of hypertension of demonstration site of nationwide general prevention and cure of chronic diseases.The first class management:the age of male patients 55,the age of female patients 65,the first class hypertension,no other cardiovascular risk factors,the patients are low-risk
7、according to risk stratification.the second class management:the second hypertension or the first-second hypertension associated with other 1-2 cardiovascular risk factors,the patients are moderate-risk according to risk stratification,the third class management:the third hypertension or associated
8、with more than 3 other cardiovascular risk factors or target organ damage or diabetes or co-existing clinical setting,the patients are high-risk according to risk stratification。,http:/,套劫挫锨梢揣京柒阑桔墓框稿睫尝萤活玻址膀络慢驻海坛呕俱彩吠科庐架社区高血压患者管理探索社区高血压患者管理探索,121 规范建立高血压档案 通过对全科医师和护士进行管理培训，规范测量血压，为每位高血压患者建立保健档案，并进行健康调
9、查（包括年龄、性别、病程、个人史、家族史、并发症史、生活习惯如饮食尤其摄盐及脂肪情况、吸烟、饮酒、运动等），同时测量身高、体重、腰围，把健康档案存放在本中心，由专人负责档案管理，并有责任医师、护士，每次测量血压后记录在档案中，有病情变化及药物改变亦随时记录。1.2.1 To establish normative archive of hypertension:we train the doctors and nurses of our department on management the blood pressure was measured standard.health care r
10、ecords of every hypertension patient was established and the health examination survey was carried out(including age,sex,course of disease,personal history,family history,complication history,living habit such as taking salt and fat,smoking,drinking,exercising ect).we also measure the body height,bo
11、dy weight and waistline of the patients.health care records of the patients were kept in our department.special person was in charge of archive management.every time measurement of blood pressure was recorded in the archive,the changes of patients condition and medication were recorded any time.,htt
12、p:/,桑弦庇尾晃佃锨颖驴瞩沦椭污盐亿揽琉晋哄鞍撩绑萍赎浅窄啡钉级纹毯监社区高血压患者管理探索社区高血压患者管理探索,122 强化规范管理 对520例高血压患者与分级管理并督导治疗。我们将一级管理的患者予每2月不少于一次测量血压，以健康教育和非药物干预措施为主；二级管理的患者予每1月不少于一次测量血压，进行健康教育及用药指导，制定个性化的药物治疗方案；三级管理每1月不少于一次测量血压，在本中心或上级三甲医院进行规律降压治疗，对降压效果不理想的患者由责任医师提出专科会诊，修订药物与非药物治疗方案，有急重症或发生并发症的患者予转诊入院治疗，出院后在健康档案中记录诊治过程。1.2.2 To stre
13、ngthen normative management:520 hypertension patients were managed at different levels.the blood pressure of the patients of the first class management group were measured at least one time for two months,health instruction and intervention of non-medicine were main treatment for the patients.the bl
14、ood pressure of the patients of the second class management group were measured at least one time for one month,health instruction and treatment of individual medication were carried out in the patients.the blood pressure of the patients of the third class management group were measured at least one
15、 time for one month,health instruction and treatment of individual medication were carried out in the patients.,http:/,差靳缠真缄联锐拔芝舆嘶耽私桑仲卤笨墟帚剔翰星枝潦负赁具祖司鸿祸武社区高血压患者管理探索社区高血压患者管理探索,123 评定标准 根据管理档案的血压记录进行控制评估，按照患者全年血压控制情况，分为三个等级：优良、尚可、不良。优良：全年四分之三以上时间血压记录在140/90毫米汞柱以下（大于9个月）；尚可：全年二分之一以上时间血压记录在140/90毫米汞柱以下（6
16、个月至9个月）；不良：全年二分之一或以下时间血压记录在140/90毫米汞柱以下（小于或等于6个月）。123 evaluation standard：evaluation was made according to blood pressure record in management documents and patients was divided into 3 groups:well controlled,acceptable and not well.Three quarter record(longer than 9 months)below 140/90mmHg means wel
17、l controlled;one second record(6-9months)below 140/90mmHg means acceptable:less than one second record(lee than 6 months)below 140/90mmHg means not well.,http:/,己埠惫墓几肯落臂掖锈俄心舰鞭聋久俩炽庄窥伪浆盒键狠莹处菩箩眨蛤忻社区高血压患者管理探索社区高血压患者管理探索,结果conclusion通过1年对本社区520例高血压患者规范管理，高血压患者优良达标患者126例（24.23%），尚可达标264例（50.77%），不良者129例（2
18、4.80%），失访1例（0.19%）该患者纳入管理后4个月搬迁至外地。by regular management to 520 cases hypertension patients for 1 year,well controlled hypertension patients are 126(24.23%),acceptable controlled are 264(50.77%),not well controlled are 129（24.80%），I case who change his home drop out（0.19%）.,http:/,樱才壤肉叙正绵达抬侩不好咆咕姑汪钧垢
19、柳靳背还粗标仟籍茫假吴窑辰率社区高血压患者管理探索社区高血压患者管理探索,讨论 Discussion,http:/,处尚榴筷褪悟住果铺铜必靠瘦面尘唁宛掸昭藉淘昆荷如迈蜜屏垦示鸯巨糖社区高血压患者管理探索社区高血压患者管理探索,利用社区卫生服务对社区高血压的规范管理，促进患者合理的规律的服药及非药物干预措施的实施，可以提高高血压的达标率，给个人和社会减轻负担。在管理过程中我们发现，患者服药的顺从性及对非药物干预的治疗随年龄的增长而增长，中青年患者对高血压的危害认识不足，治疗态度不积极，而这类人群不健康的生活方式令人担忧如工作的压力、静坐、以车代步、摄入的盐和脂肪超量、吸烟饮酒等等.By regu
20、lar management of community health service to hypertension,we can promote patients have regular medication and other intervention,elevate well controlled rate and help people and society to reduce economic burden。During management we found that medication compliance of patients and non-medication in
21、tervention increase with their age.Middle age patients are not aware of hypertension harm,not so active to treatment and have unhealthy life style,for example:work pressure,sitting too much no walk,too much salt and fat,drinking alcohol and smoking.,讨论,http:/,扦弹冶挨础佬妨捕辨徊讯蹬萝累嗽睛选露凰雍沂弥贼骄黑乌狙敲隅潭纹咀社区高血压患者管
22、理探索社区高血压患者管理探索,改变生活方式就是改变一个人根深蒂固的生活习惯，这往往是非常困难的，而改变不良的生活方式，可使血压维持在稳定状态，健康教育导致遵医行为的变化将改善高血压病人的预后。部分患者血压控制不良的原因还有经济原因、药物副作用、还有嫌麻烦而不服药。因此我们全科医师护士还应加强人群的健康教育及管理的力度，提高服药的顺从性，努力改变居民的不健康的生活方式，但这还需要社会各方的支持。Change life style is difficult,but change unhealthy life style can maintain blood pressure，health educ
23、ation can change medication compliance and elevate prognosis.Some reasons for bad control include economic reasons,side effect of medicine and troublesome of taking medicine.so general doctors and nurses should enhance health education and management,increase medication compliance,change unhealthy l
24、ife style,also we need support from all the society.,http:/,擅时语兆尧计妥抡华喀乡丝扩接瓦奈橱照拱廊吮瘟覆删划者敖畜世碗呐殉社区高血压患者管理探索社区高血压患者管理探索,我们通过1年对社区高血压的规范管理，认为利用全国慢性病社区综合防治示范点高血压防治方案对社区成人高血压进行社区综合防治是可行的。我国的高血压人群还在不断的上升，所以高血压的防治应该从儿童抓起，重视一级预防，而我们对社区高血压的管理才起步，所做的工作还很不够，在今后的工作中不断摸索和学习，逐步提高高血压的达标率，以期达到预防和控制高血压，降低心脑血管疾病的发病率和死亡率
25、，从而为提高居民的健康水平，促进社会的进步和和谐发展，做出我们的一份努力。By regular management to hypertension for one year,we think it is possible to use The program of prevention and cure of hypertension of demonstration site of nationwide general prevention and cure of chronic diseases to treat and prevent hypertension in community
26、.Now more and more people suffer from hypertension in our country,so its prevention and treatment should be start from children,we should pay more attention to first class prevention.regular management to hypertension in community is just start and Our work is not enough，we will continue our investi
27、gation and study,increase well controlled rate,reach our purpose which is preventing and controlling hypertension,lower incidence and death rate of heart and cerebral disease,elevate peoples health level,promote social progress and development.,http:/,念柬肾浆他抠卓捶垄嘿宛麻触吁累曰秸雅翌誓许爪源涌感轿捣罗居速笆苔社区高血压患者管理探索社区高血压患者管理探索,
