社區(qū)高血壓患者管理探索

1、社區(qū)高血壓患者管理探索社區(qū)高血壓患者管理探索 Exploration of Management for the Hypertension Patients in Community 我國2004年全國營養(yǎng)與健康綜合調(diào)查表明高血壓控制 率僅為6.1%。為了探索一條適合本社區(qū)高血壓管理的路 子，我們就20042005年高血壓人群納入了520例進行 統(tǒng)一規(guī)范管理，對其管理效果進行評價。 The investigation to nutrition and health in China in 2004 showed the control rate of hypertension is only

2、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. 對象與方法 Objects and Methods 1.1 對象 紫荊山社區(qū)居民高血壓患者并自愿參加管 理的520人，其中男性327人，女性193人，年齡26 至86歲，平均年齡歲，平均高血壓病史12年，管理

3、 病例均經(jīng)過常規(guī)化驗、血電解質(zhì)、心電圖、胸透、 眼底檢查等，除外繼發(fā)性高血壓。其中一級管理 227人，二級管理198人，三級管理95人。 1.1 Objects: 520 patients with hypertension in our community took part in the management voluntarily .male 327,femal 193 , age from 26 to 85, mean age 58.5 years old， mean history of hypertension 12 years. Secondary hypertension wa

4、s 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. 12 方法 按照全國慢性病社區(qū)綜合防治示范點高血壓 防治方案要求進行管理。一級管理：男性年齡小于55歲， 女性年齡小于65歲，高血壓1級，無其他心血管危險因素， 按照危險分層屬于低危的患者；二級管理：高

5、血壓2級或1- 2級同時有1-2個其它心血管疾病危險因素，按照危險分層 屬于中危的患者；三級管理：高血壓3級或合并3個以上其 它心血管疾病危險因素或合并靶器官損害或糖尿病或并存 臨床情況者，按照危險分層屬于高危和很高危的患者。 1.2 Methods: according to the The program of prevention and cure of hypertension of demonstration site of nationwide general prevention and cure of chronic diseases . The first class man

6、agement : 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 according to risk stratification. the second class management: the second hypertension or the first-second hypertension associated with

7、other 1-2 cardiovascular risk factors, the patients are moderate-risk according to risk stratification, the third class management :the third hypertension or associated with more than 3 other cardiovascular risk factors or target organ damage or diabetes or co- existing clinical setting ,the patient

8、s are high-risk according to risk stratification 。 121 規(guī)范建立高血壓檔案 通過對全科醫(yī)師和護士進行管 理培訓(xùn)，規(guī)范測量血壓，為每位高血壓患者建立保健檔案，并進 行健康調(diào)查（包括年齡、性別、病程、個人史、家族史、并發(fā)癥 史、生活習(xí)慣如飲食尤其攝鹽及脂肪情況、吸煙、飲酒、運動 等），同時測量身高、體重、腰圍，把健康檔案存放在本中心， 由專人負責(zé)檔案管理，并有責(zé)任醫(yī)師、護士，每次測量血壓后記 錄在檔案中，有病情變化及藥物改變亦隨時記錄。 1.2.1 To establish normative archive of hypertension:

9、we train the doctors and nurses of our department on management the blood pressure was measured standard. health care records of every hypertension patient was established and the health examination survey was carried out (including age, sex, course of disease, personal history, family history, comp

10、lication history, living habit such as taking salt and fat, smoking, drinking, exercising ect). we also measure the body height, body 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

11、measurement of blood pressure was recorded in the archive, the changes of patients condition and medication were recorded any time. 122 強化規(guī)范管理 對520例高血壓患者與分級管理并督 導(dǎo)治療。我們將一級管理的患者予每2月不少于一次測量血壓， 以健康教育和非藥物干預(yù)措施為主；二級管理的患者予每1月不 少于一次測量血壓，進行健康教育及用藥指導(dǎo)，制定個性化的 藥物治療方案；三級管理每1月不少于一次測量血壓，在本中心 或上級三甲醫(yī)院進行規(guī)律降壓治療，對降壓效果不理想

12、的患者 由責(zé)任醫(yī)師提出專科會診，修訂藥物與非藥物治療方案，有急 重癥或發(fā)生并發(fā)癥的患者予轉(zhuǎn)診入院治療，出院后在健康檔案 中記錄診治過程。 1.2.2 To strengthen 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 ins

13、truction and intervention of non-medicine were main treatment for the patients. the blood 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

14、 pressure of the patients of the third 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. 123 評定標準 根據(jù)管理檔案的血壓記錄進行控制評估， 按照患者全年血壓控制情況，分為三個等級：優(yōu)良、尚可、不 良。優(yōu)良：全年四分之三以上時間血壓記錄在140/90毫米汞柱 以下（大于9個月）；尚可

15、：全年二分之一以上時間血壓記錄 在140/90毫米汞柱以下（6個月至9個月）；不良：全年二分之 一或以下時間血壓記錄在140/90毫米汞柱以下（小于或等于6 個月）。 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 t

16、han 9 months) below 140/90mmHg means well 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. 結(jié)果 conclusion 通過1年對本社區(qū)520例高血壓患者規(guī)范管理，高血壓患者優(yōu)良 達標患者126例（24.23%），尚可達標264例（50.77%），不良 者129例（24.80%），失訪1例（

17、0.19%）該患者納入管理后4個 月搬遷至外地。 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%）. 討論 Discussion 利用社區(qū)衛(wèi)生服務(wù)對社區(qū)高血

18、壓的規(guī)范管理，促進患者合理的規(guī) 律的服藥及非藥物干預(yù)措施的實施，可以提高高血壓的達標率，給 個人和社會減輕負擔(dān)。在管理過程中我們發(fā)現(xiàn)，患者服藥的順從性 及對非藥物干預(yù)的治療隨年齡的增長而增長，中青年患者對高血壓 的危害認識不足，治療態(tài)度不積極，而這類人群不健康的生活方式 令人擔(dān)憂如工作的壓力、靜坐、以車代步、攝入的鹽和脂肪超量、 吸煙飲酒等等. By regular management of community health service to hypertension, we can promote patients have regular medication and other i

19、ntervention, 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 intervention increase with their age. Middle age patients are not aware of hypertension harm, not so active to treatm

20、ent and have unhealthy life style, for example: work pressure, sitting too much no walk, too much salt and fat, drinking alcohol and smoking. 討論 改變生活方式就是改變一個人根深蒂固的生活習(xí)慣，這往往是非 常困難的， 而改變不良的生活方式，可使血壓維持在穩(wěn)定狀態(tài)，健 康教育導(dǎo)致遵醫(yī)行為的變化將改善高血壓病人的預(yù)后。部分患者血 壓控制不良的原因還有經(jīng)濟原因、藥物副作用、還有嫌麻煩而不服 藥。因此我們?nèi)漆t(yī)師護士還應(yīng)加強人群的健康教育及管理的力度， 提高服藥

21、的順從性，努力改變居民的不健康的生活方式，但這還需 要社會各方的支持。 Change life style is difficult, but change unhealthy life style can maintain blood pressure，health education can change medication compliance and elevate prognosis. Some reasons for bad control include economic reasons, side effect of medicine and troublesome of t

22、aking medicine. so general doctors and nurses should enhance health education and management, increase medication compliance ,change unhealthy life style, also we need support from all the society. 我們通過1年對社區(qū)高血壓的規(guī)范管理，認為利用全國慢性病社 區(qū)綜合防治示范點高血壓防治方案對社區(qū)成人高血壓進行社區(qū)綜 合防治是可行的。我國的高血壓人群還在不斷的上升，所以高血壓 的防治應(yīng)該從兒童抓起，重視一級預(yù)防，而我們對社區(qū)高血壓的管 理才起步，所做的工作還很不夠，在今后的工作中不斷摸索和學(xué)習(xí)， 逐步提高高血壓的達標率，以期達到預(yù)防和控制高血壓，降低心腦 血管疾病的發(fā)病率和死亡率，從而為提高居民的健康水平，促進社 會的進步和和諧發(fā)展，做出我們的一份努力。 By regular management to hypertension for one year, we think it i