社区高血压患者管理探索.ppt

1、 社区高血压患者管理探索Exploration of Management for the Hypertension Patients in Community 四川省攀枝花市东区紫荆山社区卫生服务中心Community Health Service Center of Zi Jing Shan In Pan Zhi Hua,Sichuan杨荣Yangrong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 n

2、utrition and health in China in 2004 showed 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.对象与方法Objects and Met

3、hods1.1 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 26 to 85, mean age

4、 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.12 方法 按照全国慢性病社区综合 范 高

5、血压 方 进行管理。一级管理 男性年龄 55岁，女性年龄 65岁，高血压1级， 其 心血管 ，按照 的患者 二级管理 高血压2级 1-2级 1-2 其 心血管 病 ，按照 中 的患者 三级管理 高血压3级 合并3 其 心血管 病 合并 病 并currency1“者，按照 高 高 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

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

7、 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 with more than 3 other cardiovascular risk factors or target organ damage or diabetes or co- existing

8、 clinical setting ,the patients are high-risk according to risk stratification 。121 规范fi高血压fl 过对全 进行管理，规范血压，为”高血压患者fi健fl ，并进行健康调查 年龄、性 、病、 人史、史、并发史、生 其 “、 、 、 等 ， 高、 、 ， 健康fl 本中心， 人 fl 管理，并 、 ，” 血压 fl 中， 病化 。1.2.1 To establish normative archive of hypertension: we train the doctors and nurses of our

9、 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, complication history, living habit such as

10、 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 measurement of blood pressure was reco

11、rded in the archive, the changes of patients condition and medication were recorded any time.122 化规范管理 对520例高血压患者与 级管理并 。我们 一级管理的患者 ”2 一 血压， 健康 为 二级管理的患者”1 一 血压，进行健康 指 ，制定 性化的 方 三级管理”1 一 血压， 本中心 级三甲院进行规律降压 ，对降压效果理想的患者 提出 会诊，修订与 方 ， 急 发生并发的患者 转诊入院 ，出院健康fl 中 诊 过。 1.2.2 To strengthen normative manageme

12、nt: 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 blood pressure of the p

13、atients 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 time for one month

14、, health instruction and treatment of individual medication were carried out in the patients.123 评定标准 根据管理fl 的血压 进行控制评估，按照患者全年血压控制“， 为三 等级 优良、尚可、良。优良 全年四 之三 间血压 140/90毫米汞柱 下大 9 尚可 全年二 之一 间血压 140/90毫米汞柱 下6 至9 良全年二 之一 下 间血压 140/90毫米汞柱 下 等 6 。123 evaluation standard evaluation was made according to blo

15、od 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 well controlled; one second record (6-9months) below 140/90mmHg means acceptable: less than one second recor

16、d (lee than 6 months) below 140/90mmHg means not well.结果conclusion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% ，良者129例24.80% ，失访1例0.19% 该患者纳入管理 4 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

17、 controlled are 264 (50.77%), not well controlled are 129 24.80% ，I case who change his home drop out 0.19% .讨论Discussion利 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 的实 ，可 提高高血压的达标率，给 人社会减轻担。 管理过中我们发现，患者服的顺从性对的 年龄的增长而增长，中青年患者对高血压的 认识足， 态度积极，而这类人群健康的生方式令人担忧工作的压力、静坐、 车代步、 入的超、 等等.By regular management of community

18、 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 intervention 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