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 Exploration of Management for the Hypertension Patients in Community,四川省攀枝花市東區(qū)紫荊山社區(qū)衛(wèi)生服務(wù)中心Community Health Service Center of Zi Jing Shan In Pan Zhi Hua,Sichuan楊榮Yangrong,我國(guó)2004年全國(guó)營(yíng)養(yǎng)與健康綜合調(diào)查表明高血壓控制率僅為6.1%

2、。為了探索一條適合本社區(qū)高血壓管理的路子，我們就2004—2005年高血壓人群納入了520例進(jìn)行統(tǒng)一規(guī)范管理，對(duì)其管理效果進(jìn)行評(píng)價(jià)。 The investigation to nutrition and health in China in 2004 showed the control rate of hypertension is only 6.1%. We manage 520 hypertension patients

3、from 2004 to 2005 standard for investigating effective method of management of hypertension in our community ,We have evaluated the effect of management.,對(duì)象與方法Objects and Methods1.1 對(duì)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

4、327人，女性193人，年齡26至86歲，平均年齡58.5歲，平均高血壓病史12年，管理病例均經(jīng)過(guò)常規(guī)化驗(yàn)、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(jí)管理227人，二級(jí)管理198人，三級(jí)管理95人。 1.1 Objects: 520 patients with hypertension in our community took part in the management voluntarily .m

5、ale 327,femal 193 , age from 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 22

6、7 patients, the second class management group 198 patients , the third class management group 95 patients.,1．2 方法 按照《全國(guó)慢性病社區(qū)綜合防治示范點(diǎn)高血壓防治方案》要求進(jìn)行管理。一級(jí)管理：男性年齡小于55歲，女性年齡小于65歲，高血壓1級(jí)，無(wú)其他心血管危險(xiǎn)因素，按照危險(xiǎn)分層屬于低危的患者；二級(jí)管理：高血壓2級(jí)或1-2級(jí)同

7、時(shí)有1-2個(gè)其它心血管疾病危險(xiǎn)因素，按照危險(xiǎn)分層屬于中危的患者；三級(jí)管理：高血壓3級(jí)或合并3個(gè)以上其它心血管疾病危險(xiǎn)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(xiǎn)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 natio

8、nwide 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 f

9、actors, the patients are low-risk 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 patient

10、s 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

11、 clinical setting ,the patients are high-risk according to risk stratification 。,1．2．1 規(guī)范建立高血壓檔案 通過(guò)對(duì)全科醫(yī)師和護(hù)士進(jìn)行管理培訓(xùn)，規(guī)范測(cè)量血壓，為每位高血壓患者建立保健檔案，并進(jìn)行健康調(diào)查（包括年齡、性別、病程、個(gè)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(yùn)動(dòng)等），同時(shí)測(cè)量身高、體重、腰圍，把健康檔案

12、存放在本中心，由專人負(fù)責(zé)檔案管理，并有責(zé)任醫(yī)師、護(hù)士，每次測(cè)量血壓后記錄在檔案中，有病情變化及藥物改變亦隨時(shí)記錄。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.

13、 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, livin

14、g 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. specia

15、l person was in charge of archive management. every time measurement of blood pressure was recorded in the archive, the changes of patient's condition and medication were recorded any time.,1．2．2 強(qiáng)化規(guī)范管理 對(duì)520例高血

16、壓患者與分級(jí)管理并督導(dǎo)治療。我們將一級(jí)管理的患者予每2月不少于一次測(cè)量血壓，以健康教育和非藥物干預(yù)措施為主；二級(jí)管理的患者予每1月不少于一次測(cè)量血壓，進(jìn)行健康教育及用藥指導(dǎo)，制定個(gè)性化的藥物治療方案；三級(jí)管理每1月不少于一次測(cè)量血壓，在本中心或上級(jí)三甲醫(yī)院進(jìn)行規(guī)律降壓治療，對(duì)降壓效果不理想的患者由責(zé)任醫(yī)師提出專科會(huì)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(guò)程。 1.2.2 To

17、 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, healt

18、h instruction 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 instructi

19、on 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, health instruction and tr

20、eatment of individual medication were carried out in the patients.,1．2．3 評(píng)定標(biāo)準(zhǔn) 根據(jù)管理檔案的血壓記錄進(jìn)行控制評(píng)估，按照患者全年血壓控制情況，分為三個(gè)等級(jí)：優(yōu)良、尚可、不良。優(yōu)良：全年四分之三以上時(shí)間血壓記錄在140/90毫米汞柱以下（大于9個(gè)月）；尚可：全年二分之一以上時(shí)間血壓記錄在140/90毫米汞柱以下（6個(gè)月至9個(gè)月）；不良：全年二分之一或

21、以下時(shí)間血壓記錄在140/90毫米汞柱以下（小于或等于6個(gè)月）。1．2．3 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 w

22、ell. 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 record (lee than 6 months) below 140/90mmHg

23、 means not well.,結(jié)果conclusion通過(guò)1年對(duì)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(dá)標(biāo)患者126例（24.23%），尚可達(dá)標(biāo)264例（50.77%），不良者129例（24.80%），失訪1例（0.19%）該患者納入管理后4個(gè)月搬遷至外地。 by regular management to 520 cases hypertension patients for 1 year, well co

24、ntrolled 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(duì)社區(qū)高血壓的規(guī)范管理，促進(jìn)患者合理的規(guī)律的服藥及非藥

25、物干預(yù)措施的實(shí)施，可以提高高血壓的達(dá)標(biāo)率，給個(gè)人和社會(huì)減輕負(fù)擔(dān)。在管理過(guò)程中我們發(fā)現(xiàn)，患者服藥的順從性及對(duì)非藥物干預(yù)的治療隨年齡的增長(zhǎng)而增長(zhǎng)，中青年患者對(duì)高血壓的危害認(rèn)識(shí)不足，治療態(tài)度不積極，而這類(lèi)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(chē)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 hype

26、rtension, 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 compli

27、ance 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:

28、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(gè)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(jì)原因、藥物副作用、還有嫌麻煩而不服藥。因此

29、我們?nèi)漆t(yī)師護(hù)士還應(yīng)加強(qiáng)人群的健康教育及管理的力度，提高服藥的順從性，努力改變居民的不健康的生活方式，但這還需要社會(huì)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 elev

30、ate 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 med

31、ication compliance ,change unhealthy life style, also we need support from all the society.,我們通過(guò)1年對(duì)社區(qū)高血壓的規(guī)范管理，認(rèn)為利用《全國(guó)慢性病社區(qū)綜合防治示范點(diǎn)高血壓防治方案》對(duì)社區(qū)成人高血壓進(jìn)行社區(qū)綜合防治是可行的。我國(guó)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(jí)預(yù)防，而我們對(duì)社區(qū)高血壓的管理才起步，所做的工作還很

32、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(dá)標(biāo)率，以期達(dá)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(jìn)社會(huì)的進(jìn)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 is possible to use 《 The program of prevention and

33、 cure of hypertension of demonstration site of nationwide general prevention and cure of chronic diseases 》to treat and prevent hypertension in community . Now more and more people suffer from hypertension in our country

34、, 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 c

35、ontinue our investigation 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 people’s heal