社区高血压患者管理探索.ppt
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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:/ 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 from 2004 to 2005 standard for investigating effective method o
2、f management of hypertension in our community ,We have evaluated the effect of management.,http:/ Objects and Methods 1.1 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 hyper
3、tension 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 was excluded by laboratory examination such as x-ray, ECG. The first class management group 227 patients, t
4、he second class management group 198 patients , the third class management group 95 patients.,http:/ 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
5、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 management : the age of male patients 55, the age of female patients 65, the first class hypertension, no other
6、 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 other 1-2 cardiovascular risk factors, the patients are moderate-risk according to risk stratification, the
7、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 patients are high-risk according to risk stratification 。,http:/ 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
8、进行健康调查(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. healt
9、h 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 taking salt and fat, smoking, drinking, exercising ect). we also measure
10、 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 recorded in the archive, the changes of patients condition and medication wer
11、e recorded any time.,http:/ 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 strengthen normative management: 520 h
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- 社区 高血压患者 管理 探索
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