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1、社区高血压患者管理探索社区高血压患者管理探索 Exploration of Management for the Hypertension Patients in Community 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 showed the control rate of hypertension is only 6.1
2、%. 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 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
3、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 58.5 years old， mean history of hypertension 12 years. Secondary hypertension was excl
4、uded 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
5、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 of prevention and cure of hypertension of demonstration site of nationwide general prevention and cure of chronic diseases . The first class management : the a
6、ge 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 other 1-2 cardi
7、ovascular 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 patients are high-risk
8、 according to risk stratification 。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 an
9、d 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, complication history, livin
10、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. special person was in charge of archive management. every time measurement of blood pr
11、essure was recorded in the archive, the changes of patients condition and medication were recorded any time.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
12、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 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
13、-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 pressure of the patients of the
14、 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 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个月至9个月
15、）；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
16、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.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（24.80%），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
