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 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2004—2005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%. 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 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 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 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.

1．2 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 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 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 。

1．2．1 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 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, complication 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 measurement of blood pressure was recorded in the archive, the changes of patient's condition and medication were recorded any time.

1．2．2 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 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 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 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.

1．2．3 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）；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）。 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 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 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 his home drop out （0.19%）.

讨论 Discussion

利用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药及非药物干预措施的实施，可以提高高血压的达标率，给个人和社会减轻负担。在管理过程中我们发现，患者服药的顺从性及对非药物干预的治疗随年龄的增长而增长，中青年患者对高血压的危害认识不足，治疗态度不积极，而这类人群不健康的生活方式令人担忧如工作的压力、静坐、以车代步、摄入的盐和脂肪超量、吸烟饮酒等等. By regular management of community 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

改变生活方式就是改变一个人根深蒂固的生活习惯，这往往是非常困难的， 而改变不良的生活方式，可使血压维持在稳定状态，健康教育导致遵医行为的变化将改善高血压病人的预后。部分患者血压控制不良的原因还有经济原因、药物副作用、还有嫌麻烦而不服药。因此我们全科医师护士还应加强人群的健康教育及管理的力度，提高服药的顺从性，努力改变居民的不健康的生活方式，但这还需要社会各方的支持。 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 taking 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.

我们通过1年对社区高血压的规范管理，认为利用《全国慢性病社区综合防治示范点高血压防治方案》对社区成人高血压进行社区综合防治是可行的。我国的高血压人群还在不断的上升，所以高血压的防治应该从儿童抓起，重视一级预防，而我们对社区高血压的管理才起步，所做的工作还很不够，在今后的工作中不断摸索和学习，逐步提高高血压的达标率，以期达到预防和控制高血压，降低心脑血管疾病的发病率和死亡率，从而为提高居民的健康水平，促进社会的进步和和谐发展，做出我们的一份努力。 By regular management to hypertension for one year, we think it is possible to use 《 The program of prevention and 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, 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 continue 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 health level, promote social progress and development.