12、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。

13、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 。

14、 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,社区高血压患者管理探索,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 。

15、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） 。
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。

16、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,社区高血压患者管理探索,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（2 。

17、4.23%） ， 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 dro 。

18、p out （0.19,社区高血压患者管理探索,讨论 Discussion,社区高血压患者管理探索,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 。

19、 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 ar 。

20、e 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,社区高血压患者管理探索,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 。

21、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。

22、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,社区高血压患者管理探索,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 。

来源：(未知)

【学习资料】网址：/a/2021/0321/0021741395.html

标题：社区|社区高血压患者管理探索课件( 二 )