The reason why the country puts forward the health management service project for patients with hypertension is because the management mode is simple and easy to operate. By guiding patients to improve their lifestyle, rational use of antihypertensive drugs with good efficacy and little side effects, the blood pressure level can be reduced to the maximum extent, the development of hypertension can be controlled, complications can be reduced, the quality of life can be improved, and the burden on families and society can be reduced.
service content
(1) screening
1. For the resident population aged 35 and above in the jurisdiction, blood pressure is measured once a year (three times a day) for free.
2. The systolic blood pressure was found for the first time &; Ge; 140mmHg and/or diastolic pressure &; Ge; Residents of 90mmHg make an appointment for reexamination after excluding factors that may lead to elevated blood pressure. Blood pressure measured three times on the same day is higher than normal, which can be preliminarily diagnosed as hypertension. It is suggested to make a diagnosis and get a treatment plan.
The referral results were followed up within 2 weeks, and the diagnosed patients with essential hypertension were included in the health management of patients with hypertension. Patients suspected of secondary hypertension should be referred in time.
3. If there are any high-risk factors in the following six indicators, it is recommended to measure blood pressure at least 1 time every six months and receive lifestyle guidance from medical staff:
(1) hypertension (systolic blood pressure 130 ~ 139 mmHg and/or diastolic blood pressure 85 ~ 89 mmhg);
(2) Overweight or obesity, and/or abdominal obesity:
Overweight: 28kg/m2> Body Mass Index & ge; 24 kg/m2; Obesity: Body Mass Index &; Ge; 28 kg/m2
Waist circumference: male &; Ge; 2250 pixels (2.7 feet), female and male; 2125px (2.6ft) is abdominal obesity.
(3) Family history of hypertension (first and second degree relatives);
(4) Long-term high-salt diet;
(5) Long-term excessive drinking (drinking white wine every day&; Ge; 100ml)；
(6) Age&; Ge; 55 years old.
(2) Follow-up evaluation
For patients with essential hypertension, face-to-face follow-up should be provided at least 4 times a year.
(1) Measure blood pressure and evaluate whether there is any critical situation, such as systolic blood pressure. Ge; 180mmHg and/or diastolic pressure &; Ge; 1 10 mmhg；
Consciousness change, severe headache or dizziness, nausea and vomiting, blurred vision, eye pain, palpitation, chest tightness, dyspnea, inability to lie flat, higher than normal blood pressure during pregnancy or lactation, or other incurable diseases, should be referred urgently after treatment. For emergency referral, township hospitals, village clinics and community health service centers (stations) should actively follow up the referral within 2 weeks.
(2) If there is no need for emergency referral, ask about the symptoms during the last follow-up to this follow-up.
(3) Measure weight and heart rate and calculate body mass index (BMI).
(4) Ask patients about their diseases and lifestyles, including cardiovascular and cerebrovascular diseases, diabetes, smoking, drinking, exercise and salt intake.
(5) Understand the patients' medication.
(3) Classified intervention
(1) Satisfied with blood pressure control (generally, the blood pressure of hypertensive patients drops below 140/90 mmHg; & ge; The blood pressure of 65-year-old elderly patients with hypertension drops below 150/90 mmHg, and can be further reduced below 140/90 mmHg if they can tolerate it; Under normal circumstances, the blood pressure target of patients with diabetes or chronic kidney disease can be appropriately reduced on the basis of 140/90 mmHg), and patients with no adverse drug reactions, no new complications or no aggravation of existing complications can make an appointment for the next follow-up time.
(2) For patients who are dissatisfied with blood pressure control for the first time, or have adverse drug reactions, according to their medication compliance, increase the existing drug dosage, replace or increase different antihypertensive drugs when necessary, and follow up within 2 weeks.
(3) For patients who are dissatisfied with blood pressure control for two consecutive times or whose adverse drug reactions are difficult to control, and have new complications or aggravated original complications, it is recommended to refer them, and the referral situation should be actively followed up within 2 weeks.
(4) Carry out targeted health education for all patients, work out lifestyle improvement goals with patients, and evaluate the progress at the next follow-up. Tell the patient to see a doctor as soon as anything goes wrong.
(4) Healthy form
For patients with essential hypertension, 1 time comprehensive health examination every year can be combined with follow-up. The contents include routine physical examinations such as temperature, pulse, respiration, blood pressure, height, weight, waist circumference, skin, superficial lymph nodes, heart, lungs and abdomen, as well as the judgment of oral, visual, auditory and motor functions. For details, please refer to the Health Table of Service Specification for Residents' Health Records Management.