2. Identify high-risk groups and find patients with hypertension through physical examination, establishment of health records and family visits.
3. Diagnosis of hypertension:
For residents with systolic blood pressure ≥ 140mmHg and/or diastolic blood pressure ≥90mmHg for the first time, after excluding the factors that may cause the increase of blood pressure, the blood pressure on that day is higher than the normal value for 3 times, which can be preliminarily diagnosed as hypertension. When necessary, it is suggested to refer to a higher hospital for diagnosis, and follow up the referral results within 2 weeks, so as to bring the diagnosed patients with essential hypertension into the health management of patients with hypertension. For high-risk groups, it is included in the management of high-risk groups.
4. How to grade the graded follow-up management:
For patients with essential hypertension, graded management should be taken according to the cardiovascular risk of patients with hypertension, and face-to-face follow-up should be provided at least 4 times a year.
1) Primary management: For low-risk hypertensive patients with 1 grade hypertension and no other risk factors, follow up/kloc-0 for at least 3 months, monitor disease control, health education and non-drug intervention, and take medication after 3 months, paying attention to drug efficacy and adverse reactions.
2) Secondary management: Follow-up patients with moderate-risk hypertension with 1-2 hypertension and 1-2 hypertension (with or without 1-2 risk factors) at least once every two months to monitor disease control, health education and behavioral intervention treatment; 1 month blood pressure is still out of control, standardize drug treatment, pay attention to drug efficacy, adverse reactions and treatment compliance; Strengthen the early monitoring and evaluation of target organ damage.
3) Three-level management: In addition to the first-level and second-level management, high-risk and extremely high-risk patients should be followed up for at least 1 time for 1 month, so as to monitor their illness changes and provide targeted health education and behavioral intervention skills guidance; Emphasize the standardization of antihypertensive treatment, pay attention to drug efficacy, adverse reactions and treatment compliance; Strengthen the early monitoring and diagnosis of target organ damage and clinical complications of hypertension.
5. Classified intervention:
According to the follow-up evaluation results, the patients were classified and intervened:
1) Satisfied with blood pressure control (systolic blood pressure
2) Patients who are dissatisfied with blood pressure control for the first time, that is, systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥90mmHg, or have adverse drug reactions, adjust antihypertensive drugs and follow up within 2 weeks.
3) For patients who are dissatisfied with blood pressure control twice in a row, who have no improvement in adverse drug reactions twice in a row, and who have new complications or aggravated original complications, it is recommended to refer them to a higher-level hospital, and actively follow up and refer them within 2 weeks.
4) Make clear the control objectives of hypertension and its related risk factors in all patients; Carry out patient self-management education; Develop lifestyle improvement goals with patients. Tell the patient to see a doctor as soon as anything goes wrong.
6. Service requirements:
1) The health management of patients with hypertension is the responsibility of doctors, and the team members of the responsible doctors cooperate to complete it, which should be combined with outpatient service. For patients who are not followed up according to the management requirements, medical staff should take the initiative to contact patients to ensure the continuity of management.
2) Follow-up includes appointment of outpatient service, telephone tracking and home visit.
3) Township hospitals, village clinics, and community health service centers (stations) can screen patients with hypertension through community health diagnosis, physical examination, and outpatient service in the local area. Conditional areas, after standardized training of personnel, can refer to the "Zhejiang Province hypertension community comprehensive prevention and control work norms (Trial)" (Zhejiang Weifa [2009] No.290) for health management of hypertension patients.
4) Give full play to the characteristics and functions of traditional Chinese medicine in improving clinical symptoms, improving quality of life and preventing complications, and actively apply traditional Chinese medicine to carry out health management services for patients with hypertension.
5) Strengthen publicity and inform the service content, so that more patients and residents are willing to accept the service.
6) Record relevant information in the patient's health file in time after each service.
1. Flow chart of hypertension classification management:
1. Thinking: How to ensure the authenticity of the follow-up data, please put forward your plan: (Key points)
1) Confirmation of the authenticity of residents' identities 2) Safety and rigor of subsequent business operations 3) Correct analysis of subsequent data.