摘 要
随着慢性病患病率的持续上升，社区护理模式作为一种创新性干预手段在慢性病管理中受到广泛关注。本研究旨在探讨社区护理模式对慢性病患者健康状况及生活质量的影响，并评估其在实际应用中的可行性和有效性。研究采用随机对照试验设计，选取某城市300名慢性病患者作为研究对象，将其分为实验组和对照组，实验组接受为期一年的社区护理干预，而对照组仅接受常规医疗随访。通过问卷调查、生理指标检测及访谈等方式收集数据，主要观察指标包括患者的血压、血糖控制水平、自我管理能力以及心理健康状态等。结果显示，实验组患者的各项生理指标显著改善，自我管理能力评分明显提高，心理压力水平显著降低，与对照组相比差异具有统计学意义（P0.05）。此外，社区护理模式还有效促进了医患互动，增强了患者的治疗依从性。本研究的创新点在于将系统化的社区护理方案与慢性病管理相结合，强调以患者为中心的个性化服务理念，为慢性病防控提供了新思路。研究表明，社区护理模式能够显著提升慢性病管理效果，具备良好的推广价值，可为我国基层医疗卫生服务体系的完善提供重要参考。
关键词：社区护理模式，慢性病管理，健康状况，生活质量，自我管理能力
Analysis of the Application Effect of Community Nursing Model in Chronic Disease Management
Abstract
With the continuous rise in the prevalence of chronic diseases, community-based nursing models have garnered significant attention as an innovative intervention in chronic disease management. This study aimed to investigate the impact of community nursing models on the health status and quality of life of patients with chronic diseases and to evaluate their feasibility and effectiveness in practical applications. A randomized controlled trial design was employed, selecting 300 patients with chronic diseases from a city, who were divided into an experimental group and a control group. The experimental group received a one-year community nursing intervention, while the control group only received routine medical follow-ups. Data were collected through questionnaires, physiological indicator tests, and interviews, with primary observation indicators including blood pressure, blood glucose control levels, self-management capabilities, and mental health status. The results showed that the physiological indicators of patients in the experimental group significantly improved, their self-management capability scores markedly increased, and their psychological stress levels significantly decreased, with statistically significant differences compared to the control group (P0.05). Additionally, the community nursing model effectively promoted doctor-patient interactions and enhanced patient treatment adherence. The innovation of this study lies in integrating a systematic community nursing program with chronic disease management, emphasizing a patient-centered personalized service philosophy, thus providing new insights for chronic disease prevention and control. The study demonstrates that the community nursing model can significantly enhance the effectiveness of chronic disease management, exhibiting excellent potential for promotion and offering important references for improving primary healthcare services in China.
Key Words：Community Nursing Model, Chronic Disease Management, Health Status, Quality Of Life, Self-Management Ability
目 录
一、绪论 1
（一）社区护理模式研究背景与意义 1
（二）慢性病管理领域研究现状综述 2
（三）本文研究方法与技术路线 3
二、社区护理模式的理论基础与实践框架 3
（一）社区护理模式的核心概念解析 4
（二）慢性病管理中的社区护理理论支持 5
（三）社区护理模式在慢性病管理中的实践框架 6
三、社区护理模式在慢性病管理中的应用分析 7
（一）应用场景与目标群体特征分析 7
（二）社区护理干预措施的设计与实施 8
（三）应用效果的初步评估与反馈机制 9
四、社区护理模式的效果评价与优化建议 10
（一）数据收集与效果评价指标体系构建 10
（二）社区护理模式对患者健康状况的影响分析 12
（三）提升社区护理模式应用效果的优化策略 13
结论 14
参考文献 15
致 谢 18
