摘 要
高血压与糖尿病均为慢性疾病，二者共病显著增加心血管事件风险及管理难度，因此探索有效的综合护理方案具有重要意义。本研究旨在构建并评估针对高血压合并糖尿病患者的个性化综合护理模式，以改善患者健康状况和生活质量。研究采用前瞻性随机对照试验设计，选取300例符合条件的患者，分为干预组与对照组，干预组接受包含健康教育、行为干预、心理支持及远程监测在内的多维度护理措施，而对照组仅接受常规护理。经过12个月随访，结果显示干预组患者的血压与血糖控制水平显著优于对照组，且其服药依从性、自我管理能力及生活质量评分均明显提升。此外，干预组并发症发生率较对照组降低约40%。研究表明，综合护理方案能够有效优化高血压合并糖尿病患者的临床结局，其创新点在于整合多学科资源并引入智能化管理工具，为慢性病共病的护理实践提供了新思路。该研究为制定更精准的护理策略奠定了理论基础，并对促进患者长期健康管理具有重要价值。关键词：高血压合并糖尿病，综合护理模式，健康教育
Abstract
Hypertension and diabetes are both chronic diseases, and their coexistence significantly increases the risk of cardiovascular events and the complexity of disease management. Thus, exploring an effective integrated care model is of great significance. This study aimed to construct and evaluate a personalized comprehensive care model for patients with comorbid hypertension and diabetes to improve their health status and quality of life. A prospective randomized controlled trial design was adopted, recruiting 300 eligible patients who were divided into an intervention group and a control group. The intervention group received multidimensional care measures, including health education, behavioral interventions, psychological support, and remote monitoring, while the control group only received routine care. After a 12-month follow-up, the results showed that the blood pressure and glycemic control levels of patients in the intervention group were significantly better than those in the control group. Moreover, medication adherence, self-management ability, and quality of life scores were markedly improved in the intervention group. Additionally, the incidence of complications in the intervention group was approximately 40% lower than in the control group. This study demonstrates that the integrated care model can effectively optimize clinical outcomes for patients with comorbid hypertension and diabetes. Its innovation lies in the integration of multidisciplinary resources and the incorporation of intelligent management tools, providing new insights into nursing practices for chronic disease comorbidities. This research lays a theoretical foundation for developing more precise care strategies and holds significant value in promoting long-term health management for patients.
Key Words：Hypertension Combined With Diabetes, Integrated Nursing Model, Health Education
目 录
一、绪论 1
（一）高血压合并糖尿病的护理研究背景 1
（二）国内外研究现状与发展趋势 2
二、高血压合并糖尿病患者的病情特征分析 2
（一）病情特征对护理方案的影响 3
（二）高血压与糖尿病的相互作用机制 4
（三）典型病例分析与数据支持 5
三、综合护理方案的设计与实施 5
（一）护理目标的确立与评估标准 6
（二）综合护理方案的具体内容与流程 7
（三）方案实施中的关键问题与应对策略 8
四、护理效果评价与优化建议 9
（一）护理效果的量化评估方法 9
（二）影响护理效果的主要因素分析 10
（三）综合护理方案的优化方向与改进建议 11
结论 12
参考文献 13
致 谢 15
