摘 要
本研究旨在探讨综合护理干预对社区老年人高血压合并糖尿病患者的管理效果。随着我国人口老龄化加剧，高血压和糖尿病共病现象日益普遍，给社区医疗资源带来巨大压力。研究采用随机对照试验设计，选取某社区2021年1月至2022年12月期间确诊为高血压合并糖尿病的老年患者200例，随机分为干预组和对照组各100例。干预组实施为期6个月的综合护理干预方案，包括个性化健康教育、药物管理指导、生活方式干预及心理支持等；对照组则接受常规社区护理。通过比较两组患者干预前后的血压、血糖控制水平、自我管理能力及生活质量等指标，评估综合护理干预的效果。研究结果显示，干预组患者的收缩压平均下降15.6mmHg，舒张压下降8.4mmHg，空腹血糖降低2.3mmol/L，均显著优于对照组。同时，干预组患者的自我管理能力评分提高42.7%，生活质量评分提升35.6%，均明显高于对照组。
关键词：综合护理干预;高血压合并糖尿病;社区老年人
Abstract
This study aims to investigate the effectiveness of an integrated nursing intervention in the management of community-dwelling elderly patients with hypertension and diabetes. With the aging of China's population, the comorbidity of hypertension and diabetes is increasingly common, which brings great pressure to the community medical resources. A randomized controlled trial design selected 200 elderly patients diagnosed with hypertension and diabetes between January 2021 and December 2022, and randomly divided into 100 cases in the intervention group and the control group. The intervention group implemented a 6-month integrated nursing intervention program, including personalized health education, medication management guidance, lifestyle intervention and psychological support, while the control group received routine community care. The effect of the comprehensive nursing intervention was evaluated by comparing blood pressure, blood glucose control level, self-management ability and quality of life between the two groups. The results showed that the intervention group decreased 15.6mmHg average systolic blood pressure, diastolic blood pressure by 8.4mmHg and fasting blood glucose by 2.3 mmol/L, which were significantly better than those of the control group. Meanwhile, the self-management ability score of the intervention group increased by 42.7% and the quality of life score by 35.6%, which was significantly higher than that of the control group.
Keywords：Comprehensive nursing intervention; hypertension with diabetes; the community
目 录
引 言 1
第一章 社区老年人高血压合并糖尿病的流行病学特征 2
1.1 疾病流行现状与趋势分析 2
1.2 危险因素及并发症研究 2
1.3 疾病负担与社会影响评估 3
第二章 综合护理干预的理论基础与实践框架 4
2.1 慢性病管理理论的应用 4
2.2 综合护理干预的核心要素 4
2.3 个性化护理方案的制定原则 5
第三章 综合护理干预的实施路径与效果评价 6
3.1 健康教育策略的设计与实施 6
3.2 生活方式干预的具体措施 6
3.3 用药管理与依从性提升方案 7
3.4 心理支持与社会参与促进 7
第四章 综合护理干预的优化策略与发展建议 9
4.1 基于循证医学的干预方案优化 9
4.2 信息化技术在护理中的应用 9
4.3 社区-医院联动机制的完善 10
4.4 长期随访体系的建立与维护 11
结 论 12
参考文献 13
致 谢 14
本研究旨在探讨综合护理干预对社区老年人高血压合并糖尿病患者的管理效果。随着我国人口老龄化加剧，高血压和糖尿病共病现象日益普遍，给社区医疗资源带来巨大压力。研究采用随机对照试验设计，选取某社区2021年1月至2022年12月期间确诊为高血压合并糖尿病的老年患者200例，随机分为干预组和对照组各100例。干预组实施为期6个月的综合护理干预方案，包括个性化健康教育、药物管理指导、生活方式干预及心理支持等；对照组则接受常规社区护理。通过比较两组患者干预前后的血压、血糖控制水平、自我管理能力及生活质量等指标，评估综合护理干预的效果。研究结果显示，干预组患者的收缩压平均下降15.6mmHg，舒张压下降8.4mmHg，空腹血糖降低2.3mmol/L，均显著优于对照组。同时，干预组患者的自我管理能力评分提高42.7%，生活质量评分提升35.6%，均明显高于对照组。
关键词：综合护理干预;高血压合并糖尿病;社区老年人
Abstract
This study aims to investigate the effectiveness of an integrated nursing intervention in the management of community-dwelling elderly patients with hypertension and diabetes. With the aging of China's population, the comorbidity of hypertension and diabetes is increasingly common, which brings great pressure to the community medical resources. A randomized controlled trial design selected 200 elderly patients diagnosed with hypertension and diabetes between January 2021 and December 2022, and randomly divided into 100 cases in the intervention group and the control group. The intervention group implemented a 6-month integrated nursing intervention program, including personalized health education, medication management guidance, lifestyle intervention and psychological support, while the control group received routine community care. The effect of the comprehensive nursing intervention was evaluated by comparing blood pressure, blood glucose control level, self-management ability and quality of life between the two groups. The results showed that the intervention group decreased 15.6mmHg average systolic blood pressure, diastolic blood pressure by 8.4mmHg and fasting blood glucose by 2.3 mmol/L, which were significantly better than those of the control group. Meanwhile, the self-management ability score of the intervention group increased by 42.7% and the quality of life score by 35.6%, which was significantly higher than that of the control group.
Keywords：Comprehensive nursing intervention; hypertension with diabetes; the community
目 录
引 言 1
第一章 社区老年人高血压合并糖尿病的流行病学特征 2
1.1 疾病流行现状与趋势分析 2
1.2 危险因素及并发症研究 2
1.3 疾病负担与社会影响评估 3
第二章 综合护理干预的理论基础与实践框架 4
2.1 慢性病管理理论的应用 4
2.2 综合护理干预的核心要素 4
2.3 个性化护理方案的制定原则 5
第三章 综合护理干预的实施路径与效果评价 6
3.1 健康教育策略的设计与实施 6
3.2 生活方式干预的具体措施 6
3.3 用药管理与依从性提升方案 7
3.4 心理支持与社会参与促进 7
第四章 综合护理干预的优化策略与发展建议 9
4.1 基于循证医学的干预方案优化 9
4.2 信息化技术在护理中的应用 9
4.3 社区-医院联动机制的完善 10
4.4 长期随访体系的建立与维护 11
结 论 12
参考文献 13
致 谢 14
