目前国外信息技术在延续护理中的应用较多,而我国的延续护理仍以传统的家庭访视和电话回访为主.本文通过综述美国心力衰竭患者远程延续性护理的研究进展,分析了其对我国远程延续护理发展的启示,为心力衰竭患者实施远程延续性护理提供依据,促进延续护理更好地发展.

Objective To explore the relationship between social supports and post-stroke fatigue among community stroke patients.Methods A total of 164 community stroke patients in Pingshan New Area of Shenzhen City were investigated by Fatigue Severity Scale (FSS) and Social Support Rating Sale (SSRS).Results Of the 164 cases,there were 72 cases diagnosed post-stroke fatigue (accounting for 43.9％);Patients with post-stroke fatigue had lower scores of SSRS than non-fatigue patients with statistically significant difference;The scores of FSS were significantly negative related with each dimension of SSSR;Patients who signed with the family physician had lower rate of post-stroke fatigue (P＜0.01),and the total levels of subjective support,objective support and social support were higher in signed patients than those in non-signed patients (P ＜0.01).Conclusion Post-stroke fatigue may be closely related to social supports;Family physician services can improve the levels of social supports in order to reduce the incidence of post-stroke fatigue.

Objective To analyze the effect of implementation of the family physician services on Knowledge-Atti-tude-Practice (KAP)of patients with hypertension and related knowledge of their family members.Methods Three com-munity health centers were extracted from the jurisdiction of a second grade hospital in Shenzhen City,collecting health re-cords of patients with hypertension,defining the patients signed the family physician service over six months as the interven-tion group,unsigned as a control group.Questionnaire survey on Knowledge-Attitude-Practice was applied for hypertension patients in both groups,and knowledge of hypertension among the members of their families.Results Scores of knowledge, attitude,behavior and medication compliance of hypertension patients in signed group knows were (21.60 ±1.49),(7.90 ±1.42),(5.89 ±2.03),and (3.56 ±0.55)respectively.Medication treatment rate was 95.5%,and blood pressure control rate was 56.4%,both of them higher than control group (P <0.05);families of hypertension patients in signed group scored (7.27 ±1.30),(6.77 ±0.96),and (4.59 ±1.07)respectively on hypertension related knowledge at the three dimensions degrees,higher than that of the control group (P <0.05).Conclusion The family physician services not only improve KAP and medication compliance in patients with hypertension,can also improve the cognitive level of hyperten-sion in families of hypertension patients.

Objective To explore the effect of management of chronic disease: Health monitoring platform with Health coach, then giving advice for the chronic disease management. Methods 580 patients in the chronic disease management system of the 21 community health service centers were selected and divided into three groups: control group(n =282),health coach group(n =148),health monitoring platform with health coach(n =149).After 6 months,comparing the hypertension among the three groups. Results After 6 months, the results of last group are better than of the first two groups in blood pressure reduction,blood pressure value, the compliance rate of blood pressure after treatment(SBP: χ2=25.935; DBP: χ2=40.554),decreased amplitude(SBP: χ2=63.294, DBP: χ2=27.152),compliance rates(SBP: χ2=9.874; DBP:χ2=11.173) and blood pressure classification( χ2=13.584) with significance statistical differences(P0.05). Conclusion Remote blood pressure monitoring and chronic disease management mode of health coach can significantly improve the patient's blood pressure and is worth popularizing widely.

目的 了解脑卒中患者对家庭医生服务的需求及对家庭医生服务的知晓及满意度,为改善家庭医生制服务提供参考.方法 采用自行设计的问卷,对深圳某医院2013年8月-2014年8月脑卒中患者或家属开展调查.结果 调查共发放491份问卷,有效问卷483份.按是否签订家庭医生服务分为签约组和未签约组,2组在性别、婚姻状况、文化程度、职业、疾病情况及居住方式等维度差异无统计学意义(P＞0.05),在年龄(t=2.54)、家庭收入(x2 =8.39)、医疗保险类型(x2 =84.62)维度差异有统计学意义(P＜0.05),签约组年龄(58.94 ±7.66)岁小于未签约组(63.86±7.16)岁,家庭收入和医保覆盖率优于未签约组;对未签约组进行分析显示未签约原因前三位为“不了解”41例,“社康中心医疗设备不足”17例,“医生技术水平有限”15例.对签约组进行满意度调查显示家庭医生服务态度满意率84.08％、技术满意78.98％,主动服务满意率63.06％,医患沟通满意率47.13％;签约组84.28％的患者希望家庭医生能与专科医生一起,提供综合性医疗服务.结论 脑卒中患者家庭医生签约率低,与其对家庭医生制服务模式的不了解和现行家庭医生制服务的不健全有关,应加大家庭医生服务的推广,改进现有的家庭医生服务模式,从而真正做到为患者及社区居民服务.

The health monitoring platform is used to monitor the physical signs of the chronic disease. It will contribute to integrate various medical resources to offer the continuous and personalized health service,then improve the management effect of the chronic disease. This paper introduces the construction of health monitoring platform which is designed by Pingshan People' s Hospital and its applications in chronic disease management in the community.

Objective To investigate the changes of serum interleukin -1β( IL-1β) level in patients with post stroke fatigue ( PSF) and effect of early nursing intervention , to provide references for prevention and treatment .Methods From December 2013 to June 2014, 105 patients with ischemic stroke were selected in our hospital , and they were randomly di-vided into control group (n=52) and intervention group (n=53) .Control group given routine treatment and nursing , while intervention group given early nursing intervention based on routine treatment and nursing.After 2 weeks of intervention , fatigue severity scale (FSS) was used to judge PSF, and blood glucose, HbA1c, IL-1β, HDL-C, LDL-C, TC, TG were detec-ted.Results The total score of FSS of intervention group was (2.9 ±1.5), was lower than that of control group of (3.8 ± 1.7) (P<0.05) .In the intervention group, 13 cases occurred PSF (intervention-PSF group), 40 cases did not (interven-tion-non PSF group ); in the control group , 13 cases occurred PSF ( control-PSF group ) , 29 cases did not ( control -non PSF group) .Blood glucose, HbA1c, IL-1β, HDL-C of intervention -PSF group were higher than those of control -PSF group and intervention-non PSF group , and those of control -PSF group were higher than those of control -non PSF group ( P<0.05).Conclusion Serum IL-1βlevel is higher in patients with PSF , which plays a important role in the onset and devel-opment of PSF , and early nursing intervention is helpful to reduce and postpone PSF .

Objective To Analysis on effectiveness of hypertension self-management model and hypertension classification management model on blood pressure control and management for Labor Workers with hypertension.Methods 105 Labor Workers with hypertension were recruited randomly from the Community Health Service Center of Shenzhen Grand Industrial Zone as self-management group,and another 102 patients with hypertension selected from the outpatient service department of internal medicine in Pingshan Hospital as classification management group.The control of blood pressure and survey of questionnaire after continuous treatment for 6 month.Results The subjects in the self-management group showed greater improvement in management condition.The rate of blood pressure control in each Group increased to 51.4%,37.2%,respectively(self-management group inreased 29.5%,another group increased 17.6%),and the difference had statistics significance.Conclusion The community-based hypertension self-management model is more effective on the improvement of blood pressure control and management than the hypertension classification management model in labor workers patients.

我们2006-06/2006-12在深圳市大工业区对劳务工高血压患者实施高血压自我管理项目,收集参加者的意见和建议,对该项目的效果进行定性评估.

随着社区医疗的广泛开展,很多老年人会首先选择去社区医疗中心就诊.现将我院近年来收治的老年人心血管病在社区诊断中有代表性的失误举例分析如下,以期吸取经验教训,提高社区全科医生的诊断水平.

高血压病治疗的药物选择是临床医生需要综合考虑的问题,现将我院应用美托洛尔控释片对中青年高血压病进行治疗的观察结果和体会总结如下.