慢病随访包系列，专为基层慢病随访设计打造，满足基层电子建档，慢病跟踪，数据上传等需求

　　Chronic disease follow-up package series, designed and created specifically for grassroots chronic disease follow-up, to meet the needs of grassroots electronic filing, chronic disease tracking, data uploading, and more

　　什么是高血压？

　　What is hypertension?

　　到医疗卫生机构测量血压时，非同日三次测量结果：高压（收缩压）都大于或等于140mmHg,或者低压（舒张压）都大于或等于90mmHg，就可以诊断为高血压。如果高血压患者在服用降压药物期间，虽然测得血压值不高，仍属于高血压，因为这是在药物控制下的血压，一旦停了降压药，血压仍会升高的。

　　When measuring blood pressure in medical and health institutions, if the results of three non same day measurements show that high blood pressure (systolic blood pressure) is greater than or equal to 140mmHg, or low blood pressure (diastolic blood pressure) is greater than or equal to 90mmHg, it can be diagnosed as hypertension. If a patient with hypertension is taking antihypertensive medication and their blood pressure is not high, it still belongs to hypertension because it is controlled by medication. Once the antihypertensive medication is stopped, the blood pressure will still rise.

　　高血压对身体有哪些危害？??患了高血压也许没什么症状，但高血压是“无声的杀手”，每时每刻都在损害着患者的健康。如果血压没有得到很好的控制，损伤到大脑，会引起脑卒中（中风）偏瘫，造成半身不遂、痴呆等；损伤到心脏，会引起心绞痛、心肌梗死、心力衰竭等；损伤到眼睛，可引起眼底视网膜病变甚至可能导致失明；损伤到肾，可引起肾功能不全。

　　What are the hazards of hypertension to the body? Suffering from hypertension may not have many symptoms, but it is a 'silent killer' that constantly harms the health of patients. If blood pressure is not well controlled and damages the brain, it can cause stroke (hemiplegia), resulting in hemiplegia, dementia, etc; Damage to the heart can cause angina, myocardial infarction, heart failure, etc; Damage to the eyes can cause retinal lesions and even lead to blindness; Damage to the kidneys can cause renal dysfunction.

　　如何尽早发现高血压？

　　How to detect hypertension as early as possible?

　　凡年龄在35岁以上(包括35岁)的居民，原来没有高血压或者不知道是否患有高血压，每年1次到医疗机构就诊时都应主动接受测量血压。也可以每年在家里至少测量1次血压，这样就能尽早发现高血压，早期治疗。当然，初次测量血压偏高并不能确诊,还应在去除引起血压升高的原因(如失眠、劳累、急性疾病、焦虑等)后，再预约复查。非同日测量3次，血压都高于正常，可初步诊断为高血压。心电血压工作站通过条码扫描，能够采集居民的血压体温的数据，待测量完成后，能够进行数据的筛查与漏项提示，数据能够实时上传至终端系统，检测效率高，检验批量大。

　　Residents aged 35 and above (including 35 years old) who do not have hypertension or do not know if they have hypertension should actively undergo blood pressure measurement when visiting medical institutions once a year. It is also possible to measure blood pressure at home at least once a year, so that hypertension can be detected and treated early. Of course, measuring high blood pressure for the first time does not confirm a diagnosis. After removing the causes of the elevated blood pressure (such as insomnia, fatigue, acute illness, anxiety, etc.), a follow-up appointment should be scheduled. If blood pressure is higher than normal after measuring three times on different days, it can be preliminarily diagnosed as hypertension. The electrocardiogram and blood pressure workstation can collect data on residents' blood pressure and body temperature through barcode scanning. After the measurement is completed, it can screen the data and provide missing item prompts. The data can be uploaded to the terminal system in real time, with high detection efficiency and large inspection batches.

　　什么是糖尿病？

　　What is diabetes?

　　糖尿病是一种内分泌代谢性疾病，是以血糖升高为特征。如果空腹时抽取静脉血查血糖，结果大于或等于7mmoI/L,并在以后的复查中仍高于此标准者，就可以诊断为糖尿病。糖尿病可分为1型、2型和其他几型?，其中90%以上都是2型糖尿病。2型糖尿病患者纳入健康管理。如果糖尿病患者正在接受治疗，有可能测得的血糖值不高，但还是糖尿病，一旦停止有效的治疗，血糖还会升上去的。

　　Diabetes is an endocrine metabolic disease, characterized by elevated blood sugar. If venous blood is taken on an empty stomach to check blood sugar, and the result is greater than or equal to 7mmoI/L, and it is still higher than this standard in subsequent reexamination, diabetes can be diagnosed. Diabetes can be divided into type 1, type 2 and other types, of which more than 90% are type 2 diabetes. Type 2 diabetes patients were included in health management. If a patient with diabetes is undergoing treatment, the measured blood sugar may not be high, but it is still diabetes. Once effective treatment is stopped, the blood sugar will rise.

　　糖尿病对人体有哪些危害？

　　What harm does diabetes do to the human body?

　　糖尿病对人体的危害主要表现在并发症上。如果血糖长期得不到良好控制，能造成脑、心脏、神经、眼和肾等重要器官的损害，甚至导致残疾或死亡。糖尿病造成心、脑血管损害的患病率比非糖尿病者高3倍；因下肢血管损伤而截肢者比非糖尿病者多10倍；糖尿病肾病晚期可造成尿毒症；糖尿病眼病造成的双目失明者比非糖尿病都高25倍。此外，糖尿病还常伴多发性周围神经病变和自主神经损害以及各种不同部位的感染。尿液分析仪可检测尿蛋白、尿糖、尿酮体、尿潜血等10多个检测项目，数据可通过蓝牙、无线的方式，实时上传至终端系统内，支持检验数据报单打印，检测轻松，操作便捷。

　　The harm of diabetes to human body is mainly manifested in its complications. If blood sugar is not well controlled for a long time, it can cause damage to important organs such as the brain, heart, nerves, eyes, and kidneys, and even lead to disability or death. The prevalence of cardiovascular and cerebrovascular damage caused by diabetes is 3 times higher than that of non diabetes; The number of amputees due to lower limb vascular injury is 10 times more than that of non diabetes patients; Uremia can be caused by the late stage of diabetes nephropathy; The blindness caused by diabetes eye disease is 25 times higher than that caused by non diabetes eye disease. In addition, diabetes is often accompanied by multiple peripheral neuropathy, autonomic neuropathy and infection in different parts of the body. The urine analyzer can detect more than 10 detection items such as urine protein, urine sugar, urine ketone bodies, and urine occult blood. The data can be uploaded to the terminal system in real time through Bluetooth and wireless methods, and supports printing of inspection data reports, making detection easy and operation convenient.

　　参加糖尿病患者健康管理服务能给患者带来哪些好处？

　　What benefits can participating in health management services for diabetes patients bring to patients?

　　糖尿病患者参加健康管理服务可以得到基层医生主动的、连续的服务；患者会在医生的指导下建立健康的生活方式，合理使用降血糖药物，将血糖控制在理想水平，最大限度地减少糖尿病给健康带来的危害；在管理过程，医生会及时发现其他健康问题，及时调整治疗方案；当出现危急症状或存在不能处理的其他疾病时，医生会指导患者紧急转诊；降低患者及家属的精神压力，缓解因病情控制不理想而造成的经济压力。

　　Diabetes patients participating in health management services can receive active and continuous services from grass-roots doctors; Patients will establish a healthy lifestyle under the guidance of doctors, use hypoglycemic drugs reasonably, control blood sugar at an ideal level, and minimize the harm of diabetes to health; During the management process, doctors will promptly identify other health issues and adjust treatment plans accordingly; When there are critical symptoms or other illnesses that cannot be treated, doctors will guide patients to emergency referrals; Reduce the mental stress of patients and their families, and alleviate the economic pressure caused by poor disease control.

　　如何尽早发现糖尿病？糖尿病的典型症状是我们常说的“三多一少”，即多饮、多食、多尿、体重减轻。但不是所有的糖尿病患者都有“三多一少”的典型症状。如果出现些可疑症状，如:皮肤瘙痒、饥饿感、视物不清、经常感到疲乏、劳累或反复感染等时，尤其有糖尿病家族史、生活压力大、多食、肥胖、缺乏体力活动者，患病的可能性更大。建议每年去医院检查血糖，确诊或排除糖尿病。

　　How to find diabetes as soon as possible? The typical symptom of diabetes is what we often call "more than three and less", that is, drinking more, eating more, urinating more and losing weight. But not all patients with diabetes have the typical symptoms of "more than three and less". If there are some suspicious symptoms, such as skin itching, hunger, blurred vision, often feeling tired, tired or repeatedly infected, especially those with diabetes family history, high life pressure, overeating, obesity, and lack of physical activity, they are more likely to get sick. It is recommended to go to the hospital to check blood sugar every year to diagnose or eliminate diabetes.

　　高血压、糖尿病筛查方法是什么？

　　What is the screening method for hypertension and diabetes?

　　高血压的筛查：

　　Screening for hypertension:

　　1.对辖区内35岁及以上常住居民，每年为其免费测量一次血压（非同日三次测量）。2.对第一次发现收缩压≥140mmHg和（或）舒张压≥90mmHg的居民在去除可能引起血压升高的因素后预约其复查，非同日3次测量血压均高于正常，可初步诊断为高血压。

　　1. For permanent residents aged 35 and above within the jurisdiction, their blood pressure will be measured free of charge once a year (not three times on the same day). 2. For residents whose systolic blood pressure is ≥ 140mmHg and/or diastolic blood pressure is ≥ 90mmHg for the first time, after removing factors that may cause blood pressure elevation, make an appointment for follow-up. If the blood pressure is higher than normal on three non same day measurements, it can be preliminarily diagnosed as hypertension.

　　糖尿病的筛查：对2型糖尿病高危人群进行有针对性的健康教育，建议其每年至少测量1次空腹血糖，并接受医务人员的健康指导。点击图片查看更多详细信息

　　Screening of diabetes: targeted health education should be carried out for people at high risk of type 2 diabetes. It is recommended that they measure fasting blood glucose at least once a year and receive health guidance from medical personnel. Click on the image to view more detailed information

　　国家基本公共卫生智能查体采集设备及系统，依据《国家基本公共卫生服务规范》的要求，协助基层医生对辖区内居民进行健康体检及慢病随访等健康管理的工作，针对各类乡镇卫生院公卫体检设计打造。

　　The national basic public health intelligent physical examination collection equipment and system, in accordance with the requirements of the National Basic Public Health Service Standards, assist grassroots doctors in conducting health examinations and chronic disease follow-up for residents in their jurisdiction, and design and build public health examinations for various township health centers.

　　为什么要对慢性病患者提供健康管理服务？??当前慢性病已经成为了危害我国人民群众身体健康的一个重大公共卫生问题。高血压、糖尿病是可以预防和控制的，关键是提高大众的知晓率、治疗率和控制率，在医生的建议下学会自我监测，逐步改善不良生活方式及按医嘱合理使用药物，从而将病情控制在理想水平，减少并发症的发生与发展，就可以避免巨大的疾病痛苦，同时减轻家庭、国家的沉重经济负担。

　　Why provide health management services for chronic disease patients? Chronic diseases have become a major public health issue that poses a threat to the physical health of the Chinese people. Hypertension and diabetes can be prevented and controlled. The key is to improve the awareness rate, treatment rate and control rate of the public, learn self-monitoring under the doctor's advice, gradually improve the bad lifestyle and use drugs reasonably according to the doctor's advice, so as to control the condition at an ideal level and reduce the occurrence and development of complications, which can avoid huge disease pain and reduce the heavy economic burden of families and the country.

　　慢性病患者健康管理服务包括哪些内容？

　　What are the contents of health management services for chronic disease patients?

　　筛查：主要是发现高血压、糖尿病患者和具有高血压、糖尿病高危因素的易感人群。随访评估：每年至少4次的面对面随访，首先测量血压、血糖，如无危急情况，常规随访内容还包括询问、检查与病情评估。随访评估内容包括①测量血压、血糖并评估是否存在危急情况，如果血压、血糖很高，或有危急症状，或存在不能处理的其他疾病时，需要紧急转诊。②对不需紧急转诊的患者，要询问上次随访至此次随访期间的症状。③测量心率、体重，判断是否超重或肥胖，糖尿病患者还需要检查足背动脉搏动。④询问患者疾病情况以及生活方式，了解患者服药情况。⑤做针对性健康教育，与患者一起制定生活方式改进目标，并告诉患者出现哪些异常时应立即就诊。分类干预：医生根据血压/血糖控制情况、用药有无不良反应及并发症情况，对不同患者进行有针对性的干预处理并进行健康指导。健康体检：每年1次比较全面的健康体检和针对性健康指导。健康体检内容包括健康体检内容包括体温、脉搏、呼吸、血压、身高、体重、腰围、皮肤、浅表淋巴结、心脏、肺部、腹部等常规体格检查。

　　Screening: mainly to find patients with hypertension, diabetes and susceptible groups with high risk factors of hypertension and diabetes. Follow up evaluation: At least 4 face-to-face visits per year, blood pressure and blood sugar are measured first. If there are no critical situations, routine follow-up content also includes inquiries, examinations, and disease assessments. The follow-up assessment includes measuring blood pressure and blood sugar and evaluating whether there is a critical situation. If blood pressure and blood sugar are high, or there are critical symptoms, or other diseases that cannot be treated, emergency referral is needed. ② For patients who do not require emergency referral, inquire about their symptoms from the last follow-up to this follow-up. ③ To measure heart rate and body weight and judge whether overweight or obesity, patients with diabetes also need to check the pulse of the dorsalis pedis artery. ④ Inquire about the patient's illness and lifestyle, and understand their medication status. ⑤ Provide targeted health education, work with patients to set lifestyle improvement goals, and inform them of any abnormalities that require immediate medical attention. Classification intervention: Doctors provide targeted intervention and health guidance to different patients based on their blood pressure/blood sugar control, medication adverse reactions, and complications. Health check-up: A comprehensive health check-up and targeted health guidance once a year. The health examination includes routine physical examinations such as body temperature, pulse, respiration, blood pressure, height, weight, waist circumference, skin, superficial lymph nodes, heart, lungs, abdomen, etc.

　　慢性病患者应怎样配合做好健康管理工作？??国家免费为慢性病患者提供健康管理服务，延缓疾病发展，控制并发症，提高患者生活质量，患者及家属应认真配合做好该项工作。1、纳入慢性病健康管理：高血压、糖尿病患者明确诊断后，应尽快主动到常住地乡镇卫生院、村卫生室或社区卫生服务中心（站）建立健康档案，固定责任医生，接受健康管理。2、按时随访体检：按照医生通知的预约时间、地点，接受随访和健康体检服务。3、遵医服药：随访和体检时，应向医生如实告知病情与治疗情况，严格按照医嘱按时按量服药，严禁擅自停药、减量或换药，以免发生意外（服药过程中感到不适或发生不良反应时，应及时联系医生调整治疗方案）。4、接受生活方式指导：非药物治疗是高血压、糖尿病治疗中十分重要的内容，包括戒烟、限酒、减盐、减重等多个方面，患者应与医生共同制定相应的控制目标和具体的达标方法。? ??5、及时转诊：遇到危急情况或者血压持续控制不满意时，应听从医生建议，及时 转诊到大医院。

　　How should chronic disease patients cooperate to do a good job in health management? The state provides free health management services for chronic disease patients, delaying disease progression, controlling complications, and improving patients' quality of life. Patients and their families should cooperate seriously in this work. 1. Incorporated into chronic disease health management: After the hypertension and diabetes patients have been diagnosed clearly, they should actively go to the township hospitals, village clinics or community health service centers (stations) in their permanent residence as soon as possible to establish health records, fix the responsible doctors, and accept health management. 2. Follow up physical examination on time: Accept follow-up and health examination services according to the appointment time and location notified by the doctor. 3. Follow up and take medication: During follow-up and physical examinations, truthfully inform the doctor of the condition and treatment situation, strictly follow the doctor's advice to take medication on time and in the prescribed amount, and strictly prohibit unauthorized stopping, reducing or changing of medication to avoid accidents (if discomfort or adverse reactions occur during medication, timely contact the doctor to adjust the treatment plan). 4. Lifestyle guidance: Non drug treatment is a very important content in the treatment of hypertension and diabetes, including smoking cessation, alcohol restriction, salt reduction, weight loss and other aspects. Patients should work with doctors to develop corresponding control goals and specific methods to achieve goals. 5. Timely referral: In case of critical situations or unsatisfactory blood pressure control, follow the doctor's advice and promptly refer to a large hospital.

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