生命网系统对冠心病可控危险因素的临床评估和护理干预

目的 从护理专业的角度评估冠心病可控的危险因素,并给予针对性的护理干预措施,以达到帮助患者建立健康的生活方式,控制冠心病的可控危险因素,加强冠心病二级预防的目的.方法 为住院的冠心病患者和冠心病高危人群入选＂生命网＂,评估冠心病可控的危险因素,并给予针对性的护理干预措施,在患者出院后的第1、3、6个月各进行随访、评估和再指导干预1次,进一步调整干预方案,督促患者定期复查,按时上课,以确保患者可控的危险因素得到最好的控制.结果 对冠心病危险因素的认识率、戒烟率、高血脂控制率、高血压控制率、锻炼达标率、体重下降率都有明显提高,出网时与入网时对比差异有统计学意义（P〈0.01）.结论 通过＂生命网＂系统对冠心病可控危险因素的临床评估和护理干预,能有效控制冠心病的可控危险因素,对冠心病的防治具有积极意义.

The clinical assessment and nursing intervention of heart-care network systems in controlled risk factors of coronary heart disease

Objective From the point of view of nursing to assess the controlled risk factors of coronary artery disease, and give the specific nursing intervention measures to help establish a healthy lifestyle, control risk factors of coronary heart disease （CHD）, then strengthen the control of the secondary prevention. Methods For the patients with coronary artery disease and coronary heart disease in high-risk groups in life, evaluated the con- trolled coronary heart disease risk factors, and gave specific nursing intervention to patients. The first, 3, 6 months after discharge, those patients accepted evaluation and the guidance, and were given further intervention plan They were supervised to periodic review class, in order to ensure that the controllable risk factors for patients with best control. Results Risk factors for coronary heart disease （CHD） the rate of understanding of blood pres- sure control, smoking, weight loss, exercise reach the standard were improved significantly in comparison with be- fore admitted into the net （P〈0.01）. Conclusion Through the life net of coronary heart disease control system of risk factors, clinical evaluation and nursing intervention can effectively control the coronary heart disease risk fac- tors, and has the positive significance for prevention of CHD.