糖尿病高危人群筛查和社区护理干预探索

目的：探讨护理干预措施在糖尿病高危人群筛查和随访中的应用效果。方法：使用糖尿病危险评分量表开展糖尿病高危人群的筛查工作，并对高危人群进行为期3年的护理干预，开展生活方式护理干预和健康教育管理工作，评估干预前后居民糖尿病高危因素的知晓率以及相关健康指标。结果：194,万居民中共筛查出糖尿病高危个体465348人。干预后，社区居民糖尿病高危因素知晓率提高，差异有统计学意义（P〈0．01）；社区居民多数健康相关指标得到改善，差异有统计学意义（P〈0．05）。结论：以社区为单位的高危人群个性化护理干预效果显著。开展社区糖尿病高危人群护理干预，可以延缓糖尿病和糖尿病前期的发病进程，并提高高危人群生活质量。

Screening for high-risk population of diabetes and strategies for diabetic community nursing

Objectives： To evaluate the effect of nursing prevention on high-risk population screening and follow-up. Methods： Diabetes risk score was used to screen and record the high-risk population. The screened high-risk population was followed up for three years and given the nursing intervention. The effects of prevention and education were estimated by the awareness of diabetes and physical changes. Results： Among 1.94 million screeners, a total of 465 348 high-risk individuals was recorded and received health education and nursing management. Aider nursing intervention, the awareness of diabetes knowledge was significantly higher than before （P〈0.01）; Most health indicators among individuals have improved in 2009 compared with those in 2006 （P〈0.05）. Conclusion： The strategy of individual nursing intervention on high-risk population could play a great role on the diabetes risk prevention in community. The community-based nursing model may delay or prevent the process of diabetes and pre-diabetes, thus improve the quality life of high-risk population.