关键词: 医联体；高年资护士；血压达标率；自我管理能力

Abstract: Objective: To explore the effects of community hypertension management model with senior nurses as a link. Methods: Senior nurses in cardiovascular department of a tertiary general hospital were arranged into community health service center, and formed characteristic management team in the medical union. One hundred hypertensive patients were managed with senior nurses as a link. The differences of basic-level hypertensive management ability, blood pressure compliance rate and self-management ability of community staff before and after intervention were compared. Results: The community hypertension management model with senior nurses as a link can improve the basic level hypertension management knowledge of community staff, the blood pressure compliance rate and self-management ability of patients apparently. Conclusion: The community hypertension management model with senior nurses as a link has good effects and can be extended to more patients with hypertension.

Key words: integrated health care organization; senior nurses; blood pressure achievement rate; self-management ability