中文摘要：

目的分析护理干预对2 型糖尿病患者的可行性.方法：选取顺德区龙江社区病程在1 年以上的依从性不佳的老年糖尿病患者150 例,按照双盲随机数字表法将150 例患者随机分为两组,分为对照组和管理组.其中对照组患者实施常规管理.管理组患者实施医院-社区健康服务中心-家庭一体化管理模式.两组均进行为期1 年的干预.观察2 年后两组患者：生命质量的变化、空腹血糖（FBG）、餐后2 h 血糖（2 h PBG）和糖化血红蛋白（HbA1c）的变化、发病次数、住院次数、住院天数、医疗费用、生活饮食习惯、自我血糖监测、遵医嘱用药行为、运动行为依从性.结果：管理组患者发病次数、住院次数、住院天数、医疗费用明显少于对照组,组间经t 检验有显著的统计学差异（P〈0.05）.管理组干预后生命质量、FBG、2 h PBG 和HbA1c 明显优于对照组,组间经t 检验有显著的统计学差异（P〈0.05）.管理组生活饮食习惯、自我血糖监测、遵医嘱用药行为、运动行为依从性明显高于对照组,组间经x2 检验有显著的统计学差异（P〈0.05）.结论：医院-社区-家庭一体化管理模式对糖尿病患者的应用价值高,可有效提升患者遵医行为,有助于控制患者发病率,减少住院率,减轻医疗负担,还有助于改善患者血糖水平,提升其生命质量,值得推广.

英文摘要：

Objective:To analyze the feasibility of nursing intervention on patients with type 2 diabetes. Methods:150 cases with type 2 diabetes in Longjiang community of Shunde District were patients with poor compliance and their course of disease was more than one year, the patients were randomly divided into the control group and the management group. The control group received routine management while the management group received hospital-community-family integrated management model, the intervention lasted one year and the following factors of patients in two groups were observed two years later: changes in quality of life, fasting blood glucose (FBG), postprandial 2 hours blood glucose (2 hPBG) and glycosylated hemoglobin (HbA1c) changes, the number of onset, frequency of hospitalization, length of stay, medical expenses, living habits, self monitoring of blood glucose, prescribed medication behavior, behavior compliance. Results:The number of onset, frequency of hospitalization, length of stay and medical expenses of the management group were significantly less than those of the control group; the differences between two groups were statistically significant byt test (P<0.05). After intervention, the quality of life, FBG, 2hPBG and HbA1c of the management group were significantly better than those of the control group, the differences between two groups were statistically significant byttest (P<0.05). The living habits, self monitoring of blood glucose, prescribed medication behavior, behavior compliance of the management group were significantly better than those of the control group, the differences between two groups were statistically significant byx2 test (P<0.05). Conclusion: Hospital-community-family integrated management model had high application value on patients with type 2 diabetes, it could improve patients’ behavior compliance effectively, and decrease hospitalization rate and relieve medical burden in addition to decrease patients’ blood sugar level and improve their life quality, therefore, it w