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Advisor(s)
Abstract(s)
A enfermeira especialista em Enfermagem Comunitária deve ser capaz de construir um
diagnóstico de saúde referente ao indivíduo, família e comunidade, identificar prioridades de
actuação e definir, executar e avaliar projectos de intervenção comunitária. Para dar resposta a
estas necessidades e atingir a proficiência a que o grau de especialista corresponde, foram
estruturadas intervenções, baseadas na prática de Enfermagem avançada, que foram
realizadas e reformuladas de acordo com a realidade e os recursos disponíveis.
Para analisar a realidade é fundamental ter em atenção a evolução que as pirâmides
etárias têm vindo a sofrer, ao longo do tempo, em Portugal. Tem existido um envelhecimento
progressivo da população que se traduz no aumento das morbilidades a esta etapa associadas
– doenças crónicas, degenerativas, demências, insuficiência orgânica, doenças oncológicas –
que podem, em determinadas situações, conduzir à necessidade de prestação de Cuidados
Paliativos. O concelho da Maia não é excepção à evolução demográfica nacional, apesar de o
seu índice de envelhecimento ser ligeiramente inferior à média do país. Por esse motivo, foi
realizado um diagnóstico de saúde para identificar as necessidades de Cuidados Paliativos
dirigido aos clientes e cuidadores acompanhados por enfermeiros no domicílio, pertencentes às
USF Lidador, Odisseia e Pirâmides, residentes nas freguesias de Gueifães, Milheirós e
Vermoim, tal como a todos os profissionais de saúde do ACES Maia, com o objectivo de
identificar as suas necessidades de formação no primeiro módulo de estágio de Enfermagem
comunitária.
Após priorização de necessidades em consenso de peritos, foi identificada em terceiro
lugar de ordem de importância, a necessidade de formação dos cuidadores sobre a prestação
de cuidados a clientes com dependência funcional (45% dos cuidadores) e a necessidade de
formação dos profissionais de saúde do ACES Maia sobre a administração de fármacos por via
subcutânea (67% identificaram necessidade de formação no controlo de sintomas, para a qual
esta via é fundamental).
Para dar resposta a estas foram realizadas visitas domiciliárias aos cuidadores com
necessidade de formação e executada educação para a saúde de acordo com o diagnóstico
efectuado. No que concerne à necessidade de formação dos profissionais de saúde sobre a
administração de fármacos por via subcutânea foram projectadas e executadas sessões de
formação sobre a mesma temática em três momentos distintos.
No terceiro módulo de estágio, de cariz opcional, o projecto de intervenção comunitária
dirigiu-se às necessidades dos alunos do sétimo ano de uma escola de segundo e terceiro ciclo
do ensino básico, no que diz respeito à prática de Bullying.
Este relatório visa realizar uma descrição dos projectos de intervenção realizados, tal
como a sua avaliação, com os ganhos em saúde obtidos.
A nurse specialised in Community Nursing must be able to build a health diagnosis regarding the individual, family and community, identify action priorities and define, implement and evaluate community intervention projects. To meet these demands and achieve proficiency at some interventions were structured, based on advanced nursing practice. These interventions have been implemented and revised pursuant to the reality and available resources. To examine the reality it is essential to take into account the changes that the age pyramids have been experiencing over the time in Portugal. There has been a steadily aging of the population which is reflected in the increase of morbidities associated with this stage – chronic and degenerative diseases, dementia, organ dysfunction, oncological diseases - which can, in certain situations, lead to the need to provide palliative care. The Maia City is no exception to the national demographic trends, although the rate of aging here is slightly below the national average. Therefore, a diagnosis was performed to identify the health needs of palliative care clients and caregivers accompanied by nurses at home, belonging to the Lidador, the Odisseia and the Pirâmides family health units, resident in the parishes of Gueifães, Milheirós and Vermoim, such as all health professionals of the Maia Health Centers Group, in order to identify their training needs in the first stage module of Community Nursing. After prioritizing the needs in a consensus of experts, it was identified in third place, in order of importance, the need for training caregivers on the care of clients with functional dependence (45% of caregivers) and the need for training of health professionals ACES Maia on the administration of subcutaneous drugs (67% identified the need for training in symptom control, for which this pathway is crucial). To respond to this, home visits were made to caregivers in need of health education. The training was implemented in accordance with the diagnosis made. Regarding the need for training of health workers on the administration of subcutaneous drugs, training sessions were designed and performed on the same subjects at three different times. In the third (optional) module, the community intervention project, addressed the needs of students in the seventh year of a school of the second and third cycle of basic education, with regard to the practice of bullying. This report is intended to achieve a description of the intervention projects undertaken, such as rating, with health gains achieved.
A nurse specialised in Community Nursing must be able to build a health diagnosis regarding the individual, family and community, identify action priorities and define, implement and evaluate community intervention projects. To meet these demands and achieve proficiency at some interventions were structured, based on advanced nursing practice. These interventions have been implemented and revised pursuant to the reality and available resources. To examine the reality it is essential to take into account the changes that the age pyramids have been experiencing over the time in Portugal. There has been a steadily aging of the population which is reflected in the increase of morbidities associated with this stage – chronic and degenerative diseases, dementia, organ dysfunction, oncological diseases - which can, in certain situations, lead to the need to provide palliative care. The Maia City is no exception to the national demographic trends, although the rate of aging here is slightly below the national average. Therefore, a diagnosis was performed to identify the health needs of palliative care clients and caregivers accompanied by nurses at home, belonging to the Lidador, the Odisseia and the Pirâmides family health units, resident in the parishes of Gueifães, Milheirós and Vermoim, such as all health professionals of the Maia Health Centers Group, in order to identify their training needs in the first stage module of Community Nursing. After prioritizing the needs in a consensus of experts, it was identified in third place, in order of importance, the need for training caregivers on the care of clients with functional dependence (45% of caregivers) and the need for training of health professionals ACES Maia on the administration of subcutaneous drugs (67% identified the need for training in symptom control, for which this pathway is crucial). To respond to this, home visits were made to caregivers in need of health education. The training was implemented in accordance with the diagnosis made. Regarding the need for training of health workers on the administration of subcutaneous drugs, training sessions were designed and performed on the same subjects at three different times. In the third (optional) module, the community intervention project, addressed the needs of students in the seventh year of a school of the second and third cycle of basic education, with regard to the practice of bullying. This report is intended to achieve a description of the intervention projects undertaken, such as rating, with health gains achieved.