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Abstract(s)
Nos últimos anos, o envelhecimento gradual da população obrigou a redesenhar os serviços de saúde, em função dos problemas emergentes relacionados com a elevada prevalência de doenças crónicas. Pessoas com multimorbilidade expressam necessidades de cuidados complexas que não passíveis de serem abordadas por um modelo fragmentado e centrado na doença. Este modelo tradicionalista poderá ser, por si só, um entrave ao desenvolvimento de soluções potencialmente vantajosas para a saúde pública. Existem um conjunto de pessoas com doenças crónicas, neste relatório denominadas por doentes crónicos complexos, que pela complexidade da sua condição clínica e social, e por apresentarem frequentemente critérios de fragilidade, beneficiam de uma abordagem integrada e de proximidade. Os enfermeiros ao centrarem o seu raio de ação nas respostas humanas aos processos de vida, saúde e doença, ampliam o campo de visão sobre as reais necessidades dessas pessoas colocando-se numa posição privilegiada para assumir, na comunidade, um papel central na gestão dos cuidados e combater, dessa forma, a desfragmentação das respostas de saúde. É neste contexto que se realizou o estágio para a
aquisição de competências relativas à Especialização em Enfermagem Comunitária, numa Unidade
de Cuidados na Comunidade que engloba uma Equipa de Suporte a Doentes Crónicos Complexos.
No sentido de melhor planear os cuidados e antecipar as necessidades desta população alvo,
utilizou-se a metodologia do planeamento em saúde, para efetuar um diagnóstico de situação com
indivíduos que reuniam os critérios de admissão, mas que ainda não estavam sinalizados para serem acompanhados pela equipa, com o objetivo de clarificar as necessidades e os problemas mais prementes sensíveis aos cuidados de enfermagem. Em função do diagnóstico efetuado, definiu-se a gestão do regime medicamentoso como a principal área de intervenção comunitária, da qual resultou um projeto para implementação de uma árvore de apoio à decisão clínica onde, para além da avaliação do utente e prestador de cuidados, são estruturadas um conjunto de intervenções e respetivos indicadores de desempenho. Por outro lado, correspondendo a uma solicitação da própria equipa, estruturaram-se um conjunto de intervenções de modo a ampliar a sua rede de referenciação.
In recent years, the gradual aging of the population has forced health services to be redesigned due to the emerging problems related to the high prevalence of chronic diseases. People with multimorbidity express complex care needs, which cannot be addressed by a traditionalist model, fragmented and centered on the disease, which, in itself, can be an obstacle to the development of potentially beneficial solutions for public health. There are a number of people with chronic diseases, in this report called complex chronic patients, who, due to the complexity of their clinical and social condition, and because they often present fragility criteria, benefit from an integrated and proximity approach. Nurses, by focusing their intervention on human responses to the processes of life, health and illness, broaden the field of vision on the real needs that people experience and place themselves in a privileged position, in the community, to assume a crucial role in centralizing care in the person and defragmentation of health responses. The internship for the acquisition of skills related to the Specialization in Community Nursing took place in a Community Care Unit that includes a support team for complex chronic patients. In order to better plan care and anticipate the needs of this target population, the Health Planning methodology was used to make a diagnosis of the situation, with individuals who met the admission criteria, but who were not yet signaled to be accompanied by the team, in order to clarify the needs and the most pressing problems sensitive to nursing care. Due to the diagnosis made, the management of the medication regime was defined as the main area of community intervention, which resulted in a project for the implementation of a clinical decision support tree where, in addition to the evaluation of the user and care provider, a set of interventions and respective performance indicators are structured. On the other hand, corresponding to a request from the team itself, a set of interventions were structured in order to expand its referral network.
In recent years, the gradual aging of the population has forced health services to be redesigned due to the emerging problems related to the high prevalence of chronic diseases. People with multimorbidity express complex care needs, which cannot be addressed by a traditionalist model, fragmented and centered on the disease, which, in itself, can be an obstacle to the development of potentially beneficial solutions for public health. There are a number of people with chronic diseases, in this report called complex chronic patients, who, due to the complexity of their clinical and social condition, and because they often present fragility criteria, benefit from an integrated and proximity approach. Nurses, by focusing their intervention on human responses to the processes of life, health and illness, broaden the field of vision on the real needs that people experience and place themselves in a privileged position, in the community, to assume a crucial role in centralizing care in the person and defragmentation of health responses. The internship for the acquisition of skills related to the Specialization in Community Nursing took place in a Community Care Unit that includes a support team for complex chronic patients. In order to better plan care and anticipate the needs of this target population, the Health Planning methodology was used to make a diagnosis of the situation, with individuals who met the admission criteria, but who were not yet signaled to be accompanied by the team, in order to clarify the needs and the most pressing problems sensitive to nursing care. Due to the diagnosis made, the management of the medication regime was defined as the main area of community intervention, which resulted in a project for the implementation of a clinical decision support tree where, in addition to the evaluation of the user and care provider, a set of interventions and respective performance indicators are structured. On the other hand, corresponding to a request from the team itself, a set of interventions were structured in order to expand its referral network.
Description
Keywords
Doentes crónicos complexos Integração de cuidados Enfermeiro gestor de caso Gestão do regime medicamentoso Enfermagem comunitária Complex chronic patient Integrated care Nurse case manager Medication regimen management Community health nursing