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Famílias com casais com membros idosos com comorbilidades crónicas: Desenvolvimento de competências clínicas especializadas na área de Enfermagem de Saúde Familiar
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O presente relatório, elaborado no âmbito da componente clínica do Mestrado
em Enfermagem Comunitária na área de Enfermagem de Saúde Familiar da
Escola Superior de Enfermagem do Porto, descreve o processo de
desenvolvimento de competências clínicas especializadas no acompanhamento
a famílias compostas por casais idosos com comorbilidades crónicas, no
contexto dos Cuidados de Saúde Primários.
O objetivo principal consistiu na prestação de cuidados especializados a estas
famílias, considerando simultaneamente a família como unidade de cuidados e
os seus membros individualmente, ao longo do ciclo vital e nos diferentes níveis
de prevenção. Procurou-se também promover a liderança, a colaboração
interdisciplinar e a integração de referenciais teóricos na prática clínica.
A metodologia adotada baseou-se na aplicação do Modelo Dinâmico de
Avaliação e Intervenção Familiar (M. H. Figueiredo, 2012), do Modelo das Forças
(Gottlieb, 2013) e do Modelo de Autogestão (Lorig & Holman, 2003), com recurso
a técnicas como a entrevista familiar sistémica e a entrevista motivacional. Foram
realizadas avaliações clínicas, intervenções individualizadas e sessões
formativas dirigidas à equipa multidisciplinar.
Os resultados demonstraram ganhos relevantes em saúde, nomeadamente ao
nível da funcionalidade familiar, da comunicação afetiva, da literacia em saúde e
da corresponsabilização na gestão da doença crónica. Verificaram-se ainda
progressos na capacitação dos casais para a autogestão e no reforço das suas
redes de apoio.
Conclui-se que a intervenção especializada do Enfermeiro Especialista em
Enfermagem Comunitária na área de Saúde Familiar constitui um contributo
determinante para a promoção da autonomia, da funcionalidade e da qualidade
de vida de famílias em envelhecimento, permitindo uma prática clínica
fundamentada, humanizada e ajustada à complexidade das necessidades
atuais.
This report, developed within the clinical component of the Master’s Degree in Community Nursing, with a specialization in Family Health Nursing, at the Escola Superior de Enfermagem do Porto, describes the process of developing specialized clinical skills in working with families composed of elderly couples with chronic comorbidities, in the context of Primary Health Care. The main objective was to provide specialized care to these families, simultaneously addressing the family as a unit of care and its individual members throughout the life cycle and at different levels of prevention. It also aimed to foster leadership, interdisciplinary collaboration, and the integration of theoretical frameworks into clinical practice. The methodology was based on the application of the Dynamic Model of Family Assessment and Intervention (M.H. Figueiredo, 2012), the Strengths-Based Nursing Care Model (Gottlieb, 2013), and the Self-Management Model (Lorig & Holman, 2003), using techniques such as the systemic family interview and motivational interviewing. Clinical assessments, individualized interventions, and training sessions for the multidisciplinary team were conducted. The results demonstrated significant health gains, particularly in family functionality, emotional communication, health literacy, and shared responsibility in chronic disease management. Progress was also observed in the empowerment of couples for self-management and in the reinforcement of support networks. It is concluded that the specialized intervention of the Nurse Specialist in Community Nursing – Family Health contributes decisively to promoting autonomy, functionality, and quality of life in aging families, enabling a clinical practice that is evidence-based, person-centered, and responsive to the complexity of current needs.
This report, developed within the clinical component of the Master’s Degree in Community Nursing, with a specialization in Family Health Nursing, at the Escola Superior de Enfermagem do Porto, describes the process of developing specialized clinical skills in working with families composed of elderly couples with chronic comorbidities, in the context of Primary Health Care. The main objective was to provide specialized care to these families, simultaneously addressing the family as a unit of care and its individual members throughout the life cycle and at different levels of prevention. It also aimed to foster leadership, interdisciplinary collaboration, and the integration of theoretical frameworks into clinical practice. The methodology was based on the application of the Dynamic Model of Family Assessment and Intervention (M.H. Figueiredo, 2012), the Strengths-Based Nursing Care Model (Gottlieb, 2013), and the Self-Management Model (Lorig & Holman, 2003), using techniques such as the systemic family interview and motivational interviewing. Clinical assessments, individualized interventions, and training sessions for the multidisciplinary team were conducted. The results demonstrated significant health gains, particularly in family functionality, emotional communication, health literacy, and shared responsibility in chronic disease management. Progress was also observed in the empowerment of couples for self-management and in the reinforcement of support networks. It is concluded that the specialized intervention of the Nurse Specialist in Community Nursing – Family Health contributes decisively to promoting autonomy, functionality, and quality of life in aging families, enabling a clinical practice that is evidence-based, person-centered, and responsive to the complexity of current needs.
Descrição
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Enfermagem de Saúde Familiar Doença Crónica Casais Idosos Autogestão Cuidados de Saúde Primários