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Avaliação e intervenção em famílias nucleares com idosos portadores de doença crónica: Desenvolvimento de competências clínicas especializadas em Enfermagem Comunitária na Área de Enfermagem de Saúde Familiar
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O envelhecimento da população tem contribuído para o aumento da prevalência de doenças crónicas, exigindo uma resposta integrada e personalizada por parte dos Cuidados de Saúde Primários. Neste contexto, a Enfermagem de Saúde Familiar assume um papel essencial junto das famílias nucleares com membros idosos portadores de doença crónica, uma vez que presta cuidados de saúde à família como unidade em transformação, ao longo do ciclo vital. O presente relatório, elaborado no âmbito do “Estágio de natureza profissional com relatório - Módulo I e Módulo II” integrado no Mestrado em Enfermagem Comunitária na área de Enfermagem de Saúde Familiar, tem como principal objetivo demonstrar o processo de aprendizagem relativo ao desenvolvimento de competências clínicas especializadas na área da enfermagem de saúde familiar, através da avaliação e intervenção em famílias com as características acima mencionadas. O percurso metodológico baseou-se numa abordagem suportada em referenciais teóricos como o Modelo Dinâmico de Avaliação e Intervenção Familiar e a Teoria das Transições. Foram prestados cuidados a 5 famílias, selecionadas com base em critérios previamente definidos. A prestação de cuidados às famílias e aos seus membros incluiu entrevistas familiares, com recurso a instrumentos de avaliação e intervenção familiar (genograma, ecomapa, escalas, técnicas transversais e técnicas interacionais, como o reenquadramento, a conotação positiva e os rituais terapêuticos familiares) e ferramentas complementares avaliativas de caráter individual. Paralelamente, foi implementada uma formação em serviço direcionada à equipa de enfermagem da Unidade de Saúde Familiar, com a finalidade de melhorar a documentação dos cuidados de enfermagem, assim como sessões de coaching com cada profissional. Os resultados evidenciaram ganhos significativos no conhecimento e na motivação dos enfermeiros face à utilização dos sistemas de informação e à aplicação do Modelo Dinâmico de Avaliação e Intervenção Familiar na prática clínica, que se traduziram em efetiva documentação. Observou-se, ainda, um impacto positivo nas famílias intervencionadas, nomeadamente na melhoria da comunicação, no reforço da satisfação conjugal e na adesão ao regime terapêutico, refletido em ganhos em saúde. A análise crítica e reflexiva das intervenções demonstrou a relevância da articulação interdisciplinar e do papel ativo do Enfermeiro Especialista em Enfermagem Comunitária na área de Enfermagem de Saúde Familiar na gestão do processo de cuidados. Conclui-se que a integração de modelos teóricos de Enfermagem de Saúde Familiar e a capacitação das equipas para a sua aplicação concorrem para o fortalecimento das práticas centradas na família, promovendo a autonomia, o bem-estar e a continuidade dos cuidados.
The ageing of the population has contributed to an increase in the prevalence of chronic diseases, requiring an integrated and personalized response from Primary Health Care. In this context, Family Health Nursing has an essential role to play with nuclear families with elderly members suffering from chronic illnesses, as it provides health care to the family as a changing unit throughout the life cycle. This report, drawn up as part of the “Internship of a professional nature with report - Module I and Module II” integrated into the Master's Degree in Community Nursing in the area of Family Health Nursing, aims to demonstrate the learning process related to the development of specialized clinical skills in the area of family health nursing, through assessment and intervention in families with the characteristics mentioned above. The methodological approach was based on theoretical frameworks such as the Dynamic Model of Family Assessment and Intervention and Transitions Theory. Care was provided to 5 families, selected based on previously defined criteria. The care provided to the families and their members included family interviews, using family assessment and intervention tools (genogram, ecomap, scales, transversal techniques and interactional techniques such as reframing, positive connotation and family therapeutic rituals) and complementary individual assessment tools. At the same time, in-service training was implemented for the Family Health Unit's nursing team, with the aim of improving the documentation of nursing care, as well as coaching sessions with each professional. The results showed significant gains in the nurses' knowledge and motivation regarding the use of information systems and the application of the Dynamic Family Assessment and Intervention Model in clinical practice, which translated into effective documentation. There was also a positive impact on the families involved, particularly in terms of improving communication, strengthening marital satisfaction and adherence to the therapeutic regime, reflected in health gains. The critical and reflective analysis of the interventions demonstrated the importance of interdisciplinary coordination and the active role of the Community Nurse Specialist in the area of Family Health Nursing in managing the care process. It is concluded that the integration of theoretical Family Health Nursing models and the training of teams to apply them contribute to strengthening family-centered practices, promoting autonomy, well-being and continuity of care.
The ageing of the population has contributed to an increase in the prevalence of chronic diseases, requiring an integrated and personalized response from Primary Health Care. In this context, Family Health Nursing has an essential role to play with nuclear families with elderly members suffering from chronic illnesses, as it provides health care to the family as a changing unit throughout the life cycle. This report, drawn up as part of the “Internship of a professional nature with report - Module I and Module II” integrated into the Master's Degree in Community Nursing in the area of Family Health Nursing, aims to demonstrate the learning process related to the development of specialized clinical skills in the area of family health nursing, through assessment and intervention in families with the characteristics mentioned above. The methodological approach was based on theoretical frameworks such as the Dynamic Model of Family Assessment and Intervention and Transitions Theory. Care was provided to 5 families, selected based on previously defined criteria. The care provided to the families and their members included family interviews, using family assessment and intervention tools (genogram, ecomap, scales, transversal techniques and interactional techniques such as reframing, positive connotation and family therapeutic rituals) and complementary individual assessment tools. At the same time, in-service training was implemented for the Family Health Unit's nursing team, with the aim of improving the documentation of nursing care, as well as coaching sessions with each professional. The results showed significant gains in the nurses' knowledge and motivation regarding the use of information systems and the application of the Dynamic Family Assessment and Intervention Model in clinical practice, which translated into effective documentation. There was also a positive impact on the families involved, particularly in terms of improving communication, strengthening marital satisfaction and adherence to the therapeutic regime, reflected in health gains. The critical and reflective analysis of the interventions demonstrated the importance of interdisciplinary coordination and the active role of the Community Nurse Specialist in the area of Family Health Nursing in managing the care process. It is concluded that the integration of theoretical Family Health Nursing models and the training of teams to apply them contribute to strengthening family-centered practices, promoting autonomy, well-being and continuity of care.
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Palavras-chave
Enfermagem de Saúde Familiar Família Idoso Doença Crónica