Self-care and HIV/aids patients: nursing care systematization

El autocuidado y el portador de SIDA: sistematización de la atención de enfermería

Abstracts

À pesquisa tem como objetivo sistematizar a assistência de enfermagem ao portador do HIV/aids, à luz da Teoria de Enfermagem do Déficit de Autocuidado de Orem. Utilizou-se a modalidade convergenteassistencial e o Processo de Enfermagem de Autocuidado. Foram treze sujeitos, atendidos numa organização não-governamental, no município de Fortaleza/CE. Utilizou-se técnicas de entrevista, exame físico, observação e o registro de informações, com um instrumento estruturado, abordando os requisitos de autocuidado universal, os relativos ao desenvolvimento e aqueles de alterações de saúde. Os déficits de autocuidado corresponderam a dezenove diagnósticos de enfermagem, dez dos quais nos requisitos de autocuidado universal; cinco nos requisitos de desenvolvimento e quatro nos relacionados ao desvio de saúde. No planejamento da assistência, as metas e os objetivos priorizaram ações de apoio-educação com vistas ao engajamento do portador do HIV/aids no autocuidado.

autocuidado; síndrome de inmunodeficiencia adquirida; VIH; enfermería

ORGINAL ARTICLE

Self-care and HIV/aids patients: nursing care systematization¹

El autocuidado y el portador de SIDA: sistematización de la atención de enfermería

Joselany Áfio Caetano^I; Lorita Marlena Freitag Pagliuca^II

^IFaculty, State University Vale do Aracajú and University of Fortaleza, e-mail: [e-mail]

^IIFaculty, School of Pharmacy, Dentistry and Nursing, Federal University of Ceará

ABSTRACT

This research aimed at systematizing nursing care to HIV/aids patients in view of Orem's Self-care Deficit Nursing Theory, using the convergent-care method and the Self-Care Nursing Process. Subjects were thirteen HIV/AIDS patients attended at a non-governmental organization in Fortaleza/CE, Brazil. We used interview techniques, physical examination, observation and information records, with a structured instrument, addressing requisites related to universal self-care, development and health alterations. Self-care deficits corresponded to nineteen nursing diagnoses, named according to NANDA's Taxonomy II, ten of which were based on the requisites for universal self-care, five on the requisites for self-care related to development and four on the requisites for self-care related to health deviations. In care planning, goals were established and the system and health methods were selected, prioritizing support-education actions in order to engage HIV/aids patients in self-care.

Descriptors: self-care; acquired immunodeficiency syndrome; HIV; nursing

RESUMEN

La finalidad de esta investigación es sistematizar la atención de enfermería al portador de SIDA, bajo la Teoría de Enfermería del Déficit de Auto-cuidado de Orem. Se usó la modalidad convergente asistencial, a través de la operación del Proceso de Enfermería de Auto Cuidado. Los sujetos fueron trece portadores de SIDA, atendidos en una organización no gubernamental en el municipio de Fortaleza/CE, Brasil. Para el desarrollo del estudio, se usaron técnicas de entrevista, de examen físico, de observación y de registro de las informaciones - con un instrumento estructurado - tratando de los requisitos de auto-cuidado universal, los referidos al desarrollo y los de alteraciones de la salud. Los déficit del auto cuidado correspondieron a diecinueve diagnósticos de enfermería, denominados según la Taxonomía II de NANDA, diez de los cuales dentro de los requisitos de auto cuidado universal; cinco en los requisitos de auto cuidado relativos al desarrollo y cuatro en los requisitos de auto cuidado relacionados al desvío de salud. En la fase de planificación de la atención de enfermería, fueron establecidas las metas y los objetivos y seleccionados tanto el sistema como los métodos de ayuda, dando prioridad a las acciones de apoyo educacional visando al compromiso del portador de SIDA con el auto cuidado.

Descriptores: autocuidado; síndrome de inmunodeficiencia adquirida; VIH; enfermería

INTRODUCTION

Aids is a pandemic disease. In Brazil, until March 2002, 257,780 cases of the disease had been found. In the state of Ceará, 4,196 cases were registered between 1980 and 2002⁽¹⁾. A series of factors affects the disease's morbidity and mortality profile, including access to information, to opportunistic disease prevention means, lab tests, antiretrovirals, quality care, treatment adherence, early diagnosis of infections and appropriate therapeutic measures.

More than 20 years after its discovery, there are still gaps in care for HIV/aids patients, mainly in terms of how people live with the disease, with a view to attending to their psychosocial needs and encouraging autonomy skills for self-care.

Committed to delivering care to HIV/aids patients, nurses can work to improve their quality of life through nursing consultations and are responsible for preparing them for self-care. This kind of consultation is an exclusive activity of nurses who, using their professional autonomy, develop a care model to attend to their clients' health needs, as established by Law No 7.498/86, regulated by Decree No 94.406/87⁽²⁾.

Orem's general theory was developed in three related parts: Self-Care, Self-Care Deficit and Nursing Systems.

The Self-Care Theory includes self-care, self-care capability and therapeutic self-care demands, as well as self-care requisites. Self-care (SC) is the practice of activities initiated and performed by individuals, on their own behalf, to maintain life, health and well-being.

Self-care capability is the ability possessed by individuals, it is what makes them perform self-care. This ability is conditioned to internal and external factors, such as age, gender, health state, sociocultural factors, life standard, resource availability, among others⁽³⁾.

Therapeutic self-care demands include the set of SC actions developed over a period of time to comply with self-care requisites, which are: 1. universal; 2. developmental; 3. health deviations. While universal requisites are associated with life processes and maintaining the integrity of human structure and functioning, developmental requisites derive from some natural condition in the life cycle or are associated with some event, and health-deviation requisites are indicated in disease conditions⁽³⁾.

The Self-Care Deficit Theory is acknowledged as the explanatory description of the meaning of nursing and what nursing does. Fundamental concepts of this theory include: self-care agent, self-care requisite and self-care deficit⁽³⁾.

The self-care deficit is the focus of nursing activities, as nurses have the knowledge, discernment and ability to know what events, conditions and circumstances characterize people in health care situations, as well as to identify the inabilities human beings are subject to⁽³⁾. Nurses' function is to act in the offering of nursing care. For this purpose, they adopt help methods that are directed by: acting or doing for others; guiding others; supporting others; stimulating an environment that promotes personal development in terms of becoming capable of attending to current or future demands for action with a view to helping individuals to take care of themselves, focusing their actions on self-care requirements or requisites⁽³⁾.

While Nursing Systems Theory establishes the structure and contents of nursing practice, nursing systems represent the orders of nurses' and patients' roles and subsequent adjustments in these roles. Three nursing systems exist, based on self-care needs and on individuals' capacity to take care of themselves: the compensatory system, when the individual is incapable of involving in self-care actions; the partially compensatory system, when the individuals' actions are limited and, consequently, nurses and individuals play the main role in care actions; and the educative-development system, in which the individual can perform and should learn how to perform self-care actions⁽³⁾.

Self-care should be one of the goals of nursing care, as it can stimulate patients' active participation in their treatment, by sharing responsibilities for care implementation and results with the nurse. In this respect, we found various nursing studies that applied Orem's Self-Care Theory to epilepsy patients⁽⁴⁾; diabetic clients⁽⁵⁾; pregnant adolescents⁽⁶⁾; patients after bone marrow transplantation⁽⁷⁾. However, a search in the virtual health library of Bireme, using Lilacs and Medline, did not reveal any studies that applied Orem's Theory to HIV/aids patients.

This study aimed to: systemize nursing care delivery to adult HIV/aids patients in view of Orem's Self-Care Deficit Theory of Nursing; identify universal, developmental and health-deviation requisites; based on these requisites, identify self-care deficits; and plan nursing care.

MATERIAL AND METHOD

We used a convergent-care methodological research design, which maintains a narrow relation with the social situation throughout the entire process, in order to find solutions to problems, accomplish changes and introduce innovations into the social situation⁽⁸⁾. The study was developed in the Ceará group of the National Network of People Living with HIV/aids (RNP). The study population consisted of HIV/aids patients who participated in the Network. The sample was chosen from volunteers, according to the following inclusion criteria: conscious adults, with unfinished primary education as the minimum education level and physical and emotional conditions to participate in the study. Participants were thirteen HIV/aids patients.

During the nursing consultations, we used interviews, participant observation and information registers. The nursing care methodology covered phases of the nursing process, which is a set of actions on which practice is based, it is a regular and continuous action or series of actions that occur or are carried out in a defined way⁽³⁾. Based on the main concepts of Orem's Self-Care Deficit Theory of Nursing, we adopted the self-care nursing process model in the following phases: diagnosis and prescription, regulation or treatment and control and assessment operations. The diagnosis operation covers identification data; universal, developmental and health-deviation requisites and, consequently, SC deficits. This phase precedes the nursing diagnosis.

The diagnosis phase involves a careful and directed research process, including examination and descriptive analysis of persons' data and the conditions and circumstances of their life, in an attempt to explain or understand the nature of their existing conditions⁽³⁾. This process was carried out based on the NANDA Taxonomy⁽⁹⁾ (North American Nursing Diagnosis Association). Regulation or treatment operations involve the production of the nursing system, the help methods elaborated to reach nursing goals and objectives for the patient. We considered literature, knowledge in this area and our professional experience to elaborate interventions. Nursing care is implemented by carrying out educative-development nursing actions.

What the data collection instrument is concerned, it consisted of: identification, containing demographic data (age, gender, education level, occupation and family income); open questions, through which HIV/aids patients could report their feelings about the disease and treatment, facing and allowing for the identification of universal, development and health-deviation self-care requisites and the existence of self-care deficits. After the instrument had been elaborated, it was tested and some modifications were made.

Before the start of data collection, the project was submitted to and approved by the Research Ethics Committee of the Ceará Federal University Hospital. Instruments were validated before use and all ethical and legal requirements were complied with, in accordance with Resolution 196/96 by the Brazilian National Health Council⁽¹⁰⁾.

RESULTS AND DISCUSSION

Systemizing nursing care from a self-care perspective

In the study sample, ten participants were men and three women. Nine were between 26 and 40 and four between 41 and 55 years old. Education level data per were ranked as: illiterate, unfinished primary education, primary education, unfinished secondary education, secondary education and higher education. According to this criterion, we found four participants with unfinished primary education; two with unfinished secondary education; five with secondary education and only one with higher education. Thus, a majority had either unfinished primary or unfinished secondary education. Family income ranged between 1 and 2 minimum wages (MW). Only one participant gained more than 2 MW, but sustained four other persons. With respect to occupation, most participants were retired or on welfare, although six of them still performed informal activities.

We adapted the universal self-care requisites, starting from the following basic needs HIV/aids patients have in common: feeding; hydration; elimination and excretion; oxygenation; balance between activity and relaxation; maintaining a balance between loneliness and social interaction; aspects related with hazards to life and well-being⁽³⁾.

Basic needs are inherent to all human beings and need to be adequately complied with. They should constantly be assessed in order to identify patients' potentialities, limitations and the requirements of nursing orders. Thus, based on the self-care deficits mentioned by or observed in the study population, a proposal was formulated, used as a parameter to organize nursing diagnoses - NANDA's Taxonomy II⁽⁹⁾.

Table 1 shows the distribution of deficits according to the sub-requisites of universal SC and their respective nursing diagnoses. As to fluid intake, ten participants suggest inadequate levels, ranging from 1.0 to 1.5 liters per day. One patient presented alterations in the oral mucosa, due to forgetfulness, lack of will to consume fluids and medication therapy.

Most participants mentioned difficulties to assess their fluid intake and the urine volume they eliminate daily. We accepted patients' estimation about a daily consumption of 1 liter, 1.5 liters and 2 liters, while others indicated "little fluid intake".

The risk for deficient fluid volume diagnosis, related to both reduced oral intake and abnormal fluid loss, appeared as a result of low fluid intake levels; diarrhea; use of antihypertensive and diuretic therapy and antiretrovirals. The one HIV/aids patient in the sample who presented dry mucosa during the observation resulted in the deficient fluid volume diagnosis. We established increased fluid intake as a goal, without signs or symptoms of dehydration. Moreover, the objective was the individual's verbalization of improved thirst and increased fluid ingestion, besides better skin turgor. The educative-development nursing system was chosen to implement the planned care; support methods included orientation for greater fluid intake and consumption of fluid appetizers (sweets, ice lollies, cookies), suggestion to consume small quantities of water frequently, alternative fluids (juice, milk, ice cream) and hydrating fruits.

The evidence of xerostomia and changed sense of taste, demonstrated by one participant, pointed towards the nursing diagnosis of impaired oral mucous membrane, related to the prolonged use of an immunosuppressive agent. Care planning indicated the goal of decreasing the collateral effects of drugs, with the objectives of achieving the patient's adherence to the practice and clear interest in seeking options to mitigate the collateral effects, as well as SC promotion with a view to better adherence to aids treatment. Educative-development was chosen as the nursing system and, as the support method, orientation for the use of an oral lubricant, such as KY.

In the assessment of excretion/elimination, eight HIV/aids patients showed self-care demands that were exclusively related to intestinal and urinary functions. Alterations inherent to intestinal elimination were diarrhea and constipation. Six patients mentioned liquid or soft feces. This led to the nursing diagnosis of diarrhea, related to the collateral effects of antiretroviral agents. In care planning, we established controlling diarrhea as the goal and avoiding dehydration and electrolyte imbalance as the objective. Moreover, we selected the educative-development nursing system and orientation to increase oral intake as the support method. Two participants indicated hard or dry feces, with defecation twice or three times per week, leading to the nursing diagnosis of constipation, related to the collateral effects of diuretics, inappropriate diet and inadequate fluid intake. Improving intestinal elimination patterns was established as the goal in nursing care planning, and orientations for sufficient fluid intake, at least 2 liters/day, and a balanced and fiber-rich diet as the objective. This includes: bran, cucumber, cauliflower, lettuce, cabbage and fresh fruit with the peel. Educative-development was selected as the nursing system and orientation as the support method.

What urinary elimination is concerned, we found complaints of polyuria, resulting from the use of diuretics and Crixivan^®, besides the intake of alcoholic drinks. One patient mentioned oliguria, due to renal insufficiency. In combination with insufficient fluid intake, these signs indicated the nursing diagnosis risk for deficient fluid volume. In care planning, the goal was to reduce or eliminate causal factors, and the objective to provide orientations for the monitoring of daily intake/excretion. Educative-development was used as the nursing system and the identification of dehydration signs as the support method.

We assessed food intake based on participants' reports about their eating routines (breakfast, lunch and dinner). Ten HIV/aids patients mentioned inadequate intake of nutrients, mainly vitamins. Reports on irregular eating and having a snack to replace regular meals, as well as complaints about lack of appetite and weight loss (20% below ideal weight) indicated the nursing diagnosis imbalanced nutrition: less than body requirements. Another aspect of this diagnosis is the lack of care with feeding, resulting in insufficient nutrient intake.

In care planning, we established the goals of weight control and improved eating habits, as well as the following objectives: increased caloric food intake; verifying the patient's medication therapy that causes inability to ingest or digest; patient's clear interest in developing food reeducation; modifying alimentary patterns; maintaining a balanced diet with a view to obtaining nutrients that sufficient nutrients for the patient's metabolic needs. We chose educative-development as the nursing system, supported by orientation and teaching through informal dialogue. Patients were oriented about the importance of adequate eating habits, received options to establish a balanced diet and were stimulated to dedicate importance and time to food, avoiding calories to substitute for basic meals.

Based on two participants' complaints about tiredness, coughing and sinusitis, we considered an oxygenation deficit and the consequent diagnosis of risk for altered respiratory function. In this case, the goals were to teach patient to promote sinus drainage and to examine the cause of tiredness and coughing. The objective was to improve fatigue and nasal obstruction by increasing environmental humidity and fluid intake and by applying local heat. Educative-development was adopted as the nursing system, with orientation to use warm moist compresses and increase fluid intake as support methods.

As to sports activities, only four participants practiced some kind of sport, such as weight lifting and walking. One of them played volley on a not very frequent base, actually more as a recreation activity. Other participants affirmed that they do not practice any sports, despite considering this is necessary for health.

With respect to sleep and rest needs, seven HIV/aids patients evidenced difficulties to conciliate these and commonly used anxyolitics, while two others complained that they slept too much and felt constant fatigue. This points towards the nursing diagnosis disturbed sleep pattern. In view of the physical and psychological aspects of this deficit, we suggested a calm environment without lights; having a set time for waking up, sleeping and relaxing; avoiding food and drinks with caffeine before going to sleep and drinking chamomile tea or passion fruit juice; or reading something pleasant and relaxing.

What the diagnosis of activity intolerance is concerned, which was identified from patients' reports about fatigue, showing oxygen transportation system problems due to anemia and medication, increasing activity tolerance was set as the goal. The objective was for HIV/aids patients to report improved intolerance and increased participation in daily activities. Educative-development was chosen as the nursing system, supported by orientations to reduce activity intolerance.

Another noticeable aspect related to universal self-care requisites is the maintenance of a balance between loneliness and social interaction. Five participants affirmed they were lonely or did not participate in social activities.

This evidenced the nursing diagnosis risk for loneliness related to aids. The goal in nursing care planning was to identify strategies for the socialization of HIV/aids patients who feel lonely, and the objective was to promote social interaction. Educative-development was adopted as the nursing system, with the following support methods: encouraging patients to talk about their feelings of loneliness and the reasons why they exist, besides discussing the importance of socialization.

In the same context, as part of the sub-requisite preventing hazards to life and well-being, the following aspects were relevant: preventing breast, colon and prostate cancer, yearly dental and ophthalmologic appointments, immunization and investigation of basic eye care, drinking and smoking habits and sexual intercourse without condom, as shown in Table 2.

According to Table 2, eight HIV/aids patients needed ophthalmologic appointments (i.e. they did not attend regular follow-up), including one who had never taken a sight test, alleging a lack of access to ophthalmologic services.

In the context of prevention in general, these patients were worried about their eyes, mainly about losing their sight. This is because they knew other patients with a history of blindness caused by opportunistic infections, as eye infections are one of the complications that result from HIV infection. These can lead to blindness and sometimes appear unexpectedly within the biological evolution stage of the virus inside the organism.

As to patients' oral health, two of them did not get regular dental follow-up. However, promoting oral health is essential for different reasons, as there is greater probability of infections that produce painful situations and difficult eating. Moreover, these infections can be difficult to treat, whether due to more potent microorganisms or low immunity. Another relevant aspect is that cavities caused by caries act as a niche for other microorganisms that facilitate diseases⁽¹¹⁾.

Drinking (7) and smoking (6) habits were common among the participants. When asked about condom use during sexual intercourse, four patients mentioned they did not use this prevention measure. Although all participants acknowledged the risk of drinking, smoking and maintaining sexual intercourse without condom, this knowledge was not enough for them to adopt healthy habits, as each patient acts according to his/her beliefs, desires and fears, although information and risks are universal.

In short, we perceived that health behavior was fragile since, although all participants had received orientations, most of them did not adopt health promotion practices on a regular basis, such as ophthalmologic and dental appointments; breast, colon and prostate prevention exams and immunization.

What immunization is concerned, only one participant mentioned a self-care deficit. It is recommendable for HIV/aids patients with severe clinical and/or laboratory immunodeficiency to avoid vaccines with live or attenuated biological agents. There is no contraindication against non-living immunogens, although the cellular and/or humoral immune response is weaker than what is observed in immunocompetent adults. Hence, it is important to consider the risk/benefit and the epidemiological context on all occasions⁽¹²⁾.

Participants' mentions about the lack of access to health care and basic eye care services, alcohol and tobacco abuse and sexual intercourse without condom led to the identification of the nursing diagnosis ineffective health maintenance, related to the incapacity to identify, control and/or seek help to maintain health. Thus, the goal of care planning was to decrease the SC deficit in order to obtain the highest possible level of health, and the objective was for the HIV/aids patient to demonstrate knowledge about threats to their health and self-care promoting behavior. Educative-development was chosen as the nursing system, with the help of orientation, support and teaching through workshops.

Developmental self-care

Developmental SC requisites are requirements that occur during certain human development phases, derive from a condition or are associated with an event that can have a negative effect on the individual⁽³⁾.

In this study, deficit in adapting to modifications resulting from aids appears as a sub-requisite of SC, based on questions about patients' feelings when they discovered the disease, lost friends, faced financial problems, as shown in Table 3.

The first matter that was discussed was the date of diagnosis, that is, between 1992 and 1998, when aids was a synonym of strangeness and prejudice. Another aspect commented on was the condition the disease was discovered in, mainly marked by the appearance of symptoms in the patient's partner, or that person's death, or also by symptoms in patients themselves, although they did not immediately take a confirmation test. In this context, and in view of the obligation to sustain a household, female participants got even more frightened of death, due to their concern with the future of their children, while the question about their own existence remained in the background.

In general, the discovery of aids is a marking and traumatizing moment in the disease. When asked about their feelings when they discovered the disease, HIV/aids patients answered: sadness, depression, revolt, anguish and fear. Three participants felt indifference and another commented that he thought that aids was a disease like any other, that it was curable. Yet another patient said that, when he found out he was positive, he became calm and, from that point onwards, he started to drink. Feelings of loss, on the other hand, were characterized as sadness, depression and anger.

Twelve HIV/aids patients faced financial difficulties, most of them were retired or on welfare, although six of them still performed informal activities. Thus, most participants depended on welfare, which is not even sufficient to attend to basic needs for survival.

In this respect, developmental self-care seems to be interrelated, as the discovery of aids leads to retirement and, consequently, to financial problems. Article 203 of the Federal Constitution guarantees that aids patients who do not pay social welfare contributions are entitled to health insurance benefits, but not all patients can get access to this. The number of infected and sick people clearly exceeds governmental support. Hence, the continuity of this care has not been totally solved, while the epidemic is growing and increasingly affecting poor social groups. Moreover, due to being a chronic and incurable disease, many people consider death as a constant in patients' lives.

The diagnosis of fear in eight patients was based on the feelings of apprehension they mentioned in relation to the disease, sight loss and death. This feeling appeared when they discovered their disease, when people they loved were about to die and when some acquaintance experienced visual loss. It also resulted from individuals' projections about their situation as HIV/aids patients. In care planning, we suggested the goal of using effective resolution mechanisms for anxiety control, aimed at increasing psychological and physiological support. We chose educative-development as the nursing system, with the help of support and orientation by means of informal dialogue, with a view to providing calmness and comfort and allowing individuals to express their anxieties. Relaxation, music and conversations with friends were suggested as resolution mechanisms.

The disturbed body image diagnosis was evidenced by patients' expression of changes in their appearance after lipodystrophy, that is, changes in body fat distribution, resulting from the prolonged use of antiretrovirals. The main complaint was weight loss in some body regions, such as arms, legs, buttocks and face, while the abdomen, back and neck started to accumulate fat and affected self-esteem, leading to the additional diagnosis of low situational self-esteem. The goal of care planning was to improve patients' body image and, consequently, their self-esteem. The objective was to minimize the effects of lipodystrophy. Educative-development was selected as the nursing system, with the help of support and orientation to exercise and maintain a healthy diet.

The report about the death of a fellow aids patient, accompanied by sadness about the loss and ineffective behavior in the attempt to reinvest in love relations, led to the identification of the dysfunctional grieving diagnosis in 11 participants. The goal was to mitigate dysfunctional grieving and the objective to make individuals adjust themselves to coping with the death of loved ones and make them understand the importance of a stable love relation, reestablishing objectives, setting goals in their lives and demonstrating self-care ability. The educative-development system equips nursing actions through help, support and orientation. At this moment, therapeutic communication and active listening were very important to reach the proposed goal and objectives.

The ineffective coping diagnosis was present in the whole group, in line with the following indicators: altered appearance due to antiretrovirals; interruption of emotional bonds after death and hospitalization, chronic nature of the disease and treatment complexity. The goal was to decrease the SC deficit related to aids, and the objective was to achieve the individual's participation in the desired health behavior, decrease anxiety when losses occur and expression of self-care practices in aids control. Therefore, we selected the educative-development nursing system and the following help methods: orientations about drugs, disease, eye problems and self-exam of the eyes, thus stimulating self-care.

Health-deviation self-care

In the health-deviation self-care requisite, individuals must modify their self-concept and/or self-image and accept themselves when they are confronted with the condition of a particular health state⁽³⁾. In the study sample, some persons faced difficulties to assume a number of self-care requirements related with health problems, whether in terms of treatment and control, including treatment adherence, or in terms of the promotion of human functioning and development, which is related to the prevention and early detection of health problems.

Personal SC needs will vary according to the stage of the disease, as each patient's conditions are different at the time of diagnosis, treatment and after various treatment phases. These needs also differ due to the clinical syndrome patients experience, as well as their emotional reactions and personal approach methods in response to the infection phase.

When looking at people who live with HIV/aids, it is impossible not to think about the huge challenges they face every day: the amount of drugs they take, the wide range of collateral effects and interactions, their anxiety about the regularity of treatment and difficulties to get access to essential exams affect their quality of life and renew the challenge of living with aids each day.

When we analyze the distribution of health-deviation SC sub-requisites in terms of medication treatment, we find self-care demands related to medication intake, as six participants mentioned they did not take their medication regularly, mainly at weekends, due to alcohol consumption. One patient never took the drugs because of collateral effects and inadequate medication times, while two others did not take any medication prescribed by a physician.

The complexity of the therapeutic regimen and the collateral effects in three HIV/aids patients; incorrect medication intake or resistance to medication, forgetting to take medication, consuming alcohol in six patients, not attending medical appointments and not taking control tests gave rise to the nursing diagnosis of ineffective therapeutic regimen management.

In care planning, the goal was patients' adherence to the therapeutic regimen, and the objective was for patients to express their intention to practice health behaviors that were needed to adhere to the medication, as well as their acceptance of the therapeutic regimen; to take the prescribed medication sensibly and to express their intention to practice behaviors that were healthy or desirable for aids control; to show SC capacity, mainly in realizing regular medical follow-up and control tests (viral load and CD4 count).

Educative-development was chosen as the nursing system, with the help of support, teaching, orientation and adherence workshops. Orientations were aimed at clarifying patients' doubts about the drugs and their collateral effects, while encouragement actions were aimed at stimulating the group to participate in adherence workshops held at the RNP/CE.

The disturbed visual sensory perception diagnosis was identified when participants carried out a self-exam of their eyes under the supervision of the nurse researcher, and also during ophthalmologic appointments. The goal was to help patients to identify eye problems and minimize visual deficits; the objective was to enable participants to perform the eye self-exam, identify problems and use corrective means. The selected nursing system was educative-development, and help methods were orientation, support and teaching through informal dialogue and educational workshops.

The proposed Self-Care Theory is aimed at developing individuals' potential to identify and solve their health problems. Thus, the goal of nursing is to achieve self-care, considered to be a care performed by persons, for themselves, when they reach a stage of maturity that enables them to accomplish a premeditated, conscious, controlled and effective action. Thus, health can be seen predominantly as a consequence of individuals' own actions.

Four patients experienced the diagnosis of acute pain in the eye region. In this context, the goals was the minimize pain, and the objective was for the patient to indicate decreased pain. Educative-development was chosen as the nursing system and referral to an ophthalmologist as the help method. For this purpose, we looked closer into the patients' experience of eye pain, considering: intensity, frequency, situations that can interfere in the appearance or increased intensity, so that this intensity evidenced increased painful sensitivity, mainly at night, when patients were reading. Participants mentioned the use of eye drops. This tends to minimize pain and dryness, which is very unpleasant. However, eye drops should be used with care and only when prescribed by an ophthalmologist.

For the deficient knowledge diagnosis, we considered the following indicators: expressing lack of knowledge about eye problems due to aids and difficulties to perform the eye self-exam. The goal was to decrease the knowledge deficit and orient patient on how to correctly perform the eye self-exam; to achieve the objective, we suggested including the eye self-exam in self-care routine. Thus, educative-development was implemented as the nursing system, supported by orientations and teaching through educational workshops, with a view to stimulating participants to perceive the importance of eye care, to identify problems, look for solutions, establish learning plans, discuss their feelings and progressively participate in eye self-exam techniques.

It is the function of health professionals, especially nurses, to work towards the development of strategies that are able to mobilize HIV/aids patients to adopt and maintain a healthy SC behavior. Adherence to the eye self-exam requires tolerance, efficient communication and broader dissemination. It is a long-term task, as this is the only way to achieve satisfactory results, that is, a reduced knowledge deficit about eye alterations due to aids and greater clarifications about the risks of inadequate behavior.

The application of the Nursing Theory allowed us to identify self-care deficits, totaling nineteen nursing diagnoses. The educative-development system guided actions in the search for patients' autonomy to participate actively in their treatment, although some factors limited their adherence to self-care, such as: instability of the disease; low education level; resistance to behavioral changes, such as giving up drinking; and non incorporation of the eye self-exam into routine activities.

FINAL CONSIDERATIONS

In this study, self-care practice was perceived without ignoring respect for individual choices. Wanting self-care is something very particular. Even participants who were well informed about their health state continue adopting lifestyles that affect treatment efficiency and efficacy, which are considered relevant points as self-care deficits. Therapeutic demands are almost always associated with biological aspects, although we observed from participants' testimonies that lifestyle-related issues need to be systematically addressed in groups of people living with HIV.

On the whole, we identified 19 nursing diagnoses among the participants: ten in universal SC requisites, five in developmental SC requisites and four in health-deviation self-care requisites.

Applying the Self-Care Theory requires time to display results, it takes dedication and patience, which are essential components in the follow-up established in Orem's Theory, which is the educative-development system.

However, we emphasize the need to implement systemized nursing care for HIV/aids patients. It is important to use the theoretical framework of Orem's Self-Care Theory, allowing individuals to perceive their organic, psycho-affective, social, cultural and spiritual aspects, and making nurses identify and invest in the capability for self-care.

Recebido em: 11.1.2005

Aprovado em: 2.12.2005

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1

Paper Extracted from the Doctoral Dissertation

Publication Dates

• Publication in this collection
  10 July 2006
• Date of issue
  June 2006

History

• Accepted
  02 Dec 2005
• Received
  11 Jan 2005