Practices of nurses in monitoring Chronic Non-communicable Diseases in Primary Health Care

Draeger, Viviana Mariá; Andrade, Selma Regina de; Meirelles, Betina Hörner Schlindwein; Cechinel-Peiter, Caroline

doi:10.1590/2177-9465-EAN-2021-0353pt

person Viviana Mariá Draeger

schoolUniversidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem. Florianópolis, SC, Brasil.

0000-0001-5668-6468

person Selma Regina de Andrade

schoolUniversidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem. Florianópolis, SC, Brasil.

0000-0001-7449-6860

person Betina Hörner Schlindwein Meirelles

schoolUniversidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem. Florianópolis, SC, Brasil.

0000-0003-1940-1608

person Caroline Cechinel-Peiter

schoolUniversidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem. Florianópolis, SC, Brasil.

0000-0003-0032-6791

Corresponding author: Viviana Mariá Draeger. E-mail:
vividraeger@hotmail.com

groupsAUTHOR’S CONTRIBUTIONS

Study design. Viviana Mariá Draeger. Selma Regina de Andrade.

Data collection or production. Viviana Mariá Draeger. Selma Regina de Andrade.

Data analysis. Viviana Mariá Draeger. Selma Regina de Andrade. Betina Hörner Schlindwein Meirelles. Caroline Cechinel-Peiter

Interpretation of results. Viviana Mariá Draeger. Selma Regina de Andrade. Betina Hörner Schlindwein Meirelles. Caroline Cechinel-Peiter

Writing and critical revision of the manuscript. Viviana Mariá Draeger. Selma Regina de Andrade. Betina Hörner Schlindwein Meirelles. Caroline Cechinel-Peiter

Approval of the final version of the article. Viviana Mariá Draeger. Selma Regina de Andrade. Betina Hörner Schlindwein Meirelles. Caroline Cechinel-Peiter

Responsibility for all aspects of the content and integrity of the published article. Viviana Mariá Draeger. Selma Regina de Andrade. Betina Hörner Schlindwein Meirelles. Caroline Cechinel-Peiter

ASSOCIATED EDITOR

person

0000-0002-3278-5645

SCIENTIFIC EDITOR

person

0000-0002-1522-9516

Code/ Reference	Title	Year of publication	Responsible Body
Doc1 ⁷	Control of cervical and breast cancer	2013	Ministry of Health
Doc2 ⁸	Screening	2013	Ministry of Health
Doc3 ⁹	Chronic Respiratory Diseases	2010	Ministry of Health
Doc4 ¹⁰	Spontaneous Demand Management: most common complaints in Primary Care	2012	Ministry of Health
Doc5 ¹¹	Strategies for the care of the person with Chronic Disease	2014	Ministry of Health
Doc6 ¹²	Strategies for the care of the person with Chronic Illness - Diabetes Mellitus	2013	Ministry of Health
Doc7 ¹³	Strategies for the care of the person with Chronic Disease - Systemic Arterial Hypertension	2014	Ministry of Health
Doc8 ¹⁴	Strategies for the care of the person with Chronic Illness - Obesity	2014	Ministry of Health
Doc9 ¹⁵	Strategies for the care of the person with Chronic Illness - Care of the smoker	2015	Ministry of Health
Doc10 ¹⁶	Guidelines for the care of people with chronic diseases in the health care networks and in the priority lines of care	2013	Ministry of Health
Doc11 ¹⁷	Brazilian guidelines for tracking cervical cancer	2011	Ministry of Health/INCA
Doc12 ¹⁸	Reorganization plan for hypertension and diabetes mellitus care	2001	Ministry of Health
Doc13 ¹⁹	Integration between primary care and health surveillance	2018	Ministry of Health
Doc14 ²⁰	Manual of the diabetic foot: strategies for the care of people with chronic disease	2016	Ministry of Health
Doc15 ²¹	Perspectives and challenges in the care of people with obesity in UHS: results of the Laboratory of Innovation in the Management of Obesity in Health Care Networks	2014	Ministry of Health/Pan-American Health Organization
Doc16 ²²	Primary Care Protocols: Women's Health	2016	Ministry of Health
Doc17 ²³	Women's Health: meeting women's demands in different life cycles	2016	COREN/SC
Doc18 ²⁴	Hypertension, diabetes and other factors associated to cardiovascular diseases	2017	COREN/SC

Monitoring Practice	Evidence in the interviews	Documentary Evidence
“HiperDia” Group	E1; E2; E3; E4; E5; E8; E10; E11; E12 With this strategy [HiperDia], we realize that we no longer have decompensated patients. The change we have been observing is impressive. (E5)	Doc2;⁸ Doc5;¹¹ Doc6;¹² Doc10;¹⁶ Doc17²³
Health Education	E5; E11 All patients come every two months to the unit to pick up their medication, they have a day that is their day, with a consultation with a nurse, a doctor, and they all participate in an educational activity focused on the pathology of the chronic disease. (E5)	Doc2;⁸ Doc3;⁹ Doc4;¹⁰ Doc7;¹³ Doc8 ; Doc11;¹⁷ Doc12¹⁸
Telemonitoring	E9 We help them to seek quality and lifestyle changes to try to ward off the comorbidities, but without this follow-up, they can't do it. (E9)	Doc2⁸
Reception	E3; E4; E5; E6; E7; E8; E9; E10; E11 At the reception, we verify if the person is being followed up or not, if he or she is having his or her blood pressure measured or not, measuring his or her blood sugar or not. (E3)	Doc2;⁸ Doc3;⁹ Doc4;¹⁰ Doc 6;¹² Doc10;¹⁶ Doc12;¹⁸ Doc14;²⁰ Doc15;²¹ Doc18²⁴
Home visits	E2; E3; E5; E7; E8; E9; E10; E11 The health agent who identifies and monitors the patients at home and communicates with us to make the visit and, thus, check how the patient is doing. (E10)	Doc1;⁷ Doc3;⁹ Doc6;¹² Doc9;¹⁵ Doc14;²⁰ Doc16;²² Doc18²⁴
Nursing consultation	E2; E3; E4; E5; E7; E8; E9; E10; E11; E12 In the consultations, we guide lifestyle issues, necessary changes, and then we see the result. (E10)	Doc1;⁷ Doc4;¹⁰ Doc12;¹⁸ Doc14;²⁰ Doc15;²¹ Doc18²⁴
Care plan	E5; E6; E10 We determine what we are going to do with him [the patient], whether we are going to schedule a medical evaluation or previous monitoring of hypertension or diabetes for a certain period and then evaluate [...] and, thus, we make an action plan. (E6)	Doc1;⁷ Doc2⁸; Doc4;¹⁰ Doc8;¹⁴ Doc9;¹⁵ Doc10;¹⁶ Doc11;¹⁷ Doc12;¹⁸ Doc13¹⁹
Self-monitoring	E5; E10 As we follow up on this patient, we are able to do this rescue early on, before, necessarily, a stroke occurs, an amputation of a diabetic [patient]. (E10)	Doc4;¹⁰ Doc7;¹³ Doc8;¹⁴ Doc14;²⁰ Doc17²³
Protocols	E1; E2; E3; E4; E5; E6; E7; E9; E10; E11; E12 This is exactly what the protocol will bring, which is this greater autonomy for us to be more resolute in some situations. (E5)	Doc1;⁷ Doc14;²⁰ Doc15²¹

[1] Source: Survey data.

Practices of nurses in monitoring Chronic Non-communicable Diseases in Primary Health Care^a

Abstract

Practices of nurses in monitoring Chronic Non-communicable Diseases in Primary Health Carea

Abstract

Practices of nurses in monitoring Chronic Non-communicable Diseases in Primary Health Care^a