Aspects of the nursing appointments with hypertensive patients cared for in the Family Health Program

Abstracts

The objective was to observe the aspects of nursing appointments undergone by hypertensive patients. This is a descriptive study, developed in three healthcare centers in the city of Fortaleza. The subjects were 13 nurses, and data collection comprised the observation of three of each nurse's appointments, followed by an interview with this professional. It was observed that, during the anamnesis, the previous treatment, the ingestion of hypertensive substances and the existence of associated risk factors were identified. Inspections of the patient's appearance, blood pressure and weight were also evident. The identified categories were: aspects of the nurse's role in basic healthtcare; treatment of hypertension and day-to-day difficulties of people with this disease. We conclude that many aspects are not being approached during the nursing appointments, which can result in a low-quality healthcare service provided for people cared for the hypertension program in these basic healthcare centers.

Hypertension; Nursing care; Family Health Program

Objetivou-se, neste estudo, averiguar os aspectos contemplados na consulta de enfermagem ao portador de hipertensão arterial (HA). É um estudo descritivo, desenvolvido em três unidades de saúde de Fortaleza. Os sujeitos foram 13 enfermeiros. A coleta de dados ocorreu por observação de três consultas de cada enfermeiro e, posteriormente, de uma entrevista com este profissional. Foi observado que, durante a anamnese, houve identificação do tratamento prévio, da ingestão de substâncias hipertensoras e da existência de fatores de risco associados. No exame físico, constatou-se a ocorrência de inspeções da aparência do paciente e verificações da pressão arterial e peso. As categorias identificadas foram: nuances do papel do enfermeiro na atenção básica; tratamento da HA e dificuldades cotidianas das pessoas com esta enfermidade. Concluímos que muitos aspectos não vêm sendo abordados durante a consulta de enfermagem, o que pode acarretar um atendimento deficiente das pessoas acompanhadas pelo programa de HA em tais unidades de saúde.

Hipertensão; Cuidados de enfermagem; Programa Saúde da Família

ORIGINAL ARTICLE

Aspects of the nursing consultation with hypertensive patients cared for in the family health program^*

Aspectos considerados en la consulta de enfermería al paciente con hipertensión atendido en el Programa Salud de la Familia

Gilvan Ferreira Felipe^I; Rita Neuma Dantas Cavalcante de Abreu^II; Thereza Maria Magalhães Moreira^III

^INurse. Member of Anjos do Resgate ("Rescue Angels" – Emergency Medical Care). Former FUNCAP fellowship holder. Fortaleza, CE, Brazil. [e-mail]

^IINurse, Specialist in Clinical Nursing. Master in Clinical Healthcare at State University of Ceará (UECE). Former FUNCAP sponsored student. Member of Grupo de Pesquisa Políticas, Saberes e Práticas em Saúde Coletiva (Research Group on Collective Health Policies, Knowledge and Practice). Professor at Faculdade Integrada da Grande Fortaleza (FGF). Fortaleza, CE, Brazil. [e-mail]

^IIINurse, PhD. Coordinator of Specialization courses in Clinical Nursing. Professor at the Undergraduate and Master Nursing courses on Clinical Healthcare courses of State University of Ceará. Leader of Grupo de Pesquisa Políticas, Saberes e Práticas em Saúde Coletiva (Research Group on Collective Health Policies, Knowledge and Practice). Fortaleza, CE, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The objective was to observe the aspects of nursing consultation undergone by hypertensive patients. This is a descriptive study, developed in three healthcare centers in the city of Fortaleza. The subjects were 13 nurses, and data collection comprised the observation of three of each nurse's consultation , followed by an interview with this professional. It was observed that, during the anamnesis, the previous treatment, the ingestion of hypertensive substances and the existence of associated risk factors were identified. Inspections of the patient's appearance, blood pressure and weight were also evident. The identified categories were: aspects of the nurse's role in basic healthcare; treatment of hypertension and day-to-day difficulties of people with this disease. We conclude that many aspects are not being approached during the nursing consultation , which can result in a low-quality healthcare service provided for people cared for the hypertension program in these basic healthcare centers.

Key Words: Hypertension. Nursing care. Family Health Program.

RESUMEN

El estudio tuvo por objetivo, investigar aspectos considerados en la consulta de enfermería para el portador de hipertensión arterial (HA). Estudio descriptivo realizado en tres unidades de salud de Fortaleza. Los sujetos fueron 13 enfermeros. La recolección de datos fue por observación durante tres consultas y posteriormente una entrevista con el profesional. Durante la anamnesis se identificó el tratamiento previo, la ingestión de sustancias hipertensivas y la existencia de factores de riesgo asociados. Durante el examen físico se inspeccionó la apariencia del paciente y se verificó presión arterial y peso. Categorías identificadas: variaciones en el rol del enfermero para la atención básica, tratamiento de HA y dificultades frecuentes de las personas con relación a la enfermedad. Concluimos que muchos aspectos no fueron abordados en la consulta de enfermería, lo cual podría llevar a una atención deficiente del paciente en el programa HA en estas unidades de salud.

Descriptores: Hipertensión. Atención de enfermería. Programa de Salud Familiar.

INTRODUCTION

As the population grows older, its epidemiological profile is altered, emphasizing the non-transmittable chronic diseases (NTCD), which cause around 2 million deaths every year all over the world⁽¹⁾.

Within this group of diseases, high blood pressure is worth of note due to its high prevalence in Brazil, and for being one of the main risk factors for cardiovascular diseases⁽²⁾.

Population-based inquiries revealed that hypertension (HT) had a prevalence of 22.3 to 43.9% in certain places in Brazil, from 1990 to 2004⁽²⁾. Of all the registered cases of the disease, about 60 to 80% can be treated in the basic healthcare network, which proves the importance and need of developing the multiprofessional team working in this service⁽¹⁾.

The nurse, as a member of the Family Health Program (FHP) team, has an important role in monitoring the hypertensive patient. Besides acting as a healthcare educator for hypertensive patient groups, their families and the community, this professional is responsible for developing the nursing consultation, with is an exclusive activity of the nurse⁽¹⁾.

In the consultation with the hypertensive patient, the nurse must measure the blood pressure (BP); register height, weight, waist and hip circumference and calculate the body mass index; investigate risk factors and habits; educate the patient about the disease, regular use of the prescribed medication and personal and family habits⁽²⁾.

The nurses must systematize their actions in order to care for this clientele, with the execution of the history, diagnostic, planning, implementation and evolution, so that their work and knowledge may lead to continuously re-thinking the professional practice. Therefore, it is necessary to develop specific skills in basic healthcare nurses to perform a satisfactory nursing consultation with the hypertensive person.

Considering that there is a high percentage of such clientele in the Brazilian population, and also the importance of the role of the basic healthcare unit nurses in hypertension treatment, by attempting to control the disease and prevent complications, this study was designed with the goal of measuring the aspects observed in the nursing consultation with the hypertensive patient, cared for in the Family Healthcare Program (FHP) in Fortaleza, Ceará.

This theme was focused during our participation in Grupo de Pesquisas Políticas, Saberes e Práticas em Saúde Coletiva (Research Group on Collective Health Policies, Knowledge and Practice), constituting the authors' object of study^(3-6).

METHOD

This is a qualitative, descriptive study, developed in three basic healthcare units in Fortaleza-Ceará. Two of these have four family healthcare teams, and the other has five teams. Each team is formed by one nurse, one physician, one nursing technician or auxiliary and four community healthcare agents. The units also have dentistry services available.

The physical structure of the units is divergent. One of the units was recently renovated with the annexation of a poli-clinic, while the others have a structure that is still reminiscent from old healthcare stations. Therefore, they are not capable of accommodate the professionals who work there adequately.

The demand of said units comprises people who live in the area around the unit, according to the subdivision in micro-areas by the teams. The healthcare program for hypertensive patients works with the team's nurse and physician monitoring these patients, in regular consultation.

The study participants were all the nurses working in these units⁽¹³⁾. These thirteen professionals perform nursing consultation with hypertensive patients, and accepted to participate in the study. They were all approved in public exams by the Fortaleza city hall and submitted to an immersion course at the Single Health System – Sistema Único de Saúde, SUS – which aimed to prepare them better for their upcoming FHP activities.

Data collection occurred by observing three consultations of each nurse, and by filling out a checklist containing aspects related to the history (anamnesis + physical exam), diagnostic, planning, implementation and evolution of the nursing actions⁽⁷⁾. Later, the nurse who performed the consultation was interviewed, with the following question: which aspects should be observed in the nursing consultationwith the HT patient? Data collection happened from January to March, 2007.

The joint use of the checklist with the interview allowed for the contrasting of the service's reality with that presented by the professionals in their speeches, when asked about the aspects that must be observed in their working routine.

The findings registered in the checklist were organized in a chart and discussed according to the literature. The organization of data from the interviews was based in the Content Analysis⁽⁸⁾.

The ethical principles were followed in every phase of the study, in harmony with Resolution 196/96⁽⁶⁾. The study was approved by the Review Board of Universidade Estadual do Ceará, file no. 05050457-6.

RESULTS AND DISCUSSION

Three consultations were observed with each nurse, totaling 39. The obtained data are as follows.

Chart 1 - Click to enlarge

During anamnesis, previous treatment was identified in 39 consultations ; in 24, the ingestion of hypertensive substances and in 21, the existence of associated risk factors.

Analysis of Chart 1 allows us to notice that several aspects considered essential for the anamnesis were only partially executed, such as the description of socio-demographic characteristics. In several consultations, the nurses also failed to ask about the length of the hypertensive condition, the patient's family history and symptoms suggesting damage in a target organ or secondary hypertension.

As for the physical exam, 39 observations of the patient's appearance and 39 blood pressure measurements, as well as 18 verifications of body weight. Heart and lung auscultation was not performed, the same happening with the palpation of the carotid arteries and peripheral pulses. The search for edemas was not performed, either. It is interesting to note that physical exam techniques such as palpation and auscultation are being neglected by the nurses.

Eight results of laboratory exams (urine, seric creatinine dosage, seric potassium glycemy on fast; uric acid and cholesterol) were observed during the consultations. However, an important piece of data was that, in four of the nurses' appointments, these exams were requested without the verification of the results of the previous exams, which could easily be accessed online in the computer available in the nurse's room in these units.

Nursing diagnostics were not established at any time, either based on diagnostic taxonomies or not. This result converges with the findings of a study performed with hypertension programs in Fortaleza – CE⁽¹⁰⁾.

Some type of nursing care was implemented in 34 consultations, whether medication transcription or healthcare education. Most of the observed implementations (32) consisted of individual orientations to the patients. The Ministry of Health emphasizes the participation of the nurse in individual or group educational activities with these diseases, according to the Plan of Healthcare Reorganization for Hypertension and Diabetes Mellitus⁽¹⁾.

Data collected in the recorded interviews and submitted to content analysis allowed for the organization of two thematic categories: 1) aspects of the nurse's role in basic healthcare and 2) treatment of hypertension and day-to-day difficulties of people with this disease. Each of these is further explored in the following pages.

Aspects of the nurse's role in basic healthcare

In the speeches of two nurses, the development of the nursing consultation was identified as dependent on the patient's complaints, reflecting strong influence of the biomedical healthcare model, curative and individual.

When the patient arrives at the office for his consultation, the first thing we do is to check how he feels [ ], if there are any complaints [ ] symptom [ ] We start by asking what he is feeling. According to the symptoms, we start to give orientation (E8).

Investigating the reason why he came for an consultation (E12).

We know that, for the nurses to develop their healthcare work with quality, it is necessary to apply a methodology based in the systematization of the nursing assistance. The evaluation of care happens throughout the process, from history, diagnostic, planning and implementation, reflecting the quality of care. It is necessary to register the actions developed during the appointment. The importance of these registries happens as the whole team has access to the information about the state of the patient⁽⁷⁾. The nurses emphasized the importance of the nursing process, although some mention the need of capacitation to execute it:

The aspect that needs to be addressed in the nursing appointment is the actual performance of the nursing appointment, the nursing process, and we end up presenting this difficulty of intervention, of knowledge [ ] (E3).

[ ] when you get to basic healthcare, it's different [ ] Sometimes, in hospital healthcare, the nursing process is already implemented. In basic healthcare this still doesn't exist. The issue of nursing diagnostic really has to be implanted and implemented, but the capacitation of the nurses was necessary for that, because, after graduation, we really have only a faint notion of that. But I think that the implementation of the nursing diagnostic was really important, since this process is ours, which, sometimes, we overlook, sometimes even due to lack of capacitation, of reading, of studying some more about that (E9).

[ ] if one is already a patient with a prescription, the previous nursing interventions are checked, whether he followed these orientations, if they had the expected results [ ] You plan your results, and you will check whether they were achieved or not in the next appointment [ ] According to what he presents in the day, you can perform new diagnostics, observe something that he did not have before, which was not noticed by the professional and intervene, too (E11).

The need for systematizing the nursing appointment aims at giving a professional character to the activity, organizing the approach towards the patient and defining the nurse's competence, among other aspects⁽¹⁰⁾. One of the nurses reported that she attempts to know the patient's history in her first contact. Such fact is in accordance with the recommendations of other authors⁽⁷⁾.

In the first appointment with the hypertensive, we attempt to know their history. I start with the family, asking whether there are hypertension - or diabetes-related cases in their families. Next, I try to find their risk factors(E12).

The physical exam is also performed during the nursing appointment. During their academic education, the nurses have the opportunity of studying anatomy, physiology, pathology, besides techniques of inspection, percussion, palpation and auscultation, all of them essential to execute the physical exam. However, the testimonies of some nurses revealed difficulties in this execution, especially regarding auscultation. Also, many times the physical exam is limited to the verification of weight, blood pressure and the podalic examination.

The physical exam is difficult to do here, but I think it should be better approached in nursing, but we do not have a private space [ ] people come in I focus more on the physical exam when the patient is diabetic, by examining his feet. In hypertensive patients, we really fail to do the physical exam. But it should really be observed in the nursing appointment (E5).

There is the issue of the working environment, because the room is not very appropriate for that. And also in the physical exam, when the patient comes, depending on her complaints we can refer her [ ] But sometimes we also have difficulties for the physical exam, auscultations, these things [ ] Then, of course we refer them to the physician, since this is the medical part (E6).

We check the blood pressure, if it's all right, we know that he can control their pressure. If the blood pressure is altered, he's doing something wrong (E8).

The issue of evaluation, the nursing physical exam, the waist-to-hip ratio [ ] we overlook some measurements, such as the Body Mass Index (BMI), which the program calculates automatically, but we don't really look at that [ ] (E9).

When I'm developing the appointment, I try to perform the physical exam [ ] I check weight, blood pressure, investigate edemas, heart rate and other factors that could reveal some physical discomfort that they may present (E12).

The physical exam is part of the early stage of the nursing appointment (history). It is normally performed after the anamnesis. In it, objective data (signs) are detected, and information collected during anamnesis is confirmed⁽¹¹⁾. Therefore, the perception of the importance of the physical exam as a procedure to be executed as part of the day-to-day activities of the nurses becomes relevant, as a way to provide information about the functional capacities of the patient, which must be used in the elaboration of the nursing diagnostics, the determination of the interventions and the evolution of the patient's health status, as well as the evaluation of the effectiveness of the care provided by the nurse. This will allow for the individualization of the nursing healthcare⁽¹²⁾.

Exam requests were mentioned by only two nurses:

Investigate the last time he had exams [ ] If that's longer than six months, it's possible to request new routine exams – cholesterol, glycemya, urea, triglycerides, among others (E8).

[ ] and attempting to have laboratory exams at least once a year (E12).

We understand that the offer of complementary exams to identify metabolic alterations and injuries in target-organs is fundamental for monitoring hypertension patients, which is in consonance with the edicts of the Ministry of Health⁽¹⁾.

A minimal evaluation of the hypertension patient must have the following exams: urine summary, seric creatinine dosage, seric potassium, seric glycemy, total cholesterol and electrocardiogram at rest. During the nursing appointment in the Family Healthcare Program, the nurse can request the minimal exams, established in guidelines for treatment of this clientele⁽¹⁾.

Treatment of hypertension and day-to-day difficulties of people with this disease

Literature is unanimous when mentioning that the success of hypertension treatment and its complications is impossible without lifestyle changes (the so-called non-medication treatment)^(2,13), with the healthcare education being a fundamental part of it. In this perspective, the speeches of the nurses are as follows:

It's necessary to convey trust for the patient, let the person be free, without impositions[...] But you show them – see, if you change, if you take walks, if you stop smoking and drinking [...] Then, he becomes aware of it automatically [...] (E4).

One of the main points to be observed in the nursing appointment is the healthcare education [...] You have to make the patient understand that the change in habits will interfere positively with the treatment [...] (E5).

When the patient has doubts about medication or diet, we orient him about what to eat or do [...] If he's well-oriented, doing the three things (dieting, physical exercise and correct use of medication) we encourage and praise them (E8).

What would be important for the nursing team to do, and that sometimes they don't do is the healthcare orientation [...] about dieting, the care for the patient and the family (E9).

Well, the main aspect is orientation, which involves everything: dieting, medication, follow-up consultation[...] because, without it, the patient will not know how to proceed in face of their disease [...] They must be oriented about complying with the treatment, about the disease [...] Because there patients who don't know what hypertension is, its causes and consequences [...] Therefore, orientation is the basis for everything (E10).

Preventing and treating hypertension involves continuing education in order to introduce permanent changes in the lifestyle habits of those stricken by this disease. The nurse, as an integrating part of the multidisciplinary team, has a leading role in the educative process of people with hypertension. With educational strategies, the nurse seeks the adaptation of the hypertensive patient to the disease, the prevention of complications and compliance with the treatment, which means that the patient must be made into a self-care agent and a multiplier of his actions with his family and the community⁽¹¹⁾.

The orientations presented by the interviewees include healthy dietary habits, abandonment of smoking, weight reduction and fighting sedentary behavior:

It's important to change the lifestyle [...] The person has to be aware that her lifestyle changes will provide a better quality of life, so that they can live well and happily (E4).

The patient has to change his diet, avoid smoking [...] it's difficult to make them understand that reducing weight is important to treat hypertension. We're chanting the same thing in every appointment: You have to change your lifestyle, take your medication, do some physical activity, because the medication alone will not make effect (E5).

Physical exercise, dieting [...] Even though they say they do it, they must be oriented, because they often don't do it right or they even lie about it [...] (E6).

Orienting about dieting, physical exercise [...] These are the things that will help the hypertensive or diabetic person to improve their quality of life (E7).

About dieting, whether they are consuming low amounts of salt and fat. Many do not do dieting or exercise. They also have to use the anti-hypertensive medication [...] We orient them about these three things so that they can keep the blood pressure under control (E8).

Some authors⁽¹⁴⁾ emphasize the role of the nurse in the non-medication treatment of hypertension, especially regarding dieting that is adequate to the hypertensive individual, simplifying information and improving the exchange of knowledge.

If blood pressure levels cannot be controlled only with the non-medication measures, the pharmacologic treatment will be started. The speeches of the interviewees revealed the actions of the nurses in the pharmacologic treatment:

The orientation about medication must be observed in the nursing appointment. Usually, when they have a medical appointment, they receive a prescription, but they have doubts about the medication [...] In the nursing appointment, we reinforce the orientations about posology, time and dose of medication. It's not unusual for them to report not taking medication at the right time, they have doubts about the intake and interactions with other medications or alcohol [...] (E5).

We check the medication intake and orient about compliance with the pharmacologic prescription, but if the patient only uses the anti-hypertensive medication, the pressure is rarely reduced (E8).

Goals must really be established with the patient, and that is something that we don't always do (E9).

I check their medications, if he'd been complying with the prescription [...] (E11).

[...] we talk about the importance of the medication treatment, of using the medication regularly [...] (E12).

[...] because they often do not take the medication correctly. We prescribe it one way and they take it the way they think it's better, most times in doses that are lower than those prescribed. Therefore, they must be oriented, especially in relation to medication intake (E13).

Based on the stratification of individual risk, the pressure levels and the risk factors, the physician can decide for the beginning of the pharmacological treatment⁽¹⁾. The nurse's work is fundamental in the orientations about side effects, intake regularity, medication preservation, inquiries about complaints and clarifying doubts about the orientation provided⁽¹¹⁾, and also, being able to repeat the medication of controlled individuals without intercurrences⁽¹⁾.

In face of the importance of the nurse in this hypertensive treatment modality as well, it is essential for the nurse to encourage the patient to ask questions about the many aspects of the therapy and reinforce the necessity of regularly taking the hypertensive medication.

It is estimated that 40% of the strokes and 25% of the infarctions occurred in patients with hypertension could be prevented with the adequate anti-hypertensive therapy⁽¹⁵⁾. However, compliance with the hypertensive treatment is one of the main challenges for the nursing professionals. The nurses noted that treatment compliance was a difficult process:

As all diseases involving changes in habits, compliance with treatment is very difficult [...] making them change their habits, avoid eating fried foods, salt, fat, it's difficult (E5).

I believe that compliance with treatment is what matters (E7).

How important is to follow the treatment and his responsibility in this treatment. Whether he feels that this responsibility is either mine, his, or the service's (E12).

Convincing a patient, who is often asymptomatic, that he is sick, especially when this implies in lifestyle changes or the obligation of using medications for the rest of their lives is a difficult goal to accomplish. In this sense, it is important to establish a good rapport with the healthcare team for a customized orientation⁽¹⁶⁾, considering the socioeconomic level, the beliefs and the culture of the patients.

It is worth noting the issue of the user's co-participation. The single fact that healthcare is closer to home does not guarantee compliance with the therapy. One needs to make an individual decision of changing their lifestyle and take the medications correctly so that he can control the disease and prevent comorbidities. The healthcare professionals must seek strategies to improve the compliance of hypertensive patients with the treatment. In this sense, the professionals working in the Family Health Program can help them control the disease in the family context⁽¹⁷⁾.

The presence of the family is considered indispensable to monitor the hypertensive patient, encouraging them to comply with the treatment. Changes in the patient's lifestyle need intense family participation, since they require changes in factors that will have repercussions in the whole family system - for example, reducing the amount of salt and fat in food, practicing physical exercise, among other aspects⁽¹⁸⁾. The nurses emphasized the importance of family involvement:

We must talk with them about the issue of the family environment, if there are complaints or not [...] As for the help of family members, the elderly need the family for medication intake, because they often make mistakes (E6).

It would be interesting to see the whole family during the home visit, not only the hypertensive patient [...] (E9).

[...] not only seeing hypertension in that person, but also, other aspects and factors that may contribute for this altered pressure in the individual, such as family issues, among others [...] (E13).

It is necessary that the healthcare professionals see patients with hypertension holistically, as a whole; human beings who are part of a family and a social context, who have their priorities and projects for life, and who see themselves afflicted by a chronic disease. It is important to know what the disease means to them, and to find alternatives that favor the adaptation of these beings to their new reality.

[...] everything has to be considered, because it's in the context of the hypertensive patient (E1).

The most interesting and serious aspect is to check whether they have an understanding about their problem and therapy [...] if they do, they are patients with better treatment compliance, who will take the orientations more seriously, assume their responsibility to do the treatment [...] also, the emotional and spiritual issues (E2).

[...] he sees the things happening – pressure getting lower, they feel better physically, or even mentally (E4).

Several things: stress, some problem that the patient is undergoing in their life that interferes with hypertension control (E13).

We can see that the nurse has a fundamental role in the treatment of people with hypertension, especially the orientations about the many aspects of the disease. However, in the nursing consultations observed in this study, the phases of the nursing process were not all executed.

FINAL CONSIDERATIONS

When we monitored the nursing consultations, we observed that several patients did not know the disease or its treatment, which leads us to reinforce the importance of healthcare education performed by the nurse in order to reduce the difficulty for the patients and their family members to adapt and cope with the disease.

We also see that some aspects have not been approached during the nursing appointment, which can jeopardize the healthcare for the patients monitored by the hypertension programs in these Basic Healthcare Units. An investigation on whether these actions happen in other moments of the monitoring (such as exercise groups or for seniors) is valid, possibly being the object of study for new research.

The necessity of providing permanent healthcare education in the cardiovascular field and other areas for nurses working in the FHP is noted, due to the many actions they are responsible for in this program and the generalist education received in the universities.

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Correspondência:

Gilvan Ferreira Felipe

Rua dos Maias, 210 - Casa 2 - Parque Manibura

CEP 60821-640 - Fortaleza, CE, Brasil

*

Extraído da monografia "Aspectos contemplados na consulta de enfermagem ao portador de hipertensão atendido no Programa Saúde da Família em Fortaleza – Ceará", Centro de Ciências da Saúde, Universidade Estadual do Ceará.

Publication Dates

• Publication in this collection
  15 Dec 2008
• Date of issue
  Dec 2008

History

• Accepted
  21 Feb 2008
• Received
  23 Aug 2007