NURSING CONSULTATION APPLIED TO HYPERTENSIVE CLIENTS: APPLICATION OF OREM’S SELF-CARE THEORY

El objetivo fue implantar la Consulta de Enfermería para individuos hipertensos utilizando la teoría del auto cuidado de Orem y sistematizar la atención de enfermería. Fueron entrevistados 56 pacientes, de los cuales 58,9% eran mujeres, 75,0% en el intervalo de edad de 50 a 80 años, 76,4% casados, 42,9% dueñas de casa, 47,2% jubilados y 67,3% con enseñanza fundamental completa. Para realizar el estudio se utilizó un instrumento estructurado abordando los requisitos del auto cuidado universal, de desarrollo y de desvíos de salud. El análisis de los datos permitió la evaluación de los requisitos de auto cuidado alterados. En la fase de planificación de la atención de enfermería, la prioridad fueron las acciones de apoyo educacional. La teoría del auto cuidado posibilitó detectar aspectos importantes para ser analizados por el enfermero.


INTRODUCTION
Working together with clients suffering from a chronic disease like arterial hypertension has been a gratifying experience, especially concerning the challenge this entails for health professionals.The proposal to develop this research with these clients was due to the need to deliver adequate nursing care, based on the application of the nursing process.Up to now, this care occurred in a disorderly way, with a purely medical focus and incipient nursing participation.Another contributing aspect was related to the demand for nursing services to establish the Nursing Process, posed by the São Paulo State Regional Nursing Council[Conselho Regional de Enfermagem (COREn)].
Various studies have looked at a wide range of themes using Orem's Self-care Theory.These showed how this theory is applicable and how it can contribute to the development of nursing work.Some of these are: A case study that identified nursing diagnoses in high-risk pregnant women based on the self-care theory, highlighting the importance of accomplishing the nursing process and the possibility of stimulating self-care in these customers (1) ; A case report regarding self-care in planning hospital discharge after bone marrow transplantation (2) ; A qualitative study that used the self-care deficit theory in hypertensive women, stressing its contribution in the detection of aspects nurses can explore and which can contribute to arterial hypertension treatment (3) ; A study based on both Horta and Orem's principles to organize nursing consultations with alcoholic patients in the sobriety stage.The main goal of the study was to meet the patients' self-care-centered basic needs (4) ; A proposal to systematize nursing care to HIV/AIDS patients based on the self-care deficit theory (5) ; The promotion of self-care through the Eastern health perspective for patients with migraine (6) .
The present study can be justified by its objective to establish the Nursing Process, using the Nursing Consultation as a care modality to meet the needs of hypertensive clients, based on Orem's Self-Care Theory.

THEORETICAL BACKGROUND
In the general population, adults with a systolic blood pressure lower than 120 mm Hg and a diastolic blood pressure lower than 80 mm Hg have a lower risk of arterial hypertension (7)(8) .
Several studies have demonstrated that, although 90% of hypertensive individuals has essential or primary hypertension of unknown origin, several factors, called risk factors, can interfere in the triggering and aggravation of the disease, such as age, gender, previous family history, race, obesity, stress, sedentary life, alcohol use, tobacco use, contraceptive use, and high-sodium and high-fat diet (7)(8) .
Nursing consultation is a care modality that permits following-up lifestyle changes, so vital nowadays to control the disease, as well as strengthening self-care guidance (counseling) by using the Nursing Process.task with a view to direct client care delivery (9) .
Through Nursing Consultations, nurses work to improve patients' quality of life, preparing them for self-care (5)   .
In the present study, Orem's Self-Care Theory was applied to elaborate a Nursing Consultation protocol and establish the Nursing Process.
Orem developed her theory divided into the Self-care theory, the Self-care Deficit Theory, and the theory of Nursing Systems.
The Self-care theory refers to self-care, therapeutic requirements and requirements for selfcare.Self-care is defined as the practice of activities performed by an individual to his/her own benefit, seeking to maintain life, health and well-being.When an individual has skills to develop actions that meet his/her needs, he/she is apt for self-care.This aptitude is acquired through learning and influenced by age, life experiences, culture, beliefs and education, among other factors (10) .
Therapeutic requirements are classified into universal requirements -that seek to sustain human life, structure and functioning; development requirements -offer the necessary conditions to promote changes along life cycles, permitting  (10) .
The actions needed to maintain life and promote health and well-being are called therapeutic self-care requirements.However, when the requirement is greater than the individual's capacity, self-care deficit emerges.This is the kind of situation nursing professionals are inserted in to act according to different systems: a fully-compensatory systemthe ability for self-care is limited or absent.In this case, nurses should take decisions and develop actions to meet self-care requirements; partly-compensatory system -the actions are carried out by both the nurse and the individual who needs them; there is a rotation in the performance of self-care (10) .
The nursing process proposed by Orem is a method that seeks to determine the self-care deficits, as well as the role played by the nurse (or individual) in order to provide for the requirements necessary to meet self-care (10) .
The objectives of the present study were to establish the nursing consultation for hypertensive clients using Orem's Self-Care Theory to guide the Nursing Process; to detect self-care deficits; and to stimulate self-care in these clients.

Personal Data
The study population included 56 individuals.
The universal, development, and health deviation requirements were organized based on nursing diagnoses, which were worked out in detail based on the collected data, according to the classification proposed by Carpenito (11) .

Universal requirements
Universal requirements aim for maintenance of life and promotion of human functioning (10)   ..
These requisites group family history, socioeconomic status, previous and current diseases, surgeries and drug utilization.

Health deviations
Health deviations are defined as self-care needs, which manifest themselves in the presence of diseases, disabilities, and treatments necessary for individual recovery (10) .Data were organized concerning current complaints and disease perception.
Table 3 shows the nursing diagnoses related to health deviations.

DISCUSSION
Regarding patient characterization variables, the data found in the present study are in accordance with arterial hypertension literature (7)(8) .
There are several risk factors associated with arterial hypertension, such as age, gender, race, heredity, high-sodium and high-fat diet, alcohol, tobacco, sedentary lifestyle, obesity, stress and contraceptive use.Some of them, including age, gender, race and heredity cannot be modified throughout life, but the installation of diseases can be prevented along individuals' life.The remaining variables related to individuals' lifestyle can be modified in order to minimize the risk of complications (7)(8) .
Lifestyle changes are part of nonpharmacologic arterial hypertension treatment and its modifications and adjustments depend on the sick individual with a view to a successful treatment (7-8)   .
By detecting the clients' life habits, it was possible to associate these factors to the health requirements and to verify the presence of self-care deficit or not, in order to analyze the results in line with the theoretical background.
It is observed that the self-care deficit is present in the different requirements in accordance with Orem's Self-Care theory; some of the self-care deficits are present in most of the requirements, while others occur less.
The most prevalent (%) nursing diagnoses based on the universal requirements are those associated to the individuals' lifestyle.Ineffective control of therapeutic regimen was detected related to feeding (61.8%) and to sedentary lifestyle (48.2%).
The diagnosis of imbalanced nutrition: more than body requirements affected 67.9% of the study participants.
These are critical aspects to control arterial hypertension.
In a study with hypertensive women in which the self-care deficit theory was used, the following was detected: inadequate feeding, obesity, and lack of salt and fat intake control.The patients did not have any interest in losing weight and did not focus on keeping adequate behaviors to control the disease.Such factors were related to the difficulty to keep a regular diet regimen, despite awareness of its significance to maintain arterial hypertension control.
As to losing weight, there was a lack of knowledge about the relation between obesity and arterial hypertension.That study acknowledged the difficulty to maintain behaviors that met treatment requirements, involving components like pleasure, social interaction and lifestyle (3) .
Feeding is an important component in the hypertensive patient's quality of life because there are some foods that contribute to increase pressure levels (risk foods), due to their high level of salt and fats.Moreover, this type of food favors dyslipidemia and obesity which, when associated with a sedentary lifestyle, contribute to the high prevalence of arterial hypertension and coronary disease (7)(8) .The individual's commitment to his/her own health and his/her involvement with self-care can be evaluated by his/her presence at the appointments, regular use of prescribed medications and lifestyle changes (12) .
The self-care deficit in these specific clients are clear and the nurse has a huge task in guiding, stimulating, and helping all these patients assume selfcare.
The patient care planning developed by the researcher was based on the reinforcement of risk advice concerning the risk patients were running when they did not comply with non-pharmacologic treatment and the importance of changing their lifestyle in order to control arterial hypertension.An individual contract was made with each of the patients, seeking to adequate their needs to their reality and stimulating them to talk about their difficulties to perform such changes, making them ponder over the problem and trying to convince them that self-care is the way to control the disease and to prevent complications.These individuals were also invited to take part in group activities offered at the care facility, as a second opportunity to reinforce guidance and stimulus for self-care.
In a study involving high-risk pregnant women, it was observed that, during the implementation of nursing care, the patients were not always aware of the importance of self-care to maintain life, health and well-being.Encouragement and guidance were needed to engage the patient in self-care, as participation was fundamental for selfcare to occur (1) .
Regarding development requirements, a single nursing diagnosis was made: Antihypertensive therapy adverse effects.
Pharmacological treatment should be based on the choice of adequate medication, with the following criteria: progressively decreased blood pressure, except urgency cases; start with agents capable of gently reducing blood pressure, with lower incidence of side effects (7-8)   .
Asymptomatic diseases like arterial hypertension can lead the patient to non-compliance with routine controls (or total refusal), because they do not present symptoms.This explains, in some cases, noncompliance with medication and the prescribed medication (13) .
To stimulate treatment compliance, it is important: to make sure the patient understands that arterial hypertension can be controlled but not cured, and that they should not interrupt the treatment without talking to the practitioners who are taking care of them; to minimize treatment costs; and to stimulate the patients to talk about their problems and concerns (7) .
The occurrence of health deviations in the study sample was not significant, but the diagnoses made are related to the denial of the disease (14.85%) and sorrow about the treatment (10.7%).
The deficit regarding the understanding of the health-disease process observed in the study with hypertensive women was as follows: lack of knowledge, indifference and apathy regarding the aspects related to arterial hypertension, all of which could be associated to the different meanings of being a hypertensive person.The fact of being an asymptomatic disease facilitates this apathy and, as some symptoms, when present, can be ascribed to other causes, there is no association with arterial hypertension (3) .
It is not enough for an individual to have knowledge about the forms of treatment and the risks arterial hypertension can cause, but how he/she behaves and uses this information to control the disease.

Table 1 -
Distribution of individuals according to nursing diagnoses concerning universal requirements

Table 2 -
Distribution of individuals according to

Table 3 -
Distribution of the individuals according to nursing diagnoses concerning health deviations