Abordaje enfermero de un paciente con insuficiencia cardiaca en Atención Primaria / Nursing approach to a patient with cardiac insufficiency in Primary Care

Actualmente, la insuficiencia cardiaca (IC) es una de las enfermedades más frecuentes, costosas, progresivas y discapacitantes de los países desarrollados. Representa la tercera causa de muerte cardiovascular y la primera causa de hospitalización en personas mayores de 65 años. En España, un 8% en personas de entre 65-75 años padecen IC y en mayores de 75 años su prevalencia es de 16%.Mediante la exposición del caso de un paciente con insuficiencia cardiaca y su abordaje por parte de la enfermera de Atención Primaria, se pretende mostrar la importancia del seguimiento desde dicho nivel asistencial y de la continuidad de cuidados ante un problema de salud de tal magnitud y prevalencia. La valoración enfermera se realizó según el modelo de Virginia Hendersony se establecieron los diagnósticos y el plan de cuidados utilizandolas clasificaciones de North American Nursing Diagnosis Association(NANDA), Nursing Outcome Clasification (NOC) y Nursing Interventions Classification (NIC). Los resultados se evaluaron a los tres meses. El seguimiento de la enfermera comunitaria, junto con el trabajo en equipo y el uso de guías de práctica clínica fueron determinantes para evitar descompensaciones y mejorar la calidad de vida del paciente (AU)

Currently, chronic insufficiency (CI) is one of the most prevalent, costly ,progressive and disabling disorders of developed countries. It represents the third leading cause of cardiovascular death and the leading cause of hospitalization in people over 65. In Spain, 8% of people aged 65-75years suffering from CI and in people aged over 75 years the prevalence of this condition reaches 16%.By exposing the case of a patient with cardiac insufficiency and its management on the part of the primary care nurse, we aim to show the importance of monitoring and follow up from that level of care and continuity of care when faced with a health problem of such magnitude and prevalence. The nursing assessment was performed using the Virginia Henderson's model: Diagnoses and care plans were established using the classifications of Norht American Nursing Diagnosis Association (NANDA),Nursing Outcome Clasification (NOC) and Nursing Interventions Classification(NIC). Outcomes were assessed at three months. Follow up of the community nurse, along with teamwork and use of clinical practice guidelines, were crucial to avoid decompensation and improve the quality of life of patients (AU)

Seguimiento domiciliario de una paciente con diabetes mellitus complicada entre la gestora de casos y la enfermera comunitaria II / Joint home follow-up of a patient with complicated diabetes mellitus by the case manager and the community nurse: II

El presente artículo es la continuación de la publicación «Abordaje integral de un caso de diabetes mellitus en domicilio entre la gestora de casos y la enfermera comunitaria» en Enfermería Clínica. En dicho documento se planteaba el caso de una mujer de 76 años con diabetes mellitus de larga evolución y alta complejidad clínica que formaba parte del programa de atención domiciliaria en el ámbito de atención primaria. En este trabajo se expone el seguimiento del caso en el que se aparecen nuevas complicaciones en la extremidad inferior derecha que conllevan a la amputación de la segunda extremidad. A los 6 meses del plan de cuidados inicial se realiza una nueva valoración según el modelo de Virginia Henderson y se plantean los diagnósticos de enfermería según la North American Nursing Diagnosis Association (NANDA) que conllevan a cambios en los objetivos y los criterios de resultados, Nursing Outcomes Classification (NOC) y Nursing Interventions Classification (NIC). Entre los resultados obtenidos, destacan la mejora de su bienestar al conseguir que la Sra. pudiera interaccionar e integrarse socialmente en su entorno tras movilizar los recursos sociales correspondientes y la familia. Las implicaciones en la práctica clínica son la importancia de la prevención de las complicaciones de la diabetes mellitus y el pie diabético, y la dificultad del abordaje de situaciones complejas que, en ocasiones, superan las posibilidades de la enfermera comunitaria. Ésta se puede beneficiar del apoyo clínico ofrecido por el modelo de gestión de casos y el abordaje global e integrado en un equipo muldisiciplinar (AU)

This is a continuation of the article published in this journal (Enfermeria Clinica), entitled 'Integral approach by the case manager and the community nurse to a complex case of diabetes mellitus in the home'. We present the case of a 76 year- old patient with long-term and clinically complex Diabetes Mellitus. The patient was taking part in the Primary Care home care program. This article describes the follow-up of the case in which new complications appeared in the right limb, which led to the amputation of the second limb. A new evaluation following Virginia's Henderson model was performed six months after the initial care plan. Nursing diagnoses were made following the North American Nursing Diagnosis Association (NANDA). These diagnoses led to changes in objectives and performance criteria using, nursing outcomes classification (NOC) and nursing interventions classification (NIC). One of the results obtained was the improvement of her well-being by enabling the patient to interact and integrate socially within her environment after mobilising the corresponding social and family resources. Involvement in clinical practice is important in the prevention of diabetes mellitus and diabetic foot complications. Difficult and complex situations are sometimes beyond the ability of the community nurse. It can be beneficial to take advantage of the clinical support offered by the case management model and the integrated approach of a multidisciplinary team (AU)

[Joint home follow-up of a patient with complicated diabetes mellitus by the case manager and the community nurse: II]. / Seguimiento domiciliario de una paciente con diabetes mellitus complicada entre la gestora de casos y la enfermera comunitaria II.

This is a continuation of the article published in this journal (Enfermeria Clinica), entitled "Integral approach by the case manager and the community nurse to a complex case of diabetes mellitus in the home". We present the case of a 76 year- old patient with long-term and clinically complex Diabetes Mellitus. The patient was taking part in the Primary Care home care program. This article describes the follow-up of the case in which new complications appeared in the right limb, which led to the amputation of the second limb. A new evaluation following Virginia's Henderson model was performed six months after the initial care plan. Nursing diagnoses were made following the North American Nursing Diagnosis Association (NANDA). These diagnoses led to changes in objectives and performance criteria using, nursing outcomes classification (NOC) and nursing interventions classification (NIC). One of the results obtained was the improvement of her well-being by enabling the patient to interact and integrate socially within her environment after mobilising the corresponding social and family resources.Involvement in clinical practice is important in the prevention of diabetes mellitus and diabetic foot complications. Difficult and complex situations are sometimes beyond the ability of the community nurse. It can be beneficial to take advantage of the clinical support offered by the case management model and the integrated approach of a multidisciplinary team.

Prevalencia de pacientes con alta complejidad y/o alta dependencia para la gestión de casos en atención primaria / Prevalence of patients with high complexity and/or high dependency for case management in primary care

Objetivo. Identificar el porcentaje de personas adultas con alta complejidad y/o alta dependencia en población ≥ 18 años tributaria del modelo de gestión de casos. Método. Estudio descriptivo, observacional, transversal. Ámbito comunitario. Muestreo aleatorio simple. Tamaño muestral: 551 individuos (tasa de reposición por pérdidas del 40%). Variables dependientes: Alta complejidad ≥ 4criterios: edad, comorbilidad, polifarmacia, proceso terminal, ingresos hospitalarios, visitas a urgencias, caídas, dependencia funcional, deterioro cognitivo, vivir solo. Alta dependencia (Barthel ≤ 30 y/o Pfeiffer ≥ 8). Análisis: descriptivo, variables y factores asociados. IC 95%. Índice de Kappa para estudiar la correlación entre variables. Resultados. Participaron 327. X edad=49años (DE=18) y 179 (54,7%) mujeres. Presentaban alta complejidad 6 personas (1,8%, IC 95%: 0,38-3,29), 4 (67%) mujeres, 5; (83%) > 75 años, y 1 < 65 años. X edad=79,5 (DE=12,6). Presentaban alta dependencia 5 mujeres (1,5%, IC 95%: 0,49-3,53), 4 mujeres (80%) > 75 años y 1 < 65 años. X edad=82 años (DE 14,8). Presentaban alta complejidad y/o alta dependencia 7 personas (2,14%, IC 95%: 0,86-4,3), 5 mujeres (71,4%); 6 > 75 años y 1 < 65 años. X edad=81,3 años (DE=12,4). Prevalencia en > 65 años (8,3%) y en < 65 (0,6%) (p=0,001). El índice de correlación de Kappa entre las variables de alta complejidad y alta dependencia fue del 0,723. Discusión. El porcentaje de pacientes que presentan alta complejidad y/o alta dependencia sobre población general es relevante, aunque inferior al esperado. En la planificación de futuros programas de gestión de casos habrá que considerar, además de las personas con alta complejidad, las personas con alta dependencia y las menores de 65 años (AU)

Objective. To identify the percentage of the population over 18 years with high complexity or high dependency using the case management model. Method. Observational, cross-sectional, descriptive study. Community level. Simple random sampling. Sample size calculation: 551 individuals were needed, with a rate of replacement for losing participation of 40%. Variables: High complexity ≥ 4 of following criteria: age, comorbidity, high drug consumption, terminal disease, hospital admissions, visits to Emergency Departments, falls, functional dependency, mental deterioration, to live alone or with family with capacity for limited support; High dependency (Barthel ≤ 30 and/or Pfeiffer ≥ 8; social-demographic variables; health services use; chronic diseases; specific treatments and caregiver data. Analysis: Descriptive for all variables and associated factors (95% CI). Correlation between variables was studied using the Kappa index. Results. A total of 327 patients were studied, with a mean age of 49 years (SD=18), of whom 179 (54.7%) were women. Six individuals had high complexity (1.8%, 95% CI: 0.38%-3.29%), 4 women (67%), 5>75 years old (83%) and 1<65 years old, mean age=79.5 years (SD=12.6). Five women presented high dependency (1.5%, 95% CI: 0.49-3.53), 4>75 years old (80%) and 1<65 years old, mean age= 82 years (SD=14.8). Seven individuals in total presented high complexity and/or high dependency criteria (2.14%, 95% CI: 0.86-4.3), 5 women (71.4%); 6>75 years old and 1<65 years old, mean age=81.3 years (SD=12.4). Prevalence > 65 years (8.3%) and < 65 (0.6%) (P=.001). Correlation Kappa Index between high complexity and high dependency variables was 0.723. Discussion. The percentage of patients who had high complexity or high dependency compared to the general population is significant, although lower than expected. In the planning of future programs for case management those persons who have high dependency and aged less than 65 years should also be taken into account along with those who have high complexity (AU)

[Prevalence of patients with high complexity and/or high dependency for case management in primary care]. / Prevalencia de pacientes con alta complejidad y/o alta dependencia para la gestión de casos en atención primaria.

OBJECTIVE: To identify the percentage of the population over 18 years with high complexity or high dependency using the case management model. METHOD: Observational, cross-sectional, descriptive study. Community level. Simple random sampling. Sample size calculation: 551 individuals were needed, with a rate of replacement for losing participation of 40%. VARIABLES: High complexity ≥ 4 of following criteria: age, comorbidity, high drug consumption, terminal disease, hospital admissions, visits to Emergency Departments, falls, functional dependency, mental deterioration, to live alone or with family with capacity for limited support; High dependency (Barthel ≤ 30 and/or Pfeiffer ≥ 8; social-demographic variables; health services use; chronic diseases; specific treatments and caregiver data. ANALYSIS: Descriptive for all variables and associated factors (95% CI). Correlation between variables was studied using the Kappa index. RESULTS: A total of 327 patients were studied, with a mean age of 49 years (SD = 18), of whom 179 (54.7%) were women. Six individuals had high complexity (1.8%, 95% CI: 0.38%-3.29%), 4 women (67%), 5 > 75 years old (83%) and 1 < 65 years old, mean age = 79.5 years (SD = 12.6). Five women presented high dependency (1.5%, 95% CI: 0.49-3.53), 4 > 75 years old (80%) and 1 < 65 years old, mean age = 82 years (SD = 14.8). Seven individuals in total presented high complexity and/or high dependency criteria (2.14%, 95% CI: 0.86-4.3), 5 women (71.4%); 6 > 75 years old and 1 < 65 years old, mean age = 81.3 years (SD = 12.4). Prevalence > 65 years (8.3%) and < 65 (0.6%) (P = .001). Correlation Kappa Index between high complexity and high dependency variables was 0.723. DISCUSSION: The percentage of patients who had high complexity or high dependency compared to the general population is significant, although lower than expected. In the planning of future programs for case management those persons who have high dependency and aged less than 65 years should also be taken into account along with those who have high complexity.

El factor de impacto, perspectiva de los profesionales de enfermería asistenciales / The impact factor, the perspective of nursing care professionals

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Abordaje integral de un caso complejo de diabetes mellitus en domicilio entre la gestora de casos y la enfermera comunitaria / Integral approach by the case manager and the community nurse to a complex case of diabetes mellitus in the home

En este artículo se presenta el caso clínico de una paciente de 76 años con diabetes mellitus de larga evolución y de alta complejidad clínica, que forma parte del programa de atención domiciliaria en el ámbito de atención primaria. Presentaba varias complicaciones de la diabetes mellitus que afectaban de forma importante su calidad de vida, tales como ceguera, insuficiencia renal tratada con hemodiálisis y accidente vascular cerebral. Se expone una valoración siguiendo el modelo de Virginia Henderson, realizada en domicilio después del alta del centro sociosanitario donde estuvo ingresada por amputación supracondílea de la extremidad inferior derecha. Posteriormente, se diseñó el plan de cuidados de enfermería con los objetivos y criterios de resultados North American Nursing Diagnosis Association, Nursing Outcomes Classification y Nursing Interventions Classification. Se llevó a cabo de forma conjunta entre la enfermera comunitaria y la enfermera gestora de casos, las que se coordinaron con el resto de los profesionales que intervinieron en el caso. Se evaluaron los resultados a los 6 meses de la valoración inicial. Este caso, que presentaba alta complejidad y alta dependencia, requería un abordaje multidisciplinario y la integración de diversos profesionales, servicios e instituciones para poder implementar el tratamiento del paciente. Por ello, se debe destacar la importancia de una gestión del caso (case management) para garantizar la continuidad asistencial y una atención global e integrada(AU)

We present the case of a patient with long-term and clinically complex Diabetes Mellitus. She was taking part in the home care program in Primary Care. The complications of her DM affected her quality of life: blindness, kidney failure, treated with hemodialysis, and a cerebrovascular attack. We describe the evaluation following Virginia's Henderson model. This evaluation was made in the patient's home after she was discharged from the socio-health centre where she was admitted as her right leg was amputated at a supracondylar level. It was designed a care plan between the community nurse and the case manager using NANDA, NOC and NIC taxonomy. The care plan was carried out as a joint effort between the community nurse and the case manager who coordinated the planning with the rest of professionals. Results were evaluated 6 months after the initial assessment. This case, which had a high dependence and a high clinical complexity, required a multidisciplinary approach and the integration of different professionals, services and institutions to implement the patient's treatment. Because of all the above, it is important to mention the case management function to guarantee continuity, and overall and integrated care (AU)

[Integral approach by the case manager and the community nurse to a complex case of diabetes mellitus in the home]. / Abordaje integral de un caso complejo de diabetes mellitus en domicilio entre la gestora de casos y la enfermera comunitaria.

We present the case of a patient with long-term and clinically complex Diabetes Mellitus. She was taking part in the home care program in Primary Care. The complications of her DM affected her quality of life: blindness, kidney failure, treated with hemodialysis, and a cerebrovascular attack. We describe the evaluation following Virginia's Henderson model. This evaluation was made in the patient's home after she was discharged from the socio-health centre where she was admitted as her right leg was amputated at a supracondylar level. It was designed a care plan between the community nurse and the case manager using NANDA, NOC and NIC taxonomy. The care plan was carried out as a joint effort between the community nurse and the case manager who coordinated the planning with the rest of professionals. Results were evaluated 6 months after the initial assessment. This case, which had a high dependence and a high clinical complexity, required a multidisciplinary approach and the integration of different professionals, services and institutions to implement the patient's treatment. Because of all the above, it is important to mention the case management function to guarantee continuity, and overall and integrated care.