Valoración Integral de la diabetes. Consulta monográfica para detección y seguimiento de complicaciones / Comprehensive Assessment Of The Patient With Diabetes. Monographic Consultation For The Detection And Monitoring Of Complications

La enfermedad cardiovascular incide de manera más precoz y presenta mayor mortalidad en pacientes con diabetes mellitus tipo 2. El Programa de prevención y control de la Enfermedad Vascular Aterosclerótica de Canarias recomienda la realización anual de diferentes cribados en estos pacientes para la detección precoz y prevención de complicaciones. La consulta de valoración integral del paciente con diabetes tipo 2, liderada por una enfermera especialista en Enfermería Familiar y Comunitaria realiza, en una única visita, las actividades de prevención incluidas en este programa, mejorando los indicadores de proceso. Este nuevo modelo de organización mejora notablemente el desarrollo de actividades de prevención y detección precoz de complicaciones. (AU)

Cardiovascular disease affects earlier and presents higher mortality in patients with type 2 diabetes. The Program for the Prevention and Control of Atherosclerotic Vascular Disease of the Canary Islands recommends carrying out different annual screenings in these patients for early detection and prevention of complications. The Comprehensive Assessment Consultation for patient with type 2 diabetes, led by a nurse specailized in Family and Community Nursing, carries out, in a single visit, the prevention activities included in this program, improving process indicators. This new oraginzational model significantly improves the development of prevention activities and early detection of complications. (AU)

Prescripción de recursos comunitarios para la mejora del autocuidado en enfermedades crónicas. Gestión de un caso clínico en Atención Primaria / Community resources prescription for self-care improvement in chronic illnesses. Clinical case management in Primary Health Care

Se presenta el caso de un paciente varón de 52 años de edad que acude a consulta de enfermería de Atención Primaria para el control metabólico de diabetes mellitus tipo 2. Su frecuencia de visitas aumenta al percibir dificultades añadidas por cambio de tratamiento farmacológico. Se realiza entrevista focalizada, empleando el marco de patrones funcionales de salud, donde destaca que el paciente no sabe leer ni escribir, no trabaja desde hace 25 años y hay expresiones manifiestas de falta de control sobre su autocuidado. Se elabora un plan de actuación priorizando los diagnósticos enfermeros de NANDA-I Mantenimiento ineficaz de la salud, Impotencia y Deterioro de la interacción social. Los objetivos fueron orientados a la mejora de los conocimientos y control sobre su enfermedad y participación en actividades de ocio. Para ello, contactamos con los recursos sociosanitarios de la zona, acordando con el paciente la asistencia a aquellas actividades que, siendo de su interés, pudieran mejorar sus autocuidados y, en definitiva, su calidad de vida. En evaluaciones sucesivas se aprecia mejoría en el control de su enfermedad, con aumento de su nivel de conocimientos y autocuidado. Los profesionales de enfermería de Atención Primaria deben considerar los recursos comunitarios disponibles empleando un enfoque integral para el beneficio terapéutico y manejo de las enfermedades crónicas, especialmente en aquellos pacientes cuyas condiciones socioculturales sean desfavorables, como el caso que nos ocupa

A case is presented of a 52 year-old male seen in a Primary Care nursing clinic for a type 2 diabetes mellitus metabolic control. The frequency of the visits increased due to perceived difficulties caused by changing the medical treatment. A focused interview was conducted under functional health patterns framework. The patient was unable to write or read, had not worked for the last 25 years, and expressed a lack of control over his selfcare. An action plan was prepared, prioritizing Ineffective Health Maintenance, Powerlessness, and Impaired Social Interaction NANDA-I nursing diagnoses. The goals were set at improving knowledge and control over his disease and participating in leisure activities. To achieve these, the social health resources in the area were contacted, and agreed that the patient could attend activities that could improve his self-care and his quality of life. An improvement in his diabetes control was observed in the following evaluations, with an increase in his level of knowledge and self-care. The Primary Health care nurse should consider available community resources by using a comprehensive approach to chronic diseases for their therapeutic benefit and management, especially in those patients with adverse sociocultural condition

[Community resources prescription for self-care improvement in chronic illnesses. Clinical case management in Primary Health Care]. / Prescripción de recursos comunitarios para la mejora del autocuidado en enfermedades crónicas. Gestión de un caso clínico en Atención Primaria.

A case is presented of a 52 year-old male seen in a Primary Care nursing clinic for a type 2 diabetes mellitus metabolic control. The frequency of the visits increased due to perceived difficulties caused by changing the medical treatment. A focused interview was conducted under functional health patterns framework. The patient was unable to write or read, had not worked for the last 25 years, and expressed a lack of control over his self-care. An action plan was prepared, prioritizing Ineffective Health Maintenance, Powerlessness, and Impaired Social Interaction NANDA-I nursing diagnoses. The goals were set at improving knowledge and control over his disease and participating in leisure activities. To achieve these, the social health resources in the area were contacted, and agreed that the patient could attend activities that could improve his self-care and his quality of life. An improvement in his diabetes control was observed in the following evaluations, with an increase in his level of knowledge and self-care. The Primary Health care nurse should consider available community resources by using a comprehensive approach to chronic diseases for their therapeutic benefit and management, especially in those patients with adverse sociocultural conditions.