INSTRUMENT FOR NURSING CONSULTING OF HYPERTENSIVE PATIENTS IN FAMILY HEALTH: A METHODOLOGICAL STUDY

Jancelice Santos Santana¹, Maria Júlia Guimarães de Oliveira Soares², Maria Miriam Lima da Nóbrega³

1 Nurse. Master in Nursing by PPGENF /CCS/ Paraiba Federal University.

2 Nurse. PhD in Nursing by Ceara Federal University. Professor of the medical-surgery and Administration Department and of the PPGENF/ CCS/ Paraiba Federal University.

3 Nurse. PhD in Nursing, professor of the Department of Nursing, Public Health and Psychiatry and Professor of the Post-Graduation Program in Nursing of the Health Sciences Center of the Paraiba Federal University, CNPQ Researcher.

ABSTRACT

Objective: To elaborate an instrument when visiting families of hypertensive patients that are subject to Health Family Strategies, based on Horta's Basic Human Needs Theory. Method: Methodological scientific study, performed in Family Health Units, developed in five stages: identification of empiric indicators; structuring of the instrument; development and validation of the affirmatives of diagnosis/results and nursing interventions; accreditation of the content of the instrument; and application of the instrument to verify the practical operations. Result: Final version of an instrument viable to be used with hypertensive patients, with the content of past nursing procedures and the planning of future nursing assistance plan, added with the identification of diagnosis/results and nursing interventions, and some space to deliver the needed assistance. It is expected that the instrument provides better quality to the assistance and a valuation of the role of the nurse within the institutions, as well as a more efficient, more autonomous and scientific to the profession.

Describers: Nursing; Appointment; Hypertension.

INTRODUCTION

The Brazilian health system has gone through an evolutionary path that went through several models. The traditional model has as the focus of the disease and technical care given to spontaneous needs, which often results in actions less continuous and more distant from an integral approach, whereas the current model is focused on prevention, promotion and restoration of health.

Family Health is understood as a strategy for reorienting the care model, performed through the implementation of multidisciplinary teams in primary care units. These teams are responsible for monitoring a number of families, about three thousand to forty-five hundred individuals or families of a certain area located in a defined geographical space. Working in health promotion, prevention and recovery from illness and most common diseases and health maintenance of this community. The teams are composed at least by a family doctor, a nurse, a nursing assistant and six community health agents. When enlarged, there is also a dentist, a dental assistant and a dental hygienist⁽¹⁾.

The responsibility for monitoring of families induces Family Health Teams to recognize the need to go beyond the classically defined limits for primary care in Brazil, especially in the context of the Unified Health System (SUS, in Portuguese)⁽²⁾. The Nursing professional is inserted working in activities such as education, planning, organization and evaluation of health actions, nursing appointments, among others⁽³⁾.

In Brazil, the nursing consultation comes in frank expansion, and nowadays, the answer to the nurse’s social commitment strengthened and supported by Law 7498/86, Article 8, Paragraph I of the Decree 94406/87, which claims to be the prerogative of nurse. Nursing has sufficient scientific support in the task to educate and enlighten the individual, the family and the community, improving the focus on population, with regard to prevention and treatment of diseases. Such activity must be entered in the daily life of nurses. It is one of the tasks of greater importance for the Family Health nurses. Through it takes to solving assistance to the user and brings home a professional character and defines the competence of the nurse, yet it was not fully implemented in public and private institutions it was neither understood nor valued as an important activity in prevention, promotion and rehabilitation of population health⁽²⁾.

The role of nurses in programs to control chronic diseases is of paramount importance, for their vision and practical proposals for global non-pharmacological and pharmacological approach, besides its participation in virtually every moment of the contact of patients with the health unit. Ensures quality of care, streamlining the service and ensuring greater intensity of action for cases identified as a risk group

Arterial Hypertension (AH) is an important risk factor for developing cardiovascular disease, counting for 30% of deaths from coronary artery disease. Thirty-five (35%) of the population over age 40 have hypertension. This is more common in clacks than in white men that in women, after age 55 affects men and women equally. A study by the Brazilian Ministry of Health points out a drop from 20.5% in deaths from cardiovascular disease in the period from 1990 to 2006. The reduction was observed in the population between 20 and 74 years old in South and Southeast regions, while the Northeast had an increase in the same period⁽⁴⁾.

The Brazilian Ministry of Health (MS, in Portuguese) has implemented a strategic reorganization of the attention given to the Hypertensions and Diabetes Mellitus – the HIPERDIA program, which aims to equip and encourage the professionals involved in primary care to promote collective measures for primary prevention, focusing on the factors that influence cardiovascular and diabetes risk, detection, control and linkage of hypertension and diabetes in the primary healthcare; recognition of situations where the patient requires more complex care, identification of complications of hypertension and diabetes mellitus, making it possible the rehabilitation of psychological, physical and social carriers of these diseases⁽⁵⁾.

In the face of experience as a nurse for 10 years at the Family Health team (FHT), it was possible to detect some problems in nursing appointments to hypertensive patients, such as failure to identify some needs, lack of joint assessment of the client’s responses to a problem identified, actions taken in isolation, lack of a script that would allow a way to take care of an organized, planned and above all, that met the bio-psycho-socio-spiritual needs in affected hypertensive patients. In view of the problem, it recognizes the need to star the process of implementing the Specialized Assistance Service (SAE) at the Family Health Units (USF, in Portuguese) in the municipality of Cabedelo, by the construction of an instrument for nursing consultation that meets the needs of hypertensive patients assisted in those units.

Doe to its high prevalence and serious repercussions that can cause hypertension, it is essential to conduct a research so that the knowledge generated can be applied in nursing care, improving the quality of life of hypertensive patients⁽⁶⁾. The practice of nursing when transcending the use of diagnoses can help to define and improve the profession and leads it to improve the attention given to the patients⁽⁷⁾.

In search of a model care that best meets the needs of the hypertensive patients, this present study aimed to construct and validate an instrument for nursing consultations to hypertensive individuals seen at Family Health Units.

METHOD

This is a methodological study, that consists in a research referring to the investigation of acquiring methods, organization and data analysis, discoursing about the elaboration, validation and evaluation of instruments and research techniques, aiming to construct and instrument which must be reliable, precise and useful to be used by other researchers⁽⁸⁾.

The execution of this research complied with the previous step of appraisal by the Ethics in Research Committee of College Hospital Lauro Wanderley, of Paraiba Federal University – Campus I, in accordance to the ethic aspects detailed by the Resolution 196/96 of Brazilian National Health Council⁽⁹⁾, received the favorable notion #097/2010. The Resolution 311/2007 from the Brazilian Federal Nursing Board was also observed.

For the organization of this study, five steps were considered: 1) Identification of empirical indicators, 2) Structuring the instrument, 3) Development and validation of affirmatives of diagnosis/results and interventions of nursing, 4) Validation of the content, and 5) Operationalization of the instrument of nursing consultation.

The identification of empiric indicators here understood as manifestations, observed or measured, of basic human needs affected in the hypertensive client, was done based on the terminology identified within the nursing literature, where all these manifestations were taken from, when they were affecting or not these hypertensive patients. There was also an analysis of 53 medical records of hypertensive assisted patients for the identification of necessity manifestations. After this identification it was specified the quantitative of empirical indicators by necessity.

On the second stage it was initially performed a research in literature, using as database articles published in journals during the period of January 2005 and September 2009 and located by electronic search at the Virtual Library in Health (BVS, in Portuguese), at the SciELO (Scientific Electronic Library Online) database. The used describers were nursing consulting, hypertension and family health. 82 articles were found, and from those the repetitions were excluded, as well as those that were not written in Portuguese. After a skim reading of the articles, only 11 presented the concept of nursing consulting. From those, one article stated the construction of an instrument for the nursing consulting to hanseniasis carrier, but we were not able to identify any article related to the nursing consulting to the hypertensive patient. Furthermore, it was constructed an instrument using the indicators found in pertinent literature to the hypertensive clients and in the medical records referring to its psychobiological, psychosocial and psychospiritual dimensions.

Before the structuring of the instrument of nursing consulting to the assistant nurses that operate in the Strategy of Health in Family of the municipality of Cabedelo, Brazil, it was asked for them to participate in this study to indicate, among empirical indicators identified in literature and in medical records, if they agreed or not that the indicator was present in the instrument and if it would be within the adequate necessity. To perform as such, an instrument was designed and distributed to 18 nurses and all were filled and returned for evaluation.

After the evaluation of the nurses of Cabedelo’s USFs about the empirical indicators identified in literature and in the 53 records describing the necessity of each hypertensive patient, it was possible to analyze the frequency for each item of the instrument. This phase has as an objective to verify the considered significant indicators, in other words, those that achieved an acceptance rate of above 50% and were included in the first version of the nursing consulting instrument. After the identification of the indicators considered significant for the nursing consulting to hypertensive patients attended at the USFs, the first version of the instrument was developed.

The third phase of the study was performed aiming to construct and validate the affirmatives of diagnosis/results and nursing interventions. Initially all indicators were mapped within the terms of ICNP^® version 1.0, so it was possible to use the directives of the International Counsel of Nurses (ICN) to construct the affirmatives of diagnosis/results and nursing interventions. Using the relevant indicators and ICN criteria, the affirmatives of diagnosis/results and nursing interventions were constructed, organized and distributed among the basic human needs of Horta.

On the fourth phase the validation of the content, as well as the appearance of the instrument was done, which corresponded to the moment that the nurses of the USFs of Cabedelo, the population in research in this study, were invited to evaluate the instrument, giving propositions related to the content and format of presentation. In this phase, 18 nurses took part, who also were in the empirical indicators identification phase. 18 instruments were distributed and all were filled and returned. The instrument for validation of content was composed by 24 items, being all previously approved. Only the item that referred to necessity of nutrition had suggestions to add the variable overweight.

The fifth phase of the research named operationalization of the instrument was done over the clinical application with hypertensive patients aiming to verify the adequacy of the instrument in practice. The ethic aspects declared in the Resolution 196/96 of the Brazilian National Health Council were attended by the signature of the Free and Clear Consent Agreements by the hypertensive patient and his/her responsible.

RESULTS 

The instrument for nursing consulting of hypertensive patients, the object of this study, was developed based on the review of literature by the meaning of all necessities mentioned by Horta and the identification of the needs in the medical records of the hypertensive patients, which all signals and symptoms were highlighted that coud directly influence these hypertensive patients. After approval by the Ethics Committee of the CHLW, these indicators were placed in an instrument that was given to a group of 18 nurses of the USFs of Cabedelo for analysis of empirical indicators with higher frequency of hypertensive patients during the nursing consulting in the USFs.

About the characteristics of the participants of the study, it was observed that the majority of the nurses in the USFs of Cabedelo, 50% of them, are between 31 and 40 years old, while 28% are between 41 and 50 years old. In relation to gender, 94.4% are females. Referring to the years of experience as a nurse, 28% had between 1 to 5 years of experience; 22% declared between 6 to 10 years and 11 to 15 years of experience; 44.4% of the nurses reported they had between 1 to 5 years of experience with adult patients. In relation to the level of education in Nursing, 94.4% of the nurses are specialists, and among those 77.7% specialized in Family Health, while the others are specialized in Collective Health (16.7%), and 5.6% have only bachelor’s degree; none was found with a Master or PhD degree. All nurses perform care activities; however only one also teaches.

After evaluation of the nurses of the USFs of Cabedelo about the empirical indicators identified in literature and in the medical records based on each necessity of the hypertensive patient it was possible to establish the frequency for each item of the instrument. This phase had as an objective to verify the indicators considered significant, in other words, those that had acceptance rate above 50% and were included in the first, draft version of the instrument of nursing consulting. 287 empirical indicators were identified, 166 were identified in literature and 121 in medical records, and from those, 204 had frequency above 50%.

Using the relevant indicators and the criteria of ICN 35 affirmatives of nursing diagnosis and 99 affirmatives of nursing interventions were developed and distributed for the service of diagnosis of nursing by Basic Human Needs. Based on the empirical indicators obtained on the first phase of this study and the development of the affirmatives of diagnosis and of interventions, a second version of the Instrument of Nursing Consulting to the Hypertensive Patients served at the USFs, which was submitted to validation of content and design, by the nurses of the USFs of Cabedelo (Image 1 and 2).

For an instrument of measurement, or as in this case, an instrument of nursing consulting to become effective, it is necessary that it has as main characteristic the validity. Many authors affirm that an instrument is valid when it evaluates the phenomenon that they can measure^{(10,11,12,13)}. In this study, the validation of content and appearance was opted as it was the most indicated method to verify if the items (content) of the instrument reflect the reality that is intended to be measured, besides being the method ultimately most used to validate instruments directed to specific areas⁽¹⁰⁾.

The instrument of validation of content was composed by 24 items, all previously approved. There was only one item referring to the necessity of nutrition that suffered alteration to the increase of overweight variable. Among the 24 items analyzed by the nurses, 20 were 100% approved by the population: presentation design; identification; personal and family background; history of actual disease/complain; use of medication; anthropometric data and vital signs; neurological regulation necessity; oxygenation; vascular regulation, thermal; necessity of hydration, salt intake and electrolytic regulation; sleep and rest; body care; physical activity, corporal mechanics and mortality; sexuality, hormonal regulation, love and acceptance, gregarious attention, self-esteem, emotional security; education for health, learning, therapeutics; freedom; recreation and leisure, creativity and self-realization; physical safety, environment and shelter; psychospiritual necessities; and complementary notes from the nurse. Four items presented a rate above 80%: eliminations; nutritional necessities; visual, auditory, olfactory, gustatory, tactile and painful perceptions; and physical integrity and cutaneous mucus.

In the operacionalization of the instrument, the population was constituted by 18 nurses and 36 hypertensive patients of the USFs. The data was collected after the authorization of these two segments of the studied population. For the evaluation of the operation of the instrument of nursing consulting, it was asked for the nurses their participation in the study for the application of the instrument in hypertensive patients. After consent, the verbal orientation was given to explain the filling of the instrument, as well the importance of observation of the following aspects: time used to collect data; design of the instrument; content; difficulties found while filling the information, besides the registry of suggestions while applying the instrument. After clearing all doubts, the orientation towards the selection of hypertensive clients has started, obeying pre-defined criteria: to be enrolled; to have an ASH diagnose according to the clinical criteria proposed by the V Brazilian Directives for Arterial Hypertension (BDAH); to be 18 years old or above; to follow the period of data collection (August 2010).

The collection was rigorously done within the period established and the instruments were returned and analyzed from the investigated variables. This way, the following result was obtained: the time of completing the form was reported to be between 10 to 30 minutes, averaging 20 minutes; no suggestion was given in relation to the instrument design, accepted by 100% of the nurses; a third item of evaluation that referred to the questions and difficulties found in the completion of the questionnaire and 10% of the nurses considered the instrument quite long, however no observation was done related to evaluation. 100% consent was registered.

After the evaluation of all items of the instrument of the nursing consulting related to presentation and design to the testing of operation and feasibility, the final version of the instrument was presented to the hypertensive patients served in the USFs of Cabedelo. This instrument contemplates the phases of the nursing process, which was divided into two stages. The first is the history of nursing proceedings, elaborated in a systematic form to determine the necessities of the hypertensive patient, based on the following literature. The second stage, named nursing assistance planning, the instrument that has the diagnosis/results and nursing interventions were presented and portrays the indicators which are in the history, divided again by necessities aiming to serve the specificities of hypertensive patients, with enough room for the evolution of the patient.

FINAL CONSIDERATIONS

This study enable us to comprehend that the caring of the nurse must be centered and focused in the process of nursing, putting in practice in all stages, as the history of the patient, the nursing diagnosis, planning, implementation and evaluation of assistance. It is indispensible that the nurse institutes a single guide of consulting for the hypertensive patient, with data collection of all information that can enable the appropriate care based on the gravity of the hypertensive disease. The arterial hypertension is constituted an important problem of public health and demands measures of combat to stop its progression, aspiring the reduction of its high rate of morbimortality.

From the results of this study it is possible to affirm that the fulfillment of this instrument done with safety and knowledge brings to the nursing team subsidies relevant to guide the patient, the family and the nursing team as a whole in the prevention of the risk and treatment of the affected necessities and the minimizing of difficulties that are already present in the hypertensive patient. However, it is recognized that besides that there was no reported problems in executing during this study, this instrument must be validated clinically so to be considered a valid and reliable instrument for the attention to the hypertensive patient.

REFERENCES

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Contribution of the authors

-Concept and design: Santana

-Data collection: Santana

-Analysis and interpretation: Santana, Soares, Nóbrega

-Article writing: Santana, Soares, Nóbrega

-Final approval of the article: Santana, Soares, Nóbrega

Jancelice dos Santos Santana, Street: José Florentino Júnior, 320, District: Tambauzinho. CEP: 58042040, João Pessoa, Paraíba, Brazil. Telephone: (083) 243-8303/ (083) 9332-6979. E-mail: Janceli@ibest.com.br