La consulta de enfermería en Reumatología. Nuevos roles ante nuevos escenarios / No disponible

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Gestão do cuidado em saúde centrada no paciente com doença crônica não transmissível no campo da atenção secundária / Health care management focused on the patient with chronic non-communicable disease in the field of secondary care

O objeto deste estudo é a gestão do cuidado em saúde a ser aplicada na unidade de terapia biológica ao paciente com doença crônica não transmissível (DCNT) no campo da atenção secundária. Tem como objetivo geral propor um modelo de gestão do cuidado na atenção secundária em saúde para o paciente com DCNT. Os objetivos específicos são: (i)caracterizar o perfil dos pacientes com DCNT atendidos na unidade de terapia biológica; (ii)explorar o cuidado em saúde prestado ao paciente crônico sob a ótica dos profissionais que atuam na atenção secundária; (iii)avaliar o fluxograma do atendimento da unidade de terapia biológica; (iv)adaptar o fluxograma do atendimento considerando as múltiplas dimensões da gestão do cuidado em saúde; e (v)analisar as possíveis contribuições específicas para o trabalho de Enfermagem. Trata-se de um estudo de abordagem qualitativa, exploratória, realizado na unidade de terapia biológica da Policlínica Piquet Carneiro da Universidade do Estado do Rio de Janeiro, referência no campo da atenção secundária, com 80 pacientes, 14 profissionais de saúde e um funcionário administrativo. O estudo foi aprovado pelo Comitê de Ética em Pesquisa com número CAAE: 70596017.0.0000.5282. A produção dos dados abrangeu grupo focal com os profissionais, e com os pacientes foi utilizado um instrumento de coleta de dados com 32 perguntas fechadas e 2 abertas. Para análise utilizou-se o Epi-Info versão 7.1 e análise descritiva com distribuições de frequências simples e absoluta, onde a maioria era do sexo feminino (68,75%), mais da metade (62,50%) apresentava idade superior a 40 anos e 40% tinham o ensino médio completo. Quase metade (48,75%) declarou ser casada ou conviver com parceiro, ser do ambulatório da gastroenterologia (54%), fazer uso da medicação Infleximabe (55%) e tratar-se há mais de 24 meses (60%). Já para os dados provenientes dos profissionais, recorreu-se à análise de conteúdo, emergindo quatro categorias temáticas, são elas: (i) o impacto da educação em saúde e educação permanente na gestão do cuidado na UTB; (ii) as relações interpessoais entre os pacientes, equipe da UTB e da especialidade; (iii) a sobrecarga dos serviços de saúde no campo da atenção secundária; (iv) a interdisciplinaridade e a influência dos Indicadores de processos de trabalho na gestão do cuidado. Conclui-se que é possível estruturar um modelo de gestão do cuidado em saúde, com base nas análises do processo de trabalho na atenção secundária, pautado no referencial das múltiplas dimensões do cuidado em saúde. Porém, o modelo criado propõe uma sétima dimensão, de caráter epistemológico, que se caracteriza pela interdisciplinaridade. Recomenda-se a elaboração de protocolos clínicos e organizacionais pelos profissionais e gestores do serviço, utilizados como estratégia de enfrentamento de diversos problemas na gestão do cuidado, como foco a padronização de condutas na atenção secundária.

This study was aimed to address the health care management to be applied in the biological therapy unit to the patient with chronic non-communicable disease (CNCD) in the field of secondary care. Its general goal is to propose a model of care management in the secondary care of the patient with CNCD. The specific goals are: (i) to characterize the profile of patients with CNCD served in the biological therapy unit; (ii) to explore the health care provided to the chronic patient from the viewpoint of professionals working in secondary care; (iii) to assess the flow diagram of care in the biological therapy unit; (iv) to adapt the flow diagram of care considering the multiple dimensions of health care management; and (v) to analyze the possible specific contributions to the Nursing work. This study has a qualitative and exploratory approach and was performed in the biological therapy unit of the Policlínica Piquet Carneiro, belonging to the State University of Rio de Janeiro, reference in the field of secondary care, with 80 patients, 14 health professionals and one administrative worker. The study was approved by the Ethics Research Committee with CAAE number: 70596017.0.0000.5282. Data production covered a focus group with professionals, and a data collection instrument was used with 32 closed and 2 open questions with patients. In order to analyze data, we used Epi-Info version 7.1 and descriptive analysis with distributions of simple and absolute frequencies, where most were female (68.75%), more than half (62.50%) were older than 40 years and 40% had completed high school. Almost half (48.75%) reported being married or living with a partner, being assisted in the gastroenterology outpatient clinic (54%), making use of the Infliximabe® medicine (55%) and being treated for more than 24 months (60%). Regarding the data coming from professionals, we used the content analysis technique, giving rise to four thematic categories, namely: (i) the impact of health education and continuing education on care management in BTU; (ii) the interpersonal relationships among the patients, the BTU team and the specialty team; (iii) the overload of health services in the field of secondary care; and (iv) the interdisciplinarity and the influence of the Indicators of work processes in the care management. We can conclude that it is possible to organize a model of health care management, based on the analysis of the work process in secondary care, taking into account the framework of the multiple dimensions of health care. Nevertheless, the model established proposes a seventh dimension, with an epistemological nature, characterized by interdisciplinarity. We recommend the preparation of clinical and organizational protocols by the professionals and managers of the service, which may be used as a strategy to cope with several problems in the care management, focusing on the standardization of behaviors in secondary care.

El objeto de este estudio es la gestión del cuidado en salud que se debe aplicar en la unidad de terapia biológica al paciente con enfermedad crónica no transmisible (DCNT) en el campo de la atención secundaria. Tiene como objetivo general proponer un modelo de gestión del cuidado en la atención secundaria en salud para el paciente con DCNT. Los objetivos específicos son: (i) caracterizar el perfil de los pacientes con DCNT atendidos en la unidad de terapia biológica; (ii) explorar el cuidado en salud ofrecido al paciente crónico bajo la óptica de los profesionales que actúan en la atención secundaria; (iii) evaluar el diagrama de flujo de la atención de la unidad de terapia biológica; (iv) adaptar el diagrama de flujo de la atención considerando las múltiples dimensiones de la gestión del cuidado en salud; y (v) analizar las posibles contribuciones específicas para el trabajo de Enfermería. Se trata de un estudio de enfoque cualitativo, exploratorio, efectuado en la unidad de terapia biológica de la Policlínica Piquet Carneiro, perteneciente a la Universidad del Estado de Río de Janeiro, referencia en el campo de la atención secundaria, con 80 pacientes, 14 profesionales de salud y un funcionario administrativo. El estudio fue aprobado por el Comité de Ética en Investigación con el número de CAAE: 70596017.0.0000.5282. La producción de los datos cubrió un grupo focal con los profesionales, y con los pacientes se utilizó un instrumento de recolección de datos con 32 preguntas cerradas y 2 abiertas. Para el análisis, se utilizó el Epi-Info versión 7.1 y análisis descriptivo con distribuciones de frecuencias simple y absoluta, donde la mayoría era del sexo femenino (68,75%), más de la mitad (62,50%) presentaba edad superior a los 40 años y el 40% tenían la enseñanza media completa. Casi la mitad (48,75%) declararon estar casados o conviviendo con un compañero, ser del ambulatorio de gastroenterología (54%), hacer uso de la medicación Infliximabe® (55%) y tratarse por más de 24 meses (60%). En cuanto a los datos procedentes de los profesionales, se utilizó el análisis de contenido, emergiendo cuatro categorías temáticas, que son: (i) el impacto de la educación en salud y de la educación continua en la gestión del cuidado en la UTB; (ii) las relaciones interpersonales entre los pacientes, equipo de la UTB y de la especialidad; (iii) la sobrecarga de los servicios de salud en el campo de la atención secundaria; y (iv) la interdisciplinaridad y la influencia de los Indicadores de procesos de trabajo en la gestión del cuidado. Se concluye que es posible estructurar un modelo de gestión del cuidado en salud, basándose en los análisis del proceso de trabajo en la atención secundaria y en conformidad con la fundamentación de las múltiples dimensiones del cuidado en salud. Sin embargo, el modelo creado propone una séptima dimensión, de carácter epistemológico, que se caracteriza por la interdisciplinaridad. Se recomienda la preparación de protocolos clínicos y organizacionales por los profesionales y gestores del servicio, que serán utilizados como estrategia de lucha contra los diversos problemas en la gestión del cuidado, con miras a la estandarización de conductas en la atención secundaria.

Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy.

AIM: To compare and evaluate the treatment outcomes of a nurse-led rheumatology clinic and a rheumatologist-led clinic in patients with low disease activity or in remission who are undergoing biological therapy. BACKGROUND: Patients with chronic inflammatory arthritis treated with biological therapy are usually monitored by rheumatologists. Nurse-led rheumatology clinics have been proposed in patients with low disease activity or in remission. DESIGN: Randomized controlled trial. METHODS: A 12-month follow-up trial was conducted between October 2009 and August 2011, where 107 patients were randomized into two groups with a 6-month follow-up to a nurse-led rheumatology clinic based on person-centred care (intervention group; n = 53) or to a rheumatologist-led clinic (control group; n = 54). The hypothesis was that the nurse-led clinic outcomes would not be inferior to those obtained from a rheumatologist-led clinic at the 12-month follow-up. The primary outcome was disease activity measured by Disease Activity Score 28. RESULTS: A total of 47 patients in the intervention group and 50 in the control group completed the 12-month trial. The trial revealed no statistically significant differences between groups in mean change of Disease Activity Score 28, Visual Analogue Scales for pain, the Health Assessment Questionnaire, satisfaction with or confidence in obtaining rheumatology care. CONCLUSION: Patients with stable chronic inflammatory arthritis undergoing biological therapy could be monitored by a nurse-led rheumatology clinic without difference in outcome as measured by the Disease Activity Score 28.

Treating to target in rheumatoid arthritis: biologic therapies.

Treating to target is an established concept in the management of a number of long-term conditions to improve outcomes and prevent disease progression. Treatment targets in rheumatoid arthritis (RA) are to control the signs and symptoms of significant inflammatory disease activity, with the ultimate goal of remission from disease. The previous article in this series (Firth, 2011) outlined treating RA to target with conventional disease modifying drugs (DMARDs), including the role of the nurse in assessing disease activity, promoting shared clinical-decision making and monitoring treatment. In recent years, biologic agents have increased the treatment options for RA, but their use is reserved for patients with severe disease activity who fail to respond to treatment with two or more DMARDs. This article outlines the role of biologic therapies in treating RA to target, including eligibility criteria and the role of the nurse in optimizing outcomes.

Biological nurse specialist: goodwill to good practice.

The extensive use of biological agents in recent years for the treatment of rheumatological diseases has required a steep learning curve for the specialist nurses who manage and work in this specialty. Safe prescribing of biological therapies requires good infrastructure and specialist nursing personnel. With additional training, the specialist nurse may take responsibility for a number of tasks in the patient pathway including screening, treatment administration, patient education, prescription coordination for home drug delivery, patient support, monitoring and data collection. Biological treatment is becoming more widely used in several specialities, in particular gastroenterology, dermatology and ophthalmology. Since 2002, rheumatology specialist nurses have taken the lead in assessment and providing biologic therapy, not only for patients suffering from rheumatic diseases but also for those with immune-mediated inflammatory disorders. The unique nature and variable safety profiles of these agents led to the development of immune-mediated inflammatory disease infusion (IMID) centres and highlighted the importance of having biological specialist nurses. This article will discuss the evolution of the IMID/biologic specialist nurse role and how IMID services started with goodwill from the rheumatology nurse specialists to develop into a main component of the holistic approach to care.

La espondilitis anquilosante / Ankylosing spondylitis

La espondilitis anquilosante es una enfermedad inflamatoria de la columna vertebral que afecta, generalmente, a personas entre la segunda y cuarta década de la vida. Se caracteriza por la aparición de dolor lumbar de características inflamatorias, que despierta durante el reposo nocturno, asociado a rigidez espinal matutina, y acompañado, en ocasiones, de artritis y entesitis. Su prevalencia se estima entre el 0,05 y el 0,25% de la población. Afecta más a varones que a mujeres en una proporción 5:1. Los cuidados enfermeros,en esta patología, pueden ser muy importantes para facilitar el autocuidado y el afrontamiento eficaz de la enfermedad y deberían estar centrados en programas estructurados de Educación para la Salud dirigidos específicamente a estos enfermos.En este artículo, tercero de una serie dirigida a los cuidados enfermeros en reumatología, se presenta la espondilitis anquilosante, recorriendo generalidades de esta patología, sus manifestaciones clínicas y el manejo del régimen terapéutico en estos pacientes (AU)

Ankylosing spondylitis is an inflammatory disease of the spine that generally affects people between 20 and 40 years of age. It is characterized by the appearance of inflammatory lower back pain, usually during nocturnal sleep, and is associated with morning stiffness of the spine. It is sometimes accompanied by arthritis and enteritis.This disease affects approximately between 0,05 and 0,25% of the population. It affects more males than females in a 5:1 proportion.Nursing care in this pathology can be very important to facilitate self-care and the effective tackling of the disease, and should be focused on structured health education programs aimed specifically at this patient group.This article is the third of a series on rheumatology nursing care and describes ankylosing spondylitis, its main characteristics, its clinical manifestations and the management of the therapeutic regime for these patients (AU)

Actualización de cuidados enfermeros en reumatología / Development and current state of rheumatology Nursing

En los últimos años ha resurgido un debate sobre el papel de las enfermeras en el cuidado del paciente reumático. La aparición de fármacos de última generación, como los agentes biológicos y la estrecha monitorización que precisan, han sido la causa más importante del resurgir de la Enfermería en reumatología recientemente. Existen más de un centenar de enfermedades diferentes del aparato locomotor, siendo las más prevalentes la lumbalgia, la osteoporosis, la artrosis de rodilla, la artrosis de manos y la artritis reumatoide. Las enfermedades reumáticas son la segunda causa de consulta en los centros de Atención Primaria y son la primera causa de discapacidad en la población general. La Educación para la Salud ha demostrado ser una herramienta clave tanto en el manejo del enfermo como en la reducción de costes relacionados con la enfermedad. Estos factores han favorecido que algunas enfermeras inicien consultas propias de Enfermería en reumatología. Sin embargo, por el momento, se carece de una formación oficial y muchas de ellas han iniciado su andadura mediante una formación informal estructurada por reumatólogos. La llegada incesante de nuevos fármacos y la necesidad de más información por parte del paciente en temas relacionados con su enfermedad, puede estar produciendo una nueva generación de Enfermería en reumatología. El presente artículo es el inicial de una serie destinada a presentarlos cuidados enfermeros más actualizados en Reumatología y en él se recorren tantos los aspectos históricos como la situación actual (AU)

In recent years an old debate has been rekindled on the role of nursing in the care of rheumatic patients. The development of last generation drugs such as biological agents and the close monitoring required by these drugs have been the most important reason for the recent resurfacing of rheumatologic nursing. There are over one hundred different diseases of the locomotor system, the most prevalent ones being lumbalgia, osteoporosis, arthrosis of the knee, arthrosis of the hands and rheumatoid arthrosis. Rheumatoid diseases are the second leading cause of consultation in primary care centres and the first cause of disability in the general population. Health Education has proven to be a key instrument for the management of the patient as well as a tool to reduce disease-related costs. These factors have encouraged nurses to open their own consultation offices in rheumatology. Nonetheless, for the time being, no official training and many of these nurses have started their new responsibilities through a structured informal training given by rheumatologists. The continuous emergence of new drugs and the need for further information on the part of the patient with respect to disease-related issues may be resulting in a new generation of rheumatology nurses. This article is the first of a series intended to present the most updated nursing care in rheumatology and it covers both the history as well as the current state of rheumatology nursing (AU)

Management of the patient receiving parenteral biologic therapy.

Biologic therapies are becoming the preferred treatment option for many complex medical conditions, especially in the areas of oncology and immunology. Cytokines, monoclonal antibodies, and immunomodulators all have their own specific roles, clinical applications, mechanisms of action, and side effects. As newer biologic agents are approved and used for treatment, the nurse involved in the care of the patient receiving parenteral biologic therapy or in the administration of parenteral biologic therapies must know and understand the technology and mechanisms of action associated with these agents as well as guidelines for their safe administration to ensure positive patient outcomes. This article discusses biologic therapies, focusing on monoclonal antibodies used in oncology and immunology. The indications, use, and administration of parenteral biologic therapies, as well as the nursing management of the patients receiving the therapies, are presented.