Publicação: A capacitação para a autogestão na doença pulmonar obstrutiva crónica no domicílio :
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A Doença Pulmonar Obstrutiva Crónica (DPOC) tem um grande impacto na
morbilidade e mortalidade, em Portugal e no mundo. Para além de conduzir à perda de
funcionalidade e autonomia, a DPOC tem um forte impacto económico, com custos
indiretos, pela perda precoce de produtividade, e custos diretos relacionados com
internamentos recorrentes. A hospitalização causada pela exacerbação da DPOC é
frequente e deve-se, sobretudo à falta de reconhecimento precoce dos seus sintomas e
dificuldade de gestão da doença no domicílio.
Desta forma, torna-se imprescindível que o Enfermeiro Especialista em
Enfermagem de Reabilitação (EEER) desenvolva programas de reabilitação com a pessoa
com DPOC, que promovam a capacitação para a autogestão da doença, no hospital e
domicílio, um dos objetivos definidos para o estágio. O presente relatório pretende
descrever as atividades implementadas em estágio e fazer uma análise reflexiva baseada
na investigação recente. Este percurso permitiu o desenvolvimento de competências de
EEER, preconizadas pela Ordem dos Enfermeiros e as subjacentes aos descritores de
Dublin. Como referencial teórico estruturante, recorreu-se ao Modelo de Adaptação de
Roy.
O desenvolvimento de programas de reabilitação respiratória à pessoa com DPOC,
em estágio, incluiu a reeducação funcional respiratória, o treino de exercício e a educação
para a saúde com capacitação de estratégias de autogestão. Com processos de
autogestão eficázes verificou-se, na prática, um melhor controlo da doença, com ganhos
em saúde com o programa implementado: aumento da funcionalidade e da qualidade de
vida e reconhecimento precoce dos sinais de exacerbação. A melhor gestão da doença
no domicílio reflete-se em menor frequência de idas à urgência e internamentos.
Adicionalmente, os programas desenvolvidos no domicílio permitem o contacto com o
ambiente da pessoa, aumentar a inclusão dos familiares e a adesão e a manutenção do
programa de reabilitação.
The Chronic Obstructive Pulmonary Disease (COPD) has a significant impact on morbidity and mortality in Portugal and worldwide. Besides leading to a loss of functionality and autonomy, COPD has a strong economic impact with indirect costs due to early loss of productivity and direct costs related to recurrent hospitalizations. Frequent hospitalization caused by COPD exacerbation is mainly attributed to the lack of early recognition of its symptoms and difficulty in managing the disease at home. It is therefore essential that the Rehabilitation Nurse Specialist (RNS) develops rehabilitation programmes with people with COPD that promote empowerment for selfmanagement of the disease, in hospital and at home, one of the objectives defined for the practical context. This report aims to describe the activities implemented in clinical teachings and provide a reflective analysis based on recent research. This journey allowed the development of RNS skills advocated by the Order of Nurses and, those underlying the Dublin descriptors. The Roy Adaptation Model was used as the structuring theoretical framework. The development of respiratory rehabilitation programs for people with COPD in pratical context included functional respiratory retraining, exercise training, and health education with empowerment of self-management strategies. With effective selfmanagement processes, better disease control was observed in practice, resulting in health gains with the implemented program: increased functionality and quality of life and early recognition of signs of exacerbation. Better management of the disease at home is reflected in a lower frequency of emergency room visits and hospitalizations. Additionally, programs developed at home allow contact with the individual's environment, increase family involvement, and enhance adherence and maintenance of the rehabilitation program.
The Chronic Obstructive Pulmonary Disease (COPD) has a significant impact on morbidity and mortality in Portugal and worldwide. Besides leading to a loss of functionality and autonomy, COPD has a strong economic impact with indirect costs due to early loss of productivity and direct costs related to recurrent hospitalizations. Frequent hospitalization caused by COPD exacerbation is mainly attributed to the lack of early recognition of its symptoms and difficulty in managing the disease at home. It is therefore essential that the Rehabilitation Nurse Specialist (RNS) develops rehabilitation programmes with people with COPD that promote empowerment for selfmanagement of the disease, in hospital and at home, one of the objectives defined for the practical context. This report aims to describe the activities implemented in clinical teachings and provide a reflective analysis based on recent research. This journey allowed the development of RNS skills advocated by the Order of Nurses and, those underlying the Dublin descriptors. The Roy Adaptation Model was used as the structuring theoretical framework. The development of respiratory rehabilitation programs for people with COPD in pratical context included functional respiratory retraining, exercise training, and health education with empowerment of self-management strategies. With effective selfmanagement processes, better disease control was observed in practice, resulting in health gains with the implemented program: increased functionality and quality of life and early recognition of signs of exacerbation. Better management of the disease at home is reflected in a lower frequency of emergency room visits and hospitalizations. Additionally, programs developed at home allow contact with the individual's environment, increase family involvement, and enhance adherence and maintenance of the rehabilitation program.