A doença crónica, empoderamento comunitário e integração de cuidados

Abstract

Introduction - This report was designed in the scope of the “Final Internship and Report” Curricular Unit of the Master’s in Nursing, with specialization in Community Nursing – Community Health and Public Health at the Institute of Health Sciences, Porto, Universidade Católica. The internship occurred in a Public Health Unit of a Health Center Group integrated in a Local Health Unit. It was carried out in a learning, development, and knowledge integration scope for advanced nursing care to a community and to a population. The phenomenon under study concerns the Epidemiological Surveillance of Nursing Diagnoses in chronic disease (in the continuity of other studies carried out in that Public Health Unit), framed in the integration of care in one of its dimensions – Information Systems (and respective sharing) and Community Nursing Empowerment for the translation of measurable gains. Methodology - The analysis of the study focused on the use of Health Planning, integrating in the Project the clinical decision matrix – Model of Assessment, Intervention and Community Empowerment and in the Nursing Diagnosis Observatory of the Health Center Group where the Final Internship was carried out. A questionnaire was used as data collection instrument, applied to a determined intentional sample in agreement with experts. Results - It was identified as priority intervention target problems the need to improve the communication of the organizational structure for the management of chronic disease, effectively knowing about Information Systems and the activity of Epidemiological Surveillance of Nursing Diagnoses of the Nursing Diagnosis Observatory of the Health Center Group. It was found that there are training needs in the community nursing leaders in chronic disease for clinical nursing documentation in Nursing Information Systems.

Date of Award	24 May 2023
Original language	Portuguese
Awarding Institution	Universidade Católica Portuguesa
Supervisor	Pedro Miguel Almeida Melo (Supervisor)