Implantação do cuidado continuado direcionado aos indivíduos com hipertensão arterial sistêmica e Diabetes Mellitus na Unidade Básica de Saúde Fonte Grande

Abstract

In Brazil, cardiovascular disease is responsible for most of the deaths in general population, and determines significant morbidity, affecting the quality of life of patients and generating high costs to the health system. As main event triggers we have Hypertension and Diabetes mellitus, conditions whose prevalence increases considerably, following the modern trend of obesity, sedentary lifestyle and improper diet - rich in sodium, fats and carbohydrates. The Family Health Strategy is an indispensable tool in fighting these diseases, providing human, philosophical and organizational resources to make changes. The aim of this study was to develop an intervention project to continue patient care for Hypertension and Diabetes mellitus in PSF Fonte Grande. Strategic Situational Planning (SSP) was used, characterized by four moments: explanatory (identification, analysis and prioritization of problems); normative (drafting proposed solution), strategic (construction feasibility for proposals developed solution); tactical operational (implementation plan) as the methodological approach. For continued monitoring of diabetic and hypertensive patients, it was proposed a retrospective analysis of records from 56 patients. Of these, the majority was female (67.9%). Among women, the median age was 68 years, the majority stated that it was white and 84.2% had systemic hypertension, in most cases in stage 1, and 65.8% had diabetes mellitus. There was no self-reported of alcohol consumption among women, only 7.9% were smokers and 26.3% sedentary. Among men, the mean age was 70 years, with a predominance of white, 88.9% were hypertensive, mostly classified as stage 2, and 61.1% had diabetes. The prevalence of alcoholism and smoking was 22.2% and 16.7% respectively. Given the results, we organize the work process to offer continue patient care, prioritizing the most serious cases, with subsequent extension of the work to the whole accompanied diabetic and hypertensive population. Recognizing the primary and secondary prevention of Hypertension and Diabetes, with clinical and therapeutic resources available in the National Health System, and considering the possibility of modifying the risk factors, we estimated that our approach of Hypertension and Diabetes mellitus can positively affect the population health. Set priorities and goals, as well as training the agents of change, means planning. Planning, in turn, allows the optimization of human and financial resources, and promotes more effective behaviors by patients. Continual re-evaluation of goals and outcomes builds a challenge to the team, making the process work more sensitive to the reality and creating a transformative perspective on health conditions of the population.