Linha de Cuidado em Hipertensão Arterial | Sua Saúde na Rede

Summary

Dona Joana, a 64-year-old woman who recently moved to São Paulo, seeks care for her high blood pressure at a local health center. Through a series of evaluations and consultations, including blood pressure monitoring and risk assessments, she receives a tailored treatment plan. A multidisciplinary team, including a case manager, supports her in adopting healthier habits and adhering to her treatment plan. Despite challenges, including a hospital visit, Dona Joana follows through with her health regimen, improving her quality of life and managing her hypertension effectively.

Takeaways

• 😀 Dona Joana, a 64-year-old woman, moved to São Paulo and sought healthcare after feeling unwell post-move.
• 😀 She visited the UBS Jardim Japão, where she was welcomed by the porter and directed to the care room.
• 😀 Nurse Crise performed a thorough assessment of Dona Joana’s health, identifying high blood pressure as a concern.
• 😀 After the initial evaluation, Dona Joana was promptly referred to a doctor for further treatment.
• 😀 The doctor assessed her risk factors, ordered necessary tests, and prescribed medication to manage her hypertension.
• 😀 A follow-up appointment was scheduled within 30 days to monitor her progress and reassess her health status.
• 😀 Dona Joana was introduced to her case manager, Bia, who worked with her and a multi-professional team to create a tailored therapeutic plan (PTS).
• 😀 The PTS focused on physical activity, improving her diet, and reducing stress to help manage her hypertension effectively.
• 😀 Supported self-care was encouraged, with Bia motivating Dona Joana to stick to her health goals and adhere to her treatment.
• 😀 After struggling to control her blood pressure, Dona Joana was referred to a specialist and treated at the hospital for severe headaches.
• 😀 Dona Joana successfully adopted healthier habits, such as quitting smoking, losing weight, and sticking to her medication, leading to improved health and well-being.

Q & A

What is the main health concern addressed in the script?

The main health concern addressed in the script is hypertension, particularly how it is managed through a structured healthcare process.

Who is Dona Joana, and what is her medical situation?

Dona Joana is a 64-year-old woman who recently moved to São Paulo. She is dealing with high blood pressure (hypertension) and has sought medical help for her condition.

How did Dona Joana seek medical care after moving to São Paulo?

Dona Joana visited a local health unit (UBS Jardim Japão) after not feeling well due to the stress of moving. She was received by the receptionist and directed to the healthcare team for further evaluation.

What steps were taken to assess Dona Joana's condition upon arrival?

Upon arrival, Dona Joana was assessed by a nurse, who conducted a sensitive listening session, evaluated her clinical condition, and measured her vital signs. Her blood pressure was found to be high, leading to further action.

What happened after Dona Joana’s blood pressure was found to be high?

After her blood pressure was found to be high, Dona Joana was immediately referred to a doctor for further examination and treatment, including tests and risk assessments.

What is the role of the case manager in the healthcare process?

The case manager, in this case, Bia, plays a critical role in coordinating Dona Joana’s care, including collaborating with the multidisciplinary team and creating a therapeutic project (PTS) to address her health needs.

What is a therapeutic project (PTS), and how does it work?

A therapeutic project (PTS) is a personalized healthcare plan developed by the healthcare team in collaboration with the patient. It sets clear goals for improving health, such as physical activity and diet, with regular monitoring to track progress.

What are some of the key health goals prioritized in Dona Joana’s PTS?

In Dona Joana’s PTS, the key goals included increasing physical activity, improving her diet, and reducing her workload as part of her hypertension management.

How does the healthcare team support Dona Joana in maintaining her health improvements?

The healthcare team, including the case manager, regularly supports Dona Joana through encouragement, advice, and monitoring to help her stay on track with her goals, using a tool called 'self-supported care' to facilitate adherence.

What challenges did Dona Joana face during her treatment process?

Dona Joana faced challenges such as not reaching the health goals immediately, requiring further referrals to specialists, and being hospitalized for severe headaches. However, she continued to attend consultations and group education sessions.

How did Dona Joana’s health improve over time?

Over time, Dona Joana improved her health by adopting healthier habits such as losing weight, quitting smoking, adhering to her prescribed medication, and maintaining regular follow-ups with the healthcare team.

What is the significance of the care model discussed in the script?

The care model highlights the importance of a structured, multidisciplinary approach to managing chronic conditions like hypertension. It emphasizes patient involvement, continuous monitoring, and the use of personalized care plans to improve quality of life.