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Pensar Enfermagem / v.27 n.01 / October 2023
DOI: 10.56732/pensarenf.v27i1.276
Quantitative Original Article)
How to cite this article: Rego R, Sousa E, Pinto F. Training hypocoagulated users and their families in
disease management: a community nursing intervention. Pensar Enf [Internet]. 2023 Oct; 27(1):147-152.
Available from: https://doi.org/10.56732/pensarenf.v27i1.276
Training hypocoagulated users and their families in
disease management: a community nursing
intervention
Abstract
Introduction
Brain and cardiovascular diseases require regular and specialized follow-up, including
pathologies that require oral anticoagulants, in order to reduce hospitalizations due to
clinical decompensation, maintain the person active, and reduce their degree of
dependence. This requires a professional/patient/family partnership in their management.
This project was based on Dorothea Orem's Self-Care Deficit Theory.
Objective
To train hypocoagulated users and their families in disease management.
Methods
The health planning methodology was applied. The situation diagnosis was developed using
questionnaires applied to the patient to validate their knowledge about disease management
and a second one applied to the family to understand their knowledge about their relative's
needs. The non-probability convenience sample was composed of 18 patients and five
family members in the consultations performed during the internship period.
Results
The situation diagnosis revealed a deficit of knowledge about disease management: in self-
care, therapeutic regimen, and their interaction, as well as a deficit of the family's role in
monitoring their family member and perceiving their needs. Health education was used as
a strategy to improve the problems identified through the empowerment of users and
families. After intervention, there was an increase in knowledge in all the addressed points:
self-care (92.85%), therapeutic regimen and its interaction (85.71%). As for the family
intervention, we found that participants are family members who live with hypocoagulated
patients and have already taken over the role of caregiver.
Conclusion
This project contributed to the knowledge of hypocoagulated patients and family, through
the intervention of community nursing, as well as the reflection on how to develop
strategies with families, to empower them in the early detection of intervention in the self-
care of their family member and in the management of family roles.
Keywords
Patients; Family; Oral Anticoagulants; Health education; Community nursing.
Rute Rego1
orcid.org/0000-0001-5074-2836
Edmundo Sousa2
orcid.org/0000-0003-2136-4471
Fátima Pinto3
1 Master. ACES Arrábida/USF Sesimbra, Sesimbra,
Portugal.
2 PhD. Lisbon Centre for Research, Innovation and
Development in Nursing (CINDUR)/ESEL, Lisbon,
Portugal.
3 Master. ACES Arrábida/USF São Filipe, Setúbal,
Portugal.
Corresponding author:
Rute Rego
E-mail: rute-rego@hotmail.com
Received: 19.04.2023
Accepted: 14.09.2023
148 | Rego, R.
Quantitative Original Article
Introduction
Cardiovascular diseases are the main cause of death in the
member states of the European Union, amounting to 36%
of deaths in 2010, as reported by the PNDCCV.1. Brain and
cardiovascular diseases require effective, specialized follow-
up during their management in order to reduce
hospitalizations due to clinical decompensation,
maintaining patients alive, and reducing their degree of
dependency. The cardiovascular diseases that require oral
anticoagulants (OAC) are included, which requires a more
regular health vigilance and a professional/user/family
partnership during disease management. There has been a
decrease in hospitalizations due to circulatory system
disease, 8.1% in 2016 in relation to 2011, and an increase in
hospitalizations due to cardiac arrest, 20.3% in 2016 in
relation to 2011.1
Community and public health nursing “Contribute to the
process of training groups and communities”2(p.8667),
promoting interventions through education-for-health
actions (EfH) in the community, doing follow-up with
families in their health project. This transforms them into
partners and decision-makers in their care with the aim of
improving quality of life and making gains in health. EfH,
as an intervention strategy, shall devise an interactive
process “focused on utilizing strategies that help
individuals and the community to either adopt or modify
behaviors that allow better health levels”.3(p.1) The literature
review shows the importance of EfH sessions in order to
train users in performing self-care and managing their
disease more safely and effectively.
This project was guided by the Otawa4(p.3,4) letter, int he
basic condition – Training “is centered on seeking equality
in health,” in order to contribute to reducing existing
inequalities; there must be “a solid implementation in a
favorable environment, access to information, lifestyles,
and opportunities that allow healthy options.” The
intervention focused on a community action in which
“health promotion is developed through concrete, effective
intervention in the community, establishing priorities,
making decisions, planning strategies, and implementing
them in order to achieve better health,” to build up
personal skills via access to information, EfH, thus
improving their self-care skills. Moreover, in the Dorothea
Orem's Self-Care Deficit Theory, whose premise is that
“every person has the potential, in different degrees, to take
care of themselves and the others who are under their
responsibility”5(p.614).
It must be understood that family is a complex system, with
a specific structure that is developed and transformed
throughout the life cycle according to one’s life
experiences. In this intervention community, it was found
that the participating families were in the last stage of the
life cycle, as stated by Figueiredo.6 This is a transformative
stage, as it helps understand the fragilities of those who
need care, as well as those who provide it. Thus, nursing
plays a key role in doing follow-up with families, identifying
transformations throughout the life cycle, providing
information, supporting them in their decision-making,
collaborating in strategies in order to maintain them trained
to perform self-care, managing their familial roles through
positive, effective, and efficacious communication.
This article aims to briefly expose a community
intervention project developed throughout an internship
that was part of the researcher’s master’s degree in nursing,
in the Community Nursing specialization area.
Methods
“Health planning must be adequate to reality, catering to
needs and/or problems experienced in the community or
any health organization in an assertive and pragmatic way,
supposedly in service for this community”.7(p.67) It was
through the health methodology planning that project
intervention was devised. All the formative and
interventional route of the community being followed-up
was described, analyzed and assessed according to several
development stages: situation diagnosis, priority
identification, goal setting, strategy selection, project and
program creation, execution and assessment preparation.
These stages allowed to steer a sustained, systematized
path, as this “requires a logical, rational methodology” .7(p.29)
This is a descriptive, exploratory study, devised after a
favorable opinion from the Ethics for Health Commission
with reference 6272/CES/2021.
Target Audience and Sample
This project target audience consisted in the users
registered at the FHU, amounting to a total of 52 users, as
per the following inclusion criteria: hypocoagulated
patients with need for INR, who received follow-up in
consultation throughout the internship period and were
able to understand, read and write well enough to answer a
questionnaire and accepted to participate in this project. Of
these, a total of 18 users were included in a nonprobability,
convenience sample.
Data Collection Instrument
To begin the first stage of the health planning methodology
– Situation Diagnosis, a questionnaire was devised and
validated by experts. A pre-test was carried out in order to
understand the hypocoagulated users’ and their families’
knowledge, which consisted in: Part A – sociodemographic
variables that enable us to understand the study sample;
Part B – motivational variables, which enable us to
understand commitment/knowledge of users regarding
their disease management, and Part C – socio-relational
variables, which enable us to analyze the user/nurse
relationship. To understand the family role of the
hypocoagulated user, the Dynamic Model of Family
Assessment and Intervention (MDAIF), operative matrix,
in its functional dimension, was applied on the users’
families who accompanied them in their hypocoagulation
nursing consultations in order to identify intervention areas
performed by their families as caregivers. The functional
dimension assesses the dependency of several types of self
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DOI: 10.56732/pensarenf.v27i1.276
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care described by ICN (2002b): dressing, eating, drinking,
going to the bathroom, sleep-rest behavior, leisure and
physical activities, as well as knowledge about the
dependency on management of the therapeutic regimen,
self-vigilance, and self-administration of medicines, as
stated by Figueiredo.6(p.92) This helped assess the needs of
both family members and caregivers. Data collection was
carried out between October and November 2021 after
authorization from the Ethics for Healthcare Commission.
Results
The users’ ages in the sample vary between 55 and 88 years,
with an average of 73.61 years. It was found that 67% of
them are males, while 44% of them are females; of these,
67% completed basic education. Regarding family
households, it was found that 72% of the interviewees live
with their partners, 22% of them live with a relative, and
6% of them live alone.
Regarding disease knowledge, 100% of the interviewees
can identify the name of the prescribed medicine, while
72% can identify the therapeutic interval that is adequate
for them. However, 28% of the interviewees do not know
why they are taking anticoagulant medication. Regarding
medication interactions with OAC, 89% of the subjects
cannot identify medicines that may interfere with it, but
regarding food and health situations, 50% of them can give
some examples that may alter therapeutic value or even
foods that they might have to suspend. Finally, there is the
importance of the nursing consultation, in which 100% of
the interviewees refer that this is an accessible consultation,
and it is important for monitoring and surveillance of one’s
health state.
Graph 1 - Analysis of self-care dependency areas
Three relatives and a non-family-related caregiver answered
the family-focused questionnaire. It was found that the
hypocoagulated users present a dependency of several self-
care areas: Therapeutic Regimen Management, Self-Care
Physical Activity, Self-Care Leisure Activity and Self-Care
Hygiene, in which the caregiver, mostly a relative, takes
over these functions as their, as shown in graph 1.
Regarding use of the MDAIF operative matrix, there was
low family adherence to follow-up and supervision of
family member’s needs.
According to the results obtained in the health diagnosis
stage. Identification and preparation of nursing diagnoses
according to CIPE taxonomy, 2015 version: Deficit in
knowledge about the pathological process and their diet
regimen; Compromised self-care ability; Compromised
disease self-management; Compromised knowledge about
their families’ role; and Compromised relative’s ability to
manage the disease.
From Situation Diagnosis to Execution
After identifying the health problems and preparing
nursing diagnoses, their hierarchization was carried out.
Priority definition, the second phase of the health planning
methodology, was carried out by using a group of experts
as a resource and it was based on the analysis grid criteria,
which was adapted from Hartz.8 According to our results
and with a view to either minimize or solve the problems
we found, the first four priorities were focused: Deficit in
knowledge about their diet regimen; Compromised disease
management; Compromised relative’s ability to manage the
disease; and Deficit in knowledge about the pathological
process.
Based on the prioritized problems, the general and specific
objectives were set; setting objectives is the next stage,
which enables us to carry out the project so that “it is
possible to devise a path for intervention strategies (...)
from the current state of a certain community, what state
we intend to achieve, where and until when”7(p.23) Thus, the
main objective of this study is to train hypocoagulated users
and their families in disease management. The following
specific objectives were set: Identify foods that interfere
with OAC the most; Acknowledging danger situations for
users who take OAC; Relating danger situations with
actions to be taken in order to reduce risks; Support
families in identifying the areas where their family needs
support; and Understand the pathological process. Activity,
adherence, and quality indicators were set in order to
quantify and qualify the activities to be devised.
The fourth stage of the Health Planning Methodology –
Strategy Selection, whose function is “a set of specific
techniques, organized in order to achieve a certain
objective, thus resolving one or more health
150 | Rego, R.
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problems”.9(p.65) The following strategies were set according
to Dorothea Orem’s Self-Care Deficit Theory: Involving
the nursing team; presenting the project to the nursing
team; informal meetings with colleagues to maintain them
informed about project developments and ask for their
opinions. Information and Communication, participation
of the masters’ degree candidate in hypocoagulation
consultations to establish a relationship with users/family
and inform them about the project; Exposing information
at a visible location about the activities to be performed;
Information about the activities to be developed by
reinforcing it with their family nurses; Self-Care Promotion,
doing two EfH sessions at the FHU (Family Health Unit);
presenting a checklist to help register changes in patients’
daily well-being; presenting a pamphlet with a summary of
care measures to be taken so as to have good health;
Proximity of Nursing Care, making a manual of good
practices in nursing in on-line consultations. These
strategies aimed to provide a timely answer to the
difficulties pointed out by the users and their families.
Maintaining users able to self-care and improve
“performance or the practice of activities that individuals
carry out to their own benefit to maintain their lives, health
and well-being”10(p.84) is to make them autonomous
regarding their self-care.
The EfH sessions that were carried out aimed to promote
health in the community under intervention, facilitating its
development and improving knowledge about the disease.
As stated in the Ottawa (1986), “it is a process that aims to
increase the capacity of individuals and their communities
to control their health in order to improve it, understanding
health as (a resource for life and not as a life end.”8(p.160)
Assessment
After intervention execution, the project assessment was
carried out based on preset goals. The goals were set based
on the situation diagnosis. At the end of each EfH session
a checklist was used to assess the addressed themes. Thus,
the knowledge of users and families who participated in the
sessions regarding the themes addressed in the two
sessions, adding to the objectives and result indicators
defined for this intervention project, as exposed in Table 1.
Table 1 – Assessment of Prioritized Nursing Diagnoses applied to 14 participants, of which four are relatives who participated
in the two EfH sessions.
Nursing Diagnosis: Deficit in knowledge about their diet regimen
Result Indicator
Goal
Result
Percentage of users/family who received
intervention able to identify five foods that interfere
with OAC the most.
80%
85.71%
Nursing Diagnosis: Compromised disease self-management
Result Indicator
Goal
Result
Percentage of users/ family who received
intervention able to identify three danger situations.
Percentage of users/ family who received
intervention able to identify two actions to reduce
risk.
90%
92.85%
Nursing Diagnosis: Family’s knowledge about patients’ relatives’ ability to manage the disease is compromised.
Result Indicator
Goal
Result
Percentage of family who received intervention able
to identify three areas where their relative needs
support.
50%
100%
Nursing Diagnosis: Deficit in knowledge about their pathological process
Result Indicator
Goal
Result
Percentage of users/ family who received
intervention able to identify the reason for taking the
anticoagulant.
70%
92.85%
Table 1 shows that the proposed goals were achieved
despite the difficulties perceived in families’ adherence to
the project and motivation of all users who responded to
the questionnaire to participate in EfH sessions. The two
programmed sessions presented more user adherence
because the sessions had been carried out on the day of
their consultations, thus the number of participants was
smaller than that of questionnaire responders. It was found
that the users, who were mostly older persons, remain alone
during their vigilance and monitoring consultations in order
to maintain disease management within their physical and
mental abilities.
Discussion
This project aimed to strengthen mapping carried out via
scoping review. As stated by Madrid,12(p.463) “The education
level and patients’ knowledge have a direct influence on the
global management of the anticoagulation.”;
Alphonsa13(p.668) says that “Patient’s knowledge about OAT
was suboptimal.” The findings support the need for
educational interventions to improve the knowledge
regarding OAT and, thereby, achieve an appropriate and
safe secondary prevention of stroke.” Moreover, Viola,
Fekete and Csoka14(p.1265) say that “The lowest frequency of
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correct answers regarded the questions on drug interactions
(10.2%) and diet (11.4%).” There is also a need for
“(…)developing new strategies for patient education to
improve knowledge on the treatment with oral
anticoagulants.”. The questionnaires used in this project
found an older population (mode equal to 87 years of age),
with low education level (67% completed basic education),
where 28% of the sample is not able to justify why they take
OAC, and 78% of them do not acknowledge the
medication interaction; on the other hand, regarding the
foods that may interfere with it, 50% of them can identify
five foods. After intervention with this group, EfH showed
that new knowledge about the disease was acquired, along
with alert signals and actions to take in order to minimize
risk and promote self-care improvement. These sharing
moments, organized by the nurses who take care of this
community, create moments of great learning. Not only
does the target group participates actively in them, but also
raises questions and identifies difficulties to train
themselves in disease management. All articles highlight the
education factor as a key point for the users’ understanding
and participation in disease management, thus
demonstrating the importance of the EfH sessions and
how pertinent they are regarding user training. This is an
intervention area of the nursing community specialist,
where they must invest in these actions to improve health
literacy in the community and develop and document it
through clinical investigation. No articles written by
Nursing professionals were found in this intervention area.
Conclusion
The community intervention nursing specialists play a
central role in doing follow-up and guide the community in
managing their health project. EfH fostered moments of
learning and growth in order to improve the community’s
health state. By making use of on the health diagnosis and
the Dorothea Orem's Self-Care Deficit Theory and the
support-education system, it was possible to identify the
self-care deficiencies of the hypocoagulated users and their
families in disease management, as well as outline strategies
to train them in order to improve their self-care skills. The
EfS sessions made learning moments possible through the
users’ sharing knowledge and experiences, and a debate that
improved their skills regarding their disease, medication
and food interaction, as well as their identifying risk
situations and measures to be taken in order to minimize
risks and maintain a healthy, balanced life. The community
interventions that were carried out during this project were
very enriching due to the engagement of the whole
multidisciplinary team. This helped divulge information
and stimulate the users’ and their families’ participation,
thus, all together will improve health literacy in the
hypocoagulation area. However, we must focus on families
due to a difficulty we noticed in integrating them in
participating in the project and the health care intervention.
The families’ time availability difficulty was one of the
limitations we noticed in the intervention project. The
available internship time to make interventions with users
and their families is also minimal because only after a
favorable opinion from the ethics commission can we
interview and engage them in the project.
Making interventions in this community, improving their
self-care skills, engaging a multidisciplinary throughout
their route contributed to promote knowledge and develop
investigation in Nursing. However, other questions
emerged during community intervention. Noticing that this
community has a high percentage of older persons who
manage their health project on their own, led the team to
the following questions: How to make an early detection of
cognitive decline and intervene to promote better nursing
care? How to alert families to a new reality and intervene in
family readaptation in advance? How to support families in
rearranging functions or even taking over new roles?
Authors’ contributions
RR: Study conception and design; Data collection; Data
analysis and interpretation; Statistical analysis; Manuscript
writing.
ES: Study conception and design; Data analysis and
interpretation; Statistical analysis; Critical revision of the
manuscript.
FP: Data analysis and interpretation; Critical revision of the
manuscript.
Conflicts of interest and Funding
The authors declared that there is no conflict of interest.
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