RESEARCH ARTICLES

Analysis of self-care deficit in hypertensive clients and implications for nursing care

Lina Márcia Miguéis Berardinelli^I; Nathália Aparecida Costa Guedes^II; Sonia Acioli^III
INurse, Associate Professor, Medical-Surgical Nursing Department and Graduate Program at the School of Nursing at the State University of Rio de Janeiro, Scholarship holder of the Production Incentive Program, Technical and Artistic, State University of Rio de Janeiro, Rio de Janeiro Vice-Leader of the Research Group of the National Council for Scientific and Technological Development: Philosophical foundations, theoretical and technological developments in healthcare and nursing, Rio de Janeiro, Brazil, Email: l.m.b@uol.com.br
^IINurse at the Pedro Ernesto University Hospital, Rio de Janeiro, Brazil, Email: nathyyguedes@gmail.com
^IIINurse, Associate Professor, Public Health Department and Graduate Program at the School of Nursing at the State University of Rio de Janeiro, Scholarship holder of the Production Incentive Program, Technical and Artistic, State University of Rio de Janeiro, Brazil, Email: soacioli@gmail.com

ABSTRACT: this descriptive study aimed to identify self-care deficits in hypertensive inpatient clients on internal medicine wards of a university hospital in the municipality of Rio de Janeiro, and to describe the factors that influenced those deficits. Data were collected in 2012 through semi-structured interviews of 15 such clients. Content analysis brought out two categories: ‘recognizing deficits in self-care’, and ‘habits that reveal such deficits’. It was concluded that Orem’s theory can inform nurses’ practices to enable them to identify conditions where there is a deficit in the capacity for self-care. Adherence to treatment is thus understood to be linked to nurses’ role in educating clients.

Keywords: Self-care, nursing theory, hypertension, nursing.

INTRODUCTION

The healthcare, economic, political, social and cultural panorama change the ways in which individuals and communities organize their lives and elect certain ways of living¹. These changes facilitate and hinder at the same time, people's access to the more favorable living conditions towards health and therefore directly affect the changes in disease patterns.

Currently, the chronic non-communicable diseases (CNCDs) recognized globally, both in wealthy countries as in low and middle income. The underdeveloped countries, low-income suffer more, the smaller your chances of ensuring public policies that positively change the social determinants of health¹.

Among the CNCD stands out high blood pressure (HBP), which is considered a public health problem worldwide. In most cases, causes many difficulties and changes in the lives of people at different levels, from the point of view of mental health, social, economic and yet, by emergency complications, clinical outcome and the possibility of aggravation in the long run because of deficits in self-care^2,3.

Based on the epidemiological profile expression is the increasingly growing the number of people affected by the disease, in Brazil alone, about 17 million people are hypertensive. Being that 35% of this population are 40 years or older. It is estimated that 4% of children and adolescents have high blood pressure. In 2007, there were 308,466 deaths due to circulatory system diseases⁴.

Another fact pointed out by National Household Sample Survey (Pnad), held in the years 1998, 2003 and 2008, revealed in its last edition, which in total resident population, 31.3% claimed to have at least one chronic disease, corresponding to 59.5 million people. The percentage of women with chronic diseases (35.2 %) is higher than that of men (27.2 %), and increases with age: 45% for the population of 40 to 49 years of age and 79.1% in the population of 65 years of age or over. The chronic disease more frequently reported in the total population surveyed was hypertension (14.1%), followed by spinal diseases (13.5%)⁵.

Now, considering that primary HBP comprises 90-95% of cases of this disease and can be controlled as long as people understand the health / illness / care and become involved in self-care actions for their own benefit. Understanding self-care as the ability that people have to take care of themselves performing activities for their own benefit⁶.

Although the biomedical model prevails and forwards the nursing actions for the observation of the disease, imposing and not observing the ill human being. In the case of successful CNCD treatment it requires people to be in line with the actions, reactions and emotions expressed by the body, therefore health actions should be shared and learned by people according to their perceptions, knowledge of the disease process, desires, possibilities, with the changes that the disease imposes on their lives and their families.

Adding to the facts presented, it was observed that the number of clients who were hospitalized with some type of hypertension complication for have been repeat offenders in relation to the proportion to diagnosed clients admitted and the number of beds. For example, in the month of October 2012, in a unit of hospital clinic, where it comes to customers with heterogeneous diagnoses so, it was found that the 20 beds occupied, more than 57% of hospitalized patients had arterial hypertension.

Faced with these circumstances the literature suggests that the appropriate model to help in nursing actions and respond to the needs of people with CNCD, stems from the Self-Care Deficit Theory of Orem. This author and other studies carried out, consider education for self-care a dynamic process that depends on the wishes of the client and their perception about their medical condition^7-10.

Therefore, according to the arguments above, the question: what is the extent to which the data collected are sufficient to analyze the self-care deficit? In addition, what are the factors that influence the self-care deficit?

Therefore, this study's objectives are to identify the self-care deficit of hospitalized hypertensive clients in the clinic wards a university hospital and to analyze the influential factors that led to self-care deficits.

Observing the production of knowledge on the topic from the last five years, using the descriptors: arterial hypertension, nursing, self-care, the electronic databases, Latin American and Caribbean Literature in Health Sciences (LILACS), Virtual Health Library (VHL) and in Scientific Electronic Library Online (SCIELO). This reveals that the nursing professional should be able to stimulate the patient to obtain the necessary information for the proper management of hypertension, as well as strengthen the guidelines and encourage self-care^11-16.

It is observed that such studies refer to the self-care deficit, but not the clients hospitalized hypertensive clients, a fact of interest of health professionals, public managers and health institutions who desire to reduce the readmissions for people with chronic illnesses. In addition, there is a shortage in Brazilian literature focused on this aspect. The relevance is given towards the expansion of knowledge in nursing and the applicability of the theoretical foundation for the care and the implementation of the systematization of nursing assistance in the ​​clinical expertise area.

THEORETIC REFERENTIAL

The theoretical referential focused on the Self-Care Deficit Theory of Orem, which determines when there is a need for nursing intervention and becomes a requirement when the person is incapable or limited for the supply of effective and continued self-care¹⁷.

This theory is a relationship between the properties of human therapeutic self-care needs and activities of self-care, in which the capabilities of self-care and developmental constituent are not operative or appropriate to know or meet some or all components for the therapeutic self-care necessity existing or planned¹⁷.

In this theory, there are help to know methods: acting or do by another; guiding the other; supporting the other; providing an environment that promotes personal development, when they become able to meet future demands or current action; and) teach the other¹⁷.

The nurse has all the elements needed to take care of the other, thereby regulating the employment of the steps of the method, or even using all methods of this theory, in order to maximize the self-care.

METHODOLOGY

This is a descriptive, exploratory study of qualitative approach, developed at the University Hospital of the State University of Rio de Janeiro (HU/UERJ) in 2012. The subjects were 15 patients, whose inclusion criteria were: hypertension diagnosis, age above 20 years, admitted in the wards of the HUPE medical clinic, without distinction of race, gender, religion, interested in participating in all the developmental research stages, voluntarily.

The design of the study was approved by the Ethics Committee of the HU/UERJ, taking into account the Resolution no. 466/2012 of the National Health Council of research involving human beings, under protocol no. 017.3.3012. The participation of the patients in the study that has taken its toll on the signing of the Consent Form, after reading and understanding of ethical procedures on the anonymity, the objectives, the advantages and disadvantages regarding the implementation of the research.

The data were produced by means of semi-structured interviews, individual, with questions specific to the study, recorded in an MP3 electronic apparatus, supported by a previously tested script. The subjects were identified as interviewee 1 (E 1) and so on.

After the interview, the data were transcribed, arranged chronologically, distributed according to the responses, classified and categorized, according to the content analysis method¹⁸, emerging from two categories denominated: Recognizing the self-care deficits and Habits that reveal the self-care deficit.

Next, the data were interpreted in the light of concepts about self-care for authors that have been constituted in the theoretical foundations of the study.

The social profile data and those of the subjects were submitted to statistical analysis.

RESULTS AND DISCUSSION

The profile of the participants was composed as follows: of the 15 participants, 67% were female and 33% male. Regarding ethnicity most self-referenced as belonging to the black race. The majority of the respondents had complete elementary school followed by the incomplete elementary school. It was observed that only one of the interviewees had higher education. Approximately 50% of interviewees practice the Catholic religion, 42% are evangelicals and 8% prophesize candomblé. Approximately 75% are economically active. The average age was 55 years.

The study inferred that the level of schooling could contribute to the ignorance, the careless with health, illness process and self-care engagement. The age range is also a positive indication, in the sense that they are young adults and can be influenced in the changes necessary to stay healthy and return to routine activities¹⁹.

Presented below are the emerging categories.

Recognizing the self-care deficit

This category expresses the subjectivity of each interviewee on the evolution of the disease and the elapsed time until the discovery of the diagnosis and was analyzed according to the theory for the self-care, noting appropriateness of the relationship between capacity and demand for self-care for the hospitalized client, as shown by the following reports:

 I didn't have high blood pressure, at least I didn't know, but then it my stomach started to grow, then the doctors saw that I had high blood pressure. This was some five years ago. At home, I only had headache, a very strong headache, I didn't much desire to do anything, nor helped my mother with the housework because of this. (E1)

I discovered that I had high blood pressure, two years ago. I was hospitalized for a very strong pain in the chest, I thought I would die on the day, I went to the emergency room and was hospitalized for one week, they discovered I had clogged heart vein, my blood pressure was always high, even during the hospitalization. (E2)

I discovered that I had high blood pressure when I was 30 years old. I had many crises in my kidney, then I went to the hospital where I was about two days in IV and the stone cane out and then although, for years it was so until one day I was hospitalized for more time, a week, I could not expel the stone and my blood pressure was too high, 20 the highest, and not would not go down for nothing. They told me that I needed to stop smoking and drinking, because if continued I would lose my kidney. (E9)

I discovered that I had high blood pressure, 5 years ago. I have always avoided doctor visits and eating sweets. They say I started having high blood pressure because of my kidney, which is not working right, they explained to me that the high sugar damaged the kidney. (E10)

The statements of the participants show between the lines, some sensations of change in the body and, when faced with illness, many reported signs and symptoms. The disease is accompanied by significant changes in the body and for each organ affected, a different physical sensation. For example, pain is an unpleasant sensation that triggers discomfort, passing through various stages, from mild to very strong, associated with a destructive process of tissues that is expressed through an organic and/or emotional reaction. Chest pain highlights the low supply of oxygen to the tissues, arteries and veins.

The self-care deficit is identified related to the lack of the health / illness / care, time and form of diagnosis, clinical evolution, the injuries and complications of hypertension and pain, reported by all respondents. In this case, clients hospitalized are struggling to develop their self-care. At the meeting time with the hospitalized clients, nurses can help them find solutions to their health problems, which have not been met. It is important in this encounter, the attentive listening, involving with the situations raised by establishing bond and leading them to reflect on their health, leveraging the moment for the teaching-learning process. The motifs found reinforce the need to work with nursing references that provide individualized educational approach conditions for non-pharmacological treatment.

Patients with chronic diseases do not adhere effectively to treatment, especially if this is prophylactic, when the disease is more mild or asymptomatic or when the consequences of discontinuing therapy are delayed. This is the case of the arterial hypertension patient, who most often presents no symptoms of any disease and tends not to accept the treatment²⁰.

In the following statements, another reality is noted:

In my family, my grandmother had high blood pressure and my father died of a heart problem. (E1)

Everyone at home has high blood pressure, all my brothers and uncles. (E8)
My father and my brother already have high blood pressure, but they treat it. (E12)
In my family, no one has high blood pressure. (E15)

In the last statements mentioned it becomes clear the origin of hypertension, although many unaware that this problem also relates to risk factors, in addition to genetic inheritance. If they knew, they could perhaps be more attentive to healthy habits and lifestyles, so that they could postpone or avoid arterial hypertension.

The cardiovascular risk factors often present themselves together with genetic predisposition. In addition, environmental factors tend to contribute to this combination in families with an unhealthy lifestyle²¹. In this respect, self-care, according to Orem needs to be strengthened to increase the competence to overcome the necessary changes regarding the habits and lifestyles that can be changed for the maintenance of balance, well-being and life¹⁷.

 Habits that reveal the self-care deficit

Here are the subjects' statements:

Not taking the medication, eating food with fat, I didn't exercise and drank there after a long time, I saw that this was serious; I saw that I was getting more tired, with swollen legs, with a pain in the chest when I worked many hours. Then I started doing treatment. (E3)

I was without treatment some 20 years ago. I have been hospitalized due to tiredness and started to take the medicine regularly. Now I make food without salt at home, not all the time. I stopped eating fatty meat. From 2 years ago until now, I has a more sedentary life, sadder since that I cannot work anymore, my legs swell a lot and my kidney is not working well. I quit smoking about 3 months ago. 40 Years smoking, 1 pack per week. I like a beer on the weekend, but now I stopped. (E6)

I never took care, had no medical follow-up, always ate something greasy, and always ate something, which was not healthy and smoked nearly 35 years. I think that's what hurt me the most. I am still overweight and lead a life with plenty of stress. (E10)

I never did physical activity and my job does not help, as I work at home spending the day sitting at the computer. I went home taking various medicines, the first week I did everything right, quit smoking, controlled my eating, but the time passed and I returned to the same old habits, I went back to smoking. Here I am again, with another vein clogged. (E11)

Well I never took care; I started smoking at18 and drinking, as for food, just things you call unhealthy. Didn't take my medicine and not stopped with my vices and the food? Oh yes, I would eat pork meat, fat, don't eat right, did not exercise, incidentally, I have never, never liked it. (E13)

I didn't lead a healthy life, and everyday ate outside of home. My work didn't let me have a decent lunch, spent a lot of time sitting and sometimes had 15 minutes only for lunch, eating too much junk food, sandwich, fries, and almost every day had a beer, always smoked, I started at 20 years old, smoked about 1 pack per day, now I intend to stop. I have never done physical exercise, always felt very annoying, I ate everything that is prohibited now, pork then do not have anything better, didn't drank water, and I like well-chilled beer because water has no taste. (E15)

Each testimony shows how much these people need care and are not competent to take care of their own health. It is worrying for the nurse to come across this situation, the person is hypertensive, high sodium and high-fat diet, does physical activity, is obese, stopped and started smoking again, drinks alcoholic beverages and do not use medication. On the other hand, one must take into account that many people find the greatest pleasure in life, the power and the challenge is to find a way not to propose radical changes in order to sublimate the ingrained habits, creating proposals that facilitate appropriate changes individually for each one of these subjects.

There is great difficulty in relation to changes of habits, because these are part of a social construction and are influenced by the environment where patients fall, and, therefore, investment tireless of health services for the reversal of this condition¹⁹.

The Self-Care Deficit Theory focuses on the cause of nursing actions to the individual associated with the intention. Making them completely or partially able to know regular care for themselves or their dependents and can commit to the continuation of these performance measures to control or somehow, manage factors that affect the operation and development their own or their dependents²².

In considering the subject of this study, it was observed, that these people have specific needs regarding self-care, all are hypertensive and already have complications, including one has already underwent angioplasty and another will undergo to myocardial revascularization.

In addition, the cited statements indicate other health needs, namely:

I've already been admitted to the hospital Bonsucesso, of the avenue and the hospital here four times with this including cardiology to place stent, was where I stayed the longest. (E2)

I' was admitted here, in 2011, 3 times. This year (2012) is the second time, because of my failing kidney. I've been admitted to the UPA, for a few hours only. (E10)

I've been hospitalized before for high pressure, more than 10 times. (E15)

Under the circumstances presented, each interviewee has been hospitalized in different injury and complications situations from hypertension. In this case, Orem proposed support system education, and the role of nurses to promote the client in a self-care agent¹⁷.

The patient has to be focused as the subject of the action, namely, the individual is who determines and decides how to care actions should happen. The control of decisions and implementation of professional intervention are transferred to the patient, reducing the dependence on professional-patient relationship and prevent their negative sequelae¹⁴.

Considering the factors, it is necessary that the hypertensive client try to understand the meaning of the changes to accomplish them adjusting them in their habits of life, ways of living, financial situation and especially after having assimilated the substantial changes in lifestyle.

As a limitation of the study, it is noteworthy that the low number of participants and single scenario by preventing the generalization of the results.

CONCLUSION

Based on reflective analysis of Orem's theory about self-care deficits of clients hospitalized hypertensive and the influential factors that have led to the readmissions, the present study allowed in addition to analyzing the self-care deficits, allowed the meeting of the nurse with the client. This meeting was possible to share ideas, thoughts and possibilities for change that made them consider adopting attitudes and measures, within the possibilities of each, related to commitment to their own health, with regard in adopting healthier lifestyle habits.

The deficit considered of greatest relevance was ignorance of the health/disease process, the body changes, physical and emotional distress resulting from the disease itself and its complications and care needed to maintain healthy. In this sense, there was no greater injury to the non-adherence to treatment does not/and medication, which should have occurred prior to the installation of the complication, considering that the identification of the symptoms of hypertension by customers appeared late, making treatment and leading to irresponsibility with their own health.

Therefore, the care directed to this clientele needs assistance needs physical, psychological support, as well as include strategies that offer the self-knowledge, self-esteem, motivation, self-control and the active participation of these people in their own care.

For this reason, involvement is necessary by all, nurses and residents, health professionals, students and the institution, in the offering of an educational process, to constructivist social transformations. This is evidenced in so far as that opens a channel of communication with customers admitted grounded in interpersonal relations, in communicative action through the ratio of aid, hospitality, respect, confidence, warmth, interest and sensitivity with the problem of the other.

The important aspect of the theory is that it allows qualifying the care, potentiating the sick people influencing them in situations in which they need most and that self-care is deficient. In this sense this theory was considered adequate by the authors, having in view that to apply it, managed to associate education actions, allowing hypertensive clients greater understanding, comfort and autonomy.

It is recommended that other studies of this nature be carried out, in order to extend the evaluation of concepts, which have been objects of this work, in populations with different characteristics and different regions of the Country, for the confirmation of the results obtained in this study.

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