Investigating the reason why he came for an consultation E We know that, for the nurses to develop their healthcare work with quality, it is necessary to apply a methodology based in the systematization of the nursing assistance. The evaluation of care happens throughout the process, from history, diagnostic, planning and implementation, reflecting the quality of care.
It is necessary to register the actions developed during the appointment. The importance of these registries happens as the whole team has access to the information about the state of the patient 7. The nurses emphasized the importance of the nursing process, although some mention the need of capacitation to execute it: In basic healthcare this still doesn't exist. The issue of nursing diagnostic really has to be implanted and implemented, but the capacitation of the nurses was necessary for that, because, after graduation, we really have only a faint notion of that.
But I think that the implementation of the nursing diagnostic was really important, since this process is ours, which, sometimes, we overlook, sometimes even due to lack of capacitation, of reading, of studying some more about that E9.
Nursing Management of Hypertension
The need for systematizing the nursing appointment aims at giving a professional character to the activity, organizing the approach towards the patient and defining the nurse's competence, among other aspects One of the nurses reported that she attempts to know the patient's history in her first contact. Such fact is in accordance with the recommendations of other authors 7.
In the first appointment with the hypertensive, we attempt to know their history. I start with the family, asking whether there are hypertension - or diabetes-related cases in their families. Next, I try to find their risk factors E The physical exam is also performed during the nursing appointment. During their academic education, the nurses have the opportunity of studying anatomy, physiology, pathology, besides techniques of inspection, percussion, palpation and auscultation, all of them essential to execute the physical exam.
However, the testimonies of some nurses revealed difficulties in this execution, especially regarding auscultation. Also, many times the physical exam is limited to the verification of weight, blood pressure and the podalic examination. In hypertensive patients, we really fail to do the physical exam.
But it should really be observed in the nursing appointment E5. There is the issue of the working environment, because the room is not very appropriate for that. We check the blood pressure, if it's all right, we know that he can control their pressure. If the blood pressure is altered, he's doing something wrong E8. The physical exam is part of the early stage of the nursing appointment history. It is normally performed after the anamnesis. In it, objective data signs are detected, and information collected during anamnesis is confirmed Therefore, the perception of the importance of the physical exam as a procedure to be executed as part of the day-to-day activities of the nurses becomes relevant, as a way to provide information about the functional capacities of the patient, which must be used in the elaboration of the nursing diagnostics, the determination of the interventions and the evolution of the patient's health status, as well as the evaluation of the effectiveness of the care provided by the nurse.
This will allow for the individualization of the nursing healthcare Exam requests were mentioned by only two nurses: We understand that the offer of complementary exams to identify metabolic alterations and injuries in target-organs is fundamental for monitoring hypertension patients, which is in consonance with the edicts of the Ministry of Health 1. A minimal evaluation of the hypertension patient must have the following exams: During the nursing appointment in the Family Healthcare Program, the nurse can request the minimal exams, established in guidelines for treatment of this clientele 1.
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Treatment of hypertension and day-to-day difficulties of people with this disease. Literature is unanimous when mentioning that the success of hypertension treatment and its complications is impossible without lifestyle changes the so-called non-medication treatment 2,13 , with the healthcare education being a fundamental part of it. In this perspective, the speeches of the nurses are as follows: It's necessary to convey trust for the patient, let the person be free, without impositions[ One of the main points to be observed in the nursing appointment is the healthcare education [ When the patient has doubts about medication or diet, we orient him about what to eat or do [ What would be important for the nursing team to do, and that sometimes they don't do is the healthcare orientation [ Well, the main aspect is orientation, which involves everything: Preventing and treating hypertension involves continuing education in order to introduce permanent changes in the lifestyle habits of those stricken by this disease.
The nurse, as an integrating part of the multidisciplinary team, has a leading role in the educative process of people with hypertension. With educational strategies, the nurse seeks the adaptation of the hypertensive patient to the disease, the prevention of complications and compliance with the treatment, which means that the patient must be made into a self-care agent and a multiplier of his actions with his family and the community The orientations presented by the interviewees include healthy dietary habits, abandonment of smoking, weight reduction and fighting sedentary behavior: It's important to change the lifestyle [ The patient has to change his diet, avoid smoking [ We're chanting the same thing in every appointment: You have to change your lifestyle, take your medication, do some physical activity, because the medication alone will not make effect E5.
Physical exercise, dieting [ Orienting about dieting, physical exercise [ About dieting, whether they are consuming low amounts of salt and fat. Many do not do dieting or exercise. They also have to use the anti-hypertensive medication [ Some authors 14 emphasize the role of the nurse in the non-medication treatment of hypertension, especially regarding dieting that is adequate to the hypertensive individual, simplifying information and improving the exchange of knowledge.
If blood pressure levels cannot be controlled only with the non-medication measures, the pharmacologic treatment will be started. The speeches of the interviewees revealed the actions of the nurses in the pharmacologic treatment: The orientation about medication must be observed in the nursing appointment. Usually, when they have a medical appointment, they receive a prescription, but they have doubts about the medication [ It's not unusual for them to report not taking medication at the right time, they have doubts about the intake and interactions with other medications or alcohol [ We check the medication intake and orient about compliance with the pharmacologic prescription, but if the patient only uses the anti-hypertensive medication, the pressure is rarely reduced E8.
Goals must really be established with the patient, and that is something that we don't always do E9. I check their medications, if he'd been complying with the prescription [ We prescribe it one way and they take it the way they think it's better, most times in doses that are lower than those prescribed. Therefore, they must be oriented, especially in relation to medication intake E Based on the stratification of individual risk, the pressure levels and the risk factors, the physician can decide for the beginning of the pharmacological treatment 1.
The nurse's work is fundamental in the orientations about side effects, intake regularity, medication preservation, inquiries about complaints and clarifying doubts about the orientation provided 11 , and also, being able to repeat the medication of controlled individuals without intercurrences 1.
In face of the importance of the nurse in this hypertensive treatment modality as well, it is essential for the nurse to encourage the patient to ask questions about the many aspects of the therapy and reinforce the necessity of regularly taking the hypertensive medication. However, compliance with the hypertensive treatment is one of the main challenges for the nursing professionals.
The nurses noted that treatment compliance was a difficult process: As all diseases involving changes in habits, compliance with treatment is very difficult [ I believe that compliance with treatment is what matters E7. How important is to follow the treatment and his responsibility in this treatment.
Whether he feels that this responsibility is either mine, his, or the service's E Convincing a patient, who is often asymptomatic, that he is sick, especially when this implies in lifestyle changes or the obligation of using medications for the rest of their lives is a difficult goal to accomplish. In this sense, it is important to establish a good rapport with the healthcare team for a customized orientation 16 , considering the socioeconomic level, the beliefs and the culture of the patients.
It is worth noting the issue of the user's co-participation. The single fact that healthcare is closer to home does not guarantee compliance with the therapy. The outcome variable, AH, was based on the answers to two questions of the questionnaire: To both questions, the answer options were: We considered as hypertensive workers who said "yes" to at least one of the two questions.
The statistical analyses were carried out by the Stata program version Initially, the sample was characterized by absolute and relative frequencies distribution of the following variables: Then, we carried out a bivariate analysis to assess the crude association of the demand-control and of each covariable with the AH. Statistical differences were assessed by Pearson's chi-squared test, and, for the ordinal qualitative variables, we calculated the chi-squared test of linear trend.
Finally, independent associations of demand-control at work and other covariables with AH were assessed by Poisson regression with robust variances, considering a hierarchical conceptual model adapted from Da Costa et al In this model Figure 1 , we arranged three blocks of variables: In this stage, we also calculated the p values of linear trend for ordinal qualitative variables. Adapted from Costa et al.
In this study, the prevalence of AH among nursing team workers from the municipal healthcare network in Belo Horizonte MG was Regarding their demographic and socioeconomic characteristics, we found that most were female In addition, the following frequencies of life habits were present among them: In relation to labor and anthropometric characteristics, we observed that most professionals in the nursing team did not work at night Regarding the demand-control, In Table 3 , we present the multivariate analysis to the independent association of demand-control, and the other covariables, with the AH, following the hierarchical model for the adjustment Figure 1.
Sex, age, household income and demand-control remained independently associated with AH after the multivariate data adjustment, while skin color and professional category have lost their effect. Sex became significantly associated with AH. Thus, the prevalence of AH was: Because of the small number of male participants, the data analysis have been reproduced only for females. Thus, the multivariate analysis is presented in Table 4. In the same way as for the sample as a whole, age, household income and demand-control remained independently associated with AH.
The evidenced prevalence of AH in this study, The difference of magnitude among AH results can be attributed, at least in part, to methodological discrepancies in the definition, measurement, data collection strategy and sample size determination. In this study, as already explained, the outcome of interest was obtained by self-report. Thus, the individuals without confirmation of the diagnosis of AH by a doctor would not be contemplated.
On the other hand, in the mentioned studies, AH has been confirmed by direct measurement of blood pressure obtained by confined readings. Although this methodological procedure is acceptable in population surveys, the possibility of overestimation of the obtained rates is not excluded Besides, in this study, participants were recruited in the primary and secondary levels of the healthcare network, while the previous studies were restricted to the tertiary level, especially to the emergency sectors. In such locus, due to its assistance feature, workers are exposed to higher levels of stress when executing their tasks.
Consequently higher frequency of AH cases becomes plausible. The relations that are independent of sociodemographic factors with AH, advancing age, female sex, high household income highlighted in this study, have also been found in investigations concerning the topic with the professional category of nursing 12 , The increase in blood pressure among older individuals is usually associated with atherosclerosis, which results in isolated systolic AH In our study, the prevalence of AH was almost six-fold in individuals aging 50 or more compared to those aging 20 to 39 years.
The presence of AH is more frequent in men under 50, moving to the opposite direction after that age. Among women, such result can be explained, at least in part, as an effect of biological nature: The influence of the socioeconomic level in the occurrence of AH is rather complex and diffi to be fully established; nonetheless, people with high income are more likely to have full access to health services and to be more prone to healthy lifestyles less addicted to smoking, with higher frequency of physical activity and better dietetic habits than their counterpart with low income earnings Regarding the association of job strain with AH, such a finding is consistent and supported by the results of a recent meta-analysis on the topic.
In addition, in the majority of investigations included in the meta-analysis, job strain was also assessed by the questionnaire of demand-control of Karasek.
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Thus, the Odds Ratio OR of all studies included in the meta-analysis was 1. In Brazil, as mentioned above, we found one single published study on the relationship between job strain and AH, whose design was cross-sectional and within which 1, technical and administrative employees of a University were addressed. The authors found no association between job strain and AH 6. Regarding the category of nursing professionals, our study seems to be pioneer, because we did not identify previous studies that specifically explored the relationship between job strain and AH, neither at national nor at international level.
Two investigations addressed the association of job strain in the category of nursing, but the outcomes evaluated were the levels of systolic and diastolic blood pressure, and not the AH specifically. In the first of them, a study that concerned with a homogeneous sample of 56 professionals nurses or nursing assistants at a hospital in Stockholm, Sweden , job strain was associated to the increase in systolic and diastolic blood pressure during the working time, and with the diastolic blood pressure during free time In the other research, a study with nurses from a public hospital in the city of Rio de Janeiro, the job strain was also related to the higher average of systolic blood pressure at home awake in participants with domestic work overload 7.
The plausibility of the relation between job strain at work and AH is explained by the effects of psycho-emotional stress on the neuroendocrine dynamics.
The constant exposure to psycho-emotional stress causes hyperactivity of the sympathetic nervous system and dysfunction of the hypothalamic-pituitary-adrenal axis, with release of noradrenaline and adrenaline in high concentrations in the synaptic cleft and in the bloodstream, respectively, which causes, in the long term, persistent elevation of blood pressure 4 - 5. It could be said that individuals performing psychosocially demanding tasks deal with emotions and thoughts whose psychic load exceeds the possibilities of recovery in a certain environment, considering the low control margins that characterize - according to the demand-control model - such situations of job strain.
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Greater reactivity and lower margin for the recovery of the resulting psychosocial stress are two factors that, in the long term, influence the increase in blood pressure and the risk of both hypertensive and cardiovascular diseases. Although consistent, the results found in this study must be interpreted with caution because of at least two limitations: However, this has been a standard measure of AH already validated in other studies, including the cohort of American nurses 25 ; b since it is a cross-sectional study, the confidence on findings in terms of temporality and causality of associations decreases, but such effect is intrinsically related to the very design of study.
Despite these limitations, it is worth highlighting the following strengthness of this study: Not only the studies that have estimated the prevalence of AH but also the one that addressed the association between this outcome and demand-control at work in nursing team professionals focused subjects who exercised their labor activities only in hospitals tertiary level , which was not repeated in this study, whose participants were distributed in the primary and secondary levels of the healthcare network, strengthening its innovative character; b the fit of potential confounding factors by the multivariate analysis technique - the most suitable for the type of study design - avoids overfitting, once those variables overly correlated with exposure are not used in the model.
The relationship between job strain and AH in nursing professionals shows that psychosocial conditions increase the vulnerability of these workers to a disease of major importance for the Brazilian Public Health: It is also known that such disorder is the main risk factor for cardiovascular diseases, responsible for the majority of deaths in the country and for social and economic problems, mainly on social security - early disability retirement and pension payment.
In this sense, modifications in the nursing work process are essential to reduce the exposure of these professionals to psychosocial stress and to the primary prevention of AH and CVDs. In this scope, the expansion of nursing training in Brazil is necessary to achieve the goal of two professionals for every 1, inhabitants proposed by WHO. Moreover, it is up to health services managers to gather adequate in quantity nursing staffs to avoid the overload of tasks; it also important establishing a more democratic and participatory administrative model to improve staffs' autonomy in their labor activities.
Lastly, the results of this study and others related to nursing working conditions with health outcomes can contribute to justify these professionals' political demands. The year in hypertension.
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J Am Coll Cardiol. Is hypertension associated with job strain? A meta-analysis of observational studies. Chandola T, et al. Work stress and coronary heart disease: Hamer M, Malan L. Psychophysiological risk markers of cardiovascular disease. Job strain and hypertension in women: The influence of domestic overload on the association between job strain and ambulatory blood pressure among female nursing workers.
Conselho Federal de Enfermagem [Internet]. World Health Organization, The nature nursing quality of work life: