Introduction: The Program Education through Work for Health (PEW-Health) was created in 2008 as a partnership between the Ministries of Health and Education, promoting the teaching-service-management-community integration, providing opportunities for professionals, students, teachers, and service users, in line with the needs of SUS, and having the topic of interprofessionality for its ninth edition (2019-2021). This report aims to share interprofessional learning based on the experience of a singular therapeutic project (STP) for a complex case within the PEW-Health activities of a university in the Midwest region, carried out in a Family Health Unit (FHU) in the municipality of Campo Grande, Mato Grosso do Sul (MS). Experience report: Students from a tutorial group of PEW-Health Interprofessionality participated in this experience, as well as preceptors, professionals from the Extended Nucleus of Family Health and Primary Care (ENFH-PC), and a tutor, who was a teacher in a Medical School. The STP was developed with an elderly patient with polypharmacy and the following chronic conditions: diabetes mellitus (DM), depression (DEP) and systemic arterial hypertension (SAH), monitored during the period from August 2019 to February 2020, prior to the COVID-19 pandemic, in a FHU in Campo Grande-MS, selected by the team due to the complexity of the case. Discussion: Through the STP, the group had the opportunity to evaluate, assist and perform practices to strengthen the patient’s “happiness project”. The STP allows team-patient intersubjectivity, focusing not only on the diseases, but on who they are. The carried-out home visits provided moments of listening for the performance of care in accordance with the needs, perceived and not perceived by the user. In the practice of STP, comprehensive care is provided, focused on the individual, showing the potential in continuing education and interprofessional teamwork, sharing knowledge, improving the sustainability of care and, consequently, qualifying health care, corroborating the results obtained in this study. Conclusion: Participation in the program allowed experiences that were previously absent during undergraduate school, such as contact with different health courses, practice in real SUS scenarios and application of concepts seen only in theory, such as humanized care and a comprehensive view, as well as communication with the team and the patient.
Introdução: O projeto terapêutico singular (PTS) é um conjunto de condutas terapêuticas para atendimento integral, respeitando singularidades individuais, em casos complexos¹. Neste PTS, é apresentado o caso de S.R.S., 67 anos, sexo feminino, aposentada, polifármaco, diagnóstico de hipertensão arterial sistêmica (HAS), depressão e diabetes mellitus (DM), pé diabético. Objetivo: Proporcionar atendimento qualificado e interprofissional, respeitando a individualidade e contexto; vivenciar trabalho em equipe, com contribuições de diferentes núcleos de conhecimento². Metodologia: Os estudantes realizaram visitas domiciliares semanais, de agosto/2019 a fevereiro/2020, com tutora e preceptoras, efetuando anamnese ampliada, escuta ativa, aferição da pressão arterial, avaliação do pé diabético, genograma e ecomapa. Metas foram estabelecidas entre equipe e S.R.S, tendo prioridades acordadas. Discutindo o caso, intervenções por núcleo de conhecimento foram organizadas, envolvendo todos os petianos, compartilhando tarefas. Resultados: O PTS de S.R.S foi construído segundo as etapas prescritas. Foram feitas visitas domiciliares com a participação de estudantes e preceptores, envolvendo os cursos de Fisioterapia, Medicina, Odontologia, Enfermagem e Nutrição. Na avaliação do pé, foram encontradas micoses interdigitais, dedos em garra, perda da sensibilidade e vascularização, obtendo classificação³ grau 2. Foram realizados: tratamento das micoses, corte adequado de unhas, hidratação da pele, cinesioterapia e orientação para uso de calçados e palmilhas ortopédicas. Orientou-se também o uso de medicamentos e controle glicêmico. A equipe atuou no contato com a Unidade de Saúde da Família (USF) para agendamentos e revisão da prescrição. Foi organizada caixa e tabela de controle do uso dos medicamentos, com descarte dos vencidos, bem como agendados horários prescritos de sua ingesta via alarme do celular. Trabalhou-se a compreensão das condições crônicas com S.R.S. e consequências no organismo, através da elaboração de atividades de educação em saúde personalizadas. S.R.S. passou a frequentar grupo de atividades físicas na Unidade de Saúde da Família (USF), ofertada pelo Núcleo Ampliado de Saúde da Família e Atenção Básica (NASF-AB), e foi inscrita em projeto voltado à melhoria da memória, na Universidade da 3ª Idade da Universidade Federal de Mato Grosso do Sul (UFMS). Considerações Finais: As intervenções contribuíram para melhoria na qualidade de vida, gerando confiança no tratamento e vínculo com a equipe. As atividades permitiram reconhecer qualitativamente as dificuldades de conviver com condições crônicas e importância do envolvimento da equipe. A visita domiciliar mostrou-se como ferramenta potente de cuidado, envolvendo a paciente, que passou a compreender melhor sua condição e correta conduta terapêutica, proporcionando confiança no autocuidado apoiado. Palavras-chave: Atenção Primária à Saúde; Diabetes Mellitus; Pé Diabético; Planejamento de Assistência ao Paciente.
Introduction: The Program Education through Work for Health (PEW-Health) was created in 2008 as a partnership between the Ministries of Health and Education, promoting the teaching-service-management-community integration, providing opportunities for professionals, students, teachers, and service users, in line with the needs of SUS, and having the topic of interprofessionality for its ninth edition (2019-2021). This report aims to share interprofessional learning based on the experience of a singular therapeutic project (STP) for a complex case within the PEW-Health activities of a university in the Midwest region, carried out in a Family Health Unit (FHU) in the municipality of Campo Grande, Mato Grosso do Sul (MS). Experience report: Students from a tutorial group of PEW-Health Interprofessionality participated in this experience, as well as preceptors, professionals from the Extended Nucleus of Family Health and Primary Care (ENFH-PC), and a tutor, who was a teacher in a Medical School. The STP was developed with an elderly patient with polypharmacy and the following chronic conditions: diabetes mellitus (DM), depression (DEP) and systemic arterial hypertension (SAH), monitored during the period from August 2019 to February 2020, prior to the COVID-19 pandemic, in a FHU in Campo Grande-MS, selected by the team due to the complexity of the case. Discussion: Through the STP, the group had the opportunity to evaluate, assist and perform practices to strengthen the patient’s “happiness project”. The STP allows team-patient intersubjectivity, focusing not only on the diseases, but on who they are. The carried-out home visits provided moments of listening for the performance of care in accordance with the needs, perceived and not perceived by the user. In the practice of STP, comprehensive care is provided, focused on the individual, showing the potential in continuing education and interprofessional teamwork, sharing knowledge, improving the sustainability of care and, consequently, qualifying health care, corroborating the results obtained in this study. Conclusion: Participation in the program allowed experiences that were previously absent during undergraduate school, such as contact with different health courses, practice in real SUS scenarios and application of concepts seen only in theory, such as humanized care and a comprehensive view, as well as communication with the team and the patient.
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