The care offered by nurses to elders with coronary artery disease from the perspective of Transitions Theory

ABSTRACT Objective: To analyze the planning and implementation of the care offered by nurses to elders with coronary disease during the hospital-house transition. Methods: Qualitative research that used the Transitions Theory as a theoretical reference. The participants were 12 nurses who work in a hospital that specializes in cardiology, in the city of Salvador-BA. A semistructured interview was carried out from January to February 2018, and the data was analyzed using the Content Analysis technique. Results: Transition care takes place on the day of discharge. The presence of the family was found to be a facilitator; low adherence, poor financial situations, the low educational levels inhibited its implementation. The rehospitalization is an indicator of the results of the transition of care. Final considerations: The planning and implementation of transition care is not effective. It must provide safety in the management of self-care in the home of elders with coronary disease and their families.

摘要 研究目的：分析冠心病老年患者在医院-家庭照护过渡阶段，护士所提供护理服务的规划与实施现状。方法：本研究为质性研究，以过渡理论（Transitions Theory）作为理论参考依据。研究对象为巴西巴伊亚州萨尔瓦多市某心脏病专科医院的12名在职护士。研究于2018年1月至2月开展半结构化访谈，并采用内容分析法（Content Analysis）对采集的数据进行分析。结果：过渡护理实施于患者出院当日。家属的参与被证实为护理过渡的促进因素；而患者依从性低下、经济状况窘迫、受教育水平偏低则会阻碍过渡护理的推行。再住院率可作为护理过渡效果的评价指标。结论：本研究发现当前过渡护理的规划与实施效果欠佳，需为冠心病老年患者及其家属构建能够保障居家自我照护管理安全性的护理方案。