Abordaje integral de un caso complejo de diabetes mellitus en domicilio entre la gestora de casos y la enfermera comunitaria

Abstract

We present the case of a patient with long-term and clinically complex Diabetes Mellitus. She was taking part in the home care program in Primary Care. The complications of her DM affected her quality of life: blindness, kidney failure, treated with hemodialysis, and a cerebrovascular attack. We describe the evaluation following Virginia's Henderson model. This evaluation was made in the patient's home after she was discharged from the socio-health centre where she was admitted as her right leg was amputated at a supracondylar level. It was designed a care plan between the community nurse and the case manager using NANDA, NOC and NIC taxonomy. The care plan was carried out as a joint effort between the community nurse and the case manager who coordinated the planning with the rest of professionals. Results were evaluated 6 months after the initial assessment. This case, which had a high dependence and a high clinical complexity, required a multidisciplinary approach and the integration of different professionals, services and institutions to implement the patient's treatment. Because of all the above, it is important to mention the case management function to guarantee continuity, and overall and integrated care.