Trattamento dei pazienti con insufficienza renale cronica: un'esperienza di presa in carico multidisciplinare

Teamwork may offer several advantages to individual professionals and to the healthcare context in which they operate: multidisciplinary and multi-professional integration, performance improvement, skills enhancement and increased safety in clinical and organizational processes, offering a significant contribution to the improvement of the quality of life of patients with chronic diseases. The course of kidney disease is evolving and implies different treatment steps leading the patient to live in a climate of uncertainty and anxiety about the future. This situation represents for the person a condition of permanent “stress” with difficulties in maintaining positive and constructive reactions. Supporting the psycho-social uneasiness of chronic patients, making thus livable living conditions, means defining health programs which meet their needs. Our experience follows a pattern according to which every patient who begins the Peritoneal Dialysis is rated by all team professionals to highlight his/her physical and mental conditions, his/her treatment compliance and his/her ability to manage the disease. The course of the treatment is a continuous process aimed to enhance the self-management capability, taking into account the patient's main needs. In the care relationship the team should support the patient to overcome the state of dependence by transferring all the necessary tools for self-management. This case report shows how the team's active communication is essential for the implementation of an adequate care for CKD patients. (nursing)