Resumo

GARCIA GARCIA, José Eloy. Care management of a severe psyquiatric disorder: Planning, implementation and evaluation after two years. Index Enferm [online]. 2004, vol.13, n.44-45, pp.21-25. ISSN 1699-5988.

Severe psychiatric disorders are one today's mental health problems that require urgent attention and the implementation of specific programmes by the public health care system. Psychiatric rehabilitation, in a community context using an assertive model is only effective if it is allocated the resources that provide patients with a structured environment that allows them to fulfil their affective, personal and social needs. The following case study presents the work done  by a team of nurses with one such patient in La Casita, a sheltered home, run by the SESPA  (Asturian public health system) mental health network. The patient is under the care of one nurse,  who is completely responsible for the planning, implementation and evaluation of the patient's treatment programme the goal of which is to help the patient resolve problems they have to face on a daily basis throughout their rehabilitation. An initial evaluation of the patient's condition, a thorough record of the treatment's implementation and a re-evaluation after a period of two years, are all part o the process. Also demonstrates that chronic patients who have been institutionalized for long periods of time and have a severe pathology require individual treatments with concrete realistic goals that must be adjusted according to the needs and interests of the patient.