Oliveira, Jonas Sami Albuquerque deDantas, Marianny Nayara Paiva2025-02-142025-02-142024-10-29DANTAS, Marianny Nayara Paiva. Gestão do cuidado transicional aos usuários com feridas de difícil cicatrização a partir da alta hospitalar. Orientador: Dr. Jonas Sâmi Albuquerque de Oliveira. 2024. 200f. Tese (Doutorado em Enfermagem na Atenção à Saúde) - Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, 2024.https://repositorio.ufrn.br/handle/123456789/62725Users with difficult-to-heal wounds include those with wounds that have not healed 40- 50% of their extent after four weeks of adequate analysis and clinical intervention. This health situation is related to biological, clinical, non-clinical and service delivery factors, in addition, it requires the use of multiple levels of complexity in the health care network. Therefore, to reduce the impacts of this problem on public health, Transitional Care is essential, a care modality that seeks to improve results for users, caregivers and health systems during transfers between different units, services and care levels. Thus, the present study aimed to analyze the management of Transitional Care for users with difficult-to-heal wounds in the health care network, from hospital discharge and the nurse's contributions to this process. This is an integrated single case study., of a qualitative nature and has as its unit of analysis the health care network in the city of Natal, Rio Grande do Norte. It was conducted in accordance with the guidelines of Yin (2015), its sources of evidence were semi-structured interviews with users with difficult-to-heal wounds who were discharged from hospital; to nurses who work in the management or assistance of services that make up the health care network of the municipality of analysis and a scope review, on the management of transitional care for users with wounds.The data obtained were examined using the content analysis method of Yin (2015) and using the philosophical framework of the Theory of Communicative Action, by Jurgen Habermas (2022), with support from the ATLAS TI® software. The results were presented in texts, figures, tables, tables and indicate that the transition of care for users with difficult-to-heal wounds begins during hospital admission and continues at other levels of care, with the participation of the user's multidisciplinary team and caregivers. Despite observing some necessary pillars for Transitional Care, elements such as communication between members of multidisciplinary teams and coordination between network services prove to be fragile and interfere with the continuity of care for users and their post-hospital discharge recovery. Elements related to users' vulnerability conditions also stand out as critical nodes of the phenomenon examined. In all health services included, nurses participated as active workers in managing the phenomenon studied. Its prominence was also evident in the scope review carried out, where strategies for managing Transitional Care were based on the use of technologies to improve this process in health services. The analysis of weaknesses, potentialities and strategies for improving Transitional Care provide input for reflection and improvement, with a view to reorganizing the service offered in the network and the quality of results related to users, caregivers and health services. The strategies identified in the literature are potentially replicable in health care networks and can be incorporated into environments that work with users who have wounds that are difficult to heal or other chronic health conditions.Acesso AbertoFerimentos e lesõesCuidado transicionalContinuidade da assistência ao pacienteGestão em saúdeEnfermeiras e enfermeirosdoctoralThesisCNPQ::CIENCIAS DA SAUDE::ENFERMAGEM