[Patient with COPD. Comprehensive assistance in home care]

In order to respond to the objectives of a Home Care Patient Program bearing in mind the patient as the fundamental element from his/her individual and human dimensions, considering his/her family and family environs, it is necessary to establish and integrated, interdisciplinary therapeutic method based on a coordinated program involving all the professional involved in the process. The work of nurses, an essential element in this program, should be based on a conceptual model. It is important to elaborate an integral care plan based on the detection of the needs, objectives to achieve, team interventions both on the patient as the caretaker and to evaluate the results in order to achieve the highest degree of effectiveness and efficiency in home care of patients.