Family Health Care Program Report UST Medical Interns Group 12 Batch 2009-2010 Adraneda, Barranco,...

Family Health Care Program Report

UST Medical InternsGroup 12 Batch 2009-2010

Adraneda, Barranco, Belmonte F, Bernardo, Biag, Bueno

To present a case of a patient on DNR status for possible enrolment to the UST-DFM Family Health Care Program

To present a case of a patient with an acute debilitating illness necessitating prolonged hospital admission

To present the medical, psychological, social and spiritual problems of the index patient and her family

To assess the strengths and weaknesses of the family using the various family assessment tools

To formulate appropriate goals and plans for the patient and her family using the information gathered from the family assessment as a guide

Estela Delos Santos 84/F Widowed Filipino 1035 Sta. Cruz St.,

Sampaloc, Manila Protestant housewife HS graduate DOB: August 6,

1925 Informant: son Reliability: 90 %

Infected wound, 1st digit of the (L) foot

2 weeks PTC

Known hypertensive since 1991, maintained on NifedipineSuffered from cerebrovascular accident 1991

Infected wound 1st digit (L) foot(-) trauma, fever, 3P’s

Hydrogen peroxide, betadine,

papaya leaf-concoction1 week PTC Erythematous wound with

foul-smelling whitish to yellowish discharge, 1st digit (L) foot

ADMISSION

Admission • CXR, ECG and other labs were done• Referred to CV Medicine

ASHD, CAD at risk NIF Class IV-C Hypokalemia prob 2° to poor oral intakeHPN stage 24th HD • Ray amputation of the 1st digit of

the (L) foot6th HD • Pulmonary congestion• Intubated – placed on AC mode

8th HD • Referred to Pulmonary Medicinet/c HAP

14th HD • Referred to Dermatology> Decubitus ulcer grade 2,

sacral area19th HD • Referred to Family Medicine

20th HD • DNR status

(+) easy fatigability (-) weight loss, (-) loss of appetite (-) headache, dizziness (-) easy bruisability, skin allergies,

rashes (+) visual impairment (+) hearing dysfunction, (-) nasal

discharge (-) vomiting, abdominal pain, diarrhea,

constipation (-) urinary frequency, dysuria, flank pain (-) myalgia, arthralgia (-) altered sensorium

(+) HPN (1991), with HBP at 200/100 and UBP of 150/80; maintained on Nifedipine 10mg/tab 1 tab OD

s/p CVA (1991) L-sided weakness seen by a neurologist at a hospital had 3 months PT sessions was maintained on Aspirin was bedridden since 2007

No previous operationsNo previous injuriesNo previous blood transfusionNo adverse drug reactions/allergies

(+) HPN – father (+) Heart disease – father (-) Asthma (-) Allergy (-) PTB (-) Cancer (-) Liver disease (-) Thyroid disease

Non-smokerNon-alcoholic beverage drinkerNo illicit drug useHousewife

Stupurous, GCS 6 (M4, Vt, E1), not in cardiorespiratory distress

BP 120/80 HR 72 bpm, regular RR 20 cpm, regular

T 36.6oC , Wt: 50 kg, Ht: 167 cm Warm, moist skin, (+) 2 well-defined ulcers,

some clear based, some topped with blackish eschar over the midback and sacral area 1.0 x 1.5 to 2.0 x 3.0 cm

Pink palpebral conjunctivae, anicteric dirty sclerae, pupils 2-3 mm ERTL

Nasal septum midline, non-congested turbinates, (-) tragal tenderness, (-) nasoaural discharge

(+) endotracheal tube, moist buccal mucosa

Supple neck, (-) distended neck veins, (-) anterior neck mass, (-) palpable/tender cervical lymph nodes

Symmetrical chest expansion, no retractions, (+) crackles on both lung fieldsAdynamic precordium, AB at 5th LICS MCL, S1>S2

at apex, S2>S1 at base, (-) murmursFlabby, soft abdomen, NABS, (-) tenderness,(-)

masses, (-) hepatosplenomegaly, (-) CVA tenderness

(+) anasarcaDecreased pulses over (B) LE, (B) UE(+) ray amputation suture wound 1st digit

(L) with pus and areas of necrosis

Mental Status: stupurous, GCS 6 (M4, Vt, E1) Cranial Nerves: pupils 2-3mm ERTL, EOM’s full and

equal, no facial asymmetry, other CNs cannot be assessed

Motor: MMT cannot be assessed Coordination / involuntary movements: no

involuntary movements, coordination cannot be assessed Sensory: cannot be assessed Reflexes:

Superficial: not doneDeep Tendon: normoreflexive on (R) UE & LE ,

hyperreflexive on (L) UE & UEAbnormal: Babinski not done, (-) nuchal rigidity

1. Bathing: patient receives assistance2. Dressing: patient receives assistance3. Toileting: patient receives assistance4. Transfer: patient receives assistance5. Continence: patient receives

assistance6. Feeding: patient receives assistance

Patient Name: Delos Santos, Estela V.________Date:_November 7, 2009__Weight:_50kg______

Part 1: Medical History 1. Weight Change A. Overall change in past 6 months: ? kgs.B. Percent change: (X) gain - < 5% loss NOTE: d/t edemaC. Change in past 2 weeks: (X) no change

2. Dietary IntakeA. Overall change: (X) Change NOTE: feeding now via NGT

B. Duration: ~4 weeksC. Type of change: (X) full liquid diet

3. Gastrointestinal Symptoms (persisting for >2 weeks) : __?__none

4. Functional Impairment (nutritionally related)A. Overall impairment: (X) severe : bedridden, chronic

metabolic/endocrine disease, severe, infectionB. Change in past 2 weeks: (X) no change

Part 2: Physical Examination5. Evidence of: (X) Muscle wasting (X) EdemaPart 3: SGA Rating: Mildly-Moderately Malnourished

TER = BEE x stress factor x activity factor Where:TER – total energy requirementBEE – basal energy expenditure for females = 655.1 + (9.6 x wt in kg) + (1.85 x ht in cm) – (4.67 x age)

Stress factor – 1.2 to 1.4 for severe infectionActivity factor – 1.2 for sedentary

TER = 1053kcal x (1.2 to 1.4) x 1.2Total Enegy Requirement = 1516 to 1769 kcal/day

Actual diet: 1600kcal/day (50% carbohydrates, 30% fats, 20% proteins)Divided into 6 equal feedings of 2:1 dilution

+ 1 bottle yakult 3x a day+ Peptamen 5 scoops in ½ glass of water every other meal

Dietary intake assessment: ADEQUATE

Subjective Data:

84 y/o femaleLeft sided

weaknessInfected wound, 1st

digit (L) footHypertensive since

1991s/p CVA 1991

Objective Data:

Stupurous, GCS 6 (+) 2 well-defined ulcers,

some clear based, some topped with blackish eschar over the midback and sacral area 1.0 x 1.5 to 2.0 x 3.0 cm

(+) endotracheal tube (+) crackles on both lung

fields (+) anasarca Decreased pulses over (B) UE

& LE (+) ray amputation suture

wound 1st digit (L) with pus and areas of necrosis

hyperreflexive on (L) UE & UE

Wet gangrene 1st digit (L) foot 2° to Peripheral Arterial Occlusive Disease s/p ray amputation 1st digit (L) 10/23/09

ASDH, CAD at risk NIF Class IV-C SAH Stage II, controlled Decubitus ulcer gr .1 sacral area, gr 2.

sacral area with eschar at midback t/c HAPIllness Trajectory: Major Therapeutic Efforts

Delos Santos Family

1035 Sta. Cruz St., Sampaloc, Manila

Storage room

Bed room Kitchen

C.R.

• Wood and Concrete• House and Lot owned by family• Own Electricity• Own water• 2 rooms• Own Comfort Room• Have TV, radio, light, electric fan• Uses Stove with LPG to cook• Communication thru cellphone• Transportation: Jeep, Taxi, Pedicab, bus

House OwnedType WoodNo. of bedrooms 2Cleanliness UnkemptVentilation Good ventilationLighting well lightedLighting facilities Meralco Water NAWASADrinking water Distilled water refilling stationToilet type Manually flushed Refuse disposal Plastic bag, does not segregateGarbage collection dailyVermin and insect type Common houseflies, mosquitoes,

cockroaches and ratsVermin and insect control Insecticides and racuminAnimals None; many stray cats and dogsNeighborhood ResidentialAccessibility taxi, bus, jeepney, tricycle

Delos Santos Family1035 Sta. Cruz St., Sampaloc, ManilaNovember 9, 2009

Type of Family Nuclear Middle class Democratic

Life Cycle Family in later years

Family Member

Age Sex Educational Attainment

Occupation

Current Health Status

Role in Family

Estela 84 F HS Homemaker

Hospitalized:

Juanito 82 M College Dentist Deceased: CP complications 2o to

hip surgeryRodolfo 61 M HS unemploy

edGlaucoma Primary Caregiver

Armando 34 M Vocational Course

Telecom Technician

Deceased: Heart Attack

Teresita ? F ? ? ?Juanito 57 M College Dentist PTB, treatedMileth ? F College Homemak

erHeart disease

Eduardo 55 M HS ? ?? (Eduardo’s

wife)? F ? ? ?

Editha 53 F College Homemaker

In good health

Jun ? M HS Contractor In good healthCarlito 51 M College Teacher Nephrolithiasis

Fely ? F College Teacher In good healthGrace 49 F College Nurse In good health Breadwinner

Decision-makerRogelio ? M College Engineer In good healthAgnes 47 F Vocational

courseBeautician Nephrolithiasis

Henry ? M ? Telecom Technician

Deceased: ?Sepsis

Rolando 45 M HS Construction worker

Hypertension

Helen 43 F HS Homemaker

DM

Dondon ? M HS Driver In good health

1988 Armando died when he

was 34 years old due to Myocardial infarction.

1991 Estela was diagnosed to

have SAH s/p CVA

2000 Juanito, Estela’s husband

died due to complications of his operation.

2007 Estela seldom goes out

due to fear of slipping Oct 2009 Estela had a injury on her

left foot that resulted to a wet gangrene.

Admission to USTH CD

Parameter Strengths Weaknesses

Social 1. There is absence of animosity or rivalry

2. Healthy/ supportive intrafamilial relationships

3. Healthy/ supportive extrafamilial relationships

1. However, there is lack of intrafamilial lines of communication

Cultural 1. There is presence of some belief / practices that are unacceptable to our culture or negatively affect the way of living {be specific}

Religious 1. Spirituality is positively influencing way of life

2. Practicing one’s faith, enduring because of his faith.

Religion: Protestant

Educational 1. Level of education facilitates comprehension of most challenging circumstances

1. Level of education is a hindrance to achievement, livelihood, success

Economic 1. Ability to allocate funds appropriately

2. Ability to make ends meet most of the time.

Medical 1. Good compliance with medical management

2. Timely and appropriate medical consultation

Rodolfo(Son of patient)

Anna Lynn(Grand daughter)

Grace(daughter)

Adaptation 2 1 2

Partnership 0 1 2

Growth 1 0 2

Affection 2 1 2

Resolve 1 1 1

TOTAL 6 4 9

Caregiver Stress Index (Rodolfo)

Madalas

MInsan

Halos

Hindi

Naabala ang aking pagtulog dahil sa pagaasikaso sa pasyente

X

Nauubos ang aking sariling oras sa pagaalaga ng aking pasyente

X

Ang pag aalaga sa aking pasyente ay nakakapagod dahil sa pag karga, pagalalay at pag asikaso

X

Ang pag aalaga sa aking pasyente ay nagdudulot ng mga pagbabago sa buhay ng aking pamilya dahil sa nagulong pang araw araw na gawain

X

Ang pagaalaga sa aking pasyente ay nagdulot ng mga pagbabago s aking mga plano sa buhay tilad ng papalit o pagtigil sa trabaho o pagaaral, palabaslabas, pagbabakasyon atbp

X

Bukod sa pagaalaga, mayroon pang dumagdag na responsibilidad na nangangailangan ng tibay ng loob dahil hindi naiiwasan ang mga alitan at hindi pagkakaunawaan

X

Ang pagaalaga sa aking pasyente ay nangangailangan ng tibay ng loob dahil hindi naiiwasan ang mga alitan at hindi pagkakaunawaan

X

May mga pagkakataon na nauubos ang aking pasensya at at ako ay naiinis dahil sa asal ng aking pasyente

X

Ako ay nalulungkot dahil malaki na ang ipinagbago ng aking pasyente mula nang siya ay nagkasakit

X

Malaki na ang aking gastusin dahil sa pagaaaga.lubos akong nagaalala kung paano ko makakayanan ang sitwasyong ito

X

TOTAL: 24 7 x 3 3 x 1

RODOLFO’S EXPECTATIONS

He expects his siblings to: Help him take care of

their mother Someone will

accompany him in the hospital

Help do errands Financial aid

CHILDREN’S EXPECTATIONS

Her children expect that their mother will: Improve Be weaned from

mechanical ventilator Regain her strength Be like in her pre morbid

state Realistic Being met

Unrealistic Not being met

CHILDREN’S EXPECTATIONS

Her children expect that their mother will: Improve Be weaned from

mechanical ventilator Regain her strength Be like in her pre morbid

state

BARRIERS

DNR status No further laboratory

tests Cost of medications

(e.g. 1 dose of echinocandin for C. famata costs PhP 11,000.00; 1 sheet of duoderm costs PhP 800)

Breadwinner: Grace (Nurse working in New Jersey)

Monthly allowance provided for: 250 US Dollars (11,750 pesos)

Electricity: ~300 pesos Water: ~200 pesos Food: ~5000 pesos Medicine: ~5000

pesos Miscellaneous/Savings:

~1250 pesos

Accomplished Not Accomplished

Adjusting to physiologic changes of later life XRe examining their living arrangements XParticipating in group activities XMaintaining contact with younger generation X

Accomplished Not Accomplished

Maintaining own and or couple functioning and interest in the face of physiologic decline, exploration of new familial and social options

X

Support for more central role for middle generation

XMaking room in the system for the wisdom and experience of the elderly generation without over functioning them

X

Dealing with loss of spouse, siblings and other peers and preparation for own death, life review and integration

X

Delos Santos

Estela, mother

Type of care

Problem Recommendation

Medical Wet gangrene S/P Ray amputation

ASHD, CAD, atrial, NIF Class IV-C

SAH Stage II, controlled

Decubitus ulcer

HAP, on mechanical ventilator

UTI, fungal (Candida

Asepsis of wound and change of dressing

HPN meds (Amlodipine, Metoprolol)Strict adherence to turning scheduleduodermAntibiotics for HAP (Imipenem)Antifungal for Candida famata Regular change of foley catheter

Wellness Diet and Nutrition

Exercise and Daily ActivityHeath Promotion and Maintenance

Patient has adequate dietary intake via NGT

Estela, index patient

Type of care

Problem Recommendation

Environmental

The family’s home is well lit and ventilated.No overcrowding Insect and vermin control is also satisfactoryGarbage collection is done 1x/day.

Encourage the family to keep their house clean; suggest adding additional light fixtures and windows for better ventilationEncourage family to segregate garbage more frequently continue insect and vermin control methods

Economic Appropriate allocation of funds

Ensure that all needs are adequately met

Psychosocial Emotional support from the family

Frequent visit of family members

Rodolfo, eldest son

Rolando, youngest son

Problem Goal Recommendation

Medical

Rodolfo, 61 year old GlaucomaRolando, 40 year old Pterygium

Adequate treatment

Proper work ups and treatment; Refer to Ophthalmology

Wellness

Rodolfo Apparently healthyRolando Apparently healthy

Maintain health

Low fat, low salt, high fiber diet; encouraged to drink 8-10 glasses of water dailyContinue walking 3x a week as a form of exercise (at least 30 minutes). Update immunizationScreen for hypertensionGeriatric assessment (Rodolfo)Strict compliance to medications and outpatient consultation should be emphasized; Educate on the benefits health prevention (what medications?)

Psychological

Rodolfo Caregiver strain

Reduce strain

Address major causes of strainEncourage ventilation of feelings

Problem Goal Recommendation

EnvironmentalWell lit, well-ventilated, clean, non-crowded house

Encourage the family to keep their house clean; suggest adding additional light fixtures and windows for better ventilationEncourage family to segregate garbage more frequently continue insect and vermin control methods

Economic

No lack of funds Appropriate allocation of funds

Ensure that all needs are adequately met

Results of epidemiologic studies identifying family needs and barriers to compassionate care for family members have been used to improve the effectiveness of information given to families and to benefit communication between families and physicians in the ICU

An Editorial Article from the American Journal of Respiratory & Critical Care Medicine Vol 171. pp 803–805, 2005

The cornerstone of family- centered care is early, effective, and intensive communication with the patient’s relatives


Information empowers family members by: Answering their needs, enabling them to

understand the patient’s situation Reducing anxiety and depression Putting the family members in a position

to act as surrogates


Relatives of patients who died in the ICU were left with a heavy burden of emotional distress, indicating a pressing need for improving caregivers’ response to specific informational family needs at the end of life


Family conferences are held when a shift is needed from curative to palliative care, from cure to comfort


When providing care to dying patients and their families, exercising compassion is not enough: critical-care physicians and nurses must sharpen their communication skills, continuously evaluate their practices, identify inadequacies and mistakes, and work toward correcting them


By teaching ourselves how to take full advantage of all opportunities to provide effective information and emotional support, we will make the family end-of-life conference a powerful, sensitive, and enriching tool for addressing the specific needs of each patient dying in the ICU and of his or her family members. An Editorial Article from the American Journal of Respiratory & Critical Care

Medicine Vol 171. pp 803–805, 2005

The work of family caregivers of elders goes far beyond previously recognized

Despite the lack of formal training and monetary compensation, family caregivers actually operate as part of the geriatric health care workforce

Bookman, Ann and Mona Harrington. Family Caregivers: A Shadow Workforce in the Geriatric Health Care System? Journal of Health Politics, Policy and Law, Vol. 32, No. 6, December 2007DOI 10.1215/03616878-2007-040 © 2007 by Duke University Press

Reveals family caregivers untrained, under-supported unseen

shadow workforce acting as: geriatric case managers medical record keepers Paramedics patient advocates

Bookman, Ann and Mona Harrington. Family Caregivers: A Shadow Workforce in the Geriatric Health Care System? Journal of Health Politics, Policy and Law, Vol. 32, No. 6, December 2007DOI 10.1215/03616878-2007-040 © 2007 by Duke University Press

Many health care institutions are committed to patient- and family-centered care this does not usually translate into

specific support for family caregivers

In some cases, caregivers need the kind of social and emotional assistance available through support groups

Support groups enable caregivers to learn from the knowledge and experience

of others lessen their sense of isolation voice their concerns to others who truly

understand their situation

The most common support systems included extended family members

usually adult children relying on their siblings in caring for an elderly parent

adult children relying on their own adult children for help with this care

Important not to confuse what caregivers themselves are able to organize with the desirability of a multipronged approach to caregiver support organized by health care institutions and home care service organizations

84 y/o, Female Assessment

Wet gangrene 1st digit (L) foot 2° to Peripheral Arterial Occlusive Disease s/p ray amputation 1st digit (L) 10/23/09

ASDH, CAD at risk NIF Class IV-C

SAH Stage II, controlled

Decubitus ulcer gr .1 sacral area, gr 2. sacral area with eschar at midback

t/c HAP Patient is mild to

moderately malnourished, however dietary intake is adequate.

Nuclear type of family

Middle Class Life cycle: family in

later years The family has more

strengths than weaknesses in social, cultural, religious, educational, economic and medical aspects.

APGAR scores are varied among family members reflecting different degrees of satisfaction with family functioning.

High strain in Caregiver (Rodolfo)

Provide adequate work ups and treatment for the patient and other family members that have an illness

Increase family interaction and better communication

Continue with family conference to enhance understanding of the situation and for more informed decision making

We recommend that the family continue to be seen by our Department due to the patient’s medical condition and the relatives’ apparent and expected psychosocial difficulties at present.

ByUSTH Postgraduate Interns Group 12 Batch 2009-2010

Adraneda, CelinaBarranco, Grace AbigailleBelmonte, Francis Joseph

Bernardo, Mary MonicaBiag, Marika

Bueno, Jan Andrew

Family Health Care Program Report UST Medical Interns Group 12 Batch 2009-2010 Adraneda, Barranco,...

Documents

Transcript of Family Health Care Program Report UST Medical Interns Group 12 Batch 2009-2010 Adraneda, Barranco,...