Transcript Family Health Care Program Report THE LOMAHAN FAMILY

Family Health Care Program Report
UST Medical Interns
Group 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
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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
Known hypertensive since 1991, maintained on Nifedipine
Suffered from cerebrovascular accident 1991
2 weeks PTC
Infected wound 1st digit (L) foot
(-) trauma, fever, 3P’s
Hydrogen peroxide, betadine,
papaya leaf-concoction
1 week PTC
Erythematous wound with foulsmelling 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 intake
HPN stage 2
4th
HD
• Ray amputation of the 1st digit of the (L)
foot
6th HD
• Pulmonary congestion
• Intubated – placed on AC mode
8th HD
• Referred to Pulmonary Medicine
t/c HAP
14th HD
• Referred to Dermatology
> Decubitus ulcer grade 2, sacral area
19th HD
• Referred to Family Medicine
20th HD
• DNR status
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(+) 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
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(+) HPN (1991), with HBP at 200/100 and
UBP of 150/80; maintained on Nifedipine
10mg/tab 1 tab OD
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s/p CVA (1991)
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L-sided weakness
seen by a neurologist at a hospital
had 3 months PT sessions
was maintained on Aspirin
was bedridden since 2007
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No previous operations
No previous injuries
No previous blood transfusion
No adverse drug reactions/allergies
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(+) HPN – father
(+) Heart disease – father
(-) Asthma
(-) Allergy
(-) PTB
(-) Cancer
(-) Liver disease
(-) Thyroid disease
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Non-smoker
Non-alcoholic beverage drinker
No illicit drug use
Housewife
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
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 Supple neck, (-) distended neck veins, (-) anterior neck
mass, (-) palpable/tender cervical lymph nodes
 Symmetrical chest expansion, no retractions,
(+) crackles on both lung fields
 Adynamic precordium, AB at 5th LICS MCL, S1>S2 at
apex, S2>S1 at base, (-) murmurs
 Flabby, soft abdomen, NABS, (-) tenderness,(-) masses,
(-) hepatosplenomegaly, (-) CVA tenderness
 (+) anasarca
 Decreased 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:
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Superficial: not done
Deep Tendon: normoreflexive on (R) UE & LE ,
hyperreflexive on (L) UE & UE
Abnormal: Babinski not done, (-) nuchal rigidity
1.
2.
3.
4.
5.
6.
Bathing: patient receives assistance
Dressing: patient receives assistance
Toileting: patient receives assistance
Transfer: patient receives assistance
Continence: patient receives assistance
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 edema
C. Change in past 2 weeks: (X) no change
2. Dietary Intake
A. Overall change: (X) Change NOTE: feeding now via NGT
B. Duration: ~4 weeks
C. 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, infection
B. Change in past 2 weeks: (X) no change
Part 2: Physical Examination
5. Evidence of: (X) Muscle wasting (X) Edema
Part 3: SGA Rating: Mildly-Moderately Malnourished
TER = BEE x stress factor x activity factor
Where:
TER – total energy requirement
BEE – 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 infection
Activity factor – 1.2 for sedentary
TER = 1053kcal x (1.2 to 1.4) x 1.2
Total 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:
Objective Data:
 84 y/o female
 Left sided weakness
 Infected wound, 1st digit
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(L) foot
 Hypertensive since 1991
 s/p CVA 1991
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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
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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
Illness Trajectory: Major Therapeutic Efforts
Delos Santos Family
1035 Sta. Cruz St., Sampaloc, Manila
Storage room
C.R.
Kitchen
Bed room
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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
Type
No. of bedrooms
Cleanliness
Ventilation
Lighting
Lighting facilities
Water
Drinking water
Toilet type
Refuse disposal
Garbage collection
Vermin and insect type
Vermin and insect control
Animals
Neighborhood
Accessibility
Owned
Wood
2
Unkempt
Good ventilation
well lighted
Meralco
NAWASA
Distilled water refilling station
Manually flushed
Plastic bag, does not segregate
daily
Common houseflies, mosquitoes,
cockroaches and rats
Insecticides and racumin
None; many stray cats and dogs
Residential
taxi, bus, jeepney, tricycle
Delos Santos Family
1035 Sta. Cruz St., Sampaloc, Manila
November 9, 2009
LEGEND:
Hypetension
Nephrolithiasis
Glaucoma
DM
CP complications 2o to hip surgery
Intestinal Parasitism
Stroke
PTB treated
Osteoarthritis
Peripheral Arterial Occlusive Disease
Heart Attack
Delos Santos Family
1035 Sta. Cruz St., Sampaloc, Manila
November 9, 2009
LEGEND:
Hypetension
Nephrolithiasis
Glaucoma
DM
CP complications 2o to hip surgery
Intestinal Parasitism
Stroke
PTB treated
Osteoarthritis
Peripheral Arterial Occlusive Disease
Heart Attack
Type of Family
 Nuclear
 Middle class
 Democratic
 Life Cycle
 Family in later years
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Family
Member
Estela
Age
Juanito
82
Sex Educational Occupatio
Attainment
n
F
HS
Homemak
er
M
College
Dentist
Rodolfo
61
M
HS
Armando
34
M
Teresita
Juanito
Mileth
?
57
?
F
M
F
Vocational
Course
?
College
College
Eduardo
? (Eduardo’s
wife)
55
?
M
F
HS
?
84
unemploy
ed
Telecom
Technician
?
Dentist
Homemak
er
?
?
Current Health
Status
Hospitalized:
Deceased: CP
complications 2o
to hip surgery
Glaucoma
Deceased: Heart
Attack
?
PTB, treated
Heart disease
?
?
Role in Family
Primary Caregiver
Editha
53
F
College
Jun
Carlito
Fely
Grace
?
51
?
49
M
M
F
F
HS
College
College
College
Rogelio
Agnes
?
47
M
F
Henry
?
M
Rolando
45
M
Helen
43
F
Dondon
?
M
Homemak
er
Contractor
Teacher
Teacher
Nurse
College
Engineer
Vocational Beautician
course
?
Telecom
Technician
HS
Constructi
on worker
HS
Homemak
er
HS
Driver
In good health
In good health
Nephrolithiasis
In good health
In good health
In good health
Nephrolithiasis
Deceased: ?Sepsis
Hypertension
DM
In good health
Breadwinner
Decision-maker
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
1. There is presence of some belief /
practices that are unacceptable to our
culture or negatively affect the way of
living {be specific}
Cultural
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
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
1. Level of education is a hindrance to
achievement, livelihood, success
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
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
MInsan
Halos
Hindi
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
7x3
3x1
RODOLFO’S EXPECTATIONS
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He expects his siblings to:
 Help him take care of their
mother
 Someone will accompany him
in the hospital
 Help do errands
 Financial aid
 Realistic
 Being met
CHILDREN’S EXPECTATIONS
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Her children expect that
their mother will:
 Improve
 Be weaned from mechanical
ventilator
 Regain her strength
 Be like in her pre morbid state
 Unrealistic
 Not being met
CHILDREN’S EXPECTATIONS
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Her children expect that
their mother will:
 Improve
 Be weaned from mechanical
ventilator
 Regain her strength
 Be like in her pre morbid state
BARRIERS
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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)
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Breadwinner: Grace (Nurse
working in New Jersey)
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Monthly allowance
provided for: 250 US
Dollars (11,750 pesos)
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Electricity: ~300 pesos
Water: ~200 pesos
Food: ~5000 pesos
Medicine: ~5000 pesos
Miscellaneous/Savings:
~1250 pesos
Accomplished
Adjusting to physiologic changes
of later life
X
Re examining their living
arrangements
X
Participating in group activities
Maintaining contact with younger
generation
Not
Accomplished
X
X
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
X
Making 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
Not
Accomplished
X
Delos Santos
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Estela, mother
Estela, index patient
Type of care
Problem
Recommendation
Medical
Wet gangrene S/P Ray amputation
Asepsis of wound and change of
dressing
ASHD, CAD, atrial, NIF Class IV-C
SAH Stage II, controlled
Decubitus ulcer
HAP, on mechanical ventilator
UTI, fungal (Candida
Wellness
Diet and Nutrition
Exercise and Daily Activity
Heath Promotion and Maintenance
HPN meds (Amlodipine,
Metoprolol)
Strict adherence to turning
schedule
duoderm
Antibiotics for HAP (Imipenem)
Antifungal for Candida famata
Regular change of foley
catheter
Patient has adequate dietary
intake via NGT
Type of care
Problem
Recommendation
Environmental
The family’s home is well lit and
ventilated.
No overcrowding
Insect and vermin control is also
satisfactory
Garbage collection is done 1x/day.
Encourage the family to
keep their house clean;
suggest adding additional
light fixtures and windows
for better ventilation
Encourage 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
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Rodolfo, eldest son
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Rolando, youngest son
Problem
Goal
Recommendation
Adequate
treatment
Proper work ups and treatment; Refer to Ophthalmology
Maintain
health
Low fat, low salt, high fiber diet; encouraged to drink 8-10
glasses of water daily
Continue walking 3x a week as a form of exercise (at least 30
minutes).
Update immunization
Screen for hypertension
Geriatric assessment (Rodolfo)
Strict compliance to medications and outpatient consultation
should be emphasized; Educate on the benefits health
prevention (what medications?)
Medical
Rodolfo, 61 year old
Glaucoma
Rolando, 40 year old
Pterygium
Wellness
Rodolfo
Apparently healthy
Rolando
Apparently healthy
Psychological
Rodolfo
Caregiver strain
Reduce strain Address major causes of strain
Encourage ventilation of feelings
Problem
Goal
Recommendation
Environmental
Well lit, well-ventilated,
clean, non-crowded house
Encourage the family to keep their house clean; suggest
adding additional light fixtures and windows for better
ventilation
Encourage family to segregate garbage more frequently
continue insect and vermin control methods
Economic
No lack of funds
Appropriate Ensure that all needs are adequately met
allocation
of funds

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
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The cornerstone of family- centered care is
early, effective, and intensive communication
with the patient’s relatives
An Editorial Article from the American Journal of Respiratory & Critical Care
Medicine Vol 171. pp 803–805, 2005
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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
An Editorial Article from the American Journal of Respiratory & Critical Care
Medicine Vol 171. pp 803–805, 2005

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
An Editorial Article from the American Journal of Respiratory & Critical Care
Medicine Vol 171. pp 803–805, 2005

Family conferences are held when a shift is
needed from curative to palliative care, from
cure to comfort
An Editorial Article from the American Journal of Respiratory & Critical Care
Medicine Vol 171. pp 803–805, 2005

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
An Editorial Article from the American Journal of Respiratory & Critical Care
Medicine Vol 171. pp 803–805, 2005

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 2007
DOI 10.1215/03616878-2007-040 © 2007 by Duke University Press

Reveals family caregivers
 untrained,
 under-supported
 unseen

shadow workforce acting as:


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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 2007
DOI 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
 SAH Stage II, controlled
 Wet gangrene 1st digit
sacral area, gr 2. sacral
area with eschar at
midback
 t/c HAP
 Patient is mild to
moderately
malnourished, however
dietary intake is
adequate.
(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
 Decubitus ulcer gr .1
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.
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APGAR scores are
varied among family
members reflecting
different degrees of
satisfaction with family
functioning.
 High strain in Caregiver
(Rodolfo)

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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.
By
USTH Postgraduate Interns
Group 12 Batch 2009-2010
Adraneda, Celina
Barranco, Grace Abigaille
Belmonte, Francis Joseph
Bernardo, Mary Monica
Biag, Marika
Bueno, Jan Andrew