Transcript Document

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) {any deficits? Any ffup with
AMDs? Medications? Therapy?}
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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
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 _______nausea _____vomiting____ diarrhea
________ anorexia
4. Functional Impairment (nutritionally related)
A. Overall impairment:
A. (X) severe : bedridden, chronic metabolic/endocrine disease,
severe, infection
B. Change in past 2 weeks:
(X) no change
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
Part 2: Physical Examination
5. Evidence of:
(X) Muscle wasting
(X) Edema
Part 3: SGA Rating (check one)
B. Mildly-Moderately Malnourished
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? Matriarchal?
 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
daught
er)
Grace
(daughter
)
A
Ako ay nasisiyahan dahil nakakadama ako ng
tulong aking amilya sa oras ng problema
(ADAPTATION)
2
1
2
P
Ako’y nasisiyahan sa paraang nakikipagtalakayan
sa akin ang aking pamilya tungkol sa aking
problema (PARTNERSHIP)
0
1
2
G
Ako’y nasisiyahan at ang aking pamilya ay
tinatanggap at sinusuportahan ang mga bagay
na nais kong subukan para sa aking
ikabubuti at ikauunlad (GROWTH)
1
0
2
A
Ako’y naissiyahan sa paraang pinadadama ng aking
pamilya ang kanilang pagmamahal at
natutugunan ang aking damdamin tulad ng
galit, lungkot, at pag-ibig (AFFECTION)
2
1
2
R
Ako’y nasisiyahan dahil ako at ang aking pamilya
ay nagkakaroon ng oras para sa isa’t-isa
(RESOLVE)
1
1
1
Total
6
4
9
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
Bukod sa pagaalaga, mayroon pang dumagdag na
responsibilidad na nangangailangan ng tibay ng
loob dahil hindi naiiwasan ang mga alitan at hindi
pagkakaunawaan
MInsan
Halos Hindi
X
Madalas
MInsan
Halos Hindi
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
7
3
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
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Presently, medical problems are being
addressed as much as the limitations allow.
However, the expectations of the patient’s
family are not realistic and therefore, cannot
be met, and this will undoubtedly be a source
of stress and conflict, as well as a possible
mistrust towards the health system.
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The family conference was held wherein
these expectations as well as concerns
regarding the adequacy of care of the patient
were raised.
Family conferences are held when there is a
shift in the goal of management of the
patient.
It has been found by several studies that
communicating relevant information with the
family results in better care
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Information sharing with the family
empowers them in several ways.
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The roles of the family members, however,
are significant stressors that may or may not
be adequately addressed.
While it is important to look into the
biological well-being of each member of the
family, it is equally important to give focus on
the psychological, social and spiritual wellbeing as well.
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Thus, as we recommend the basic health
practices to the members of the family, we
also strongly recommend addressing the
psychosocial issues arising during this period
in the life of their family. This would include
the uncertainty of the patient’s future, the
stress being undergone by each family
member in their own capacity, and the
impact of this stage in their own personal
experience.
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Specific goals that we propose for the family
are:
To ensure this, we have formulated the
possible actions that may be undertaken
giving consideration to the current
resources, strengths and weaknesses of the
family:
Parent (Elsa Delos Santos)
Problem
Goal
Plan
Wet gangrene S/P Ray
amputation
Prevent infection of wound Asepsis of wound and
change of dressing
ASHD, CAD, atrial, NIF
Class IV-C
SAH Stage II, controlled
Further control of BP
HPN meds (Amlodipine,
Metoprolol)
Decubitus ulcer
Treatment for decubitus
ulcer
Turning schedule
duoderm
HAP, on mechanical
ventilator
Treatment for HAP
Antibiotics for HAP
(Imipenem)
UTI, fungal (Candida
Ensure adequate
treatment
Antifungal for Candida
famata
DNR status
Ensure that all family
members are aware of and
have accepted this
decision
Family meeting
Problem
Goal
Plan
Depression due to death of Resolve depression
spouse
Loneliness
Lessen loneliness
Frequent visit of family
members
Financial problems due to
medical condition of Elsa
Financial adjustment
Family members chip in
with medical fees
Children
Problem
Goal
Plan
Rolando, 61 year old
Glaucoma
Adequate treatment
Proper work ups and
treatment; Refer to
Ophthalmology
Juanito 57 years old
PTB (year unrecalled)
Adequate treatment 
done
(-)
Carlito 51 years old
kidney disease
Adequate treatment
Proper work ups and
treatment; Refer to IMNephrology
Agnes 47 years old
kidney disease
Adequate treatment
Proper work ups and
treatment; Refer to IM
Nephrology
Rolando 45 years old
hypertension
Adequate treatment
Proper work ups and
treatment;
Anti HPN meds
Helen 43 years old
Diabetes Mellitus
Adequate treatment
Proper work ups and
treatment; Regular CBG
monitoring; Anti DM meds
An Editorial Article from the
American Journal of Respiratory & Critical Care
Medicine
Vol 171. pp 803–805, 2005
Author?
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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

the cornerstone of family- centered care is
early, effective, and intensive communication
with the patient’s relatives
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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
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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
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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.

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

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
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Patient is mild to moderately malnourished,
however dietary intake is adequate.
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)



Nuclear type of family
Middle Class
Life cycle: family in later years


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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
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