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