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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 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 (+) 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) {any deficits? Any ffup with AMDs? Medications? Therapy?} No previous operations No previous injuries No previous blood transfusion No adverse drug reactions/allergies (+) HPN – father (+) Heart disease – father (-) Asthma (-) Allergy (-) PTB (-) Cancer (-) Liver disease (-) Thyroid disease 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 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: 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 (L) foot Hypertensive since 1991 s/p CVA 1991 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 HAP Illness Trajectory: Major Therapeutic Efforts Delos Santos Family 1035 Sta. Cruz St., Sampaloc, Manila Storage room C.R. Kitchen Bed room • • • • • • • • • • 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 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 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 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 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 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. 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 Information sharing with the family empowers them in several ways. 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. 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. 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? 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 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. 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: 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 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 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