Preventive Medicine

Preventive MedicinePreventive Medicine

Members: Epetia-Erestain-Esguerra-Esmael-Eugenio-Evangelista Members: Epetia-Erestain-Esguerra-Esmael-Eugenio-Evangelista E, Evangelista K, Facton, Fajardo, Fang, Florendo, Fontano, E, Evangelista K, Facton, Fajardo, Fang, Florendo, Fontano,

Francsico, Gabuat, Gaffud, Gagtan, Gallardo, GaranFrancsico, Gabuat, Gaffud, Gagtan, Gallardo, GaranSection BSection B

HOME CAREHOME CARE

It is the provision of health care in the patient’s It is the provision of health care in the patient’s home to promote, maintain, and restore health or home to promote, maintain, and restore health or minimize the effects of illness and disabilityminimize the effects of illness and disability

formal careformal care

skilled careskilled care

informal careinformal care

non-medical carenon-medical care or or custodial carecustodial care

home health carehome health care

To get betterTo get better

To become independentTo become independent

To become self-sufficientTo become self-sufficient

to maintain your highest level of ability or health, to maintain your highest level of ability or health, and help you learn to live with your illness or and help you learn to live with your illness or disabilitydisability

Older people unable to care for themselvesOlder people unable to care for themselves

Disabled peopleDisabled people

w/ Chronic illnessesw/ Chronic illnesses

w/ Acute episodic illnessesw/ Acute episodic illnesses

Discharged patients requiring medical supervision or Discharged patients requiring medical supervision or rehabilitationrehabilitation

Terminally ill patientsTerminally ill patients

ASPECTS OF HOME ASPECTS OF HOME CARECARE

PREVENTIVEPREVENTIVE Health promotionHealth promotion

Maintenance for each family memberMaintenance for each family member

Screening in the home for undetected diseasesScreening in the home for undetected diseases

DIAGNOSTIC• Includes laboratory and ancillary procedures in the management of the patient and their family members

THERAPEUTICTHERAPEUTIC Pharmacologic and non-pharmacologic Pharmacologic and non-pharmacologic

management of the patient’s illness as well as management of the patient’s illness as well as that of their familythat of their family

REHABILITATIVE

• various exercises and rehabilitation measures

LONG TERM MAINTENANCELONG TERM MAINTENANCE

Sustaining the care of the chronically or Sustaining the care of the chronically or terminally-ill patientsterminally-ill patients

PSYCHOSOCIAL CARE• addressing the psychological, emotional and social needs of the patients and their families

Preparation for Home Preparation for Home CareCare

Preparation for Home Preparation for Home CareCare

Planning includes :Planning includes :

Assessment and preparation of the Assessment and preparation of the patientpatient and and the the home environmenthome environment

facilitate the safest and smoothest facilitate the safest and smoothest transitiontransition

I. Preparing the PatientI. Preparing the Patient

1.1. Sharing information about the Sharing information about the diagnosis diagnosis considered.considered.

2.2. Treatment plans Treatment plans and and therapeutic options therapeutic options are are also discussed.also discussed.

II. Patient AssessmentII. Patient Assessment

Includes the evaluation of the patient’s :Includes the evaluation of the patient’s :

1.1. physical conditionphysical condition

2.2. Functioning of extremitiesFunctioning of extremities

3.3. Sensory componentsSensory components

4.4. Excretory functionsExcretory functions

Prior to Discharge :Prior to Discharge :

Physical Functioning Physical Functioning must be enhanced by :must be enhanced by :

1.1. Eliminating unnecessary bed rest in the Eliminating unnecessary bed rest in the hospital.hospital.

2.2. Physical activity must be encouragedPhysical activity must be encouraged

appropriate limit of tolerance will be appropriate limit of tolerance will be reached.reached.

III. Preparation of the III. Preparation of the Physical Environment at Physical Environment at

HomeHome

Done with the help of the caregiversDone with the help of the caregivers

Caregivers should be trainedCaregivers should be trained

Safety measures Safety measures and and mobilitymobility for the for the bathroom, bedroom, doors and stairs should bathroom, bedroom, doors and stairs should be planned.be planned.

ConclusionConclusion

The patient’s The patient’s QUALITY OF LIFE QUALITY OF LIFE must be the must be the concern of the physician.concern of the physician.

With With proper coordination and planningproper coordination and planning, the , the patient could be relegated to an independent patient could be relegated to an independent life.life.

Organizing a Home Organizing a Home Care ProgramCare Program

Organizing a home care Organizing a home care programprogram

Get manpowerGet manpower

Train staffTrain staff

Prepare a home care programPrepare a home care program

Do networking and linkagesDo networking and linkages

Implement the programImplement the program

Evaluate the programEvaluate the program

1. Get manpower1. Get manpower

Home care team consist ofHome care team consist of Primary care physicianPrimary care physician NurseNurse TherapistTherapist Social workerSocial worker volunteersvolunteers

1. Get manpower1. Get manpower

The home care team works togetherThe home care team works together

Blend their skills and servicesBlend their skills and services

Meets the needs of the patients and familyMeets the needs of the patients and family

2. Train staff2. Train staff

Staff must be trained inStaff must be trained in Assessing hazards of homeAssessing hazards of home Conducting functional assessmentConducting functional assessment Monitoring medicationsMonitoring medications Assessing caregiversAssessing caregivers

3. Prepare a home care 3. Prepare a home care programprogram

Various servicesVarious services

Mechanics of implementationMechanics of implementation

Policies and fees including reimbursementsPolicies and fees including reimbursements

4. Do networking and 4. Do networking and linkageslinkages

Communications with various agenciesCommunications with various agencies

Community resourcesCommunity resources

Awareness of what they have to offerAwareness of what they have to offer

5. Implement the 5. Implement the programprogram

Meet the patient and establish rapportMeet the patient and establish rapport

Know their expectations and do goal settingKnow their expectations and do goal setting

Assess educational and clinical needsAssess educational and clinical needs

Schedule visitsSchedule visits

Checklist of gadgets and equipmentsChecklist of gadgets and equipments

Financial agreementsFinancial agreements

6. Evaluate the 6. Evaluate the programprogram

Monthly health management meetingMonthly health management meeting

Adjustments are done depending on the Adjustments are done depending on the results of the evaluationresults of the evaluation

Guidelines for Home Guidelines for Home VisitVisit

Guidelines for home Guidelines for home visitvisit

Enables the physician to identify problems Enables the physician to identify problems hidden during clinic visitshidden during clinic visits

family interactionfamily interaction

family role in illnessfamily role in illness

role in healingrole in healing

Home visits can deepen the physicians Home visits can deepen the physicians understanding of the familyunderstanding of the family


Preparation Preparation

PlanningPlanning

CoordinationCoordination


Select the patient and schedule the visitSelect the patient and schedule the visit Review medical recordsReview medical records Background regarding the disease is warrantedBackground regarding the disease is warranted REVIEW LITERATUREREVIEW LITERATURE Prepare home care planPrepare home care plan


During the visitDuring the visit Necessary instrumentsNecessary instruments Develop rapportDevelop rapport History and psychosocial issuesHistory and psychosocial issues Living conditionsLiving conditions Cleanliness and safetyCleanliness and safety

It is important to select a PRIMARY CAREGIVERIt is important to select a PRIMARY CAREGIVER


During the post visitDuring the post visit Write the reportWrite the report Problem list Problem list Intervention performedIntervention performed Schedule follow up visitsSchedule follow up visits Coordinate if referral is neededCoordinate if referral is needed

Home Care Technique: Home Care Technique: NGT insertionNGT insertion

1.1. Lubricate NGT with water soluble jelly Lubricate NGT with water soluble jelly for 3-4 inches at the dital end.for 3-4 inches at the dital end.

2.2. Introduce lubricated tube along the floor Introduce lubricated tube along the floor of the nose with the patient sitting and of the nose with the patient sitting and the head supported to prevent reflex the head supported to prevent reflex withrawal.withrawal.

3.3. Advance the tube towards nasopharynx Advance the tube towards nasopharynx then to esophagus.then to esophagus.

4.4. The gastroesophageal junction is The gastroesophageal junction is reached typically at 40 cm.reached typically at 40 cm.

Technique:Technique:5. Once the tube has been passed, confirm 5. Once the tube has been passed, confirm

if placement is correct by:if placement is correct by:

a. open end of the tube placed in a glass of water. a. open end of the tube placed in a glass of water.

Air bubbles = tube in bronchi or tracheaAir bubbles = tube in bronchi or trachea

b. patient asked to hum or talk. b. patient asked to hum or talk.

Not possible = tube in larynx. Withraw Not possible = tube in larynx. Withraw tube.tube.

c. a 60ml syringe with air is connected to the c. a 60ml syringe with air is connected to the suction lumen of the NGT. The examiner suction lumen of the NGT. The examiner auscultates the stomach while an assistant auscultates the stomach while an assistant empties the syringe slowly.empties the syringe slowly.

whooshing sound of borborygmi produced whooshing sound of borborygmi produced only at 10-20ml of air = tube is in the stomachonly at 10-20ml of air = tube is in the stomach

Technique:Technique:

6. Secure the tube by anchoring it into the nose 6. Secure the tube by anchoring it into the nose with a hypoallergenic tape.with a hypoallergenic tape.

Mechanical VentilationMechanical Ventilation Indicated for respiratory failure.Indicated for respiratory failure.

Recommended Set-upRecommended Set-up Tidal volume – 60-80 breaths/minTidal volume – 60-80 breaths/min FiO2 0.40FiO2 0.40 Ventilator mode – assisted controlVentilator mode – assisted control Inspiratory flow – 50%Inspiratory flow – 50% Peak P – 50cm HPeak P – 50cm H2200 I:E ratio – 1:2I:E ratio – 1:2 Humidifier T – 35Humidifier T – 3500CC

Tracheostomy Tube Suctioning and Tracheostomy Tube Suctioning and CleaningCleaning

Removal of accumulated secretions facilitates:Removal of accumulated secretions facilitates:

patient comfortpatient comfort

increases respiratory frequencyincreases respiratory frequency

decreases risk of complete airway obstruction with decreases risk of complete airway obstruction with secretionssecretions

decreases risk of infection.decreases risk of infection.


Suctioning ProcedureSuctioning Procedure

1.1. Wash hands.Wash hands.

2.2. Position patient in a semi-sitting position.Position patient in a semi-sitting position.

3.3. Prepare materials.Prepare materials.

4.4. Attach catheter to suction tubing.Attach catheter to suction tubing.

5.5. Suction the sterile saline to moisten the Suction the sterile saline to moisten the catheter.catheter.

6.6. Cover the suction port with thumb while Cover the suction port with thumb while inserting the catheter and rotating it inserting the catheter and rotating it between the thumb and forefinger. between the thumb and forefinger. Periodically release the suction pressure for Periodically release the suction pressure for a brief second.a brief second.


Suctioning ProcedureSuctioning Procedure

Inner canula – soaked in Inner canula – soaked in hydrogen peroxide then hydrogen peroxide then rinse with normal saline.rinse with normal saline.

Tracheostomy site – cleaned Tracheostomy site – cleaned with sterile cotton buds and with sterile cotton buds and normal saline.normal saline.

7. Allow the patient to breath or cough between 7. Allow the patient to breath or cough between suctioning.suctioning.

8. Observe for sign of respiratory distress. Use manual 8. Observe for sign of respiratory distress. Use manual amby bagging if needed.amby bagging if needed.

9. Flush catheter with saline.9. Flush catheter with saline.

Catheter InsertionCatheter Insertion

FemalesFemales – half of the catheter must be inserted before inflating – half of the catheter must be inserted before inflating the balloon. Place it in the urethral meatus to the urethra then the balloon. Place it in the urethral meatus to the urethra then upwards towards the bladder.upwards towards the bladder.

MalesMales – catheter inserted at least 24 cm before inflating the – catheter inserted at least 24 cm before inflating the balloon. balloon.

IV insertionIV insertionPeripheral Iv lines are Peripheral Iv lines are

used for used for maintenance of fluid maintenance of fluid balance, balance, administration of administration of drugs and nutrition.drugs and nutrition.

Butterfly or catheter Butterfly or catheter may be used.may be used.

Connected to the Connected to the tubing of the IV tubing of the IV system.system.

Nursing CareNursing Care

Positioning of the patient in the bedPositioning of the patient in the bed

Moving patient in bedMoving patient in bed

Perineal CarePerineal Care

Oral CareOral Care

Bed bathBed bath

TransfersTransfers

ExercisesExercises

ROM exercises – to maintain muscle tone and ROM exercises – to maintain muscle tone and joint mobilityjoint mobility

Types of ROM:Types of ROM: Active in which patient performs movements on Active in which patient performs movements on

a non-functioning jointa non-functioning joint Active-assisted – patient and care-giver Active-assisted – patient and care-giver

participatesparticipates Passive – exercise performed by the caregiver.Passive – exercise performed by the caregiver.

Common geriatric Common geriatric problems in the homeproblems in the homeHome care of a stroke patientsHome care of a stroke patients

Home care of Stroke Home care of Stroke PatientsPatients

IMMOBILITYIMMOBILITY

PEPE Sitting balanceSitting balance

Neck turningNeck turning Ability to rise from a Ability to rise from a

sitting positionsitting position Evaluate ROM of all Evaluate ROM of all

joints and contractures joints and contractures notenote


consequences of consequences of immobilityimmobility↓↓CV fitnessCV fitnessJoint stiffness and Joint stiffness and

contracturescontracturesMuscle wastingMuscle wastingAccelerated Accelerated

osteoporosisosteoporosisPneumoniaPneumoniaVenous stasisVenous stasisPulmonary emboliPulmonary emboliDecubitus ulcerDecubitus ulcer


Treatment goal: Treatment goal: Maintain ADLMaintain ADL Achieve functional Achieve functional

independenceindependence

Non pharmacologicNon pharmacologic First approachFirst approach Patient’s educationPatient’s education Avoid complete bed restAvoid complete bed rest PhysiotherapyPhysiotherapy Occupational therapyOccupational therapy


ROM exercises without ROM exercises without excess stressexcess stress Flexibility Flexibility Avoid contracturesAvoid contractures

Progressive work Progressive work programsprograms Promote CV fitnessPromote CV fitness

Assistive devices- Assistive devices- enhancement of ADLenhancement of ADL CrutchesCrutches CanesCanes Contour pillowContour pillow


Analgesic- pain and anti-Analgesic- pain and anti-inflammatory effectinflammatory effect

TENS- painful shoulderTENS- painful shoulder


INCONTINENCEINCONTINENCE

5 clinical classification5 clinical classification UrgeUrge StressStress OverflowOverflow ReflexReflex FunctionalFunctional

Home care of Stroke Home care of Stroke PatientsPatientsHistory PE

Funtional Inability to reach bathroom in time

Confused, immobile

Urge Frequent sensation of need to urinate

Abnormal gait, Motor and sensory deficits

reflex No sensation of need to urinate

Abnormal gait, Motor and sensory deficits

Overflow ↓ force of stream, dribbling, necessity to strain

Palpable bladder and Fecal impaction

Stress dyspareunia Signs of estrogen lack


Management of incontinence

cause treatment

Spastic bladder Bladder retrainingDisposable undergarmentsImipramineOxybutinepropantheline

Hypotonic bladder Frequent voidingIntermittent catheterizationDisposable undergarmentsBethanecolphrnoxymebenzamine

Urethral insufficiency Weight loss and pelvic exercisePessaryEstrogen and imipramine


SKIN PROBLEMSSKIN PROBLEMS

a.a. Positioning of the patientPositioning of the patient

b.b. Sensory level and skin careSensory level and skin care

c.c. Pressure reliefPressure relief

d.d. Wound managementWound management


Nutritional problemsNutritional problems

evaluate nutritional status and requirementsevaluate nutritional status and requirements Dietary prescription Dietary prescription

Nutrients, electrolyte, volume Nutrients, electrolyte, volume Parenteral, enteral or oralParenteral, enteral or oral


BP CONTROLBP CONTROL Low saltLow salt Low fatLow fat MedicationsMedications activityactivity


THROMBOSISTHROMBOSIS Antiplatelet drugAntiplatelet drug

Prevent further aggregation →thrombosisPrevent further aggregation →thrombosis AspirinAspirin TiclopidineTiclopidine dipyridamoledipyridamole


WELLNESS PROGRAMWELLNESS PROGRAM Health maintenance plan Health maintenance plan

for all the family for all the family membersmembers

Periodic PE, screening Periodic PE, screening tests and developmental tests and developmental monitoringmonitoring


Physician as social mobilizerPhysician as social mobilizer Preparing for home while in the hospitalPreparing for home while in the hospital Facilitation of referralsFacilitation of referrals Coordinating with other agenciesCoordinating with other agencies Facilitation of community resourcesFacilitation of community resources


Physician as counselor and Physician as counselor and educatoreducator Educating the patient: Educating the patient:

treatment, medications, treatment, medications, supportive measures and supportive measures and course of diseasecourse of disease

Training of caregiversTraining of caregivers Counseling family members if Counseling family members if

they are stressedthey are stressed


Physician as a managerPhysician as a manager Coordinate the home environmentCoordinate the home environment Home care needsHome care needs

Modifying home for accessibilityModifying home for accessibility safetysafety


BEDROOMBEDROOM Large Large Bed should be at the Bed should be at the

height level with the height level with the wheelchairwheelchair

Electrical outletsElectrical outlets

BATHROOMBATHROOM Minimum of 3 feetMinimum of 3 feet Minimum of 30 inchesMinimum of 30 inches Toilet barsToilet bars Raised toilet seatRaised toilet seat Rubber matRubber mat Hand held showersHand held showers


DOORSDOORS Lever type handleLever type handle Automatic doorAutomatic door Door peephole must be Door peephole must be

lowered to the eye lowered to the eye

FURNITUREFURNITURE Unobstructed Unobstructed

passagewaypassageway

KITCHENKITCHEN Refrigerator, sink and Refrigerator, sink and

range should be range should be accessibleaccessible

Home Care Of COPD Home Care Of COPD PatientsPatients

Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease

Common among geriatricsCommon among geriatrics

One of the leading causes of permanent One of the leading causes of permanent disabilitydisability

Treatment not known to decrease morbidity Treatment not known to decrease morbidity or mortalityor mortality

Goal: improve quality of lifeGoal: improve quality of life Pulmonary rehabilitationPulmonary rehabilitation

Evaluation of Pulmonary Evaluation of Pulmonary Function and DisabilityFunction and Disability

Class IClass I Normal Activities: not significantly restrictedNormal Activities: not significantly restricted EmployableEmployable DyspneaDyspnea

Unusually strenuous activityUnusually strenuous activity


Class IIClass II Independent in essential activities of daily Independent in essential activities of daily

livingliving Restricted in other activitiesRestricted in other activities Employable if job is sedentaryEmployable if job is sedentary DyspneaDyspnea

Climbing stairsClimbing stairs


Class IIIClass III Does not require physical assistanceDoes not require physical assistance Probably not employableProbably not employable DyspneaDyspnea

Absent at restAbsent at rest During usual activitiesDuring usual activities

ShoweringShowering DressingDressing

Can walk at own pace but cannot keep up with Can walk at own pace but cannot keep up with othersothers


Class IVClass IV Some help in performing essential activities of Some help in performing essential activities of

daily livingdaily living Restricted to home if living aloneRestricted to home if living alone DyspneaDyspnea

Minimal exertionMinimal exertion Pausing after one flight of stairsPausing after one flight of stairs Walking more than 100 yardsWalking more than 100 yards Dressing upDressing up


Class VClass V Dependent on help of most needsDependent on help of most needs Entirely restricted to homeEntirely restricted to home Activity limited to bed and chairActivity limited to bed and chair Dyspnea at restDyspnea at rest


Goals and modalitiesGoals and modalities Prevention of exacerbationPrevention of exacerbation Relief of bronchospasmRelief of bronchospasm Reduction of secretionsReduction of secretions Breathing restrainingBreathing restraining


Goals and modalitiesGoals and modalities Exercise conditioningExercise conditioning Oxygen therapyOxygen therapy Educating the patientEducating the patient Family psychosocial managementFamily psychosocial management

Home Care of Cancer Home Care of Cancer PatientsPatients


Natural course of the diseaseNatural course of the disease Advancing diseaseAdvancing disease Terminal phaseTerminal phase

Primary goalPrimary goal Symptomatic treatmentSymptomatic treatment


QuestionsQuestions Are there adequate resources at home?Are there adequate resources at home? What are the expected morbidities of cancer What are the expected morbidities of cancer

treatment?treatment? Will the family be willing to act as caregivers?Will the family be willing to act as caregivers? Where will the patient die?Where will the patient die?


Needs of the patientNeeds of the patient MedicalMedical PsychosocialPsychosocial EnvironmentalEnvironmental SpiritualSpiritual


PhysicianPhysician EducationEducation

Key service to both patient and familyKey service to both patient and family Patients needsPatients needs Anticipation of deathAnticipation of death

Counseling and supportCounseling and support FamilyFamily FriendsFriends

Prevented from caregiver strainPrevented from caregiver strain


CounselingCounseling Set of techniques, skills and attitudes to help Set of techniques, skills and attitudes to help

people manage their own problems using their people manage their own problems using their own resourcesown resources

ObjectivesObjectives Symptom reliefSymptom relief Behavioral changeBehavioral change Self-sightSelf-sight

Function of Family Function of Family CounselingCounseling

EducationEducation

PreventionPrevention

SupportSupport

ChallengeChallenge

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Preventive Medicine

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