dr. YUDHI WIBOWO, M.PH

DIAGNOSIS HOLISTIK (MULTI ASPEK) DAN PENANGANAN KOMPREHENSIF

(PARIPURNA)

Daftar Pustaka

� Azwar.A. Pengantar Ilmu Kedokteran Keluarga. UI

� Rakel. Textbook of Family Practice 6th

ed.Pennsylvania.2001.

� Goh, Azwar, Sugito.(2004) A Primer on Family

Practice. Singapore.

� Kekalih.(2008) Diagnostik Holistik. UI.

� Murtagh, J. General Practice 3rd Ed.

TUJUAN

� MAMPU MENERAPKAN PRINSIP-PRINSIP PENDEKATAN PELAYANAN KEDOKTERAN KELUARGA

� MAMPU MENINGKATKAN LEVEL KETERLIBATAN DOKTER DENGAN KELUARGA PASIEN

� MAMPU MENEGAKKAN DIAGNOSIS HOLISTIK

� MAMPU MENERAPKAN PENANGANAN KOMPREHENSIF

OUTLINE

� INTRODUCTION

� PENTINGNYA FAMILY AS UNIT OF CARE

� LEVEL KETERLIBATAN DOKTER DENGAN KELUARGA PASIEN

� PENILAIAN FAMILY DYNAMIC

� DEFINISI DIAGNOSIS HOLISTIK

� TUJUAN DIAGNOSIS HOLISTIK

� PENDEKATAN DIAGNOSIS HOLISTIK

� PENANGAN KOMPREHENSIF (PARIPURNA)

INTRODUCTION

� Prinsip pendekatan pelayanan KK meliputi :� Personal care : individual, menghormati pasien, hubungan& komunikasi intim, personal & privacy setting, alokasi waktucukup

� Primary care : kewenangan di layanan primer, tempatkontak pertama dgn pasien, peran sebagai gate keeper

� Continuity of care : tidak hanya di ruang periksa, konsultanuntuk seluruh keluarga, fokus pada monitoring risk factors, mencegah keadaan memburuk

� Comprehensive care : tidak hanya fokus pada disease, sickness & illness, semua aspek manusia (bio-psiko-sosio-kultural-spiritual)�whole person (holistik), semua level pencegahan dari konsep Level & Clark, tidak hanya fokus padakonten tapi konteks.

� Central Value of FM :� Patient-centered care :

� Cari tahu alasan kedatangan pasien (reason for encounter)

� Perhatikan Ideas, Concern, Expectation, Anxiety (ICEA)

� Holistic approach

� Emphasis of preventive medicine

� Mampu menangani masalah kesehatan yang initially unclear in terms of seriousness

�whole spectrum of age groups

� not only in the consulting room

� The five star doctor: � Care Provider� Communicator � Decision maker� Manager � Community leader

� Gate Keeper� Care Coordinator/Case Manager� Advisor, konselor, teman bagi pasien� Researcher

Roles of Family Medicine

Prepathogenesis Period Pathogenesis period

Sign and symptoms

Illness

Disability

Chronic state

Death

DiscernibleEarly lesion

AdvancedDisease

Recovery

Convalescence

Early Pathogenesis

HostAge,Race,SexHeredity,FamilialHabit,CustomsPre cancer

Stimulus +

ClimateAir & Water QualityAnimalSociocultural, economic

AgentChemicalPhysicalBiologicalNutrition

1.Health education

2.Good standard of Nutrition

3. Physical exercise

4.Attention to Personality development

5.Adequate housing, recreation, agreeable working condition

6.Marriage counseling, sex education

7.Genetic

8. Periodic selective examination

1.Specific immunization

2. Personal hygiene3.Environment

sanitation4. Protection against

occupational hazards

5. Protection from accident

6. Protection from carcinogens

7.Use of specific nutrient

8.Avoidance of allergens

1.Case finding measure,individual and mass

2.Screening survey3.Selective examinationsObjectives1.Cure and prevent disease

processes2. Prevent the spread of

communicable disease3.Prevent complication and

sequelae4.Shorten the period of ability

1.Adequate treatment to arrest the disease process and prevent further complication and sequelae

2. Provision and facilities to limit disability and to prevent death

1. Provision of hospital and community facilities for retraining and education for maximum use of remaining capacities

2. Education on the public and industry to utilize the rehabilitation

3.As full employment as possible

4. Selective placement5.Work therapy in hospitals6.Use sheltered colony.

Interaction Host Reaction

Health promotion Specific ProtectionEarly diagnosis

and Prompt Treatment Disability limitation Rehabilitation

A course of a disease in humans

C o n t i n u u m

Biological Onset

ClinicalHorison

Natural History

Of Disease and

Prevention

8

PENTINGNYA FAMILY AS UNIT OF CARE

� Keluarga sebagai unit terkecil dlm masyarakat & melibatkan mayoritaspenduduk

� Keluarga sbg suatu kelompok yg mempunyai perananmengembangkan, mencegah, mengadaptasi, & atau memperbaikimasalah kesehatan yang ditemukan dalam keluarga

� Ada salah satu anggota keluarga yang sakit akan mempengaruhipelaksanaan fungsi-fungsi yang dapat dilakukan oleh keluarga�mempengaruhi fungsi-fungsi masyarakat secara keseluruhan

� Keluarga adalah pusat pengambilan keputusan kesehatan yang penting�mempengaruhi keberhasilan pelayanan kesehatan masyarakatsecara keseluruhan

� Keluarga adalah wadah dan ataupun saluran yang efektif untukmelaksanakan berbagai upaya dan atau menyampaikan pesan-pesankesehatan

� As many as 50-75% of patients utilising primary care clinics have a psychosocial

The psychosocial hallmarks of the patient

�The patient as a person

�Emotional reactions to the illness

�The family

�The effect on relationships

�Work and leisure

�Lifestyle

�The environment

How to evaluate the family dynamics

�Carefully observe family members interacting.

�Invite the whole family to a counselling session (if possible).

�Visit the home

�Prepare a genogram

DEFINISI DX HOLISTIK (MULTI ASPEK)

�Kegiatan identifikasi & menentukan :

�Dasar & penyebab penyakit, injury sertakegawatan

�Yang diperoleh dari :

�Anamnesis

�Observasi

�Penilaian risiko

�Dalam kehidupan pasien & keluarganya

TUJUAN

1. Penyembuhan penyakit dgn pengobatan yang tepat

2. Hilangnya keluhan yang dirasakan pasien

3. Pembatasan kecacatan lanjut

4. Penyelesaian pemicu dalam keluarga(masalah sosial)

5. Jangka waktu pengobatan pendek

6. Percepatan perbaikan fungsi sosial

7. Terproteksi dari risiko yang ditemukan

8. Terwujudnya partisipasi keluarga untukpenyelesaian masalah

28

The disease-centreddx

HistoryExamSpecial inves

Emphasis on making dx & treating the disease

Etiology of disease

Another dimension (psychosocial hallmark):•The patient as a person•Emotional reactions to the illness•The family•The effect on relationship•Work•Lifestyle•The environment

The patient centred dx

WHOLE PERSON APPROACH

30

How the diagnostic process could focus on the implemented

holistic patient daily life ?

1.Interview; complains, reasons of encounter, hopes, and worries

2.Clinical Observation; physical examination findings, supporting

tests

3.Analysis; clinical data, individual & family health problems &

risk factors

• What kind of diseases • Who gets the disease• Why it happened (confounding & determinant factor)• What the functional status (based on physical disability)• What is the decision (based on evidence)

4.Diagnosis Holistic

31

Holistic diagnosis(multi aspects& multidisciplinary approach)

• 1st aspect: • Chief complain

• Fear

• Wishes/ hope

• 2nd aspect:• Clinical diagnosis & differential diagnosis

• 3rd aspect:• Health behavior & perception (internal risk/confounding fs)

• 4th aspect:• Family’s psychosocial & economy problems, occupation &

environment factors (external risk factors/determinant)

• 5th aspect:• Social function scale

PENANGANAN KOMPREHENSIF

� PATIENT – CENTERED� PLAN PENEGAKKAN DIAGNOSIS DEFINITIF

� PLAN KIE

� PLAN PENGOBATAN

� PLAN MONEV

� FOCUS FAMILY� PLAN KIE

� FOKUS PENCEGAHAN RISK FACTOR

� SUPPORT KELUARGA

� FOCUS LOCAL COMMUNITY� PLAN KIE

� PENCEGAHAN

33

Examplecase: Mr.A.36 yo, security in Kelurahan Office, unmarried, live with his sister who married with 3 children

I: - Productive cough no blood-tinged since 1 month

- going to be worst condition

- possible to cure

II: - Pulmonum tuberculosis with acid-fast bacili (+), broad lesion & left lung fibrosis

- Obesity

- Suspect Diabetes Mellitus

III: - drop out from anti-tuberculosis treatment after 1 month

- lack motivation and supporting behavior

- unmarried & dependent

IV: - less harmony interpersonal relationship with brother in law

- no family participation in patient management

- high risk transmitted in the family

- un-comfort living for patient and family

V: functional scale: 2 (partly willingness, provider dependency)

34

comprehensive planning

• A. Patient-centered:– Therapy of PTB by long term 3 combinations drug therapy

(package 2)

– Special diet with adjusting of family capacity (lower calorie, high protein & zinc)

– Supportive therapy by vitamin B6

– Special attention on blood glucose

– Special attention on PTB complication and drug compliance per 2 weeks in 2 month, and monthly on 3rd -6th months after.

– Chest exercise after treatment when necessary

– Regular exercise

– B.......

35

comprehensive planning

• B. Family-focused:– Assigned possible caregiver in the family

– PTB guidance of treatment to his caregivers

– Active screening of PTB of all family member to find the contact source and in purpose of early detection

– Nutrition guidance for all family member with adjusting of family resources

– Preventive care guidance for all family member

• C. Community-oriented:– Circulation and ventilation guidance at house

– Case infectious disease report to local government to be active screening for PTB in the living area of the patient

35