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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.
• Prinsip-prinsip kedokteran keluarga(pendekatan kedokteran keluarga) : memberikan/mewujudkan :� Pelayanan komprehensif (paripurna) dgn pendekatan
holistik (menyeluruh)
� Pelayanan kontinu
�Mengutamakan pencegahan
� Koordinatif & kolaboratif
� Penanganan personal pasien sbg bagian integral keluarganya
� Pelayanan yg mempertimbangkan keluarga, lingkkerja, tempat tinggalnya.
� Pelayanan ygmenjunjung tinggi etika&hukum
� Sadar biaya
� Pelayanan yg dapat diaudit & ACCOUNTABILITY
PRINSIP FAMILY MEDICINE
� 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
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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
29
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
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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
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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
34
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)
35
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.......
36
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
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