ELDERY CARE

Elderly care or simply eldercare is the fulfillment of the SPECIAL NEEDS:

social and personal requirements that are unique to senior citizens.
The elderly need an environment that encourages social interaction
and quality care.

This broad term encompasses such services

*assisted living
*adult day care
*long term care
*nursing homes
*hospice care
*in-home care.
Services available to elders
These include a broad range of services including:
Meals (in-home or in congregate settings)
Socialization
Personal care
Housekeeping in the home
Residential facilities (retirement homes, Board and Care facilities, and nursing facilities)
Adult day care
Transportation
Telephone reassurance
Friendly visiting
Caregiver support
Respite care
Emergency response systems such as Lifeline
CULTURAL AND GEOGRAPHIC DIFFERENCES
TRADITIONALLY : elder care has been the responsibility of family members
MODERN SOCIETIES : elder care is now being provided by state or
charitable institutions.

The reasons for this change include

*decreasing family size,
*the greater life expectancy of elderly people,
*the geographical dispersion of families, and
*the tendency for women to be educated and work outside the
home.

These changes have affected European and North American countries first, it
is now increasingly affecting Asian countries.
In most western countries, elder care facilities are
freestanding assisted living facilities,
nursing homes, and
Continuing Care Retirement Communities (CCRCs).

In the United States:

Most of the large multi-facility providers are publicly owned and
managed as for-profit businesses.

Exceptions; the largest operator in the US is the

Evangelical Lutheran Good Samaritan Society, a not-for-profit
organization that manages 6,531 beds in 22 states (1995)
Given the choice,
Aging in place :
*continue to live in their own homes (most elders would prefer)
*problem : majority of elderly people gradually lose functioning ability and
require either additional assistance in the home ---Eventually most of
them move to an eldercare facility.

The adult children of these elders often face a difficult challenge in helping their
parents make the right choices.
1. IN THEIR OWN HOME
One relatively new service that can help keep the elderly in their homes .
Determined that your elderly loved one NEEDS ASSISTANCE, it is important to honor
their wish to remain happy and independent in their own home
2. MOVE TO AN ELDERCARE FACILITY.
3. PART IN ELDERCARE FACILITY
The family is one of the most important providers for the
elderly.
In fact, the majority of caregivers for the elderly are often members of
their own family, most often a daughter or a grand daughter.
Family and friends can provide a home (i.e. have elderly relatives live with
them), help
1.with money and
2.meet social needs by visiting,
3.taking them out on trips, etc.

Some United States companies, like Senior Helpers, Home Instead Senior
Care, Visiting Angels, All Valley Home Care, and Comfort Keepers, offer
long-term, in-home care for seniors.
Medical (skilled care) versus Non-Medical (social care)

A distinction is generally made between medical and non-

medical care.

In the US, 86% of the one million or so residents in assisted

living facilities pay for care out of their own funds.
The rest get help from family and friends and from state
agencies.

Assisted living facilities usually do not meet Medicare's

requirements.
In-home care can include a wide range of medical and non-medical
services such as:
Adult Day Care / Respite Care
Bill Payment / Financial Management / Financial Planning

Geriatric Assessment / Evaluation/ Care Management

Home / Safety Monitoring
Home Healthcare (Medical)
Home Renovation / Maintenance
Homecare (Non-Medical)
Another Services
Homemaker / House Cleaning
Hospice Service
Insurance Services
Live-In Home Care
Meal Preparation
Personal Care (e.g. Bathing, Toileting or Grooming)
Rehabilitation Services (e.g. Physical Therapy)
Transition Services ( e.g. home sale, relocation, downsizing or asset
liquidation)
Transportation (Non-Medical, e.g. errands, shopping)
Transportation (Non-Emergency)
Visiting / Private Duty Nursing
Visiting Physician / House Calls
Improving mobility in the elderly
Impaired mobility is a major health concern for older adults,
= 50 % > 85 year old
= 25 % > 75 year old
As adults lose the ability to walk, to climb stairs, and to rise
from a chair, they become completely disabled.
The problem cannot be ignored because people over 65
constitute the fastest growing segment of the U.S. population
and recently in Asia ( Japan, China etc).
Therapy designed to improve mobility in elderly patients

Usually built around diagnosing and treating specific impairments, such as reduced
strength or poor balance.
Specific goals related to strength, aerobic capacity, and other physical qualities.
Today, many caregivers choose to focus on leg strength and balance.
New research suggests that limb velocity and core strength may also be important
factors in mobility.
BEGINNING YOUR JOURNEY THROUGH ELDER CARE

Must be prepare
= Your loved one's medical history,
= Financial resources, personality,
= Relationships with potential caregivers,
= Proximity to services and other factors all determine the best approach to take.

Each elder care situation is unique :

Caring for an aging parent, elderly spouse, domestic partner or close friend presents
difficult challenges – especially when a crisis hits and you are suddenly faced with the
responsibilities of elder care.
Perhaps your aging mother fell, is hospitalized with a broken hip and needs to go to a
rehab facility or nursing home to recover.
How to Deal With Aging Parents
Statistics show that people are living longer and longer.
The age that people live to has grown dramatically in the past 20 years---
people are living longer there is usually greater need for assistance as we
age.
RECENTLY PROBLEM ELDERLY CARE IN CHINA : 4 PARENT ----- 2 YOUNG ADULT
In the majority of households the assistance that seniors
receive usually comes from their children.

In many families
Seniors never imagined that they might need assistance from
the children.
Likewise, many children of aging parents never thought that
they would be assisting their parents as they age.
Sometimes, children assisting parent role reversal can lead to
conflicts for the children and the parents.
Because of this, many children want to know how to deal with
aging parents.
THERE ARE SIX (6) KEY STEPS TO FOLLOW ON HOW TO DEAL
WITH AGING PARENTS:
1. Prepare :
You should prepare yourself and your family for the undertaking.
Your spouse and your children should be aware of what you plan to do.
There will be less resistance or conflict if everyone knows the plan.
If you can get your spouse or children to actively participate that is even better.
2. Different stage / different era
Remember that you are at a different stage in life than your parent.
For most of us, development does not stop once we reach adulthood. You are not the
same person you were when you were 21. Your parent is not the same person they were
when they were your age.

3.Ready for change.

Try to look at their concerns from their perspective.
None of us are comfortable with change and this is even truer with seniors. Remember
that the only thing worse than change, is change that you have no control over. Be sure
to make your parents feel that they still have some control over their life.
4. Independence
Try to help your parent maintain the highest level of independence for as long as
possible.
The level of independence you start with will depend on the unique situation of your
family.
Don’t be afraid to include assistance and decrease the level of independence if necessary.

5. Money management .
Have a management plan for the essentials like money management; bills; health plans;
and any necessary equipment or modifications.

6. Live in health
Most importantly, help your parent maintain as good of health as possible.
No one will live forever, but there are things we can do to help maintain our health as
long as possible.
Studies show that this factor, more than any other, can make the greatest difference in
the quality of life of aging parent.
GERIATRIC
Definition
Seniors' health refers to the physical and mental conditions of senior citizens, those who are in
their 60s and older.

Medical conditions that affect the elderly

The most glaring of these is dementia in it's many forms (i.e., Alzheimer's Disease, vascular
dementia, etc.).
Other serious conditions affecting function include strokes, Parkinson's Disease, chronic
obstructive pulmonary disease (COPD) and emphysema, near or total blindness, diabetes and
advanced heart disease.

Principles while caring for older adult :

1. Many disorders are multi factorial in origin
2. Disease often present atypically
3. Not all abnormalities require evaluation and treatment
4. Complex medication regimens, adherence problem, and poly pharmacy are common challenges
Cost
Cost of medical treatment varies --will be determined by
The type of procedure
Whether a person has medical insurance.
Another factor is the fee assessed by the health plan.
NUTRITION :

Nutrition plays an important role in senior health.

Proper diet can help prevent a condition like diabetes or keep it from worsening.
The senior diet should consist of foods that are :
*LOW IN FAT, particularly saturated fat and cholesterol.
*PROVIDE NUTRIENTS such as iron and calcium.
* NOT TOO MUCH CALORI
* VEGETABLES + FRUITS
Other healthy menu choices include:
fish, skinless poultry, and lean meat
proteins such as dry beans (red beans, navy beans, and soybeans), lentils, chickpeas,
and peanuts
low-fat dairy products
vegetables, especially those that are dark green and leafy
citrus fruits or juices, melons, and berries
whole grains like wheat, rice, oats, corn, and barley
whole grain breads and cereals
EXERCISE
Depend on health condition
Physical activity should be
1.rhythmic, repetitive, and should challenge the circulatory system,
2.enjoyable
3.exercising regularly for 30 minutes each day.
It may be necessary to check with a doctor to determine the type of exercise that can
be done.

Walking is recommended for weight loss, stress release, and many other conditions.
Brisk walking is said to produce the same benefits as jogging. Other forms of exercise
gardening, bicycling, hiking, swimming, dancing, skating or ice-skating.
If weather prohibits outdoor activities, a person can work out indoors with an exercise
video.
OSTEOPOROSIS

Prevention is the best method of treating osteoporosis.

Methods of preventing osteoporosis include regular weight-bearing
exercise such as walking, jogging, weight lifting, yoga, and stair climbing.
People should not smoke since smoking makes the body produce less
estrogen.
Care should be taken to avoid falling.
Diet should include from 1,000–1,300 mg. of calcium each day.
Sources of calcium include:
leafy, dark-green vegetables such as spinach, kale, mustard greens, and turnip
greens
low-fat dairy products such as milk, yogurt, and cheeses such as cheddar, Swiss,
mozzarella, and parmesan; also helpful are foods made with milk such as
pudding and soup
canned fish such as salmon, sardine, and anchovies
tortillas made from lime-processed corn
tofu processed with calcium-sulfate
calcium tablets
MEDICAL TREATMENT.
An x ray will indicate bone loss ------ density has decreased---- will indicate
whether a person is at risk for fractures.
A more effective way of detecting osteoporosis is the DEXA-scan (dual-
energy x-ray absorbt iometry).-----useful for people at risk for osteoporosis
as well as women near the age of menopause or older.

During menopause, a woman loses estrogen. A pill or skin patch containing

estrogen and progesterone eases symptoms of menopause and is used to
treat osteoporosis. This treatment is known as hormone replacement
therapy (HRT). In addition to restoring estrogen, HRT could reduce the risk
of colon cancer and Alzheimer's disease.
OSTEOARTHRITIS
Preventive and maintenance remedies include :
Exercise : Low-impact exercise such as swimming and walking, along with maintaining proper
posture.
Body weight : BMI < 2.5
Nutritional aids include foods rich in vitamin C such as citrus fruits and broccoli.
Also recommended is daily consumption of 400 international units of Vitamin E.
A person should cut back on fats, sugar, salt, cholesterol, and alcohol.
SURGICAL TREATMENT.

In cases of severe osteoarthritis, joint replacement surgery or joint

immobilization may be required.
Acupuncture may be helpful in treating mild osteoarthritis.
Generally, a person should have one to two treatments a week for several
weeks. Afterward, one treatment is recommended.
FALL PREVENTION
Fall prevention starts with regular exercise such as walking.
This improves balance and muscles.
Other methods for preventing falls include:
when rising from a chair or bed, a senior should move slowly to avoid dizziness
shoes with low-heels and rubber soles are recommended
medications should be monitored because of side effects that increase the probability of a fall
vision and hearing should be checked periodically
fall-proofing the home, including the installation of lighting, especially stairways, clearing up clutter
and electrical cords that can cause falls, and the installation handrails and strips in bathtubs and
rails on stairs.

MEDICAL TREATMENT FOR FALLS.

After a fall, a senior may need First Aid treatment for cuts or fractures.
Evaluate whether medications cause balance problems.
If indicated, may examine the patient's central nervous system function, balance, and muscle/joint
function.
A hearing or vision test may be ordered.
VISION

Presbyopia may need bifocals or reading glasses

These lenses may need to be changed as vision changes over the years.
Publishers aware of this condition produce books with large print.

A senior should schedule periodic vision exams because early treatment helps prevent or
lessen a risk of cataracts or glaucoma.
Diet also plays a role in vision care: dark green vegetables like broccoli are said to help
prevent cataracts from progressing.
Glaucoma
Cataracts
HEARING

An audiologist can administer tests for hearing loss.

Presby cusis, hearing aids can help a senior affected by age-related hearing loss.
If this treatment is not effective, the person might need to learn to read lips.

SLEEP DISORDERS

SNORING AND SLEEP APNEA.

A doctor may advise the senior to quit smoking, reduce alcohol consumption, or to sleep on his or
her side, reduce body weight .
In some cases, a doctor may refer the senior to a sleep disorder clinic.
.
INSOMNIA treatments include exercising and treating depression, stress, and other causes for
sleeplessness.
MENTAL HEALTH

After retirement, a senior must find activities and interests to provide a

sense of fulfillment. Otherwise, feelings of loneliness and isolation can
lead to depression and susceptibility to poor health.

Activities that stimulate a person physically and intellectually contribute

to good health.
A senior can start an exercise program, take up hobbies, take classes, or
volunteer. Senior
Centers offer numerous activities.
Lunch programs provide nutritional meals and companionship.
This is important because a senior living alone may not feel motivated to
prepare healthy meals.
Dementia

Diagnosis of Alzheimer's disease starts with a thorough medical

examination.
The doctor should administer memory tests.
Blood tests may be required, as well as a CT scan or MRI scan of the brain.
If Alzheimer's is diagnosed, may prescribe medication to slow down
progression of this form of dementia.
DECLARING ELDERLY INCOMPETENCE

In almost all cases in which elderly persons are declared mentally or physically
incompetent to adequately take care of themselves---- state laws require that a
minimum of two doctors, or other health professionals

If doctors' corroboration cannot be obtained by interested parties, then other proof

must be proffered to support the case for incompetence, including outstanding bills
and financial debt, or substandard living conditions that would be deemed unsafe or
hazardous to the elderly person(s).
THE END
 Good Chronic Care in
Diabetes Mellitus and Hypertension

dr. Indra Wijaya, SpPD, M.Kes

Department of Internal Medicine
Faculty of Medicine UPH
 Strategies for Good Chronic Care

• Treatment decisions should be timely

and based on evidence-based guidelines that are
tailored to individual patient preferences,
prognoses, and comorbidities.

• A patient-centered communication style should be

employed that incorporates patient preferences and
addresses cultural barriers to care.

ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2013;36(suppl 1):S50.
Chronic Disease and Chronic Complication
 Support Patient Behavior Change

• Implement a systematic approach to support patient

behavior change efforts
– a) Healthy lifestyle:
physical activity, healthy eating, no use of tobacco, weight
management, effective coping

– b) Disease self-management:
medication taking and management, self-monitoring of
glucose and blood pressure

– c) Prevention of complications:
self-monitoring of foot health, screening for eye, foot, and
renal complications, cardiac risk, and immunizations

ADA. X. Strategies for Improving Diabetes Care. Diabetes Care. 2013;36(suppl 1):S50.
Estimating Cardiac Risk
Estimating Stroke Risk
Hypertension Guidelines
Diabetes Mellitus Guidelines
 Psychosocial Aspects
of Palliative Care:
Communication with Patients
and Families

Dr. WASKITA ROAN, Sp.KJ

BAGIAN PSIKIATRI.
FK UNIVERSITAS PELITA HARAPAN
25 November 2016
WHO Definition of Palliative Care
• Palliative care is an approach that
improves the quality of life of patients
and their families facing the problem
associated with life-threatening illness,
through the prevention and relief of
suffering by means of early identification
and impeccable assessment and treatment
of pain and other problems, physical,
psychosocial and spiritual.
Palliative care
•provides relief from pain and
other distressing symptoms;
•affirms life and regards dying
as a normal process;
•intends neither to hasten or
postpone death;
•integrates the psychological and
spiritual aspects of patient care;
•offers a support system to help
patients live as actively as
possible until death;
•offers a support system to help
the family cope during the
patients illness and in their own
bereavement;
•uses a team approach to address
the needs of patients and their
families, including bereavement
counselling, if indicated;
•will enhance quality of life, and
may also positively influence the
course of illness;
•is applicable early in the course
of illness, in conjunction with
other therapies that are
intended to prolong life, such as
chemotherapy or radiation
therapy, and includes those
investigations needed to better
understand and manage
distressing clinical
complications.
From Mike Harlos MD, CCFP, FCFP
Professor and Section Head, Palliative Medicine, University of Manitoba
 Psychosocial Domains in Palliative Care:

•Psychological and Psychiatric

•Social
•Spiritual, Religious and Existential
•Cultural
•Ethical and Legal
National Consensus Project Clinical Practice
Guidelines for Quality Palliative Care
 Psychosocial Domains in Palliative Care

•Psychological Assessment and Management

•Reaction to Serious Illness
•Care Conferences
•Social Care Plan
•Spiritual Assessment, services
•Cultural Assessment
•Advance Care Planning
A Biopsychosocial-Spiritual Model of Care

• Healing is possible even if death is

imminent
– Relationship between mind and body-
relief of pain, nausea, anxiety
– Relationship between person and
family and friends-reconciliation
– Relationship between with the
transcendent-ability to give/receive
love, see oneself as valuable even if no
longer economically productive
 Interdisciplinary Team
•Multidisciplinary
•Interdisciplinary
•Consults
 Early Conversations
•How much do you want to
know about your disease
and the various treatment
options available?
•What past experiences
influence your feelings about
your care?
•What frightens you most?
•Under what circumstances
would you want the goal of
care to switch from
attempting to prolong life to
focusing on comfort?
•What will help you to live
with joy and meaning?
 Identified Patient Fears
•Infection •Rude doctors and
•Incompetence nurses
•Death •Germs
•Cost •Prognosis
•Mix-Ups •Communication
•Needles issues
•Loneliness
 Transitional Conversations
• How comfortable are you?

• You told me XXX was important to you-is

that still the case? Are there any other
things that have come into play now?

• What questions do you have at this point?

 Effective Family
Conferences
•Pre-meeting!
•Setting
•Participants
–Interdisciplinary Team +
Patient/Family
•Follow-up
 Facilitating conversations
about Goals of Care
• Attend to affect and provide
opportunities for patients to talk.
• Ask for questions.
• Remind patients that they don’t
need to make an immediate
decision and can always change
their mind.
•Ensure shared understanding of
conversation by asking “why”
when patients ask for specific
treatments or express their
goals.
•Restate your understanding
and ask for confirmation that
you got it right.
 Facilitating conversations (continued):

• Remember that you are offering

to let people talk about this issue,
not forcing them to “give up.”
• Remember to talk about the
positive things that you can do to
help the patient accomplish their
future goals
“The aim of the care for the dying
patient is to make the body
comfortable to live in so that
patient (if they desire) can prepare
for death mentally and
spiritually.”

-Richard Lamerton, MD
St. Joseph’s Hospice, London
Manajemen Terpadu
Balita Sakit (MTBS)

83
 LATAR BELAKANG
•Setiap tahun, lebih dari 10 juta anak
di dunia meninggal sebelum
Latar Belakang
mencapai usia 5 tahun
• Lebih dari setengahnya akibat dari 5
Latar Belakang
KONDISI yang sebetulnya dapat
dicegah dan diobati:
§ Pneumonia
§ Diare
§ Malaria • Bila kematian pada masa neonatus
§ Campak, dan ditambahkan, 8 dari 10 kematian tsb.
§ Malnutrisi, dan seringkali dapat dicegah bila anak-anak ini
kombinasi beberapa penyakit. mendapatkan pelayanan kesehatan
yang tepat dan tidak terlambat 84
Penyebab kematian balita di dunia
2008

35% kematian disertai dengan

adanya malnutrisi
Penyebab kematian balita
di Asia Tenggara, 2008
 Distribusi dari 11.6 juta kematian
balita di negara berkembang, 1995

Malaria*
5% Campak*
7%
Lain-lain
32%

Diare* * Kurang lebih 70%

19% dari semua kematian
Malnutrisi*
54%
balita berhubungan
dengan satu atau lebih
dari 5 kondisi tersebut
ISPA
19%
Perinatal
18%

* Based on data taken from The Global Burden of Disease 1996, edited by Murray CJL and Lopez AD, and Epidemiologic evidence for a
potentiating effect of malnutrition on child mortality, Pelletier DL, Frongillo EA and Habicht JP, AmJ Public Health 1993;83:1130-1133

87
 Sebagian Besar Anak Menderita Lebih dari
Satu Gejala pada satu waktu
20.5%
18.6%
16.9%
15.3%
13.7%

7.6%

4.1%
2.3%
0.7% 0.2%

1 2 3 4 5 6 7 8 9 10
Jumlah Gejala
Jumlah gejala yang dilaporkan oleh balita sakit dalam dua minggu terakhir (Matlab
Thana, Bangladesh, 2000; n= 1302)
Source: Arifeen S, et al. MCE-Bangladesh baseline household health and morbidity survey, ICDDR,B, 2000. Not yet published.
88
BAGAIMANA DI INDONESIA?

89
Penyebab Kematian Bayi 0-11 bulan di Indonesia

Tidak diketahui penyebabnya, 3.7 % Tetanus, 1.7 %

Meningtis, 4.5 %

Kelainan Kongenital, 5.7 %

Pneumonia, 12.7 % Masalah

Neonatal
46,2 %

Diare, 15 %

Masalah neonatal :
-Asfiksia
-BBLR
-Infeksi, dll
Sumber : Riskesdas 2007
91
Penyebab Kematian Balita 0-59 bulan di Indonesia

Tetanus, 1.5 %
Tidak diketahui penyebabnya, 5.5 %

Meningtis, 5.1 %

Masalah
Kelainan Kongenital, 4.9 % Neonatal
36 %

Pneumonia, 13.2 %

Diare, 17.2 %
Masalah neonatal :
-Asfiksia
-BBLR
-Infeksi, dll
Sumber : Riskesdas 2007

92
Manajemen Terpadu Balita Sakit (MTBS)

Integrated Management of Childhood

Illnesses (IMCI)
93
 Apa itu MTBS ?
Suatu PENDEKATAN
keterpaduan dalam tata laksana
balita sakit di fasilitas
kesehatan tingkat dasar

94
 TUJUAN MTBS
§ Memberikan kontribusi terhadap penurunan
angka kesakitan dan kematian yang terkait
dengan penyebab utama penyakit pada balita,
melalui peningkatan kualitas pelayanan kesehatan
di unit rawat jalan fasilitas kesehatan dasar
(puskesmas, pustu, polindes).

§ Memberikan kontribusi terhadap pertumbuhan

dan perkembangan kesehatan anak

95
 STRATEGI MTBS
• MTBS merupakan kombinasi perbaikan tata
laksana kasus pada balita sakit (kuratif)
dengan aspek gizi, imunisasi dan konseling
(promotif dan preventif).

• Penyakit anak dipilih yang merupakan

penyebab utama kematian dan kesakitan
bayi dan anak balita.

96
 Intervensi yang tercakup dalam strategi MTBS
Meningkatkan pertumbuhan. Pelayanan kuratif
Pencegahan penyakit

1. Intervensi untuk meningkatkan 1. Tata laksana kasus secara dini

gizi di tingkat rumah tangga/ 2. Pola pencarian pertolongan
Di rumah masyarakat yang tepat
2. Pemasangan kelambu yang 3. Kepatuhan terhadap
mengandung insektisida pengobatan

1. ASI dan MP-ASI 1. Tata laksana kasus : ISPA,

Pelayanan 2. Suplemen vitamin A diare, campak, malaria, DBD,
kesehatan 3. Imunisasi masalah telinga dan malnutrisi,
4. Mikronutrien infeksi serius yang lain
5. Pelayanan kesehatan neonatal 2. Konseling tentang pemberian
esensial ASI dan pemberian makan
3. Pengobatan dengan zat besi
4. Pengobatan kecacingan
97
 Inti dari Layanan MTBS

• Holistik
- Tiap anak dilihat secara holistik, lengkap
- Promotif, preventif, kuratif
- Rumah, FasKes Dasar & FasKes Rujukan

• Rasional
- Tata laksana berbasis pedoman dan bukti ilmiah
- Mengurangi risiko over / under / mis - treatment

98
 MTBS sebagai strategi kunci
untuk meningkatkan kesehatan anak

Manajemen Gizi Imunisasi Pencegahan

balita sakit berbagai
penyakit dan
promosi
tumbuh
kembang
MTBS

99
 3 KOMPONEN PADA MTBS

§ Meningkatkan keterampilan
petugas kesehatan dalam
tata laksana kasus.

§ Memperbaiki sistem kesehatan

agar penanganan penyakit pada balita
lebih efektif dan rujukan dilakukan
dengan tepat

§ Memperbaiki praktik keluarga

& masyarakat dalam perawatan di
rumah dan pola pencarian pertolongan.

100
 PELAKSANA MTBS
Tenaga kesehatan di unit rawat jalan tingkat
dasar: puskesmas, pustu & polindes, yaitu:

♦Paramedis (perawat, bidan).

♦Dokter (sebagai penerima rujukan dan
sebagai supervisor dari perawat dan
bidan).

♦Bukan untuk rawat inap

♦Bukan untuk kader.

101
 Buku KIA
Sebagai alat integrasi pelayanan kesehatan Ibu dan
Anak

102
 1 bulan,
ASIX

Batuk
Pilek

Sudah ditarik

…Facts are:
 Age 1 yr,
acute diarrhea (2 days),
No blood

NO ORS ?
Puyer C ???
AB not indicated Do NOT forget:
No Feeding counseling ??? Antibiotic associated diarrhoea
• Is it an evidence based practice ?
• Do we know the pharmacology
and pharmacokinetic of each drug ?
• Is it really necessary to prescribed
“puyer” for our children ?
If yes, where is it in the clinical practice
guideline ??
WHO: The highest-risk preparative activities
 Angina Pectoris and Heart Failure
Management in Primary Care Setting
Antonia Anna Lukito

Lecturer :
 Learning Objective

• To understand how to manage cardiovascular

disorder in primary care setting as family medicine
– Angina pectoris (workup and management)
– Heart failure (workup and management)
– Prevention of CVD
 10 STEPS BEFORE YOU REFER FOR
CHEST PAIN

BR J CARDIOL 2009;16:80-84
 1. Take a Detailed History

• Typical characteristics
of chest pain will
increase the likelihood
of angina and caused
by coronary heart
disease (CHD)
Clinical Presentation of NSTE-ACS
 Stable vs Unstable Angina
• Stable angina is characterized by
the type of discomfort and
location:
– it is elicited by physical exertion or
emotion
– and relieved by rest or nitrate
– duration is short and worse in cold
weather or after a meal
• In unstable angina, the symptoms:
– more severe
– more prolonged
– more frequent
– and may occur at lower thresholds or
even at rest
• Patients who are considered to
have unstable angina should be
admitted to hospital acutely
2. Consider non-cardiac causes of chest pain

• Non-cardiac chest pain

usually differentiated by
careful history taking
• Gastro-esophageal reflux
suggested by the
character of pain with
epigastric burning, acid
reflux and relief with
antacids
Cardiac and Non-cardiac Conditions
Mimic NSTE-ACS
Pulmonary Embolism
 3. Establish the risk factors:
how likely is it that your patient has CHD?
• Non-modifiable risk factors:
– Increasing age
– Gender
– Ethnic groups
– Positive family history
• Modifiable risk factors:
– Smoking
– Diabetes mellitus
– Dyslipidemia
– Hypertension
– Obesity
 4. Perform a physical examination
• It may identify conditions
that can precipitate
angina such as :
– Anemia
– hyperthyroidism
• Conditions other than
CHD that can present with
angina:
– Aortic stenosis
– Hypertrophic obstructive
cardiomyopathy
5. Carry out the relevant investigation
ECG of ACS
Possible Non-ACS Causes of Troponin Elevation
6. Estimate the cardiovascular disease risk

• TIMI Risk Score for UA/NSTEMI

• Grace ACS Risk Score and Mortality
• Heart Score for Major Cardiac Events
• TIMI Risk Score for STEMI

http://www.mdcalc.com
Positive Angina Likelihood Ratio
 TIMI Risk Score for UA/NSTEMI

http://www.mdcalc.com
 TIMI RISK SCORE CALCULATOR

http://www.mdcalc.com
 Grace ACS Risk Score

http://www.mdcalc.com
 Heart Score

http://www.mdcalc.com
 TIMI Risk Score for STEMI

Morrow D A et al. Circulation. 2000;102:2031-2037

Copyright © American Heart Association, Inc. All rights reserved.

7. Give lifestyle advice
8. Treatment to control symptoms and reduce
cardiovascular disease
9. Consider a rapid access chest pain clinic referral
10. Consider referral to a cardiologist
 Angina or not?

• A 50 years old male

• Came to ED with chest dyscomfort after exercise and
meal
 CVRF

• His father died suddenly of a heart attack

• Dyslipidemia
ECG at ED
Lab Results at ED
Risk Score ?
TIMI Risk Score
Grace ACS Risk Score
Heart Score
ECG at ICCU
Lab Results at ICCU
LCA-angiogram
RCA-angiogram
http://www.bpac.org.nz/BPJ/2013/February/docs/bpj50
 Heart Failure

• In developed countries the prevalence of heart failure

among adults is approximately 1–2%, although the
prevalence may be more than 10% among older adults ( ≥ 70
years)
• A typical primary care clinician, caring for 2000 patients, is
therefore likely to have approximately 40 patients with
heart failure, and more if their patient population is older
 Heart Failure

• People with heart failure often have:

– a reduction in quality of life
– require frequent hospital admissions and
– have a poor prognosis
• Mortality from heart failure remains high, in the first year
after diagnosis, 30 – 40% of patients die
 Defining Heart Failure

• Heart failure can be defined as an abnormality of the

structure or function of the heart that leads to a failure of
the heart to deliver sufficient oxygen to the metabolising
tissues
• Compensatory mechanisms, e.g. an increase in heart rate,
cardiac muscle mass, cardiac filling pressures and blood
volume, work to maintain the ability of the heart to pump
effectively, however, over time the heart progressively fails
HF with Reduced or Preserved Ejection Fraction
 Multiple Risk Factors for Heart Failure
• Coronary heart disease
• Hypertension – 75% of patients with heart failure have a history of hypertension
• Valvular heart disease, including valvular damage from rheumatic fever
• Abnormalities of rhythm (e.g. atrial fibrillation) or conduction (e.g. left bundle branch block)
• Cardiomyopathy, e.g. idiopathic, viral, alcoholic, toxic, peripartum
• Diabetes
• Male gender
• Excessive alcohol use – increasing cardiovascular risk and as a direct cardiotoxin
• Smoking – increasing cardiovascular risk and as a direct cardiotoxin
• Obesity – increasing cardiovascular risk and an independent risk factor
• Dyslipidaemia
• Respiratory conditions, e.g. COPD, obstructive sleep apnoea
• Thyroid disorders – both hypo- and hyperthyroidism
• Medicines e.g. NSAIDs, pioglitazone
• Cardiotoxins e.g. chemotherapy medicines, cocaine
• Infections or inflammation – leading to myocarditis or cardiomyopathy
• Congenital heart disease
Symptoms and Signs of Heart Failure
Chest X-Ray in Heart Failure
 The MICE rule
• The MICE rule is a clinical decision rule for use in primary care, developed in
the UK because of concerns about the accuracy and lack of sensitivity of
ECG and BNP for diagnosing heart failure
• This rule relies on the use of a number of clinical features to increase the
diagnostic value of BNP and therefore to guide decisions about the need for
referral for echocardiography
• The clinical features are:
– Male gender
– Infarction (history of myocardial infarction)
– Crepitations (basal crepitations on auscultation)
– Edema (peripheral oedema)
• Symptomatic patients, who have either crepitations or a history of a
previous myocardial infarction, or are male and have ankle oedema should
be referred for echocardiography without the need for a BNP
• For all other patients, arrange a BNP test and refer for echocardiography
depending on the results of the BNP test
Investigations for Diagnosis and Monitoring HF
Investigations for Diagnosis and Monitoring HF
 New York Heart Association
Functional Classification of Heart Failure
Asymptomatic – no limitation of physical activity.
Class I The patient does not develop undue dyspnoea, fatigue or palpitations with
ordinary physical activity

Mild symptoms – slight limitation of physical activity.

Class II The patient is comfortable at rest, but develops dyspnoea, fatigue or palpitations
with ordinary physical activity

Moderate symptoms – marked limitation of physical activity.

Class III The patient is comfortable at rest, but develops dyspnoea, fatigue or palpitations
with less than ordinary physical activity

Severe symptoms – unable to do any physical activity without discomfort.

Class IV The patient may have symptoms at rest and if any physical activity is undertaken,
the level of discomfort is increased
Heart Failure Staging
 Differential Diagnosis of Heart Failure
• Symptoms that may be suggestive of heart failure,
e.g. dyspnoe can be caused by conditions other than
heart failure
• These include non-cardiac causes of dyspnoe such as:
– respiratory infections
– COPD
– pulmonary embolism
– adult respiratory distress syndrome
• Other cardiac causes such as :
– myocardial ischemia
– atrial fibrillation
– pericardial disease
Managing Patients with Heart Failure in Primary
Care Setting

http://www.bpac.org.nz/BPJ/2013/February/docs/bpj50
 The General Principles of Management

• Once heart failure has been diagnosed, the goal of

treatment is to:
– improve symptoms and signs and
– avoid or reduce hospital admissions
• In the majority of patients with symptomatic heart
failure:
– a diuretic is used first-line to reduce fluid overload
– an ACEI and BB are then added
– followed by spironolactone if the patient is still symptomatic
– an ARB, digoxin and anticoagulants can be added as
appropriate
• Surgical interventions may be considered for some
patients
Decompensation in a previously stable, compensated
patient
 Device Therapy
• Device therapy for heart failure includes implantation of a
cardioverter defribillator or cardiac resynchronisation therapy
(CRT), using devices that provide biventricular pacing or may
combine the ability for both pacing and defibrillation
• Device therapy may be considered for some patients with heart
failure, e.g. those who remain symptomatic despite optimal use
of medicines, those with an ejection fraction that remains low (<
35%) or those with LBBB on ECG and a prolonged QRS duration
(>150 ms)
• Device therapy can improve symptoms, quality of life and
ventricular function and reduce the risk of sudden death
• Patients with co-morbidities that are likely to reduce their life
expectancy (within one year) are generally considered not
suitable for device therapy
 When to refer to Cardiologists?

• Referral to a cardiologist is recommended for patients with:

– Valvular heart disease
– Heart failure and syncope – insertion of a pacemaker may be
required
– Heart failure and LBBB and a wide QRS on ECG associated with
dyssynchrony – CRT may be indicated
– A history of cardiac arrest or ventricular tachycardia - defibrillator
therapy may be indicated
Non-pharmacological aspects of management of
heart failure
• Patient education and self-management are important
aspects in the management of heart failure
• Educate patients to be aware of their symptoms and how to
manage them if their condition deteriorates
• Many patients will be comfortable with modifying their
doses of diuretic
• Patients may also be able to gradually increase the dose of
other medicines such as beta-blockers, e.g. by increasing the
dose by half a tablet at night and then waiting for a few
weeks
 Patients Encouragement
• Weigh themselves daily. It is useful to establish a “dry weight” so that
changes in the patient’s condition are detected and managed early. If the
patient’s weight increases rapidly and they become increasingly
symptomatic, have a plan in place for the patient to increase their
furosemide dose for a few days until the weight decreases again.
• Participate in regular exercise and if appropriate, suggest dietary
measures to assist with fat weight loss (as opposed to fluid weight loss)
• Avoid an excessive intake of salt and alcohol
• Monitor their fluid intake – fluid should be restricted to between 1.5 and
2 L/day in patients with moderate or more severe symptoms of fluid
overload
• There is less evidence that fluid restriction is beneficial in patients with
mild symptoms of heart failure
• Maximise adherence to medicines
• Have an annual influenza vaccination
 Review Regularly
• All patients with heart failure require regular review. If medicine
doses are being gradually increased, monthly review is
recommended
• For patients who are stable on optimal doses of medicines, six
monthly review may be appropriate
• If doses of medicine are being decreased, regular monitoring
remains important because of the risk that the ejection fraction
may reduce again and the patient may redevelop symptoms
• The aim of long-term treatment is for the patient to be no longer
taking a diuretic but to be maintained on maximal doses of an
ACE inhibitor and a beta-blocker to ensure their ejection fraction
remains > 40%
The Importance of Primary Prevention
Manajemen Terpadu
Kesehatan Remaja
ADOLESCENCE FRIENDLY
HEALTH SERVICE
Dr. Fransisca Handy, SpA
 Big 5 Of Mortality Causes ?
1. Stroke
2. Traffic accident
3. Ischemic Heart Disease
4. Cancer
5. Diabetes Melitus
*Kemenkes,2015

Root of cause à Life style : poor diet, low

physical activity, smoking
à start when?
• MMR and IMR are the indicators of development

• The Highest Risk of Pregnancy is pregnancy

occured at age that too young or too old ?
• Eldest crime of man history ?

SEXUAL CRIME

• Biggest world crime and global enemy?

• Most Critical Periode Of
Life Time Which Defines The Quality
Adulthood And The Future Offspring ?
Why ?

Puberty Peer preasure

Growth Spurt Conflict with parents
Brain developement School preasure
Emotional Control Social norm conflict
• Adolescence Accident
Violance
Sexual
• Adolescence Infectious Transmitted
Disease Diseases
• Adolescence Risky Reproductive
behaviours Health
• Adolescence Mental Nutrition
Health Problem
• Adolescence Problems Non-
Puberty infectious
• Adolescence problems disease
 Who is the most reluctant with the
fewest number of visit
to health services?
SDKI 2012
 When An Adolescence Coming To
Health Service.....

1. Where to go?
2. Whom to meet?
3. What do they need? How is the service
they need?
4. What to do differently?
 Karakteristik Pelayanan
Ramah Remaja
1. Fasilitas yang mudah digunakan oleh pengguna
- Lokasi yang mudah terjangkau oleh remaja
- Jam pelayanan yang fleksibel bagi remaja untuk berkunjung
- Administrasi yang sederhana
- Layanan yang terpadu
- Layanan yang dapat melayani remaja dengan beragam usia

2. Lingkungan layanan yang mendukung

- Ruang yang memadai
- Privasi terjaga
- Nyaman

3. Staf yang berkualitas

- Ramah
- Terlatih untuk pelayanan kesehatan remaja

4. Manajemen yang mendukung

- Ketersediaan SOP layanan
- Supervisi yang memadai
• - Pemantauan dan peningkatan kualitas layanan
• - Promosi layanan yang adekuat

5. Pelibatan remaja dalam pemberian layanan

- Penilaian kepuasan layanan oleh remaja yang datang
- Pelibatan peran serta remaja dalam peningkatan kualitas layanan (peer counselor)
 Prinsip Komunikasi
dengan Remaja
•

1. Menjaga kerahasiaan
• pribadi dan tertutup dari pandangan orang lain, tiidak ada orang lain
• Tidak membahas rahasia remaja dengan rekan kerja ataupun pihak lain.

2. Membuat remaja merasa nyaman

• Ramah,
• Menghargai,
• Memperhatikan komunikasi non verbal
• Menggunakan tehnik komunikasi efektif
• Setiap kali hendak melakukan pemeriksaan atau prosedur/tindakan klinis, minta
persetujuan (informed concent) dari remaja dan jelaskan prosedur yang akan dilakukan.
• Minta persetujuan remaja sebelum berbicara dengan keluarganya atau pihak lain

3. Jelas dan Mudah dipahami

• Gunakan bahasa sederhana yang mudah dipahami
 Tehnik Komunikasi Efektif
1. Mulai dengan masalah yang tidak sensitif
2. Pertanyaan terbuka
3. Gunakan orang ketiga
4. Menunjukkan perhatian
5. Hindarikata-kata menghakimi
6. Kurangi stigma
7. Menerima dengan refleksi
8. Empati
9. Afirmai
10. Informasi relevan
 GATHER:
Tahapan Konseling Remaja
Greet (Salam) H- Help (Bantu)
• Sapa klien, persilahkan duduk § Bantu klien mengambil keputusan
• Perkenalkan diri tentang permasalahan yang
• Yakinkan kerahasiaan dan privasi dihadapinya
akan terjaga. § Dorong mereka menentukan
• Ciptakan suasana yang tenang dan pilihan yang bisa diambil
tanpa gangguan selama wawancara § Diskusikan kemungkinan hasil
masing-masing pilihan,
A- Assess (Tanyakan)
§ bantu klien untuk membuat
§ Tanyakan kepada klien apa yang dapat
keputusan yang akan
dilakukan untuknya
dilaksanakan.
§ Gali informasi pribadi
§ Nilai situasi dan kondisi yang sedang E- Explain (Jelaskan)
dialami remaja, termasuk permasalahan § Kenali kemungkinan pilihan lain
dan juga sumber-sumber solusi yang § Jelaskan tanggung jawab klien terhadap perubahan
dimiliki remaja yang dinginkan.
T- Tell (Uraikan) § Kenali sumber dukungan lain, termasuk komunitas
§ Minta persetujuan klien sebelum pendukung, peralatan (contoh: kontrasepsi),
memberikan informasi termasuk pelayanan (contoh: klinik PKPR,
§ Diskusikan bahaya dan masalah yang pengobatan IMS)
timbul akibat perilaku atau kebiasaan § Sediakan pelayanan atau peralatan yang diperlukan
remaja yang berisiko. Minta ijin klien R- Return Visit/Refer (Undang datang kembali)
sebelum memberikan informasi tentang § Jadwalkan kunjungan ulang, sebisa mungkin berikan
apa pun. jadwal kunjungan ulang secara tertulis dan informasikan
§ Berikan informasi tentang pencegahan kepada pendamping remaja yang ada
atau pengurangan/penghentian perilaku § Rujuk untuk pelayanan lain bila diperlukan, upayakan
berisiko tersebut proses pendampingan selama perujukan ini.
§ Tanggapi semua kekhawatiran dan Akhiri aktivitas dengan pesan positif, pujian dan ucapan terima
pertanyaan klien. kasih
 HEEADSSS
• Jika tidak bertanya, maka remaja tidak
H ome akan menjawab
• Menjaga rahasia kecuali:
E ducation – Seseorang dapat mencelakakan Anda
– Anda dapat mencelakakan diri sendiri
E ating & exercise
– Anda dapat mencelakakan orang lain
A ctivity • Dokter adalah jaring pengaman
• Menemukan masalah utama
D rugs

S exsuality Praktis Sederhana

S uicide

S afety Hemat
Powerfull
waktu
HOME
• Remaja dalam keluarga
terpecah à gangguan
emosi dan kesehatan
mental

Drug abuse

Seksualitas Psikologis

Keluarga
 EDUCATION AND EMPLOYMENT

• Keterlibatan kegiatan
sekolah dan pendidikan Keterlibatan
kegiatan
sekolah dan
pendidikan

Penggunaan obat-
obatan terlarang
Hubungan seksual dini
Kekerasan
Absen di sekolah
Morbiditas lain
 EATING & EXERCISE

Bentuk
tubuh

Pola makan Percaya

Depresi
tidak sehat diri

Psikologi
ACTIVITIES & PEER RELATIONSHIP

• Teman sebaya mempunyai

pengaruh besar
• Figur-figur idola diluar
lingkungan rumah
• Nongkrong dengan teman
• Sering merasa bosan
• Sering main game

Risiko Tinggi
DRUG USE / CIGGARETTES / ALCOHOL

• Mulai dari kebiasaan

teman-temannya
• Hal yang tidak sensitif
menjadi sensitif
• Tanya hal yang spesifik:
Alkohol? Rokok? Ekstasi?
SEXUALITY

• Bagian paling sensitif

• Perlu persetujuan dan
pendekatan khusus
• Tawarkan pendapat,
perasaan, dan nasihat
hanya bila mereka mau
SUICIDE AND DEPRESSION
• Bosan à gejala depresi
tersering
• Mudah tersinggung
• Cemas
• Moodiness
• Menarik diri dari pergaulan
• Pola tidur
SAFETY

• Cedera
• Bunuh diri
• Pembunuhan
• Strategi melindungi diri
 Summary
• More adolescence coming to health facility due to
medical problems
• Health service – adolescence friendly
• Promotive, preventive, curative
• Decreases mortality, decreases crime, improve the
next generation quality
Adolescence Health Scheme
Saving Adolescence Is Saving
2 Generations At Once!