Workshop – 8

Respiratory Home Care

Thursday , 2nd December 2010

The 12th International Meeting on Respiratory Care

Indonesia (Respina) 2010

 Workshop – 8

Respiratory Home Care

Thursday , 2nd December 2010

Room : Ceria Room

PROGRAM

07.15 – 07.30 Registration

07.30 - 07.40 Speech of IJMSC

07.40 – 07.50 Speech of JPCI

07.50 – 08.00 Speech of Presdir PT. Astelas

08.00 – 08.30 Medical Aspect in Respiratory Home Care

Menaldi Rasmin - INA

08.30 – 09.00 Infection Control in Home Care

Usman Chatib Warsa - INA

09.00 – 09.30 Ventilatory Support in Respiratory Home Care

Prasenohadi - INA

09.30 – 10.00 Respiratory Monitoring

Wahju Aniwidyaningsih – INA

10.00 – 10.30 Respiratory Nursing Home Care

Ratna Sitorus - INA

10.30 – 10.45 Coffee Break

10.45 – 11.15 Nutritional Care in Respiratory Home Care

Sri Sukmaniah - INA

11.15 – 11.45 Medic Rehab. in Respiratory Home Care

Siti Chandra Widjanantie - INA

11.45 – 12.15 Case Discussion

12.15 – 13.15 Lunch

Medical Aspect in Respiratory Home Care

Menaldi Rasmin

Curriculum Vitae

Academic Qualification:

1981 MD, University of Indonesia, Jakarta

1991 Pulmonologist, University of Indonesia, Jakarta

Current Position:

Professor and consultant of respiratory emergency & pulmonary intervention, Faculty of

Medicine Univ. of Indonesia, Persahabatan Hospital Jakarta, Department of Pulmonology and
Respiratory Medicine.

Head of Indonesian Medicine Counsil

Infection Control in Home Care

Usman Chatib Warsa

Infection Control in Home Care

Usman Chatib Warsa, Department of Microbiology, Faculty of Medicine, University of Indonesia

Abstract: Home care has also broadened in type and scope in the past decade. Most patients are
elderly and have chronic conditions requiring skilled nurses and aides. High-tech home care is
provided to patients of all ages and may include home infusion therapy, tracheotomy care and
ventilator support, dialysis, and other highly invasive procedures. In addition, home-care nurses
provide assessment, education, and support to post-acute-care patients who might have spent
several additional days in the hospital but are now discharged to cut costs. This category of
patient may include postoperative patients, postpartum mothers and their newborns, and patients
with acute medical conditions such as newly diagnosed diabetes and recent strokes.

Infection prevention strategies in home care should focus on home infusion therapy, urinary
tract care, respiratory care and wound care therapy. Surgical site infection should rarely, if ever,
be a home-care acquired infection if the wound is primarily closed and no drains are left in
place. However, if a surgical patient is sent home with drains, a surgical site infection may
develop, and wound-care procedures must address this risk. More frequently, home-care
patients have other types of wounds, which are commonly colonized with gram-negative flora
and may become infected with the patient's own organisms. Again, procedures for care of these
wounds must be based on the genuine potential for contamination and infection

The rationale and strategy for use of precautions in home care differ substantially from those
applied in hospitals. In most cases, the use of gowns, gloves, and masks in the care of
homebound patients is recommended to protect the health-care provider, not the patient. In
addition to standard precautions, care givers in the home may need to use masks only when
caring for patients with pulmonary tuberculosis. The exception to this rule may be the home-
care patient who is colonized or infected with multidrug-resistant organisms. Although these
organisms are not known to be a risk to providers, they may be transmitted to other home-care
patients through inanimate objects or hands. Thus, home-care patients known to have a
multidrug-resistant organism should be cared for through use of appropriate barriers.

Reference: Emily Rhinehart: Infection Control in Home Care; AIG Consultants, Inc., Atlanta,
Georgia, USA
Ventilatory Support in Respiratory Home Care

Prasenohadi

Curriculum Vitae

Nama : Prasenohadi
Tempat, tanggal lahir : Jakarta, 19 Maret 1965
Pendidikan
1) SD : Triguna, Jakarta, Desember 1977
2) SMP : Negeri 11, Jakarta, Juli 1981
3) SMA : Negeri 6, Jakarta, Juli 1984
4) Dokter : Fakultas Kedokteran Universitas Indonesia, Jakarta, April 1991
5) Spesialis Paru (Sp.P): Fakultas Kedokteran Universitas Indonesia, Jakarta, September 2004
6) Philosophy Doctor (Ph.D) : Universitas Tohoku, Sendai, Jepang, Maret 2003
7) Konsultan Intensive Care (KIC): Kolegium Anestesiologi, Jakarta, Juli 2007
Pekerjaan
1) Puskesmas Bonegunu, Kabupaten Muna, Sulawesi Tenggara (Dokter Pegawai Tidak Tetap &
Kepala Puskesmas) : 1992–1995
2) Rumah Sakit Persahabatan, Jakarta (Dokter di SMF Paru) : 1995–2006
3) Rumah Sakit Umum Daerah Provinsi Sulawesi Tenggara, Kendari (Dokter Spesialis Paru) :
2006–2007
4) Rumah Sakit Persahabatan, Jakarta (SMF Paru) : 2007–sekarang
Pendidkan tambahan / Kursus / Workshop
1) Research Student, Universitas Tohoku, Sendai, Jepang
2) Bronchoscopy, Singapura
3) Thoracoscopy, Singapura
4) Infection Control, Singapura
5) Bioetik, Hak Asasi Manusia dan Hukum Kedokteran
6) Training of the Trainer, Alexandra Hospital, Singapura
Organisasi
1) Ikatan Dokter Indonesia/IDI (Anggota)
2) Ikatan Dokter Indonesia BP2KB (Ex-Officio)
3) Perhimpunan Dokter Paru Indonesia/PDPI (Sekretaris)
4) Kolegium Pulmonologi Indonesia
5) Redaktur Pelaksana Jurnal Respirologi Indonesia
6) Pehimpunan Dokter Manajemen Medik Indonesia/PDMMI (Anggota)
7) Perkumpulan Pemberantasan Tuberkulosis Indonesia/PPTI (Bidang Penyuluhan, Diklat dan
Pelayanan Medik)
8) Yayasan Kanker Indonesia/YKI (Unit Rokok)
9) Dewan Asma Indonesia/DAI (Anggota)
10) Institute of Human Virology and Cancer Biology–University of Indonesia/IHVCB–UI (Pengurus)
11) Komisi Mutu dan Keselamatan, RS Persahabatan (Ketua Komisi Pelayanan Unggulan dan
Pelayanan Terpadu)

Tulisan ilmiah
1) Prasenohadi. PPOK dan Tuberkulosis. J Respir Indon 2007, 27: 141-2.
2) Pradono P, Tazawa R, Maemondo M, Tanaka M, Usui K, Saijo Y, Hagiwara K, Nukiwa T. Gene
transfer of thromboxane A(2) synthase and prostaglandin I(2) synthase antithetically altered
tumor angiogenesis and tumor growth. Cancer Res 2002; 62: 63-6.
3) Tazawa R, Pradono P, Hagiwara K, Nukiwa T. Gene therapy and clinical trial. Nippon Rinsho
2002; 60 Suppl 5: 625-9.
4) Andarini S, Kikuchi T, Nukiwa M, Pradono P, Suzuki T, Ohkouchi S, Inoue A, Maemondo M, Ishii
N, Saijo Y, Sugamura K, Nukiwa T. Adenovirus vector-mediated in vivo gene transfer of OX40
ligand to tumor cells enhances antitumor immunity of tumor-bearing hosts. Cancer Res. 2004;
64: 3281-7.
5) Prasenohadi. Beberapa aspek klinis dan nonklinis penatalaksanaan Tb paru pada sebagian
pusat pelayanan kesehatan di Indonesia. J Respir Indon 2008; 28: 8-9.
6) Prasenohadi, Tazawa R, Nukiwa T. Transfer of prostaglandin I2 synthase gene reduced tumor
growth and angiogenesis of lewis lung carcinoma cell. Respir Indo 2006; 26: 90-8
7) Prasenohadi. Kriteria penyapihan dari ventilasi mekanik. J Respir Indon 1997; 17: 214-7.
8) Prasenohadi. Penatalaksanaan emfisema subkutis. J Respir Indon 2005; 25: 189-91.
9) Prasenohadi. Siklooksiganase dan kanker paru. J Respir Indon 2005; 25: 132-7.
Respiratory Monitoring

Wahju Aniwidyaningsih

Doctorante, de l’Ecole Doctorale Chimie et Sciences du Vivant, Université

Joseph Fourier France - Faculté de Médecine de l’Université de l'Indonésie
(cotutelle) 1ere année
Thesis : The influence of endobronchial valve treatment in emphysematous patients
to physical activity and body composition

Postgraduate Program in Pulmonology - Faculty of Medicine University of

Indonesia
Jakarta, Indonesia
Pulmonologist (September 2004)

Faculty of Medicine, University of Indonesia

Jakarta, Indonesia

Doctor (August 1997)

Faculty of Medicine, University of Indonesia

Depok, Indonesia
Bachelor Degree in Medicine (August 1995)
Respiratory Nursing Home Care

Ratna Sitorus

Name : Dr. Ratna Sitorus M.App.Sc

Address : Jl. Nusa Indah Raya, Cipinang Indah

Jakarta Timur

Educational backgrounds

1970 – Graduates from D3 Nursing, Jakarta

1971 – Intensive care training , Melbourne

1987 – Graduates from S1 Nursing , Universitas Indonesia

1989 – Graduates as Master in Nursing , Sydney

2002 – Graduates as Doctor from FKM – Universitas Indonesia

Working experiance

1970 – 1979 – working at ICU – RSCM

1985 – 1987 – Academic Staf at D3 Nursing , Jakarta

1990 – now – Academic Staf at FIK – UI

2003 – 2007 – Head of Post graduate Nursing Program FIK UI

 Respiratory Nursing Home Care
By. Dr.Ratna Sitorus M.App.Sc

Nursing in Indonesia is in the moving stage to be a professional care. These development affects
all the nursing care provided to patients including the respiratory nursing home care. The
purpose of respiratory nursing home care is to provide nursing care to individuals with
respiratory problems and their families in their homes. The nursing approach for respiratory
nursing home care is holistic, so the nurse will asses the biopsychosocial needs of the patient and
family, identify nursing diagnosis and develop a nursing care plan. The nursing interventions for
respiratory nursing include e.q respiratory monitoring, airway management, Oxygen therapy,
mechanical ventilation (Physiologic) and behaviour management ,self modification assistance,
spiritual support, support group, Anxiety reduction etc ( psychosocialspiritual ).
The needs are fulfilled by several nursing team, and beside that there are also other health team.
It is needed to have one professional to be responsible about the provision of home health care
and its called case manager. In Indonesia until now, the is already some activities related to home
care e.q for stroke patients, cardiac patients as part of medical care. Respiratory nursing home
care as a professional care home care needs, to be developed inline with utilizing nursing man
power with their specialization effectively.
 Respiratory Home Care Nursing
By

Dr. Ratna Sitorus MApp.Sc

(Academic Staff FIK-UI)

I. Introduction

Nursing in Indonesia is in the moving stage to be a professional care. This process could
be seen in the provision of care to patient and family both in the hospital and in the
community. These development affect all the nursing care provided to patients including
the respiratory home care nursing. The nursing care provided mostly to implement
collaborative/medical intervention and only provide nursing activities not as nursing
treatment. The nursing treatment provided was 0% (Sitorus, et al 2009). Nursing
treatment is the composite of several nursing activities, including activities derived from
nursing theory that is identified, implemented and evaluated by a professional nurse, as
a manager/leader of nursing care with the help of vocational nurses.

According to Watson (1979) who developed theory of caring said that is the patient who
knows what hurts and the facilitator (nurse), should allow the direction of the
therapeutic process to come from the patient (Issel & Kahn, 1998). The nurse will help
the patients to maintain their health through interpersonal process. These interpersonal
process Is built on nurse patient trusting relationship. In providing care to patients with
respiratory problems, the nurse will consider patient as a holistic well being in order to
promote adaptation and self care (Meleis, 2007).

One aspect of nursing need to be developed is respiratory home care nursing due to
changing in health care delivery system. The shifting demographics of the population,
the increase, in chronic disease, the health care costs and highly technology advances
have resulted in changing emphasis in health care delivery and in nursing. In Indonesia,
there is already some activities related to home care nursing, e.g. For stroke’s patients,
cancer’s patient’s, but home care nursing as a professional care is in the stage of
preparation. The provision of respiratory home care nursing as a professional care in
needed ,to prevent readmission, because the most frequent primary diagnosis at
hospital readmission from home care was COPD(Anderson et al, 1996)

II Home health nursing / Home care Nursing

A. Definition

Home health nursing combines aspects of community health nursing with

selected technical skills from other specialty nursing practices and delivers care for
individuals in collaboration with the family and/or designated caregivers.(ANA, 1992
in Mc Ewen, 1998). The conceptual model depicts the integration of
medical/surgical, community health, parent – child, gerontological, and psychiaticts –
mental health nursing into home health care nursing practice, as could be seen in.
Figure I: Conceptual model of home care nursing

Source Ana (1992) in Mc. Ewen (1998).

The home health nurses role is to be care manager in coordinating and directing
all involved disciplines and caregivers to optimize patient out comes, through sharing
knowledge of community health resources with the patient and caregivers. The
home health care nurse must recognize that influences of family dynamics and the
home environment on the physical and emotional state of the patient are essential
inclusion in the nursing care plan. (ANA,1992 in Mc Ewen,1998)
Home health care nursing is not limited to a particular age group or diagnosis.
Depending on the specific patients need, care may be episodic or continuous and
may be primary , secondary, and/or tertiary in nature. But the major goal for home
care nursing is the tertiary preventive nursing care, including rehabilitation and
restoring maximum health function. Home health nursing should be holistic and
 focused on the individual patient, integrating family/caregiver, environmental , and
community resources to promote optimal well being for the patient (Anderson et al.
1996). Holistic care is provided in the home through the collaboration of an
interdiscipline team that includes professional nurses, home health aids, social
workers, physical , speech and occupational therapists and physicians. An
interdisciplinary approach is used to provide health and social services with oversight
of the total health care plan by a case manager. (Smeltzer et al,2008).

B. Role Function of the Home Health Nurse

The role expectations of home health nurse are similar to those of the professional nurse in
any setting. The function of home health nurse including as provider of direct care, educator,
an advocate and as coordinator of service
1. Provider of direct care.

Home health nurses usually are not involved in providing personal care patients
(bathing, changing linens, and soon). Routine personal care usually is provided by
the family or a home health aids arranged for by the nurse. If a personal care
need arises during the course of the skilled visit ( for example, if a patient
experiences an incontinent episode), the nurse typically either bathes and
changes the patient or assists the caregiver to do so before moving on the skilled
activities planned for the visit.

As a provider of direct care, the professional nurse uses the nursing process to
assess, diagnose, plan care, intervene, and evaluate patient needs. During the
course of this process, home health nurses frequently are involed in perfoming
specific procedures and treatments, such as physical assessments, care of
intravenous lines, management of oxygen therapy, mechanical ventilation,
suctioning and care of tracheostomies, wound care, pain management, and so
on. However, most of the home health nurses time is spent teaching.( Lemone, &
Burke, (1996). Event though some of these procedures, could be performed by
vocational nurses, who already skilled full in providing the procedures.

To increase the competencies of nurses with advancements in health related

techniques need for continuing education. This education may be formal or
informal but must be supported by nursing management to guarantee the
delivery of -up- date, skilled nursing interventions. ( Mc, Ewin, 1998 )

2. As educator.
The nurse provides information to promote health for the patient and family.
The nurse is responsible for implementing teaching/learning strategies to assist
the patient in adapting to personal circumstances. The nurse and patient, in
 partnership, identify needs, set goals, and develop and implement an
educational plan. Interactions characterized by caring and compassion
throughout the teaching/learning exchange support the development of trust
between the nurse and patient.

3. As an advocate

As patient advocate, the nurse explores, informs, supports, and affirms the
choices of patients. Advocacy begins on the first visit, when patients are
introduced to the philosophy and process of home care, that is, to empower,
enable, and enhance self care. During the course of care, patients may need help
negotiating the complex medical systems ( especially in regard to medical
insurance ), accessing community resources, recognizing and coping with
required changes in life style, and making informed decisions.

When the families desires differ from those of the patient, advocacy can be a
challenge. It is impossible for the nurse to please everyone. If a conflict arises ,
the nurse must remain the primary patients advocate, regardless of any negative
response from the family (Lemone & Burke, 1996 ).

4. Coordinator of service / clinical care manager

The nurse collaborates with the multidisciplinary team to create a plan that
optimize patient response. This collaboration is required in home health nursing
in order to ensure continuity of care. Although members my vary, the team
frequently includes a nurse, physician, physical therapist, occupational therapist,
speech pathologist, social work and homemaker/home health aide. Regardless of
the composition of the team, it is important to remember that the delivery of
comprehensive, skilled nursing care is and will continue to be the predominant
component of home health services. The home health nurse is responsible for
the management and coordination of care. As a coordinator of care she/he
should create an environment where open & accurate communication can be
accomplished among all team members. This will help all members of the team
to identify care improvement opportunities (Scott &Vogelsmeier).

5. Researcher
The home health nurse participates in the research process at multiple levels.
The nurse may be involved in activities such as identifying problem areas;
collecting, analyzing, and interpreting data; applying findings; and evaluating,
designing, and conducting research. All research efforts are designed to provide a
specialized, scientific knowledge base for home health nursing practice.
 C Standards of home health nursing practice

Standards of home health nursing practice develop by ANA, 1996 in Lemone, &
Burke ( 1996 ) including

Standad I. Organization of Home Health Services:

All home health services are planned, organized, and directed by a masters-prepared
professional nurse with experience in community health and administration.

Standard II. Theory: The nurse applies theoretical concepts as a basis for decisions
in practice.
Standard III. Data Collection: The nurse continuously collects and record data that
are comprehensive, accurate, and systematic.
Standard IV. Diagnosis. The nurse uses health assessment data to determine nursing
diagnose.
Standard V. Planning. The nurse develops care plans that establish goals. The care
plan is based on nursing diagnoses and incorporates therapeutic, preventive, and
rehabilitative nursing actions.
Standard VI. Intervention: The nurse, guided by the care plan, intervenes to provide
comfort, to restore, improve, and promote health: to prevent complications and
sequelae of illness: and to effect rehabilitation.
Standard VII. Evaluation: The nurse continually evaluates the patients and family’s
responses to interventions in order to determine progess toward goal attainment and
to revice the database, nursing diagnoses, and plan of care.
Standard VIII. Continuity of care: The nurse is responsible for the patients
appropriate and uninterrupted care a long the health care continuum and therefore
uses discharge planning, case management, and coordination of community
resources.
Standard IX. Interdisciplinary Collaboration: The nurse initiates and maintains a
liaison relationship with all appropriate health care providers to ensure that all efforts
effectively complement one another.
Standard X. Professional Development: The nurse assumes responsibility for
professional depelovment and contributes to the professional growth of others.
Standard XI. Rescarch: The nurse participates in research activities that contribute
to the professions continuing development of knowledge of home health care.
Standard XII. Ethics: The nurse uses the code for nurses established by the
American nurses Association as aguide for ethical decision making in practice.

III Management of home health Nursing care

A. Albbrecht’s conceptual model
Albrecht’s conceptual model (1990) in Nies & Mc. Ewin (2001) for home care
identifies structural and process elements, in order to achieve professional
satisfaction and effective patient outcomes, as seen in figure 2.

Figure 2: Albrecht’s nursing model for home health care

 Source: Nies, M.A. & Mc. Ewin (2001)

B. Nursing approach for respiratory home care nursing

Nursing Assessment

Nursing assessment is a holistic approach. For adult nursing assessment data base including

a. Demograhic data
b. Health history
c. Familly medical history
d. Psychosocial history
e. Social history
f. Environment background
g. Physical examination
h. Functional health pattern.eg.health perception and health maintenance, nutritional&
metabolic, elimination, activity & exercise, sllep and rest.( Mc Ewen, 1998).
C. Nursing diagnosis
According to Lewis et al ( 2007), examples of nursing diagnosis for patient requiring
respiratory home care nursing including

1. Acute pain related to tissue damage, therapy, decreased joint mobility

2. Chronic pain related to actual or potential tissue damage, disease progression
3. Constipation related to decreased fluid intake, lack to mobility, narcotic
analgesics
4. Deficient fluid volume related to inadequate nutrition and hydration,
dysphasia, and confusion
5. Fatigue related to disease process and therapy
6. Imbalance nutrition: less than body requirements related to inability to ingest
or digest food, inability to absorb nutrients
7. Impaired home maintenance related to decreased endurance
8. Impaired skin integrity related to physical immobility, radiation, pressure.
9. Ineffective airway clearance related to excessive mucus production
10. Risk for aspiration realated to enternal tube feedings, impaired gag reflexs for
sowallowing, inability to expectorate sputum
11. Risk for infection related to inadequate primary or secondary defenses,
impaired immune status, malnutrition
12. Risk for injury related to altered mobility, confusion, fatigue
13. Self-care deficit (any combination of the following): Bathing/hygiene,
dressing/grooming, feeding, or toileting related to pain, musculoskeletal
impairment, decreased endurance
14. Social isolation related to physical immobility, alteration in physical
appearance

D. Nursing Intervention

Nursing intervention classification,( NIC ) had been identified in 7 domain including

physiological basic, physiological complex, behavioral, safety, family, health system
and community. Until now there were 543 NIC identified by North American Nursing
Diagnosis Association (Nanda) (2004).
The Nursing intervention Classification blended with several nursing theory became
a nursing treatment for the patients& family, e.g there is one professional nurse who
is trusted by the patient & family that plan implement several activities and evaluate
the whole activities to achieve the goal.
The NIC, related to respiratory home care nursing including :
1. Airway management
2. Airway Suctioning
3. Anxiety reduction
4. Aspiration precautions
5. Behaviour managament
 6. Body mechanics promotion
7. Bowel management
8. Cough enhancement
9. Coping enhancement
10. Environment management
11. Family Support
12. Mechanical ventilation management.
13. Positioning
14. Patient Contracting
15. Self Care Assistance
16. Teaching.

Each of NIC, consists of several nursing activities

E. Implementation & Evaluation

In providing NIC, e.g. airway management should be integrated with activities based
on nursing theory such as develop trusting relationship, interaction to identity the
strengths of patients and to use these strengths to empower the patients. These
activities are provided several times and by several nurses. In order to implement the
NIC as a nursing treatment a professional nurse will monitor the implementation of
the whole activities and to evaluate the outcome.
IV. Conclusions
Until now, home care nursing in Indonesia already exist in several places. The activities
of home care nursing including respiratory home care if any, is still focus on the
implementation of medical intervention. Respiratory home care nursing need to be
developed as a professional nursing care in order to have quality of care. The
development of respiratory home care nursing become one strategy to improve the
health care system in the community by redesigning structural and process elements in
providing home care.
One aspect in structural elements is the proper utilization of several educational
background of nurses, including master / specialization, baccalaureat and diploma of
nursing and there should be a professional nurse as a manager / leader of nursing care

References

Alligood, M.l. & Tomey, A.M. (2006). Nursing Theory Utilization & Application. St. Louis:
Mosby company
Anderson,M.A.,Hanson, K., Devilder,N.W.,& Helms, L.B.(1996) .Hospital readmissions
during home care: a pilot study.Journal of community health nursing, 13(1), 1-12.
Available at:www.informaworld.com/smpp/title. Accessed November 22,2010

Hitchock, J.E, Schubert, P.E.& Thomas,S.A.(1999). Community Health Nursing: caring for
action. Albany: Delmar Publishers

Issel, M.L. 7 Kahn D. (1998). The economics value of caring Health Care Management
Review. Fall 23 (4): 43-45

Lewis, S.L; Heitkemper, M.M; Dirksen, S.R; Obrien, P.G. & Bucher, L. ( 2007 ). Medical
Surgical Nursing: assessment and management of clinical problems. St Louis: Mosby
Elsevier

Mc Ewen, M,(1998). Community Based Nursing: An introduction. Philadelphia: W.B.

Saunders Company.

McClosky,J. C & Bulecheck,c.M. (2004) Nursing Intervention Classification.st.Louis:

Mosby

Mellis, A.I. (2007). Theoretical Nursing: Developmen & Propess. Philadelhia: Lippincott
Williams & Wilkins

Smeltzer,S.C;Bare,B.G.; Hinsde, J.L.& Cheever, K.H. ( 2008 ). Text book of medical Surgical
Nursing. Philadelphia: Lippincott Williams& Wilkins.

Scott,C.J.& Vogelsmeier,A.(2006).Nursing home safety a review of literature. Annual

Reviu Nursng Research 24:179-215.Available at:www.ncbi.nlm.nih.gov/pubmed.
Accessed November 18,2010

Sitorus,R., Masfuri, Sukmarini, L.(2009). Analysis of nursing care professionalism based

on nursing intervention provided for hospitalized patients with medical surgical problem,
at two hospitals in Jakarta.
Nutritional Care in Respiratory Home Care

Sri Sukmaniah

CURRICULUM VITAE

Full name with title : dr Sri Sukmaniah, MSc, SpGK

Place/Date of birth : Jakarta, 30 January 1953
Address : Department of Nutrition, Faculty of Medicine of
University of
Indonesia, Jl. Salemba Raya, no. 6,
Jakarta pusat, 10430
Email Address : srisukmaniah30@gmail.com
Education : 1. December, 1978 : Medical Doctor,
graduated from Faculty of Medicine of University
of Indonesia, Jakarta.

2. September, 1987 : Master of Science in

Human Nutrition,
London School of Hygiene and Tropical Medicine,
University of London, U.K.

Occupation / Position : 1979 up to now : Teaching staff of

undergraduate and postgraduate
Study Program of Faculty of Medicine,
University of Indonesia, Jakarta.

Supporting activities : Speaker of national and international

seminars/symposiums/workshop/training

Organization :

1. Member of The Indonesian Medical Association.

2. Member of The Indonesian Clinical Nutrition Specialist Association.

3. Member of The Indonesian Medical Nutrition Association

 NUTRITION IN RESPIRATORY HOME CARE

Sri Sukmaniah

Department of Nutrition,

Faculty of Medicine, University of Indonesia

Patients of respiratory disease with stable condition who are predicted need a long-term
nutritional therapy should be prepared to undergo Home Nutrition Care (HNC). Home Nutrition
Care, at present has become a focused sector of medical care, and in general is defined as an
effort to provide an appropriate and cost-effective nutrition services to the patients in the home-
setting. The purpose of HNC are to increase survival, to decrease morbidity, to improve the
function and the quality of life of the patients, to support independency and self-management, as
well as to encourage positive health behavior, and in children to promote optimal growth and
development (Morley and Silver, 1995; GMCT, 2007). A major goal of Nutrition support of the
patients with respiratory disease is to prevent or to minimize depletion of respiratory muscle
mass and function, therefore the patient can breathe without mechanical ventilation. To achieve
this goal for a patient with respiratory disease, the feeding regimens have to contain adequate
nutrients in amount to meet the nutrient requirement for this specific condition. To be an
effective home-based nutrition services, it should involve the patient, family member, and/or
other care giver, and there should be adequate cooperation and understanding concerning home
nutrition among them. It has been reported that patients who received nutrition care at home
showed the improvement in survival and general well being, this is not just because of nutrition-
or pharmaco-therapy it self, but this was suggested that home care provide a convenient
psychological environment for the patients. It is also reported that HNC may save the cost up to
50% for Home Parenteral Nutrition and & 70% for Home Enteral Nutrition. (Liptack (1997);
Puntis (2001)

ASPEN (2005) mentioned that there is an important role of a multidisciplinary care team
in coordinating HNC, by which the team should involve:

• Physician (Nutrition-trained physician; disease-related specialist physician)

• Nutrition support professionals such as dietitian, nutrition-trained nurse,

• Nutrition product provider,

• Other health care professional, as appropriate (speech pathologist for patients with
dysphagia)
 It has been developed some guidelines of nutrition support for individual with respiratory
disease. The patients with respiratory disease usually had difficulty to consume adequate
nutrients orally because often felt dyspneic, satiated, and bloated or, sometimes get diarrhea,
therefore nutrition support for respiratory patients has to be appropriately formulated to provide
sufficient nutrition without hard effort to swallow the foods. The nutrition guidelines include: 1.
the patients with respiratory disease who have difficulty to ingest adequate nutrition orally
should be given enteral feeding to meet the nutrition requirement. The enteral feeding has the
advantages i.e., low expense, less risk of sepsis and better preservation of gut mucosal barrier,
therefore maintain the gut mucosal barrier integrity, reduce GI bleeding from stress ulcer, and
protect from translocation of luminal bacteria or their toxin through intestinal wall into lymphatic
& blood circulation.The exposure of intestinal mucosa to foods may prevent the development of
sepsis, acute respiratory distress syndrome (ARDS), systemic inflammatory response syndrome
(SIRS), and multiple organ failure syndrome (MOFS). When the GI is not fully functioning the
combination of enteral and parenteral feeding is recommended, and when the entire GI is not
functioning, the enteral feeding becomes contraindication and therefore the parenteral route must
be applied. 2. The formulation of feeding regimen depend on patient’s respiratory function, and
the composition of macronutrients especially carbohydrate and fat proportion have been in long
debates. Recent findings reveal that adequate energy intake with balanced composition of
protein, carbohydrate, and fat, as well as adequate intake of vitamins and minerals may improve
nutritional status, immune response, and respiratory muscle function, as well as the prognosis of
patient with chronic obstructive pulmonary diseases (COPD). 3. The patients who have stable
and normal nutritional status, the energy intake is suggested to be 1.3 times resting metabolic rate
(RMR), and the other 10% of RMR is needed when a recurrent infection present. The full
energy intake should be applied by steps according to patient tolerance. 4. The protein
requirement depends on the need to establish homeostasis, positive nitrogen balance, or tissue
repletion. For maintenance therapy with moderate stress, the protein need is about 1.0 to 1.5 g/kg
BW/day, and about 1.6 to 2.0 g/kgBW/day for repletion therapy with marked stress. Increased
branch chain amino acids will stimulate respiratory function and further improve ventilator
efficiency. When there is a need to increase the amount of protein, it should be applied slowly,
along with careful respiration monitoring. 5. Administration of carbohydrate to cover RMR may
increase respiratory work in proportion in increase of CO2 production and the response to
hypoxia. The ingestion of excessive carbohydrate was reported to cause accumulation of carbon
dioxides and difficulty of weaning from ventilator. The feeding regimens for maintenance and
tissue repletion of COPD patients is recommended to contain about 50% of total energy from
carbohydrate. 6. The fat compositions of feeding regimens for maintenance and tissue repletion
of patients with COPD is recommended about 20-30%, when there is hypercapnea the fat
proportion should be increased individually depend on patient tolerance. The fat composition
should provide adequate amount of essential fatty acids. As oxidative stress increases free radical
productions, the antioxidant interventions should be considered to prevent essential fatty acid
oxidation (Weckwerth, J. and Ireton-Jones, C.(1998); Newton & Morgan (2006).
 To carry out home nutrition care, it has to define properly a nutrition care plan including to
prepare patient and family or care giver, as well as to organize a home care team. Preparation of
the patient and family include providing education and training how to care feeding devices and
how to prepare feeding regiment. This activity should begin in the hospital before the patient
going home. The hospital should support the patient and family by monitoring and evaluating the
clinical and nutritional condition of the patient and coordinating with Supplier to supply
regularly the feeding product as well as the equipments. A numbers of factors should be
considered before sending the patient for home care and ethical implications must also be
reviewed before the initiation of home care.
Medic Rehab. in Respiratory Home Care

Siti Chandra Widjanantie

Name : Siti Chandra Widjanantie

Birth : 27th April 1975

Education : Physical Medicine & Rehabilitation Specialist, FKUI, 2006

JARM traveling fellowship, kobe, 2007

Position: Medical Staff, Medical Rehabilitation Dept, Persahabatan Hospital.

 Medical Rehabilitation in Respiratory Home Care

Siti Chandra Widjanantie

Patients with chronic respiratory disorders living at home may have a wide variety respiratory care
needs. They are suffering from many respiratory conditions that cause impairment and disability in their
respiratory function, even affected their daily activity and ended as their handicap in their role in the
community.

Some disabilities that can be relieved by medical rehabilitation team are low endurance, inefficient
breathing method, and inadequate sputum evacuation due to mucus retention with improper cough
technique.

Programs related problems or symptoms that are most often conducted in respiratory rehabilitation at
home care setting are breathing strategies, mucus clearance technique, endurance training, energy
conservation and work-simplification techniques.

The medical rehabilitation approaches in term of respiratory or pulmonary rehabilitation are consistent
to help patient with respiratory disorder achieve and maintain maximum functioning and independence
in the community.