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Pelayanan Home Care

Penderita CKD di Rumah


Home Care


Medical Terminilogy
Home care
Adalah pelayanan kesehatan yang berkesinambungan dan
komprehensif yang diberikan kepada individu dan keluarga di tempat
tinggal mereka yang bertujuan untuk meningkatkan, mempertahankan,
atau memulihkan kesehatan atau memaksimalkan tingkat kemandirian
dan meminimalkan akibat dari penyakit
(DepKes 2002)
What is Home Healthcare?

Home healthcare
skilled care to help someone get healthy while at home. It comes after a
doctors visit OR a hospital stay and provided by medical professionals.
What you get from home health care:
Skilled nursing
At-home physical therapy
Pain Management
Caring for wounds
Prescription management
What is Home Care?

Sustaining and maintaining the loved ones quality of life in

their home keeping them safe and comfortable.

What you get from home care:

Personal grooming like bathing OR getting dressed
Moving around: getting in and out of the bed/shower
Medication reminders
The goals of home care
Improve the health and quality of life of the patient through
comprehensive primary medical care and nursing and rehabilitative
Reduce the need for hospitalization and nursing home and other
institutional placement
Provide support for the informal caregiver
Reduce emergency department visits
Reduce hospital length of stay and the risk of hospital readmission
Allow terminal patients to die at home in comfort if that is their wish
Enhance optimal growth and development of infants and children
Enhance functional potential of patients on life-sustaining devices
Home care programs effectiveness
Home care programs are effective in all aspects of care
Preventive care
Prenatal visits for high-risk mothers
Alternative to hospitalization in the management of acute problems
Venous thrombosis
Exacerbations of chronic obstructive pulmonary disease
Early discharge for low-birth-weight babies
Chronic disease management
Congestive heart failure, CKD, etc.
General conditioning
Considerations for initiating in-home care
Patient autonomy
Patients desire to remain in the home
Elimination of need for more restrictive environment (hospital, nursing home, etc.)
Transportation barriers
Patient stressed by need for transportation to other settings
Patient unable to leave home for functional reasons
Service can be provided in the home
Personal, financial, and family/community resources available
Severity of illness is such that care needs can be met
Technology exists
Physicians, and other home health staff, can be accessible in a timely manner
Expected outcomes
Improved function, compliance, and quality of life as a result of intervention
Better chance of achieving expected outcomes in home than in other settings
Enhance family health, socialization
The physicians role in home care
Management of medical problems
Identification of home care needs of the patient
Establishment/approval of a plan of treatment with identification of
both short- and long-term goals
Evaluation of new, acute, or emergent medical problems based on
information supplied by other team members
Reassessments of care plan, outcomes of care
Evaluation of quality of care
Services that may be provided by a home health agency
Registered nurse (RN), medical or surgical
Certified WOCN nurse (wound/ostomy/continence nurse; previously known as ET
Certified infusion nurse
Certified psychiatric nurse
Certified diabetic educator (either nurse or dietitian)
Physical therapist
Occupational therapist
Medical social worker
Registered dietitian
Speech therapist
Home health aide
Licensed practical nurse (under supervision of a registered nurse)
Physical therapy assistant (under supervision of physical therapist)
When Home care may not be appropriate ?
Goals of treatment have been reached and the patient and/or caregiver are
Changes in the course of illness or the required treatment make the home
an inappropriate site for care
Patient or caregiver refuses to continue home care
Patient is nonresponsive to home care interventions
Caregiver burnout and inability to obtain alternate caregiver is evident
There is evidence of patient abuse or neglect that has not responded to
home care interventions
Gross noncompliance is identified
Safety of patient or provider is threatened
Irresolvable problems persist between patient/caregiver and home care
Clinical Practice Guidelines for the Detection,
Evaluation and Management of CKD
Stage Description GFR Evaluation Management
At increased
Test for CKD Risk factor management
Comorbid Specific therapy, based on diagnosis
damage with
1 >90 conditions Management of comorbid conditions
normal or
CVD and CVD Treatment of CVD and CVD risk factors
risk factors
Rate of
2 damage with 60-89 Slowing rate of loss of kidney function 1
mild GFR
3 30-59 Complications Prevention and treatment of complications
Preparation for kidney replacement therapy
4 Severe GFR 15-29
Referral to Nephrologist
5 Kidney Failure <15 Kidney replacement therapy
Target blood pressure less than 130/80 mm Hg. Angiotension converting enzyme inhibitors
(ACEI) or angiotension receptor blocker (ARB) for diabetic or non-diabetic kidney disease with spot
urine total protein-to-creatinine ratio of greater than 200 mg/g.
Curative/remittive care

Palliative/supportive care

Presentation of illness
Patient is identified as dying
(usually prognosis 6 months)

Conceptual framework for supportive care in chronic kidney disease (CKD)

Symptoms in CKD: literature synthesis

Summary of
Symptom prevalence and Impact Management
Uremic pruritus a mean prevalence of Associated with decreased The highest levels of evidence for
40.6%. HRQL, and contributes to efficacy are for topical agents (e.g.,
other symptoms such as capsaicin, emollients if concurrent dry
poor sleep and depression skin), oral medications (e.g.,
gabapentinoids), and ultraviolet B
Sleep disorders a mean prevalence of Associated with fatigue, Management involves basic sleep
60.1% poor HRQL, and depression. hygiene measures, management of
concurrent symptoms,
nonpharmacologic interventions
including exercise and cognitive
behavioural therapy, and
pharmacologic management
including simple sedatives.
Symptoms in CKD: literature synthesis

Summary of
Symptom prevalence and Impact Management
Restless legs Prevalence 1020% Associated with impaired Nonpharmacologic measures may
syndrome (RLS) of long-term sleep and HRQL, premature include removal of stimulants, good
dialysis, withdrawal from dialysis, sleep hygiene, changes in the dialysis
80% of RLS and increased regime, aerobic exercise, pneumatic
sufferers also cardiovascular morbidity compression devices, and correction
experience the and mortality of hyperphosphatemia and iron
sleep disorder deficiency.
periodic limb Pharmacologic approaches might
movements (PLMS) include cessation of medications that
interfere with the dopamine pathway,
or trials of levodopa, nonergot
dopamine agonists, or low-dose
Symptoms in CKD: literature synthesis

Summary of
Symptom prevalence and Impact Management
Anorexia prevalence of 56% Associated with Management has not been studied
(range 982%). malnutrition, poor HRQL, systematically in CKD.
depression, greater
hospitalization rates, and
increased mortality
Nausea prevalence of 46% Impact has not been Management has not been studied
(range 990%). assessed systematically in systematically in CKD.
Vomiting prevalence of 23% Impact has not been Management has not been studied
(range 1168%). assessed systematically in systematically in CKD.
Constipation prevalence of 40% Impact has not been Management has not been studied
(range 865%). assessed systematically in systematically in CKD.
Symptoms in CKD: literature synthesis
Summary of prevalence and
Symptom Impact Management
Diarrhea prevalence of 21% (range 8 Impact has not been assessed Management has not been studied
33%). systematically in CKD. systematically in CKD.
Depression prevalence of 21.5% in Associated with increased A systematic review assessed
CKD stages 14, morbidity, hospitalization, and pharmacologic treatment in CKD stages
22.8% in dialysis Patients, mortality rates, and is 35, including 28 studies assessing 24
25.7% in kidney transplant integral to the assessment of antidepressants.
recipients, HRQL. Efficacy of nonpharmacologic treatments
prevalence of depressive (e.g., more frequent hemodialysis,
symptoms was 26.5% in cognitive behavioral therapy, and
CKD stages 14, exercise) have also been demonstrated.
39.3% in dialysis patients,
26.6% in kidney transplant
Symptoms in CKD: literature synthesis
Summary of prevalence
Symptom Impact Management
and severity
Pain ~ 58% of CKD patients associated strongly with Management is determined by both etiology and
experience pain, and many substantially lower HRQL severity. Nonpharmacological approaches may be
rate their pain as and greater psychosocial appropriate (such as exercise and local heat) for
moderate or severe in distress, insomnia, and musculoskeletal pain. For pharmacologic management,
intensity. depressive an adapted World Health Organization (WHO) analgesic
Although data on symptoms ladder that takes into account pharmacokinetic data of
peritoneal dialysis patients analgesics in CKD is recommended.
This may include the conservative dosing of opioids for
and stage 5 CKD patients
moderate to severe pain that adversely affects physical
cared for conservatively
function and HRQL and that does not respond to non-
without dialysis are more opioid analgesics.
limited, evidence suggests
similar prevalence rates
and severity to HD
Take Home Message

Appropriate medical management in the home is a function of the

physicians skills in optimizing the patients independence while
utilizing medical and social resources to minimize the effects of illness
and disability in the patients daily life

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