CHRONIC DISEASE MANAGEMENT 2 Flashcards
Multidisciplinary team
▪ Dietician ▪ Physiotherapist ▪ Occupational Therapist ▪ Medical Practitioner ▪ Speech Pathologist ▪ Social Worker ▪ Aboriginal Health Worker ▪ Pharmacist
NURSE
▪ Coordinating the multidisciplinary team –
ensuring timely involvement and being an
advocate of quality care for the individual.
▪ Patient assessment
▪ Meeting chairperson
▪ Educator
▪ Tailoring of individual treatment plans
▪ Complex care co-ordinator
DIETICIAN
▪ Improve individual and community health
wellbeing through food
▪ Understand the relationship of food to health
and making healthy choices
▪ Public health nutritionists, clinical dietician
▪ Specialist advice for different conditions, may
include enteral, parenteral as well as oral
nutrition recommendations
▪ Use recommended dietary intakes, dietary
guidelines, nutritional reference values,
biochemical values
PHYSIOTHERAPIST
▪ Focus on healthy movement, enhancing mobility, physical activity and quality of life ▪ Practice in a variety of settings ▪ Work on a clinical diagnosis ▪ Treatment plan ▪ Non drug therapies ▪ Use manual and assistive therapies i.e.. Respiratory therapies, hydrotherapy
OCCUPATIONAL THERAPIST
▪ Daily life comprises participation in
‘occupations’ e.g. self-care
▪ Enable them to be independent – enhance and
maintain function
▪ Work across a spectrum of healthcare services
▪ Focus on self-management e.g. assistive
devices, environmental modifications
SPEECH PATHOLOGIST/THERAPIST
▪ Diagnosis and treatment of swallowing and
communication disorders
▪ Typically patients will present with one of 4
disabilities; lifelong disability, acquired
disability, temporary and degenerative
conditions
▪ Most often referred by nurses
SOCIAL WORKER
▪ Help people achieve optimal health and wellbeing in their own environment, including their family, community and society. ▪ Concerned with those disadvantaged by underlying social inequities ▪ Often use a biopsychosocial approach to patient wellbeing ▪ Involved in case management ▪ Carer support ▪ Counselling
ABORIGINAL HEALTH WORKER
▪ Generally based in Aboriginal community-controlled
health services and are usually the first health care
worker an Indigenous patient would see
▪ Role is to assist the ATSI communities to take a
strong role in controlling and managing their own
health and lifestyles
▪ Provide a range of primary healthcare services,
immunisations, screening, referrals health
education and patient transport
PHARMACIST
▪ Educate patients about their illness, medication effects and side effects ▪ Promote safe and efficacious use of medicines ▪ Medication reviews ▪ Liaison with GP
Specialised
support
May include but not limited to;
▪ Drug and Alcohol Team ▪ Mental Health Team ▪ Psychologist ▪ Diabetic Educator ▪ Continence Nurse ▪ Pain Team
Working with people in
context
Working with a person in context means getting to know them and their families and how they live
with their chronic illness.
Nurses need to support the patient develop their capacity and capability to self-manage.
Nursing decisions can then be guided by
what the person needs and perceives as working uniquely
for them. The nurse needs to be ready to step in and help by offering suggestions, strategies and
support and at times taking over care; they also need to be ready to step back when not required.
Principles of
practice
▪ Person-centred ▪ Empowerment ▪ Partnership ▪ Compliance vs. adherence ▪ Collaborative decision making ▪ Self-management ▪ Care for the carer ▪ Storytelling
