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Contextul actual al serviciilor de sanatate

Sanatatea populatiei este o problema importanta,care


necesita o atentie sporita la nivel national, fiind in acelasi timp
o problema de actualitate la nivel european si mondial


Starea de sanatate este influentata in mare masura de
calitatea serviciilor medicale, de rapiditatea interventiei si de
masura in care pot fi adresati un numar cat mai mare de
pacienti simultan
Contextul actual al serviciilor de sanatate
Nevoia de ingrijire la domiciliu in crestere
Sistemul medical se confrunta cu o insuficienta critica a
resurselor publice si cu o lipsa importanta de personal
de specialitate (asistenti medicali, medici)
Sistemul de sanatate si furnizorii de servicii medicale
sunt fortati sa ofere servicii de o calitate tot mai ridicata
care sa aduca beneficii clinice, in conditiile in care
fondurile alocate de Casa de Sanatate sunt reduse,
implicit costurile per pacient
Contextul actual al serviciilor de sanatate
Furnizorii de asistenta medicala se confrunta cu o serie
de provocari:
- cresterea costurilor serviciilor de sanatate
- cresterea importantei calitatii serviciilor medicale si
siguranta pacientului
- schimbarile demografice si imbatranirea populatiei
- lipsa de personal si reducerea bugetelor
- cresterea consumerismelor pacientilor
- cresterea asteptarilor pacientilor privind calitatea
serviciilor medicale
- dezvoltarea serviciilor de ingrijire la domiciliu
Contextul actual al serviciilor de sanatate
Reactii la provocarile sistemului de sanatate:

- etapa I: AUTOMATIZARE (1995)
- administrarea sistemelor:
- inregistrarea pacientilor
- costuri
- achizitii
- cerere electronica, verificarea eligibilitatii
- inregistrarea membrilor
Contextul actual al serviciilor de sanatate
Reactii la provocarile sistemului de sanatate
- etapa II: DIGITIZARE (2005)
- fisa pacientului: Electronic Health Record- HER
- comenzi ale medicilor (Computerized Physician
Order Entry CPOE)
- card de sanatate (Consumer Smart Card)
- reteta electronica (ePrescribing)
- flux de pacienti (E-Clinical WorkFlow)
- mijloace de suport pt medici in luarea deciziilor
- comunicarea doctor-pacient

Contextul actual al serviciilor de sanatate
Reactii la provocarile sistemului de sanatate
- etapa III: INFORMATIZARE (2015)
- personal health records(PHR) gestionate de pacient
- monitorizare la distanta a pacientilor/asistenta la
domiciliu
- telehealth
- servicii suport pt cetateni
- Health Advocate
Actiuni la nivelul statelor membre UE
- consolidarea increderii si acceptarea serviciilor de
telemedicina
- stabilirea de normative legale clare
- rezolvarea problemelor tehnice si facilitarea
dezvoltarii serviciilor medicale in aceasta directie
- Susteins- initiativa EU pentru implementarea
accesului pacientului la propriile inregistrari medicale
pana in 2015
http://ec.europa.eu/information_society/activities/health/policy/telemedicine/ind
ex_en.htm
COMUNICARE A COMISIEI EUROPENE CTRE
PARLAMENTUL EUROPEAN CONSILIU, COMITETUL ECONOMIC I
SOCIAL EUROPEAN I COMITETUL REGIUNILOR
privind telemedicina i beneficiile sale pentru pacieni, pentru
sistemele de sntate i pentru societate (Bruxelles, 4.11.2008
COM(2008)689 ):
Telemedicine can improve access to specialised care in areas suffering
from a shortage of expertise, or in areas where access to healthcare is
difficult. Telemonitoring can improve the quality of life of chronically ill
patients and reduce hospital stays. Services such as teleradiology and
teleconsultation can help to shorten waiting lists, optimise the use of
resources and enable productivity gains.
Telemedicine can also make a significant contribution to the EU economy
The use of telemedicine services is still limited, and the market remains
highly fragmented. Although Member States have expressed their
commitment to wider deployment of telemedicine, most telemedicine
initiatives are small-scale projects that are not integrated into healthcare
systems.


Aplicatiile medicale
- Progresele realizate in domeniul tehnologiilor de
telecomunicatii utilizate in sistemele de sanatate din
ultimul deceniu au extins posibilitatile de dezvoltare a
aplicatiilor dedicate acestuia
- Astazi, aplicatiile destinate acestui domeniu sunt in
extindere datorita posibilitatilor de utilizare a serviciilor
video interactive, prin posibilitatile de transmitere si
stocare a informatiilor, care au fost realizate in ultimul
timp
I. DEFINITII
Telemedicine Definition 1
- Telemedicine involves the use of modern information technology, especially
two-way interactive audio/video communications, computers, and telemetry,
to deliver health services to remote patients and to facilitate information
exchange between primary care physicians and specialists at some distances
from each other

Telemedicine Definition 2
- Telemedicine is health care carried out at a distance

Telemedicine Definition 3
- Telemedicinethe use of advanced telecommunications technologies to
exchange health information and provide healthcare services across geographic,
time, social and cultural barriers

Telemedicine Definition 4
- The World Health Organization (WHO) makes a distinction between
telemedicine and telehealth: telehealth is understood to mean the integration of
telecommunications systems into the practice of protecting and promoting health,
while telemedicine is the incorporation of these systems into curative medicine

e-Sanatate (e-Health):

The term encompass a range of services that are at the edge of
medicine/healthcare and information technology:
Electronic Health Records: enable easy communication of patient data
between different healthcare professionals (GPs, specialists, care team,
pharmacy)
Telemedicine: includes all types of physical and psychological
measurements that do not require a patient to travel to a specialist. Patients
need to travel less to a specialist or conversely the specialist has a larger
catchment area.
Consumer Health Informatics (or citizen-oriented information provision):
both healthy individuals and patients want to be informed on medical topics.
Health knowledge management (or specialist-oriented information
provision): e.g. in an overview of latest medical journals or best practice
guidelines. Examples: physician resources such as Medscape and MDLinx.
Virtual healthcare teams: consist of healthcare professionals who
collaborate and share information on patients through digital equipment (for
transmural care).
mHealth or m-Health: includes the use of mobile devices in
collecting aggregate and patient level health data, providing
healthcare information to practitioners, researchers, and patients,
real-time monitoring of patient vitals, and direct provision of care (via
mobile telemedicine)

pHealth or p-Health: personal health, collection of H&S tools for
(tele)monitoring of health status of a subject

Medical research uses eHealth Grids that provide powerful
computing and data management capabilities to handle large
amounts of heterogeneous data

Healthcare Information Systems: patient data management, work
schedule management and other administrative tasks surrounding
health. These tasks are part of eHealth and interface with most
eHealth implementations due to the complex relationship between
administration and healthcare at Health Care Providers.

ICT (Information and Comunication Technologies) sunt o prioritate
tematica a PC7/FP7 al U.E.: sisteme informatice n servicii
publice, dar si a PNCDI II al Romaniei (2007-2013)

E.C.: telemedicine encompasses a wide variety of services:
teleradiology, telepathology, teledermatology, teleconsultation,
telemonitoring, telesurgery, telenursing and teleophthalmology.
Other potential services include call centres/online information
centres for patients, remote consultation/e-visits or
videoconferences between health professionals.
Health information portals (http://www.ehealthnews.eu ,
http://www.ehealthserver.com ), electronic health record systems [1],
electronic transmission of prescriptions or referrals (e-prescription,
e-referrals) are not regarded as telemedicine services for the
purpose of this Communication.

Telemonitoring and teleradiology services are especially outlined
as together they encompass most of the challenges that are relevant
to the implementation of telemedicine services in general.




Telemonitoring
Telemonitoring is a telemedicine service aimed at monitoring the
health status of patients at a distance. Data can be collected either
automatically through personal health monitoring devices or through
active patient collaboration .

Telemonitoring is very useful in the case of chronic illnesses (e.g.
diabetes, chronic heart failure, COPD chronic obstructive
pulmonary disease). Many of the patients - who are often elderly
people - need regular monitoring because of the prolonged duration
of their disease, the nature of their health condition and the drugs
that they are using.

Telemonitoring supports patients and health professionals
(Glucoboy).

It also results in less frequent visits to healthcare facilities, with
increasing the quality of life for patients and reducing medical costs.


Telemonitoring
Telemonitoring has specific characteristics:
- It can contribute to re-organisation and re-
deployment of healthcare resources, for instance by
reducing hospital visits, thus contributing to the greater
efficiency of healthcare systems.
- It has proven to increase quality of care for
patients, in particular chronically ill patients. In the
context of an ageing population and an increasing
burden of chronic diseases, the benefits and its wider
deployment can be crucial.
- It requires a coherent approach and partnership
involving patients, health professionals, healthcare
providers, payers and the industry, to ensure
sustainability of the services.

Telemonitoring
- Telemedicine Equipment:
- Audiostethoscopes
- Digital Thermometers
- Glucometers
- Video Cameras
- PulseOximetry Devices
- Spyrometers
- Digital Tensiometer
- Store and Forward Software
- Radiology Scaners
- Infrared Technologies
Exemplificare!!!
Teleradiology has specific features:

It is currently the telemedicine service in the most
advanced stage of deployment.
It is usually carried out as an outsourced service, on a
commercial contract basis.
The service can be offered in a national or cross-border
mode involving other EU countries or third countries.
The most important challenges for teleradiology are to
ensure benefits of patient care and overall patient safety.
Telemedicine does not in any way reduce the quality of
radiology services provided to the citizen.

The aim is to support Members States in achieving
large-scale and beneficial deployment of telemedicine
services, by focusing on three strategic sets of actions:
building confidence in and acceptance of telemedicine
services ;
bringing legal clarity ;
solving technical issues: broadband access and full
connectivity is a prerequisite for the deployment of
telemedicine; interoperability and standardisation in
telemonitoring ;
facilitating market development.

These different sets of actions are partially interlinked.

III. STAREA ACTUALA
Romnia
Bucureti, Iai, Timioara, Targu-Mures: Firma Romsoft SRL din Iai
a realizat nc din 2002, prin finanare n PC5 al U.E. (Proiectul
MEDCARE; www.euroines.com ; TELEMON (UMF-Bioinginerie:
www.bioinginerie.ro/telemon); TELMES (INSCC Buc.) s.a.;
Europa: proiectele (n PC5 i PC6): EPI-MEDICS (pentru
detectarea sindromurilor cardiologice), E-REMEDY (telemedicin
pentru reabilitarea la domiciliu, folosind Internet), HEALTHMATE i
HEALTHSERVICE24 (sisteme mobile de teleconsultare bazate pe
calculatoare PDA), INCA (asistarea inteligent a diabeticilor),
TELECARE (telemonitorizare folosind senzori de semnale vitale, cu
ajutorul telefoniei mobile);
Germania, UK, Spania, Scandinavia (Norvegia), Italia s.a.

SUA: Code Blue - Universitatea Harvard - este un proiect de
referin
Necesitatea e-sanatatii si telemonitorizarii:
numr mare de pacieni bolnavi cronic sau cu risc medical crescut
(n U.E. i S.U.A. peste 20% dintre ceteni sufer de o boal
cardiovascular i cca. 45% dintre decese se datoreaz acestor
boli); >20% dintre adulti diabet sau prediabet (!!);

supraveghere postoperatorie;

mbtrnirii populaiei (persoane n vrst i eventual singure cca.
72% dintre persoanele peste 70 de ani triesc singure dar 90%
dintre ele doresc s fie independente, deci necesit
(tele)supraveghere la domiciliu);

accesul la ngrijirea sntii pentru persoanele din locuri izolate sau
defavorizate socio-economic;

reinserie profesionala i incluziune sociala a unor categorii de
ceteni.

Studii medicale
- 2 studii importante publicate in 2003 si 2007 au analizat
sistematic datele din litaratura legate de telemonitorizarea
bolilor cardiace cronice
- date publicate intre 1966-1993 (Louis, Turner, 2003)
- date publicate intre 1966-2006 (Chaudry et al, 2007)
Concluzii:
- telemonitorizarea reprezinta o strategie eficienta pentru
controlul bolilor cardiace cronice, in special al celora cu
risc ridicat de infarct
Perspective
- Serviciile de telemedicina la nivel mondial cunosc o
crestere semnificativa


- Estimarile facute au estimat o crestere de la 9,8 miliarde
dolari in 2010 la 23 miliarde dolari in 2015 (o crestere
anuala de peste 18%)

Telenursing
Definition:
- is a subset of telehealth that focuses on the
delivery, management, and coordination of care
and services using telecommunications
technology within the domain of nursing
Telehealth nurses use the nursing process to
provide care for individual patients or defined
patient populations over a telecommunication
device.
Importantly, the nursing process and scope of
practice are the same in telenursing as in
traditional nursing practice.

Telenursing
Roles:
- monitoring patients with chronic diseases
- helping patients manage their symptoms
and co-morbidities
- coordinating care for patients who
require services from numerous health
professionals
- patient triage
Telenursing
Tehnologii de telecomunicatii folosite:
- telefon

- videofone

- videoconferinte

- dispozitive de ingrijire la domiciliu

- internet

Applications in nursing

Telenursing promises to make nurses more ubiquitous and to
expand nursings involvement in primary care. The applications of
telemedicine for nursing include the following:
- Patient consultations. These can range from a simple follow-up
session after a procedure, to patient education as part of a disease
management program, to more involved consultations that involve diagnosis
and treatment. The tools used may include audio and still or live images to
facilitate communication between patient and provider. The Internet allows
patients to connect from home, or they might visit a remote clinic staffed by
nurses to connect with a physician farther away. Consulting
via telemedicine connects patients to medical resources that dont exist in
their communities.
- Remote monitoring. Devices used by the patient at home can
collect and transmit medical data to clinicians for interpretation, so a
medical intervention can be planned. These technologies can supplement
or, in some instances, replace home nursing visits. When nurses are
monitoring patients remotely, they can eliminate travel times and see more
patients each day. A large body of evidence suggests that telenursing
produces outcomes equal or superior to those seen with traditional clinical
encounters.
Applications in nursing
Domeins:

- home nursing:
- immobilized patients
- patients who lives in remote or difficult-to-reach places
- patients with chronic illnesses: COPD, DM, stroke,
neural degenerative diseases (Parkinson, Alzheimer d.)
- patients in immediate post-surgical situations
- the care of wounds, ostomies, handicapded individuals

Applications in nursing
Domeins:
- patient education
- nursing teleconsultations
- examination of results of medical tests
- assistance to physicians in the implementation of medical
treatment protocols
- training nurses remotly
- assisting and training nurses in developing countries
- nursing care for soldiers on or near the battlefield
- collaborating and mentoring by nurses around the globe
Applications in nursing
Education and career opportunities
Telenursing is a sort of frontier within the nursing field, as its full
potential has yet to be explored. So what does it take to become a
telemedicine professional? From the clinical aspect, youll use the
same skills and competencies required by traditional bedside
nursing. Youll still be performing nursing assessments and taking
on the role of patient advocate. Its just that technology adds another
piece to the puzzle you should be skilled with healthcare
informational technology (HIT). Its an added bonus if you can help
to design or refine technology-based delivery models, in addition to
feeling comfortable with existing and emerging technologies. For
this reason, a degree in nursing informatics is useful for those
wanting a career in telemedicine. Online nursing programs like
those offered by American Sentinel University can help you get the
informatics skills you need.
Telenursing also offers many opportunities for those with
strong nursing leadership skills who want to move into
administrative roles. They can oversee or design telemedicine
programs, maintain medical data, and supervise other nurses.
As telemedicine continues to evolve and become an accepted part
of the healthcare system, opportunities for nurses will expand at
every level.
Telenursing
Benefits:
- driving down the costs of health care
- reducing distances and saving travel time
- keeping patients out of hospital
- decreasing the number of patients admission to ER
- helping to solve increasing shortages of nurses
- comfort of own-home
- sense of control
Telenursing
Benefits
- education and counceling beneficial
- decrease weight (James, 2001)
- pre-operative education (Thomas, 2003)
- outcomes
- patient self-care adherence, medications, health
status and satisfaction did not differ from ordinary
situation (Jerant, 2003)
- remote interpretation and diagnosis with ECG
results was just as good as interpretation in person
(Scwaab, 2005)
Telenursing
Benefits
- remote home health monitoring
- showed improvement in clinical scale and a
significant reduction in emergency visits and
medical appointments (Frangou, 2005)
- automatic transmission of blood pressure data over
telephone lines was efficacious in reducing the mean
arterial pressure of patients with establised essential
hypertension (Rogers, 2001)
Telenursing
Example:

The Case of Mr. H. Mr H, a 76-year-old man who had received open-heart
surgery 6 days earlier, was not feeling well. It was Saturday, and he had just
had a follow-up visit with his cardiologist the previous day. Ordinarily, a
patient in Mr. H's situation might make a trip into the local ED, but Mr. H had
what he called "his guardian angel." Mr H. called his nurse on the
videophone, as he did every day since returning home from the hospital.
Mr. H's telenurse, Brenda, saw that Mr. H was lying on his couch, alert, but
complaining of feeling poorly. Brenda asked him if he had chest pain or
shortness of breath, both of which he denied. Mr. H transmitted his vital
signs with the telemedicine unit. His blood pressure was 98/59, heart rate
72, and blood glucose 147mg/dL. Brenda knew that Mr. H's blood pressure
medication had been increased the previous day. She called Mr. H's
cardiologist, who then called Mr. H at home and instructed him to readjust
his medication dosage again. Brenda called Mr. H back later in the day to
check on him and recheck his blood pressure. Mr. H's blood pressure was
stable and within normal limits and he was doing well.
Telenursing
- The preceding scenario illustrates the tremendous benefit that
telenursing can offer patients who are "in the gap" between cardiac
surgery and structured rehabilitation programs.
- A recent study evaluated the safety and feasibility of a remote,
home-based post discharge cardiac monitoring rehabilitation
program for postoperative coronary artery bypass graft surgery
patients. Patients received telenursing monitoring visits that included
surgical incision assessments, vital sign monitoring (heart rate,
pulse oximetry, blood pressure, 3-lead electrocardiography), a
standardized, medically approved pain/physical assessment and
brief educational interventions and support during each telenursing
visit.
- Compared with patients who received traditional care, the
telenursing monitored patients scored better on measures such as
physical function, social functioning, role limitations due to physical
health and pain.
Telenursing







LTC Joy Walker, RN, conducts a telenursing monitoring
visit with a patient following surgery.
Telenursing
Some nurses are more comfortable with computers and technology
than others. Most did not learn about telehealth in nursing school.
These 2 facts may explain some of the reticence about telehealth
voiced by nurses.
"Nurses need to realize that telenursing is here, and it's growing"
maintained Schlachter-Fairchild, continuing, "It's not futuristic and
it's not science fiction. Telenursing is real, and it's doable. It's not a
cold, impersonal replacement for a nurse, but an enhancement to
nursing care. Rather than patients feeling more distant from nurses,
telenursing actually makes them feel more connected, because the
nurse's presence is extended, and there is a sense that someone is
watching over them all the time." Bonnie Wakefield agrees, noting
that "patients don't always recognize when they are getting into
trouble, but they are reassured to know that someone will be calling
to check up on them the next day." Patient satisfaction with
telenursing, according to Wakefield and Schlachter-Fairchild, is
overwhelmingly positive.
Telenursing
Others have even questioned whether nursing care
provided electronically, over a distance, is truly nursing
practice. There is a misperception that because
telenursing, by definition, isn't "hands-on," it isn't nursing.
Hutchinson argues that telenursing meets the definition
of nursing practice that requires nurses to use
knowledge, skill, judgment, and critical thinking achieved
through nursing education in providing care. A nurse
assessing a patient over the telephone using this
information to plan, intervene, and evaluate the
outcomes of care, is undoubtedly engaged in the
practice of nursing, albeit with a different delivery
medium.
Telenursing
Neajunsuri:
- lipsa interactiunii face-to-face
- posibilitatea unor disfunctionalitati tehnologice
- riscuri crescute privind securitatea si confidentialitatea datelor
medicale
- imposibilitatea aplicarii ingrijirilor adecvate anumitor cazuri (ex.
managementul medical al unei rani cronice la un pacient cu poliartrita
reumatoida sau Boala Parkinson)
- posibilitatea de a iesi din aria scopurilor propuse de catre furnizorii
de sanatate
- dificultate crescuta in a furniza pacientilor informatiile necesare pt
a semna consimtamantul informat in deplina cunostinta de cauza
- disponibilitatea redusa a tehnologiilor comunicationale in anumite
arii geografice

Telenursing
Neajunsuri:
- lipsa de credibilitate si confuzia asupra rolului teleasistentei
- selectivitatea teleasistentelor (asistente cu experienta)
- formarea teleasistentelor (training)
- responsabilitatea angajatorilor de a angaja personal calificat
- consideratii legate de politele de asigurare daca pacientii traiesc in
alta tara
- lipsa de interactiune directa diminueaza calitatea actului medical
- ,,tentatia furnizorilor de sanatate de a reduce cheltuielile de
sanatate prin inlocuirea intalnirilor directe cu cele de tip telemedicina,
chiar si in situatiile care ar impune prima varianta (de ex. nevoia
crescuta de suport emotional, atingeri terapeutice)
- ingrijorari legate de securitatea si confidentialitatea datelor
- deficienta unor date consistente legate de raportul cost-eficienta
- potentiale probleme legate de responsabilitatea actului medical

Telenursing
Nurses and Telehealth
- 1996: first US study (Horton) on the role of telemedicine-
telehealth nurses
- major findings: 80% of nurses working in
telemedicine/telehealth programs reported
directly interacting with all patients
- 2000: US Telenursing Role Study
- major findings: increase of 600% in number of
telenurses active in USA
- 2004-2005: International Telenursing Role Study
- aimed to survey global telenurses in 130 countries
Telenursing
International Telenursing Role Study
Aims:
- where telenurses were in the world

- telenurses satisfaction with their telenursing role

- specific telenursing knowledge and skilss

- perceptions about effectiveness of telehealth as a
nurse extender to affect nursing shortage

- demand from telenurses worldwide
Telenursing
International Telenursing Role Study
- Where telenurses worked in 2004:
- 36 countries around the world
- 49 of 50 states in USA
- distribution:
- USA: 68%
- Canada: 10%
- Australia: 5%
- UK: 4%
- Norway: 3,5%
- New Zealand: 1,1%
Telenursing
International Telenursing Role Study
- Characteristics of telenurses:
- 719 nurses (489 USA) completed the survey
- age range: 22 to 84 yrs
- 43% of telenurses had Advanced degrees in
Nursing
- 47% were part-time telenurses
- 75% would like certification as a way to insure a
standard of care and credibility
Telenursing
International Telenursing Role Study
- Patients treated by Telenurses:
- chronic care: 16%
- medical surgery: 14%
- pediatrics: 11%
- coronary: 9%
- psyhiatrics: 8%
- obstetrics: 8%
- orthopedics: 7%
- newborn: 6%
- rehabilitation: 6%
- other: 9%
Telenursing
International Telenursing Role Study
- Satisfaction
- 59% of telenurses stated they were more satisfied
with their telenursing position than ``regular``
nursing positions they had
- AUTHONOMY and INTERACTION were the most
important factors contributing to telenurses work
satisfaction
- WHY ELSE: better hours, new skills, challenging,
less physically demanding
- WHY NOT: lack of face to face contact with patients, lack of
technical support
Telenursing
- International Council of Nurses Telenursing Network
(2011)
The principal goals of ICN's Telenursing Network are:
to serve as a global resource for nurses working or
interested in telenursing practice, technology
development, policy, standards, education and
research;
to promote effective networking and linkages, and
to enable the sharing of telenursing knowledge and
expertise and stimulate reflection on the changing
nature of nursing care delivery systems across the
globe.
Telenursing
ICN Telenursing Network:

Provides a global forum for addressing issues related to
telenursing/telehealth.
Promotes awareness of telenursing so that the roles and expertise of
telenurses are understood, respected and optimized within the health care
system.
Promotes telenursing as an accepted means for nurses to extend their reach
to patients via the use of information and telecommunications technologies.
Assists with the development and sharing of knowledge, tools and guidelines
which nurses can use to embed telenursing skills and competencies into their
practice.
Promotes sound telenursing practice.
Examines how telenursing can serve as a nursing force multiplier, extending
the reach of nurses to more patients and providing better access to care.
Establishes links between ICNs Telenursing Network and those international
organizations that promote and support the use of telehealth and advanced
technologies for telenurses.
Provides opportunities for the exchange of knowledge and experience to
develop the science and practice of telenursing.
Organizes meetings and conferences.
Telenursing
Atributiile unei asistente de telenursing:
- Triajul diferitelor probleme de sanatate
- Furnizarea de informatii medicale clientilor folosind protocoale sau
algoritme bine definite
- Promovarea autoingrijirii pacientilor prin furnizarea de informatii
medicale
- Sa raspunda la intrebarile pacientilor prin telefon sau prin mesaje de
email securizate
- Sa ofere informatii specifice legate de boala si consiliere adecvata
- Sa faciliteze consultatii prin audio si videoconferinte cu furnizorii de
sanatate sau intre acestia si clientii lor (de ex. clinici rurale, stabilirea
statusului clinic al pacientilor cu boli cronice insuf.cardiaca, diabet
zaharat etc)

Telenursing
Atributiile unei asistente de telenursing:
- Folosirea de videocamere in cadrul consultarii cu alti profesionist ai sanatatii
pt a transmite imagini relevante ale pacientilor (de ex. gradul de mobilitate a
unui membru, statusul unei rani cronice, imagini ale unor leziuni cutanate)
- Sa transmita informatii vitale despre pacienti, de ex. ECG
- Sa utilizeze echipamente video, computere pt a monitoriza starea de
sanatate a pacientilor
- Sa monitorizeze starea clinica a pacientilor sau a celor externati prematur
din spital prin telefon (ex. TA, puls)
- Sa ofere informatii utile calatorilor legate de destinatiile lor turistice
- Sa foloseasca videoconferinte pt a oferi educatie continua de nursing
- Sa creeze site-uri web pt a furniza informatii medicale si consiliere in real-
time asupra diverselor aspecte educationale(de ex. renuntarea la fumat)

Telenursing
Calitatile unei asistente de telenursing:
- caracteristici personale (atitudine pozitiva, amabilitate deschidere
catre tehnologie)
- cunostinte si abilitatea de a utiliza sistemele tehnologice (de ex.
capacitatea de a folosi videocamere manuale, echipamente pentru
videoconferinte, computere etc)
- sa inteleaga limitele tehnologiilor utilizate (de ex. sa fie capabila
sa realizeze daca semnele vitale sunt monitorizate adecvat de catre
dispozitive speciale)
- abilitatea de a recunoaste situatiile in care abordarea telemedicala
nu este adecvata nevoilor pacientului
- abilitatea de a modifica planul de ingrijire al pacientului
- abilitati de colaborare multidisciplinara
Telenursing
Calitatile unei asistente de telenursing:
- constientizarea riscurilor pacientului asociate telemedicinei si
initierea de planuri de rezerva
- cunoasterea, intelegerea si aplicarea protocoalelor operationale
specifice telenursingului si a diverselor proceduri
- aptitudini speciale de comunicare
- comportament adecvat telefonic/videofonic
- constientizarea practicarii nursingului pe baza evidentelor,
precum si a domeniilor care inca necesita cercetare
- abilitatea de a oferi servicii competente de nursing prin evaluari
regulate ale propriei competente, identificand arii de studiu care sa
surmonteze deficientele existente
- cunostinte care sa permita evaluare clinica adecvata (``to smell
emergencies`` - 3-5 ani de experienta)


Telenursing
- Structura patologiilor intalnite la om s-a schimbat in ultimele decenii
(de la boli infectioase acute si cronice catre boli legate de stilul de
viata)
- Pe masura ce creste speranta de viata, proportia acestor boli devine
tot mai evidenta
- WHO a anuntat ca un numar tot mai mare de oameni sufera de o
serie de boli cronice care sunt responsabile de 60% din decese
- Acesti pacienti au si vor avea nevoie de o paleta tot mai larga de
ingrijiri medicale, adaptate nevoilor individuale
- Consecinta directa este acordarea unei atentii speciale domeniului
telenursing ca o modalitate noua de a furniza ingrijire medicala
continua pt acesti pacienti

Telenursing
Boli cronice in relatie cu telenursingul:
- diabetul zaharat
- hipertensiunea arteriala
- insuficienta cardiaca
- cardiopatia ischemica cronica
- bronhopneumopatia obstructiva cronica
- cancerul
- boli neurologice degenerative
- SIDA
Telenursing in Diabetul zaharat
Diabetul zaharat
- sindrom cuprinzand un grup
heterogen de tulburari, care pot avea o
etiologie diferita, dar care au in comun
hiperglicemia, asociata cu modificari lipidice
si proteice la fel de importante
Telenursing in Diabetul zaharat
Clasificare

- DZ insulino-dependent (tip 1)

- DZ insulino-independent (tip 2)

- Scaderea tolerantei la glucoza
Telenursing in Diabetul zaharat
Risc crescut pt DZ tip 1:
- predispozitie genetica: frati, surori
- microsomie fetala
- menarha intarziata
Risc crescut pt DZ tip 2:
- Rude de grad I cu DZ tip 2
- obezitatea
- macrosomia fetala (risc pt mama)
- cresterea tranzitorie a glicemiei in diferite conditii
(sarcina, tratamente diuretice, infectii, contraceptive)
Diabetul zaharat tip 1:

Diabetul zaharat tip 1


Tablou clinic
- debut inainte de 35-40 ani
- coma acidocetozica: 75%
- starea de constienta afectata in grade variabile
(majoritatea se interneaza ``pe picioare``)
- deshidratare (limba prajita, turgor prelungit, hTA)
- respiratie acidotica (Kussmaul)
- halena acetonemica
- manifestari digestive: greturi, varsaturi, dureri
- cei 3 P: poliurie, polidipsie, polifagie
- scadere ponderala

Diabetul zaharat tip 1:

Diabetul zaharat tip 2


Tablou clinic
- debut dupa 40 ani
- poliurie, polidipsie, polifagie: 30%
- diagnosticat intamplator (analize uzuale) sau cu
ocazia unei intercurente: infectii, IMA, stres psihic
- obezitate: 80%
- cetoacidoza apare foarte rar!!!

Telenursing in Diabetul zaharat
Evaluarea paraclinica a diabetului:
- examinari de laborator ale sangelui:
- glicemia (70-110mg/l)
Diagnostic pozitiv:
1. o glicemie > 200mg%
2. doua glicemii >127mg%
3. glicemia 110-126mg% TTOG
Tehnica TTGO
Se recolteaza sange pentru glicemie AJ (inainte de masa) dupa care
se administreaza 75gr glucoza pulvis dizolvata in 200ml de apa. Dupa
prima recoltare pacientul inghite glucoza. Timpul in care pacientul
inghite nu trebuie sa depaseasca 5 minute. La 2 ore dupa
administrarea glucozei se recolteaza din nou sange pentru glicemie.
Se considera diagnostic pozitiv atunci cand valorile glicemiei la 2 ore
dupa administrarea de glucoza este mai mare sau egal cu 200mg%.

Telenursing in Diabetul zaharat
- rezerva alcalina care se recolteaza pe anticoagulant
cu heparina. Valoarea normala e de
27mlEq(echivalenti)/litru si scade in diabetul zaharat
decompensat.
- hemoglobina glicozilata (HbA1C) care se recolteaza
la fel ca si hemograma pe vacutainere specifice pentru
hemograma cu anticoagulant EDTA
- valoarea normala a hemoglobinei glicozilate:
4-6,5% la adulti iar la copii pana la 6%. Glicata ne arata
controlul glicemiei in ultimele 6 luni.

Telenursing in Diabetul zaharat
examene de laborator ale urinei
- glicozuria care arata prezenta glucozei in urina
Recoltarea glicozuriei:
- Glicozuria se recolteaza din urina colectata pe 24h din care se
trimit la laborator 150-200ml dar pe bilet se noteaza intreaga
cantitate de urina eliminata. In diabetul decompensat va aparea
glucoza pozitiva.
- corpii cetonici sau cetonuria care se recolteaza, se
eticheteaza si se trimite la laborator in mod similar. Din aceeasi
urina se poate cere si glicozurie si dozarea corpilor cetonici
Prezenta corpilor cetonici in urina o intalnim in coma
diabetica si la pacientii cu varsaturi multiple

Telenursing in Diabetul zaharat
Explorari functionale utile bolnavului diabetic
- EKG
- Ecocardiografia
- Ecografia si radiografia renala
- Ecografia abdominala (ficat, pancreas, colecist)
- Examenul fundului de ochi pentru evidentierea
modificarilor arterelor retiniene (retinopatia diabetica)
- Examenul acuitatii vizuale
- Oscilometria pentru determinarea circulatiei periferice
- Ecodoppler arterial al membrelor inferioare
- Examenul neurologic pentru descoperirea polineuropatiei
diabetice

Complicatiile diabetului zaharat
Complicatii cronice
1. Nefropatia diabetica:
- duce la insuficienta renala cronica (principala
cauza de deces la pacientii diabetici)
- diagnostic:
- clearance la creatinina
- uree, creatinina
- proteinurie
Complicatiile diabetului zaharat
Complicatii cronice
2. Retinopatia diabetica
- principala cauza de cecitate < 60 ani
- 80-90% din pacientii cu vechime > 30 ani
- evidentiata de catre oftalmolog (FO)
Complicatiile diabetului zaharat
Complicatii cronice
3. Neuropatia diabetica
- polineuropatii periferice
- neuropatia vegetativa (organe interne)
- majoritatea evolueaza cu SEMNE CLINICE
NEGATIVE (scaderea sensibilitatilor)
Complicatiile diabetului zaharat
Complicatii cronice
4. Gangrena diabetica
- leziunile trofice ale piciorului reprezinta una
din cele mai grave probleme medicale
- > 50% din amputatiile netraumatice ale
membrului inferior sunt cauzate de diabet
- majoritatea amputatiilor diabetice sunt
PREVENIBILE
Complicatiile diabetului zaharat
Complicatii cronice
4. Gangrena diabetica
- 3 factori implicati: neuropat, vascular, infectios
- 2 tipuri:
- gangrena umeda extensiva:
- instalare brusca, pacient febril, stare gen alterata
- tumefactie a labei piciorului, semne inflamatorii
- gangrena uscata:
- instalare progresiva, pe fond de ischemie cronica
- haluce/calcaneu: culoare vinetiu-negricioasa, cu
sau fara dureri, afebril
- ulcerul trofic: localizat la nivel plantar sau la nivelul
gambei, in jumatatea inferioara


Complicatiile diabetului zaharat
Complicatiile cronice
5. Macroangiopatia diabetica
- cardiopatia ischemica cronica
- infarctul miocardic
- arteriopatia obliteranta a membrelor inferioare
- accidentul vascular cerebral
Complicatiile diabetului zaharat
Complicatii cronice
6. Alte complicatii
- afectarea cutanata: xantoame, buloza etc
- osteoartropatia diabetica
- complicatii osteo-tendino-articulare
- boala Dupuytren
- parodontopatia
- infectiile cutanate, respiratorii, urinare
- hepatopatia diabetica
Complicatiile diabetului zaharat
Complicatii acute
1. Coma acidocetozica (cetoacidoza diabetica)
- la DZ tip 1
2. Coma hiperosmolara
- la DZ tip 2
3. Coma hipoglicemica

Complicatiile diabetului zaharat
Coma hipoglicemica
- Semne de hipoglicemie:
- foame intensa
- cefalee
- slabiciune
- ameteli
- tulburari vizuale
- iritabilitate
- transpiratii reci
- tremuraturi
- confuzie
- coma
Tratamentul in Diabetul zaharat
Masuri de profilaxie primara
- identificarea pacientilor cu risc crescut de DZ

- depistarea pacientilor cu DZ in stadii incipiente
Telenursing in Diabetul zaharat
Masuri de profilaxie secundara
- dispensarizarea bolnavilor cu diabet zaharat pentru controale
periodice de laborator si clinice.
- invatarea pacientului sa-si administreze corect medicatia fie
ca este vorba de medicatie orala sau injectabila (insulina)
- invatarea pacientului despre regimul alimentar destul de strict
pe care trebuie sa il urmeze un diabetic
- invatarea pacientului sa evite toxicele: alcoolul, fumatul
- invatarea pacientului sa evite eforturile fizice mari, obezitatea
- invatarea pacientului sa-si monitorizeze glicemia la domiciliu

Telenursing in Diabetul zaharat
Masuri de profilaxie tertiara
- In cazul aparitiei unor complicatii invalidate cum ar fi:

- arteriopatia diabetica care intr-un final duce la obturarea
vaselor de sange si intr-un final la amputare,

- retinopatia diabetica,

- ajutam la readaptarea individului in familie si in societate

Masuri de profilaxie de gradul 4
- In stadiile finale ale bolii asigurarea unei morti demne, linistite

Plan de ingrijire a pacientului cu diabet zaharat


Culegerea de date si circumstante de aparitie
- persoane cu risc genetic
- persoane cu boli care scad rezerva
functionala a pancreasului
- persoane care fac tratamente cu
citostatice, imunosupresoare care inhiba
sinteza insulinei

Telenursing in DZ
Manifestari de dependenta (Semne si simptome)
-poliurie
-polidipsie
-polifagie
-scaderea ponderala
-astenie fizica si intelectuala
-crampe musculare
-prurit in sfera genitala si infectii genitale care nu
raspund la tratamentele obisnuite
-manifestari diverse: plagi greu vindecabile,
furunculoza

Telenursing in DZ
Diagnostice de nursing
-alimentatie inadecvata datorita polifagiei
accentuate
-deshidratare datorita poliuriei
-intoleranta la activitate fizica si intelectuala
datorita asteniei
-anxietate legata de complicatiile bolii

Telenursing in DZ
Diagnostice potentiale
-risc de infectii
-risc de complicatii acute : coma hipoglicemica sau coma
hiperglicemica
-risc de complicatii cronice: scaderea acuitatii
vizuale(retinopatie), lipsa de irigare in membrele
inferioare(arteriopatie diabetica care duce la gangrena),
afecteaza rinichii (nefropatie diabetica manifestare prin
proteinurie), furnicaturi, arsuri, dureri, hipersensibilitate
cutanata care poate duce la ulceratii si gangrene (neuropatie
diabetica)
-risc de complicatii: infectii virale sau microbiene din cauza
imunitatii scazute
-risc de tulburari digestive: diaree sau constipatie
-risc de tulburari sexuale: impotenta la barbati si frigiditate la
femei

Telenursing in DZ
Obiective
-mentinerea echilibrului metabolismului glucidic
-pacientul sa se alimenteze in raport cu nevoile sale cantitativ
si calitativ pe 24h
-pacientul sa-si recapete conditia fizica si intelectuala
-pacientul sa fie hidratat corspunzator in functie de eliminare
-pacientul sa fie constient de importanta regimului alimentar
-pacientul sa cunoasca semnele de hipoglicemie, hiperglicemie
-pacientul sa fie ferit de complicatii acute sau cronice
-sa se obtina un echilibru psihic al pacientului
-in ingrijirea pacientului sa se implice si familia daca este cazul

Evaluarea pacientului diabetic

1. Activitatea/odihna
- simptome:
- astenie, fatigabilitate, dificultati de mers, crampe
musculare, tonus muscular scazut

- semne:
- scaderea fortei musculare

Evaluarea pacientului diabetic

2. Circulatia
- simptome
- senzatie de ``picioare reci``, parestezii
- semne
- piele calda, uscata, rosie
Evaluarea pacientului diabetic

3. Integritatea ego-ului
- simptome:
- dependenta de altii
- semne:
- anxietate
Evaluarea pacientului diabetic

4. Eliminari:
- simptome
- poliurie, nicturie
- semne
- urina diluata, poliurie
Evaluarea pacientului diabetic

5. Hrana/Aport hidric
- simptome:
- inapetenta, greturi, varsaturi, nerespectarea
dietei, scadere ponderala
- semne
- tegumente uscate, turgor prelungit
Evaluarea pacientului diabetic

6. Durere/confort
- simptome:
- dureri la nivelul leziunilor tegumentare
- semne:
- grimase, priviri foarte atente la contactul cu
leziunile
Evaluarea pacientului diabetic

7. Consiliere/invatare
- simptome:
- factori de risc familiali
- boli cardiace
- AVC
- HTA
- vindecari dificile ale ranilor
- folosirea unor medicamente hiperglicemiante
(diuretice tiazidice, betablocante)
Diagnostice de nursing in diabetul zaharat
- Deficitul volemic
- Nutritie inadecvata
- Risc de infectii
- Fatigabilitate
- Deficitul informational
Diagnostice de nursing in diabetul zaharat
Deficitul volemic
- diureza osmotica
- diaree
- varsaturi
- deficit de aport
Diagnostice de nursing in diabetul zaharat
- Nutritie inadecvata
- scaderea aportului alimentar
- anorexie
- greturi
- dureri abdominale
- status hipermetabolic
- eliberarea hormonilor de stres
Diagnostice de nursing in diabetul zaharat
Risc de infectii
- deprimarea imunitatii
- modificari ale circulatiei
- hiperglicemie
- proceduri invazive
- leziuni tegumentare
Diagnostice de nursing in diabetul zaharat
Fatigabilitate
- productie energetica scazuta
- modificari ale biochimiei sangelui
- deficienta de insulina
- cresterea nevoilor energetice
- infectii
Diagnostice de nursing in diabetul zaharat
Deficitul informational
- despre conditiile, prognosticul si tratamentul
diabetului zaharat in legatura cu interpretarea
gresita a informatiilor sau din surse dubioase
Interventiile asistentei in ingrijirea pacientului
diabetic
1. Deficitul volemic
Obiective
- pacientul sa prezinte o imbunatatire in balanta hidrica:
- diureza normala
- semne vitale stabile
- puls periferic adecvat
- turgor normal
- mucoase umede
Interventiile asistentei in ingrijirea pacientului
diabetic
1. Deficitul volemic
Interventii
- monitorizarea semnelor vitale
- masurarea tensiunii arteriale
( hipovolemia se manifesta prin hTA, tahicardie)
- monitorizarea temperaturii, culoarea tegum
(febra, frisoanele, transpiratiile apar frecvent in infectii,
la fel eritemul locoregional)
- evaluarea pulsului, turgorul, hidratarea mucoaselor
- monitorizarea balantei hidrice (aport/eliminare)
- monitorizarea greutatii corporale
- corectarea imbalantei hidrice (aport crescut de lichide)
Interventiile asistentei in ingrijirea pacientului
diabetic
2. Nutritie inadecvata
Interventii:
- determinarea greutatii corporale
- realizarea unui program dietetic in corelatie cu
posibilitatile financiare ale pacientului
- auscultatia sunetelor intestinale, prezenta durerii
abdominale, greturi, varsaturi
- observarea semnelor de hipoglicemie (alterari ale
constientei, foame, transpiratii, ameteli)
Interventiile asistentei in ingrijirea pacientului
diabetic
3.Riscul de infectii
Interventii
- identificarea semnelor de infectie/inflamatie:
- febra, roseata, puroi la nivelul ulcerelor,
sputa purulenta, urina tulbure
- prevenirea infectiilor (spalat adecvat pe maini)
- mentinerea asepsiei in timpul procedurilor invazive
- ingrijire adecvata a tegumentelor
- pozitionarea pacientului in semisezand
- sfaturi legate de administrarea antibioticelor
- monitorizarea evolutiei ulcerelor
Interventiile asistentei in ingrijirea
pacientului diabetic
4. Fatigabilitatea

- sfaturi legate de alternarea judicioasa a perioadelor
de activitate cu cele de odihna
- consultarea unui diabetolog in cazul persistentei
fatigabilitatii
Interventiile asistentei in ingrijirea
pacientului diabetic
5. Deficitul informational
Interventii
- stabilirea nivelului de cunostinte legate de boala
al pacientului si al familiei
- oferirea de explicatii legate de boala si de unele
simptome/semne prezentate de pacient
- incurajarea pacientului si familiei sa acorde o atentie
deosebita dietei

Dieta in Diabetul zaharat
- Este cel mai constant element terapeutic
- Este indispensabila tuturor formelor de DZ
- Peste 30% din diabeticii de tip 2 sunt echilibrati doar prin
dieta
- Trebuie individualizata in functie de varsta, sex, activitate
fizica, preferinte alimentare, disponibilitati financiare, boli
asociate
Dieta in Diabetul zaharat
Recomandari nutritionale:
1. calorii: - normocalorica la normoponderali
- hipocalorica la obezi
- hipercalorica la subponderali
2. glucide: - 50-55% din aportul caloric
- se evita glucidele cu absorbtie rapida,
produsele rafinate (zahar)
3. fibre alimentare: predominanta in dieta a glucidelor
complexe (legume, cereale, fructe)

Dieta in Diabetul zaharat
Recomandari nutritionale:
4. lipide: - 30% din calorii
5. proteine: - 12-15% din calorii
6. sodiu: - <7g/zi; la hipertensivi <3g/zi
7. alcoolul: ocazional, in cantitati mici
8. edulcorante: zaharina, aspartam, ciclamat
9. mesele: fractionate, 3 mese principale, 2 gustari

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