הטיפול והמעקב בחולה הכרוני

דף הבית / הייחוד שלנו / הטיפול והמעקב בחולה הכרוני

מחלה כרונית [בניגוד למחלה חריפה] הינה הפרעה במערכות הגוף השונות' שאינה ניתנת לריפוי מוחלט. המחלה הכרונית בדרך כלל יציבה [הפוגה] אך לעיתים מתרחשת התפרצות [התקף] והיא יכולה להתקדם ולהחמיר. כיום המחלות הכרוניות נחשבות כבעיה הבריאותית החשובה ביותר, ולדעת ארגון הבריאות העולמי היא הגורם הראשון לתחלואה ותמותה.

מחלות כרוניות של מערכת העיכול הן מחלות רב מערכתיות, ולעיתים קרובות פוגעות גם במערכות גוף מחוץ למערכת העיכול, כמו עיניים, פרקים, עור, אלרגיה, ריאות, אא"ג, פסיכיאטריה ועוד. במקרים רבים, מחלות כרוניות המערבות את מערכת העיכול מהוות בעיה קשה לא רק לחולה, אלא גם למשפחתו ולצוות הרפואי.

הטיפולים במחלות כרוניות אינם מרפאים, אלא מסייעים בעיקר לטפל בתסמינים, לאזן את מצבו של החולה ולשפר את איכות חייו

מודל הטיפול במחלה הכרונית מבוסס על המרה לטיפול יומיומי ממצב של תגובה, למצב פרואקטיבי – יזום, מתוכנן ומבוסס אוכלוסייה.

6 מרכיבים למודל הטיפול במחלה הכרונית:

1. ניהול עצמי בשיתוף עם הצוות הרפואי בהתאם ליעדים ומטרות הטיפול
2. תמיכה בקבלת החלטה בהתאם להנחיות וסטנדרטים מקובלים
3. עיצוב מערכת מסר בהתאם לרישומי טיפול יומיומי
4. קשר קהילה ולרופא המטפל ולמחלת האשפוז – צוות, מודעות, חינוך
5. ארגון הבריאות – תכניות אסטרטגיות ושיפור
6 מערכות מידע קליניות -. ניהול מסדי נתונים

בגסטרומד מטפלים ועוקבים אחר חולים הסובלים ממחלות כרוניות. לחולים אלו מומלץ להצטרף לאחד מהמרכזים המיוחדים שהקמנו:

מחלת קרון

דלקת מעי כיבית

הפטיטיס כרונית

תסמונת המעי הרגיש

צרבת

פוליפוזיס משפחתית

צרידות וכחכוך בגרון

סוכרת

ליקויי אכילה

דלקת כרונית של הלבלב

אי ספיקת לבלב

אי ספיקת כבד

כאב בטן פונקציונאלי

תת ספיגה

סרטן

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