Acute Interventions for the Chronic Care Patient

Ray Taylor

Valencia Community College

Home Health Care

Home Care Providers

Home Care Pathologies

ALS Support for Home Care Patients

Hospice

Topics

Introduction

A major trend of health care involves the shifting of patients out of the hospital and back into their homes as soon as possible.

The result has been a huge increase in home health care services.

Epidemiology of Home Care

A number of factors have promoted the growth of home care in recent years. They include:

Enactment of Medicare in 1965The advent of HMOs Improved medical technologyChanges in the attitudes of doctors and

patients toward hospital care

In 1992…

Almost 75% of home-care patients were age 65 or older.

Of the elderly home-care patients, almost two-thirds are female.

Responses to Home Care

A number of situations may involve you in the treatment of a home-care patient:

Equipment failure

Unexpected complications

Absence of a caregiver

Need for transport

Inability to operate a device

Home Health Care

Home health care problems requiring intervention by a home health practitioner or physicianChemotherapyPain managementHospice care

Figure 6-3

Types of Home Care Patients

Airway pathologies Inadequate pulmonary toilet Inadequate alveolar ventilation Inadequate alveolar oxygenation

Circulatory pathologies Alterations in peripheral circulation GI/GU pathologies Ostomies Catheters Home dialysis

Types of Home Care Patients

Infections Cellulitis, sepsis

Wound care Surgical wound closure Decubitus wounds Drains

Hospice care

Maternal child care Apnea monitors New parent

Progressive dementia in the patient at home

Chronic pain management

Home chemotherapy

Transplant candidate

Infection and Ulceration

Table 6-4

Home Health Preparation

Table 6-5

Prevention

General System Pathophysiology Assessment/Management

Assessment of the home-care patient follows the same basic steps as any other patient.

The one thing home-care calls have in common is their diversity.

Try to ascertain from the primary health care provider a baseline presentation for the patient.

Patient Assessment

Assessment

Scene size-up Body substance isolation

Infectious waste issues in home care environment

Safety Pets Firearems

Milieu Ability to maintain a healthy environment Adequate nutritional support available (electricity, heat,

etc.)

Common Acute Home Health Situations

Respiratory disordersCOPDBronchitisAsthmaCHFCystic fibrosisBronchopulmonary dysplasia

Common Acute Home Health Situations

Neuromuscular degenerative diseasesMuscular DystrophyPoliomyelitisGuillain-Barré SyndromeMyasthenia Gravis

Patients awaiting lung transplantsSleep apnea

Respiratory Disorders

Account for more than 630,000 of hospital patients discharged for home care annuallySimple pneumonia and pleurisy account for

37%COPD accounts for 50%

Respiratory Pathology

Increased risk of airway infections in the respiratory compromised patientProgression of chronic respiratory diseasesIncreased secretionsObstructed or malfunctioning airway devicesImproper application of medical device

Common Respiratory Equipment

Oxygen equipment

Portable suctioning machines

Aerosol equipment and nebulizers

Incentive spirometers

Home ventilators

Tracheostomy tubes and collars

COPD

Triad of diseases Emphysema, chronic bronchitis, asthma Outflow obstructive diseases impending the

exhalation of air from lungs Minimal lung capacity Inability to meet normal metabolic demands

Decreased patient activity with increase use of 02

Increase C02 and decrease oxygenation

Bronchitis/EmphysemaBronchitis Chronic excessive production of mucus Narrowing bronchial passages restricting air flow

Large, obese patients (blue bloater)

Emphysema Enlargement and stiffening of alveoli and acenus Loss of elasticity and compliance requires a higher

pressure in lungs to facilitate gas exchange at alveolar level

Patients have increased A/P dimensions (increased air retention and decreased outflow

Thin patients due to increase caloric output

Acute ExacerbationPatients have difficult compensatory mechanisms Signs and symptoms

Wheezing, diminished breath sounds, use of accessory muscles, retractions, tripod positioning, inability to speak or form sentences

Home health care treatments Oxygen, nebulized aerosol treatments Ventilator: PEEP (via ETT), CPAP, BiPAP (mask

therapy)

Treatment Intervention

Oxygenation and ventilation

Nebulized beta-2 agonists

Nebulized anti-cholinergics

IV corticosteriods

AsthmaReactive and reversible airway disease seen at any age Characterized by bronchospasm and swelling of mucus

membranes

Signs and symptoms of acute attackHome therapy O2, oral medications, variety of nebulizers and/or

inhalants

Treatment Oxygenation and ventilation, beta agonists, anti-

cholinergics, corticosteriods Avoidance or elimination of reactants that trigger

problem

Cystic FibrosisGeneric disorder usually recognized in childhood Terminal disease

Characterized by chronic overproduction of mucus, inflammation of small airways and hyperinflation of alveoli, chronic infections, and erosion of the pulmonary blood vessels secondary to infectionExocrine disease causing other abnormalities GI disturbances, pancreatic disorders, glucose

intolerance

Home Health Treatment

Postural drainage of mucus

Chest physiotherapy

Mechanical vibrators to facilitate breakage of secretions

Medications aimed at mucus reduction and control of systemic bacterial infections

Bronchopulmonary Dysplasia

Primarily affects infants of low birth weightCharacterized by ongoing need for

mechanical ventilation in newborns Infants fail to wean from mandatory

ventilation or oxygenation Increased risk of respiratory infection

Management

EMSOxygenation and oximetric monitoringNeonatal transport to appropriate facility

Home health Intermittent mandatory ventilation (IMV)Pulmonary congestion and edemaLimit fluid intake

Management/Summary

Improving airway patency

Improve ventilation

Improve oxygenation

Psychological supportCommunication with the intubated patientCommunication using a “talking trach”

Neuromuscular Degenerative Diseases

Affect respiratory action through degeneration of muscles used for breathing

As disease progresses and involves more muscle groups, inability to ambulate increases infections and rapid decline of patients

Neuromuscular Diseases

Muscular Dystrophy Genetically inherited disorder causing a defect in

the intracellular metabolism of muscle cells Leads to degeneration and atrophy of muscles

which are replaced by fatty and connective tissues No cure to date EMS involvement: respiratory failure, accidental

injuries usually related to falls

Neuromuscular Diseases

Poliomyelitis Infectious disease rarely seen today

because of vaccineDestroys motor neurons leading to

muscular atrophy, weakness, and paralysisChildren often suffer crippling effects

Neuromuscular Diseases

Guillain-Barre Syndrome Autoimmune response to a viral infection Usually preceded by a febrile episode with a

respiratory or GI infection Characterized by muscle weakness leading to

paralysis caused by nerve demylenation Usually begins in distal extremities and moves

proximally No cognitive or CNS involvement

Neuromuscular Diseases

Myasthenia GravisRare disease that affects the neuronal

junctionDue to a breakdown in acetylcholine

receptors, nerve impulses are delayedCharacterized by muscle weakness

proximal to the body versus distalNo cure to date

Sleep Apnea

Complex condition not fully understood by expertsCharacterized by long pauses in respiratory cycle that can be caused by a relaxation of the pharynx or lack of respiratory driveCan result in hypertension, arrhythmias, and chronic fatigue

Sleep Apnea

Symptomology Muscles of airway become more relaxed as mind

falls deeper into sleep Leads to snoring, and in some cases, blockage of

airway Decreased 02 levels cause a partial awakening of

the patient Breathing then resumes and patient returns to

sleep, often with no memory of the event Repeated over and over, interruptions destroy

normal sleep patterns and the patient spends much of the sleeping in a hypoxic state

Sleep Apnea

General treatmentSurgical alteration of the airwayMedicationsPrescribed weight lossAvoidance of any CNS depressants

(alcohol)Use of CPAP ventilator

Medical Therapy Found in the Home Setting

Home oxygen therapy

Artificial airways/tracheostomies

Vascular access devices

Home Oxygen Therapy

Many advantages for home care patientsEasy to use Tolerated well by most patientsAdd to quality of a patient’s lifePrevents hypoxia that may result in

permanent cognitive damage or degeneration

Oxygen Systems

Artificial Airways/TracheostomiesUsed for patients with long-term upper airway problemsTracheostomy may be temporary or permanentTechnique is used on patients who require

artificial ventilation for long periods of timePatients with damage to larynx, epiglottis,

or upper airway structures from surgery or trauma

Artificial Airway

Tracheostomy consists: Surgical opening (stoma) Outer cannula

Keeps stoma open Held in place by twill tape or velcro strap

Inner cannula Similar to a mini ET tube Slides down into trachea a few inches Distal low pressure cuff to hold in place and provide a

good seal

Tracheotomy tubes Top: Plastic tube

Bottom: metal tube with inner cannula

Artificial Airways

SpeechArtificial larynx

Looks like a small flash lightCreates an electronic vibration by pressing the

device up against the neck and by patient changing shape of his/her mouth

Routine Care of Tracheostomy

Keep stoma clean and dry Prevent pulmonary infections

Periodic changing of the outer cannulaChanging and cleaning the inner cannnula from every few weeks to every months, depending on the patientFor ventilator patients, routine changing of the ventilator hose connectionsFrequent suctioning, due to increased secretion

Common Complications of Tracheostomy Patients

Blockage of the airway by mucus and/or dislodged cannula Patient coughing to clear and suctioning Patient movement and child growth

Infection of the stomaDrying of tracheal mucus leading to crusting or bleedingTracheal erosion from an over-inflated cuff Tracheal necrosis

Management/Ventilation

ManagementOxygenation and ventilationSterile suctioning of the stoma/trachea with an endotracheal suction catheterCannula obstruction Deflate cuff and remove

Stoma intubation Remove inner cannula Use appropriate sized tube size and advance tube

1-2cm inside trachea Attach end tidal CO2 device and monitor with

pulse oximetry

Home VentilationTypes of ventilatorsPositive pressureNegative pressure

Provision for ventilationVolume cycled ventilation

Historical standard for ventilatorsUsed to support multiple forms of respiratory

failure

Home VentilationPositive pressure ventilators (PPV) Recommended for acute respiratory failure Push air into lungs through a mask, nasal mask, or

tracheostomy Features

Variations: tidal volume respiratory rate flow rate pressure

Home Ventilation

Negative pressure ventilators Imitate normal breathing processApply negative pressure to the chest (pull

chest allowing it to expand)Allows air to flow into lungs

Patients usually use this form of device at night

Iron lung is an old example

PEEP/CPAP/BiPAP

Three ventilator options

Add pressures at various times during respiratory cycle

May be used on a full-time or part-time basis

Always possibility of pneumothorax due to increased pulmonary pressure

PEEPPositive end expiratory pressureUsed to maintain inflation of alveoliFunctions by providing a little back pressure at the end of expirationUses Premature infants with insufficient surfactant Adults with surfactant washout from PE, ARDS,

near drowning COPD

Emphysema patients require higher diffusion pressures for gas exchange

CPAPContinuous positive airway pressureUsed to keep pharyngeal structures from

collapsing at end of a breathOften prescribed for sleep apnea

Most patients use nasal CPAPPatients must keep mouth closed

Idea behind CPAP is the same a PEEPCPAP is delivered with a mask while PEEP

is delivered via ETT

Figure 6-7

Ventilation/CPAP-Nasal

BIPAP

Bilevel positive airway pressure

Provides two levels of pressure InspirationExpiration

Used for patients who require higher levels of pressure than CPAP

Assessment Findings

Work of breathing

Tidal volume

Peak flow

Oxygen saturation

Capnography

Breath sounds

Vascular Access Devices

Approximately 500,000 long term therapy catheters inserted each yearVAD’s are used to provide parenteral treatment on a long term basisUsed for Chemotherapy Hemodialysis Peritoneal dialysis Total parenteral nutrition Antibiotic therapy

Vascular Access Devices

Hickman, Broviac, Groshong

Peripherally inserted central catheters

Surgically implanted medication delivery systems

Dialysis shunts

Hickman, Broviac, or Groshong Catheters

Single, double, triple lumen catheters inserted into a central vein Subclavian vein most common All have an external port that look like an IV port External hub of the catheter is sutured into skin

and has a cuff that promotes fibrous in-growth Anchors catheter to body and prevents infection from

traveling down catheter

Care of device includes: cleanliness and administration of anticoagulant therapy

Peripherally Inserted Central Catheters

PICC lines are most commonly inserted into median cubital vein in the ACF

Catheter is threaded from insertion site into central venous circulation

PICC lines are inserted under fluoroscopy

Surgically Implanted Medication Delivery Systems

Port-a-cath or Medi-portInfusion port is implanted completely below the skinDisc shaped devices that have a diaphragm that requires a specially shaped needle (Huber needle)Typically implanted in upper chest

Dialysis Shunt

Used for patients undergoing hemodialysis to filter their blood

Types of shunts AV shunt

Loop connecting an artery and vein, most common in distal arm where dialysis apparatus evacuates and returns blood

Fistula Connects artery and vein creating an artificially large

blood vessel for access

AV Shunt

VAD Complications

ObstructionThrombusEmbolus (air embolus)Catheter kinkingCatheter tip embolus Inactivity increases risk of clots

InfectionHemorrhage

Cardiac Conditions (Home Health)

Post MI recovery

Post cardiac surgery

Heart transplant

CHF

Hypertension

Implanted pacemaker

Atherosclerosis

Congenital malformation (pediatric)

GI/GU Crisis

Devices to support GI/GU function are common.

Be familiar with the various devices and their complications.

GI/GU Devices

Urinary catheters or urostomiesSurgical diversion of the urinary tract to a

stoma, or hole in the abdominal wall

Indwelling nutritional support device (peg tube, G-tube)

Colostomies

NG tube

Figure 6-9

External Urinary Catheter (Texas Sheath)

Figure 6-10

Foley Catheter(Indwelling Catheter)

Urinary Device Complications

Infection or device malfunction Catheter device provides a pathway for infectious entry Foul smelling urine Discolored (cloudy) urine Blood tinged urine Systemic infection (fever) Redness, swelling of abdominal wall site with

urostomies

Device malfunction: accidental placement, obstruction, balloon ruptures

Gastrointestinal DevicesNasogastric tubes Decompress gastric contents Lavage GI system Short term use

Feeding tubes Rest on the duodenum or jejunum Weighted with steel filament to aid insertion and

passage through pyloric sphincter

Percutaneous endoscopic gastrostomy (PEG) Via abdominal wall Long term nutritional support

Nasogastric Feeding

Figure 6-12

Gastrostomy (PEG)

Colostomy

Opening of a portion of the large intestines (colon) through the abdominal wall, allowing feces to be collected outside the bodyTemporary or permanentIndications CA of bowel Diverticulitis Crohn’s disease Trauma

Figure 6-13

Colostomy

Assessment Findings

Abdominal pain and distention

Bowel sounds

Palpation of bladder

Color, character, amount of urine

Acute InfectionsIncreased rate of infections in the elderly, chronically ill and homebound

Decreased ability to perceive pain or perform self-care in many homebound populations

Pathophysiology

Increased risk of respiratory infection in the immunocompromised patient

Poor peripheral perfusion results in decreased healing and increased peripheral infections

Sedentary existence leads to skin breakdown and peripheral infections

Pathophysiology

Percutaneous and implanted medical devices increase risk for infections and sepsis

Patients discharged to home with open wounds and incisions

Chronic diseases may further impair healing

Poor nutrition, hygiene or ability to care for self impact infection rates

Maternal & Newborn Care

Many women who deliver their babies in the hospital will be discharged in 24 hours or less.

ALS providers may be called upon to assist new parents in caring for newborns or post-partum complications.

Post-partum bleeding and embolus are common complications

Management includes:

Massage of uterus

Administration of fluids

Administration of pitocin

Rapid transport, if necessary

Postpartum Depression

“Let down” feeling experienced during the period following birth

Occurs in 70%-80% of mothers

Women have difficulty caring for both themselves and newborn

Be sensitive to needs and non-urgent responses

Infants and Children with Special Needs

Many different types of childrenPremature babiesLung diseaseHeart diseasesNeurological diseasesChronic diseasesAltered functions from birth

Infants and Children with Special Needs

Common home-care devicesTracheostomy tubesApnea monitorsHome artificial ventilatorsCentral intravenous linesGastric feeding and gastrostomy tubes Shunts

Common Infant/Child Complications

Signs/symptoms of cardiorespiratory insufficiency include:

Cyanosis

Bradycardia (<100 BPM)

Rales

Respiratory Distress

Hospice

More than 2250 hospices provide support for the terminally ill and families.

The goal of hospice care is to provide palliative or comfort care rather than curative care.

Hospice

Hospice

Palliative care

Comfort care

Hospice care DNRMedical direction considerations

Pain control in the terminal patient

Common Hospice Diseases

Congestive heart failure

Cystic fibrosis

COPD

AIDS

Alzhemier’s

Cancer

Figure 6-14

HIV Children

Summary

Home Health Care

Home Care Providers

Home Care Pathologies

ALS Support for Home Care Patients

Hospice