Transcript Chapter_002_LO

Chapter 2
Patient Care Settings
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
1
Learning Objectives
• Describe the role of the nurse in community and home
health, rehabilitation, and long-term care settings.
• Differentiate between community health and communitybased nursing.
• Describe the types of specialty care that nurses may
provide in home health care.
• Describe the principles of rehabilitation.
• List the four levels of disability.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
2
Learning Objectives
• Discuss legislation passed to protect the rights of the
disabled.
• Identify the goals of rehabilitation.
• Name the members of the rehabilitation team.
• List the types of long-term care facilities.
• Discuss the effects of institutionalization on the older
adult.
• Describe the principles of nursing care in long-term
residential facilities.
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
3
Community Health Nursing Roles
• Work with many different individuals and
groups to create or modify systems of care to
improve the health of a defined group
• Box 2-1 lists many of the roles assumed by the
community health nurse
• Most roles require a bachelor’s degree in
nursing; however, the LPN is increasingly
visible in community health settings
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
4
Community-Based Nursing
• Deriving health care services based on
identified community needs and providing
various types of care that meet the needs of
citizens at various levels of wellness and
illness
• Traditional and nontraditional community settings
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
5
The Home Health Nurse
• Gives direct care to the patient, and teaches
patient and family to care for themselves
• Homes often have only a fraction of the
resources of the hospital
• Must assess patient, family, and environment
to plan care
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
6
Figure 2-1
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
7
Reimbursement Realities in
Home Health
• Home treatment must be authorized by physician
• Plan of care must include
•
•
•
•
•
•
•
•
•
•
Pertinent diagnoses
Mental status evaluations
Identification of the types of services needed
Supplies and equipment ordered
Frequency of visits
Prognosis
Rehabilitation potential
Functional limitations
Nutritional requirements
Medications and treatments
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
8
Reimbursement Realities in
Home Health
• Care must be skilled, intermittent, reasonable, and
necessary
• Skilled
• Care must be the kind that only a nurse trained in that care could
be expected to do
• Intermittent
• Visits occur periodically; usually do not exceed 28 hours/week
• Reasonable and necessary
• Objective clinical evidence must clearly justify the type and
frequency of services
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
9
Reimbursement Realities in
Home Health
• Patient must be homebound
• Must exert considerable effort to leave the home
• Medicare also requires that absences from home
be infrequent and of short duration
• According to Medicare regulations, if patients are
well enough to leave home frequently, they are
able to visit a physician’s office for treatment and
are not in need of home care
• Home health agency must be Medicare
certified
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
10
Types of Home Health Services
• Skilled nursing
• “Skilled observation and assessment”
• The skills of a nurse are required to observe a patient’s
progress, to assess the importance of signs and
symptoms, and to decide on a course of action
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
11
Types of Home Health Services
• Teaching
• The most important skill in home care
• Much of what is done in the home must be done by
the patient and caregiver
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
12
Figure 2-2
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
13
Types of Home Health Services
• Specialty home care
• Intravenous therapy
• The most common intravenous therapies provided in the
home are hydration, antibiotics, pain control, total
parenteral nutrition, and chemotherapy
• The nurse’s roll in the delivery of high-technology care in
the home includes skilled observation and assessment, the
ability to perform skilled procedures, and teaching
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
14
Types of Home Health Services
• Specialty home care
• Ventilator therapy
• This type of care is complex and should be provided only
by nurses and caregivers specifically trained in the use of
necessary equipment and procedures
• Requires around-the-clock observation
• Physicians and respiratory therapists must be on call for
any problems
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
15
Communication Among Home Health
Care Team Members
• Documentation
• Provides interdisciplinary communication
• Reimbursement for home health nursing visits
depends on clear documentation of the patient’s
homebound status, the skilled nature of the services
provided, and the medical need for the services
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
16
Communication Among Home Health
Care Team Members
• Case conferences
• The case manager schedules periodic, formal case
conferences
• All disciplines work together to solve clinical
problems
• Conferences provide detailed information about the
complexity of problems that may justify increased
visits
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
17
Rehabilitation Concepts
• Rehabilitation
• A process of restoration
• The process of restoring an individual to the best possible
health and functioning after a physical or mental
impairment
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
18
Rehabilitation Concepts
• Impairment
• A disturbance in functioning
• May be either physical or psychological
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
19
Rehabilitation Concepts
• Disability
• A measurable loss of function
• Usually delineated to indicate a diminished capacity for
work
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
20
Rehabilitation Concepts
• Handicap
• An inability to perform daily activities
• An individual is not able to perform one or more normal
activities of daily living (ADLs) because of a mental or
physical disability
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
21
Levels of Disability
• Level I
• Slight limitation in one or more ADLs; able to work
• Level II
• Moderate limitation in one or more ADLs; able to
work but workplace may need modifications
• Level III
• Severe limitation in one or more ADLs; unable to
work
• Level IV
• Total disability, with nearly complete dependence on
others for assistance with ADLs; unable to work
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
22
Rehabilitation Goals
• Return of function
• Restoration of as much as possible in the traditional
ADLs, such as bathing, dressing, eating, toileting,
and walking
• Ultimate goal is to live independently
• Not all patients can be restored to their previous
state; can learn to adapt to changes
• Emphasis on abilities rather than disabilities
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
23
Rehabilitation Goals
• Prevention of further disability
• Secondary disabilities may be caused by the
patient’s primary disability
• For example, a stroke patient may develop pneumonia,
decubitus ulcers, and/or contractures
• Rehabilitation process can place additional burdens
on family members when roles once filled by the
disabled family member must be filled by other
members
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
24
Rehabilitation Legislation
• Federal government has passed laws to
protect the rights of the disabled
•
•
•
•
Vocational Rehabilitation Act of 1920
Social Security Act of 1935
Rehabilitation Act of 1973
Americans with Disabilities Act of 1990
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
25
The Rehabilitation Team
• Nurses must consider the whole patient when
planning interventions
• Difficulties in functioning may affect many
aspects of a person’s life and require
coordinated services of several health care
professionals so the individual can stay well
• Successful rehabilitation depends on health
care workers considering how the individual
functions within the family and working closely
with other health professionals toward a
common goal
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
26
Approaches to Rehabilitation
• Rehabilitation patients should be encouraged
to do as much as possible for themselves
• The program should commence immediately
after an injury and should involve the patient
and family from the outset
• Nurses should be prepared to handle a wide
range of patient and family emotions, from
extreme optimism to depression
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
27
Long-Term Care
• 16,500 Medicare- or Medicaid-certified nursing
homes in the United States provide residential
skilled nursing care
• Nursing home population is about 3.5 million
• Required by people of all ages who are
temporarily or permanently unable to function
independently
• Refers to a range of services that address the
health, personal care, and social needs of
people who lack some ability for self-care
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
28
Risks for Institutionalization
• Age
• 1% of people ages 65 to 74 years reside in nursing
homes
• 6% of people ages 75 to 84 years reside in nursing
homes
• 20% of people ages 85 years and older reside in
nursing homes
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
29
Risks for Institutionalization
• ADL dependency
• 12% of those with one or two ADL limitations reside
in nursing homes
• 50% with five or six ADL limitations reside in nursing
homes
• Other factors
• Financial resources, living alone or with family,
mental illness, type of disease process, and degree
of social support
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
30
Long-Term Care: Levels of Care
• Domiciliary care
• Facilities providing basic room, board, and
supervision
• 24-hour care is not provided, and residents usually
come and go as they please
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
31
Long-Term Care: Levels of Care
• Sheltered housing
• Similar to domiciliary care facilities, sheltered
housing settings have some modifications to provide
care for the frail older adult
• Usually includes community dining facilities
• 24-hour care is not provided
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
32
Long-Term Care: Levels of Care
• Intermediate care
• Custodial care at a level usually associated with
nursing homes
• Patients often need assistance with two or three
ADLs
• Must have personnel available 24 hours a day
• Receive no reimbursement under Medicare; some
receive financing under Medicaid
• Require an RN to serve as director of nursing and
an LPN to be on duty at least 8 hours a day
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
33
Figure 2-3
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
34
Long-Term Care: Levels of Care
• Skilled care
• Facility must have skilled health professionals
present around the clock
• Care must be supervised by a physician and
requires the services of a registered nurse, physical
therapist, or speech therapist
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
35
Long-Term Care
• Effect of relocation
• The more prepared the patient, the better the
adjustment
• Provide as much choice as possible for the patient,
and respond to questions and concerns
• Choices of facility, room location, types of personal
belongings, and room decor are helpful, as are tours
of the facility before entering
• Patients should be introduced to other residents
with like interests and invited or helped to participate
in appropriate activities
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
36
Effects of Institutionalization
• Depersonalization
• Plays a major part in institutional life
• Caregivers often know little of a resident’s life
history and therefore treat the individual resident in
light of his/her diagnosis or dysfunctional behavior
patterns
• One way to help see the resident of a long-term
care facility as a whole person with past
relationships, accomplishments, and interests is to
ask family members to bring in photographs
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
37
Effects of Institutionalization
• Indignity
• Routine activities such as toileting and obtaining
food and drink must be respected
• Simple courtesies, such as using a person’s title
and last name, knocking before entering the room,
and draping during care activities, help the resident
maintain dignity
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
38
Effects of Institutionalization
• Redefinition of “normal”
• Behaviors considered normal at home may be
labeled abnormal/unacceptable in institution
• Watching television at 3 AM, loud singing, or sexual activity
may not be tolerated, depending on the residence’s rules
and routines
• Important to give residents of long-term care
facilities some flexibility and some measure of
control in their daily lives
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
39
Effects of Institutionalization
• Regression
• The resident’s physical, mental, and social abilities
may be lost because of disuse
• Important to encourage independence and social
interaction as much as possible
• Avoid infantilizing older patients
• May be necessary to simplify language and
activities for those who are cognitively impaired, but
avoid baby talk
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
40
Effects of Institutionalization
• Social withdrawal
• If resident never leaves nursing home, or if family
visits are few, the institution can become a barrier,
cutting off interest and participation in the outside
world
• The facility becomes patient’s entire world
• Withdraw into the boundaries of their own room
• Nurses can help by conversing about events inside
and outside the nursing home
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
41
Principles of Long-Term
Residential Care
• Promotion of independence
• Successful relocation to long-term care facility
depends in part on the ability of patients to do things
for themselves; older adult family member in contact
with the outside world
• Set specific goals for each patient that encourage
independent functioning
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
42
Principles of Long-Term
Residential Care
• Maintenance of function
• Often it is loss of function that prevents an older
adult from staying at home
• Health professionals who are disease oriented
concentrate on the disease process at the expense
of a functional assessment
• Interventions, whenever possible, should focus on
restoring and preserving function
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
43
Principles of Long-Term
Residential Care
• Maintenance of autonomy
• Successful relocation to a long-term care facility
depends on preserving as much autonomy as
possible
• Older adults who help select the facility adjust better
than those who have no choice in the matter
• Allow as much flexibility as possible in establishing
a routine for the new resident
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
44
Principles of Long-Term
Residential Care
• Mutually established goals are more likely to
be achieved than those selected for the
resident
• Autonomy depends on knowing one’s place in
the world and what roles one still plays within
the family structure
• Families who relate to their elder members,
reinforce their importance in the family, and
keep them up to date on family happenings
and decisions support the idea that the elder
remains a valued family member
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
45
Other Patient Care Settings
•
•
•
•
•
•
Clinics
Physicians offices
Schools
Adult daycare
Respite care
Correctional facilities
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
46