Exam 14 - Community Health Nursing

Home Health Care

• Home health care services are provided to all ages in the comfort of their homes.
• Home health care services increase family support, familiarity with surroundings, participation in care, and shorter hospital stays.
• Home health care services preserve individual independence and integrity.
• Home health care services include skilled nursing, physical and occupational therapy, respiratory therapy, wound care, IV administration, and acquiring medical supplies or equipment.
• To qualify for Medicare, patients must be homebound, meaning they are unable to leave their homes or need significant effort to travel for appointments.
• Commonly qualified discharged patients include those who have had a stroke, COPD, fractured hip, joint replacement, heart failure, diabetes, or hypertension.
• Home health care utilizes both Licensed Practical Nurses (LPN) and Registered Nurses (RN).
• RNs provide case management, administration, and supervision.
• LPNs provide most of the direct patient care.
• Home health care embraces a medical model of practice with defined limits on the services reimbursed by Medicare.

Home Health Care: History

• Medicare became effective in 1966, impacting home health care services.
• The Prospective Payment System (PPS) was enacted in 1983, leading to earlier hospital discharges and an increase in demand for home health care services.
• The Balanced Budget Act of 1997 imposed payment limits for home health care, which reduced expenditures and services provided.
• The Balanced Budget Act of 2000 provided authority for a prospective payment system, which produced incentives for efficiency and limited Medicare expenditures.
• Home health care has expanded since 1990 with a slight decrease in costs.
• A reduction in home health care is expected over the next several years.

Types of Home Health Agencies

• Home health agencies must comply with federal, state, and local laws and regulations.
• Agencies must be licensed and certified to operate and receive Medicare payments.
• Agencies may also seek accreditation through external organizations.
• Agencies are classified by tax status (profit vs. nonprofit), location (freestanding vs. institutional-based), and governance (private vs. public).
• Telehealth services are increasing in popularity and allow for patient-provider interaction and monitoring through telephone, computers, or two-way monitors.

Changes in Home Health Care

• Home health care utilizes various services, including ethical committees, psychiatric nurse clinicians, social workers, nurse pain specialists, hospice care, pet care programs, and home infusion therapy.

Service Components of Home Health Care

• Home health care provides primary services and other therapy services, such as respiratory therapy and nutritional counseling, but these may not be directly reimbursable by Medicare.
• Home health care can provide medical equipment, including durable medical equipment (DME).
• Medicare requires a signed treatment plan outlining all disciplines, treatment frequency, duration, and a face-to-face visit with the patient.

Skilled Nursing Services

• The four major goals of skilled nursing care are restorative, improvement, maintenance, and promotion.
• Skilled nursing providers should exhibit technical proficiency, good organizational skills, innovation, independence, decision-making ability, prompt responsiveness to problem-solving, positive communication skills, patient rapport, cultural sensitivity, and respect for patient dignity, privacy, and autonomy.

Role of LPNs in Home Health Care

• LPNs provide many of the same services as RNs and should also exhibit flexibility, compassion, patience, empathy, and teamwork.
• LPNs often operate in less restrictive work environments.
• LPN duties include teaching, psychosocial support, and procedure assistance.

Physical Therapy Services

• Physical therapists communicate with RNs to ensure continuity of care.
• Physical therapy aims to provide restorative treatment for Medicare reimbursement, but some cases involve maintenance or prevention.
• Physical therapists assess patients to determine treatment, education, and assistive devices needed.
• Treatments include muscle strengthening, transcutaneous nerve stimulation, and ultrasound treatments.

Speech-Language Therapy Services

• Speech-language therapy services require a master's-prepared and certified clinician for Medicare reimbursement.
• Speech-language therapy aims to minimize communication disorders and their impact and rehabilitate speech, particularly after stroke or surgery.
• Services include language relearning, eating/swallowing disorder treatment, and lip reading instruction.

Occupational Therapy Services

• Occupational therapy focuses on practical tasks and aims to restore functional levels of task completion to assist with activities of daily living (ADLs).
• Services aim to increase independence, identify self-help devices, and assess for vocational training.

Medical Social Service Services

• Medical social services focus on the emotional and social aspects of illness.
• Care plans include education, counseling, payment source identification, and referrals.

Homemaker-Home Health Aide (HHA) Services

• Medicare requires a primary skilled or therapy service to be provided before HHA services are arranged.
• Many insurers do not reimburse HHA services.
• HHA services fall into three categories: personal care, physical assistance, and household chores.
• Medicare and Medicaid require on-site supervision of HHA services every two weeks by an RN.

Home Health Care Process

• Referrals can be initiated through formalized hospital discharge or a direct call from the patient's physician.
• An RN typically conducts the initial evaluation and admission visit within 24-48 hours of referral.
• The admission process involves a physical and psychosocial assessment, environmental assessment, and identification of functional impairments and support systems.
• During the admission process, patient rights, costs, payment sources, and billing practices should be explained to the patient.
• Care plans must be signed by the physician.

Home Health Care Visits

• Skilled visits are conducted according to orders and typically last 30-45 minutes.
• There may be a predetermined number of visits per week during each episode of care.
• Telehealth can be utilized to monitor patients remotely, generating data to impact clinical decisions.

Home Health Care Documentation

• Documentation can be handwritten or electronic.
• Documentation serves to provide extended periods of health information, monitor patient compliance and care needs, and promote quality of care.
• Comprehensive documentation is required by Medicare for reimbursement purposes.
• Discharge planning begins at admission to promote continuity of care in the patient's home and involves patient and family involvement.

Quality Assurance and Improvement in Home Health Care

• Quality management techniques aim to meet the needs of home care clients and continuously improve the quality of care provided.
• Quality management is measured through structural criteria, process criteria, and outcome criteria.
• Quality assessment plans include plans for remediation or improvement.

Reimbursement for Home Health Care

• Medicare and Medicaid are primary sources of income for most home health agencies.
• Medicare requires agencies to be certified in meeting the federal conditions of participation.
• Medicare beneficiaries must be at least 65 years old, disabled, or have end-stage renal disease and must be under the care of a licensed physician.
• Medicaid programs pay for home care services to indigent and low-income individuals of all ages.
• Third-party payers reimburse for limited home care services.
• Private pay is another source of reimbursement.
• Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) negotiate contracts with home health agencies.

Cultural Considerations in Home Health Care

• Cultural considerations are important in the home environment, as they may create conflict in values, increasing complexity in nursing interventions.
• Communication strategies are vital in addressing cultural differences.

Nursing Process in Home Health Care

• Patient needs should guide care planning.
• LPNs and RNs should review and follow defined prioritization for patient care.
• The nursing process includes assessment, patient problem identification, expected outcomes and planning, implementation, and evaluation.
• Maintain a family nursing perspective when addressing patient problems.
• Set family-oriented goals and outcomes by involving both the family and the patient.

Conclusion

• Home health care provides a variety of services for individuals with illnesses, disabilities, and across all age groups.
• Home health care is expected to increase in importance as the population over 65 continues to rise.
• Home health providers support healthy living, illness prevention and education while promoting "family life."

Long-Term Care

• Long-term care services are provided to individuals who need assistance in meeting various personal needs.
• The goal of long-term care is to keep individuals as independent as possible after they are no longer able to meet their daily needs independently due to physical or psychological impairment.
• Long-term care is provided in various settings for individuals of all ages.
• Long-term care encompasses a range of services, including health maintenance, rehabilitation, and assistance with ADLs.
• Long-term care focuses on patient-centered care and maintaining quality of life.
• Long-term care services may be needed after an acute illness or as a result of a chronic illness.

Culture and Health

• Culture, religion, and ethnicity significantly influence patients' beliefs about health and illness, impacting health behaviors.
• Ethnicity refers to a person's identification with a particular ethnic group based on shared traditions, national origin, physical characteristics, language, religion, food, and dress.
• Long-term care needs are increasing, with an estimated 9 million Americans over 65 requiring care in 2012, rising to 12 million estimated in 2020.

Home Care Settings

• Racial and ethnic demographics influence the elderly living at home, with white American women comprising the majority of single-person households, followed by Hispanic, African American, Asian, and other race/ethnicities.
• Home care involves participation from loved ones, including spouses, children, grandchildren, and even great-great-grandchildren.
• Home care costs approximately half as much as care in a long-term care facility unless the individual requires significant physical assistance.
• Home health agencies offer a range of services, including physical, occupational, speech, respiratory therapy, social services, nutritional support, durable medical equipment rentals/purchases, and nursing services.
• Services may include assistance from shoppers, respite care workers, personal care attendants, CNAs, LPN/LVNs, and RNs.
• The Program of All-Inclusive Care for the Elderly (PACE) program, offered by Medicare and Medicaid, provides interdisciplinary services at home, in the community, and at designated PACE centers.
• PACE eligibility criteria include living in a service area, being 55 years or older, qualifying for nursing home-level care, and being deemed safe to live at home with PACE support.
• PACE services include dentistry, home care, meals, adult day care, physical therapy, and medication management.

Roles of LPN/LVN and RN in Home Care

• Responsibilities include home visits, data gathering, and evaluation of care.
• Staffing Coordinator: Schedules appropriate care providers to meet patient needs, verifies financial coverage, and receives information from the intake coordinator.
• Intake Coordinator:
• Medical Chart Auditor/Reviewer: Uses healthcare knowledge to ensure quality assurance documentation guidelines.
• Hospice: Provides services to patients and families as end-of-life approaches.

Hospice Care

• The philosophy of hospice care prioritizes maintaining comfort as death nears.
• Hospice care can be provided in a home setting, inpatient hospice unit, long-term care facility, or stand-alone hospice facilities.
• When delivered in the home, family members serve as primary caregivers, with hospice staff making regular visits and offering 24-hour availability.

Palliative Care

• Extends hospice care principles to a broader population who may benefit from comfort care early in an illness or disease process.
• Provides nursing interventions for basic needs, ADLs, pain and symptom management, and spiritual/psychosocial support.
• Volunteers offer respite relief for caregivers, socialization, and companionship.
• Parish nurses can assist patients and families with psychosocial concerns and bereavement issues.

Community Resources

• Adult daycare services: Provide supervised healthcare, social, and recreational activities for functionally or cognitively impaired adults.
• Services include physical care, mental stimulation, socialization, assistance, and health referrals.
• Transportation services: Funded by the community or operated privately, offering transportation to appointments, shopping, etc.
• Respite care: Provides a break for family members and caregivers, allowing time off from caring for patients who are unable to care for themselves.

Residential Care Settings

• Serve the older adult population and those with mental or physical disabilities.
• Assisted Living: Rent a small one-bedroom or studio apartment.
• Offers personal care services, such as housekeeping/laundry, social activities, transportation, and nursing care.
• Continuing Care Retirement Communities (CCRC): Offers a full range of housing and healthcare accommodations, from independent living to 24-hour skilled nursing care.
• Individuals typically enter a CCRC while in relatively good health, with most cases requiring a lifelong commitment.

Institutional Settings

• Subacute Units: Less expensive alternative to acute care for patients with high-acuity medical and nursing needs.
• Acts as a bridge between acute and long-term care.
• Provides care comparable to hospital settings.
• Cost savings allow for services like IV medication administration, complex dressing changes, peritoneal dialysis, and ventilation.

Long-Term Care Facilities

• Also known as nursing homes or extended-care facilities.
• Philosophy focuses on restoring and maintaining residents' physical, mental, social, vocational, and economic capacity.
• Care is provided for individuals who don't need inpatient services but cannot receive care at home or through community agencies.
• Most residents have multiple health disorders, including cardiovascular disease, hypertension, depression, dementia, and type 2 diabetes.

Long-Term Care Residents

• Cognitive impairment, incontinence, inability to perform ADLs, and being single or widowed are key factors determining placement in a long-term care facility.
• Short-term residents: Admitted for rehabilitation with expected discharge within six months.
• Long-term residents: Typically remain in the facility until death or transfer to an acute care facility.

Long-Term Care Team

• Includes the resident, nursing personnel, primary or facility health care provider, social worker, pharmacist, dietitian, activities director, rehabilitation specialists (PT, OT, speech therapy), podiatrist, psychiatrist, audiologist, and dentist.
• Regular meetings are held to discuss the resident's care plan, involving family members and power of attorneys.
• The care plan should reflect residents' needs and goals, striving to maintain a homelike atmosphere.
• A certified medication technician (CMA/CMT) is a unique role in long-term care, requiring CNA certification, additional education/training, and certification.
• CMAs/CMTs administer medications under the guidance of a licensed nurse.

Legal, Ethical, and Financial Issues

• Most long-term care providers adhere to federal and state guidelines for healthcare services.
• The Omnibus Budget Reconciliation Act (OBRA) of 1987 outlines quality of care standards for residents, addressing nutrition, staffing, and personnel qualifications.
• Positive outcomes of OBRA include resident empowerment, resident rights, reduced restraint use, improved staffing, and expanded roles for LPN/LVNs.
• The Health Care Financing Administration (HCFA) monitors OBRA guidelines with unannounced annual and as-needed surveys.
• Advance directives, DNR orders, guardianship, and responsible party designation require discussion and documentation.

Functional Assessment and Documentation

• The resident assessment instrument (RAI) is completed by LVNs under the direction of an RN.
• The RAI includes three parts: the minimum data sets (MDS), resident assessment protocols (RAPs), and utilization guidelines.
• Documentation in long-term care differs from acute care settings.
• Vital signs, weights, and summaries are documented monthly, with acute changes or incidents reported promptly.

Safety Issues in Long-Term Care

• The Joint Commission establishes national patient safety goals, encompassing these five major areas:
  • Correct resident identification
  • Safe medicine use
  • Infection prevention
  • Fall prevention
  • Pressure injury prevention

Nursing Process in Long-Term Care

• The LPN/LVN participates in care planning based on patient needs.
• Responsibilities include reviewing the plan of care, recommending revisions, following defined prioritization for patient care, and utilizing clinical pathways, care maps, or care plans.
• Assessment: Ongoing process that occurs upon admission and involves data and information collection to meet residents' needs.
• The plan of care is reviewed every 90 days.
• Patient Problems: Prioritized based on individual needs.
• Expected Outcomes and Planning: Patient-centered and individualized, prioritizing basic physiological needs (ABCs) and considering individual conditions/needs.
• Implementation: Emphasizes safety, including 2-hour rounding to assess residents, position changes, incontinence assessment, skin care, and fluid offers.
• Evaluation: Evaluates progress with implemented interventions, focusing on patient outcomes.

Rehabilitation Nursing

• Focuses on supporting patient restoration of health state or adaptation to changes resulting from chronic illness, disability, or injuries.
• It is a holistic process delivered by an interdisciplinary team, aiming to restore patients to maximum physical, mental, social, vocational, and economic capacity.

Need for Rehabilitation

• Precipitated by:
  • Impairment: Any loss or abnormality of psychological, physical, or anatomical structure or function.
  • Disability: Loss of ability to participate in major life activities due to mental, emotional, or physical impairments (employment, home/community activities, social events).
  • Functional limitations: Loss of ability to perform tasks or ADLs.
  • Chronic Illness: Conditions lasting three months or longer, potentially having periods of remission or exacerbation.

Chronic Illness and Disability

• Affects 40% of the population, including children.
• 86% of medical costs are related to chronic illness.
• Chronic illnesses can have abrupt or gradual onset, persisting indefinitely.
• Individuals may still function with limitations.

Scope of Individuals Requiring Rehabilitation

• Serves as a bridge between uselessness and usefulness, restoring hopefulness and happiness.
• Community rehabilitation services focus on maintaining functional abilities, ensuring safety, promoting coping skills, preventing complications, and modifying the environment for independence.
• Disability can negatively impact patients and families, leading to behavioral and emotional changes, body image issues, self-concept alterations, and family dynamic changes.

Rehabilitation Goals

• Maximize quality of life.
• Address specific patient needs.
• Assist with adjusting to an altered lifestyle.
• Promote wellness and minimize complications.
• Attain the highest level of function and self-sufficiency.
• Promote home and community reentry.

Cornerstones of Rehabilitation

• Focuses on:
  • Individual-centered care and goal setting
  • Community reentry
  • Independence (physical and emotional)
  • Functional outcomes
  • Team approach involving the rehabilitation team, patient, and family
  • Quality of life (quality vs. quantity focus)
  • Prevention and wellness (preventing complications and maximizing function)
  • Directed change in a positive manner
  • Positive adaptation and coping methods
  • Patient and family education promoting independence and understanding.

Comprehensive Rehabilitation Plan

• The Commission on Accreditation of Rehabilitation Facilities requires an individualized comprehensive rehabilitation plan initiated within 24 hours of hospital admission.
• The plan includes personal goals, strengths, needs, abilities, and preferences.
• Goals must be measurable, described functionally or behaviorally, with timeframes for achievement and listed responsible team members.

Rehabilitation Team

• Includes the patient, nurses, PT/OT/Speech Therapy, Psychologist, Chaplain, etc.
• Models of team functioning:
  • Multidisciplinary: Discipline-specific goals, clear boundaries, and outcomes based on each individual discipline.
  • Interdisciplinary: Collaboration to identify individual goals, combining expanded problem-solving and discipline-specific work towards goal attainment.
  • Transdisciplinary: Blurred disciplinary boundaries, cross-training, and flexibility to minimize duplication of effort.

Rehabilitation Nurse

• Remains with the patient 24/7, facilitating identification of subtle changes.
• Educates, provides care, collaborates, advocates for the patient, and encourages them.
• Focuses on enabling patients to transition from dependence to independence using family/patient education, adaptive equipment, community integration activities, specialized programs, and professional/team therapies.
• Areas of application include arthritis, multiple sclerosis, mental illness, stroke, spinal cord injury, burn, and traumatic brain injuries.
• Essential nursing measures include position changes, maintaining body alignment to prevent deformities, and pressure ulcers.
• Understanding and implementing change and new knowledge are crucial for rehabilitation nurses.

Nursing Assessment

• Part of nursing care that assesses a patient's ability to perform activities of daily living (ADLs) such as dressing and self-feeding to determine their level of independence
• Identifies patient problems and determines nursing interventions based on the patient's needs
• Nursing interventions are geared towards supporting and reinforcing activities included in the interdisciplinary plan of care, involving a 5-step approach including assessing patient/family needs and concerns, planning interventions, implementing the educational plan, documenting the educational process, and evaluating and revising the educational plan.

Family and Family-Centered Care

• Recognizes the pivotal role families play in the lives of children with disabilities or other chronic conditions
• Goal of family-centered care is to support families in their natural caregiving roles by building on the strengths and unique qualities of the parents
• Promotes normal patterns of living, equal partnership, and opportunity for families to advocate for themselves and their children.
• Key elements include:
  • Policies recognizing that family is a constant while services are transitional
  • Family-professional collaboration at all levels of care
  • Sharing complete and unbiased information in a supportive manner
  • Encouraging and supporting family-to-family support and networking
  • Recognizing the unique characteristics of families and children.

Cross-Cultural Rehabilitation

• Addresses and recognizes cultural competency and biases to promote cultural proficiency and development of a culturally competent practice
• Encourages awareness and acceptance of other cultures and behaviors
• Involves self-assessment, being sensitive to patient values and cultures, recognizing dynamic differences, disseminating cultural knowledge, and adapting to diversity.

Issues in Rehabilitation

• Rehabilitation focuses on improving quality of life instead of quantity of life
• Care is focused on adapting and accepting altered lives rather than treating the illness itself
• High cost of interdisciplinary care versus long-term care
  • Research shows that early intervention and implementation of rehabilitation services saves thousands of dollars and increases the likelihood of independent living and return to the workforce, eliminating the expense of caregivers and residential long-term care.

Cardiac Rehabilitation

• May be done after a myocardial infarction or cardiac surgery to improve function and return to normal activities
• Employs an exercise program, education about heart-healthy living, and counseling in stress reduction to reduce modifiable risk factors and prevent future hospitalizations.

Pulmonary Rehabilitation

• May be done for patients with chronic breathing problems such as COPD or lung surgery
• Includes an exercise program, counseling regarding diet and nutrition, education about the lung disease process and management, energy conservation techniques, and breathing strategies
• Can be done inpatient or outpatient.

Polytrauma and Rehabilitation Nursing

• Focuses on treating soldiers wounded in conflicts such as Iraq, Afghanistan, and Syria with variable patterns of multiple traumas, known as polytrauma-blast-related injury (PT/BRI)
• Blast-related injuries are categorized as:
  • Primary: air-filled cavities in the body (ears, lungs, and GI tract) and organs enveloped by fluid (brain and spinal cord) are most susceptible to compression damage from high explosive blasts
  • Secondary: injuries from airborne debris, bomb fragments, and shrapnel
  • Tertiary: injury sustained from being thrown because of an explosive shock wave
  • Quaternary: inhalation of and exposure to toxic chemicals, traumatic amputations of limbs, and burns
• Rehabilitation teams for Soldiers who have experienced PT/BRI gear their care toward discovering and treating additional injuries not detected during the post-acute phase, as well as treating those originally identified injuries.

Posttraumatic Stress Disorder

• A mental health condition related to the experiencing or witnessing of a traumatic event outside the normal range of human experience
• Symptoms often worsen over time, and a person with PTSD may try to avoid people, places, and activities that remind them of the traumatic event.
• Before 1980, PTSD was known as “shell shock” or “war neurosis” and was not widely accepted as a psychiatric diagnosis
• PTSD diagnosis is considered if symptoms do not improve or worsen after at least 1 month and are dependent on the identification of a traumatic event, and/or the re-living of traumatic events through dreams or vivid memories or flashbacks, interfering with normal life functions
• Without proper treatment, PTSD can lead to other mental health problems such as depression, anxiety, alcohol and drug use, and even suicidal thoughts or actions
• A combination of cognitive and prolonged-exposure therapy is the most effective in treating the disorder, sometimes with the aid of medications such as selective serotonin reuptake inhibitors
• Nurses play a critical supportive role during rehabilitation by assisting patients in adapting to or regaining control over the symptoms of PTSD.

Disability

• The Americans with Disabilities Act became law in 1990, providing protection against discrimination for people with disabilities.
• A disabled person is someone with a physical or mental impairment that substantially limits one or more major life activities, has a history of such impairment, or is regarded as having such an impairment.
• All individuals are only temporarily able-bodied and at some point in life, everyone experiences some form of disability.
• Disabilities/illnesses do not identify people, and care should be holistic with a person-first approach in which the shared experience of being human, along with the uniqueness of the individual is honored and strengths as well as impairments are recognized.

Spinal Cord Injuries

• Spinal cord injuries (SCI) are any injury in which the spinal cord undergoes compression by fracture or displacement of vertebrae, by bleeding, or by edema.
• Injury to the spinal cord is irreversible, and the cord is unable to repair itself.
• The effects of an injured spinal cord include paralysis, loss of normal bowel and bladder function, and loss of sensation.
• Injury level and the extent of damage largely determine functional disabilities.
• Common terminology associated with SCI includes:
  • Complete Injury: No motor or sensory function below the level of injury.
  • Incomplete Injury: Some or all motor or sensory function below the level of injury.
  • Quadriplegia: Damage to the cervical spine or the neck that involves weakness or paralysis in all four extremities.
  • Paraplegia: Damage below the cervical area that involves weakness or paralysis in the trunk and lower extremities.
  • Paresis: A slight paralysis, incomplete loss of muscular power or weakness of a limb.
  • Cervical Cord Injury: Level of injury is at the cervical spine (C2 to C7) and involves paralysis of all extremities and trunk, respiratory failure, bladder and bowel disturbance, bradycardia, perspiration, elevated temperature, and headache.
  • Thoracic Cord Injury: Level of injury is at the thoracic spine (T1 to T12) and involves paralysis of lower extremities. Initially after the injury, muscles are flaccid (weak, soft, flabby, lacking normal muscle tone) and later become spastic (having spasms or other uncontrolled contractions of the skeletal muscles). Other potential symptoms are paralysis of bladder, bowel, and sphincters; pain in chest or back; abdominal distention; and loss of sexual function.
  • Lumbar Cord Injury: Level of injury is at the lumbar spine (L1 to L2) with paralysis of lower extremities, bladder, and rectum and loss of sexual function.
• Postural hypotension
  • A drop in blood pressure while sitting in a wheelchair is common and can be lessened by raising the head of the bed 15 to 20 minutes before moving the patient to the wheelchair, wearing TED hose, and/or using abdominal binders.
• Autonomic Dysreflexia
  • Occurs with spinal cord lesions above T5, causing a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system.
  • It is the result of some stimulation of the body below the level of the injury, usually bladder distension from a blocked catheter but any stimulation as potential to produce the syndrome including constipation, diarrhea, sexual activity, pressure ulcers, position changes, and even wrinkles in clothing or bedsheets.
• Heterotopic Ossification
  • Is the abnormal formation of bone cells in joints below the level of injury resulting in limited range of motion.
  • Commonly affects the hips and sometimes knees and occurs more frequently 1 to 4 months after the injury and rarely occurs more than 1 year afterwards.
  • Common symptoms include localized edema then a few days after a firm mass can be palpated in underlying tissue. After several weeks range of motion is diminished.
  • Treatment involves aggressive range-of-motion exercises, medications, and occasionally surgery.
• Deep Vein Thrombosis
  • Signs include localized swelling, redness, and heat in the involved area.
  • Movement is not encouraged because it may dislodge the clot and as the potential to become an embolus to the lungs.
  • Anticoagulants are used preventatively, as well as passive and active ROM.

Traumatic Brain Injuries

• Traumatic brain injuries (TBI) range from mild concussion to the more devastating kind that renders injured people comatose for the remainder of their lives.
• Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, necessitate at least 5 to 10 years of difficult and painful rehabilitation, and many require lifelong treatment.
• The primary goal is to restore the patient to the highest level of independent functioning as possible.
• Head injuries are either:
  • Penetrating: An object lacerates the scalp, fractures the skull, and injures the soft tissue in its path and destroys nerve cells.
  • Close-headed injuries: Application of force causes the brain to collide with an inner surface of the skull, often involving a violent twisting action, which causes the upper section of the brain to rotate while the lower end remains securely anchored in a stationary position causing shearing (when the brain is rotating in the cranial vault)
• May also be a result of other traumas such as electrocution and drug overdose.
• Brain injuries are classified as:
  • Mild: Brief or no loss of consciousness (majority of head injuries) Neuro exams are often normal. May have post concussive syndrome for months, years or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed and difficulties with memory, understanding, learning and perception.
  • Moderate: Characterized by a period of unconsciousness ranging from 1 to 24 hours. Cognitive skills including planning, sequencing, judgment, reasoning, and computation skills are usually impaired. May experience psychosocial problems such as self-centeredness, denial, mood swings, agitation, depression, lethargy, sexual dysfunction, emotional lability, low tolerance for frustration, poor judgment, and behavioral outbursts.
  • Severe: Experience unconsciousness or post trauma amnesia for longer than 8 days.
  • Catastrophic: Experience a coma lasting several months or longer. Individuals appear to be awake but never regain significant, meaningful communication with their environment.
• Patients with a TBI may exhibit inconsistent performance, anger and frustration, ineffective problem solving, cognitive barriers, and impaired memory, impaired processing, and may lack initiative, resulting in depression or even egocentric (self-centered) behavior.
• Communication and patient and family involvement are important. It is important to connect them with community resources and remain empathetic of their concerns and fears.

Pediatric Rehabilitation Nursing

• Recognized as a true specialty since the 1990s
• Collaboration within the team provides a continuum of care so that children can become contributing members of society and function at their maximum potential
• Holistic care approach provides specialized care from hospital to home, from clinic to school.
• The goal is to cherish and foster the unique qualities of each child.
• The primary difference between rehabilitation of children and adults is the developmental potential of each child.
• Whereas rehabilitation refers to the relearning of skills or behaviors lost as a result of disease or injury, habilitation refers to the process of acquiring skills and behaviors by an individual whose development has been affected by disease or other disabling conditions since birth or very early childhood.
• By facilitating transition from hospital to home and community and by offering counseling and support to families, the nurse aids in meeting identified needs and the opportunity to affect the quality of life of the child for the better.

Gerontologic Rehabilitation Nursing

• A specialty practice that focuses on the unique requirements of older adult rehabilitation patients focusing on unique needs of the elderly.
• A primary goal in gerontologic rehabilitation nursing is the assistance of older adult patients in achieving their personal optimal level of health and well-being through holistic care in a therapeutic environment.
• Has a special focus on their unique needs, roles, and social relationships and the potential physical limitations they are experiencing.

Conclusion

• Rehabilitation nursing is a career with several key requirements and rewards and expands across different specialties and age groups.

Hospice Care—Introduction

• Provides care and support to patients with a terminal illness - a disease in an advanced stage with no known cure and poor prognosis
• Recognizes that dying is a natural part of life. The goals are to maximize the quality of life and keep the patient as comfortable as possible in the home or setting that he/she chooses
• Studies show higher quality of pain management accompanied by pain-related assessments when on hospice.

Historical Overview

• The hospice concept originated in Europe where hospices were resting places for travelers. Monks and nuns ran typical medieval hospices as a place of refuge for the poor, sick, and travelers on religious journeys.
• In 1960 the idea of hospice came to London when Dame Cicely Saunders, a nurse and physician, realized that terminally ill patients needed a different kind of care with an emphasis on improving pain management and symptom control.
• In 1968 St. Christopher’s Hospice of London was opened and continues to serve as an education, training, and research center for professionals involved in the hospice approach.
• In 1971 the first hospice program opened in Connecticut, and now more than 4,000 hospice programs exist and serve between 1.6 and 1.7 million patients in the United States.
• Common myths about hospice include:
  • Hospice means giving up hope.
  • Hospice means a DNR must be signed.
  • Hospice is only for cancer patients.
  • Hospice is only for patients actively dying or close to death.
• The most common diseases serviced are cancer, dementia, cardiac, and lung diseases.
• Hospice facilities vary in structure and organization and may be inpatient, hospital-based, or free-standing, or home health.
  • Patients usually wear their own clothes, move about as they choose, and can socialize in open kitchens.
• Hospice can be delivered intermittently or continuously and involve skilled team members to provide comfort measures, medications, therapy, education, and daily care.
  • Support is available to the patient and caregiver 24-hours a day either by phone or in person.
• In 1983 the Medicare Hospice Benefit came into effect, and today hospice services are reimbursable through Medicare, Medicaid, and most private insurance companies.

Palliative vs. Curative Care

• Palliative care improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical psychosocial, and spiritual.
  • Palliative care is not curative but aims to relieve pain and distress and to control symptoms of a disease.
• Curative treatment is aggressive care in which the goal and intent are curing the disease and prolonging life at all costs.

Criteria for Admission to Hospice

• The patient must have a prognosis of 6 months or less to live, and it must be signed by a provider.
• Many hospices request that the patient have a primary caregiver - a person who assumes ongoing responsibility for health maintenance and therapy for the illness.

Goals of Hospice

• Controlling or alleviating the patient’s symptoms.
• Allowing the patient and caregiver to be involved in decisions regarding the plan of care.
• Encouraging the patient and caregiver to live life to the fullest.
• Providing continuous support to maintain patient and family confidence.
• Educating and supporting the primary caregiver in the home setting that the patient chooses.

Interdisciplinary Team

• Involves a holistic approach, considering the physical, emotional, social, economic, and spiritual needs of the patient. This approach involves an interdisciplinary team that develops and cares for the patient by considering all aspects of the family unit.
• Medical Director:
  • Has a doctorate of medicine or osteopathy and assumes overall responsibility for the medical component of the hospice patient’s care program.
  • Does not take place of the primary health care provider but acts as a consultant and a mediator between the interdisciplinary team and health care provider.
• Nurse Coordinator and Hospice Nurses:

Hospice Care Team Roles

• Hospice Nurse: Coordinates care for patients, performs initial assessments, develops and monitors the plan of care, assigns nurses and aides, facilitates meetings, and determines payment methods.
• Social Worker: Evaluates psychosocial needs, assists with community resources, insurance filings, emotional support, and grief counseling.
• Spiritual Coordinator: Provides spiritual assessment and support, respecting patient and family beliefs, and helps cope with fears and uncertainty. Also assists with funeral planning and bereavement support.
• Volunteer Coordinator: Finds and trains volunteers to provide respite care (e.g., grocery shopping, yard work). Ensures volunteer involvement meets Medicare and Medicaid requirements.
• Bereavement Coordinator: Supports family members in the grieving process, identifying potential needs after the patient's death, and providing ongoing care for at least a year.
• Hospice Pharmacist: Evaluates drug interactions, dosing, administration times, and routes.
• Nutrition Consultant: Provides dietary counseling, meal planning, and educates caregivers about nutritional needs in end-stage diseases.
• Hospice Aide: A CNA who works under the nurse's supervision, assisting patients with activities of daily living (ADLs).
• Other Services: Physical therapy, occupational therapy, and speech therapy.

Palliative Care and Symptom Management

• Goal: Symptom management and palliative care.
• Assessment Tool: Edmonton Symptom Assessment System is used to assess comfort level.
• Pain: One of the most feared symptoms, disrupting activities and quality of life.
  • Causes: Tumor invasion, organ or nerve compression, tissue erosion.
  • Assessment: Severity, history, what brings relief.
  • Types:
    • Somatic Pain: Musculoskeletal pain, described as aching, stabbing, or throbbing. Treated with NSAIDs, nonopioid drugs, and opioids.
    • Visceral Pain: Internal organ pain, described as cramping, pressure, dull, squeezing. Treated with anticholinergic medication or as an adjuvant to opioids or nonopioids.
    • Neuropathic Pain: Nerve and nervous system pain, described as tingling, burning, or shooting. Treated with anticonvulsants as an adjuvant for control.
  • Management:
    • Prioritize oral medications for ease of use.
    • Morphine is often the preferred drug due to multiple delivery routes.
    • Titrate doses to therapeutic levels.
    • Address common myths and fears of addiction, tolerance, and respiratory depression.
    • Encourage alternative therapies and nonpharmacologic options (radiation therapy, nerve blocks, music therapy, relaxation techniques).
• Nausea and Vomiting: Nausea can be worse than vomiting.
  • Causes: Chemotherapy, tumor, obstruction, opioid medications, anxiety.
  • Treatment: Antiemetics, opioid analgesics.
  • Nursing Interventions: Monitor electrolytes and hydration.
  • Patient Teaching: Eat slowly, rest after eating, avoid sweet, greasy or spicy foods.
• Constipation: A common problem caused by anxiety, discomfort, or pain, and opioids.
  • Treatment: Adjust opioid dose or route, encourage fluids, stool softeners, and stimulants.
  • Nursing Interventions: Monitor for abdominal discomfort, bowel sounds, and firmness. If impaction suspected, premedicate with anxiolytics and analgesics and consider removal.
  • Patient Teaching: Take bowel softeners with opioids and encourage comfort.
• Anorexia and Malnutrition: Can lead to cachexia (severe malnutrition and weakness).
  • Causes: Nausea, vomiting, constipation, pain, tumor invasion, general deterioration, depression, infection, food odors, inability to tolerate sweet or bitter tastes.
  • Nursing Interventions: Nutritional assessments, medications for underlying causes, encourage oral hygiene, small frequent drinks, crushed ice, attractive meals, high protein supplements, avoid weighing the patient.
  • Patient Teaching: Anorexia is part of the dying process, forcing the patient to eat can be harmful.
• Dyspnea and Air Hunger: Commonly caused by heart failure, dysrhythmias, infection, ascites, or tumor growth.
  • Management: Oxygen therapy (for anxiety), morphine, bronchodilators.
  • Death Rattle: 24-48 hours before death, caused by fluid accumulation in pharynx.
  • Nursing Interventions: Relieve anxiety, education on positioning, use of fans, morphine, good oral hygiene, anticholinergic drugs (transdermal scopolamine, atropine).
• Psychosocial and Spiritual Issues
  • Signs: Depression, bitterness, hallucinations, or dreams that may indicate unmet spiritual needs.
  • Nursing Interventions: Involve spiritual coordinator and social worker for counseling support. Foster trust between patient and team.
• Other Common Signs and Symptoms:
  • Weight loss, dehydration, skin impairment, weakness, activity intolerance, comments of suicide (may reflect a desire for independence), sleeplessness, insomnia.
  • Nursing Interventions: Skin care, cleanliness, skin inspections, avoid harsh soaps and detergents, use of egg-crate or air flotation mattress, heel/elbow protectors, fall prevention, emotional support.

Hospice Care: Patient and Caregiver Teaching

• Bereavement Period: Hospice care continues after patient's death to support family and primary caregiver. Bereavement group meetings can provide a space for communication and sharing.
• Team Members: Hospice staff also grieve and may attend funerals, memorials, or visit caregivers to offer support and healing.

Ethical Issues in Hospice Care

• Withholding or Withdrawing Nutritional Support: Difficult decisions for families about withholding or withdrawing life support.
• Right to Refuse Treatment: Patients have the right to refuse treatment and opt for a natural death (DNR orders).
• Advanced Directives: Prepared while an individual is competent and provides guidance about their wishes regarding life support, organ donation, and who can make decisions for them.
• Physician Orders for Life-Sustaining Treatment (POLST): Completed by the medical provider and patient to inform healthcare providers about their wishes. Shorter than an advanced directive.
• Discrimination: Unacceptable and hospices cannot exclude patients based on sex, race, age, religion, or diagnosis. Hospices must serve all patients, regardless of ability to pay.

Future of Hospice Care

• Growth: Hospice is becoming more popular as an alternative to clinical settings. Educating the public about hospice care is important.