Exam 14 - Community Health Nursing

Home Health Care

• Home health care services are provided to people of all ages in their homes, aiming to promote independence, support family involvement, and shorten hospital stays.
• Common services include skilled nursing, physical and occupational therapy, respiratory therapy, medical supply procurement, wound care, and intravenous administration.
• Medicare patients qualify for home health care if they are homebound, meaning they cannot leave the home easily or require significant effort to travel for appointments.
• Common reasons for home health care include stroke, chronic obstructive pulmonary disease (COPD), fractured hips, joint replacement procedures, heart failure, diabetes, and hypertension.
• The roles of registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs) blend in home health care, with RNs providing case management, administration, and supervision, and LPNs/LVNs delivering most of the care.

Historical Overview of Home Health Care

• Medicare's implementation in 1966 significantly influenced home health care by establishing a medical model of practice and defining reimbursable services.
• The Prospective Payment System (PPS) enacted in 1983 led to shorter hospital stays and increased demand for home health care due to a set payment rate for hospital care.
• The Balanced Budget Act of 1997 aimed to control home health care costs, initially reducing beneficiary numbers and services, but the act in 2000 established a prospective payment system to promote efficiency and increase utilization again.
• In recent years, home health care has grown with a slight decrease in cost but is anticipated to decline over the next several years.

Types of Home Health Agencies

• Home health agencies offer diverse services contingent on funding sources.
• Agencies must adhere to federal, state, and local laws and regulations, including licensure, certification, and certificate of need.
• Agencies can be classified by tax status (profit or nonprofit), location (freestanding or institutional-based), and governance (private or public).
• Telehealth services have grown in home health care, providing patient-provider interaction and monitoring digitally, offering advantages like family unit return, cost savings, family participation in care, and expanded care options in rural areas.

Changes in Home Health Care

• Home health care services have expanded to include ethics committees, psychiatric nurse clinicians, social workers, nurse pain specialists, and hospice care.
• Pet care programs are newer services, aiming to reduce stress for patients unable to care for their pets, and allow arrangements for pet care during hospitalization or after death.
• Home infusion therapy, providing antibiotics, hydration, and total parental nutrition, has seen rapid growth, reducing hospitalization stays and costs.

Service Components of Home Health Care

• Home health care offers a variety of services, including primary services and therapy services like respiratory therapy, nutritional counseling, podiatry, dentistry, mental health, and pharmacy, though some may not be Medicare-reimbursable.
• Medical equipment, including durable medical equipment (DME), is provided, ranging from hospital beds to respirators and apnea monitors.
• Medicare requires a signed treatment plan by a physician outlining treatment specifics and a face-to-face visit with the patient.
• Recertification of benefits is needed every 60 days and requires another face-to-face visit and an updated treatment plan.

Skilled Nursing

• Skilled nursing services have four major goals: restorative (returning to previous function), improvement (achieving better health and function), maintenance (preserving capacities and independence), and promotion (teaching healthy lifestyles).
• Skilled nursing providers should exhibit technical proficiency, self-motivation, organizational skills, innovation, independence, decision-making skills, responsiveness to problem-solving, positive communication skills, the ability to build rapport, respect for cultural values, maintenance of dignity and privacy, and recognition of autonomy needs.

Role of the LPN/LVN

• LPNs/LVNs are supervised by RNs in home health care.
• They should possess attributes similar to RNs, such as flexibility, compassion, patience, empathy, and teamwork.
• Home health care often provides a less restrictive environment for LPNs/LVNs.
• LPN/LVN functions include teaching (bowel and bladder care, catheter care, glucose readings, nutrition, ostomy care, pain management, medication education, tracheostomy care, physical status monitoring), psychosocial support, and procedure assistance (IV therapies, home dialysis, respirator management).

Physical Therapy

• Communication between physical therapists and RNs is crucial to ensure continuity of care.
• Physical therapy assistants may be utilized under the supervision of a licensed therapist.
• The main goal of physical therapy is restorative treatment for Medicare reimbursement, but maintenance and preventive services may be provided.
• Treatments range from muscle strengthening to transcutaneous nerve stimulation and ultrasound treatments.
• Physical therapy is commonly utilized for patients with orthopedic conditions (hip or knee replacements), but may also be used for wound care, heart failure complications, and diabetes education.

Speech-Language Therapy

• Medicare reimbursement mandates a master's-prepared and certified speech-language pathologist.
• The goal of speech-language therapy is to minimize communication disorders and their physical, emotional, and social impact, and to promote speech rehabilitation, often after stroke or surgery.
• Services may include language relearning, eating/swallowing disorder treatment, and lip reading instruction.

Occupational Therapy

• Occupational therapy focuses on everyday practical tasks and aims to restore functional levels of task completion to aid in activities of daily living (ADLs) and sensory-motor, cognitive, and neuromuscular functioning to achieve self-care independence.
• Services include increasing independence, analyzing activities related to patient skin, environment, family, and routine, expanding disease management into lifestyle management, identifying self-help devices, and assessing for vocational training.

Medical Social Services

• Medical social workers focus on the emotional and social aspects of illness.
• Care plans include education, counseling, payment source identification, and referrals.
• Medical social services are generally short-term in home health care.

Homemaker-Home Health Aide (HHA)

• Medicare requires a primary skilled or therapy service (speech or physical) to be provided before HHA services are arranged.
• Many insurers do not reimburse for HHA services, necessitating private pay.
• HHA aid services fall into three categories: personal care (bathing, oral hygiene, eating, dressing, toileting), physical assistance (transferring, medication, ambulation), and household chores (cooking, light housekeeping, shopping, laundry).
• Medicare and Medicaid necessitate on-site supervision of the aide every two weeks by the RN.

Typical Home Health Process

• Referrals for home health care can be initiated through formal hospital discharge or direct calls from the patient's physician.
• The RN completes the initial evaluation and admission visit within 24 to 48 hours of referral, unless nursing care is not initially needed, in which case the physical therapist may complete the admission process.
• Evaluation and admission generally include assessing physical and psychosocial factors, the environment for safety and service viability, primary functional impairments, disease or disability impact, the support system, knowledge and adherence to treatments and medications, desire for care and services, patient and family involvement in the plan of care and goals, notification of patient rights and costs, payment source and billing explanations, explanation of self-determination rights and advance directives, and initial nursing interventions.

Care Plan

• The care plan outlines the patient's current physical status, medications, treatments, necessary disciplines, service frequency and duration, goals and outcomes, and implementation timeframe.
• The physician must sign the care plan.

Home Health Visits

• Skilled visits are conducted based on orders to meet patient-centered goals, typically lasting 30 to 45 minutes, but may be longer depending on the service provided.
• To reduce home health costs, a predetermined number of visits per week are usually scheduled.
• Telemonitoring may be utilized.
• Patients may remain on the caseload for a week or years based on their needs.

Documentation

• Home health care documentation may be handwritten but is more frequently done electronically to provide detailed health information, improve accessibility for healthcare professionals, monitor compliance, and elevate quality of care.
• Documentation is a legal document with legal ramifications and influences reimbursement, with Medicare requiring extensive paperwork compared to private insurance.

Discharge Planning

• Discharge planning begins at admission with the purpose of promoting continuity of care in the patient's home.
• Patient and family involvement is encouraged.
• Agencies often follow up post-discharge to track progress and patient satisfaction.

Quality Assurance, Assessment, and Improvement

• Quality management encompasses guidelines and techniques used to meet home healthcare client needs and continuously improve care quality, measured by structural criteria (philosophy, policies, practices, facilities), process criteria (care delivery evaluation), and outcome criteria (patient behavior, health indicators, and satisfaction).
• Quality assessment plans now reflect standards, objectives, measurable outcomes, and include remediation or improvement plans.
• The Joint Commission redefines quality assessment activities as quality improvement through principles focusing on patient care and desired outcomes, processes carried out, coordination and integration, and employee motivation and competency, including educational and certification opportunities.

Reimbursement Sources

• Medicare and Medicaid are primary income sources for most agencies, though reliance has decreased in recent years.

Medicare

• Medicare is a federal program requiring agencies to be certified, meeting federal conditions of participation, which outline organization, staffing, training, and covered service requirements.
• Beneficiaries must be at least 65 years old, disabled, or have end-stage renal disease, and must be under a licensed physician's care..
• The Affordable Care Act in 2011 mandated face-to-face visits (in-office or telehealth) up to 90 days before or 30 days after the start of home health care for payments to be made.

Medicaid

• Medicaid pays for home care services for low-income people of all ages, administered by the state, but funded through state-federal subsidies.
• Many states require Medicare certification for Medicaid home health agencies.
• Services covered by Medicaid vary by state but include basic Medicare services and expanded aide and personal care services.

Third-Party Payers

• Third-party payers provide limited home care services and coverage, with requirements and payment rates varying.
• Reimbursement is often tied to post-hospitalization recoveries, like aide services for new mothers returning home within 24 hours of delivery.
• Case management (typically by a nurse or social worker) determines and arranges for a mix of services and supplies/equipment needed by the patient.

Private Pay

• Private pay covers services personally by the patient.

Other Sources

• Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) negotiate contracts with home health agencies, providing prepaid health plans independently or through employer groups.

Cultural Considerations

• Cultural considerations are especially important in the home environment, as they may lead to value conflicts, adding complexity to nursing interventions.
• It's crucial to anticipate both your own and others' values.
• Communication strategies are increasingly important in culturally diverse settings.
• Breaking through cultural barriers requires assessing your own and others' attitudes towards different cultures, assessing communication variables from a cultural perspective, modifying communication to cultural needs, respecting patient needs, communicating in a non-threatening manner, and utilizing interpreters to improve communication.

Nursing Process for Home Health Care

• LPNs/LVNs participate in care planning based on patient needs, review care plans and recommendations, follow defined prioritization for patient care, and utilize clinical pathways, care maps, or care plans to guide and review care.

Assessment

• Assessments should consider the patient, family, and their dynamic, particularly the family's ability to provide emotional support, coping skills, and goal-setting.

Patient Problems

• Patient problems often focus on the family's ability to cope with illness, especially during acute illness.
• Maintaining a family nursing perspective is crucial when addressing patient problems.

Expected Outcomes and Planning

• Family-oriented goals and outcomes are set by involving the family and patient, requiring their understanding and agreement.

Implementation and Evaluation

• Assist in learning health promotion practices and understanding the diagnosis and prognosis.
• Plans are revised based on evaluation findings, seeking to determine if expected outcomes have been met.

Conclusion

• Home health care provides a range of services for various illnesses, disabilities, and age groups.
• Home health care is especially crucial as the population over 65 years old continues to increase, projected to reach 20% by 2030, with a majority being poor or near-poor and 80% having at least one chronic disability.
• Home health providers promote healthy living, illness prevention, education, and "family life."

Long-Term Care

• Long-term care, as defined by the US Centers for Medicare and Medicaid Services (CMS), encompasses services needed to meet personal needs, often following an acute illness or for chronic conditions.
• Long-term care services may include:
  • Nursing care
  • Personal care
  • Rehabilitation services
  • Social services
  • Supportive services

Long-Term Care

• Long-term care caters to individuals who require assistance with daily living due to physical or psychological impairments.
• Care encompasses health maintenance, rehabilitation, and assistance with activities of daily living (ADLs).
• Focus is on patient-centered care, maintaining quality of life, and individual well-being.
• Cultural and ethnic backgrounds significantly influence patients' health beliefs and behaviors.
• Ethnicity is a key indicator of cultural identity and encompasses shared traditions, national origin, physical characteristics, language, religion, food, and dress.
• The need for long-term care is increasing, with an estimated 9 million Americans over 65 needing care in 2012 and an estimated 12 million in 2020.

Home-Based Long-Term Care

• Ethnicity and race influence where older adults reside.
• Single-person households predominantly consist of white American women, followed by Hispanic, African American, Asian, and other racial/ethnic groups.
• Home care involves significant participation from loved ones, including spouses, children, grandchildren, and great-grandchildren.
• Home care costs approximately half as much as long-term care facilities unless the individual has a high degree of physical impairment.
• Home health agencies provide various services, including rehabilitation with physical therapy, occupational therapy, speech therapy, respiratory therapy, social services, nutritional support, durable medical equipment, and nursing services.
• Home healthcare providers may include shoppers, respite care workers, personal care attendants, Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs) to provide care and education.
• The Program of All-Inclusive Care for the Elderly (PACE) is a joint Medicare and Medicaid initiative offering interdisciplinary care in homes, communities, and PACE centers.
• PACE requires individuals to live in a service area, be 55 years or older, qualify for nursing home-level care, and be deemed safe to live at home with PACE support.
• PACE services encompass dentistry, home care, meals, adult day care, physical therapy, and medications.

LPN/LVN and RN Roles in Home Care

• Responsibilities include home visits to gather data and evaluate care, staffing coordination, intake coordination, and medical chart auditing.
• Staffing coordinators, using established protocols, ensure the appropriate care provider is assigned based on patient needs and financial coverage.
• Intake coordinators manage patient admissions and ensure necessary documentation and information are collected.
• Medical chart auditors/reviewers utilize healthcare knowledge to maintain documentation quality assurance guidelines.

Hospice Care

• Hospice services are provided to patients and families approaching end-of-life.
• The core philosophy of hospice care is maintaining comfort as death approaches.
• Hospice services are available in homes, inpatient hospice units, long-term care facilities, and stand-alone hospice facilities.
• When provided at home, family members are the primary caregivers, with hospice staff making regular visits and available 24 hours a day.

Palliative Care

• Palliative care extends hospice care principles to a broader population requiring comfort care earlier in an illness or disease process.
• Nursing interventions encompass meeting basic needs, ADLs, pain and symptom management, and spiritual/psychosocial support.

Community Resources

• Adult day care programs provide supervised healthcare, social, and recreational activities for adults experiencing functional or cognitive impairments.
• Adult day care services include physical care, mental stimulation, socialization, assistance, health referrals, and typically serve disabled individuals over 75 years of age.
• Activity directors are usually a social worker or an RN, while personal care attendants, such as CNAs, must meet state requirements for assistance and observation.
• Transportation services can be community-funded or privately operated, often charging fees.
• Transportation services provide access to appointments, shopping, and other destinations.
• Respite care gives family members and caregivers a break from caregiving responsibilities for individuals who cannot care for themselves.
• Respite care can be offered for as little as one hour or as long as several days and is sometimes reimbursed by private and government-sponsored insurance.

Residential Care Settings

• Residential settings cater to older adults and those with mental or physical disabilities.
• Assisted living offers rental of small apartments with optional care services such as bathing, dressing, and medication administration.
• Assisted living can be provided within freestanding residences, skilled nursing homes/hospitals, or independent housing complexes.
• Services may include personal care (housekeeping, laundry), social activities, transportation, and nursing care for individuals with ADL or instrumental activity of daily living (IADL) impairments.
• More complex services include shopping, phone usage, tube feeding, and oxygen therapy.

Continuing Care Retirement Communities (CCRCs)

• CCRCs offer a full spectrum of housing and healthcare accommodations, from independent living to 24-hour skilled nursing care.
• Individuals typically enter CCRC when they are relatively healthy and capable of independent or minimal assistance.
• Signing a CCRC contract is usually a lifetime commitment, offering housing and care for the duration of their lives.
• CCRCs allow for gradual transitions to skilled nursing care (if required) while remaining in the same location.
• CCRC accommodations range from apartments to houses and may include luxurious amenities such as tennis courts, swimming pools, and hotel-style dining experiences.

Institutional Settings

• Subacute units are less expensive alternatives to acute care for patients with high-acuity medical and nursing needs.
• Subacute units serve as a bridge between acute and long-term care, providing care similar to hospital settings.
• ICU, step-down, and medical-surgical units have limitations on length of stay and cost reimbursement, which can restrict hospital stays.
• Subacute units contribute to cost savings and provide services like IV medications via central or peripheral venous catheters, complex dressing changes, peritoneal dialysis, and ventilation.

Long-Term Care Facilities

• Long-term care facilities, commonly known as nursing homes or extended-care facilities, prioritize maintaining and restoring health and functional abilities to residents' highest levels.
• They focus on creating a homelike atmosphere and promoting dignity, independence, restoration, maintenance, and assistance in ADLs and skilled nursing.
• Residents of any age can be cared for, but most are over 65 and are referred to as residents, not patients.
• Long-term care provides 24-hour support to individuals who do not need inpatient services but lack options for home care or other community services.
• The majority of residents have multiple health conditions, with cardiovascular disease being the most frequent diagnosis on admission.
• Cognitive impairment, incontinence, inability to perform ADLs, and being single or widowed and unable to care for oneself often lead to placement in long-term care facilities.

Short-Term vs. Long-Term Residents

• Short-term residents are typically admitted for rehabilitation and are expected to be discharged within six months.
• Long-term residents usually remain in the facility until death or transfer to an acute care facility.

Long-Term Care Interdisciplinary Team

• Team members include the resident, nursing staff (RNs, LPNs/LVNs, CNAs), primary or facility healthcare provider, social worker, pharmacist, dietitian, activity director, rehabilitation specialists (PT, OT, and speech therapy), podiatrist, psychiatrist, audiologist, and dentist.
• The team regularly meets to discuss resident care plans, often including family members and power of attorney to attend.
• The goal is to create a care plan that aligns with the resident's needs and goals while maintaining as much of their home life as possible.

Long-Term Care Facility Management

• Facilities are managed by an administrator and a Director of Nursing (DON) who is typically an RN.
• Large facilities may have an Assistant Director of Nursing (ADON).
• Management also involves a staffing coordinator, managers, shift charge nurses, facility supervisors, medical record technicians, staff development assistance, and admissions coordinators.

Certified Medication Technicians

• Certified Medication Technicians (CMAs/CMTs) are unique to long-term care and must be CNAs with additional education/training.
• CMAs/CMTs work under the guidance of licensed nurses and are limited in certain medication administrations.
• Some states permit a CMA/CMT to resident ratio as high as 1:60 with a two-hour window (one hour before and one hour after medication administration).

Legal, Ethical, and Financial Issues

• Long-term care providers are often subject to federal and state regulations, serving as minimum standards for healthcare services, reimbursement, and quality indicators.
• The Omnibus Budget Reconciliation Act (OBRA) of 1987 (nursing home reform legislation) outlines quality of care requirements, encompassing aspects like nutrition, staffing, and personnel qualifications.
• OBRA's positive effects include resident empowerment, resident rights, reduction or elimination of restraint use, improved staffing, and expanded LPN/LVN roles.

Health Care Financing Administration (HCFA) and OBRA Oversight

• HCFA administers and monitors OBRA guidelines through periodic facility surveys.
• Surveyors conduct unannounced visits annually and as needed to assess quality of life and facility standards.

Advance Directives and DNR Orders

• Advance directives and do-not-resuscitate (DNR) orders require collaboration between residents, their families, and healthcare providers.
• Discussions may extend to guardianship, responsible party designation, and other relevant legal matters.

Functional Assessment and Documentation

• The objective is to provide long-term care interventions based on individual assessments and resident wishes and needs.
• LPNs may complete the Resident Assessment Instrument (RAI) under the direction and with the RN's signature.
• The RAI comprises:
  • Minimum Data Sets (MDS): Assesses a resident's functional, medical, mental, and psychosocial status upon admission.
  • Resident Assessment Protocols (RAPs): Address common clinical issues such as delirium, falls, and urinary incontinence, aiming to enhance long-term care planning and care provision.
  • Utilization Guidelines: Provide guidance on service usage and care planning.
• Documentation in long-term care differs from acute care settings.
  • Vital signs, weights, and summaries are typically required monthly, with acute changes or incidents requiring immediate reporting after occurrence.

Safety Issues in Long-Term Care Settings

• The Joint Commission establishes national patient safety goals, with five key areas:
• Identifying residents correctly
• Using medicines safely
• Preventing infections
• Preventing resident falls
• Preventing pressure injuries

Nursing Process

• The LPN/LVN's role in the nursing process involves:
  • Participating in care planning based on patient needs.
  • Reviewing patient care plans and suggesting revisions.
  • Following defined prioritization for patient care.
  • Utilizing clinical pathways, care maps, and care plans.

Nursing Assessment in Long-Term Care

• Assessment is ongoing and occurs upon admission.
• It includes a health history, medication history (herbals and supplements), and functional assessments regarding ADLs and personal preferences (hobbies, routines, likes and dislikes).
• Care plans are reviewed every 90 days.

Identifying Patient Problems

• High priority is given to patient problems based on their individual needs.
• Patient Problems are prioritized according to individual needs.
• Examples of patient problems can be found on page 1185.

Expected Outcomes and Planning

• Patient-centered and individualized care is essential.
• Prioritization starts with meeting basic physiological needs (ABCs) and progresses to address specific conditions and needs.

Implementation in Long-Term Care

• Safety is paramount, emphasized through two-hour rounding to assess residents, repositioning, incontinence assessments, skin care, and fluid offerings.
• Assessment components are listed on page 1185.

Evaluation

• Evaluation focuses on patient outcomes, encompassing assessment and data gathering to evaluate progress.
• Key questions for evaluation include:
  • Was the expected outcome achieved for the resident?
  • Does the outcome align with the resident's desired goals?
  • Do significant others and family members support the outcomes developed by the interdisciplinary team with the resident?
  • Nursing interventions are prioritized based on: Airway, breathing, circulation, nutrition, fluids, elimination, sexuality, safety, and security, belonging, self-esteem, and self-actualization.

Rehabilitation Nursing

• Rehabilitation nursing focuses on supporting patient restoration of health or adaptation to changes resulting from chronic illness, disability, or injury.
• It emphasizes a holistic approach, providing outcome-focused patient care delivered by an interdisciplinary team.
• The goal is to restore patients to their fullest physical, mental, social, vocational, and economic capacity.

Need for Rehabilitation

• Rehabilitation can be prompted by:
• Impairment: Loss or abnormality in psychological, physical, or anatomical structure or function.
• Disability: Inability to participate in major life activities due to mental, emotional, or physical impairments.
• Functional limitations: Loss of ability to perform tasks or ADLs.
• Chronic illness: Conditions lasting at least three months, potentially with periods of remission or exacerbation.

Chronic Illness and Disability

• Chronic illness affects 40% of the population, including children.
• Approximately 86% of medical costs are associated with chronic illness.
• Chronic illnesses have the potential for abrupt or insidious onset and persist for an extended, indefinite period. Individuals may still function but often with limitations.

Scope of Rehabilitation

• Rehabilitation serves as a bridge for patients, bridging uselessness and usefulness, hopelessness and hopefulness, and despair and happiness.
• Community rehabilitation services focus on maintaining functional abilities, ensuring safety, promoting effective coping mechanisms, preventing complications, and modifying the environment for maximum independence.
• Disability can negatively impact patients and families, leading to behavioral and emotional changes, body image concerns, self-concept challenges, and family dynamics shifts.

Rehabilitation Goals

• Rehabilitation aims to:
  • Maximize quality of life.
  • Address patient-specific needs.
  • Assist with adjusting to an altered lifestyle.
  • Promote wellness and minimize complications.
  • Support attaining the highest degree of function and self-sufficiency.
  • Assist with home/community reentry.

Cornerstones of Rehabilitation

• Rehabilitation focuses on achieving the following goals:
  • Individual-centered care and goal setting
  • Participation in social, vocational, and recreational activities
  • Physical and emotional independence
  • Functional outcomes
  • Involving the rehabilitation team, patient, and family
• Focus on quality of life over quantity
• Prevention and wellness, minimizing complications and maximizing function
• Directing positive change
• Learning to adapt and cope positively
• Promoting independence and understanding through patient and family education.

Comprehensive Rehabilitation Plan

• The Commission on Accreditation of Rehabilitation Facilities mandates the development of an individualized comprehensive rehabilitation plan of care within 24 hours of hospital admission.
• The plan incorporates individual goals, strengths, needs, abilities, and preferences.
• Goals must be measurable, described in functional or behavioral terms, have associated timeframes for achievement, and specify responsible team members.

Rehabilitation Team

• The team includes the patient, nurses, physical therapists (PTs), occupational therapists (OTs), speech therapists, psychologists, chaplains, and other specialists.
• 3 Team Functioning Models:
  • Multidisciplinary Rehabilitation Team: Discipline-specific goals, clear boundaries, and outcomes are the sum of individual disciplines.
  • Interdisciplinary Rehabilitation Team: The most common model in rehabilitation hospitals, featuring collaboration on individual goals and expanded problem-solving with discipline-specific contributions towards goal attainment.
  • Transdisciplinary Rehabilitation Team: Blurs disciplinary boundaries, cross-training, and flexibility to minimize effort duplication.

Rehabilitation Nurse

• Rehabilitation nurses provide continuous 24-hour patient support, enabling them to recognize subtle changes in patients.

Rehabilitation Nursing Roles

• Rehabilitation Nurses support patients in transitioning from dependency to independence.
• Focus Areas: Education, patient care, collaboration, advocating, and promoting patient well-being.
• Common Conditions: Arthritis, Multiple Sclerosis, Mental Illness, Stroke, Spinal Cord Injury, Burns, Traumatic Brain Injury.
• Nursing Assessment: Evaluates patient's ability to perform ADLs (dressing, self-feeding) to determine independence level.
• Nursing Interventions: Support and reinforce activities in the interdisciplinary care plan (e.g., speech exercises, minimizing distractions, cueing/reminders).

Family-Centered Care

• Core Concept: Family plays a crucial role in supporting individuals with disabilities or chronic conditions.
• Goals: Empower families as caregivers by building on their unique strengths and fostering a natural caregiving environment.
• Key Elements: Collaboration, policies acknowledging family's permanence while services are transitional, family-professional collaboration at all levels of care, unbiased information exchange, support and networking for families.

Cross-Cultural Rehabilitation

• Cultural Competency: Awareness, acceptance and inclusion of diverse cultures and behaviors.
• Cultural Proficiency: Developing a practice that understands and responds appropriately to different cultures.
• Cultural Competence Strategies: Self-assessment, adapting care to patient values and culture, recognizing dynamic differences, disseminating cultural knowledge.

Issues in Rehabilitation

• Quality of Life vs. Quantity of Life: Focus prioritizes improving quality of life.
• Care vs. Cure: Emphasis on adaptation and acceptance of altered life rather than disease resolution.
• High Cost of Interdisciplinary Care: Rehabilitation services are expensive but research shows that early intervention and implementation save costs, increase patient independence, and reduce long-term care expenses.

Chronic Conditions Necessitating Rehabilitation Therapy

• Cardiac Rehabilitation: Implemented after heart attack or surgery to improve function, promote heart-healthy practices, and reduce risk factors.
• Pulmonary Rehabilitation: Focuses on managing chronic breathing problems (COPD, lung surgery) through exercise, diet counseling, education, and energy conservation techniques.

Polytrauma and Rehabilitation Nursing

• Polytrauma-Blast-Related Injury (PT/BRI): Common in soldiers involved in conflicts, caused by explosions.
• Blast Injury Categories:
  • Primary: Compression damage to air-filled cavities (ears, lungs, GI tract) and fluid-enveloped organs (brain, spinal cord).
  • Secondary: Injuries from airborne debris, bomb fragments.
  • Tertiary: Injuries from being thrown by an explosive shock wave.
  • Quaternary: Inhalation of toxic chemicals, amputations, burns.
• Rehabilitation Teams: Focus on addressing undetected injuries, treating original injuries, and managing PTSD.

Posttraumatic Stress Disorder (PTSD)

• Definition: Mental health condition triggered by traumatic events.
• Symptoms: Intensify over time, avoidance of event reminders, flashbacks, difficulty with daily life.
• Historical Context: Known historically as "shell shock" or "war neurosis" and gained recognition as a psychiatric diagnosis after the Vietnam War.
• Diagnosis: Symptoms persist for at least a month, linked to a traumatic event, involving reliving the event through dreams or memories.
• Treatment: Cognitive and prolonged-exposure therapy, sometimes with medications (selective serotonin reuptake inhibitors).
• Nursing Role: Provide supportive care, develop trust, use therapeutic communication techniques.

Disability

• Americans with Disabilities Act (1990): Provides protection against discrimination for individuals with disabilities.
• Disability Definition: Physical or mental impairment significantly limiting major life activities.
• Holistic Approach: Person-first approach recognizing shared humanity, individual uniqueness, acknowledging strengths and impairments.

Spinal Cord Injuries (SCI)

• Injury Mechanism: Compression of the spinal cord by fracture, displacement, bleeding, or edema.
• Irreversible Damage: Spinal cord cannot repair itself, leading to paralysis, bowel and bladder dysfunction, sensory loss.
• Functional Disability: Determined by injury level and damage extent.
• Terminology:
  • Complete Injury: No motor or sensory function below injury level.
  • Incomplete Injury: Some or all motor/sensory function below injury level.
  • Quadriplegia: Cervical spine damage, weakness/paralysis in all extremities.
  • Paraplegia: Damage below the cervical area, weakness/paralysis in trunk/lower extremities.
  • Paresis: Slight paralysis or weakness.
  • Cervical Cord Injury: Paralysis of all extremities and trunk, respiratory failure, bladder/bowel issues, bradycardia, elevated temperature, headache.
  • Thoracic Cord Injury: Paralysis of lower extremities, initial flaccidity followed by spasticity, bladder/bowel dysfunction, pain, abdominal distention, sexual dysfunction.
  • Lumbar Cord Injury: Paralysis of lower extremities, bladder, rectum, sexual dysfunction.
• Postural Hypotension: Low blood pressure when sitting in a wheelchair due to blood pooling in the lower extremities and abdomen.
• Autonomic Dysreflexia: Sudden, extreme blood pressure elevation due to reflex action, often triggered by bladder distention or other stimulation below injury level.
• Heterotopic Ossification: Abnormal bone formation in joints below injury level, hindering range of motion.
• Deep Vein Thrombosis (DVT): Blood clots in the legs, requiring anticoagulation to prevent embolism.

Traumatic Brain Injuries (TBI)

• Severity: Range from mild concussion to severe coma.
• Goal: Restore patient to the highest level of independent functioning possible.
• Head Injury Types:
  • Penetrating: Object penetrates skull, causing tissue damage.
  • Closed-headed Injuries: Force causes brain to collide with skull, often involving a twisting motion.
• Classification:
  • Mild: Brief or no loss of consciousness, often normal neurological exams, may have post-concussive syndrome.
  • Moderate: Unconsciousness for 1-24 hours, impaired cognitive skills.
  • Severe: Unconsciousness or post-traumatic amnesia for over 8 days.
  • Catastrophic: Prolonged coma, lack of meaningful communication.
• Challenges: Inconsistent performance, anger, frustration, cognitive barriers, impaired memory, lack of initiative, depression, egocentric behavior.
• Communication: Empathetic support, involvement of patient and family, connecting them with community resources.

Pediatric Rehabilitation Nursing

• Specialty: Focus on children's development and maximizing their potential.
• Care Approach: Holistic care from hospital to home, ensuring children can become contributing members of society.
• Developmental Potential: Unique consideration in children's rehabilitation.
• Habilitation: Acquiring skills and behaviors for individuals with developmental challenges since birth or early childhood.

Gerontologic Rehabilitation Nursing

• Specialty: Focus on the unique needs of older adult rehabilitation patients.
• Goal: Assisting older adults in achieving their optimal health and well-being.
• Key Focus: Unique needs, roles, social relationships, and potential physical limitations of older adults.

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 of the patient's choosing

Interdisciplinary Team

• Involves a holistic approach, considering physical, emotional, social, economic, and spiritual needs of the patient.
• An interdisciplinary team develops and cares for the patient by considering all aspects of the family unit.

Medical Director

• Doctorate of medicine or osteopathy with overall responsibility for the medical component of the patient's care program.
• Acts as a consultant and a mediator between the interdisciplinary team and primary health care provider.

Nurse Coordinator and Hospice Nurses

• Coordinates the implementation of the plan of care for each patient
• Performs the initial assessment, admits the patient to the hospice program
• Develops the plan of care along with the interdisciplinary team
• Ensures the plan is being followed
• Coordinates assignments of the nurses and aides
• Facilitates meetings
• Determines methods of payment

Social Worker

• Evaluates and assesses the psychosocial needs of the patient
• Assists with accessing community resources and filing insurance papers
• Supports the patient and caregiver with emotional and grief issues
• Assists with counseling

Spiritual Coordinator

• Affiliated with any religion and assists with the spiritual assessment of the patient
• Develops a plan regarding spiritual matters, keeping with the patient's and families' beliefs
• Assists the patient and caregiver to cope with fears and uncertainty
• Funeral planning and performing funeral services may be included, as well as continued support for the family through the bereavement period.

Volunteer Coordinator

• Must have experience in volunteer work and the ability to assess the needs of the patient and caregiver regarding "burnout", providing respite care.
• Respite care provides relief from responsibilities of caring for a patient, and coordinators ensure the volunteer is adequately trained and prepared for working with a dying patient.
• Medicare and Medicaid funding requires agencies to demonstrate that at least 5% of the work being completed is done by volunteers.

Bereavement Coordinator

• Assesses the patient and the caregiver at admission and identifies potential risk factors that may arise after the death
• Follows the plan of care for the bereaved caregiver for at least a year after the death of the patient, facilitating support groups and volunteers.
• The goals of bereavement counseling are to provide support and assist survivors in the transition to a life without the deceased person.

Hospice Pharmacist

• Evaluates for drug interactions, dosing, and administration times, routes, etc.

Nutrition Consultant

• May be consulted for assistance with diet counseling, meal planning, and educating the caregiver about nutritional issues in end-stage diseases.

Hospice Aide

• Certified Nursing Assistant (CNA) working under the supervision of the hospice nurse
• Develops and assists the patient with Activities of Daily Living (ADLs)
• Often develops a close relationship with the patient

Other Services

• Include Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy.

Palliative Care/Hospice

• The goal and emphasis of hospice is symptom management and palliative care.
• Assessment of comfort level is necessary, and the Edmonton Symptom Assessment System is a tool often used.

Pain

• Pain is the most dreaded and feared symptom that a dying patient experiences, disrupting activities as well as the qualities and enjoyment of life.
• Caregivers may become frustrated and feel helpless trying to control the discomfort, which leads to feelings of guilt and inadequacy.
• Pain may be related to pathological processes such as tumor invasion, compression of organs or nerves, erosion of tissue, etc.
• Controlling symptoms is central to the successful management of pain for terminally ill patients.
• Pain assessment should include information about severity, history of the pain, what brings relief to the patient.

Types of Pain

• Somatic pain: Arises from the musculoskeletal system and is described as aching, stabbing, or throbbing.

  • Treated with NSAIDs, nonopioid drugs, and opioids.

• Visceral pain: Originates from the internal organs and described as cramping, pressure, dull, squeezing.

  • Treated with anticholinergic medication alone or as an adjuvant to nonopioids or opioids.

• Neuropathic pain: Arises from the nerves and the nervous system and described as tingling, burning, or shooting pains.

  • Treated with anticonvulsants as an adjuvant to assist with pain control.

• Lifestyle considerations are important in determining the route and type of medication for pain control.

  • Oral medications may be preferable for ease of use for the patient and caregiver.
  • Oral administration of analgesics is not always feasible due to nausea, vomiting, obstruction, or inability to swallow, and other routes may be considered.
  • Morphine is often the drug of choice because it can be delivered by all routes.

• Doses may be titrated to the level at which the drug is therapeutic.

• Ineffective pain management is often associated with undermedication as a result of common myths and fears of addiction, tolerance, and respiratory depression.

• Alternative therapies and nonpharmacologic options are encouraged, such as radiation therapy, nerve block, repositioning, music, relaxation, etc.

Nursing Interventions and Patient Teaching

• The goal of the nurse is to focus on the effectiveness of the care plan and patient education; collaboration and understanding are necessary.
• It may be possible to control pain, and using large doses of opioids is common and necessary.

Nausea and Vomiting

• Nausea is often worse than vomiting because it is unnoticeable and easily overlooked.
• Important to investigate the cause, such as chemotherapy, tumor, obstruction, opioid medications, anxiety, etc.
• Treated with antiemetics and opioid analgesics.
• If caused by an opioid, it is best to use an antiemetic rather than discontinue the opioid.

Nursing Interventions and Patient Teaching

• Monitor labs for electrolyte imbalances and hydration.
• Treated with antiemetics, IV therapy, oral medication such as Serotonin antagonists (ondansetron, dolasteron) and phenothiazine medications (prochlorperazine, promethazine).
• Educate patients to eat slowly, rest after eating, and stop eating if vomiting occurs.
• Encourage drinking fluids, small light bland meals, and avoid sweet, greasy, spicy, or strong-smelling foods.

Constipation

• A common problem of the terminally ill.
• May be caused from anxiety, discomfort, or pain, opioids.
• Symptoms may include abdominal pain, nausea or vomiting.
• If caused by opioids, the dose or route may need to be adjusted, encouraging fluids and stool softeners and stimulants.
• Enemas may need to be considered, and a rectal exam may be necessary to check for an impaction and potentially manual removal.

Nursing Interventions and Patient Teaching

• Premedicate with anxiolytic and analgesics prior to impaction removal.
• Taking laxatives with opioids and encouraging comfort.
• If the patient has not had a bowel movement, assess for discomfort, bowel sounds, and abdominal firmness.

Anorexia and Malnutrition

• Produces major anxiety and symptoms related to terminal illness.
• Poor appetite may arise from nausea, vomiting, constipation, dysphagia, stomatitis, tumor invasion, general deterioration, depression, or infection, food odors, inability to tolerate sweet foods, or bitter taste in the mouth.
• Inability to eat may lead to cachexia: malnutrition marked by weakness and emaciation.

Nursing Interventions and Patient Teaching

• Nutritional assessments and medications for the cause.
• Oral swabs may be soaked in mouthwash, encourage oral hygiene, small frequent drinks, crushed ice, attractive meals, high protein supplements, avoid weighing the patient to avoid discouraging the patient.
• Educate that anorexia is part of the dying process, and forcing the patient to eat may be harmful.

Dyspnea and Air Hunger

• Arises from conditions such as heart failure, dysrhythmias, infection, ascites, or tumor growth.
• Breathing effectively is difficult for many patients, and air hunger may occur from tumor pressure, fluid and electrolyte imbalances, or anemia.
• Anxiety, fear, and panic may develop.
• Dyspnea may be relieved by providing oxygen, morphine, or bronchodilators (although oxygen will not relieve the dyspnea, it may ease anxiety).

Nursing Interventions and Patient Teaching

• Relieve anxiety, educate on positioning, use of a fan and morphine, good oral hygiene, anticholinergic drugs such as transdermal scopolamine or atropine.
• The "death rattle" may be exhibited 24 to 48 hours before death due to an accumulation of mucus and fluids in the posterior area of the pharynx.

Psychosocial and Spiritual Issues

• Some patients question their faiths and beliefs and search for spiritual support they never had.
• Symptoms like depression, the need to suffer, bitterness, anger, hallucinations, or dreams of fire can be indicative of unmet spiritual needs, in some cases.

Nursing Interventions and Patient Teaching

• Use the spiritual coordinator, and the social worker may provide counseling; note that they do not "fix" conflicts but assist in problem solving.
• Trust between the patient and team is imperative.

Other Common Signs and Symptoms

• Include weight loss, dehydration, skin impairment, weakness, activity intolerance, comments of suicide (may reflect a desire for independence rather than a desire to kill oneself), sleeplessness, insomnia, etc.

Nursing Interventions and Patient Teaching

• Skin care, cleanliness, skin inspections, dry and clean skin, avoid harsh soaps, strong detergents, use an egg-crate mattress, air-floatation mattress, heel/elbow protectors, fall prevention, emotional support.

Patient and Caregiver Teaching

• Hospice care does not conclude once the patient dies and continues to support the family and primary caregiver.
• Bereavement group meetings may benefit families by providing the opportunity to communicate and share their feelings.
• Team members also go through a grieving period and attend funeral services, memorials, or visit caregivers after the death to help ease their grief and heal.

Ethical Issues in Hospice Care

• May arise when withholding or withdrawing nutritional support, the right to refuse treatment, allowing a natural death, and DNR orders.
• Families find these decisions difficult, and sometimes the decision-making regarding these issues falls on one family member, creating feelings of guilt, especially if other family members disagree.

Advanced Directive

• Prepared while an individual is alive and competent, providing guidance regarding the patient's wishes when they are no longer able to do so themselves.
• States preferences concerning life-support, organ donation, and sometimes gives authority to another person to make decisions for the individual.

Physician Orders for Life-Sustaining Treatment (POLST)

• A form completed by the medical provider and the patient to inform health care providers of the patient's wishes.
• A shorter form than an advanced directive with a few simple questions that can be filled out in minutes.
• Can be used in addition to or instead of an advanced directive and is encouraged to be completed for all nursing home patients and patients entering a hospital or hospice.

Discrimination

• Is never tolerable, regardless of sex, race, age, religion, and diagnosis.
• Hospices cannot exclude or refuse patients who need high-cost care, and their mandate is to serve everyone regardless of the ability to pay.

Future of Hospice Care

• Hospice is becoming increasingly attractive as an alternative to facing death in a clinical setting as more education regarding hospice is occurring.

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