Download Acute Interventions for the Chronic

Acute Interventions for
the Chronic Care
Patient
Ray Taylor
Valencia Community College
Topics
Home Health Care
Home Care Providers
Home Care Pathologies
ALS Support for Home Care
Patients
Hospice
Introduction
A major trend of health care involves
the shifting of patients out of the
hospital and back into their homes as
soon as possible.
The result has been a huge increase in
home health care services.
Epidemiology of Home Care
A number of factors have promoted the
growth of home care in recent years.
They include:
Enactment of Medicare in 1965
 The advent of HMOs
 Improved medical technology
 Changes in the attitudes of doctors and
patients toward hospital care

In 1992…
Almost 75% of home-care patients were
age 65 or older.
Of the elderly home-care patients,
almost two-thirds are female.
Responses to Home
Care
A number of situations may involve you in
the treatment of a home-care patient:
Equipment failure
Unexpected complications
Absence of a caregiver
Need for transport
Inability to operate a device
Home Health Care
Home health care problems requiring
intervention by a home health
practitioner or physician
Chemotherapy
 Pain management
 Hospice care

Figure 6-3
Types of Home Care
Patients
Airway pathologies



Inadequate pulmonary toilet
Inadequate alveolar ventilation
Inadequate alveolar oxygenation
Circulatory pathologies





Alterations in peripheral circulation
GI/GU pathologies
Ostomies
Catheters
Home dialysis
Types of Home Care
Patients
Infections

Cellulitis, sepsis
Wound care



Surgical wound closure
Decubitus wounds
Drains
Hospice care
Maternal child care


Apnea monitors
New parent
Progressive dementia in
the patient at home
Chronic pain
management
Home chemotherapy
Transplant candidate
Infection and Ulceration
Home Health Preparation
Table 6-4
Prevention
Table 6-5
General System
Pathophysiology
Assessment/Management
Assessment of the home-care patient
follows the same basic steps as any
other patient.
The one thing home-care calls have in
common is their diversity.
Try to ascertain from the primary health
care provider a baseline presentation
for the patient.
Patient Assessment
Assessment
Scene size-up

Body substance isolation


Safety



Infectious waste issues in home care environment
Pets
Firearems
Milieu


Ability to maintain a healthy environment
Adequate nutritional support available (electricity, heat,
etc.)
Common Acute Home
Health Situations
 Respiratory
disorders
 COPD
 Bronchitis
 Asthma
 CHF
 Cystic
fibrosis
 Bronchopulmonary dysplasia
Common Acute Home
Health Situations
Neuromuscular degenerative diseases
Muscular Dystrophy
 Poliomyelitis
 Guillain-Barré Syndrome
 Myasthenia Gravis

Patients awaiting lung transplants
Sleep apnea
Respiratory Disorders
Account for more than 630,000 of
hospital patients discharged for home
care annually
Simple pneumonia and pleurisy account for
37%
 COPD accounts for 50%

Respiratory Pathology
Increased risk of airway infections in the
respiratory compromised patient
Progression of chronic respiratory
diseases
Increased secretions
Obstructed or malfunctioning airway
devices
Improper application of medical device
Common Respiratory
Equipment
Oxygen equipment
Portable suctioning machines
Aerosol equipment and nebulizers
Incentive spirometers
Home ventilators
Tracheostomy tubes and collars
COPD
Triad of diseases




Emphysema, chronic bronchitis, asthma
Outflow obstructive diseases impending the
exhalation of air from lungs
Minimal lung capacity
Inability to meet normal metabolic demands


Decreased patient activity with increase use of 02
Increase C02 and decrease oxygenation
Bronchitis/Emphysema
Bronchitis


Chronic excessive production of mucus
Narrowing bronchial passages restricting air flow

Large, obese patients (blue bloater)
Emphysema


Enlargement and stiffening of alveoli and acenus
Loss of elasticity and compliance requires a higher
pressure in lungs to facilitate gas exchange at
alveolar level


Patients have increased A/P dimensions (increased air
retention and decreased outflow
Thin patients due to increase caloric output
Acute Exacerbation
Patients have difficult compensatory
mechanisms

Signs and symptoms

Wheezing, diminished breath sounds, use of accessory
muscles, retractions, tripod positioning, inability to speak
or form sentences
Home health care treatments


Oxygen, nebulized aerosol treatments
Ventilator: PEEP (via ETT), CPAP, BiPAP (mask
therapy)
Treatment Intervention
Oxygenation and ventilation
Nebulized beta-2 agonists
Nebulized anti-cholinergics
IV corticosteriods
Asthma
Reactive and reversible airway disease seen at
any age

Characterized by bronchospasm and swelling of
mucus membranes
Signs and symptoms of acute attack
Home therapy

O2, oral medications, variety of nebulizers and/or
inhalants
Treatment


Oxygenation and ventilation, beta agonists, anticholinergics, corticosteriods
Avoidance or elimination of reactants that trigger
problem
Cystic Fibrosis
Generic disorder usually recognized in
childhood

Terminal disease
Characterized by chronic overproduction of
mucus, inflammation of small airways and
hyperinflation of alveoli, chronic infections,
and erosion of the pulmonary blood vessels
secondary to infection
Exocrine disease causing other abnormalities

GI disturbances, pancreatic disorders, glucose
intolerance
Home Health Treatment
Postural drainage of mucus
Chest physiotherapy
Mechanical vibrators to facilitate
breakage of secretions
Medications aimed at mucus reduction
and control of systemic bacterial
infections
Bronchopulmonary
Dysplasia
Primarily affects infants of low birth
weight
Characterized by ongoing need for
mechanical ventilation in newborns
 Infants fail to wean from mandatory
ventilation or oxygenation
 Increased risk of respiratory infection

Management
EMS
Oxygenation and oximetric monitoring
 Neonatal transport to appropriate facility

Home health
Intermittent mandatory ventilation (IMV)
 Pulmonary congestion and edema
 Limit fluid intake

Management/Summary
Improving airway patency
Improve ventilation
Improve oxygenation
Psychological support
Communication with the intubated patient
 Communication using a “talking trach”

Neuromuscular
Degenerative Diseases
Affect respiratory action through
degeneration of muscles used for
breathing
As disease progresses and involves
more muscle groups, inability to
ambulate increases infections and rapid
decline of patients
Neuromuscular
Diseases
Muscular Dystrophy




Genetically inherited disorder causing a defect in
the intracellular metabolism of muscle cells
Leads to degeneration and atrophy of muscles
which are replaced by fatty and connective tissues
No cure to date
EMS involvement: respiratory failure, accidental
injuries usually related to falls
Neuromuscular
Diseases
Poliomyelitis
Infectious disease rarely seen today
because of vaccine
 Destroys motor neurons leading to
muscular atrophy, weakness, and paralysis
 Children often suffer crippling effects

Neuromuscular
Diseases
Guillain-Barre Syndrome





Autoimmune response to a viral infection
Usually preceded by a febrile episode with a
respiratory or GI infection
Characterized by muscle weakness leading to
paralysis caused by nerve demylenation
Usually begins in distal extremities and moves
proximally
No cognitive or CNS involvement
Neuromuscular
Diseases
Myasthenia Gravis
Rare disease that affects the neuronal
junction
 Due to a breakdown in acetylcholine
receptors, nerve impulses are delayed
 Characterized by muscle weakness
proximal to the body versus distal
 No cure to date

Sleep Apnea
Complex condition not fully understood
by experts
Characterized by long pauses in
respiratory cycle that can be caused by
a relaxation of the pharynx or lack of
respiratory drive
Can result in hypertension, arrhythmias,
and chronic fatigue
Sleep Apnea
Symptomology

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Muscles of airway become more relaxed as mind
falls deeper into sleep
Leads to snoring, and in some cases, blockage of
airway
Decreased 02 levels cause a partial awakening of
the patient
Breathing then resumes and patient returns to
sleep, often with no memory of the event
Repeated over and over, interruptions destroy
normal sleep patterns and the patient spends
much of the sleeping in a hypoxic state
Sleep Apnea
General treatment
Surgical alteration of the airway
 Medications
 Prescribed weight loss
 Avoidance of any CNS depressants
(alcohol)
 Use of CPAP ventilator

Medical Therapy Found
in the Home Setting
Home oxygen therapy
Artificial airways/tracheostomies
Vascular access devices
Home Oxygen Therapy
Many advantages for home care
patients
Easy to use
 Tolerated well by most patients
 Add to quality of a patient’s life
 Prevents hypoxia that may result in
permanent cognitive damage or
degeneration

Oxygen Systems
Artificial
Airways/Tracheostomies
Used for patients with long-term upper
airway problems
Tracheostomy may be temporary or
permanent
Technique is used on patients who require
artificial ventilation for long periods of time
 Patients with damage to larynx, epiglottis,
or upper airway structures from surgery or
trauma

Artificial Airway
Tracheostomy consists:


Surgical opening (stoma)
Outer cannula

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Keeps stoma open
Held in place by twill tape or velcro strap
Inner cannula

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
Similar to a mini ET tube
Slides down into trachea a few inches
Distal low pressure cuff to hold in place and provide a
good seal
Tracheotomy tubes
Top: Plastic tube
Bottom: metal tube with inner cannula
Artificial Airways
Speech

Artificial larynx
Looks like a small flash light
 Creates an electronic vibration by pressing the
device up against the neck and by patient
changing shape of his/her mouth

Routine Care of
Tracheostomy
Keep stoma clean and dry

Prevent pulmonary infections
Periodic changing of the outer cannula
Changing and cleaning the inner cannnula
from every few weeks to every months,
depending on the patient
For ventilator patients, routine changing of
the ventilator hose connections
Frequent suctioning, due to increased
secretion
Common Complications of
Tracheostomy Patients
Blockage of the airway by mucus and/or
dislodged cannula


Patient coughing to clear and suctioning
Patient movement and child growth
Infection of the stoma
Drying of tracheal mucus leading to crusting
or bleeding
Tracheal erosion from an over-inflated cuff

Tracheal necrosis
Management/Ventilation
Management
Oxygenation and ventilation
Sterile suctioning of the stoma/trachea with
an endotracheal suction catheter
Cannula obstruction

Deflate cuff and remove
Stoma intubation

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Remove inner cannula
Use appropriate sized tube size and advance tube
1-2cm inside trachea
Attach end tidal CO2 device and monitor with
pulse oximetry
Home Ventilation
Types of ventilators
Positive pressure
 Negative pressure

Provision for ventilation

Volume cycled ventilation
Historical standard for ventilators
 Used to support multiple forms of respiratory
failure

Home Ventilation
Positive pressure ventilators (PPV)

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Recommended for acute respiratory failure
Push air into lungs through a mask, nasal mask,
or tracheostomy
Features
 Variations:




tidal volume
respiratory rate
flow rate
pressure
Home Ventilation
Negative pressure ventilators
Imitate normal breathing process
 Apply negative pressure to the chest (pull
chest allowing it to expand)



Allows air to flow into lungs
Patients usually use this form of device at
night

Iron lung is an old example
PEEP/CPAP/BiPAP
Three ventilator options
Add pressures at various times during
respiratory cycle
May be used on a full-time or part-time
basis
Always possibility of pneumothorax due
to increased pulmonary pressure
PEEP
Positive end expiratory pressure
Used to maintain inflation of alveoli
Functions by providing a little back pressure
at the end of expiration
Uses



Premature infants with insufficient surfactant
Adults with surfactant washout from PE, ARDS,
near drowning
COPD

Emphysema patients require higher diffusion pressures
for gas exchange
CPAP
Continuous positive airway pressure
Used to keep pharyngeal structures from
collapsing at end of a breath
 Often prescribed for sleep apnea

Most patients use nasal CPAP
 Patients must keep mouth closed

Idea behind CPAP is the same a PEEP
 CPAP is delivered with a mask while PEEP
is delivered via ETT

Ventilation/CPAP-Nasal
Figure 6-7
BIPAP
Bilevel positive airway pressure
Provides two levels of pressure
Inspiration
 Expiration

Used for patients who require higher
levels of pressure than CPAP
Assessment Findings
Work of breathing
Tidal volume
Peak flow
Oxygen saturation
Capnography
Breath sounds
Vascular Access
Devices
Approximately 500,000 long term therapy
catheters inserted each year
VAD’s are used to provide parenteral
treatment on a long term basis
Used for


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Chemotherapy
Hemodialysis
Peritoneal dialysis
Total parenteral nutrition
Antibiotic therapy
Vascular Access Devices
Hickman, Broviac, Groshong
Peripherally inserted central catheters
Surgically implanted medication delivery
systems
Dialysis shunts
Hickman, Broviac, or
Groshong Catheters
Single, double, triple lumen catheters inserted
into a central vein



Subclavian vein most common
All have an external port that look like an IV port
External hub of the catheter is sutured into skin
and has a cuff that promotes fibrous in-growth


Anchors catheter to body and prevents infection from
traveling down catheter
Care of device includes: cleanliness and
administration of anticoagulant therapy
Peripherally Inserted
Central Catheters
PICC lines are most commonly inserted
into median cubital vein in the ACF
Catheter is threaded from insertion site
into central venous circulation
PICC lines are inserted under
fluoroscopy
Surgically Implanted
Medication Delivery Systems
Port-a-cath or Medi-port
Infusion port is implanted completely below
the skin
Disc shaped devices that have a diaphragm
that requires a specially shaped needle
(Huber needle)
Typically implanted in upper chest
Dialysis Shunt
Used for patients undergoing hemodialysis to
filter their blood
Types of shunts

AV shunt


Loop connecting an artery and vein, most common in
distal arm where dialysis apparatus evacuates and
returns blood
Fistula

Connects artery and vein creating an artificially large
blood vessel for access
AV Shunt
VAD Complications
Obstruction
Thrombus
 Embolus (air embolus)
 Catheter kinking
 Catheter tip embolus
 Inactivity increases risk of clots

Infection
Hemorrhage
Cardiac Conditions
(Home Health)
Post MI recovery
Post cardiac
surgery
Heart transplant
CHF
Hypertension
Implanted
pacemaker
Atherosclerosis
Congenital
malformation
(pediatric)
GI/GU Crisis
Devices to support GI/GU function are
common.
Be familiar with the various devices and
their complications.
GI/GU Devices
Urinary catheters or urostomies

Surgical diversion of the urinary tract to a
stoma, or hole in the abdominal wall
Indwelling nutritional support device
(peg tube, G-tube)
Colostomies
NG tube
External Urinary
Catheter (Texas Sheath)
Figure 6-9
Foley Catheter
(Indwelling Catheter)
Figure 6-10
Urinary Device
Complications
Infection or device malfunction

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Catheter device provides a pathway for infectious entry
Foul smelling urine
Discolored (cloudy) urine
Blood tinged urine
Systemic infection (fever)
Redness, swelling of abdominal wall site with
urostomies
Device malfunction: accidental placement,
obstruction, balloon ruptures
Gastrointestinal Devices
Nasogastric tubes



Decompress gastric contents
Lavage GI system
Short term use
Feeding tubes

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Rest on the duodenum or jejunum
Weighted with steel filament to aid insertion and
passage through pyloric sphincter
Percutaneous endoscopic gastrostomy (PEG)


Via abdominal wall
Long term nutritional support
Nasogastric Feeding
Gastrostomy (PEG)
Figure 6-12
Colostomy
Opening of a portion of the large intestines
(colon) through the abdominal wall, allowing
feces to be collected outside the body
Temporary or permanent
Indications




CA of bowel
Diverticulitis
Crohn’s disease
Trauma
Colostomy
Figure 6-13
Assessment Findings
Abdominal pain and distention
Bowel sounds
Palpation of bladder
Color, character, amount of urine
Acute Infections
Increased rate of infections in the
elderly, chronically ill and homebound
Decreased ability to perceive pain or
perform self-care in many homebound
populations
Pathophysiology
Increased risk of respiratory infection in
the immunocompromised patient
Poor peripheral perfusion results in
decreased healing and increased
peripheral infections
Sedentary existence leads to skin
breakdown and peripheral infections
Pathophysiology
Percutaneous and implanted medical devices
increase risk for infections and sepsis
Patients discharged to home with open
wounds and incisions
Chronic diseases may further impair healing
Poor nutrition, hygiene or ability to care for
self impact infection rates
Maternal & Newborn Care
Many women who deliver their babies in
the hospital will be discharged in 24
hours
or less.
ALS providers may be called upon to
assist new parents in caring for
newborns or post-partum complications.
Post-partum bleeding and
embolus are common
complications
Management includes:
Massage of uterus
Administration of fluids
Administration of pitocin
Rapid transport, if necessary
Postpartum Depression
“Let down” feeling experienced during
the period following birth
Occurs in 70%-80% of mothers
Women have difficulty caring for both
themselves and newborn
Be sensitive to needs and non-urgent
responses
Infants and Children with
Special Needs
Many different types of children
Premature babies
 Lung disease
 Heart diseases
 Neurological diseases
 Chronic diseases
 Altered functions from birth

Infants and Children with
Special Needs
Common home-care devices
Tracheostomy tubes
 Apnea monitors
 Home artificial ventilators
 Central intravenous lines
 Gastric feeding and gastrostomy tubes
 Shunts

Common Infant/Child
Complications
Signs/symptoms of cardiorespiratory
insufficiency include:
Cyanosis
Bradycardia (<100 BPM)
Rales
Respiratory Distress
Hospice
More than 2250 hospices provide
support for the terminally ill and families.
The goal of hospice care is to provide
palliative or comfort care rather than
curative care.
Hospice
Hospice
Palliative care
Comfort care
Hospice care DNR

Medical direction considerations
Pain control in the terminal patient
Common Hospice
Diseases
Congestive heart failure
Cystic fibrosis
COPD
AIDS
Alzhemier’s
Cancer
HIV Children
Figure 6-14
Summary
Home Health Care
Home Care Providers
Home Care Pathologies
ALS Support for Home Care Patients
Hospice