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Preventive Medicine Members: Epetia-Erestain-Esguerra-Esmael-Eugenio-Evangelista E, Evangelista K, Facton, Fajardo, Fang, Florendo, Fontano, Francsico, Gabuat, Gaffud, Gagtan, Gallardo, Garan Section B HOME CARE It is the provision of health care in the patient’s home to promote, maintain, and restore health or minimize the effects of illness and disability formal care skilled care informal care non-medical care or custodial care home health care To get better To become independent To become self-sufficient to maintain your highest level of ability or health, and help you learn to live with your illness or disability Older people unable to care for themselves Disabled people w/ Chronic illnesses w/ Acute episodic illnesses Discharged patients requiring medical supervision or rehabilitation Terminally ill patients ASPECTS OF HOME CARE PREVENTIVE Health promotion Maintenance for each family member Screening in the home for undetected diseases DIAGNOSTIC • Includes laboratory and ancillary procedures in the management of the patient and their family members THERAPEUTIC Pharmacologic and non-pharmacologic management of the patient’s illness as well as that of their family REHABILITATIVE • various exercises and rehabilitation measures LONG TERM MAINTENANCE Sustaining the care of the chronically or terminally-ill patients PSYCHOSOCIAL CARE • addressing the psychological, emotional and social needs of the patients and their families Preparation for Home Care Preparation for Home Care Planning includes : Assessment and preparation of the patient and the home environment facilitate the safest and smoothest transition I. Preparing the Patient 1. Sharing information about the diagnosis considered. 2. Treatment plans and therapeutic options are also discussed. II. Patient Assessment Includes the evaluation of the patient’s : 1. physical condition 2. Functioning of extremities 3. Sensory components 4. Excretory functions Prior to Discharge : Physical Functioning must be enhanced by : 1. Eliminating unnecessary bed rest in the hospital. 2. Physical activity must be encouraged appropriate limit of tolerance will be reached. III. Preparation of the Physical Environment at Home Done with the help of the caregivers Caregivers should be trained Safety measures and mobility for the bathroom, bedroom, doors and stairs should be planned. Conclusion The patient’s QUALITY OF LIFE must be the concern of the physician. With proper coordination and planning, the patient could be relegated to an independent life. Organizing a Home Care Program Organizing a home care program Get manpower Train staff Prepare a home care program Do networking and linkages Implement the program Evaluate the program 1. Get manpower Home care team consist of Primary care physician Nurse Therapist Social worker volunteers 1. Get manpower The home care team works together Blend their skills and services Meets the needs of the patients and family 2. Train staff Staff must be trained in Assessing hazards of home Conducting functional assessment Monitoring medications Assessing caregivers 3. Prepare a home care program Various services Mechanics of implementation Policies and fees including reimbursements 4. Do networking and linkages Communications with various agencies Community resources Awareness of what they have to offer 5. Implement the program Meet the patient and establish rapport Know their expectations and do goal setting Assess educational and clinical needs Schedule visits Checklist of gadgets and equipments Financial agreements 6. Evaluate the program Monthly health management meeting Adjustments are done depending on the results of the evaluation Guidelines for Home Visit Guidelines for home visit Enables the physician to identify problems hidden during clinic visits family interaction family role in illness role in healing Home visits can deepen the physicians understanding of the family Guidelines for home visit Preparation Planning Coordination Guidelines for home visit Select the patient and schedule the visit Review medical records Background regarding the disease is warranted REVIEW LITERATURE Prepare home care plan Guidelines for home visit During the visit Necessary instruments Develop rapport History and psychosocial issues Living conditions Cleanliness and safety It is important to select a PRIMARY CAREGIVER Guidelines for home visit During the post visit Write the report Problem list Intervention performed Schedule follow up visits Coordinate if referral is needed Home Care Technique: NGT insertion 1. Lubricate NGT with water soluble jelly for 3-4 inches at the dital end. 2. Introduce lubricated tube along the floor of the nose with the patient sitting and the head supported to prevent reflex withrawal. 3. Advance the tube towards nasopharynx then to esophagus. 4. The gastroesophageal junction is reached typically at 40 cm. Technique: 5. Once the tube has been passed, confirm if placement is correct by: a. open end of the tube placed in a glass of water. Air bubbles = tube in bronchi or trachea b. patient asked to hum or talk. Not possible = tube in larynx. Withraw tube. c. a 60ml syringe with air is connected to the suction lumen of the NGT. The examiner auscultates the stomach while an assistant empties the syringe slowly. whooshing sound of borborygmi produced only at 10-20ml of air = tube is in the stomach Technique: 6. Secure the tube by anchoring it into the nose with a hypoallergenic tape. Mechanical Ventilation Indicated for respiratory failure. Recommended Set-up Tidal volume – 60-80 breaths/min FiO2 0.40 Ventilator mode – assisted control Inspiratory flow – 50% Peak P – 50cm H20 I:E ratio – 1:2 Humidifier T – 350C Tracheostomy Tube Suctioning and Cleaning Removal of accumulated secretions facilitates: patient comfort increases respiratory frequency decreases risk of complete airway obstruction with secretions decreases risk of infection. Tracheostomy Tube Suctioning and Cleaning Suctioning Procedure 1. Wash hands. 2. Position patient in a semi-sitting position. 3. Prepare materials. 4. Attach catheter to suction tubing. 5. Suction the sterile saline to moisten the catheter. 6. Cover the suction port with thumb while inserting the catheter and rotating it between the thumb and forefinger. Periodically release the suction pressure for a brief second. Tracheostomy Tube Suctioning and Cleaning Suctioning Procedure 7. Allow the patient to breath or cough between suctioning. 8. Observe for sign of respiratory distress. Use manual amby bagging if needed. 9. Flush catheter with saline. Inner canula – soaked in hydrogen peroxide then rinse with normal saline. Tracheostomy site – cleaned with sterile cotton buds and normal saline. Catheter Insertion Females – half of the catheter must be inserted before inflating the balloon. Place it in the urethral meatus to the urethra then upwards towards the bladder. Males – catheter inserted at least 24 cm before inflating the balloon. IV insertion Peripheral Iv lines are used for maintenance of fluid balance, administration of drugs and nutrition. Butterfly or may be used. catheter Connected to the tubing of the IV system. Nursing Care Positioning of the patient in the bed Moving patient in bed Perineal Care Oral Care Bed bath Transfers Exercises ROM exercises – to maintain muscle tone and joint mobility Types of ROM: Active in which patient performs movements on a non-functioning joint Active-assisted – patient and care-giver participates Passive – exercise performed by the caregiver. Common geriatric problems in the home Home care of a stroke patients Home care of Stroke Patients IMMOBILITY PE Sitting balance Neck turning Ability to rise from a sitting position Evaluate ROM of all joints and contractures note Home care of Stroke Patients consequences of immobility ↓CV fitness Joint stiffness and contractures Muscle wasting Accelerated osteoporosis Pneumonia Venous stasis Pulmonary emboli Decubitus ulcer Home care of Stroke Patients Treatment goal: Maintain ADL Achieve functional independence Non pharmacologic First approach Patient’s education Avoid complete bed rest Physiotherapy Occupational therapy Home care of Stroke Patients ROM exercises without excess stress Assistive devicesenhancement of ADL Flexibility Crutches Avoid contractures Canes Progressive work programs Promote CV fitness Contour pillow Home care of Stroke Patients Analgesic- pain and anti-inflammatory effect TENS- painful shoulder Home care of Stroke Patients INCONTINENCE 5 clinical classification Urge Stress Overflow Reflex Functional Home care of Stroke Patients History PE Funtional Inability to reach bathroom in time Confused, immobile Urge Frequent sensation of need to urinate Abnormal gait, Motor and sensory deficits reflex No sensation of need to urinate Abnormal gait, Motor and sensory deficits Overflow ↓ force of stream, dribbling, necessity to strain Palpable bladder and Fecal impaction Stress dyspareunia Signs of estrogen lack Home care of Stroke Patients Management of incontinence cause treatment Spastic bladder Bladder retraining Disposable undergarments Imipramine Oxybutine propantheline Hypotonic bladder Frequent voiding Intermittent catheterization Disposable undergarments Bethanecol phrnoxymebenzamine Urethral insufficiency Weight loss and pelvic exercise Pessary Estrogen and imipramine Home care of Stroke Patients SKIN PROBLEMS a. Positioning of the patient b. Sensory level and skin care c. Pressure relief d. Wound management Home care of Stroke Patients Nutritional problems evaluate nutritional status and requirements Dietary prescription Nutrients, electrolyte, volume Parenteral, enteral or oral Home care of Stroke Patients BP CONTROL Low salt Low fat Medications activity Home care of Stroke Patients THROMBOSIS Antiplatelet drug Prevent further aggregation →thrombosis Aspirin Ticlopidine dipyridamole Home care of Stroke Patients WELLNESS PROGRAM Health maintenance plan for all the family members Periodic PE, screening tests and developmental monitoring Home care of Stroke Patients Physician as social mobilizer Preparing for home while in the hospital Facilitation of referrals Coordinating with other agencies Facilitation of community resources Home care of Stroke Patients Physician as counselor and educator Educating the patient: treatment, medications, supportive measures and course of disease Training of caregivers Counseling family members if they are stressed Home care of Stroke Patients Physician as a manager Coordinate the home environment Home care needs Modifying home for accessibility safety Home care of Stroke Patients BEDROOM BATHROOM Large Minimum of 3 feet Bed should be at the height level with the wheelchair Minimum of 30 inches Electrical outlets Raised toilet seat Toilet bars Rubber mat Hand held showers Home care of Stroke Patients DOORS Lever type handle FURNITURE Unobstructed passageway Automatic door Door peephole must be lowered to the eye KITCHEN Refrigerator, sink and range should be accessible Home Care Of COPD Patients Chronic Obstructive Pulmonary Disease Common among geriatrics One of the leading causes of permanent disability Treatment not known to decrease morbidity or mortality Goal: improve quality of life Pulmonary rehabilitation Evaluation of Pulmonary Function and Disability Class I Normal Activities: not significantly restricted Employable Dyspnea Unusually strenuous activity Evaluation of Pulmonary Function and Disability Class II Independent in essential activities of daily living Restricted in other activities Employable if job is sedentary Dyspnea Climbing stairs Evaluation of Pulmonary Function and Disability Class III Does not require physical assistance Probably not employable Dyspnea Absent at rest During usual activities Showering Dressing Can walk at own pace but cannot keep up with others Evaluation of Pulmonary Function and Disability Class IV Some help in performing essential activities of daily living Restricted to home if living alone Dyspnea Minimal exertion Pausing after one flight of stairs Walking more than 100 yards Dressing up Evaluation of Pulmonary Function and Disability Class V Dependent on help of most needs Entirely restricted to home Activity limited to bed and chair Dyspnea at rest Evaluation of Pulmonary Function and Disability Goals and modalities Prevention of exacerbation Relief of bronchospasm Reduction of secretions Breathing restraining Evaluation of Pulmonary Function and Disability Goals and modalities Exercise conditioning Oxygen therapy Educating the patient Family psychosocial management Home Care of Cancer Patients Home Care of Cancer Patients Natural course of the disease Advancing disease Terminal phase Primary goal Symptomatic treatment Home Care of Cancer Patients Questions Are there adequate resources at home? What are the expected morbidities of cancer treatment? Will the family be willing to act as caregivers? Where will the patient die? Home Care of Cancer Patients Needs of the patient Medical Psychosocial Environmental Spiritual Home Care of Cancer Patients Physician Education Key service to both patient and family Patients needs Anticipation of death Counseling and support Family Friends Prevented from caregiver strain Home Care of Cancer Patients Counseling Set of techniques, skills and attitudes to help people manage their own problems using their own resources Objectives Symptom relief Behavioral change Self-sight Function of Family Counseling Education Prevention Support Challenge
