Acute Interventions for the Chronic Care Patient
How to Take Care of Those Who are Already Sick
Introduction to Home Health Care
•A major trend in 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.
History 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 were female.
The home care provider is an important source of information.
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
Many of the pathologies that you will encounter in a home care setting are
the same as others. You must always keep in mind that the home care
patient is in a more fragile state.
•Typical Responses
–Airway complications
–Respiratory failure
–Cardiac decompensation
–Alterations in peripheral circulation
–Altered mental status
–GI/GU crises
–Infections/septic complications
Pressure sores are classified by the depth of tissue destruction.
General System Pathophysiology, Assessment, and Management
Assessment
•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 care provider the patient’s baseline
health status.
Tailor your questions to the home care setting.
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
•Sleep apnea
•Patients awaiting lung transplants
Medical Therapy Found in the Home Setting
•Home oxygen therapy
•Artificial airways/tracheostomies
•Vascular access devices
Common Technical Problems with Oxygen Systems
Artificial ventilation in a patient with a tracheostomy tube
Use of continuous positive pressure airway pressure—CPAP—for sleep
apnea patients
Vascular Access Devices
•Hickman, Broviac, Groshong
•Peripherally inserted central catheters
•Surgically implanted medication delivery systems
•Dialysis shunts
An A-V shunt is used in home care patients requiring dialysis.
Vascular Access
•Never access a surgically implanted port unless protocols allow you to do
so—and you have the training/ equipment.
•Avoid vascular access and blood pressure in the extremity of a shunt.
GI/GU Crisis
•Devices to support GI/GU function are common.
•Be familiar with the various devices and their complications.
An external urinary tract device
An internal urinary catheter with balloon
A nasogastric feeding tube
A gastrostomy feeding tube
Examples of colostomy stoma locations
Maternal and 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.
Postpartum bleeding and embolus are common complications.
•Management includes:
–Massage of uterus
–Administration of fluids
–Administration of Pitocin
–Rapid transport, if necessary
Common Infant/Child Complications
•Signs/symptoms of cardiorespiratory insufficiency include:
•Cyanosis
•Bradycardia
•Crackles (rales)
•Respiratory distress
Commonly found medical therapies for children who are home care
patients include:
•Mechanical ventilators
•IV medications
•Oxygen therapy
•Tracheostomies
•Feeding tubes
•Pulse oximeters
•Apnea monitors
Hospice
•More than 2,250 hospices provide support for the terminally ill and their
families.
•The goal of hospice care is to provide palliative or comfort care rather
than curative care.
Percentage of Hospice Patients by Age
Children with AIDS or HIV infection in a hospice setting
Children with Special Health Care Needs
•Children with disabilities including:
–Physical limitations
–Mental limitations
–Chronic illness
Children with Special Health Care Needs
•Technology-assisted Children = Those with special health care needs
who depend on medical devices to support vital bodily functions.
Children with Special Health Care Needs
•Assessment
–Critical to ask parent or home care attendant about patient’s
•baseline
•present problem (why did they call?)
•past history
•past treatment for similar problem
•hospital where the patient is normally seen
Children with Special Health Care Needs
•Tracheostomy
–bypass upper airway obstruction caused by birth defect, surgery,
trauma
–allow long-term mechanical ventilatory support as result of chronic
disease
–temporary following severe illness, trauma
–mucus obstruction is common problem
–instill sterile saline, then suction while withdrawing catheter
Children with Special Health Care Needs
•Constant Positive Airway Pressure
–Recurring partial airway obstruction
–Weak inspiratory effort
–Some only wear device at night
–May be disconnected but child may tire easily
Children with Special Health Care Needs
•Central Venous Catheters
–May be used to deliver
•nutrition
•special medications
–Usually on chest but may be at neck, groin or arm
Children with Special Health Care Needs
•CSF shunt
–Used to drain fluid from cranial cavity into abdomen
–Obstruction may result in  ICP or seizures
Children with Special Health Care Needs
•Feeding Catheters
–Deliver nutrition or medication
–NG/OG tube used for brief periods or surgically implanted for
longer periods
•gastrostomy tube (GT) passes through abdomen into
stomach
•jejunostomy tube (JT) passes through abdomen into small
intestine
•percutaneous endoscopic gastrostomy (PEG) (button)
similar to GT but is equipped with a cap and valve
Children with Special Health Care Needs
•Pacemaker
–Demand, constant, or antiarrhythmic
–Generator can usually be felt under skin
–Leads may fracture causing failure
–Ask about type of pacemaker and its function
Children with Special Health Care Needs
•Congenital Heart Disease
–Usually manifested in first few days of life
–Often detected prenatally
–Examples
•Patent ductus arteriosus
•Atrial septal defect
•Ventricular septal defect
•Tetralogy of Fallot
•Transposition of great vessels
•Aortic coarctation
Children with Special Health Care Needs
•Congenital malformation
–Trisomy 21 (Down’s syndrome)
•1 in 800 births
•more common in older mothers
•smaller stature; developmental delays; small midface with
upturned nose; flat occiput, short broad hands and feet;
short ears; exaggerated space between first and second
toes
Children with Special Health Care Needs
•Congenital Malformation
–Trisomy 18
•1 in 8,000 births
•higher risk of spontaneous death in utero
•small, premature appearance; narrow nose; prominent
occiput; cleft lip or palate; congenital heart disease;
overlapping of finders (index over 3rd, 5th over 4th);
developmental delays; underdeveloped nails
•most die in infancy; few survive > 1 year
Children with Special Health Care Needs
•Congenital Malformation
–Trisomy 13
•1 in 10,000 births
•higher risk of spontaneous death in utero
•scalp defects; cleft lip or palate; microcephaly; sloping
forehead; congenital heart disease; overlapping of fingers
and toes; underdeveloped nails; developmental delays
•most die in infancy; few survive > 1 year
The Challenged Patient
Hearing Impairments
Conductive Deafness
•A blockage of the transmission of sound waves through the external ear
canal to the middle or inner ear
Sensorineural Deafness
•Deafness caused by the inability of nerve impulses to reach the auditory
center of the brain because of nerve damage to either the inner ear or to
the brain
Recognizing Deafness
•Asking questions repeatedly
•Misunderstood questions or inappropriate responses
•Presence of a hearing aid
•Sign language or gestures
Hearing aids come in various shapes and sizes.
Accommodations for Deaf Patients
•Address patient face to face.
•Speak slowly in a normal voice.
•Reduce background noise as much as possible.
•Help find or adjust hearing aids.
•Use pen and paper.
•Utilize an interpreter.
Visual Impairments
Causes
•Disease
•Congenital conditions
•Infection
•Degenerative disorders
When approaching a service dog, do not pet the dog or disturb it while it is
in its harness.
Individuals who are visually impaired can maintain active, independent
lives.
Speech Impairments
Types of Speech Impairments
•Language disorders
•Articulation disorders
•Voice production disorders
•Fluency disorders
Accommodations for Speech Impairments
•Never assume the person lacks intelligence.
•Form questions that require short, direct answers.
•Never pretend to understand when you don’t.
•Let the patient write answers to questions.
Obesity
•40% of people in the US are obese.
•Excess weight can exacerbate the complaint for which you were called.
•Obesity can lead to many serious medical conditions.
Accommodations for Obese Patients
•Don’t dismiss signs or symptoms, such as shortness of breath, as being a
result of obesity.
•Adipose tissue presents an obstruction—EKG electrodes may need to be
placed on the arms and legs.
•Do not compromise your health or safety—ask for assistance when lifting
or moving a patient.
Paralysis
•The patient may have a home ventilator; be sure to keep the airway clear
and patent.
•If the patient is in halo traction, be sure to stabilize the traction before
transport.
•Be aware of other assistive devices— colostomy, canes, wheelchairs,
etc.
Developmental Disabilities
Developmentally disabled people may have trouble communicating, but
can often still understand what you say.
Remember that a person with a developmental disability can recognize
body language, tone, and disrespect just like anyone else. Treat them as
you would any other patient.
Developmental Disabilities
•Down Syndrome
•Fetal Alcohol Syndrome (FAS)
Pathological Challenges
•Arthritis
•Cancer
•Cerebral palsy
•Cystic fibrosis
•Multiple sclerosis
•Muscular dystrophy
•Poliomyelitis
•Previous head injury
•Spina bifida
•Myasthenia gravis
Rheumatoid arthritis causes joints to become painful and deformed.
Take every effort to protect cancer patients from infection. Keep a mask on
yourself and the patient during transport and during transfer at the
hospital.
Patients with multiple sclerosis and muscular dystrophy may use a cane to
aid ambulation. Be sure to take such devices with you on the ambulance.
Other Challenges
•Culturally diverse patients
•Terminally ill patients
•Patients with communicable diseases
•Financial challenges
United States society is becoming diverse, with the largest number of
immigrants coming from Asia and Latin America.
If a patient refuses care because of cultural or religious beliefs, be sure to
have the patient sign a Refusal of Treatment and Transportation form.
Financial Challenges
•Treat the patient, not the financial condition the patient is in.
Homeless people sometimes refuse care, thinking they cannot afford to
pay the medical bills. Become familiar with public hospitals and clinics that
provide services to the needy.