HOME CARE Cueto, Cunanan, Dadgardoust, Daguman, Damo, David H.L., David H.A., De Guzman J. , De Guzman R., De Leon, De Mesa, De Vera, Dela Cruz C., Dela Cruz F., Dela Cruz I., Dela Rosa, H., Delos Santos K.
Home Care • Provision of comprehensive health services to individuals and families in their own residence -promote, maintaine or restore health - Minimize the effect of illness and disability • Being prepared to become a member of the team caring for a chronically-ill or terminally-ill patient at home • More people-oriented
Services Offered in a Home Care Program • Medical Care • Rehabilitation • Counseling and health education • Wellness program • Diagnostic and therapeutic procedures • Nursing care • Spiritual care • Support group • Community resources • Transportation • Bereavement and respite care • First aid
Therapeutic Procedures Transferred at Home • Parenteral nutrition • Home enteral nutrition (nasogastric tube) • Intravenous antibiotics • Blood transfusions • Respiratory therapy • Renal and peritoneal dialysis
Home care services must be able to provide comfortable transition to home, maintenance of optimal clinical condition, ongoing health education and reinforcement of learning and continuity of care
Role of the Physician • Manager • Acquisition of appropriate home care assessment skills • Assessment of the adequacy of family caregivers and resources • Knowledge of community resources • Knowledge of home care technology • Integration of home and hospital care for patients • Ability to lead the home care team.
Multifaceted • Assessment and preparation of both patient and home environment – facilitate safest and smoothest transition
Sharing information about diagnosis being considered • Discussion of treatment plans and therapeutic options • Assessment includes: • Evaluation of physical conditions • Functioning of extremities • Sensory components • Excretory functions • Social factors
Prior to discharge, physical functioning must be enhanced by: • Elimination unnecessary bed rest • Physical activity must be encouraged • Caregivers (trained) • Safety measures • Careful planning of mobility for bathroom, doors, and stairs
a. Get manpower • Home care team consists of: • Primary care physician • Nurse • Therapist • Social worker • Volunteers • Effective • Cost-saving manner to the patient
b. Train staff • Assess hazards in the home • Conduct functional assessment • Monitor medications • Assess caregivers
c. Prepare a home care program • Includes the various services offered • mechanics of implementation • Set policies • Issues on reimbursement or fees
d. Establish networking and linkages • Help people deal with health and social problems • Establish good lines of communication (agencies, communities, etc) • Awareness of what they offer
e. Implement the program • Diagnosis and prognosis should be clear • Verify if the patient & family is informed about the referral • Clarifications: Call the attending physician • Meet and establish rapport, know their expectations, Do goal setting. • Schedule-frequency of visits • Checklist of gadgets and equipments • Financial agreement
f. Evaluate the program • Monthly health management meeting • Determine if the planned care is effectively achieving its expected outcome • Adjustments to be done
Guidelines for Home Visit • Preparation • Planning • Coordination
Guidelines for Home Visit Prior to home care: • Patient selection • Admission criteria • Review medical records – goal for a patient • Take notes, form questions, make hypothesis • Schedule visit
Guidelines for Home Visit • Prepare a home care plan • Medical • Psychosocial • Wellness • Economic • Environmental • Including short and long term goals for the patient and his family
Guidelines for Home Visit During the visit: • Establish rapport • Brief review of medical history • Exploration of psychosocial issues • Living conditions • Select a primary caregiver • appraise his capabilities
Guidelines for Home Visit During post-visit: • Write the report of visit • Problem list • Specific interventions performed • Schedule follow-up visits • Check compliance • Render continuing care • Refer to other disciplines and coordinate with them, if needed.
NGT (Nasogastric Tube) Insertion Source: http://emprocedures.com/ngt
NGT (Nasogastric Tube) Insertion 1. Gloves, protective gown, and face shield2. Nasogastric tube3. 2% lidocaine jelly4. Phenylephrine nasal spray 5. Atomized lidocaine or benzocaine spray6. Cup of water with straw 7. Emesis basin8. Towels, chux9. 60cc catheter tip syringe10. Stethoscope11. Tape12. Suction Source: http://emprocedures.com/ngt
NGT (Nasogastric Tube) Insertion INDICATIONS: • Aspiration of stomach contents for either diagnostic or therapeutic reasons • Feeding • Administration of therapeutic substances Source: The Filipino Physician Today, 2nd Edition, Maglonzo
CONTRAINDICATIONS: • Esophageal strictures • Facial fracture • Comatose patients with unprotected airways • Penetrating cervical wounds Source: The Filipino Physician Today, 2nd Edition, Maglonzo
Mechanical Ventilation • Indication: respiratory failure • Recommendations • VT = 10-15 mL/kg • Rate = 60-80 breaths/min • FiO2 = 0.40 • Ventilator mode: assisted control • Inspiratory flow = 50% • Peak pressure = 50 cm H2O • I:E ratio = 1:2 • Humidifier temperature = 35˚C
3. Tracheostomy Tube Suctioning and Cleaning • Tracheostomy tube consists of: inner canula, obturator, ties and fenestrations • Remove accumulated secretions to: • facilitate patient comfort • increase respiratory efficiency • decrease risk of complete airway obstruction • decrease the risk of infection • Clean the inner cannula - done twice a day - done by immersing it in hydrogen peroxide and then rinse with normal saline • Clean tracheostomy site with sterile cotton buds and normal saline • Replace soiled ties
Catheter Insertion Female Catheterization • Half the catheter must be inserted before inflating the balloon. • Place it in the urethral meatus. • From the urethral meatus, catheter advances towards the bladder as it proceeds in a slightly upward direction.
Catheter Insertion Male Catheterization • Insert at least 24cm before inflating the balloon. • Place the distal urethra in a slight stretch straight up to straighten the urethra. • Catheter then needs only a single curve on its way to the bladder.
Intravenous (IV) Medications • enter the patient’s bloodstream directly by way of a vein • Appropriate when: • rapid effect is required • Medications are too irritating to tissues to be given by other routes
Take note! • Assess caregiver’s eyesight & manual dexterity • Check appearance of medication and expiration date • Know which medications are unsuitable for IV administration • Observe patients for any adverse reactions
Home CareIV Infusion • For shortened hospital stays and the need to cut costs • Peripheral IV lines are used for the maintenance of fluid balance, administration of medications and nutrition. • The butterfly or catheter set may be used. Then it is connected to the tubing of the intravenous system.
Home CareIV Infusion • Permanent access • Long-term or home parenteral nutrition • Achieved by placement of a catheter with a subcutaneous part for access, by tunneling a catheter w/ a substantial subcutaneous length, or threading a long catheter through the basilic or cephalic vein into the SVC. • Temporary/ Short-term access • Achieved w/ 16- gauge, percutaneous catheter inserted into a subclavian/ IJV and threaded into the SVC
Nursing Care • Includes: • Positioning and moving the patient in bed • Perineal care • Oral care • Bed bath • Transfers
Nursing care Positioning and moving the patient in bed
Nursing Care Perineal care Oral Care
Nursing Care Bed Bath
Nursing Care Patient transfers
Immunizations • Most cost-effective form of disease control and the only form effective against many viruses • 2 types: • Active immunization occurs by administration of antigen, and requires an immune response. • Passive immunization occurs by transfer of preformed immunoglobulin. • “Booster” immunizations generate secondary responses and increase the strength of immunological memory. • Home vaccination are provided by physicians themselves, including a pre-assessment • Several factors needed to be considered before any patient is vaccinated: susceptibility of the patient, the risk of exposure to the disease, the risk from the disease, and the benefits and risks of the immunization.
Wound Dressing • One of the most common services provided • Wounds that are difficult to heal, usually because of underlying disease processes, anemia, poor nutrition, wound contamination, chemical irritants and other factors • Chronic wounds: basic wound care including frequency of dressing change, type of dressing used, cleaning solutions, and topical medications, is generally determined by the physician • Wound treatment and management include the following: • Prevention of further tissue destruction • Prevention of infection • Planning treatments as appropriate for the type of wound, condition and size of the wound
Lab Screening • Yearly physical examination and home laboratory screening for undetected diseases at the confines of your home • Complete with interpretation by a fully licensed physician • Cholesterol screening, Blood pressure screening, Obesity screening, Diabetes mellitus screening • Cancer screening tests
Ancillary Procedures Mobile x-rays Ultrasound
Caregiver Training • Modules are designed to train family members, informal household carers, and caregivers on the proper management of patients • Treatment plan that addresses needs of caregiver and the patient. Identification of caregiver burn-out or stress.
Issues in Home Care • LEGAL ISSUES • Home care policies must be properly drafted to avoid medicolegal risk • Includes documentation of all examinations, conversations and care rendered • Constant surveillance and attention to quality of care are the best preventive measures
Ethical Issues • There must be an informed consent • All risks regarding the procedure must be explained to the patient • There must be an agreement before a procedure can be started • If the patient is not competent to make a decision, the guardian or any family member can give the consent
Financial Issues • The Philippine Health Care Insurance System does not have any provisions for reimbursement in the home care setting. • Before entering the home care, the patient’s family should be informed regarding the financial agreement.
Legalities of Home Care • legal documents and formalities for completion • Done ASAP • Include the person/patient involve and his/her family in the decision making • Only a very close friend or family member with no conflicting motives should be given these powers.