Home Health Flashcards
Home/ Alternate Site Care
• Goals of Home/Alternate Site Care
- optimum level of patient function
- Educate patients and caregivers
- Administer diagnostic and therapeutic services
- manage disease
- Increase survival
Objectives of Home/ Alternate Site Care
• Support and maintain life
• Improve physical, emotional, social well-being of patient
• Promote patient and family self-sufficiency
• Ensure cost-effective delivery of care(being@ home less expensive than hospital stay)
Standards
• Government Laws & Regulations
- Majority of patients on Medicare or Medicaid
- State health departments conduct surveys
• Two types of care
- Equipment management care - NO hands on
- Clinical respiratory services - if any assessment
EDUCATION, monitoring services provided
Discharge to Home/ Alternate Site
• Supplies and equipment procured from DME
(Durable Medical Equipment provider)
- 24/7 coverage
- Home instruction and follow-up by RT
Site Assessment
• Access - getting in and out of home
• Wheelchair mobility
- Doorways, carpet, bathrooms
• Electrical power supply
- Grounded outlets
• Heating ventilation
• General cleanliness of site
- Lack of vermin or rodents
- Screens to keep out flies and mosquitos
Oxygen Therapy
• Up to 800,000 patients have home oxygen
• Oxygen improves survival and quality of life
• Prescription/care plan - based on documented hypoxemia
- Flow rate/FiO2, frequency of use, duration of need, diagnosis, laboratory evidence…ABG or pulse oximetry… (evidence of need not performed by DME company)
Certificate of Medical Necessity for Home Oxygen (CME)
• Qualifying criteria-(ABG, overnight pulse oximetry)
- Pa02 ≤ 55 mmHg or Sp02 ≤ 88%
• If oxygen evidence from hospitalization, needs to be repeated after 1 to 3 months to determine continued need
Oxygen System
• Three different oxygen systems
- Which system used is determined by:
• How ambulatory patient is
• Reimbursement
• Availability
• Duration of daily usage
Compressed Oxygen Cylinders
• C,D, E for ambulation (also smaller cylinders M6 etc)
- C weighs about 6 ½ pounds
- D weighs about 9 ½ pounds
• E,H/K for back-up to liquid or concentrator in home
• Use regulator for pressure reduction and flowmeter
• If we add humidity - use distilled water
• Problem - no alarm to indicate when cylinder is empty/kinked
• No batteries or electric needed, will always work
Liquid Oxygen System
• Maximum flow usually 5 to 8 LPM, but some can go to 15 LPM
• Large stationary Unit
- Storage bottle suspended within an insulated vacuum
- Contains equivalent of two K cylinders
- Last from 6 to 11 days when full depending on brand name, size, and usage
• Portable Unit
- Provides up to 8 hours at 2LPM
- Weighs between 5 and 14 pounds when full
- Must use gloves when filling
Oxygen Concentrator
• Three types
- Stationary
- Ones that fill compressed gas systems
- Portable concentrators
• Electrically powered stationary concentrator in home - if runs 24 hours/day will increase electric bill by 5 to 10%
Oxygen Concentrator
Flow Rates
• Separates oxygen from room air by passing through molecular sieves
• Not 100% oxygen, % decreases as flow rates increase or if >50ft tubing
- 94 to 95% at 1 to 2 LPM
- 85 to 93% at 3 to 5 LPM
- Most are limited to 5LPM; must run 2 in tandem to get higher flows when needed
Oxygen Precautions
• Education - very important
• No smoking/candles/close to gas stove, away from wall
• Liter flow is prescribed by physician - DO NOT ADJUST!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!!!!!!!!!
• Emergency or back-up supply of tanks for liquid and concentrators
• If concentrator used, notify local power company
• Tanks secured in well ventilated area
• Never use grease or oil on any oxygen supply system
• Post an oxygen in use/no smoking sign
• Check connections regularly and change hoses/NC as needed-teach about alarms on stationary unit
Maintenance
• Concentrators
- Filters cleaned weekly changed monthly
- Monthly
• Checked FiO2 and flow accuracy
• Must deliver at least 85% at 4LPM or machine switched out/serviced
- Humidifiers
• Filled as necessary-distilled water-check level daily
• Cleaned weekly or more often if patient has an infection
• Make sure lids on properly(crossthread), check for leaks, cracks, empty H20 trap for condensate
Oxygen Delivery Devices
• Cannula
- Most common
- Tubing up to 50ft in length
• Venti mask
- Not accurate FiO2 due to concentrator not delivering
100% 02
• Reservoir Masks (partial/non rebreathers)
- Need to use 2 systems in tandem to get adequate flow-again not accurate
• Oxy mask- open oxygen mask
- Less room for error if mask is needed in home
Conserving Device for Portable O2
• Uses flow sensor and valve to coordinate delivery of oxygen to patient with patient inspiratory effort
• Special regulator for tanks
• Patient must have sufficient inspiratory force to trigger sensor (pulse dose)
Humidification
• For any home system of oxygen-should use distilled water or boil own water
Nebulizer Therapy in the Home
• Must be ordered by a physician
• Compressor units
- Electrically powered - small air compressor
• Cleaning of neb circuits - daily
- Wash in mild soap and water, rinse
- Soak in one part white vinegar to 3 parts distilled water (once a week) wash, rinse
- Air dry
Nasal CPAP/BiPAP
• Primarily used for treatment of sleep apnea
• BiPAP can be used for non-invasive ventilation for patients who don’t need continuous ventilation or who have central sleep apnea
• CPAP - Continuous Positive Airway Pressure
- Most often used for obstructive sleep apnea
• BiPAP - Bilevel Positive Airway Pressure
- IPAP = inspiratory pressure level
- EPAP = expiratory pressure level
Problems Associated with CPAP
• Skin irritation
- Redness on face or around nose
- Fix - loosen straps and/or clean mask, try different mask or use moleskin/gel
• Conjunctivitis
- Caused by air leaking around bridge of nose into eyes
- Fix - correct adjustment of mask or gel overlay
• Epistaxis, Nasal dryness, burning, congestion
- Drying of mucosa
- Humidifiers, room vaporizers, chin strap
• Inability to reach set pressures
- Inadequate flow or system leaks
- Incorrect size/fit of mask
- Dirty filters - need to clean weekly
Determination of Proper Level
For CPAP
• Polysomonography with CPAP titration
- Sleep study-done in lab for titration of pressure
- Apnea Hypopnea Index (AHI) >5 abnormal
- Respiratory Disturbance Level
• Mild 1-15
• Moderate 15-30
• Severe >30
• Qualification requires level of 15 without other symptoms, or >5 with other symptoms.
Determination of Proper Level
CPAP AND AUTO PAP
• CPAP titration with pulse oximetry-in lab to determine proper level of pressure needed to maintain airflow/airways patent
• Auto-PAP
- Machine senses apneas and sets appropriate CPAP level automatically and fluctuates with patient during sleep. MD sets a high and low pressure range (standard is 4-20 cmH20)
- Lower settings are usually achieved which leads to better compliance-machine only uses amount of pressure needed to keep airways open
Ventilators in the Home Care Setting
• Ventilators in home can be used invasive or non invasive-mask interface
• Three categories of patients
- Patient requires intensive, sophisticated care with > 20 hours/day on vent (trach pt normally)
• High spinal cord injury, severe COPD, late stage advanced ALS or muscular dystrophy, paralysis
• Patients who have persistent respiratory insufficiency.
- Patient can provide some of own care; may only required ventilation at night or part of the time
• COPD, Multiple Sclerosis, Diaphragmatic paralysis
• Patients with significant CO2 retention, nocturnal hypoventilation or oxygen desaturation(stable but slowly progressive respiratory failure)
- Terminally ill patient returning home at patient/family request - advanced lung cancer or end of life
Profile of ideal Candidate
• Stable on ventilator settings
- ABG’s compensated, patient responding well
• FiO2 stable at 40% or less
- Due to capabilities of home oxygen and if pt requires higher Fi02 then… not stable
• Minimal use of cardiac drugs
• No current infections, pleural effusions, atelectasis
- Reasoning is-if patient is currently experiencing issues then respiratory status can change or deteriorate quickly
Primary Care Givers
• Discharge planning required for patient to go home on mechanical ventilation-team approach with good communication is key!
• Requires preparation time to ensure home environment is appropriate for this level care and ensure caregivers are educated/trained.
• Family-24/7 undertaking
- Minimum 2 persons-able to demonstrate, explain proper use, troubleshoot, and do basic maintenance. Must be trainable
• Encourage use of multiple care givers to prevent burn-out, sleep deprivation, malnutrition
• Readiness to discharge
- Hospital or facility will do a minimum 24 hour period in which caregivers perform all care without help from staff as a final indicator or readiness to go home
- Have “checkoffs” essentially as documentation that family has been trained/educated
Caregiver Training
• Provide information-disease process, medications
• Pulmonary hygiene measures
- Importance of adequate hydration
- CPT (percussion, vibration, turning, etc)
- Suctioning
- Trach care
• Usage instruction, upkeep and care of equipment
• Nutrition (enteral training done by nursing)
• Physical therapy
• How to respond to emergency-CPR training strongly encouraged
Choosing a Ventilator
• Must be electrically powered with battery back-up-always keep plugged in if possible when home
• Must be portable
• Easy to operate: too many options=confusion
• Loss of power & patient disconnect alarms are essential! Alarms are set to maintain a balance between safety and nuisance. Alarms are set and tested per patient. Invasive vent will always have set alarms!! Non-invasive will be set but… made less sensitive (very high or very low) because device is not life sustaining-this helps keep patient/family from being awakened all night
Event Monitoring at Home
• Most common cause of death after neonatal period up to 1 year old is SIDS (Sudden Infant
Death Syndrome)
• Most common event monitoring in home setting for infants is apnea monitoring
• For infants: setup to alarm if cessation of breathing >20 seconds (10 sec in adults) can be accompanied by bradycardia HR <80 bpm, Sp02 <90% or cyanosis
Event Monitoring at Home
• Infants at risk:
- Symptomatic infants - have experienced apnea of some sort (witnessed by parent or hospital) causes include:
• Sleep apnea, feeding-induced apnea, GERD-induced apnea, seizure-induced apnea, central apnea, apnea of prematurity
• Infant requiring supplemental oxygen and/or mechanical ventilation, infant with tracheostomy or anatomic abnormalities-vulnerable to airway compromise
• Have neurologic or metabolic disorders affecting respiratory control, newborns weaning off narcotics
• BRUE (brief resolved unexpected event)
- Siblings of SIDS infants
• Will be monitored until they are 1 month older than the age that their earlier sibling died
Risk Factors SIDs
• Peak age is 2-4 months; however range is 2 weeks to 1 year
• Gender: male more than females
• Season: more common in winter
• Economic level: more common in poorer class
• Birth weight: more common in low-birth weight infants
• Maternal age - highest risk with mother < 20 years old
• Bronchopulmonary dysplasia and laryngomalacia
• Normally done on any preemie
How Apnea Monitors Work
RT will go to hospital for setup, instruction, proper use, troubleshooting. Also demonstrate CPR
• EKG - senses electrical depolarization and repolarization of heart
• Respirations - impedance pneumograph detects respiratory rate as the thoracic case changes size during inspiration and expiration
• Audio and visual indicators: some monitors also include pulse ox pleth
• Pneumogram - 12 or 24 hour recording of EKG and respiratory wave form
• Uses belt around chest with sticky pads
• Considered medically necessary until infant is event free for 6 weeks-avg monitoring duration is about 3 months
• Apnea monitors-monitor and record vital information
How Apnea Monitors Work
Other Points
- Keep a log
- Stress to parent:
• Must respond to EVERY alarm quickly!
• Observe infant for respiratory effort, color, and activity- may be false alarm-probe off or loose, low battery, if baby is mobile/movement may interfere
• If true alarm-stimulate baby vigorously! Flick feet, rub back and arms/legs
• Other ways to protect from apneas/SIDS-put baby on back, use firm crib mattress, keep pillows and stuffed animals out of bed
- Discontinuance - after infant demonstrates negative pneumogram-no events detected
