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Prevention and Long Term Respiratory Care > Home Health > Flashcards

Home Health Flashcards

1
Q

Home/ Alternate Site Care

A

• Goals of Home/Alternate Site Care

  • Achieve optimum level of patient function
  • Educate patients and caregivers
  • Administer diagnostic and therapeutic services
  • Conduct disease management and promote health
  • Increase survival
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2
Q

Objectives of Home/ Alternate Site Care

A

• 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)

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3
Q

Standards

A

• 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

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4
Q

Discharge to Home/ Alternate Site

A

• Supplies and equipment procured from DME

(Durable Medical Equipment provider)

  • 24/7 coverage
  • Home instruction and follow-up by RT
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5
Q

Site Assessment

A

• 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
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6
Q

Oxygen Therapy

A

• 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)
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7
Q

Certificate of Medical Necessity for Home Oxygen (CME)

A

• 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

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8
Q

Oxygen System

A

• Three different oxygen systems

  • Which system used is determined by:

• How ambulatory patient is

• Reimbursement

• Availability

• Duration of daily usage

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9
Q

Compressed Oxygen Cylinders

A

• 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

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10
Q

Liquid Oxygen System

A

• 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
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11
Q

Oxygen Concentrator

A

• 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%

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12
Q

Oxygen Concentrator

Flow Rates

A

• 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
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13
Q

Oxygen Precautions

A 
 • 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

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14
Q

Maintenance

A

• 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

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15
Q

Oxygen Delivery Devices

A

• 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
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16
Q

Conserving Device for Portable O2

A 
 • 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)

17
Q

Humidification

A

• For any home system of oxygen-should use distilled water or boil own water

18
Q

Nebulizer Therapy in the Home

A

• 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
19
Q

Nasal CPAP/BiPAP

A

• 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
20
Q

Problems Associated with CPAP

A

• 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
21
Q

Determination of Proper Level

A

• 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.

22
Q

Determination of Proper Level

CPAP AND AUTO PAP

A 
 • 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
23
Q

Ventilators in the Home Care Setting

A 
 • 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
24
Q

Profile of ideal Candidate

A

• 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
25
Q

Primary Care Givers

A

• 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
26
Q

Caregiver Training

A

• 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

27
Q

Choosing a Ventilator

A

• 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

28
Q

Event Monitoring at Home

A

• 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

29
Q

Event Monitoring at Home

• Infants at risk:

A
  • 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

30
Q

Risk Factors SIDs

A

• 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

31
Q

How Apnea Monitors Work

A

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

32
Q

How Apnea Monitors Work

Other Points

A
  • 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

Prevention and Long Term Respiratory Care (7 decks)

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