Midterm #2 Flashcards
What is continuum of care?
integrated system of care
*involves services & integrating mechanisms that guide people over time
physical/mental/social services with all levels of intensity
3 major forces driving continuum of care
1) Decreased length of hospital stay
2) Movement towards more home care/community care e.g. increased family involvement in care
3) Regionalization
2 goals of continuum of care
to provide seamless care from hospital to home
(pt/family educated on what to expect)
to maintain quality/continuity of patient care in different environments
what is seamless care
is a smooth and safe transition of a patient from the hospital to the home.
what is continuity of patient care?
personalized, continuous care that begins at point of entry into HC system until problems/needs resolved
how to ensure continuity of patient care
interpersonal/interdisciplinary practice
collaboration/communication
focus on patient/family
Regionalization history
emerged in 1993 in New Directions for Health BC
1996: downsized from 20 to 11
2002: downsized to 6 (5 geographical, 1 provincial)
5 goals of regionalization
to integrate continuum of care concept
looks at unique health needs of each community
to promote collaboration/communication between agencies
to ensure patient-centered care via interdisciplinary teams
to reduce agency centeredness (decreasing cost/resource waste)
How many stages are in discharge planning for nurses?
When does it begin?
4 stages
Begins upon admission
Stage 1
The nurses role at first point of contact with hospital:
Involves:
admission assessment
full dimensional: home environment, social supports, preferences
getting to know patient
Stage 2
Nurse as the patient advocate
Involves:
other HCP (referrals, family conference)
initial d/c date is decided
Stage 3
Getting ready to go home
Nurse contacts community team
Stage 4
Transition back home or to another facility
Involves other services: home health, patient, family, PT, OT etc.
5 components of an effective discharge
1) occurs in stages
2) Inter-professional collaboration
3) Good timing and receipt of information
4) Clear communication (pt, family, PT, community resources)
5) “Close the loop” and “fill in the picture”
5 Barriers to discharge planning
Time Cost Lack of motivation Patient being overwhelmed Communication barriers
3 benefits to discharge planning for the patient/HCP
patient:
Improved quality of care -> improved outcome
Decreased hospital stays
Improved pt/family fears/anxiety
HCP:
Increased awareness of resources
Decreased frustration
More efficient use of professional time
4 key objectives to delivery of home care*
1) Provide the support necessary for clients to remain in their own homes
2) Provide at-home services to clients who would otherwise require admission to hospital
3) Provide assisted living and residential care services to clients who can no longer be effectively supported in their own homes
4) Provide End of Life Care
Home health philosophy
2 points
promote well-being, dignity, independence of both pt. & family
to offer support (not replace) and complement care provided by clients/families/community services
4 Principles guiding home care philosophy
Ensure informed decision making
Clients have right to make own care decisions including right to ‘live at risk’
Care will *supplement/complement but NOT replace client’s efforts to care for self *
HHC services will promote the well-being, dignity and independence of clients
3 triggers for home health:
D/C from hospital r/t acute event i.e. CVA
Worsening of chronic health condition requiring more care than available in home setting
Person with ongoing difficult health issues finding it more and more difficult to care for themselves at home.
Who can make a referral for home care
Clients Family Physicians Concerned neighbours/friends The hospital
All referrals go through HHC office Intake nurse
Home health intake process
Community vs. Hospital
Within Community:
All referral sent to HHC office intake nurse
Nurse screen referral & prioritizes it (1-3)
Nurse forwards referral to appropriate discipline
Within Hospital:
In hospital referalls made online
The Hospital Liaison Nurse will respond to discharge planning needs that arise
Home health professionals involve..
Case Managers
Liaison Nurse ( formerly known as Hospital Case Managers)
Home Care Nurses(RNs & LPNs)
Social Worker/Palliative Social Worker
Rehabilitation Therapists (OT/PT)
5 steps to case management?
- comprehensive assessment- I.D. strengths/weaknesses
- develop individualized care plan
- arrange various services
- monitor ongoing client needs
- re-assess/review care plan
purpose of long-term care
to assist adults with chronic health related issues to maintain optimal level of independent functioning
3 common health care resources that case managers use
Respite/Respite Beds
Community Health Workers
Residential Care
3 common community resources that case managers use
Family/friend support & other support groups
Life Line
Shopping Programs
7 functions of home care RNs
*Coordinate care
Assess
Teach
Support/counsel
Direct Care
Referrals
End of Life Care
home care LPN functions
Simple dressings
DOTs ( e.g..medication management, catheter care, eye drops, ostomy care)
What do rehab therapists do?
Includes OT and PT
Assesses: safety in home equipment needs mobility/adaptive aids falls prevention post surgical therapy
What do social workers do?
Assisting with complex care needs of clients including:
financial assistance
housing issues
drug and alcohol issues
abuse issues
Criteria for costs of home health
Which program they are on
i.e. if the client is palliative they receive 6 months free service.
If the client is coming out of hospital they will likely get 2 weeks free
If the client is to receive services for an extended time then the charge is based on a financial assessment which will be made by HHC Case Manager.
Who is eligible to receive home care servies?
- Canadian Citizen/landed immigrant status
- BC residency
- Require care following D/C from hospital, care at home rather than hospital, or care because of a terminal illness
- Have a local doctor
We do not serve:
Persons whose primary handicap is developmental disability.
Who is eligible for subsidized services? (financial support)
Under 19 years of age
Lived in BC for 3 months
Canadian citizen or permanent resident status*
Unable to function independently d/t chronicity or terminal illness
what are DOT’s?
Delegation of tasks
DOT’s are often for medication management, catheter care, eye drops, ostomy care
What is cognition?
“PR-JIM”
Cognition refers to a system of interrelated abilities that allows us to be aware of ourselves/our surroundings
Perception Reasoning Judgment Intuition Memory
Types of cognitive disorders
Dementia
Delirium
Depression
What are amnestic disorders?
memory impairment not related to cognitive disorders
e.g. exposure to environmental toxins
substance abuse
head trauma
What is delirium?
An acute cognitive impairment
reversible
symptoms may differ
3 causes of delirium?
Medical conditions: acute crisis, Infections, F&E imbalances, hypoxia/ischemia
Medications & substances (surgical sedatives)
Elderly (65-75)
Unknown factors
4 types of delirium
hypoactive/mild (Lethargic/depressed, fatigued/drowsiness- highest mortality rate)
hypoactive/severe (more intense symptoms)
hyperactive (Psychomotor agitation, aroused/restless)
Mixed
Delirium interventions
Bed alarm
one-to-one
“soft” restraints (e.g. pelvic restraints, wrist constraints)
What is dementia
Global, chronic cognitive impairment
irreversible & progressive
Symptoms are the same no matter what the cause
5 types of dementia
Alzheimer’s vascular dementia dementias 2o to medical condition dementias 2o to substance uses dementias with mixed / unknown causes
*different dementias effect different areas of brain
Causes of dementia
anything that damages brain cells- depends on type of dementia
Multiple theories (plaques, tangles, cell death, genetics)
not a disease- but can occur as a result of diseases (CVA, Parkinson’s, head trauma)
Hippocampus function
formation of memories (long-term)
shrinks in dementia
Parietal lobe function
sensation & sensory processing
Occipital lobe function
visual reception and interpretation
Cerebellum function
movement
muscle coord
Temporal lobe function
Language
Learning
Short-term memory
Frontal lobe function
Thought processing
Language output
Programming of activities
Prioritization
Personality
Bheaviour
Difference between delirium/dementia/depression
** see chart
6 Risk factors for delirium
Age
Admission to new facility
pre-existing dementia
poly-pharmacy
changes in vitals
pain
Diagnostics for delirium
Note cognitive changes
review patient history
assessment
S&S of delirium
changes in:
A&O, focus, speech, language, memory
insomnia
social changes
fluctuating symptoms throughout the day.
3 priorities for delirium
Elimination or correction of underlying causes
Symptomatic measures e.g. treat cause of Delirium such as UTI
Supportive measures e.g. bring patient by nurses station
Interventions for delirium:
physiological/psych/social
physiological: assessment, labs, meds, safety checks, avoid anticholinergics
psychological: MSE, reduce stimuli, non pharmacological comfort measures e.g. pets, warm blankets
social: family roles, social supports, providing information
Why avoid anticholinergics with delirium
further depresses the CNS
Delirium prognosis
Reversible if treated
Often causes lasting complications e.g. higher risk of developing dementia
Risk factors for dementia
Age (65+)
genetics
Down’s syndrome/Parkinsons
Cardiac disease
Head trauma
lower socioeconomic status
lifestyle factors
exposure to viruses/environmental toxins
5 Diagnostics for Dementia
Aphasia: alterations in language/speech
Agnosia: failure to recognize/identify objects
Apraxia: impaired motor activity
Disturbance of executive functioning - Ability to think abstractly, plan, initiate, stop inappropriate behaviour
Significant decline in normal functioning
4 priorities with dementia
Delay cognitive decline
Attend to physical needs
Protect from harm
Support family members
Interventions for dementia
psych/physical/social
Physiological interventions:
Promote self-care, monitor activity, nutrition, bowel/bladder, sleep/wake cycle, PRN meds
Psychological interventions:
Validation, tools for memory enhancement (pictures, whiteboard),
Social interventions: encourage participation, alter environment, home visits, create a home-style atmosphere
Alzheimers
4 points
memory/ADL impairments
effects all areas of brain
more common in women
the younger the age, the more rapid/severe
Vascular dementia (3 points)
Symptoms dependent on area effected
Executive functioning goes early
Cerebrovascular lesions
Sudden onset & step wise progression
What medical conditions often result in dementia
AIDS
syphillis
Parkisons
Huntingdons
head trauma
hydrocephalus
meningitis
Substance induced dementia causes
drugs, alcohol, environmental toxins, Korsakoff’s
Types of mixed dementia
Lewy body, frontotemporal lobe dementia
What does cognitive assessments involve?
MMSE A&O (person,place,time) Attention span Speech Appearance (appropriateness)
Ask family questions
Compare to baseline/chart
How well they attend to ADL’s
Spatial recognition (unable to find front door)
What is poverty?
Material/social deprivation d/t political/public policies re: distribution of resources in the community
4 types of poverty
Absolute:
no resources to meet basic biological/physical needs
Relative:
standards/resources below average person
Low income cut-off line (LICO):
majority of income is spent on basic needs, strained compared to other average families
Core need:
Household falling below 1 or more standards: adequacy, suitability, affordability.
*Use 50% or more of TOTAL household income for rent
e.g. pay rent/bills or feed children
What does homelessness result in?
powerlessness
hopelessness
vulnerability
decreased resiliency
continuum of homelessness
from inadequate housing, to living in shelters, to absolute homelessness
Two categories of homelessness
Absolute (primary)
Relative (secondary)
What is absolute homelessness
Totally without shelter of any kind
Basic needs totally unmet
What is relative homelessness
Does not meet basic needs as defined by UN
protection from elements secure/personal safety Safe water/sanitation access to employment/education/health care affordable
4 types of homelessness
Chronic: long-term, engage in substance abuse, psychiatric problems
Periodic: temporary, leave home when tensions/pressures become intense
Temporary: result of crises from situational transition
At risk: too much of household income going to rent
Causes of homelessness
1) structural factors
2) personal factors
** see powerpoint for more specific
Structural factors resulting in homelessness
social safety-net cutbacks:
e.g. government policies/programs cut back on disability, EI
broader macro-economic & societal factors:
e.g. globalization, changed social contract, less job security, less affordable housing available
Personal factors resulting in homelessness
Morals (deserving poor vs. undeserving poor)…
leading to various discourses*
What are discourses
the way which society chooses to make sense of phenomenon
Types of discourses r/t homelessness
Neo-liberal
Conservatism
Neo-liberal discourses
Believe that government/state interferes with the operation of market/economy to provide benefits r/t welfare
Neo-liberal discourse history
1990- federal public policy changes
Chretien government withdrawal funding/involvement with affordable housing initiatives, more funding put towards business/trade
as a result increase in homelessness
Neo-conservatism discourse
Similar to neo-liberal discourse but adds moral tone by attributing blame to those who are poor (Campbell-BC, Klein-Alberta)
people living in poverty are responsible for themselves
other provinces express this more subtly via decreasing funding/not raising minimum wage
What does neo-conservative discourses result in
poor bashing
blaming the poor –> ostracism
disrespectful treatment
Types of discourses related to poverty
Moral underclass (MUD) Social Integrationist (SID) Redistributionist (RED)
MUD
believes that the underclass or socially excluded individuals are culturally different from mainstream
Impacts public policies re: social assistance minimum wage EI eligibility resulting in: difficult living conditions for those who rely on these services, "poor bashing" - stigmatization- adding psychological/social insult to the exisiting difficulties, become more dependent
SID
Believe in coercing non-working individuals into paid-labour
e.g. punitive workfare initiative programs across Canada
Hides issues of inequality of paid workers
e.g. ignores gender issues (men being paid more)
RED
Believe that poverty is caused by social exclusion
Believes that poverty can be reduced through benefit increases
Values un-paid work, and aims to increase power/resources
5 poverty/homeless theories
By choice/personality theory Social disengagement/disaffiliation theory Social disconnection theory Housing/poverty theory Poverty as social issue theory
3 social factors r/t poverty/homelessness
often are the breaking point resulting in homelessness
1) severe addiction/mental illness
2) Youth “aging out of care”
3) Family violence/social breakdown (women/youth)
What is a “harm reduction” approach
attempts to decrease the harms of illegal drugs
involves safety promotion, death/disability prevention, treating all individuals with respect/dignity/non-judgemental
What is insite
the only legal supervised drug injection site in North America
4 purposes of insite
- improve health of drug users: prevent overdose, drug transmission
- reduce harms associated with illegal drugs: discarded needles, crime
- increase access to social/health services by IV drug users
- reduce social/legal/incarceration costs associated with drug use
4 roles of outreach nurses
build relationship
primary nursing care
education
partnership & referrals to health/social systems
Examples of micro, meso, macro collaboration
READ ARTICLE (Insite)
Common homeless populations
adults
youth
sex-trade workers/MSWM
mentally ill
aboriginals
single parents (women & children)
5 common homeless health issues adults
psych episodes (as a result of medication lapses, chaotic lifestyle)
Infections- upper resp., TB
Impaired skin integrity: wound, abscess, cellulitis (as a result of poor injection technique, IV substance abuse etc.)
Scabies/lice/bed bugs
Malnutrition/dehydration/dental
3 common health issues in homeless youth
STD’s/HIV/HCV
anxiety/fear/insomnia
depression/suicidal ideation
4 health issues in homeless sex trade workers
STD’s/HIV/AIDS
unwanted pregnancies/unsafe abortions
GU infections/GI diseases
Risk-taking lifestyle
Rape