Vol.5-Ch.8 "Acute Intervention for the Chronic Care Patient"

Question 1

What are 4 reasons that home care has been increasing?

What are some reasons why home care is preferred?

Answer 1

4 reasons that home care has been increasing:

• Enactment of medicare in 1965
• Advent of health maintenance organizations and patient centered medical homes
• Improved Medical Tech
• Studies showing improved recovery rates and lower costs with the home care (These two are the 2 reasons why home care is preferred in the book)

Question 2

What are 5 common reasons for ALS intervention calls to Home Care Patients?

Answer 2

• Equipment failure
• Unexpected Complications
• Absence of a caregiver
• Need for transport
• Inability to operate a device

Question 3

What are some signs of infection (4) and sepsis (7)?

Answer 3

INFECTION: (mostly talks about infection at sites of surgically implanted drains or tubes)

• Redness/swelling
• Purulent discharge at the insertion site
• Warm skin at the insertion site
• Fever

SEPSIS: (remember on a cellular level infection is called cellulitis and if not controlled can lead to sepsis or septic shock)

• Redness at insertion site
• Fever
• AMS
• Poor skin color or turgor
• Signs of shock
• Vomiting
• Diarrhea

Question 4

What are 9 Typical Responses you may be called to for At Home Care problems?

Answer 4

• Airway Complications
• Respiratory Failure
• Cardiac Decompensation
• Alterations in Peripheral Circulation
• AMS
• GI/GU Crisis
• Infections and Sepsis
• Equipment Malfunctions
• Other Medical Disorders and Home Care Pts

Question 5

What are some common at home medical devices? (11x)

Answer 5

• Glucometers
• IV infusions and indwelling IV sites
• Nebulized and aerosolized med administrators
• Shunts, fistulas, and venous grafts
• O2 Concentrators, O2 tanks, and liquid O2 systems
• O2 masks and nebulizers
• Tracheostomy and home ventilators
• G-Tubes, colostomies, and urostomies
• Surgical drains
• Apnea or cardiac monitors, and pulse oximeters
• Wheelchairs, canes, and walkers

Question 6

What are a few things to be aware of when dealing with an at home patient?

Answer 6

They may have a physician they correspond with frequently and may have contacted them first. If so, find out what the doctor said to do and what the patient has already done.

If a physician is needed and on their way, but what the pt needs is out of your scope then your role is to be supportive. This can occur in situations of:

• Chemotherapy
• Pain Management
• Hospice Care

Question 7

What is the most effective intervention?

Answer 7

PREVENTION

William Haddon created 10 steps that can be used to protect both the medic in the line of duty and the pt at home.

1) Prevent the creation of a hazard to begin with
2) Reduce the amount of the hazard brought into existence
3) Prevent the release of the hazard that already exists
4) Modify the rate of distribution of the hazard from the source
5) Separate the hazard and that which is to be protected in both time and space
6) Separate the hazard and that which is to be protected by a barrier
7) Modify the basic qualities of the hazard
8) Make that which is to be protected more resistant to the hazard
9) Counter the damage already done by the hazard
10) Stabilize, repair, and rehabilitate the object of the damage

Question 8

What is “Patient Milieu”

Answer 8

I think it refers to the general quality of living for the patient and the quality of the devices used for at home care. This is something you should pay attention to and report to the proper people if needed to increase the pt living status

Question 9

What is an important consideration when assessing the AMS pt?

Answer 9

Remember to try to inquire if this is a normal AMS for the pt or if he is more altered than normal

Question 10

What is an important detail when dealing with a DNR or living will?

Answer 10

The purpose of them is to prevent unwanted treatment and invasion of the body when natural death or dying occurs.

So if the pt is still alive with say CHF you can still start a line, give nitro or diuretic, cpap, ect unless the will or will of the conscious pt specifically says not to.

Question 11

What type of restriction does COPD create in breathing?

Answer 11

All 3 diseases are outflow restrictive diseases causing an increase in CO2 and decrease in oxygenation

Keep in mind a pt can have up to all 3 at the same time which will make their respiratory system at best only be able to keep up with the minimum required oxygenation which means any stress to their systems can cause stress that requires an O2 supplement at least

Question 12

Bronchitis and Emphysema review

Answer 12

BRONCHITIS:

• the over production of mucus by the goblet cells in the lungs which leads to a narrowing of the bronchial passages.
• This often arises secondary to smoking but other typical traits is the “blue bloater” aesthetic. This is from the chronic poor oxygenation causing cyanosis and the fact that they are typically overweight pts

EMPHYSEMA:

• This is the stiffening and enlargement of alveoli, and this loss of elasticity and compliance requires higher pressures in the lung to facilitate gas exchange at the alveolar level.
• The patients are the “pink puffers” they are typically very frail because they spend so much caloric energy trying to breath, they are also barrel chested because of the chronic air entrapment in the lungs. They are pink because of the polycythemia secondary to the bodies response to low oxygenation (it thinks the problem is that there are not enough transport units or RBCs to carry O2 so it makes more than is actually needed)

BOTH:
- these patients will not be able to compensate for acute exacerbations and may present with wheezing, diminished lung sounds, use of accessory muscles, retractions, tripod positioning, and 2-to-3 word dyspnea.
- Some at home treatments you may expect to find include a vent using PEEP, CPAP, or BiPAP, O2, nebulizers or aerosolizers meds.
(***PEEP will be provided via a ET tube, while CPAP and BiPAP are administered using a mask)
- Some meds you can give that may be useful include: Nebulized beta2-specific agonist bronchodilators (albuterol or metaproterenol), IV or oral corticosteroids (Solu-Medrol), or nebulized anticholinergic (ipratropium)

Question 13

CHF often presents as a _____ problem?

Answer 13

CHF often presents as a respiratory problem?

Question 14

What is Cystic Fibrosis?

Answer 14

It is a genetic disease in which there is chronic and copious amounts of mucus production, inflammation of the small airways, hyperinflation of of the alveoli, chronic infections, and erosions of the pulmonary blood vessels secondary to infection.

It is an Exocrine disease that can cause other systemic problems such as GI disturbances, pancreatic disorders, and glucose intolerance.

The vigorous coughing can also lead to hemoptysis or a pneumothorax. The disease itself can also lead to Cor Pulmonale from chronic pulmonary hypertension.

Treatment often involves meds that aim to reduce mucus production and chest percussions (usually done by a mechanical vibrator)

Question 15

What is Bronchopulmonary Dysplasia (BPD)?

Answer 15

It is an ongoing need for mechanical ventilation or O2 in newborns who have been treated for respiratory distress of any cause. The pts may have failed to ween successfully away from the vent or O2 as this is a long process and cannot happen to quickly. Often the at home providers are told to ween infants to lower Intermittent Mandatory Ventilation (IMV).

These kids are prone to lower respiratory infections, especially viruses, and may need immediate hospitalization if signs increase

Pts with this problem can quickly develop pulmonary edema with fluid administration so ask the parents about their intake and if any diuretics are prescribed/used

Question 16

What are Neuromuscular Degenerative Diseases?

Answer 16

They are diseases that affect respiration through the degeneration of the muscles used for breathing. They include:
- Muscular Dystrophy:
A disorder in which the intracellular metabolism has a defect and causes the atrophy of muscles all over the body and is eventually replaced with fatty and connective tissue

• Poliomyelitis:
  a disease in which the motor neurons are destroyed or damaged leading to muscular atrophy, muscle weakness, and paralysis. This becomes lethal when it affects respiratory muscles but often it leaves the pt paralyzed in the legs. There is also post poliomyelitis in which years later destruction of the myelin sheath occurs causes further damage.
• Guillain-Barre syndrome:
  This is thought to be an autoimmune response to a viral infection that leads to muscle weakness or paralysis because of nerve demyelination. It often starts as a febrile episode with a respiratory or GI infection. The weakness often starts in distal extremities and moves towards the trunk when respiratory compromise becomes a major concern. The biggest sign that differentiates this from a spinal cord injury is the amount of motor involvement, BG causes much more motor function loss than sensory loss.
• Myasthenia Gravis:
  This is a breakdown of acetylcholine receptors at the neural junction that leaves nerve impulses dampened. It causes muscle weakness and often in proximal muscles like the respiratory ones

Question 17

What is sleep apnea and what causes it?

Answer 17

Sleep apnea is when you have chronic interruptions to your normal sleep cycle caused by a relaxation of the pharynx or lack of respiratory drive that decreases oxygen levels and causes your body to wake up in response.

The fall out of this problem is a risk of hypertension, cardiac arrhythmias, and chronic fatigue.

Question 18

What are the 3 types of home oxygen therapy you may run into?

Answer 18

• Oxygen Concentrators:
  These supply the lowest concentration of home oxygen. They extract O2 from the room and add to the flow received by the patient. They typically provide no more than 6lpm
• Oxygen Cylinders:
  These are used when a pt needs more than 6lpm of O2. These are the same as what is used in EMS
• Liquid O2:
  For pts who require constant O2. This allows pts to fill their O2 cylinders that they may take and use outside the home

Question 19

What are some complications that may arise from a Tracheostomy airway? (5x)

Answer 19

• The most common problem faced is a blockage from either mucus or a dislodged cannula
• B/c it negates a lot of the natural filtering the body does, they are more prone to respiratory infections
• A bulb used to hold in place may be aired up to much causes necrosis of the tissues
• The cannula may be the wrong size
• Tissues may be dried out by the O2 causing damage or bleeding

Question 20

Can yo intubate a stoma?

Answer 20

Yes! If the pt is having a problem that you cannot figure out yo may have to place an ET tube through the stoma or through the outer cannula if in place just 1-2cm inside the trachea and inflate the cuff to hold in place

Question 21

Positive VS Negative pressure ventilators

Answer 21

Positive Pressure Ventilators:
- Recommended form of vent for acute respiratory disorders. It pushes air into the lungs through either a face mask, nasal mask, or tracheostomy .

Negative Pressure Ventilators:
- Apply negative pressure to the chest b/c it requires a rigid structure to support the vacuum. When they expand they pull on the chest causing it to expand and allow air to flow into the lungs. The iron lung is the best example of this. Another common at home one is the Poncho Wrap which is a suit that is sealed at all openings, this is mostly used at night.

Question 22

PEEP VS CPAP VS BiPAP

Answer 22

PEEP:
Positive End Expiratory Pressure is used to keep the alveoli open by adding back pressure at the end of an exhale.

CPAP:
Continuous Positive Airway Pressure is used to keep pharyngeal structures from collapsing at the end of the breath. Most patient use this for sleep apnea and use a nasal mask, but keep in mind in order for the nasal mask to work the pt must sleep with their mouth CLOSED. The biggest difference between CPAP and PEEP is that CPAP uses a mask where as PEEP uses an ET tube.

BiPAP:
Bilevel Positive Airway Pressure provides 2 levels of pressure, one on inspiration and one on exhalation.

Question 23

What are the 4 main types of Vascular Access Devices (VADs)?

Answer 23

• Hickman, Broviac, and Groshong Catheters:
  These can be placed into any central vein but most commonly used is the Subclavian Artery. They al have an external port that looks like any other but it is sutured to the skin and had a cuff that promotes fibrous ingrowth. This growth helps to prevent infection and further stabilized the catheter to the skin. Highest risk of infection or accidental removal is within the first 2 weeks, they must be kept clean, dry, and pt should take anticoagulant therapy to prevent clot formation.
• Peripherally Inserted Central Catheters (PICCs):
  Are placed into a peripheral vein, most commonly the cubital vein at the antecubital fossa. These are easily accessible and allow a doc to thread a catheter through and into central venous circulation. The are done under fluoroscopy by radiology and therefore have a low complication rate. (Believe this is what they use in angiograms for a specific placement as well as the last one for a different view)
• Surgically Implanted Medication Delivery Systems:
  These are disk shaped devices that go completely under the skin, and have a diaphragm that requires a specifically shaped needle for access. A regular one will damage the device. THIS SHOULD NOT BE ACCESSED unless your protocols allow it and you have special training to do so, they should only be accessed with STERILE TECHNIQUE. EX. Port-A-Cath or Medi-Port. They are typically found under the upper chest and can be palpated through the skin.
• Dialysis Shunts:
  There are AV SHUNTS which are a loop connecting an artery to a vein or a FISTULA which connects and artery and a vein directly creating an artificially large blood vessel. These are used for hemodialysis. Both are surgically created and very delicate, you SHOULD BE ABLE TO AUSCULTATE A BRUIT, if you do not it may mean there is an occlusion. DO NOT access these and do not put a blood pressure cuff over them.

Question 24

What is one aspect to consider when you have a pt with a VAD?

Answer 24

They will most likely be on some type of anticoagulant therapy. Most common is those used to flush the device to prevent coagulation but they may also be on systemic anticoagulation therapy as well. B/c of this they will be much more prone to bleeding, GI bleeds, stroke, and extremity bruising.

Question 25

What are your common complications with VADs?

Answer 25

The most common problem is some sort of obstruction, this is because a thrombus may form at the catheter site or catheter tip, an air emboli can enter through the catheter, or the catheter itself can kink.

Another common problem is infection, be sure to look for swelling, redness, tenderness, heat, or discharge.

Question 26

Urinary Tract Devices (4x) and Complications

Answer 26

DEVICES:
- Texas Catheters (Condom Catheters): Are external and attach to the external male genitalia. B/c they are not inserted inside the risk of infection is reduced but they DO NOT collect urine in a sterile manner.

• Internal Catheters (Foley/Indwelling Caths): are the MOST COMMON, and involve a tube going up into the bladder were a small fluid filled balloon inflates to hold placement in the bladder.
• Suprapubic Catheters: Similar to internal catheters but these are placed through the abdominal wall and into the bladder as opposed to through the penis or vagina.
• Urostomy: is a surgical diversion of the urinary tract to a stoma or hole in the abdominal wall. A collection device is then attached to the stoma to collect urine.

COMPLICATIONS:
Most complications are from infection or device malfunction. Infections are common because of the high density of pathogens in the area and the catheter providing a pathway directly into the body. Look out for smelly or mis-colored urine as well as signs of systemic infection, or urosepsis. Infections in suprapubic catheters or urostomies can also cause infection within the abdominal wall. Device malfunctions can include displacement of the device, obstruction, blood ruptures, or leaking of the collection devices.

Question 27

Gastrointestinal Tract Devices (4x) and Complications

Answer 27

DEVICES:
- Nasogastric Tube (NG tube): Used for short term use, are commonly used by EMS for gastric decompression as well as for a lavage or to release blood or substance from ingestion.

• Feeding Tubes: Typically rest in the duodenum or jejunum and are weighted with a steel filament to help pass through the pyloric sphincter. These are used for supp nutrition when a person cannot swallow.
• Gastric Tubes: Used for long term, and may be inserted through the abdominal wall into the small intestine. There are many different kinds but are typically classified by means of insertion, location, and function.
• Colostomy: Used to bypass part of the large intestine and allow feces to collect outside the body in a collection bag.

COMPLICATIONS:
Typically involve misplacement, obstruction, or infection. When you suspect misplacement you can ask them to talk, if they cannot it may be in the airway, or you can use a 60mL syringe to push air into the tube and listen to epigastric sounds for if it is placed in the stomach. Clogged tubes may require irrigation.

Question 28

What is the most common device for securing a wound?

Answer 28

Sutures are the most common but there are also staples and adhesives. Wires are typically used for wounds inside the body such as musculoskeletal structures

Question 29

What are some common problems you may find with maternal or newborn care?

Answer 29

The most common problem with mothers of newborns is postpartum bleeding or an embolus (especially high risk of this after a C-section). Postpartum depression is also a common problem.

For newborns, their greatest problem is trying to adjust to life. They need to be positioned properly, nose cleared, and kept warm in order to do so. The most common problems you may find are respiratory or cardiac compromise. Also common for newborns is infections or sepsis as their immune systems are still under developed.

Question 30

Stages of greif

Answer 30

Denial
Anger
Depression
Bargaining
Acceptance