Home Care and Pulmonary Rehabilitation

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17 Home Care and Pulmonary Rehabilitation

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will simply be shown as: (Code: …). If an item is only testable on the ELE, it will be shown as: (ELE code: …). If an item is only testable on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown an average of 3 questions (out of 140), or 2% of the exam, will cover Home Care and Pulmonary Rehabilitation. A review of the most recent Written Registry Examinations (WRE) has shown an average of 5 questions (out of 100), or 5% of the exam, will cover Home Care and Pulmonary Rehabilitation. The Clinical Simulation Examination is comprehensive and may include everything that should be known by an advanced level respiratory therapist.

MODULE A

2. Explain the planned therapy and goals to a patient in understandable terms to achieve optimal therapeutic outcomes (Code: IIIA6) [Difficulty: ELE: R, Ap; WRE: An]

Determining the patient’s ideal therapeutic goals is best done with a team approach. The patient’s physician, nurse, and respiratory therapist should work together. The first consideration should be the patient’s diagnosis. Next, determine whether the patient’s condition is permanent, improving, or worsening. Objective information such as arterial blood gas results, pulmonary function testing results, chest radiographs, sputum production, and vital signs must be evaluated. The patient’s physical capabilities must also be considered when establishing therapeutic goals. It is also important to evaluate the patient’s mental state. Is the patient emotionally ready to be discharged home and learn about self-care or start a rehabilitation program? Each patient’s therapeutic goals must be individualized. If the patient is not physically or emotionally ready to take care of himself or herself, the family or a paid care provider is needed.

The patient and family must understand the therapeutic goals and how they are to be achieved. Effective teaching methods include the following steps:

3. Counsel a patient and family concerning smoking cessation (Code: IIIK6) [Difficulty: ELE: R, Ap; WRE: An]

Absolute proof exists that smoking causes emphysema, chronic bronchitis, lung cancer, and heart disease. These conditions occur in the smoker who directly inhales the smoke as well as in the nonsmoking spouse and children who inhale secondhand smoke. Asthmatic patients often find that their bronchospasm is worsened when they inhale tobacco smoke. Obviously it is important that any patient with a smoking-related cardiopulmonary disease cease smoking. The patient’s family must also stop smoking. Continued exposure to tobacco smoke harms the patient.

Because the nicotine found in tobacco is highly addictive, many patients find that they cannot stop smoking without having withdrawal symptoms such as agitation and craving for a cigarette. To aid in smoking cessation, it is often helpful to meet with a group of people who also are trying to stop. This group support helps the patient feel less alone in his or her efforts to stop smoking. The patient’s physician also must be involved in this process.

If the patient has been unable to stop smoking because of withdrawal symptoms, it is likely that he or she is addicted to nicotine. A nicotine replacement system that allows gradual withdrawal greatly aids in smoking cessation. Although no smoking cessation plan works in every case, the highest percentage of patients are able to stop smoking if they have a combination of psychological support and a gradual reduction in nicotine intake.

Several well-established nicotine replacement and reduction systems currently exist. All are available without prescription. The Commit lozenge is held in the mouth to release a controlled amount of nicotine. Nicotine polacrilex (Nicorette) is a gum that is chewed by the patient to release a dose of nicotine. The Nicotrol Inhaler allows the user to inhale nicotine through a device shaped like a cigarette. Nicotine transdermal patches are another nicotine reduction system. ProStep, Nicoderm, and Habitrol are three brands of patches that, when placed onto the skin, allow a set amount of nicotine to be absorbed. With these systems, the patient starts with a relatively high dose of the drug and, over a period of weeks, transitions through a series of patches with less and less nicotine. It is critical that the patient not smoke while using one of these systems. Patients who continue to smoke run the risk of a nicotine overdose, which increases the risk of myocardial infarction.

Another option involves the patient taking a medication to change how the brain reacts to nicotine. Zyban (bupropion HCl) alters the brain’s chemistry so that nicotine craving is reduced. It was originally found helpful in the care of patients with depression. Chantix (varenicline) is incorporated into the nicotine receptors of the brain. As a result, nicotine withdrawal cravings are reduced and if the patient “cheats” by smoking, there is no nicotine stimulating effect. Both medications require a physician’s prescription.

Some patients experience problems with nicotine replacement and reduction systems. The transdermal patch can cause skin irritation. If this happens, the patch should be moved to another site. Some patients report insomnia or strange dreams while wearing a nicotine patch at night. Patients with this problem should remove the patch before sleeping.

MODULE B

1. Interview the patient to determine the presence of dyspnea, sputum production, and exercise tolerance (Code: IB5c) [Difficulty: ELE R, Ap; WRE: An]

The following subject areas and questions can help the therapist to further determine the patient’s exercise tolerance and activities of daily living:

c. Out-of-home activities

See Chapter 1 for the discussion on interviewing a patient about sputum production. The patient with chronic and severe cardiopulmonary disease may describe a very restricted and limited lifestyle. Extra O2 may have only limited benefit. The patient with chronic, but moderate, cardiopulmonary disease can live a somewhat limited but full lifestyle. Extra O2 may help greatly at times when the patient becomes short of breath. The otherwise healthy patient with an acute cardiopulmonary disease should describe a previously full and enjoyable lifestyle. Extra O2 may be needed now, but it is hoped that it will not be needed upon recovery.

2. Interview a patient to determine his or her social history (e.g., smoking, substance abuse) (Code: IB5e) [Difficulty: ELE: R; WRE: Ap]

The patient’s family and social life is an important consideration in discharge planning with the patient and family. Whether the patient is an adult or a child, it is important to know about his or her home life. Probably no one knows more about the patient or cares more about his or her well-being than the immediate family. Very close friends can assist the family or even replace a nonexistent one. The following questions can be asked of an adult patient and family:

The following questions can be asked of the family of a minor child:

The answers to these types of questions may lead you to think of other questions about the patient’s family and social life. Consider the patient’s disease or condition and the answers that are given to determine a discharge plan that minimizes any disturbances in family life.

The home environment is an important consideration in discharge planning with the patient and family. Barriers to the patient’s mobility and complete recovery must be identified so that they can be eliminated or minimized. Ideally, the patient’s home environment is determined by visiting the patient’s home; however, the following questions also can be asked in the hospital:

The answers to these types of questions may lead to other questions about the patient’s home environment. Consider the patient’s disease or condition and the answers that are given to determine a discharge plan that minimizes any inconveniences or barriers.

4. Instruct the patient and family to assure safety and infection control (Code: IIIK7) [Difficulty: ELE: R, Ap; WRE: An]

Evaluate the following aspects of the patient’s home environment:

Ensure that all respiratory care equipment is cleaned (see Chapter 2 for suggestions on methods of disinfection) and functioning properly.

6. Apnea monitoring

b. Perform apnea monitoring (Code: IB9p) [Difficulty: ELE: R, Ap; WRE: An]

Apnea monitoring is indicated in an infant who has documented periods of apnea of prematurity resulting from an immature central nervous system. This condition is most commonly seen in infants younger than 35 weeks’ gestational age. The usual monitoring guidelines include apneic periods that last longer than 20 seconds and are associated with bradycardia with a heart rate of less than 100 beats/min. Hypoxemia is often demonstrated by cyanosis, pallor, or documented desaturation through pulse oximetry. In addition, the infant may show marked limpness, choking, or gagging. Other conditions such as intracranial hemorrhage, patent ductus arteriosus, upper airway obstruction, hypermagnesemia, infection, and maternal narcotic agents, for example, should be ruled out before apnea of prematurity is confirmed. If this is the infant’s problem, it is usually outgrown by the time the infant is 40 weeks’ postconceptional age. Home apnea monitoring is not indicated in normal infants, in preterm infants without symptoms of apnea, or to test for sudden infant death syndrome (SIDS). See Box 17-1 for guidelines on starting and stopping home apnea monitoring.

Apnea monitors currently in use sense respiratory efforts through the changing electrical impedance measured through the chest wall as the infant breathes. Impedance is resistance to the flow of electricity through the skin and other organs. The monitor transmits a small, constant electrical current that results in a voltage across the two electrodes on the infant’s chest. As the infant breathes and the chest wall expands and contracts, a resulting change in voltage occurs. This fluctuation is measured and interpreted as inhalation and exhalation. Similarly, smaller voltage changes are measured with each heartbeat. This is measured and interpreted as the heart rate.

The following are desirable features on a home apnea monitor: (1) ability to store and display events for later analysis, (2) identification of breathing patterns and apnea periods, (3) identification of heart rate patterns, (4) estimation of tidal volume, and (5) identification of hypoxemia by pulse oximetry. Assembling a home apnea monitor involves placing the electrodes properly on the infant’s chest, turning on the monitor, and setting the proper high and low limits for the alarms.

Two electrodes are usually placed where the greatest amount of movement occurs during breathing. Most often, this is on the infant’s upper chest between the nipples and armpits (Figure 17-1). With older infants, the electrodes might have to be placed on the sides over the lower ribs. Occasionally one electrode is placed on the chest and the other on the infant’s abdomen. Some monitoring systems require that a Velcro belt be placed around the infant over the electrodes to secure their positions. (Obviously this works only if both electrodes are on the chest.) Other systems employ electrodes with an adhesive. In either case, for best results, the infant’s chest should be washed with mild soap and water and dried before the electrodes are placed. This results in the best electrical conduction. Do not use baby oils, lotions, or powders over the electrode sites. Attach the lead wires to the electrodes. These connect to the patient cable that is then connected to the monitor. Occasionally static electricity causes some interference with the signal. A third chest electrode is then added to act as a ground wire.

image

Figure 17-1 Block diagram for impedance apnea and heart rate monitor.

(From Lough MD. In Lough MD, Williams TJ, Rawson JE, editors: Newborn respiratory care, St Louis, 1979, Mosby.)

The monitor should be plugged into a working electrical outlet and turned on. Set the unit to charge the internal battery so that it can be made portable for later use. Confirm that the infant’s respiratory and heart rates are being sensed and displayed. If pulse oximetry is a feature on the unit, the probe should be properly placed on the infant, and an Spo2 value should be displayed. Set the high and low alarm values according to the physician’s orders or established protocols. For example:

Multiple alarms provide for a greater margin of patient safety. They also indicate what physiologically deteriorates first in the infant. These backup alarm systems are important because the apnea monitor senses chest wall movement, not air movement. It is possible for the infant to have an upper airway obstruction and continue to make breathing attempts; therefore the apnea monitor will not alarm because the chest wall is moving. The bradycardia or desaturation alarms will signal that the infant is in trouble.

It is critically important that the parent(s) know(s) about the infant’s medical condition. They need to understand how the monitor functions and what to do if the alarms sound. They should demonstrate their knowledge of the monitor’s functions and be given written instructions about the monitor. The parents should not be more than 10 seconds away from the infant at any time, which means that the infant will not be apneic for more than 30 seconds (20-second alarm delay and 10 seconds for the parents to respond). The parents must know how to give tactile stimulation to the infant, use the manual resuscitator, call for emergency help, and perform infant cardiopulmonary resuscitation.

c. Interpret apnea monitoring results (Code: IB10p) [Difficulty: ELE: R, Ap; WRE: An]

Alarm situations fall into two basic categories: patient alarms and equipment alarms. Patient alarms mean that the infant either is apneic, has a heart rate below or above an acceptable level, or is desaturated. One, any two, or all three alarms may be triggered. Other than the audible alarm, a visual alarm flashes to show the problem(s), and the recording device keeps track of the events. The parents should be instructed first to care for the infant, and then, when the infant is back to normal, the alarms can be reset.

Three types of equipment alarms are found: electrode or lead problem, low battery, or monitor failure. The unit should have different visual and audible alarms for equipment failure so that the family does not mistakenly believe that the infant is in trouble. An electrode or lead problem alarm usually occurs because the electrode fell off of the infant or the lead became disconnected. The family should be taught how to fix these types of problems. A low battery alarm indicates that time is limited for the monitor to function on battery power. The family should be instructed to plug the monitor into a functioning electrical outlet, and the unit should be set to recharge the battery. A monitor failure alarm indicates a serious internal problem with the monitor. It is not functioning properly and should not be used. The family should be instructed to observe the infant continuously and call the home care company for a replacement monitor.

Apnea monitors in current use record and store the alarm situations discussed previously. The information can usually be downloaded into a computer for a visual display of breathing and heart rate patterns, equipment problems, and the dates and times of their occurrences. The therapist or physician should review all these data to determine what kinds of problems the patient experienced.

8. Monitor and maintain all respiratory care equipment used in the home (ELE code: IIIK1) [ELE difficulty: R, Ap]

Home care equipment is essentially the same as that found in any hospital. The same types of equipment problems can occur in the patient’s home as in the hospital. Those who wish to learn more about specific brands of home care equipment are referred to the several excellent books that discuss respiratory care equipment or the manufacturer’s literature. Review, if necessary, the respiratory care procedures presented in this or other respiratory care books because they can be performed in the home care setting as well as in the hospital.