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

Patient and family teaching

1. Assess a patient’s learning needs (Code: IB6) [Difficulty: ELE: R, Ap; WRE: An]

It is very important to determine what the patient understands about his or her cardiopulmonary condition and its treatment. If the patient is found to need additional teaching in some area, it should be incorporated into the respiratory care plan. See Chapter 1 for more discussion on teaching methods.

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:

1. Speak at the patient’s and family’s level of understanding. Medical language usually reserved for peer discussions is not understandable to people without a medical background, yet using overly simple explanations can be insulting to someone who is intelligent or well educated, or both. In either case, the important information will not be perceived as intended. Give the patient written instructions as needed.
2. Frequently ask the patient and family whether they have any questions, and then answer them.
3. Have the patient and family explain back to you in their own words how they understand what you just described.
4. Have the patient and family demonstrate back to you all procedures and techniques.
5. Reteach anything that is misunderstood.
6. Retest the patient and family as needed.
7. Document in the patient’s chart what has been instructed.

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.

Exam Hint 17-1 (WRE)

Most past examinations have included a question related to recommending a nicotine replacement system to a patient wishing to stop smoking or the possible side effects of the nicotine system.

4. Counsel a patient and family in health management (Code: IIIK4) [Difficulty: ELE: R, Ap; WRE: An]

The respiratory therapist should have a solid understanding of the pathophysiology of the commonly found cardiopulmonary and cardiovascular conditions. This includes, but is not limited to asthma, emphysema, chronic bronchitis, pneumonia, pulmonary fibrosis, cystic fibrosis, right and left heart failure, stroke, and neuromuscular diseases. Be prepared to teach the patient and family about the patient’s disease, its cause, and its medical management.

MODULE B

Home respiratory care services

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:

a. Personal grooming

• Do you get short of breath when dressing?
• What is the most difficult part of dressing?
• Are you able to wash your hair regularly?
• (For men) Are you able to shave regularly?
• Does using extra O2 help you to do these things without getting as short of breath?

b. In-home activities

• Can you go up and down stairs without getting short of breath?
• Can you walk through your home without getting short of breath?
• Can you cook and prepare nutritious meals?
• Does using extra O2 help you do these things without getting as short of breath?

c. Out-of-home activities

• Can you go shopping without getting short of breath?
• What clubs, church, or other organizations do you attend regularly?
• Can you do yard or garden work?
• Do you have a pet dog that you walk through the neighborhood?
• Does using extra O2 help you do these things without getting as short of breath?

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:

• Have you ever smoked? If yes, for how long? How many packs of cigarettes a day?
• Have you used illegal drugs? What have you used? For how long?
• Is your spouse able to help you at home?
• Do you have other family members who can help you at home?
• Can neighbors or family friends help you at home?
• Do you belong to any clubs or church? Can you get to them?
• Do you garden, have a pet, or do any hobbies at your home?

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

• Do both parents live at home? If not, with whom does the child live? Do both parents care for the child?
• Can any siblings help care for the child?
• Do you have other family members who can help you care for the child at home?
• Can neighbors or family friends help you care for the child at home?
• Does the child belong to any clubs or church? Can you get the child to them? Can they help you care for the child at home?
• Can you get the child to and from school?

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:

• How many floors does your home have?
• Do you have to go up a set of stairs to get into your home?
• Is your bedroom on the main floor?
• If your bedroom is upstairs, can it be relocated to a room on the main floor?
• If your bedroom were relocated to the main floor, would it be easy for you to get to a bathroom and the kitchen?
• Does anyone who lives with you smoke?
• Is there anything else in or around your home that puts smoke or dust into the air?

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.

3. Interview the patient to determine his or her nutritional status (ELE code: IB5d) [ELE difficulty: R]

Patients who have been ill for more than a few days should be suspected of suffering from malnutrition and/or dehydration to some degree. The longer they have been ill and not eating and drinking, the worse their condition will be. Ask the following questions of the patient or family:

• How long have you been sick?
• Were you able to eat and drink normally before you became sick?
• How long has it been since you were able to drink normally? Do you feel thirsty now?
• How long has it been since you were able to eat normally? Do you feel hungry now?
• Is it more difficult to cough out your secretions now than before you became sick?

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:

• Does the patient live alone or have a spouse or companion to help provide care? Make sure that telephone numbers to relatives, helpful neighbors, the patient’s physician, ambulance service, local hospital, pharmacy, and any other support services are posted by each telephone.
• Ensure that all respiratory care equipment is cleaned (see Chapter 2 for suggestions on methods of disinfection) and functioning properly.
• Check that home oxygen systems are working properly. If the patient has an oxygen concentrator, confirm that the filters are cleaned and that the alarms are set and working. Ensure that an oxygen cylinder, regulator, and oxygen delivery system are working properly as a backup system if the oxygen concentrator fails.
• Have the patient centrally locate all necessary items for daily living. The patient should avoid unnecessary stair climbing. It might be recommended that the patient convert the living room, if it is located near the kitchen and bathroom, into a bedroom. Clothing can be modified with Velcro fasteners, snaps, or zippers if the patient cannot use buttons easily. Shoes can be put on more easily with a long-handled shoehorn. Avoid shoes with laces. A long-handled comb or brush makes grooming easier.
• The kitchen should be modified so that all commonly used equipment is on the counter. Everyday dishes, utensils, and foods should be placed so that they can be easily reached in cabinets and drawers within an arm’s reach. The patient should not have to bend over, stoop down, or climb onto a footstool to get anything that is needed.
• The bathroom may need handholds added to the walls by the toilet and shower or tub for extra security when using these facilities. A shower chair can be added so that the patient can sit while bathing. A handheld shower head might make bathing easier.
• Check the home for airborne irritants. Smoking by the patient or anyone else in the home must be stopped. The patient should avoid contact with other forms of indoor pollution such as aerosol sprays, paints, varnishes, and dust. A high-efficiency particulate air (HEPA) filtration system is best for removing indoor airborne pollutants and irritants. Indoor kerosene-fueled space heaters should not be used because they release carbon monoxide.
• The patient should avoid contact with any known allergens, people who smoke, or substances that have resulted in a bad reaction.

5. Home sleep apnea management

a. Perform overnight pulse oximetry (Code: IB9q) [Difficulty: ELE: R; WRE: Ap, An]

b. Interpret the results of overnight pulse oximetry (Code: IB10q) [Difficulty: ELE: R, Ap; WRE: An]

While it less expensive to perform overnight pulse oximetry in the home than polysomnography in the hospital, most patients who are suspected of having sleep-disordered breathing will be evaluated in the hospital. See the discussion on sleep-disordered breathing and overnight pulse oximetry in Chapter 18.

c. Initiate treatment for sleep disorders (e.g., CPAP) (WRE code: IIIK9) [WRE difficulty: Ap, An]

See Chapter 18 for the discussion on treatment for sleep disorders. CPAP systems are presented in Chapters 15 and 18.

6. Apnea monitoring

a. Initiate and adjust sleep apnea monitors (WRE code: IIIK2) [WRE difficulty: Ap]

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.

BOX 17-1 Guidelines for Starting and Stopping Home Apnea Monitoring

INDICATIONS TO START HOME APNEA MONITORING

Infant has experienced one or more apparent life-threatening apnea events.
Infant is preterm and symptomatic of apnea.
Infant is a sibling of two or more SIDS victims.
Infant has central nervous system–based hypoventilation.

INDICATIONS TO STOP HOME APNEA MONITORING

Two to three months have passed without a significant number of alarms.
Two to three months have passed without an apnea episode.
Infant can tolerate stress of illnesses (e.g., nasopharyngitis) or immunizations (e.g., diphtheria-pertussis-tetanus [DPT]) without apnea episodes.

SIDS, Sudden infant death syndrome.

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:

1. Set the apnea alarm to trigger after 20 seconds.
2. Set the low heart rate alarm to trigger if the heart rate is less than 100 beats/min.
3. If available, set the pulse oximeter alarm to trigger if the Spo2 value decreases to less than 90%.
4. If available, set the high heart rate alarm to trigger if the heart rate is greater than 150 beats/min.

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.

7. Modify respiratory care procedures for use in the home (Code: IIIK8) [Difficulty: ELE: R, Ap; WRE: An]

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.

Exam Hint 17-2 (ELE)

Past examinations have included questions on the maintenance of O2 concentrators for low-flow oxygen in the home and the use of backup sources of O2 when an O2 concentrator fails. In addition, questions have been asked about how to treat a home care patient whose nasal cannula has no flow. Telephone instructions include having the patient place the cannula under water to check for bubbling, tightening all tubing connections, confirming that gas is flowing from the O2 concentrator, cleaning the concentrator’s filters, replacing a defective cannula, and switching to an O2 cylinder if the concentrator has malfunctioned.

Exam Hint 17-3 (WRE)

Past examinations have included a question related to home respiratory care equipment. Examples include (1) recommendation of the use of an oxygen-conserving nasal cannula and oxygen concentrator for the economic delivery of low-flow oxygen; (2) recommendation of the maintenance of an oxygen concentrator (cleaning its filters) and the use of a backup source of oxygen (switching to an oxygen cylinder) when an oxygen concentrator fails; and (3) provision of telephone instructions to a home care patient whose nasal cannula has no flow. This includes having the patient place the cannula under water to check for bubbling, tightening all tubing connections, confirming that gas is flowing from the oxygen concentrator, or replacing a defective cannula.

MODULE C

Pulmonary rehabilitation

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 will help you to further determine the patient’s exercise tolerance and activities of daily living (ADLs):

a. Personal grooming

• Do you get short of breath when dressing?
• What is the most difficult part of dressing?
• Are you able to wash your hair regularly?
• Are you (men) able to shave regularly?
• Does using extra oxygen help you to do these things without getting as short of breath?

b. In-home activities

• Can you go up and down stairs without getting short of breath?
• Can you walk through your home without getting short of breath?
• Can you cook or prepare nutritious meals?
• Does using extra oxygen help you to do these things without getting as short of breath?

c. Out-of-home activities

• Can you go shopping without getting short of breath?
• What clubs, church, and other organizations do you attend regularly?
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