L4 Home assessment in community nursing

Objectives of Community Nursing Services in HK (4)

• To enhance client’s self-care ability

• To empower client/carer towards self-reliance on illness management

• To promote client’s rehabilitation through active liaison with the supportive network across the hospital and the community

• To promote primary health care

Suggest the services to be done during home visits for community nurses ? (8)

1. Conduct comprehensive health assessment

2. Formulate holistic care plan to provide continuous care and addresses the total needs of client

3. Implement client focused care with modification of nursing practice to adapt diverse home environment

4. Assist client and family to build a home environment that ensures safety and facilitates rehabilitation

5. Educate and empower the client and the caregiver to achieve independence and self-care

6. Evaluate client progress and outcome continuously, as well as the ability of the client and the caregiver (e.g. domestic helper) to successfully manage their own healthcare needs at home

7. Maintain effective communication with the client, family, healthcare team members and other service providers to facilitate coordination and continuity of care

8. Act wittily in emergency situation and respond effectively to rapidly changing situations in the community setting

What is the indication for community nursing services ? (Ie. Target clients have what conditions ?) (4)

• Unable to attend health care facilities for receiving nursing care because of debilitated health profiles

• Require nursing care at home for health support, monitoring on treatment regime, compliance, or during times of stress.

• Promote self-reliance and empowerment to cope with chronic illness or specific nursing condition at the early stage of discharge from hospitalization

• Adopt case management model of care (e.g. those who can’t walk, but need to go clinic for TB drugs) while caring at home for complex chronic diseases e.g. pulmonary, diabetic, cardiac or stroke care

List the scope of services of community nursing services (3) + examples

Chronic disease management

• Cardiac rehabilitation

• Pulmonary rehabilitation

• Stroke rehabilitation

• Diabetic care

• Renal care

Specialty nursing service

• Surgical care (wound and drain care, ostomy care)

• Geriatric care

• Postnatal and infant care

• Continence care

• Palliative care/end-of-life care

Rehabilitation counseling

• Utilization of community resources

• Nutrition counseling and feeding tube care

• Medication management

• Home safety assessment/home adaptation and exercise

• Home infection control education

• Community health education (e.g. drug)

Which type of community nurses will conduct the following tasks:

Conduct pre-discharge assessment interview with the patients and refer them to related CNS center according to their residential address

Station nurse

Which type of community nurses will conduct the following tasks:

Deliver nursing care and education for home case and support C&A (care & attention) home

Community nurse

Which type of community nurses will conduct the following tasks:

Deliver nursing care and education in private old age home.

Coordinate geriatric OPD (Outpatient Department) in old age home (for those bed/chair bound patients)

CGAS (Community Geriatric Assessment Team) nurse

Outline the pre-visit preparation (6)

1. Receive the referral with an order from the physician to initiate care

2. Review client’s information (Diagnosis, history, discharge summary, medication list…)

3. Determine a plan

   • Gather the required equipment and supplies for the ordered treatment

4. Make the initial phone call to the client

   1. To confirm the visiting schedule

   2. To start the patient-nurse relationship

   3. Giving some tasks to clients (e.g. have all medications available for review)

5. Location of the visit

6. Personal safety

Outline the process of home visit (8)

1. Sit with the client to review the referral and history information

2. Ask the client what happened to result in the last admission to home care

3. Assess the home environment, the general appearance of the client, the status of the client’s speech, hearing and cognition

4. Subjective and objective assessment

5. Hands-on care: Always get permission beforehand, inform the client what and why is being done

6. Health education

7. Evaluate Client’s response to the care provided

8. Goal setting: Client-centered, work with the client collaboratively

9. Care coordination with internal (members of the home care team) or external (community resource) providers

8. Concluding the visit & Discuss the plan for the next visit

Outline the post-visit tasks (2)

1. Document the details of the encounter, the progress and any coordination care provided

   • Electronic in HA: Community Based Nursing System (CBNS)

2. Continue the coordination of care

What are the care elements to be assess during home visit ? (9)

• physical status

• psychosocial status

• home environment & safety

• client’s knowledge on medication and his/her compliance

• diet compliance

• elimination pattern

• Hygiene

• Detect any disease related complications

• daily activities and exercise tolerance

Suggest the specific assessment for COPD

6 Minutes Walk Test

• Instruction to client:

  • a walking test lasts 6 minutes, not to run.
  • walk as fast as possible back and forth 向前 along a corridor.
  • may rest but must resume walking as soon as the client is able.

• Inform the client every 60 seconds how much time has passed and how much is left to complete the test.

• All patients needing continuous oxygen therapy must perform the test with supplemental oxygen.

• When performing the test without supplemental oxygen and a

  patient’s oxygen saturation falls below 90%, the test should be repeated with the administration of oxygen, and the greater distance of the 2 tests be taken as valid.

• Under any circumstances, the saturation should fall below 80%, the test should be suspended.

• During the test, heart rate and oxygen saturation are measured every 60 seconds. The number of times the patient stops is also recorded.

• The distance walked in 6 minutes is recorded in meters.

What should be documented for specific assessment for COPD? (7)

• Breathing pattern

• Respiratory accessories

• Findings of physical examination

• 6 minutes walk tolerance test (in meter)

• Last vaccine against COVID-19

• Last influenza vaccine

• Last pneumovax vaccine

List 3 nursing diagnosis for COPD patient in home setting

• Ineffective airway clearance related to chronic inflammation of bronchi as evidenced by increased production of thick mucus and coughing.

• Impaired gases exchange related increased damage of alveoli surface as evidenced by difficulty in breathing and increased crackling and wheezing during auscultation.

• Knowledge, deficient related to disease process and lack of understanding in treatment plan as evidenced by verbalization and ineffective health maintenance.

What education elements should be given to home patients ? (8)

• Rectify risky health behaviour

• Modify home environment

• Maintain home safety

• Safe use & maintenance of device

• Use & storage of medication

• Maintenance of dietary intake: well-balanced diet and high fibre intake

• Minimize physical exertion during ADLs

• Making referral (e.g. home help, meal delivery, volunteers )

Describe the procedure of educating coughing exercise for COPD self-care (7)

1. Sit on a hard-backed, stable chair & relax

2. Take in 2-3 deep breaths through your nose and exhale slowly through pursed lips

3. Fold your arms across your abdomen

4. Breathe in a deep breath through your nose

5. Lean forward, pressing your arms against your abdomen and cough while leaning forward

6. Rest 5-10 minutes

7. Repeat again if necessary

Describe how to educate COPD patient about bronchial hygiene ?

METHOD 1: Postural drainage (Perform at least 2 hours after eating/feeding to avoid aspiration pneumonia)

1. Stay in the position of lying on your back or side/sitting or lying with your head flat, up, or down

2. Stay in the position for 5-10 minutes

3. Breathe in slowly through your nose

4. Breathe out through your mouth 2 times as long as you breathe in

METHOD 2: Percussion

1. Form a cup shape with your hand and wrist

2. Clap your hand and wrist against your chest

3. You should hear a popping sound

What should be regularly monitored for COPD patients in home setting ? (7)

• LOC, vital signs

• Exercise tolerance

• PEFR (Peak Expiratory Flow Rate), SpO2, sputum examination

• Drug compliance

• Use of O2, nebulization 霧化 & inhaler therapy

• Education

• Psycho-social care and support – client & carer

What are the red-flag situation that require contingency care plan for COPD patients ?

• Increase thick sputum and difficult to cough out

• Increase cough with chest distension

• Increase shortness of breath

• Dyspnea , copious 豐富 cough and sputum

• Orthopnea

• Fever

• Increase edema

• Decrease in conscious level

What will be included in the emergency kit for COPD patients ?

1. Using Ventolin with aero-chamber

• 2 puffs, Q4H

• If dyspnea persist or worsen → 4-8 puffs, Q2-4 H

2. Oral Augmentin 375mg,TDS,1week

• If having ≥ s/s of chest infection

3. Oral Prednisolone 30mg, daily, 1 week

• For worsening dyspnea

Contact CNS for step 2 & 3