NURS 487- Exam III
paliative care
-Symptom management, pain management,relief from suffering, -Embraces comfort, improves QOL, assesses individual needs... -Not only physical, but psychosocial as well.
palliative care & hospice
"Treatment that embraces comfort and improves the quality of an individuals life during the last phase of life."
proprietary agencies
-Agencies classified as for-profit pay federal taxes on the profits generated. -Can be individual owned, profit partnerships, or profit corporations. -Investors in corporate proprietary partnerships receive financial returns on their investments in the agencies. -A percentage of the profits are also reinvested into the agency. -Agencies within chains have financial advantage over single agencies.
generalist home health nurse
-Baccalaureate-level education required because of the autonomy and critical thinking skills necessary in home care -Care based on ANA standards and QSEN competencies -Associate RN and LPN can see pts. RN, -BSN is the case mgr. - signs care plan, HHA supervision, oasis, discharge, re admit -Primary function of managing an interdisciplinary team (PT, OT, ST, HCA, chaplains, etc.)
hospice care: team considerations
-Maintain boundaries -Ok to show emotions-limited -Burn out-high rate -Self care -Do not bring "work" home -Call time, weekends-boundaries -Wakes, services, bereavement
certified home health agencies
-Meet federal standards -Receive Medicare payments for services provided to eligible individuals
non-profit agencies
-Not required to pay federal taxes because of tax-exempt status. -Agency reinvests any profits into the agency. -Examples: independent home health agencies and some hospital-based home health agencies
hospice criteria
-Not seeking curative treatment -Need MD/NP order -Must sign consent -Must have RN and MD follow -Can pick other services you wish -Do not have to be homebound** -Can have anyone you wish to be called your "family" -Do not have to be DNR-work in progress ***In order for hospice care, you HAVE TO HAVE A 24 HR caregiver***
Albrecht Conceptual Model for Home Health Care
-Nursing programs (undergraduate and graduate) must prepare competent providers of home health care. -Curricula must include concepts related to the suprasystem, health service delivery system, and home subsystem, which includes structural, process, and outcome elements. -Undergraduate students need at least one clinical observation or experience in a home care agency. -Graduate-level students need specific courses that cover concepts present in the model, including knowledge of education; preventive, supportive, therapeutic, and high-tech nursing interventions for home health care; a multidisciplinary approach to home health care; health law and ethics; systems theory; economics covering supply, demand, and productivity; and case management and coordination.
types of home health agencies
-Official (i.e., public)-local/state organized by county health-separate but fall under public health -Nonprofit-Boston VNA, All Care -Proprietary-Company/individual, for profit -Hospital-based agencies-Hallmark Health
non-certified home care agencies
-Operate outside the Medicare system -Provide non-Medicare-covered services (i.e., do not provide skilled nursing care) -They are not eligible to receive Medicare reimbursement
official agencies
-Organized, operated, and funded by local or state governments. -Located within the county public health system. -Taxpayers fund official home health agencies. -Agencies also receive reimbursement from third-party payers such as Medicare, Medicaid, and private insurance companies. Specific regulations to follow
hospice eligibility
-Physician certifies that patient's life expectancy is less than 6 months (if it runs its natural course) -Patient agrees to give up aggressive curative treatment. -Average hospice length of service 4-7 days
hospital-based agencies
-Receive fixed reimbursement under PPS and the hospitals' incentive to decrease length of stay. -Hospitals are able to discharge patients who have skilled health care needs, provide necessary services to patient, and receive reimbursement through third-party payers. -Often considered profitable endeavors that provide hospitals with an additional revenue source. -Stop the re admission, "revolving door"
purpose of home health services
-To allow individuals to remain at home -To provide health care services that would otherwise be offered in a health care institution such as a hospital or nursing home setting -To encourage cost containment through timely hospital discharges -To focus on the care of sick patients (skilled nursing care) with some expansion to include health promotion and disease prevention interventions
Hospice covers ____ months of bereavement after death
13 months
A pathogen lives and multiplies in a __ and transfers from one host to another by a __. A. host, susceptible portal of entry B. reservoir, mode of transmission C. infectious agent, portal of exit D. mode of transmission, reservoir
A pathogen lives and multiplies in the reservoir and transfers from one host to another by a mode of transmission.DIF: Cognitive level: KnowledgeREF: Page 496
home health care
A system in which health care and social services are provided to homebound or disabled people in their homes rather than in medical facilities
hospice care team
Nursing, MD, NP HHA Social worker Chaplain Volunteers PT, OT, SLP (for palliative reason) Expressive therapy: Massage therapist, acupuncturist, music therapist Therapeutic Touch, Reiki master, art therapist Pet therapy
Which of the following factors causes primary vaccine failure? A. Inefficient storage B. An intramuscular vaccine injection given subcutaneously C. Waning immunity in immunocompromised patients D. Light-sensitive vaccines exposed to light E. Seroconversion
A. Inefficient storage B. An intramuscular vaccine injection given subcutaneously D. Light-sensitive vaccines exposed to light E. Seroconversion Primary vaccine failure is the failure of a vaccine to stimulate any immune response. It can be caused by improper storage that renders the vaccines ineffective, an improper administration route, or light-sensitive vaccines exposed to light. Additionally, some immunized persons never seroconvert, either because of failure of their own immune system or for some other unknown reason. Secondary vaccine failure is the waning of immunity after an initial immune response.DIF: Cognitive level: KnowledgeREF: Page 498
eligibility for palliative care
All stages of cancer Life limiting disease Life expectance of less than one year Multiple medical problems Not based on age or life expectancy
A public health nurse is surveying a population of coal miners. Which of the following questions would elicit information about related risk to a miner's children? A. "Do you wear a respirator?" B. "How close do you live to your workplace?" C. "How many accidents has the mine had this year?" D. "Do you have a good rapport with your boss?"
B. "How close do you live to your workplace?" Environmental health effects can be immediate, long term, or intergenerational. Although often overlooked, a parent's occupation may put his or her children in danger. Living close to a coal mine could increase the children's risk for exposure to water or ground contamination from the mine, among other environmental hazards. The other options do not assess the proximity of the environmental hazard.DIF: Cognitive level: ApplicationREF: Pages 261-262
Which of the following does NOT accurately describe home health nursing as "officially" defined by the U.S. Department of Health and Human Services (USDHHS)? A. Home health care is a system of comprehensive health care for people in their homes. B. Home health care is provided to homebound or disabled people in any residence or medical facility. C. Home health care has as its purpose to promote, maintain, or restore a client's health. D. Home health care requires a coordinated plan of care provided by professional health care providers.
B. Home health care is provided to homebound or disabled people in any residence or medical facility. Modern home health care is defined by the USDHHS as "a system in which health care and social services are provided to homebound people in their homes rather than medical facilities, and requires a comprehensive and coordinated plan to promote, maintain, or restore health or maximize level of independence. Services appropriate to the needs of the individual patient and family are planned, coordinated, and made available by providers organized for the delivery of home care through the use of employed staff, contractual arrangements, or combination of the two patterns." Home health services focus on allowing the individual to remain at home while receiving services they would otherwise receive in a hospital or long-term care setting.DIF: Cognitive level: KnowledgeREF: Page 649
Which of the following statements would indicate that the hospice patient's caregiver understood the nurse's instructions related to pain management? A. "I didn't wake him (the patient) up last night for the 2:00 AM dose because he was sleeping." B. "I gave him (the patient) the ordered medicine whenever he complained of pain." C. "I gave the pain medicine every 3 hours as we planned even when he (the patient) didn't complain of pain." D. "I'm worried he (the patient) will become hooked on the medicine, so I only gave one-half of the dose."
C. "I gave the pain medicine every 3 hours as we planned even when he (the patient) didn't complain of pain." Pain management is an important goal for hospice nurses and their patients. The premise of pain management is to educate the patient and family to administer the medication on a regular schedule instead of PRN ("as needed"), to prevent the majority of the pain. Patient and family education includes explaining how the traditional view of patients becoming "junkies" or "drug addicts" is not an issue with terminally ill patients.DIF: Cognitive level: ApplicationREF: Pages 658-659
The current home health care industry grew until the late 1990s, when the number of agencies and home health care services significantly declined. This decline was the result of which of the following? A. Failure of traditional home health services to change to meet the needs of clients with new needs such as AIDS patients, terminally ill patients, and increasing numbers of elderly B. Advanced technology that resulted in new procedures and equipment not possible for use in the home C. Changes in reimbursement that resulted from the implementation of the prospective payment system (PPS) for home health care, particularly for Medicare patients D. Changes in the official definition of what a home health care "skilled nursing visit" is by Social Security Amendment P.L. 98-21
C. Changes in reimbursement that resulted from the implementation of the prospective payment system (PPS) for home health care, particularly for Medicare patients A drastic decline in the number of home health agencies occurred in 1997 and the following years as a result of implementation of the PPS by P.L. 98-12 of the Social Security Amendment in 1983. Home health services have continued to evolve to meet the needs of their clients. Many new technologies can be provided in the home by skilled nurses.DIF: Cognitive level: KnowledgeREF: Page 649
Katie, a 2-year-old child, is brought to the doctor's office after 2 days of vomiting and diarrhea. Upon completion of the medical history, the mother tells the nurse that several of the other children at the daycare who played with the same toys as Katie have the same symptoms. The mode of transmission for the pathogen more likely was which of the following? A. Vector B. Direct C. Indirect D. Airborne
C. Indirect The stem of the question indicates that the children played with the same toys. This would indicate the indirect mode of transmission. The other modes of transmission do occur through the sharing of toys.DIF: Cognitive level: ApplicationREF: Page 496
Which of the following interventions would be the most appropriate to implement for a community that has a high risk for environmental health hazards? A. Facilitate the evaluation of ongoing community health interventions. B. Document participation levels of families in environmental issues. C. Involve citizens in decision-making processes about proposed activities that could pose an environmental threat. D. Screen at-risk populations for asthma and test blood levels for air pollutants.
C. Involve citizens in decision-making processes about proposed activities that could pose an environmental threat. Community health nurses have a mandate to assist vulnerable aggregates who have fewer options in protecting themselves from pollution, inadequate housing, toxic poisoning, unsafe products, and other hazards. An appropriate nursing intervention would be to involve citizens in decision-making processes about proposed activities that could pose an environmental threat. Evaluating ongoing health interventions, documenting participation levels of families, and screening at-risk populations are important evaluation methods for determining the needs of the community but are not the most appropriate intervention.DIF: Cognitive level: ApplicationREF: Pages 264, 267
Which of the following statements differentiating hospice and traditional home health is NOT true? A. Hospice patients need not be homebound but must be certified as within the last months of life by a physician. B. Hospice services may be provided in the home, hospital, nursing home, or other health care site as appropriate. C. The type of hospice services are limited as in home health care to skilled nursing, social services, physical therapy, occupational therapy, and speech therapy. D. The hospice plan of care includes caring for the caregiver during and after the death of the patient.
C. The type of hospice services are limited as in home health care to skilled nursing, social services, physical therapy, occupational therapy, and speech therapy. Hospice patients, unlike traditional home health care, need not be homebound but must be certified by a physician as terminally ill and requiring care. The type of services and location of services are broader in hospice and may include coordination with long-term care, hospitals, and other agencies. The services provided also include traditional home care providers and pastoral care, respite, and volunteers. Attention to the caregiver is also important in the hospice plan of care. Bereavement services are offered following the death of the hospice patient.DIF: Cognitive level: KnowledgeREF: Pages 657-658
Transmission of an infectious disease can be efficiently controlled by: A. breaking all links in the transmission chain. B. destroying all reservoirs of infectious agents. C. breaking only one link in the transmission chain. D. maintaining high levels of herd immunity.
C. breaking only one link in the transmission chain. Breaking just one link of the chain can control transmission of an infectious agent. Destroying all reservoirs of infectious agents and maintaining high levels of herd immunity are two of several ways to break a link in the chain of transmission.DIF: Cognitive level: KnowledgeREF: Page 497
The home health nurse receives a referral for an evaluation visit for a patient. The nurse notes that the patient's primary diagnosis is end-stage lung cancer and that the patient is currently receiving daily palliative radiation treatments for pain management. This is not an appropriate home health referral because: A. the patient is receiving palliative care. B. the patient's needs are too complex. C. the patient is not homebound. D. the patient does not have a skilled need.
C. the patient is not homebound. This is an inappropriate home health referral because the person is not homebound. If a patient can receive daily care at another health care facility, he or she is not suitable for home care. This referral may also be more appropriate for hospice services. Based on the information provided, the patient's needs that are appropriate for home care and skilled needs include pain management and end-of-life care. Palliative care is an appropriate need for home care services.DIF: Cognitive level: ApplicationREF: Page 650, 655
home health services can be provided in
Community nursing centers Private home Group boarding homes Homeless shelters Adult day care Intermediate skilled extended care facilities/rehab Assisted living facilities
Which of the following is classified as a vector of disease? A. Humans B. Door handles C. Water and food D. Mosquitos
D. Mosquitos Vectors can be animals or arthropods and can transmit disease through biological and mechanical routes. The other options are not vectors.DIF: Cognitive level: KnowledgeREF: Page 496
hospice care
Hospice care is an organized program for delivering palliative care.
difference between VNA and hospice
In hospice, you do not need to be homebound. You will not lose reimbursement for homebound setting Hospice can take care of patients in inpatient settings. The one place VNA does not go is in the hospital.
palliative care team
Includes the patient and family Nursing team Physician/nurse practitioner Social worker Nurses aides, home health aides Pastoral care Nutrition Pharmacist PT, OT, ST
home care is ____________ acute
NEVER ACUTE You are taking care of them AFTER the acute episode
reimbursement for home care
PPS-prospective payment system-cost containment in a managed care environment. Hospital costs soaring-PPS-hospitals receive fixed payment for services. Medicare benefits under Title XVIII of the Social Security Act -Individual over 65 -Homebound and under the care of a physician-document homebound-" more than 50% assistance, extreme burden " -Requires medically necessary skilled nursing care or therapy services-no longer medication refill, BP check -Exceptions for Medicare Hospice Benefit Medicaid benefits under Title XIX if eligible Private health insurance Private pay
special home health programs
Patients who require continuous skilled care in an acute or skilled nursing institution are able to return to their homes and receive care at home. -Beneficial to the patient's health -Less costly than hospitalization Family or caregiver support determine success. Examples of high-tech services: -Daily infusions of TPN or antibiotic therapy -Pediatric services for children with chronic health problems -Follow-up for premature infants at risk for complications -Ventilator therapy -Home dialysis programs
goals of hospice care
Quality of life Pain management Symptom management Relief from suffering Spiritual and cultural considerations
home health services may include
Skilled nursing care (provided by RNs) Supportive social services (PT, OT, ST) Social workers Home care aides Respite care
OASIS
The Outcome and Assessment Information Set (OASIS) -a data set that determines Medicare pay rate -measures outcomes of adult home care patients to monitor outcome-based quality improvement. OASIS data set includes sociodemographic, environmental, support system, health status, and functional status attributes of an adult patient. OASIS is mandatory for all Medicare and Medicaid patients receiving skilled care.
A new home health nurse realized that what was being observed and now being said by the client were very inconsistent with what had been documented while the client was hospitalized. Which of the following conclusions should be drawn by the nurse? a. The amount of support available is different from what was stated earlier. b. The client had difficulty distinguishing truth from falsehood. c. The client had to admit the truth when it was obvious to the nurse. d. The family was embarrassed by their living situation.
a. The amount of support available is different from what was stated earlier. It is not unusual to find inconsistencies between information the patient provides during hospitalization concerning the amount of physical and emotional support available to the patient in the home and the amount of help actually available to the patient in the home. The nurse validates or modifies the referral information to reflect the actual home situation. The client's perception of support and the actual support provided may be different. Thus, it is unlikely that the client was trying to lie about or was embarrassed by the situation.
Which of the following best explains the purpose of the Outcome and Assessment Information Set (OASIS)? a. To analyze the cost-effectiveness of health agencies b. To evaluate and improve clinical performance quality c. To measure and publicize hospital data on outcomes such as death rates d. To survey patient satisfaction with care received from health agencies
b. To evaluate and improve clinical performance quality OASIS is a data set that measures outcomes of adult home care patients to monitor outcome-based quality improvement. These items are used to monitor outcomes, plan patient care, provide reports on patient characteristics for each agency, and evaluate and improve clinical performance. The use of OASIS is mandatory for all Medicare and Medicaid patients receiving skilled care. The primary purpose of OASIS is not to analyze the cost-effectiveness of health agencies. This data set does not publicize hospital data or survey patient satisfaction of care from the health agencies.
palliative care can be delivered by
by all members of the team...and in any setting...hospital, home care, long term care... where ever the patient is.
Which of the following is the primary task to be accomplished during the initial telephone contact between the home health nurse and the client? a. Make sure that the name, address, telephone, and other data are accurate b. Confirm that the nurse will be a guest in their home so socialization can occur c. Allow the client to give permission and agree to a time for a home visit d. Warn the family that the nurse will always need to immediately see the proof of insurance before proceeding further
c. Allow the client to give permission and agree to a time for a home visit The nurse contacts the client and informs him or her about the service referral. The first telephone contact with the client or family consists of an exchange of essential information, including an introduction by the nurse, identification of the agency that received the referral, and the purpose of the visit. After the initial exchange of information, the nurse informs the client of his or her desire to make the home visit, the client gives permission, and the group sets a mutually acceptable time for the visit. The nurse is a guest in the client's home but not in the usual social sense. Public health nurses who are reimbursed by tax dollars may not require evidence of insurance coverage.
Which of the following is the major assumption of Albrecht's conceptual model? a. Nurses are the only appropriate case managers for home health patients. b. Quality is best measured by using data from assessments, interventions, and outcomes. c. Patient outcomes depend primarily on the education and experience of the nurse. d. The most important outcome measure is the cost-effectiveness of the care given.
c. Patient outcomes depend primarily on the education and experience of the nurse. An underlying premise of Albrecht's conceptual model is that professional satisfaction and effective patient outcomes depend on the education and experience of the home health nurse. Within the Albrecht nursing model, the three major elements for measuring the quality of home health care patient outcomes include structural, process, and outcome elements. Although nurses are usually the case managers, Medicare pays for skilled services, including occupational therapy and physical therapy. If nursing is not involved, the skilled professional would be the case manager.
Which of the following should be included when the nurse writes a proposed treatment plan for a home health client? a. Outline of specific client goals with measurable outcomes b. Specific nursing interventions to treat identified client problems c. Type of services needed and frequency of visits by each discipline d. Typical nursing care plan information from assessment to evaluation
c. Type of services needed and frequency of visits by each discipline There are differences between the treatment plan and the nursing care plan. The plan of treatment includes the type of home health services received, the projected frequency of visits by each discipline, and the necessary interventions. The nursing care plan addresses specific nursing interventions designed to treat the patient's actual or potential problems and includes identified goals with measurable outcomes.
Which of the following 66-year-old clients who needs skilled nursing care would be eligible for home health care reimbursement by Medicare? a. A client who always worked for the state and enjoys going to the neighborhood coffee shop on a daily basis b. A client who needs his wounds cared for every day, including weekends, and needs the nurse to visit at 8 AM every day c. A client who is a loner and has no one to assist him except for the home care agency d. A client who is homebound and has a very strong support system e. A client who is an illegal immigrant who has lived in the United States for 25 years but begged the nurse not to tell
d. A client who is homebound and has a very strong support system Medicare pays for short-term, skilled health care on a part-time or intermittent-care basis for persons aged 65 years or older who are eligible under Title XVIII of the Social Security Act. If family and caregiver support is available in the home to care for the patient between nurse visits, the patient is eligible.
Which of the following best describes the documentation that the nurse should expect to complete during the home visit? a. Creation of a carefully laid out nursing care plan for future visits b. Documentation of assessment data and care given demonstrating the nurse's effectiveness c. Necessary documentation will depend on the agency policies and forms d. Completed Medicare forms per the Health Care Financing Administration (HCFA) regulations for reimbursement
d. Completed Medicare forms per the Health Care Financing Administration (HCFA) regulations for reimbursement Home health nurses often identify documentation as a frustration. Medicare holds a prominent position as a home health care payer; therefore, the HCFA's regulations determine the home health industry's documentation. Correct and accurate completion of required Medicare forms is the key to reimbursement. The forms require documentation of the nurse's care given.
Which of the following is the most important task to be accomplished during the initial home visit? a. Assess the client and the family b. Discuss social topics c. Educate the client and the family regarding the health problem d. Establish rapport and trust
d. Establish rapport and trust Many clients in need of nursing visits do not trust the health care system and are uncomfortable with the representative from an agency visiting their home. The nurse must build a trust relationship early in the visit or the client will not allow additional visits. Beginning with social topics is often a helpful tool to help establish trust and rapport. After rapport and trust have been established, the nurse can assess the client and family and provide education. Discussion of social topics would not be the primary task to accomplish during any nurse-client interaction.
Albrecht Model for Home Care
the relationship between the structural elements and the process elements directs the interventions. The nurse executes the nursing process, including assessment, nursing diagnosis, planning, intervention, and evaluation, and then the nurse coordinates patient care