Nursing Care of Patients at Home - Chapter 16

The nurse is making a first-time visit to a patient at home. Which of the following techniques could the home health nurse use to develop trust with the patient? 1. Review patient's history to plan patient needs before visit. 2. Call the night before the visit to set a time for the visit. 3. Acknowledge patient's fears that are expressed. 4. Discuss treatment plans with the patient only.

(1) is correct because it shows caring, understanding, and insight into the patient's needs. (1, 2, 4) are incorrect.( 2) is part of the process for making a visit but does not influence trust. (3) should be done as needed as part of providing nursing care but does not influence trust. (4) reflects confidentiality requirements, but others may be included with patient's permission such as family members as well as other health care team members involved in the patient's care.

The LPN is visiting a patient to check blood glucose and administer insulin. As the LPN obtains the insulin from the refrigerator where the patient stores it, the LPN observes that dirty dishes are stacked in the kitchen sink, and there is only a moldy opened can of soup, a sandwich, and cat food in the refrigerator. Which of the following actions should the LPN take regarding the visit findings? 1. Inform the RN of the moldy and sparse food. 2. Tell the patient to wash the dishes. 3. Notify the RN that the patient is eating cat food. 4. Wash the dirty dishes.

(1) is correct so that the RN can perform an assessment and determine an appropriate plan of action. (2, 4) are not correct because it is inappropriate to direct the patient as to what to do in the patient's own home and washing the dishes is not the LPN's function. (3) is not correct because this is an assumption that may not be true and requires assessment by the RN.

The nurse is visiting an 89-year-old woman in the home to assess the need for skilled nursing care after a fall resulting in a broken collarbone. Which of the following should be included in the nurse's initial visit? Select all that apply. 1. Identify fall risks in the home environment. 2. Observe the patient perform activities of daily living. 3. Collect baseline vital signs. Obtain a urine sample for culture and sensitivity. 5. Review patient medications and schedule.

(1, 2, 3, 5) are correct. The nurse should perform a complete patient assessment during each visit. Assess the home environment for potential safety hazards and need for devices to assist with care. (4) Collecting a urine sample is not ordered or necessary.

Which of the following could the nurse do to prepare for a home health visit and ensure that it is a safe and effective visit? Select all that apply. 1. Give the patient a time range for arrival. 2. Provide an exact time for arrival. 3. Obtain driving directions to the patient's home. 4. Park in the patient's driveway. 5. Keep gas tank filled. 6. Carry a whistle.

(1, 3, 5, 6) are correct. (2) is not usually possible, so a time range should be given. (4) is not done for safety but so that the nurse's car is not blocked in.

The nurse arrives at a patient's home. Which of the following interventions performed by the nurse would demonstrate understanding of the importance of following infection control principles in the home? 1. Setting the nurse's home health bag on the floor 2. Cleaning supplies after each home health visit 3. Hand washing in the patient's kitchen sink 4. Using dressing supplies sitting opened on a table

(2) is correct. (1, 3, 4) are incorrect because they promote the risk of infection.

The nurse is making a home visit to a 68-year-old patient and is reinforcing medication teaching that was done in the hospital setting. The nurse understands that the teaching will be more effective with which of the following techniques? Select all that apply. 1.Provide a long teaching session. 2. Include a support person. 3.Make instructions simple. 4.Provide demonstration. 5. Repeat instructions often.

(2, 3, 4, 5) are correct to promote learning. (1) is incorrect because information should be provided in brief, organized concepts to allow learning and retention

1. Which of the following nursing leaders demonstrated the impact nurses can have with the care and improvement of patients in the home? 1. Florence Nightingale 2. Clara Barton 3. Lillian Wald 4. Jean Watson

(3) is correct. (1, 2, 4) are incorrect because those individuals were involved in nursing in other ways

A patient has just been discharged from the hospital after open heart surgery. The patient's spouse is the primary caregiver and confides that handling all of the finances, the patient's complex medication regime, assistance with ADLs, and general household manage ment is a concern. Which of the following would be an appropriate nursing diagnosis for the patient's spouse? 1. Ineffective Coping 2. Powerlessness 3. Ineffective Health Maintenance 4. Risk for Caregiver Role Strain

(4) is correct because the spouse is the caregiver. (1, 2, 3)are incorrect as they do not relate to the caregiver

3. When providing care to a patient in the patient's home, the nurse understands that which of the following persons is in control of the home care environment? 1. Family 2. Health care provider 3. Nurse 4. Patient

(4) is correct. (1, 2, 3) are incorrect because the patient is in control in the home environment.

The nurse collects safety data on an initial visit to the home of a patient who has returned home from the hos pital and has an infected abdominal wound requiring dressing changes. Which of the following interventions should the nurse include in the plan of care to promote safety in the home? Select all that apply. 1. Explain to the patient never to get out of bed without assistance. 2. Instruct a family member to be available at all times to assist with ambulation. 3.Clean the patient's home each visit to maintain asepsis. 4. Instruct the family to remove all scatter rugs. 5. Ask family to install handrails in the hallway for ambulation. 6. Clear walkways of all clutter.

(4, 5, 6) are correct and are general safety measures for any person who is ambulating. (1, 2) are incorrect as the patient may need to get out of bed or ambulate when others are not there—the means to do so safely should be provided. (3) is not a skilled nursing function. If there are concerns with housekeeping, it can be discussed with family and possibly addressed with other services.

Communication

* A process in which messages are exchanged between a sender and a receiver * Is successful when the receiver interprets the sender's message as it was intended

Open-Ended Questions

* Cannot be answered with a yes/no answer * Requires a more complete response and are used to encourage patients to provide more detailed information of explanations

Active Listening

* Characterized by focusing fully on what a speaker is saying * Requires concentration, attention, and observation

Communication goals

* Gather as much objective and subjective information as possible from a patient * Instruct individuals on postsurgical home care procedures so family members will understand and follow them correctly * Inform a patient about the benefits of the treatment procedure you are administering * Report patient care information to a coworker who is taking over the care of the patient

Nonverbal Communication

* Included tone of voice, body language, gestures, facial expressions, touch, and physical appearance * Up to 70% of the meaning of messages is expressed nonverbally

Communication Barriers

* Language differences * Cultural differences * Defense mechanisms * Physical distractions * Sensory impairments * Medication effects * Pain

Telephone Communications

* Often provides the first means of contact between patients and health care facilities

Patients with Special Needs

* Patients who are terminally ill * Patients who are in pain, medicated, confused, or distorted * Patients who have hearing, visual, or speech impairments * Patients who are angry * Patients that do not speak English

Probing Questions

* Requests for additional information or clarifications. * Can be used to lead a patient to more fully discuss the symptoms being experienced

Guidelines for Telephone Communication

* Speak clearly and pronounce words correctly and distinctly * Speak at a moderate rate of speed. When giving instructions or directions, speak more slowly * Strive for a pleasant tone, not too high-pitched * Project warmth, friendliness, and caring * Smile as you speak unless it in inappropriate in the situation * Put expression in your voice. Avoid speaking in a monotone * Allow appropriate periods of silence to give the opportunity to speak * Never chew gum or eat when speaking on the telephone

Communication and Patient Well-Being

* The ability of health care professionals to communicate effectively is influenced by their attitude * Health care professionals can help relieve patient stress by showing compassion, providing information, and answering questions * Good communication has been shown to increase the speed of patient recovery

Sender

* The person who creates and delivers a message * Also known as the speaker

Receiver

*The person to whom the sender directs the message

The nurse is to give a patient morphine 8 mg intra muscular for pain. The nurse has available 10 mg of morphine/mL. How many mL will the nurse give?

0.8 mL is correct.

7.The nurse is determining if a patient is eligible for home-care services. Which criteria would exclude the patient from receiving home health services? 1. Driving daily2. Being generally housebound3. Attending church or special events4. Needing physical or occupational therapy

1 To receive home health care, the patient generally must be housebound, but may attend special events, church, and medical appointments. If a patient drives daily, the need for home health care is questioned. The person who drives daily can get to a clinic for blood pressure readings or to an outpatient physical or occupational therapy program.

10.During a weekly scheduled visit, the nurse notes that a 75-year-old patient recovering from knee surgery goes to the bathroom frequently and has wet clothing, a temperature of 100.5°F, and a slightly rapid pulse. What action(s) should the nurse take? Select all that apply.1. Document findings.2. Observe symptoms at the next visit.3. Report the findings to the supervising RN.4. Provide the patient with incontinence pads.5. Encourage the patient to use an incentive spirometer tid.6. Immediately contact the patient's HCP.

1 , 3 ,4 The findings are significant and suggest a possible urinary tract infection, which in an older person can lead to serious complications. The findings should be reported to the RN, who will contact the HCP. In the meantime, the nurse could explain to the patient that incontinence pads could be used temporarily until the patient becomes more mobile and the frequent urination problem resolves; the nurse should note that use of the pads would increase the patient's comfort. The use of an incentive spirometer is common after surgery, but will not alter this patient's symptoms.

3.During the initial home health care visit, the RN identified the diagnosis Ineffective Self-Health Management as appropriate for an older patient newly diagnosed with type 2 diabetes mellitus and heart failure. Which action(s) should the nurse take on the next visit to support this patient's needs? Select all that apply.1. Review the use of the home glucometer.2. Assess the patient for any changes in health status.3. Contact community agencies to establish services for the patient.4. Review the home for any previously identified or new safety hazards.5. Answer any questions the patient may have about eductional materials provided during the first visit.

1 ,2 ,4 ,5 Actions to support the diagnosis of Ineffective Self-Health Mangement include reviewing the use of the home glucometer, assessing the patient for any changes in health status, reviewing the home for safety hazards, and answering questions about educational materials. The social worker is responsible for contacting community agencies to establish services for the patient.

12.The home health agency administrator is planning an orientation for new staff hired to provide care through the agency. Which individual(s) should the administrator include when discussing the members of the home health team? Select all that apply.1. Social worker2. Speech therapist3. RN4. Financial planner 5. Physical therapist 6. Occupational therapist

1, 2 ,3, 5 ,6 Members of the home health team include social worker, speech therapist, RN, physical therapist, and occupational therapist. The financial planner is not a member of the home health team.

4.The nurse is hired to provide private duty care to an older patient in the home. What task(s) should the nurse expect to complete when providing care to this patient? Select all that apply.1. Assisting with filling medication dispensers2. Engaging in recreational activities with the patient3. Completing the patient's personal banking and writing bills4. Providing family members with a respite from providing care5. Spending 2 to 3 hours each day with the patient in his or her home

1, 2 ,4 ,5 Private duty nursing consists of scheduled care to assist patients with personal and homemaking needs. Many of these services focus more on companionship and respite care. Families who are taking care of a patient with complex needs may need time away from the home to complete personal tasks. Families can contract with an agency to have a staff member spend 2 to 3 hours a day in the home. The staff can complete homemaking tasks and companion tasks such as arts and crafts or playing cards. Nurses can work in these agencies in the role of supervisor to unlicensed assistive personnel (UAP). Nurses also may be involved in helping patients fill weekly medication dispensers. Working with a patient's finances is not an identified activity in the role of private duty nurse.

8.The nurse desires a position as a home-care nurse. What can the nurse do to prepare for providing care in patients' homes? 1. Obtain at least 1 year of acute care nursing experience.2. Return to school to obtain an advanced nursing degree.3. Learn the major streets and neighborhoods in the community.4. Attend continuing education programs to learn patient education strategies.

1. Because home health care is autonomous, most agencies require at least 1 year of medical-surgical nursing experience. This helps ensure that the nurse has the basic knowledge needed to work in home care. An advanced nursing degree is not required to work as a home-care nurse. Learning the major streets and neighborhoods is not a required of a home-care nurse. Learning patient education strategies would be beneficial for any nurse who provides direct patient care.

5. What steps can the home health nurse take to ensure that a patient is not exposed to infectious materials in the home? 1. Disinfect the home health bag after each patient visit with a germicidal spray supplied by the home health agency. 2. Perform hand hygiene in the kitchen sink rather than the bathroom sink. 3. Use the same red bag from patient to patient for disposing of soiled dressings. 4. If a chemical spill occurs, contact the agency to send personnel to clean it up.

1. Disinfect the home health bag after each patient visit with a germicidal spray supplied by the home health agency. 1. Infection control is an important function of the home health nurse, and disinfecting the home health bag is important.

2. Which of the following are members of the home health team? Select all that apply. 1. LPN/LVN 2. Health care provider 3. Social worker 4. Home health aide 5. Lawyer 6. Patient

1. LPN/LVN 2. Health care provider 3. Social worker 4. Home health aide 6. Patient 1, 2, 3, 4, 6. All are team members except a lawyer.

Messages

1. Orally 2. Nonverbally (facial expressions, gestures) 3. In written form 4. Electronically

Six Steps of the Communication Process

1. Set communication goals - determine what is to be accomplished. 2. Create the message - select and organize appropriate content based on the communication goals 3. Deliver the message - choose the delivery method best suited for ensuring that the receiver will understand the intent of the message 4. Listen to the response - employ listening and observational techniques to determine whether the message was received as intended 5. Offer feedback and seek clarification - rephrase what is heard or ask questions to check your understanding of the response 6. Evaluate the encounter and revise the message - determine whether the goal was met.

Patient Education

1. Set educational goals 2. Create the instructional message 3. Deliver the instruction 4. Listen 5. Check for understanding (use feedback and seek clarification) 6. Evaluate

11.The nurse is determining a patient's eligibility for home-care services. Which patient activity should the nurse recognize as potentially disqualifying the patient as homebound? 1. The patient can't read.2. The patient drives to Bingo every day.3. The patient uses a local bus service to attend church weekly.4. The patient requires complex sterile dressing changes daily.

2 If the patient is able to drive, then the patient should be able to self-transport to health care services. Reading, leaving the home to attend church, and needing complex sterile dressings all qualify the patient as having homebound status.

2.Upon entering a patient's home for the first home-care visit, the nurse determines that a variety of safety hazards are present. Which observation(s) should the nurse discuss with the patient as potential home safety hazards? Select all that apply.1. Hot water temperature is set at 120°F.2. Lightbulb in the patient's bathroom is burned out.3. Extension cord from a power outlet is extended over a walkway.4. Bannister on the stairwell leading up to the patient's bedroom is loose.5. Books are stacked along each of the steps leading down into the basement.

2, 3 ,4 ,5 Safety hazards in the home that the nurse should address with the patient include having the lightbulb in the bathroom replaced, removing or rerouting the extension cord that is stretched across the walkway, having the bannister repaired, and removing the books on the stairs. A temperature of 120°F is a safe hot water temperature.

13.The nurse is completing a visit to the home of a patient recovering from a stroke. The patient is prescribed a thickener for fluids and occasionally coughs when eating. Which home-care service should the nurse recommend for this patient? 1. Social worker2. Speech therapy3. Physical therapy4. Occupation therapy

2. A speech therapist focuses on language, speech, and swallowing. Since the patient is prescribed a thickener and occasionally coughs when eating, the services of a speech therapist should be considered. There is no information to support the services of a social worker or physical or occupational therapist.

4. An LPN/LVN has started working for a local home health agency and is concerned about the transition to home health nursing after working in the hospital for 10 years. What are some recommendations that would ease this transition for the LPN/LVN? 1. Explain that home health nursing is just like hospital nursing. 2. Instruct the nurse to always be prepared, to keep paperwork organized, and spend some time the night before a visit to review patient health information to help gain confidence in the home. 3. Allow an opportunity for exploring feelings and acknowledging that this is a hard transition. 4. Let the nurse know it is not possible to completely adjust to home health nursing because of variability in the home.

2. Instruct the nurse to always be prepared, to keep paperwork organized, and spend some time the night before a visit to review patient health information to help gain confidence in the home. 2. Organizing the night before a visit will instill confidence in the nurse and the patient during the visit.

6.After a home health visit, the nurse is completing a tool to document patient care, outcomes, and reimbursement for the skills the patient will need. Which mnemonic should the nurse use when completing this tool? 1. PES2. BITES3. OASIS4. CAUTION

3 The Outcome and Assessment Information Set (OASIS) is a tool used to generate information about a home health agency, patient plan of care, and outcomes; it also provides information pertinent for Medicare reimbursement to the home health agency. CAUTION is a mnemonic that lists warning signs of cancer, and BITES is for assessing side effects of chemotherapy or radiation. The mnemonic PES has no clinical significance.

5.The nurse is making a visit to the home of a patient with diabetes. What should the nurse do prior to checking the patient's blood glucose level? 1. Wear sterile gloves.2. Prepare a sterile field.3. Wash hands in the kitchen sink.4. Wash hands in the bathroom sink.

4 The bathroom sink, rather than the kitchen sink, is used by staff to wash hands, and a sterile field is not necessary for a glucose check. Sterile gloves are not needed to assess a patient's glucose level.

9.The nurse is telephoning patients to schedule a visit for the current day. Which approach should the nurse use when scheduling the visit with the patient? 1. State that the visit will occur at exactly 1200.2. State that the visit will occur sometime in the morning.3. Explain that the visit should be complete within 2 hours.4. Explain that the visit should occur within a pre-determined 1- to 2-hour window.

4 Each patient needs to be contacted and given a 1- to 2-hour window for the nurse's arrival time. Since the nurse cannot anticipate what is going to happen during a visit, it is better to give a time range as opposed to an exact time. The nurse needs to be more exact than stating that the visit will occur sometime in the morning. The length of the visit cannot be determined at this time.

3. A patient is being seen by home health nurses for monitoring of weight and vital signs and education about medication changes following an acute exacerbation of heart failure. The nurse must document which of the following? 1. What the patient ate for breakfast 2. Distance the patient was able to ambulate while working with physical therapy 3. Education about the role of the home health aide in assisting the patient with personal care 4. Education about how to keep a log of daily weights and when to contact the HCP about a potential problem

4. Education about how to keep a log of daily weights and when to contact the HCP about a potential problem 4. The performance of the skills related to the purpose of the visit must be documented for reimbursement.

1.The health care provider (HCP) has prescribed home health care visits for an older patient recovering from abdominal surgery. After receiving the order, what is the first step taken to implement the prescribed order? 1. The registered nurse (RN) discusses home health care with the patient's family, and together they decide on what is needed.2. The home health aide visits the patient and reports activities of daily living (ADLs) that the patient cannot do independently.3. The social service department coordinates community resources, such as Meals on Wheels, financial assistance, and transportation, to assist the patient.4. The RN visits, completes the initial assessment, establishes a plan of care that includes the frequency with which visits are required, and reports to the HCP.

4. The RN visits, completes the initial assessment, establishes a plan of care that includes the frequency with which visits are required, and reports to the HCP. The RN is considered the case manager and makes the initial assessment of the patient and the specific home health needs, establishes a plan of care, and submits it to the HCP for approval. Then the plan is put into action, with scheduled visits by licensed practical nurses (LPNs), home health aides, and therapists as needed to help the patient reach the best possible health. The members of the team give the RN periodic reports on changes made to the plan of care, and these are submitted to the HCP as necessary. The family may be consulted and kept informed, but the family does not decide what the patient needs; that is the collaborative responsibility of the patient, the RN, and the HCP. Copyright © 2015 F.A. DAVIS, All Rights Reserved.

1. What impact did Lillian Wald have on the nursing profession? 1. Allowed nurses to function as medical care providers. 2. Demonstrated the impact nursing can have on patients' health and wellness. 3. Made it possible for nurses to obtain prescription drugs for patients in the home. 4. Developed the Henry Street Settlement in 1890.

4. Wald established the Henry Street Settlement in New York City, which laid the groundwork for establishing home care as a nursing specialty.

Feedback

A method for the receiver of communication to check his or her understanding of what the sender has said

Closed-Ended Questions

Can be answered with a yes/no answer

Reflecting

Communication technique that involves prompting the sender to either complete of add more detail to the original message

The Communication Process

Consists of simply talking and listening

Leading Questions

Questions in which all or part of the answer is included in the wording of the question

Paraphrasing

Rewording the sender's message in the listener's own words and asking the sender for confirmation

Empathy

Striving to understand another person's thoughts, feelings, and behavior