PRN 0093 Christensen-Kockrow Foundations of Nursing Chapters 38 and 39
Long-Term Care
Long-term care is defined by the American Nurses Association (ANA) as the provision of physical, psychologic, spiritual, social, and economic services to help people attain, maintain, and regain their optimum level of functioning. Long-term care is provided in a variety of settings and offers a broad spectrum of services.
Setting for Long-Term Care
The Home
Most older adults live in a home setting, with only a small percentage of those aged 65 or older residing in an institutional setting. Care of the older adult at home may involve a great deal of participation from loved ones. It costs approximately half as much to care for an older adult at home as it would cost in a long-term care facility. Home patients may require only minimal assistance, or they might receive complex medical therapies.
Figure 38-1
Family is important in helping to maintain quality of life for the older adult.
Setting for Long-Term Care
Hospice
Provides services to patients and families as the end of life approaches. The philosophy of maintaining comfort as death approaches is central to hospice care. Provide nursing interventions to meet basic needs; ADLs; pain and symptom management; and spiritual and psychosocial support for the patient, family, and significant others. Care providers include CNAs, HHAs, LPN/LVNs, and RNs.
Setting for Long-Term Care
Adult Daycare
Community-based programs are designed to meet the needs of functionally or cognitively impaired adults through an individualized plan of care. These structured, comprehensive programs provide a variety of services, including physical care, mental stimulation, socialization, assistance with health maintenance, and health referrals, during any part of the day but providing less than 24 hours’ care. They are designed to serve adults who require supervision, social opportunities, or assistance due to a physical or cognitive impairment.
Figure 38-2
Available settings that provide long-term care services.
Setting for Long-Term Care
Residential Care Settings
Primarily an older adult population, offering a wide variety of services Assisted living
A type of residential care setting whereby the adult patient rents a small one-bedroom or studio-type apartment and can receive several personal care services
Continuing care retirement communities
Offer a complete range of housing and health care accommodations, from independent living to 24-hour skilled nursing care
Setting for Long-Term Care
Institutional Settings
Subacute Unit
This type of institutional setting provides a lessexpensive alternative to acute care when patients have high-acuity medical and nursing intervention needs. Most are located in freestanding skilled nursing facilities; others are former hospital units that have been reclassified to provide subacute care. They provide a stronger rehabilitative focus and shorter length of stay than a long-term care facility.
Setting for Long-Term Care
Institutional Settings
Long-Term Care Facility
Most dominant setting for long-term care services Commonly known as a nursing home or extended care facility Provides services to primarily older adults Provides 24-hour care to individuals who do not require inpatient hospital services but who do not have options for care at home or by other community agencies/services
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Because the long-term care facility becomes a home for the older adult, the adults are referred to as residents rather than as patients. Most residents have more than one health disorder when they are admitted, and more than half have three or more medical diagnoses.
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
The most common disorders on admission are as follows
Cardiovascular disease, including hypertension and cerebrovascular accident Mental and cognitive disorders, including depression, anxiety, and dementia Endocrine disorders, including type 2 diabetes mellitus and hypothyroidism
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Two categories of residents
Short-term: transferred from an acute care facility to which he or she had been admitted for an acute illness or worsening of a chronic illness; admitted primarily for rehabilitation and expected to be discharged within 6 months Long-term: usually stays in the facility until he or she dies or is transferred to an acute care facility. Most residents are long term.
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Interdisciplinary setting
Health care professionals work together as an interdisciplinary team to meet the needs of the older adult.
Facility is managed by an administrator and has a director of nursing (DON). These facilities are highly regulated by state and federal agencies to ensure quality services to a potentially vulnerable population.
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Restorative nursing care
Basic concepts of physical therapy for maintenance of functional mobility and physical activity; care is provided by CNAs who have completed an educational program for restorative care Defines requirements for the quality of care given to residents of long-term care facilities
Omnibus Budget Reconciliation Act (OBRA)
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Medicare
A federally funded national health insurance program in the United States for people over age 65 Provide funding to long-term care facilities by adhering to the HCFA guidelines for reimbursement
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Medicaid
A federally funded, state-operated program of medical assistance to people with low incomes A large source of revenue for the long-term care facility
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Several different types of nursing can be seen in this setting
Team nursing Functional nursing Total resident care Combination of the above
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
The interdisciplinary functional assessment of the resident is the cornerstone of clinical practice. Resident Assessment Instrument (RAI)
OBRA-prescribed method of resident assessment and care plan development Consists of three parts Minimum Data Set (MDS) Resident Assessment Protocols (RAP) Utilization Guidelines
Setting for Long-Term Care
Institutional Settings (continued)
Long-Term Care Facility
Documentation of the resident’s condition including vital signs and weights, is only required on a monthly basis. The exception to this charting is a condition change, acute illness, or incident reporting, which must be documented at or soon after the time of occurrence.
Nursing Process
Nursing Diagnoses
Aspiration, risk for Airway clearance, ineffective Gas exchange, impaired Cardiac output, decreased Nutrition: less than body requirements Fluid volume, risk for deficient Incontinence Thought process, disturbed Confusion, chronic
Nursing Process
Nursing Diagnoses (continued)
Self-care deficit Injury, risk for Mobility, impaired physical Skin integrity, risk for impairment Self-esteem, chronic low Grieving Anxiety Social isolation
Issues in Rehabilitation
Quality of Life versus Quantity of Life
Rehabilitation focuses on continually improving the quality of the person’s life, not merely maintaining life itself. Many conditions are irreversible; therefore, the focus of care is related to adaptation and acceptance of an altered life rather than to resolving an illness.
Care versus Cure
Rehabilitation Defined
The process of restoring the individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable Relearning of former skills; learning new skills necessary to adapt and live fully in an altered lifestyle Must begin from the very onset of a traumatic event or diagnosis of a chronic illness Every aspect of the individual’s needs and care assessed and addressed
Issues in Rehabilitation
High Cost of Interdisciplinary Care versus Long-term Care
Rehabilitation is expensive. Success is sometimes seen as a return to productive employment; may be if the individual becomes sufficiently independent that no caregiver is required.
Need for Rehabilitation
Need for Rehabilitation Precipitated by
Impairment
Any loss or abnormality of psychologic, physical, or anatomic structure or function Any restriction or lack of an ability to perform an activity in the manner or within the range considered normal for a human being
Disability
Need for Rehabilitation
Handicap
A disadvantage for a given individual resulting from an impairment or disability that limits or prevents fulfillment of a role that is normal for that particular individual Any loss of ability to perform tasks and obligations of usual roles and normal daily life
Functional limitation
Chronic illness
An irreversible presence, accumulation, or latency of disease states or impairments that involves the total human environment
Goals of Rehabilitation
All Rehabilitation Goals Shall
maximize the quality of life of the individual address the individual’s specific needs assist the individual with adjusting to an altered lifestyle be directed toward promoting wellness and minimizing complications assist the individual in attaining the highest degree of function and self-sufficiency possible assist the individual to return to home and community
Cornerstones of Rehabilitation
The cornerstones of rehabilitation may be seen as stepping stones on the “road to recovery”
Individually centered Community reentry Independence Functional ability Team approach Quality of life Prevention and wellness Change process Adaptation Patient/family education
Rehabilitation Team
Models of Team Functioning
Multidisciplinary Rehabilitation Team
Characterized by discipline-specific goals, clear boundaries between disciplines, and outcomes that are the sum of each discipline’s efforts Collaborates to identify individuals’ goals and is characterized by a combination of expanded problem solving beyond discipline boundaries and disciplinespecific work toward goal attainment
Interdisciplinary Rehabilitation Team
Rehabilitation Team
Models of Team Functioning (continued)
Transdisciplinary Rehabilitation Team
Characterized by the blurring of boundaries between disciplines, as well as by cross-training and flexibility to minimize duplication of effort toward individual goal attainment
Rehabilitation Team
Rehabilitation Nurse
Must have a broad knowledge base of pathophysiology of a wide range of medical-surgical conditions and a body of highly specialized knowledge and skills regarding rehabilitation Must believe that individuals with functional disabilities have an intrinsic worth that transcends their disabilities Specialized training necessary for the rehabilitation nurse to become an effective team member Practices in a variety of settings
Rehabilitation Team
Comprehensive Rehabilitation Plan
This is an overall individualized comprehensive rehabilitation plan of care. It is initiated within 24 hours of admission and ready for review and revision by the team within 3 days of admission for each individual. The plan is developed based on the results of the interdisciplinary admission assessment. All clinicians treating the patient will use this comprehensive plan of care.
Patient Education
Crucial for the rehabilitation process to be comprehensive An ongoing and integral process by which patients and families build knowledge, skills, and confidence to regain physical and psychosocial functioning following an illness or injury
Patient Education
The following five-step process may be used.
Assess the patient's and family’s needs, abilities, and concerns. Plan interventions based on these needs, abilities, and concerns. Implement the educational plan. Evaluate the educational plan. Review the educational plan.
Scope of Individuals Requiring Rehabilitation
Rehabilitation is a bridge for the patient, spanning the gap between
uselessness and usefulness hopelessness and hopefulness despair and happiness
The scope of conditions requiring rehabilitation is broad and spans the life continuum.
Family and Family-Centered Care
A philosophy that recognized the pivotal role of the family in the lives of children with disabilities and other chronic conditions Strives to support families in their natural caregiving roles by building on their unique strengths as individual parents Promotes normal patterns of living at home and in the community and views families and professionals as equals in a partnership committed to excellence at all levels of health care
Family and Family-Centered Care
Key Elements of Family-Centered Care
Incorporating into policy and practice the recognition that the family is the constant in a child’s life Facilitating family/professional collaboration at all levels of hospital, home, and community care Exchanging complete and unbiased information between families and professionals in a supportive manner at all times
Family and Family-Centered Care
Key Elements of Family-Centered Care (continued)
Encouraging and facilitating family-to-family support and networking Appreciating families as families and children as children; recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support
Gerontologic Rehabilitation Nursing
This specialty practice focuses on the unique requirements of older adult rehabilitation patients. The gerontologic rehabilitation nurse is knowledgeable about both techniques of caring for the aged and rehabilitation concepts and principles. The main goal is to assist older adult patients in achieving their personal optimal level of health and wellbeing by providing holistic care in a therapeutic environment.