Homework now will save emergency visits later
"Don’t worry, Mom; I’m not going to make you go to a nursing home. You’re not sick enough to have to leave your home. After all, home health nurses will be visiting to make sure you’re OK."
This is a familiar scenario for home health personnel. A family member makes a promise that may not be in the best interest of the patient. While environmental, safety, and even clinical issues can be addressed in most cases, what about cognitive problems?
"Being able to correctly assess cognitive problems is critical to keeping patients in their homes safely or to making a correct referral to another living arrangement," says Phyllis W. Fredlund, RNC, BSN, executive director for Health Personnel Inc. in McKees Rock, PA.
Medical conditions can cause impairments
"Cognitive impairments can be the result of medical conditions such as diabetes, depression, lack of oxygen, thyroid malfunctions, hearing loss, pain, or toxicity from a variety of medications," she says. "It’s important to conduct a thorough physical assessment that checks blood sugar and oxygen levels, temperature, blood pressure, and signs of infection."
The nurses at Health Personnel have a good working relationship with their physicians, Fredlund explains. "We can call and ask for extra blood work, urine cultures, or other lab tests if we suspect that any cognitive impairment is the result of an ongoing or a new disease. We have trained all of our nurses to conduct a thorough cognitive assessment so that we can give the physician a complete picture of the patient and what we suspect," she says.
An example of good detective work is the congestive heart failure patient who lived in an assisted-living facility but used emergent care four times within a month of being discharged from the hospital, Fredlund says. The patient’s physician told her not to use salt, but the home health nurse discovered that although no additional salt was added, the meals prepared for the patient contained foods in which salt was used in cooking, or foods that naturally contain high salt levels, she says. After the home health nurse worked with the assisted-living facility dietician to ensure that the patient did not receive foods with salt, the emergent care visits stopped, Fredlund adds.
Combine training and experience
The success with which Health Personnel nurses pick up on cognitive problems and their causes is the result of a combination of training and experience, Fredlund points out. "First, our patients have a primary nurse who sees them on each visit and gets to know them well enough to notice small changes in behavior. Secondly, we have a cognitive assessment checklist that prompts nurses to ask about sleep patterns, diet, ability to concentrate, mood, confusion, mental state, and ability to handle activities of daily living," she adds.
The agency also offers regular inservices on topics such as identifying and treating causes of confusion, interactions of medications that result in cognitive impairment, and evaluation of signs such as color of fingernail beds, Fredlund says. "It’s important that a nurse remember to check for pale or white fingernail beds for anemia and blue fingernail beds for respiratory problems that result in low oxygen in the blood," she explains.
Because home health patients often are on multiple medications, Fredlund emphasizes the importance of understanding interactions. "A pharmacist can explain interactions of medications, but we also had a pathologist conduct an inservice that explained the physiological interaction of medications with other medications as well as with physical conditions. "It’s important to realize that some antianxiety or antidepressant medications as well as pain medications can actually increase confusion and mask other symptoms," she adds.
Being alert to even the smallest changes in a patient’s cognitive behavior also is important, Fredlund adds. When one of her nurses made a visit to an elderly, mentally disabled patient who never has been able to communicate, the nurse noticed that the patient seemed less alert than normal in terms of responding to prompts or activities of the nurse with her eyes or head motions, she explains. "The nurse took the patient’s temperature and discovered a fever, then listened carefully to the patient’s lungs where she heard rales," Fredlund says. After calling the physician and getting a chest X-ray for the patient, a diagnosis of pneumonia was made.
"This is a good example of the nurse catching a minor change in cognitive behavior that was a result of an illness," she adds.
Family members often make promises that may not be in the best interest of the patient. While environmental, safety, and even clinical issues can be addressed in most cases, what about cognitive problems?
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content