Event 2: Home Health Nursing

In this Home Health Nursing’s event, you will look at six snippets which include a summary of a physical exam, home safety, pain assessment, medication review, and nutritional status. You will also have a chance to examine “Lock Your Meds.”

Past Medical History

• Osteoarthritis
• Previous knee injury in high school and in his 20’s (Vietnam War)
• Highly stressful and anxious about his prior physical therapy treatment during the Vietnam War. He experienced excessive overpressure and pain during his therapy.
• benign prostatic hypertrophy (BPH)
• Hypertension
• Myocardial infarction, age 53 and cardiac rehab was successful, no subsequent problems/clinical sequela

Nursing Physical Exam

• Alert and oriented
• Neck has no lymphadenopathies
• Thyroid gland palpable, no nodules
• Lungs clear bilaterally
• Heart sounds S1S2 present and no irregularities
• Abdomen:  Soft, no tenderness, no masses palpable, no rebound, no hepatosplenomegaly; bowel sounds present
• Lower Extremities: 2+ peripheral pulses bilaterally, 
• Left leg: no edema or ecchymosis of left leg, normal motion 
• R Ankle: full motion, no warmth or erythema, 
• R Hip no pain to palpation, decrease ROM in flexion due to knee pain
• Right knee-swelling noted to right leg to mid-calf without tenderness
• Right Knee Motion:  15-85 in seated position
• Visual Inspection: mild ecchymosis noted around incision, skin without warmth or erythema, incision tender with motion and to palpation; swelling present  from proximal knee to the ankle

Home Safety

Home Safety Concerns

• Floors and Pathways
• Lighting 
• Handrails 
• Kitchen
• Bathrooms
• Bedrooms
• Vision
• Medication Safety

Donald's Apartment

• Good lighting at night bathroom and hallways for night time
• Removal of throw rugs bathroom and kitchen
• Walkways big enough for rolling walker in all areas of the home
• Medication – lock up medications

Pain Assessment

Pain with Activity and Location

Pain Description

Pain Interference

Goal For Pain and Function

Medication Review

Medication Changes

Current Medications

Medications Location

Medications Storage

Nutrition Status

Assessment

• Body Weight
• Height
• BMI
• Changes in Weight
• Diet History
• Physical Activity

Donald's Information

• Height: 6 feet, 0 inches
• Weight: 170 pounds
• BMI is 23.1, Normal range (136 to 184 pounds)
• No change in weight with hospitalization
• Diet History: Follows cardiac diet
• Physical Activity: Light to moderate activity
• Overall Nutrition Status: Good
• Has meals provided 2 times a day at his apartment complex

Lock Your Meds

• Lock Yours Meds™ is a national campaign to combat prescription drug abuse.  
• The purpose of this campaign is to keep prescription and over the counter pharmaceuticals away from drug abusers of all ages.
• The most commonly misused medications are opioids, central nervous system depressants and stimulants.
• 6.5 million Americans abuse prescription drugs(2013).
• Medication concerns for older adults is easy accessibility by family or other teenagers who may misuse analgesics.

Learn more: http://www.lockyourmeds.org/wp-content/uploads/2017/01/LYM-MEDucation-Kit-Final.pdf

Test Your Knowledge

Locking Storage for Donald

Which locking storage would you pick for Donald?

Home Health Nursing Acute Pain Management Plan

Dorothy, the Home Health Nurse, has completed her initial home health visit. Here is her visit summary:

Donald has a moderate degree of pain and swelling in his right knee following his total knee arthroplasty with mobility limitations.

Acute Pain Management Plan

• Acetaminophen and non-pharmacological approaches for his acute pain management.
• Donald should take his medications at the correct dose and frequency .
• Donald is to gradually increase his activity, elevate his right knee 2x day to reduce discomfort and swelling.
• Donald will use a cold pack for swelling and pain reduction for his knee pain as needed up to every 2 hours for 10 minutes.
• The nurse will follow up 2 times per week and recommends Social Services, Physical and Occupational Therapy to help meet Donald’s acute pain management goals

Social Services Acute Pain Management Plan

• Continue medications and activity as directed by your primary care provider, nurse, physical and occupational therapist
• Continue to increase your interaction with friends and family as distraction, humor, and social activities can all help with reducing pain.

Physical Therapy Acute Pain Management Plan

• Donald has limitations in range of motion and strength following his right knee surgery.
• Continue medications and activity as directed by your primary care provider, nurse, social service and occupational therapy.
• Continue with your home exercise program, activity and increasing your walking as directed to help reduce your pain and swelling. His pain was reduced after therapy sessions with exercise and walking.
• Use a cold pack for swelling and pain reduction for his knee pain as needed up to every 2 hours for 10 minutes.
• Elevate your knee above your heart 2 times a day for 30 minutes by laying on your bed and elevating your leg to help reduce your swelling.

Occupational Therapy Acute Pain Management Plan

• Donald has limitations in range of motion and strength following his right knee surgery. He has some weakness in bilateral upper extremities and limitations in the length of time to complete his self-care activities and activities around his home.
• Continue medications and activity as directed by your primary care provider, nurse, social service and physical therapy.
• Continue with your arm home exercise program and increasing your walking as directed to help reduce your pain and swelling.
• Continue interaction with friends and activity to decrease pain.
• Continue to increase our activity as able to help reduce pain.

Plan of Care

1. Nursing:
   • Ready to discontinue Nursing
   • Able to lock medications, taking and storing medications appropriately
2. Pharmacy
   • Independent with medication taking and understanding
3. Physician
   • Recheck at six weeks for motion, strength, walking and medication review.
4. Social Service
   • Ready to discontinue Social Service
   • Patient to call if needed
5. Physical therapy
   • Progress to outpatient physical therapy
   • Independent with Home Exercise Program (HEP) for lower extremities; progress in PT.
   • Utilizing cane for walking on level surfaces and stairs; progress to independent with physical therapy.
6. Occupational Therapy
   • Discontinue Occupational therapy
   • Independent with HEP for upper extremities 2-3 times a week.
   • Independent with home activities and able to resume community activities.

Acute Pain Management Plan

Continue to take medication as directed. Utilize non-pharmacological strategies to decrease pain and increase activity including home exercise program, elevation and ice as needed. Increase social activity and interaction as able to assist in pain reduction.