Deactivation of automatic implantable cardioverter-defibrillators in hospice and home care patients at the end of life

For patients at the end of life, active automatic implantable cardioverter-defibrillators (AICDs) may no longer achieve the treatment goals present at the time of implantation. It is possible to deactivate AICDs in patients with terminal and life-limiting diagnoses, thereby preventing the pain and distress of nontherapeutic discharge. This article presents a moral argument for the right of such patients to have their AICDs deactivated. It then explains that hospice and home care agencies have an obligation to address AICD deactivation at a policy level and offers recommendations for doing so.     

Determining risk status in a primary care setting.

Nurses working in primary health care settings often care for large numbers of clients in brief periods of time. Both clients and nurses express frustration toward the care provided in these circumstances. Development of a screening tool to identify high-risk clients could assist nurses in targeting interventions to these individuals; in turn, this has the potential for increasing nurse and client satisfaction. A general procedure for identifying persons at risk in primary health care settings is described. The procedure is illustrated with a specific population of clients--incarcerated women. Factors found important in assessing risk were social characteristics such as education, situational factors such as sentence length, and indicators of psychological distress such as depression. These broad categories may serve as a basis for the development of screening tools for a variety of populations.     

End-of-life competencies and the NCLEX-RN examination.

With the aging of the population, health care workers must be prepared to deal with clients and families facing end-of-life (EOL) issues. Nurses, as one of the primary providers of care and the largest professional group to provide care, can make a significant impact on EOL care. This article uses 15 nursing competencies that have been identified as important in providing high-quality care to clients and the families of clients at the end of life and delineates where these competencies are addressed in the 1998 NCLEX-RN Test Plan. Available resources that provide information on EOL content are mentioned as well as how to become involved in the NCLEX item development process.     

Acculturation and adherence: issues for health care providers working with clients of Mexican origin.

Providing care to clients who come from different countries is a challenge for the American health care providers as they traverse the issues of cultural health beliefs and practices and language and knowledge deficits. It is just as difficult for the clients as they face new cultural customs, language barriers, and unfamiliar health care systems and medical management plans. Both parties face acculturation and adherence challenges. This article intends to address these issues as they pertain to clients of Mexican origin and to identify key points to be considered by providers when working with this population.     

Acoustic neuroma: nursing implications related to surgical management.

Acoustic neuromas are benign tumors originating from the Schwann cells of the eighth cranial nerve. Symptoms occur related to compression and stretching of cranial nerves which alters their function. Surgical management is by middle fossa, translabyrinthine, suboccipital or combined approach craniotomy. Prevention and early recognition of postoperative complications are important aspects of nursing care for these clients. A holistic approach to client and family nursing needs is presented. Discharge planning should include assessment of client learning and home care needs. The Acoustic Neuroma Association as a source of information and support for these clients is discussed.     

Respite for caregivers. A community-based model in a rural setting

Currently in the United States, 4 million Americans suffer from Alzheimer's disease (AD), and projections are that this population will increase to 7 million by the year 2040. Traditionally, care for these clients is provided by family, relatives, and friends--an informal caregiver network (ICN). Changing demographics in the United States are threatening this caring network. When these factors are coupled with the recent emphasis on cost containment in health care, caring for this client population has become a significant political, economic, and societal issue. Strategies must be developed to meet the needs of both the clients and their caregivers. Respite services have been identified as an effective strategy in the ongoing management of clients with AD. A model is proposed to provide community-based respite services in a rural setting in northeast Georgia. The need for respite services, along with barriers to the use of such services by clients and their caregivers, is described. Strategies to overcome barriers and provide needed services in a cost effective and sensitive manner are presented. Implications for nursing and related disciplines are discussed.     

Home visiting for a posthysterectomy population.

There are many valid indications for providing home visits to posthysterectomy clients. In-home assessment of the client's status permits immediate care or referrals and saves unnecessary acute care visits to emergency rooms and physicians' offices. Nursing interventions have identified holistic healthcare needs and prevented other problems from developing. Assisting the clients in developing their problem-solving abilities enhances the goal of return to self-care during the immediate postoperative follow-up and afterward. Finally, the vital role the clinical nurse specialists can play in the healthcare system is more clearly established for these consumers of care.     

Postacute care organizations: a solution for Medicare risk HMOs.

A postacute care organization is a company that contracts with HMOs and other types of insurers and risk-bearing groups to ensure the health plan's appropriate and cost-effective use of medical services available outside of the hospital setting. Through proactive and intensive case management of patients and postacute care providers, these organizations minimize inappropriate or unnecessary hospitalizations and deliver the following results to clients: reduced overall medical costs; higher quality postacute care services; increased plan retention of members through increased patient, family, and provider satisfaction. Postacute care organizations represent a solution for Medicare Risk HMOs and other health plans who are experiencing great difficulty in managing the financial risk and operational challenges related to their benefit plans for higher risk groups. Coordinated Care Solutions, Inc. (CCS) is an example of a company meeting the rapidly growing demand for postacute care management services. This article describes why there is a need for these services and studies CCS's model of delivering postacute care management services and value to its clients.     

Multiple sclerosis: will it come between us? Sexual concerns of clients and their partners.

Multiple sclerosis (MS), an unpredictable neurologic disease, is sometimes called the crippler of young adults. This crippling effect often involves sexual functioning. Sexuality is an issue that is frequently difficult for clients, their partners and health care providers to discuss. To address this difficulty, a teaching pamphlet entitled, MS ... Will it Come Between Us? was produced. Open communication and creativity are helpful in dealing with problems frequently encountered by clients with MS: fatigue, impotence, decreased vaginal lubrication, bladder and bowel dysfunction. The pamphlet helps clients with these issues as well as the basics of sexuality as a whole.     

A six-month profile of community case coordinated older adults.

The purpose of this study was to assess the needs of older case coordinated clients receiving community health services, by examining changes in cognitive status, physical and mental health status, social support, risk for institutionalization, and service use over a 6-month period from initial intake into home care. Significant predictors of professional and supportive home care, as well as emergency room use and hospital days, were also examined. Standardized interviews were conducted with 234 clients at the time of referral; follow-up interviews were conducted with 179 of these clients after 6 months of case coordination. Results reveal that physical and mental health improved, while cognitive status remained stable. Although social interaction and instrumental support decreased, subjective support remained stable. Risk of institutionalization decreased. Occupational therapy, nursing, and homemaking were the most frequently used services.The best predictor of professional and supportive home care was a risk of institutionalization score.The needs of this older adult population changed even within the relatively short span of 6 months. Frequent review of needs in some form may be warranted in order to maintain effective service plans.     

Pressure sore and skin tear prevention and treatment during a 10-month program.

This article reports the results of a 10-month skin care program for 30 clients on a residential Alzheimer's disease unit. The majority (n = 26) of the clients were free of pressure sores and skin tears through preventive care during this study. Four clients with Stage I pressure sores and/or skin tears were successfully identified by consistent assessment and healed quickly due to rapidly initiated treatments. This skin care program's success was attributed to consistent education, preventive care, assessment, documentation, and treatment executed by the entire care team under the leadership of nurse practitioners, one of whom was certified as a rehabilitation nurse.     

Critical care nursing and delirium management in the mentally ill client

The critical care environment is an experience of stress for the patient and the practitioner. Turbulence can occur during the critical care course, which can cause exacerbation of chronic conditions. These exacerbations can lead to delirium and/or psychosis. Nursing professionals must be alert to changes in all conditions which increase morbidity and mortality in the critical care patient. Although critical care nurses may feel unable to care for the psychiatric needs of clients with a chronic mental disorder, implementing tools to aid in assessment will empower the nurses. Truly, the key to viewing all clients is wholly, rather than by diagnosis. Critical care nurses care for clients with many comorbidities and illnesses. Many conditions may be a new experience. Mental disorders should not be viewed as being out of the scope of the critical care nurse. On the contrary, mental disorders are chronic conditions, not unlike diabetes mellitus or congestive heart failure. What the critical care nurse needs is a knowledge base in order to feel more comfortable in caring for these clients. Knowledge is empowerment.     

Transcultural nursing: providing culturally congruent care to the Hausa of Northwest Africa.

Research around the world is now beginning to validate the theory of Cultural Care as an important means to provide culturally congruent care to clients, families, and groups of diverse cultures. Knowledge of Leininger's Theory of Cultural Care Diversity and Universality can provide meaningful care to clients who have different traditional and current beliefs and values. The Leininger Sunrise Model can serve as a valuable guide to discover care meanings and practices related to the theory, and to provide practical and meaningful culture specific care decisions and actions by nurses. The three major modes of action, namely, cultural care maintenance or preservation, accommodation or negotiation, and repatterning or restructuring, are important differential means to provide culturally congruent care to clients within their own cultural setting. This article considers the application of such care for the Hausa of Northwest Africa.(ABSTRACT TRUNCATED AT 250 WORDS)     

Unplanned hospital readmissions: a home care perspective

BACKGROUND: The extensive literature concerning hospital readmissions is grounded in a medical or hospital perspective, and fails to address hospital readmissions during home care. OBJECTIVES: To describe clients who have unplanned returns to an inpatient setting during the first 100 days of home care service delivery. METHOD: Using the Hospital Readmission Inventory (HRI), an audit tool with previously established validity and reliability, 916 medical records for clients from 11 midwestern home care agencies were reviewed retrospectively. RESULTS: Typically, clients were referred for their first home care admission after a 9-day hospital length of stay for a cardiovascular, respiratory, or neoplastic disorder. After an average 18-day length home care stay, clients were readmitted to the hospital, usually due to the development of a new problem, or due to deterioration in health status related to the primary or to a secondary medical diagnosis. Significant respiratory, cardiovascular or GI symptoms were generally present at hospital readmission. Typically, readmitted clients were 75 year old married females, who had been able to care for themselves at home. At hospital readmission, home care nurses judged these clients to be moderately ill, and likely in need of acute care. CONCLUSIONS: Chronic illness appears to be the best indicator for hospital readmission. The crucial time period for hospital readmission during home care is the first 2-3 weeks following hospital discharge. Intensive study of home care service arrangements utilized by readmitted patients, as well as agency variations, are needed. Study findings concerning patients readmitted from home care point to similarities with rehospitalized patients generally. Findings may assist home care clinicians in targeting high risk patients who could benefit from interventions aimed at minimizing unplanned returns to the hospital.     

Integrating health care for women diagnosed with HIV infection, substance abuse, and mental illness in Detroit, Michigan.

This article describes the evolution of Personalized Nursing, a comprehensive nursing practice model of care. Findings from several nursing research studies contributed to the development of Personalized Nursing. The model includes a practice model of the art of nursing care based on nursing theory and a specific nursing process that directs nursing care delivery. The process of care delivery includes location of hard-to-reach clients; linkage to health care providers; integration of care among providers for clients diagnosed with HIV, mental illness, and substance abuse; and strategies to promote retention in health care. Use of Personalized Nursing is designed to assist clients to improve their well-being and increase positive health-related behaviors. Personalized Nursing has been used in urban landscapes to serve multiply diagnosed clients at risk for HIV infection. The model is currently being used in a study targeting multiply diagnosed women who are lost to follow-up from medical care.     

Process, costs, and outcomes of community-based prenatal care for adolescents

An evaluation of a community-based prenatal care program for teens compared 180 adolescent clients with a sample of adolescents matched on age and year of delivery who received care through a traditional prenatal care program at a university medical center. Evaluation criteria describing the process of receiving care were the mean number of prenatal visits, nonscheduled outpatient visits, nonstress tests, ultrasounds, and inpatient days during pregnancy. The two programs were significantly different as measured by these criteria. Outcome criteria included gestational age, birthweight, the percentage of infants requiring neonatal intensive care, and the percentage of clients with maternal complications. A multivariate analysis showed no statistically significant differences in these outcomes. The average cost of resources consumed during prenatal care for the study group was 41% that of controls.     

Quality of life issues identified by palliative care clients using two tools

Reported are issues impacting upon the Quality of Life (QoL) of 59 palliative care clients within a district nursing service. These issues reinforce the emerging conceptualisation of QoL as being subjective and multidimensional. The issues were identified during a trial of two QoL assessment and measurement tools, the Client Generated Index (CGI) and the McGill Quality of Life (MQOL). In this era of considerable concern about QoL for the terminally ill, the article's intent is to present the QoL issues identfied, the grades of impact and priority for improvement of the issues according to the clients, and to discuss these aspects. This information can inform the assessment of palliative care clients (the CGI tool was found ideal for such an assessment), and may also inform further research on the QoL of palliative care clients.     

Partial hospitalization. An alternative to inpatient psychiatric hospitalization

Partial hospitalization programs provide alternatives to traditional inpatient hospitalization. The initial optimism generated by the development of partial hospital programs has been moderated by the realization that it is quite difficult to make changes in mental health care, even though the effectiveness of traditional approaches has not been demonstrated. Research findings about partial hospital programs have provided information that many persons formerly treated as inpatients can be treated in partial hospital programs, probably at an economic savings. Several conceptual models are briefly reviewed for providing direction and rationale to guide thinking, planning, and decision making regarding client care. Continual effort must be given to the development and expansion of useful models and sets of interventions for care directed not only at symptom reduction but toward facilitation of health induction. Partial hospitalization programs have the potential to provide the settings and services to meet this need. Changing times offer nurses new opportunities to consider alternatives for providing psychiatric care. It is a challenge which nurses are well prepared to accept. To ignore the current situation and the needs of clients, families, and communities for these services would be to lose an opportunity for nurses to share a significant role in providing services to psychiatric clients.     

Stigma and psychiatric day care

Comparatively little is known about the stigma which attaches to psychiatric day care, as opposed to in-patient care. This study uses grounded theory to analyse the views of 21 clients of a psychiatric day unit. The results suggest that clients have difficulty in interpreting their reasons for continuing to attend the unit, and that these difficulties are connected with a fear of being labelled 'mad'. The issue of stigma management was important to the clients, and some thought that the move to a locally-based service would exacerbate problems by reducing the number of available stigma management strategies.