Critical thinking question for all you experts

  1. A client has a postive medical history for morbid obesity, incontinence, pulmonay emboli, sleep apnea, and chronic back pain. The client has a Foley catheter and a PICC line that is flushed with heparin, and is on coumadin. Does this client, living at home, need a home health nurse, and why?
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  2. 13 Comments

  3. by   Elenaster
    I'm no home health nurse, but I certainly think this patient needs home health for a number of reasons. First of all, the patient's foley needs to be monitored for signs and symptoms of infection. Urosepsis is a nasty thing and the primary cause is long-term foley catheter placement. This is not meant to be judgemental in any way, but because the patient is morbidly obese, he/she may have a difficult time caring for the foley properly.

    Secondly, the patient is on coumadin and needs to be assesed for signs of coagulopathy, such as bruises, petichiae, bleeding from the urethra, etc. I had a patient in my unit just last week who was on coumadin for chronic a. fib and had fallen. She had a huge subdural hematoma and was thought to have been down for about three days before anyone found her.

    The PICC line also should be monitored as a potential source of infection and I'm guessing that the dressing should be changed by either the nurse, or the nurse should at least be making home visits to make sure that caregivers are using proper techniques in caring for the PICC.
  4. by   AmyB
    Thank you for your response. Next contestant?
  5. by   SmilingBluEyes
    this is a contest? sorry, I am not playing....I really think----------

    the answer you were given above is more than good and very well-stated!

    are you doing a homework assignment or something?
  6. by   AmyB
    Just a hypothetical I came across. I wanted to see if anyone had any variations in care they would perform. No homework here. It's spring break time! Sorry for any confusion. Just trying to make what would be a serious situation a little lighter.
    Last edit by AmyB on Mar 9, '04
  7. by   bellehill
    Quote from Elenaster
    I'm no home health nurse, but I certainly think this patient needs home health for a number of reasons. First of all, the patient's foley needs to be monitored for signs and symptoms of infection. Urosepsis is a nasty thing and the primary cause is long-term foley catheter placement. This is not meant to be judgemental in any way, but because the patient is morbidly obese, he/she may have a difficult time caring for the foley properly.

    Secondly, the patient is on coumadin and needs to be assesed for signs of coagulopathy, such as bruises, petichiae, bleeding from the urethra, etc. I had a patient in my unit just last week who was on coumadin for chronic a. fib and had fallen. She had a huge subdural hematoma and was thought to have been down for about three days before anyone found her.

    The PICC line also should be monitored as a potential source of infection and I'm guessing that the dressing should be changed by either the nurse, or the nurse should at least be making home visits to make sure that caregivers are using proper techniques in caring for the PICC.
    Exactly! :chuckle
  8. by   rpbear
    I agree with the above posts but would like to add. If the morbid obesity causes some physical mobility problems then that would call for home health, maybe not a nurse, but an aide.
  9. by   EastCoast
    I think a home health aide at least is probably needed but more than that i think if she had a good physical therapy regimen and a nutritionist than maybe her back pain and sleep apnea would improve. If one d'c's her foley that will be one less source of sepsis. And why does she have a picc line anyhow with no notation made of iv meds...is it for blood draws?
  10. by   AmyB
    She is also on coumadin therapy for the pulmonary emboli. Blood draws are needed for PT and INR.
  11. by   jkaee
    Does the patient have any family living with her....one who could take over basic care of the Foley and PICC and monitor for s/s infection?

    Either way, I agree that she would need some type of home health care, certainly need some counseling from an RD and maybe PT eval.
  12. by   AmyB
    Thank you all so much for your responses. I really appreciate it.
  13. by   RubyRN,CHPN
    Speaking from an experienced home heath nurse, I think evaluation for appropriate skilled home health services would be appropriate. In order for a person to receive home health services, generally an insurance requires pt to be homebound. Which means its a taxing effort for them to leave home, they do not drive, leave home only very infrequently usually for medical purposes. Management of foley catheter and cath changes, picc line, skilled observation and assessment of CVP status, all are considered skilled care in home health and would warrent home health nursing services. To receive home health services requires a Dr's order. Have you contacted him to advocate for your pt?
  14. by   jenfnp
    Quote from AmyB
    A client has a postive medical history for morbid obesity, incontinence, pulmonay emboli, sleep apnea, and chronic back pain. The client has a Foley catheter and a PICC line that is flushed with heparin, and is on coumadin. Does this client, living at home, need a home health nurse, and why?
    Is the client able to provide his/her own care? If the person is able to ambulate, drive, cook, bathe, etc. on their own, then, no they don't need a home health nurse. They should be able to go to an outpatient facility (including the home health agency office) for any dressing changes or lab tests. It is also possible in some cases to teach the client to perform their own dressing changes and flushes. How long is the PICC going to be needed? Does the patient need a port-a-cath? If the client is capable of the care, medicare or other insurance provider may not cover home health care. It is important to preserve the client's self-care abilities, and dignity in addition to conserving our health care resources to ensure the ability to provide care when it is really needed.
    have a great day.
    jenfnp

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