Vol. 10, No.1 Perspectives

1 PerspectivesRecovery Strategies From the OR to HomeVol. 10, on page 7 Jan Foster, RN, PhD, MSN, CCRNA ssociate Professor of NursingTexas Woman s University, Houston, TXMikel Gray, PhD, CUNP, CCCN, FAANP rofessor and Nurse PractitionerUniversity of VirginiaDepartment of Urology and School of Nursing,Charlottesville, VATim Op t Holt, EdD, RRT, AEC, FAARCP rofessor, Dept. of Respiratory Care and Cardiopulmonary SciencesUniversity of South Alabama,Mobile, ALPaul K. Merrel, RN, MSN, APN-2 Advance Practice Nurse, Adult Critical CareUniversity of Virginia Health System,Charlottesville, NCJennifer A.

2 Wooley, MS, RD, CNSDC linical Nutrition ManagerUniversity of MichiganHealth SystemAnn Arbor, MIAdvisory BoardDale Medical is committed to nursing education and is the proud sponsor of Perspectives , a source of free, quality CEs for nurses for the past 15 years. CEs for NursesBy 2050, an estimated 27 million people will need some type of long-term care. Home healthcare and hospice agencies are the major providers of community based long-term care. Currently, about million people receive community-based care for post-acute and chronic conditions, often with multiple co-morbidities.

3 This number is expected to increase as the population ages. This issue of Perspectives focuses on best practices in the management of home care patients , in particular patients with either an indwelling catheter or a there is ample research-based evidence regarding indwelling urinary catheter management in acute and long-term care settings, there is limited home care information. Dr. Wilde s and Mr. Zhang s article describes the application of evidence-based practices for the home care of the tracheostomy in the home is a growing trend due to the increased efforts to transition patients to less costly points of care, along with the technologic advances that allow caregivers to deliver limited forms of medical care in the home.

4 Indwelling urinary catheters can be used for short periods of time, such as post-hospitalization, or indefi-nitely for persons with chronic urinary retention. Long-term catheters (LTC) are reserved for people who cannot per-form intermittent catheterization, have no one to do it for them, or cannot man-age any other way. Also, in certain indi-viduals a catheter might be a quality of life decision making it easier to travel or work. Nevertheless, use of an indwelling urinary catheter puts the person at risk for persistent catheter-related problems. The purpose of this article is to address the nursing management of people with indwelling urinary catheters, primarily those with long-term catheters, and to suggest best practices based on evidence to minimize or prevent catheter related problems.

5 Short and Long-term Catheters DefinedShort-term catheters are defined as catheters that are used for less than one month. In actual home care practice, this time frame could be extended to a few months before the catheter is dis-continued. Sometimes a trial without a catheter by removal and monitoring voiding and residual urine is not suc-cessful and the catheter is reinserted. Short-term catheter users need to keep a closed system, which can minimize or delay bacteria in the urine (bacteriuria) and possibly symptomatic catheter-asso-ciated urinary tract infection (CAUTI);1 Best Practices in Managing the Indwelling Urinary Catheter for the Homecare Patient By Mary H.

6 Wilde, RN, PhD and Feng Zhang, RN, BShowever all with a catheter will have bac-teriuria after 30 Irrigations should not be done unless they are prescribed by a physician for a specific purpose such as removal of blood clots. The cath-eter type can include polytetrafluoro-ethylene (PTFE or Teflon)-coated latex, which is soft but provides some protec-tion from latex. It can be used for up to a month. Coatings on catheters, such as silver alloy but not silver oxide might be of value in decreasing bacteria in urine for short-term use up to 2 weeks, but neither silver alloy nor antimicrobial catheters have prevented symptomatic ,4 Long-term catheter use requires different considerations.

7 First, the deci-sion should be made about whether the catheter will remain in situ, and whether other options would be better. Persons with persistent retention, hand dexter-ity and mental capacity can be taught to use intermittent catheters, as well as family or caregivers. For men with se-vere incontinence and no retention, an external catheter could be an option. Sometimes a catheter has been placed inappropriately in the hospital,5 and the home care nurse should ask the physi-cian about removing the catheter if the indication is unclear. Catheter valves, which clamp off the catheter until time for voiding, are not FDA-approved and thus not available in the ; however 2 PerspectivesTracheostomy, the creation of an opening in the neck into the trachea, is performed in the event of airway obstruc-tion, prolonged endotracheal intu-bation, and for tracheobronchial In adults, tracheostomy is done by traditional surgical opening of the trachea in the operating room and by the more recent percutaneous dilation-al tracheostomy technique at the bed-side, usually in the intensive care unit.

8 At a local hospital in south Alabama, it was reported that a total of 191 trache-otomies had been performed in 2010 and 2011. Of those, 79 (41%) patients were discharged with the tube in place. It may be common for a patient to be discharged with the tube in place, put-ting the burden for care on the fam-ily and the responsibility for prepar-ing the family for this task on hospital educators. Care of the tracheostomy in the home is a growing trend due to increased economic pressures on acute-care medical facilities, efforts to transition patients to less costly points of care, technologic advances that al-low caregivers to deliver limited forms of medical care in the home, and the growing social acceptance of persons with When the tracheos-tomy is no longer indicated, the tube is removed (decannulation), and the pa- tient resumes ventilation through the native airway.

9 Information from a large database of pediatric patients revealed that in 2009, 4341 tracheotomies were per-formed on children in the 46 states participating in the Healthcare Cost and Utilization Project (HCUP) Kid s Inpatient Database, sponsored by the Agency for Healthcare Research and While data on the number of children discharged with a tracheosto-my are unavailable, many children are discharged to home with a tracheos-tomy, as evidenced by the numbers of health care workers engaged in teach-Tracheostomy Care in the Home Care PatientTim Op t Holt, EdD, RRT, AE-C, FAARCJ ennifer McDaniel, RRT-NPSK athleen Deakins, MSHA, RRT-NPS.

10 FAARCing caregivers how to care for children with tracheostomy in the for TracheostomyTracheostomy is indicated for up-per airway obstruction, prolonged me-chanical ventilation, and neuromus-cular disease. Airway obstruction may be caused by or related to infection, trauma, tumor, foreign body, obstruc-tive sleep apnea, or tracheal stenosis. Once the upper airway obstruction is bypassed by the tracheostomy, the tra-cheostomy tube is inserted and the pa- tient may be able to ventilate sponta-neously. After a period of time (2 days to several weeks of oral intubation) a tracheostomy is considered for pa-tients requiring prolonged mechani-cal ventilation, the timing of which is a topic of considerable In patients with respiratory failure, the tracheostomy facilitates tracheobron-chial hygiene and may speed the ven-tilator liberation process, since airway patency is better assured.