CHALLENGES OF HOME CARE NURSING IN NIGERIA: A CASE OF HEMIPLEGIA By Omolola Adams Olatayo RN

INTRODUCTION

A Nursing Home, Convalescent Home, Skilled Nursing Facility (SNF), Care Home, Rest Home or Intermediate Care provides a type of residential care. They are a place of residence for people who require continual nursing care and have significant deficiencies with activities of daily living. (http://en.wikipedia.org/wiki/nursing_home, retrieved 30thmay, 2013). Home care nursing is for individuals who need direct nursing care, but who do not wish to live in a nursing facility. A nurse can visit the home and provide care in that setting. A home health care patient is referred to as a client, and home care can last for a short period of time or an indefinite amount of time, according to medicare.gov. (Annie, 2010).

 Jose 2009 , explained Hemiplegic is a common outcome of stroke, and setting goals for its rehabilitation is extremely important. Because hemiplegia affects muscles of the face, arm and leg on one side, it prevents patients from doing a variety of activities which range from walking to feeding themselves. Therefore, the goals of the rehabilitation plan are very specific to each patient, and they must be agreed upon before the rehabilitation program is initiated. Even the side of the body affected by hemiplegia can influence the rehabilitation plan, as people with right-sided hemiplegia may also have difficulty with speech and language (aphasia). When this is the case, they also require a comprehensive plan of aphasia rehabilitation.

Blood supplies nutrients and oxygen to the body. The brain, which coordinate every action of the body makes from walking and talking to moving your arm and breathing, receives about 20% of the blood that flows through the entire body. A stroke, also called ‘brain attack’ occurs when the vessels supplying blood to the brain is blocked. This results in the death of the brain cells. Depending on the area of the brain involved and the extent of brain cells death, the specific body functions such as speech, movement, or memory may be affected. (http://www.healthplus24.com/diseases/stroke.aspx retrieved 30thmay, 2013).

Hemiplegia is a difficult condition to treat. Basically, the results depend upon the extent of regression of the pathology within the brain. Good nursing plays a very important part in the physical and mental care of the patient until he reaches the stage where, with sufficient restoration of motor function, he again considers himself a relatively normal member of society. Whether he then leads a more or less vegetative type of existence in his effort to prolong his life, or whether he re-enters into his previously energetic activities even though he realizes that such conduct may hasten another apoplectic stroke which may be fatal, depends on his own philosophic concepts of life. (http://www.jstor.org/discover/10.2307/... Retrieved 30thmay, 2013).  

Home health care is a burgeoning issue that will continue to grow. Looking at it from a narrow lens, it needs a broad, multi-disciplinary approach. Yet, home health care involved use of technology, including telemedicine, robotic aids, virtual coaches, respiratory equipment, and other to think about the diversity of the people dealt with – their language, literacy, and support –both technical characteristics of home health populations’ care receivers’ and providers are essential for developing equipment. (http://www.ahqr.gov... Retrieved 31may, 2013)

According to Marcia (2010), As a home health care nurse you will be expected to work with patients of different ages and with different medical conditions. This may include working with post-operative patients, pediatrics cases, mothers and newborns, adults with a variety of medical conditions and even terminally ill patients. At times you may also be called upon the help in health screening clinics, flu clinics blood drives, etc., but basically your work will be in the patient’s home’.

LITERATURE REVIEW

INTRODUCTION

Hemiplegia is not a progressive disorder, except in progressive conditions like a growing brain tumor. Once the injury has occurred, the symptoms should not worsen. However, because of lack mobility, other complications can occur. Complications may include muscle and joint stiffness, loss of aerobic fitness, muscle spasms, bed sores, pressure ulcers and blood clots. (http://en.wikipedia.org/wiki/hemiplegia retrieved 30thmay, 2013). The elderly people are increasingly moving out of institutions and into client’s homes. To cope with the challenges, nursing staff have to recognize the specific nursing problems involved in home care, as well as the most appropriate nursing interventions. The focus of home care problems forms the basis for planning, implementing and evaluating interventions. (Soini & Valimaki 2002).

CONCEPTUAL LITERATURE

DEFINITION OF HEMIPLEGIA

Hemiplegia is the total paralysis of the arm, leg, and trunk on the same side of the body. Hemiplegia is more severe than hemiparesis, wherein on half of the body has less marked weakness. Hemiplegia and hemiparesis may be congenital, or they might be acquired conditions resulting from an illness, an injury, or a stroke. (http://en.wikipedia.org/wiki/hemiplegia retrieved 30thmay, 2013)

CAUSES OF HEMIPLEGIA

Many conditions give to rise to hemiplegia. Generally, an injury to the right part of the brain will cause a left-sided hemiplegia while an injury to the left side brain will cause a right-sided hemiplegia.

Stroke: is the commonest cause of the hemiplegia. Insufficient blood supply the brain leads to loss of brain functions. The stroke may be caused by the following;

·       A clot formed within the blood vessel blocking the blood supply- thrombus

·       A thrombus breaks away from its site of origin and forms a bolus elsewhere in the circulation – an emboli

·       A bleed from a blood vessel supplying the brain - a hemorrhage.

  Head injury

Diabetes

Brain tumour

Infections – meningitis, encephalitis

Migraine syndrome – recurrent headaches of severe intensity occasionally accompanied by sensations of numbness and tingling in one half of head.

Diseases affecting the nerves – multiple sclerosis, acute necrotizing myelitis

Inflammation of the blood vessels – vasculitis

Conditions presenting from birth – cerebral palsy. Lack of blood supply damages nerve cells in the brain. Birth trauma, difficult labour, perinatal strokes in infants within 3 days of birth can also cause cerebral palsy

Hereditary diseases – leukodystrophies. This is a rare disorder affecting myelin sheath which covers and protects nerve cells in the brain. The condition usually appears in infancy or childhood. (http://www.askdrshah.com/app... Retrieved 30thmay, 2013).

RISK FACTORS

The risk factors may be controllable or uncontrollable

Uncontrollable risk factors are:

*age

*a family history of stroke

*diabetes

Controllable risk factors may include:

*high blood pressure

*heart disease

*coronary heart disease and high cholesterol

Lifestyle risk factor that increase stroke risk may include; smoking, excessive alcohol intake and obesity. (http://www.healthplus24.com/… retrieved 30thmay, 2013).

SYMPTOMS OF HEMIPLEGIA

Injury or insults to the brain cells that control movements in one half of the body cause hemiplegia. Hence, symptoms largely depend upon the part of the brain affected. The same can be said about the severity of individual symptoms.

·       Difficulty in walking.

·       Problems in balance, losses balance when trying to walk

·       Difficulty in swallowing

·       Trouble with vision. Blurred vision or weakness of the eyes.

·       Speech becomes difficult.

·       Numbness, tingling or loss of sensations on one half of the body.

·       Loss of control over bladder and bowel movements leading to an inability to hold on to stool or urine.

·       Unable to perform tasks like holding objects, tying laces, dressing oneself, buttoning, etc.

·       Feeling depressed.

·       Heightened emotional sensitivity with inability to handle stressful situations

·       Memory seems poor, unable to recall recent or past events concerning people, places and activities. (http://www.askdrshah.com/app... Retrieved 30thmay, 2013).

PATHOGENESIS

The exact cause of hemiplegia is not known in all cases, but it appears that the brain is deprived of oxygen and this result in the death of neurons. When the corticospinal tract is damaged, the injury is usually manifested on the opposite side of the body. For example if one has an injury to the right side of the brain, the hemiplegia will be on the left side of the body. This happens because the motor fibres of corticospinal tract (also called pyramidal fibers), which take origin from the motor cortex in the brain, cross to the opposite side in the lower part of medulla oblongata and then descend down in spinal cord to supply their respective muscles. Depending on the site of lesion in brain, the severity of hemiplegia varies. A lesion in internal capsule where all the motor fibers are condensed in a small area, will cause dense hemiplegia i.e. complete loss of power of all muscles of one half of body while a lesion at cortical or subcortical level will cause varied amount of weakness of one half of the body. (http://en.wikipedia.org/wiki/hemiplegia retrieved 30thmay, 2013).

DIAGNOSIS

·       Complete blood count.

·       Blood biochemistry test.

·       Cranial CT – a highly detailed, non-invasive, imaging procedure that combines x-ray with computer technology and allows the study of the brain from many angles.

·       Cranial MRI – a non-invasive, highly sensitive procedure that uses electromagnetic properties of tissues providing detailed studies of their structures.

·       An EEG (electroencephalogram) – can measure the nerve activity within the brain. (http://www.askdrshah.com/app... Retrieved 30thmay, 2013).

TREATMENT

Treatment should be based on assessment by the relevant health professionals, including physiotherapists, doctors and occupational therapists. Muscles with severe motor impairment including weakness need these therapists to assist them with specific exercise, and are likely to require help to do this. Pharmacological: drugs can be used to treat issues related to the upper motor neuron syndrome. Librium or valium could be used as relaxant. Surgery: it may be used if the individual develops a secondary issue of contracture from a severe imbalance of muscle activity. Rehabilitation: this is the main treatment of individuals with hemiplegia. In all cases the major aim of rehabilitation is to regain maximum function and quality of life. Both physical and occupational therapy can significantly improve the quality of life.   

EMPIRICAL LITERATURE REVIEW

Patients with hemiplegia constitute one of the largest groups of persons suffering from chronic neurologic defects. It has been estimated that there are more than 1,000,000 at any one time in the United States. (Donald 2010).  Nursing care in hemiplegia, as in other conditions where destructive processes have been arrested, should aim toward restoration of function. The amount of improvement will depend largely on the extent of the initial injury. It may be limited to the patient’s being able to walk only from his bed to the bathroom or may consist of complete rehabilitation. No matter how small the improvement, the gratitude of the patient and his family warrants the attempt. (Anne 2009).

There are three main types of nursing facilities;

1.    Intermediate care facility (ICF): an intermediate care facility is a health care facility for individuals who are disabled, elderly, or no-acutely ill, usually providing less intense care than that offered at a hospital or skilled nursing facility. Typically, an ICF is privately paid by the individual or by the individual’s family. An individual’s private health insurance and/or a third party service like a hospice company may cover the cost.

2.    Assisted living facility (ALF): Assisted living residences or assisted living facilities (ALF) are housing facilities for people with disabilities. These facilities provide supervision or assistance with activities of daily living (ADLs); ALFs are an eldercare alternative on the continuum of care for people, for whom independent living is not appropriate but who do not need the 24-hour medical care provided by a nursing home and are too young to live in a retirement home. Assisted living is a philosophy of care and services promoting independence and dignity.

3.    Skilled nursing facility (SNF): a skilled nursing home certified to participate in, and be reimbursed by Medicare. Medicare is the federal program primarily for the aged (65+) who contributed to social security and Medicare while they were employed. Medicaid is the federal program implemented with each state to provide health care and related services to those who are below poverty line. Each state defines poverty and, therefore, Medicaid eligibility. Those eligible for Medicaid may be low-income parents, children, including state children’s health insurance programs (SCHIPs) and maternal-child wellness and food programs. Seniors and people with disabilities. (http://en.wikipedia.org/wiki/nursing_home, retrieved 30thmay,2013)

REASONS FOR HOME CARE

There are basically 4 reasons for home care settings;

1.    For living longer since most patients want to age in place with dignity.

2.    Patients have more chronic, complex conditions.

3.    They leave the hospital earlier and thus need more intensive care.

4.    Sophisticated medical devices have been moved into homes. Devices that were only used in homes and bedrooms. (Agency for healthcare research and quality, 2011).

TYPICAL NURSING HOME STAFF

Administration; once a patient has moved into the nursing home, their relatives may not have significant contact with the administration team, unless there are specific concerns that arise. Depending on the size of the nursing home, the administration staff may be very small, consisting of only a handful of people.

Support personnel; some staff members focus solely on caring for the buildings and grounds. Custodians, maintenance staff and groundkeepers. Nursing home may have an activities director who is responsible for planning and implementing holiday events, daily and weekly educational and social activities, coordinating special visitors and religious services.

Direct care staff; the direct care staff have direct, daily contact with the patient. The following are types of direct care staff included in all nursing homes;

·       Registered nurse (RN)

·       Licensed practical nurse (LPN) or licensed vocational nurse (LVN)

·       Certified nursing assistance (CAN)

Services; nursing homes offer the most extensive care a person can get outside hospital. Nursing homes offer help with custodial care – like bathing, getting dressed, and eating – as well as skilled care given by a registered nurse and includes medical monitoring and treatments. Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists. The services nursing homes offer vary from facility to facility, services include;

·       Room and board

·       Monitoring of medication

·       Personal care (including dressing, bathing, and toilet assistance)

·       24-hour emergency care

4.    Social and recreational activities. (http://en.wikipedia.org/wiki/nursing_home, retrieved 30thmay,2013)

Resident – oriented care; with resident – oriented care, residents are able to make more choices and decisions about their lifestyle. Their families are more involved in the residents care, and employees have greater degree participation with the residents. Resident – oriented care combines the clinical models of care with a flexible social model. (http://en.wikipedia.org/wiki/nursing_home, retrieved 30thmay, 2013)

Qualities of home healthcare nurse

Clinical skills; due to a need for a cost containment, hospitals are discharging patients home much earlier. These patients still have acute care needs. Their needs will require knowledgeable, skilled nursing care. As a home healthcare nurse there is a need to be more than just a compassionate, friendly disposition. A strong clinical skills and good problem solving abilities is needed. The nurse must also have an excellent ability for ongoing assessment and evaluation of patient and be able to devise and work within a care plan that is tailored to patient’s needs. Home healthcare nursing require to be independent and confident in many technical areas of nursing skill, including drawing blood work, starting and maintaining IVs, providing wound assessment and dressing changes, working with wound vacs, oxygen and managing other medical equipment.

Critical thinking skills; when you work in home healthcare, you are working alone for the most part. Your supervisor at the agency is assessable by phone but for the most part you have to be an independent decision maker. You must be able to recognize and handle emergency situations and have sound nursing judgments.

Supervisory skills; the registered nurse is a case manager in home healthcare. You will be responsible for overseeing the case as a whole. This includes supervising the work of home health aide and the LPN or LVN. Good supervisory skills are imperative to assure the case runs as smoothly as possible.

Organizational skills; a home healthcare nurse has to be organized. It will be your responsibility to make your own daily schedule. Each day you will be making visits, phone calls, providing patient care, interacting with other agency staff members, contacting physicians and working with the patient’s family. You may need to adjust your schedule often. For example, if one patient cancels his visit or if your supervisor unexpectedly needs you to accept a new case, you have to organize your day to accommodate this.

Good communication skills; you will interact with a lot of people in your role as a home healthcare nurse. You must have effective verbal and written communication skills for this. (Marcia 2010).

Nursing care during the acute stage of hemiplegia

After the first stroke there is always danger of second stroke. The nursing responsibility in preventing this is the provision of complete rest for the patient. The equipment necessary for rest is quite, orderly room, and a firm spring and mattress on a single bed, placed so that it is accessible from both sides. If the bed sags, a ply board of the same size as the spring may be placed between it and the mattress. Blocks may be put under each leg of the bed to elevate it to a desired height. The next consideration is the bed posture of the patient; the paralyzed side, which the patient is not able to move to ease a strain, needs special consideration. The leg is usually rolled out at the hip, the knee is bent, and the foot is dropped, with pressure on the outer aspect of the ankle bone. The arm is held closely to the body; the forearm lies across the chest with the hand usually clenched. The pillows under the head may push it forward and flatten the chest. If this kind of posture is permitted, contractures and deformities will surely develop. The foot will assume drop-foot position because of shortening of the heel tendon and it will be difficult to straighten the knee and the hip. Moving the arm away from the body will become painful because of the tight muscles in the axilla. Pneumonia, pressure sores, contracture and urinary retention are common complications in hemiplegia. All the complications suggest maintenance of one position for too long a time, and may be prevented by changing the position frequently. (Anne 2009).

JOB DUTIES OF HOME CARE NURSE

Job duties for a home health nurse vary based on an individual client’s needs. Medical tasks completed by the nurse can include administering medication, tube feeding, ventilator monitoring and suction of the airway. Some clients may require some light housekeeping duties and assistance with activities of daily living as well.

CHALLENGES IN HOME CARE NURSING

·       In an emergency situation ,no other nurses or physicians are present to help in the home setting

·       The nurse is the sole provider for all medical care

·       No one is there to relieve the nurse for breaks or launches, which mean the nurse, can work up to 12hours straight with no breaks. (Annie 2010).

·       Capabilities of patients and caregivers – this range in literacy and health, as well as cultural traits.

·       Tasks and medical therapies undertaken, the devices and technologies used – tasks range from simple feeding and bathing to managing home dialysis and complex intravenous drips.

·       Physical as well as community environment – environments range from those with low lighting or stairs that block wheel users, to home with no internet access for data transfer or remote monitoring. (AHRQ 2011).

·       Lots of paperwork; the home healthcare agency you work for has to adhere to government regulations and requirements to maintain licensure. Paperwork has to be completed for each skilled visit that complies with these regulations.

·       Environmental factors; remember, you are providing care in a person’s private home. You must respect that this is their house and accept the way they live. Although not always the case, you might find yourself working in home environment that are not very clean. You still must remember your duty and take care of the patient regardless of their standard of living.

·       Personal attachment; working one on one with your patients can form attachments that are not usually formed in a hospital or clinic setting. You tend to become quite involved in their lives since you may visit their homes for weeks or more. You must know where your professional boundaries are and adhere to them. Always stay within the scope of what you were hired to do. ( Marcia 2010).

CONCEPTUAL FRAMEWORK

Jean Watson’s philosophy of nursing stated ten primary carative factors

1.    The formation of a humanistic – altruistic system of values.

2.    The installation of faith – hope.

3.    The cultivation of sensitivity to one’s self and to others.

4.    The development of a helping – trust relationship.

5.    The promotion and acceptance of the expression of positive and negative feelings.

6.    The systematic use of the scientific problem – solving method for decision making.

7.    The promotion of interpersonal teaching – learning.

8.    The provision for a supportive, protective and/ or corrective mental, physical, socio – cultural and spiritual environment.

9.    Assistance with the gratification of human needs.

10.The allowance for existential – phenomenological forces.

APPLICATION OF THE FRAMEWOK

As earlier discussed by jean Watson, care of hemiplegic patient at home setting, it’s a holistic care in which all aspect of patient’s wellbeing is taken into consideration. The care begins from the formation of humanistic - altruistic system that begins developmentally at an early age with values shared with the parents, mediated through ones won life experiences, the learning one gains and exposure to the humanities which is perceived as necessary to the nurse’s own maturation which then promotes altruistic behavior towards others, to, the allowance for existential – phenomenological forces.

Cultivation of sensitivity to one’s self and to others, explores of the need of the nurse to begin to feel an emotion as it presents itself, development of one’s own feeling is needed to interact genuinely and sensitively with others, the theory promote health and higher level functioning only when the hemiplegic patient form person to person relationship.

Establishing a helping – trust relationship, the theory form  strongest tool mode of communication which establishes rapport and caring, characteristics needed to in the helping – trust relationship are; congruence ,empathy, warmth and communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.    

  Finally, provision for a supportive, protective and / or corrective mental, physical, socio-cultural and spiritual environment, the theory dwelt much with these ingredients that basically form a homecare settings, Watson divides these into external and internal variables, which the nurse manipulates in order to provide support and protection for the person’s mental and physical well-being, the external and internal environments are interdependent, the theory provides comfort, privacy and safety as part of this carative factor.

Therefore, the theory establishes care expected to render the hemiplegic patient within home care which ranges from physical care, mental care, social care, environmental care, psychological care, socio-cultural care, communication care, spiritual care, supportive care, protective care, family care to achieve fullest health status in which the patient has a good rehabilitation care.

CONCLUSION

The considerable practical application to the home care sector is between the client’s needs and assigned tasks. This issue gets to the heart of the loop-hole that currently exists in our policies provision of home supports. Client needs in quantity, breadth and scope greatly outstrip the ability of homecare setting to make clients unhappy and frustrated health personnel, who want to do more but are restricted by the limitations of the system. Also of practical application, but even more challenging than the lack of fiscal and human resources, is the difficulty to meet the needs and preferences.

Sudden recovery from hemiplegia is very rare. Many of the individuals will have limited recovery, but the majority will improve from intensive, specialized rehabilitation, and homecare. Potential to progress may differ in cerebral palsy, compared to adult acquired brain injury. It is vital to integrate the hemiplegic child into society and encourage them in their daily living activities by homecare nurse. With time, some individual may make remarkable progress.

IMPLICATION TO NURSING PRACTICE

Care of patient with hemiplegia may be quiet challenging; it requires all human effort most especially when there is no adequate manpower or technological gadgets that can minimize energy to be expended. It’s amazing to belief that  in Nigeria setting where a nurse will have to care for an hemiplegic patient within 1o hours without break nor relieve, this also make home care nursing to be tasking such  that patient lifting is dangerous to the nurse health as the career. Its therefore imperative to understand the specific care an hemiplegic patient require before embarking on the work while other parameters are structured such that it facilitates the care.

Health education about the causes, courses, prognosis of hemiplegia should well elaborated for society to digest so as to minimize the illness in the society, also ways of prevention should be well instituted most especially among the risk individual and non – risk individual. Prevention of the unaffected among them should be well highlighted and continual monitoring of the state of the health. 

RECOMMENDATION

All through my findings and personal encounter during work as homecare nurse, it’s been discovered that certain areas need to be well harmonized so to meet the standard of acceptable international practice. In fact home setting in Nigeria system is quite different from what is practice in most part of developed world. Basically, home nursing in Nigeria setting is exactly what is known as resident – oriented care in USA. Therefore below are my recommendations;

1. There should be a policy and law that will regulate and guide the activities of the practice.

2. The mode of recruitment exercise should be adequately looked into so as to distinguish a registered nurse from an auxiliary nurse in Nigeria context.

3. Nursing and Midwifery Council of Nigeria should work with different agencies that specialize in homecare nursing to collaborate with each power in homecare experience for nursing students so as to prepare them for future work.

4. Nursing and Midwifery Council of Nigeria should take up the task of developing a curriculum that will guide activities of auxiliary been used by these agency to possess a few months training before been qualified for such work, this will further reduce or minimize patronizing ‘quake’ nurse in the society, also will reduce level of damage that patient may be exposed to.

5. Training and retraining of homecare nurse should be instituted so as to refreshing their knowledge and widen their horizon on the latest type of care in vogue and skilled.

6. Nursing and Midwifery Council of Nigeria should find a way of making homecare nursing a post – basic course so as to meet up with the developed world.

7. Health hazard allowance should be paid to homecare nurse due to hazard been exposed to such as breaking of backbone while lifting patient.

8. Federal Government should also set up Intermediate Care Facility (ICF), Assisted Living Facility (ALF) or Skilled Nursing Facility (SNF) that will contain essential equipment at various level of government, at least one at each senatorial district, also allow participation of both State and Local government participation as well as private participation, with reference to USA model.

9. The agency should encourage research work so as to know modern happenings in homecare setting that will assist in quality type of care and disseminated the result findings to every aspect of nursing and those in the field.

10. Homecare nursing should be introduced into the basic, post-basic and university curriculum and be exposed to practice in the course of training.

11. Contract agreement between the patient and the agent should not be secrecy such that the nurse will know the exact things to do which may stand as case in the court of law in any eventuality.

12. Professionalism and ethic as well as etiquette of nursing should be hold in the course of training and practice because too much familiarism disregards code of practice.

13. Federal government of Nigeria should enforce pension and insurance scheme unto the agencies so that the job will be secured and provide funds when quiting or retiring.

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