Challenges of Home Care Nursing in Nigeria ; A case of hemiplegia

7/27/2019 Challenges of Home Care Nursing in Nigeria ; A case of hemiplegia

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CHALLENGES OF HOME CARE NURSING IN

NIGERIA:

A CASE OF HEMIPLEGIABy

Omolola Adams Olatayo RN

INTRODUCTION

A Nursing Home, Convalescent Home, Skilled NursingFacility (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 carein 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 fromdoing 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
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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 patientuntil 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
http://www.healthplus24.com/diseases/stroke.aspxhttp://www.jstor.org/discover/10.2307/http://www.healthplus24.com/diseases/stroke.aspxhttp://www.jstor.org/discover/10.2307/


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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 receiversand 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 patients 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,
http://www.ahqr.gov/http://en.wikipedia.org/wiki/hemiplegiahttp://www.ahqr.gov/http://en.wikipedia.org/wiki/hemiplegia


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2013). The elderly people are increasingly moving out of

institutions and into clients 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 careproblems 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
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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 raredisorder 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
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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, symptomslargely 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


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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 rightside 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 capsulewhere 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.
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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 groupsof 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
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restoration of function. The amount of improvement will

depend largely on the extent of the initial injury. It may be

limited to the patients 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 thepatient 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 theindividual or by the individuals family. An individuals

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 notappropriate 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 careand 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

childrens 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)
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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 oncaring 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 directcare staff included in all nursing homes;

Registered nurse (RN)

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


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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, andeating 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
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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 planthat is tailored to patients 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 ofhome 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 thepatients 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.


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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. Thepillows 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 complicationsin 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


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Job duties for a home health nurse vary based on an

individual clients 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 assistancewith 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

persons 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.


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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 withinthe scope of what you were hired to do. ( Marcia 2010).

CONCEPTUAL FRAMEWORK

Jean Watsons 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 ones 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, its a holistic care in which all

aspect of patients wellbeing is taken into consideration. The

care begins from the formation of humanistic - altruistic

system that begins developmentally at an early age with


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spiritual care, supportive care, protective care, family care to

achieve fullest health status in which the patient has a good

rehabilitation care.

CONCLUSIONThe considerable practical application to the home care

sector is between the clients 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. Its 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.


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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, its 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.


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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 thesociety, 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 tomeet 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 variouslevel 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.


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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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Annie McElfresh (2010). What is home care nursing?

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Cathy Hecimovich (2008). Home cares unique challenges,

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Challenges of Home Care Nursing in Nigeria ; A case of hemiplegia

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