Chapter 5
Intermediate Care
THERE IS NO SECURITY
IN FOLLOWING THE CALL TO ADVENTURE
|
STORIES FROM THE PATH After more than a month in the ICU, Jane was transferred to intermediate care, the Neuro-stepdown unit as it was called in this hospital. After a few days there she pulled out her feeding tube, which I felt showed progress in her return to consciousness. The second time she did it I asked the nurse not to replace it and volunteered to feed her—soup and soft food that she could easily swallow. Being off tubes and catheters made it possible for Jane to get out of bed and we began taking corridor walks.
There was a television set attached to the wall near the ceiling in Jane’s room,
with the option to rent program service or not; if not, they would broadcast the
hospital channel for free. We kept the television turned off, but one day
when we returned from a corridor walk the hospital channel had been turned on,
probably by a nurse’s aide when the room was being cleaned. We looked up
at the program as Jane was getting into bed and realized that it was showing a
surgical procedure from somewhere in the hospital. I involuntarily
exclaimed, “look, Jane, they're showing your operation,” at which we both began
laughing uncontrollably. When I saw Jane laughing so heartily, I realized
that her sense of humor was still intact and that it would provide an important
path to her
recovery. |
Summary of Resource Development Thus Far
The duration of time in the ICU may be extended or not. It really
represents a sequence of events in a process the object of which is survival.
The purpose of intermediate care is stabilization and observation before
discharge and transition to rehabilitation. For the caregiver/partner a
number of elements should be in place now as part of your developing management
system.
1.
Hand held or notebook PC computer:
- Microsoft Outlook Express address book listings
- Microsoft Word files for:
The patient health bulletin
Standard letter of thanks
Listings of medical personnel
associated with the case
Daily journal
2.
Ring binder notebook (5x8), sections:
Notes on tests, medications and procedures
used
Medical personnel associated with the case (print-out)
Visitors record: date, time, signature
Addresses
Weekly calendar
Glossary of medical terms related to brain injury
3.
File boxes--label and keep where you open your mail, separate boxes for:
Health insurance notices
Medical bills related to the case
Information about useful rehabilitation programs and services
4. Cell phone with speed dial numbers for your team and emergency resources.
Resources to Develop During
Intermediate Care
When the the period of crisis has more or less passed and the patient's
condition is stable, the caregiver/partner can begin to prepare for the period
after discharge from the medical hospital. A number of issues will emerge
in rapid succession that will need to be resolved. Work can be started to
identify and lay the groundwork for later action. The intermediate care
unit is less structured and rigorous than the ICU. The effect of the
nursing shortage is greater due to departmental priorities. The knowledge
and experience that the caregiver obtained while the patient was in the ICU will
be needed more at this point. You will need to act even more as the
patient's advocate with nursing staff and physicians and you will need to be
involved in the decisions about further medical treatment and rehabilitation.
There are many things that the hands-on caregiver can do at this time now that the patient has been unhooked from many of the tubes that were necessary in the ICU. The feeding tube should go as soon as possible. It is annoying to the patient and the liquid food is unhealthy. You can help feed or supervise the patient's eating during the transition period, making sure that they get lots of liquids.
The urinary catheter should also be removed but bring in several packages of adult diapers. The catheter stretches the urinary tract which causes incontinence. The patient's reduced awareness contributes to incontinence as well. For these reasons, it will take an extended period of time to overcome the condition.
As soon as possible the patient should begin walking and exercising as much as possible. The light massaging that was begun in the ICU should be continued combined with cleaning the patient and checking for bed sores and infections.
Hugging and holding the patient, hand-holding and other signs of affection are extremely important. The patient is coming back to reality from near death and needs lots of love and encouragement. Brain injury, especially, results in a state of vulnerability and openness.
1. Rehabilitation, traditionally, includes physical, speech and occupational therapies. These therapies may be administered in a special rehabilitation facility but they can also be provided by the facility or another facility on an out-patient basis or by third-party providers in the home.
2. A clinical neuropsychologist could be consulted to help determine the best arrangement for rehabilitation therapy.
3. Rehabilitation services and facilities should be examined and evaluated beginning with the nearest to home. An extensive, high priced rehabilitation hospital may not necessarily be the best choice, even if your insurance will pay for it.
4. A VNA case manager could be consulted to determine the need for nursing resources in the home and advise you about special equipment and arrangements to accommodate the patient. If the patient has Medicare, it should cover related costs once the patient is home, although it may not cover the cost of the pre-discharge consultation. VNA also maintains a liaison with hospitals that provides for transition to home care.
4. If the patient is an adult, a lawyer specializing in estates should be consulted in order to draw up a package to include living will, living trust, pour-over will, power of attorney and any other matter relevant to the administration of the patient's property and other assets.
Things to do Checklist
● Check out
patient safety issues with the National Patient Safety Foundation,
http://www.npsf.org/
●
Learn the symptoms of hospital acquired disease (Internet search using "hospital
acquired disease, nosocomial infection") and look for them daily:
Dehydration--reduced urination
(30 cc per hour or less)
Mouth deterioration--severe dryness, bleeding gums
Pneumonia--light coughing
Hydrocephalus--Glasgow Coma Score
Infection, sepsis,
nosocomial infections--local or
systemic: fever
Bed sores
Peripheral vascular disease, deep vein thrombosis, clotting--pain in extremities
Infiltration caused
when an IV penetrates through a vein--pain, redness
Local infection at
entry ports or other skin breaks--pain, redness, pus, swelling, odor, drainage,
heat at the site.
Urinary tract infection; can result in sepsis, blood systemic
infection, in the extreme
Medication errors: Observe the 5 rights: Right patient, right
time, right form, right route. (advocate should ask "what is that you're
giving the patient?")
-- See citations, Useful Publications, Ch. 3.
● Get information on seizures. There
is a substantial incidence of seizures in patients recovering from brain injury.
Medication is prescribed by a neurologist and may be recommended initially on a
preventive basis. Locate a neurologist as near to home as possible; ask
your neurosurgeon for a recommendation and then check to see if the neurologist
is board certified (whenever possible use board certified physicians).
Check anti-seizure drugs in Worst Pills, Best Pills,
www.worstpills.org
or hard copy. The alternative to using anti-seizure drugs
prophylactically is simply to wait to see if a seizure occurs before doing so.
In either case it is important to know proper procedures to follow.
● Take the Red Cross First Aid course, including CPR. Ask the instructor about any special issues, such as how to deal with seizure. The hospital may offer a first aid course, otherwise check with your local Red Cross Chapter.
● Get information on monitoring and maintenance requirements for implanted devices such as ventriculoperitoneal shunt. Shunt failure and infection occurs in a substantial number of cases where this device is used.
● Meet the VNA
case worker and the social worker with you at your house and do a walk-through.
Their recommendations will make life easier for both you after the patient
comes home.
●
Join the Brain Injury Association, state chapter. Although this
organization deals almost exclusively with traumatic brain injury, it has much
information useful for acquired brain injury.
● Apply for a handicap sticker for your car on the patient's behalf. The patient will not be driving for the foreseeable future but you both will appreciate being able to park closer to entrances and it will be faster to get to the car after the patient has become exhausted from mall-walking.
Managing the Case
The point was made in Chapter 1 that there are two basic approaches to
care giving: Case management or hands-on. Actual practice will use both
approaches, hopefully, in a balanced way, drawing on external or third-party
resources and services in a flexible way as the situation calls for.
Constructing Your
Team
Your
patient is your partner
Clinical neuropsychologist
Neurologist
Reference librarians
Contract social worker
Life coach (see Ch. 2)
Visiting Nurse Association (VNA) case worker. VNA may also provide the
social worker
Useful Publications
To browse additional selections click on
Books.
American Medical Association. Handbook of First Aid and Emergency
Care. Washington DC: AMA, 1990.
American Red Cross. The American Red Cross First Aid and Safety
Handbook. New York: Little, Brown & Co, 1992.
Useful Websites
Worst Pills, Best Pills
www.worstpills.org
Visiting Nurse Association
www.vnaa.org
American Red Cross, local chapter search
http://www.redcross.org/
American Medical Association
http://www.ama-assn.org/
Brain Injury Association of America
http://www.biausa.org/Pages/home.html
National Stroke Association
www.stroke.org
Go to: Chapter 6