Improve patient self-care using these guidelines

Key step is to think from patient’s perspective

Home care nurses continually strive to assist patients with attaining the best level of health at home that is possible. Mutual cooperation between patients and nurses is sometimes taken for granted. Without patient participation, it would be nearly impossible for frail and elderly patients to achieve the level of independence necessary to enable them to remain active at home.

Yet, nurses do not always understand some of the barriers patients face in attempting self-care. Those barriers include their own perception of their health and what it would take for them to remain active.

"The first thing nurses need to think about and appreciate is the patient’s perspective of his or her health and to realize that health is best defined by the patient," says Robyn Rice, RNC, MSN-R, PhD-C, a clinical associate professor at Barnes College of Nursing at the University of Missouri in St. Louis. Rice is the author of a book, Home Care Nursing Practice: Concepts and Applications, that is published by Mosby Inc. of St. Louis. The third edition will be published in October.

"When nurses work with patients, one thing they need to do is decide how the patient regards his or her health and what the patient wants to occur with his or her health now and in the future," Rice adds.

Taking time to consider the patient’s perspective will reap rewards later when the patient becomes more active in learning how to prevent future health crises and improving the ability to perform activities of daily living.

"Nurses can offer a lot of recommendations and treatments from physicians, but the ideal of being independent at home and to have the best health largely relies on each person’s endeavors to care for themselves," Rice says.

Rice offers these guidelines to encouraging patients to improve their self-care:

Assess the patient’s motives, abilities. Nurses first should make sure they know who it is they are working with and what that person’s abilities are.

"Do they value what we’re trying to do here because that’s the simple way of saying to someone, particularly if you’re looking at cultural issues, Do you think this treatment will be helpful to you?’" Rice says.

OASIS is minimum standard for assessment

The Outcome and Assessment Information Set (OASIS) should be considered the minimum standard for a patient assessment, and nurses should expect to do much more than that, Rice says. "It’s up to each nurse to bring each patient quality customer service."

This means moving beyond the minimum data collecting requirements and instead conducting a holistic assessment that considers that individual patient’s motives and abilities.

"What I’m talking about is professional," she explains. "We don’t go in and look at a person’s toe because a toe doesn’t heal. It’s the person that heals."

The initial patient assessment is a holistic assessment that focuses on the reason for the referral, what the physician has written, what other health care providers have written, as well as the diagnosis, she says.

Then the person should be assessed within the home environment, answering these questions:

— What are the patient’s activities of daily living needs?

— Who in the home is capable of assisting the patient with wound dressing changes?

— Who in the home should be taught about caring for the patient?

— What are the patient’s or caregiver’s special learning needs?

— What is unique about this patient or caregiver?

"The basis of self-care is learning," Rice says. "We assess physiological, cultural, and social issues, and then look at the household and ask ourselves, What are the resources here that we can utilize to care for this patient?’"

Assess patient’s community resources

Resources could include other people, the home itself, services the home care agency offers, community programs, and others.

Then, the nurse should discuss this information with the patient, family, and physician, looking for a collaborative way to provide a comprehensive plan of care to the patient, Rice suggests.

"Ask the patient, What do you want to happen to your health care?’ and then incorporate that into the plan of care," Rice says.

Look at the patient’s survival needs at home. Particularly when nurses have a limited number of visits, it’s important to determine the critical goals that need to be accomplished.

"What of all the things I have assessed here are the most critical ones I have to get done today, and then you work from that basis," Rice says. "And recognize that people in the home move from a very dependent role on the nurse to a very independent one, as they learn to care for themselves."

Survival needs include the problems that could potentially put the patient back into the hospital, such as a huge gaping wound that needs a dressing change. Other survival needs might be addressed include teaching patients about their medications; what these are for, how they can pay for them, and how they take them. And teaching patients about managing their medical equipment might also be considered a survival need.

Teaching caregivers also addresses survival needs because they should be part of the process, particularly when patients cannot handle all of their own care.

Provide spiritual aesthetic care. Nurses by nature provide care to people, but the home care setting is an environment in which they can carry this caring a step further, by developing a close and even spiritual relationship with their patients, Rice suggests.

"In home care, nurses can provide therapeutic touch, or when working with hospice clients, nurses can participate in prayer," she explains.

"In terms of spiritual aesthetic communion, it could be as simple as a matter of humor and storytelling," she says. "Sometimes, storytelling is very therapeutic in getting someone to tell what they’ve experienced and how they’re managing it."

Find patients soothing music

Nurses also might assist patients in finding music that soothes or relaxes them, as well as teach patients relaxation exercises.

Look at discharge issues. Nurses will want to ask themselves whether the goals of care have been met or whether this patient and family are at the best level of functioning.

Again, nurses should keep in mind that performing an OASIS discharge assessment is only the minimum standard.

"It’s a resource quality standard and it provides uniformity," Rice says. "But OASIS would never say hug your patient good-bye, but I would bet good money there are lots of nurses who do that."

The discharge assessment provides the nurse the opportunity to make sure the patient is ready for optimal self-care. Therefore, these questions should be addressed:

— Is the patient at the best possible level of functioning?

— Is the patient satisfied with the home care services?

— Does the patient exhibit harmony or contentment with who the patient is and where the patient is health-wise?

Nurses should keep in mind that the purpose of home care isn’t always to make a person as healthy as the person was prior to the injury or illness, Rice says. Sometimes it’s to help the patient achieve the best health possible and achieve some acceptance for living a more limited life and experiencing less robust health.

"I don’t think the sole purpose of home care is to make people well," Rice explains. "It’s to provide people with education, case management, advocacy for giving hands-on care, and what I’ve perceived as a spiritual aesthetic communion to help the patient achieve his or her best level of health."

Robyn Rice, RNC, MSN-R, PhD-C, Clinical Associate Professor, Barnes College of Nursing, University of Missouri, 8001 Natural Bridge Road, St. Louis, MO 63121-4499. Telephone: (314) 516-7026. Fax: (618) 667-0046.