Chapter 57The Patient Who Is Homebound

Chapter 57The Patient Who Is Homebound

“No matter how hard the past, you can always begin again.”

Buddha

Homebound Patients

Residence Home-based healthcare services Institutionalized setting: hospital, nursing home,

or residential facility To classify for homebound

1) Limitation of one or more ADLs (Activities of Daily living)

2) ASA III-V3) Be functionally dependent on caregivers

Common Oral Problems Need for routine dental care Difficulty biting and chewing Weight loss due to oral problems Toothache/pain and abscess/swelling Trauma/fractured or loose teeth Dental caries Periodontal disease Restorative issues Loose dentures

Significance of Oral Health Systemic conditions affecting oral status Oral health affecting systemic conditions Oral pain compromising nutritional status Physical limitations and oral care abilities Self-esteem and quality-of-life issues

Barriers to Access Few on-site dental clinics in nursing homes Lack of practitioners Cost Limited or no Medicaid coverage Transportation Fear Patient attitude and beliefs Patient daily pain/discomfort levels

ReviewWhich of the following is not a barrier to accessing

dental services for patients who are homebound? A) Lack of transportationB) High costC) Ageism or negative attitudes of

practitionersD) Large number of practitioners who provide

home-based servicesE) Patient’s health attitudes and beliefs

ReviewWhich of the following is not a barrier to accessing

dental services for patients who are homebound? A) Lack of transportationB) High costC) Ageism or negative attitudes of

practitionersD) Large number of practitioners who provide

home-based servicesE) Patient’s health attitudes and beliefs

Eliminating Barriers

Home health agency visitsMidlevel allied health professionals

increasingNew models for healthcare delivery

Collaboration for onsite and supervisors Web-based communication tools

Dental Hygiene Care and Instruction Mobile dental clinics Care objectives

EIOE to triage patient needs Detecting pathology and care needs Education interventions for prevention Palliative care Encouragement

Preparation for the Home Visit

Understanding the patient Review med hx in advance for precautions Consult MD if need to prior

Instruments and equipment Portable Routine with manual instruments

Appointment time When best for patient (not during naps)

Approach to Patient Communication

Empathy, understanding Direct with gentle firmness

Depression common Long-term painful illness Introduce everything prior to performing Move more slowly Listen attentively Avoid over-tiring the patient

Treatment Location Chair best, avoid providing care in patient’s bed Instability of patient’s head is the biggest barrier

for the RDH Patient in bed: pillow, adjust bed to correct height

for you Patient in wheelchair: portable head-rest, firm

pillow

ReviewTo provide dental hygiene treatment for a patient who is

homebound and uses a wheelchair, which of the following techniques can be used?

A) The patient should be moved to a straight chair B) Adjust the bed to a desirable heightC) Dental hygiene treatment cannot be completed if

the patient must stay in a wheelchairD) Attach a portable headrest to back of wheelchair

ReviewTo provide dental hygiene treatment for a patient who is

homebound and uses a wheelchair, which of the following techniques can be used?

A) The patient should be moved to a straight chair B) Adjust the bed to a desirable heightC) Dental hygiene treatment cannot be completed if

the patient must stay in a wheelchairD) Attach a portable headrest to back of wheelchair

Additional Considerations Tray for instruments near treatment Adequate lighting

Headlamp Floor lamp May need to turn off over-head light to

prevent glare

Assessment and Planning Comprehensive patient assessment just

like any other setting/patient care Preventive strategies to meet

individualized needs Maintenance and continuing care Education (Wilkins p.881, Table 57-1

Outlines protocols)

Unconscious Patient Methods for head placement may be difficult Instructions for caregivers

Try to motivate them to care for the patient’s oral cavity

Clean mouth @ least 3x/day Prevent dryness and sordes (crust-like material

that collects on lips, teeth, gingiva) Soft tb, swabs, gauze for cleaning teeth Electric tb with suction (next slide) Cleaning removable appliances Salivary substitutes

Toothbrush With Suction Attachment Tubing connected from the end of

the hollow tb handle to an aspirator outlet or portable suction unit

Bite block should be used Dip brush in nonalcoholic,

fluoridated mouthrinse, not toothpaste

Moisten brush frequently Apply water-based lubricant to lips

Review

How often should caregivers clean the mouths of their unconscious patients?

A) DailyB) Twice a dayC) Three times a dayD) Weekly

Review

How often should caregivers clean the mouths of their unconscious patients?

A) DailyB) Twice a dayC) Three times a dayD) Weekly

Terminally Ill Patient

Provide comfort care, symptom relief Thorough, gentle cleaning of teeth,

tongue, mucosa Dentifrice not necessary Visual inspection for sores, ulcers,

candidiasis, glossitis, xerostomia 79% terminally ill patient have candidiasis 75% terminally ill have pathologic changes

to gingiva Denture problems

Factors to Teach the Patient

Relationship of oral to general health Oral wellness contributes to quality-of-life

factors Preventive strategies

Dietary modifications for caries control

Factors to Teach the Caregiver

Need to care for patient’s oral hygiene and oral infection control

Dental appliance care Dietary strategies for caries prevention Use of devices to accomplish home care