Home Nursing

Today was my home care nursing observation day. The home care agency I was assigned to is within walking distance from my home, a welcome change from far-flung clinical sites. The beginning of the day consisted of organization, collecting the patient assignment and calling ahead to make sure they were home and willing to allow a student to tag along. All of the nurses had laptops equipped with touch-screens, and outfitted with a Cerner product for charting and retrieving data.

The nurse who volunteered to take me with her demonstrated the staggering amount of assessment data required by medicare/medicaid, nearly 100 different "Screens" worth of check boxes and fields to type in. Thankfully the process is somewhat automated by the software, which populates some of the fields itself. She showed me the ropes of her personal organization scheme, which included a redundant paper copy of the charting that will eventually go into the computer. She explained that in the past, computer failures have wiped out irreplaceable assessment data, so she backs up everything by hand before charting it in the mobile electronic record. Another lamentable example of time-saving technology actually stealing more time from already busy people.

Once the charts had all been organized and all the patients had been contacted, it was time to roll. Home care nursing is one of the better excuses I can think of to get a swanky GPS navigation system installed in your car. The nurse who was driving, I came to find out, is the step-mother of one of my friends from high school. Small world! In the car, she showed me her bag of diagnostic equipment, and demonstrated appropriate "bag technique", which allows her to remove and replace equipment and cleaning supplies while minimizing the transfer of microbes from home to home.

First up was a middle-aged male with AIDS. His partner had recently died due to intentional non-compliance with his therapeutic regimen, and he had been adjusting to the loss and sorting out issues related to the property, which his partner left with debt still attached to.

The assessment took place in his living room, while his sister and father watched TV. A quick set of vitals, assessment of lung and heart sounds, some teaching about lowering his sodium intake, a couple of questions about his CD4 count and viral load, and it was all smiles and handshakes and on to the next site. The home care nurse told me she only needs to visit him once a month, since he manages his own medications effectively and takes good care of himself.

The next visit was a routine assessment of the home health aide's performance. The RN is responsible for making sure the aides are "doing their job" safely and thoroughly. The idea was to get there before the aide so the patient could be interviewed in private about the quality of care she has been receiving. The RN had worked with her for a long time and didn't have any concerns about this particular aide.

When we arrived, we found that the aide had arrived early, beating us there by several minutes. The patient was a pleasant Italian LOL (little old lady) with a colostomy on the left side. She had no active complaints and was able to demonstrate that she could, in fact, complete her own ostomy care, as she has been doing for well over 20 years now. The aide (the ostensible purpose of our trip there) was a bright, energetic 30-something who gave up on getting in to our nursing school because of the notorious (and artificially difficult) microbiology class that has lead me to council every pre-nursing student I meet NOT to take microbiology at our school. Thankfully, as part of a consortium of community colleges, there are plenty of other places to take it. She switched to ECE at that point. She really seemed to know her stuff, and after spending 3 years as an aide I told her she'd have a great head-start on the nursing program. I encouraged her to try Microbiology again at a different school and reapply for next year. I hope she does, I'd work with her any day! The aide, as the RN predicted, had been giving superior care.

Next up was an admission to the service. Admission was a funny way to think about it, since the patient was home-bound, and being "admitted" to a service rather than a place. I reviewed the chart with the RN before we went in, he's had a Ventrico-Peritoneal shunt in place for over 20 years! This tube connects the ventrical on the right side of his brain to his abdominal cavity, to shunt excess cerebro-spinal fluid. Hydrocephalus ("water on the brain") was the reason it was installed. After a nasty fall a few days ago, crippling headaches brought him to the hospital, where enlargement of the left ventrical was discovered through diagnostic imaging. A new shunt was implanted on the left side. The documentation from the hospital mentioned MRSA, but the agency paperwork made no mention of it.

Watching the admission assessment was instructive. In additional to the routine vital signs, a series of questions were asked about his ability to carry out his activities of daily living, bowel habits, drug/alcohol use and things of that nature. This seemed less detailed than the admission assessments I've seen performed in the hospital. The bandages from the surgery were clean, dry and intact. The orders said not to remove them for five days, and since there was no visible drainage, warmth or redness, the dressings were left in place. We reviewed his medications with him and made sure he could safely self-administer them. Mild mental retardation was present in the history, he was also receiving the services of a job coach. During the assessment he told us he had quit cigarettes three weeks ago, and alcohol over 100 days ago. In assessing his bowel function, he noted he hadn't had a bowel movement in 2 days, so we made sure someone would bring him some whole fruit and juice that day, and gave some teaching on increasing fluid intake besides just coffee. Since he was admitted under medicaid, he had to be home-bound. The advantage of this was that the RN could visit him as often as she was needed, instead of being limited to two visits per week.

Our last stop was another elite-LOL, just a week away from her 99th birthday. She was hard of hearing and had suffered extensive bone demineralization. She was able to get around more or less independently with the walker, but still depended on family to help her with her ADLs. She made several negative verbalizations while we were there, commenting on how all of her friends are dead, and how once you can't take care of your own house it was "time to go". She mentioned she had no idea why she was still alive and was "ready to die". A conflict arose when the RN told her that the mattress that was propped against the corridor wall was a threat to her safety and should be moved somewhere temporarily. The patient didn't want anyone to disturb it, she liked the house "just so". She has been waiting for over a month for people to finish remodeling her sunroom so she can sleep there during the summer. She was afraid moving the mattress from where it was left would somehow interfere with the remodeling process. This posed a problem, because in home care nursing the patient is "in charge", not the health care team. If she wanted to leave the mattress there, there was nothing we could do about it. With some patient explaining she finally agreed to let us move it out of the way temporarily so it wouldn't interfere with the use of her walker.

Reflecting on the day, it's clear that home care RNs benefit from self-directed organizational skills, independence and confidence in their skills. There is a strong support system in place for them, since they can call the agency if they encounter something they're not sure of. Following a home care RN around for a day was very enjoyable, home care lends itself to some unique challenges in lateral thinking and problem solving skills. The RN apologized, saying that she didn't have her usual full schedule of interesting wound-care, I told her that was alright, since I was mostly there to learn about her work rather than practice techniques. She serves an important and interesting role in the health of the community, the more care people can receive in their homes instead of in the hospital, the better!

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