Remembering the Basics in Home Health Nursing

Home Health Care “breeds” some very special nurses that enter into our community away from the hospital setting. They are a confident crew of individuals from different backgrounds who venture into the lives of patients in their homes. Manned with the tools of our trade (BP cuffs, stethoscopes, thermometers and such) they leave the safety net of the hospital and actually get to see exactly how our patients live in their homes. Many times, after meeting patients in the hospital, we wonder just how our patients function at home for one reason or another. These nurses actually get to see the patient from a much different perspective. Such was the case of Adrianna Vince.

Adrianna, she liked to be called Andy, had been operated on for a partial obstruction of her large intestine and was three weeks post op. Home health care had been ordered by her doctor so that the nurses could keep an eye on the incision and do some teaching about wound healing.

The morning I was assigned to this patient we were discussing our patient visitations for the day and making calls to the patients to set up times when we would be visiting. Andy’s significant other answered the phone. His name was Charlie and they had been together for about 10 years caring for each other and providing companionship. He readily agreed to the time I suggested and said they weren’t planning on going anywhere, and he would make sure there was hot coffee available. Clark, the primary nurse who was admitting a patient into Home Care today, happened to overhear my conversation and asked if I had ever visited their home before. Yes I had, but it had been right after she was released from the hospital. Clark said that he had been there two times to visit last week and updated me on where he had left off teaching. He also expressed concern that Andy’s mental status had become “a little foggy” with the second visit; but then again, he explained that Charlie had just given her pain medication and possibly that was the cause.  He made a point of mentioning this as something worth keeping an eye out for.

I arrived at their home, a very old row house covered with yellow siding that had seen its better days probably about 20 years ago. Charlie had been waiting for me, along with their little black dog that they called Satan. I never asked but thought that somewhere along the line Satan must have been a very naughty pup! Charlie was a tall robust man with a heck of a grip when he shook your hand.  I knew from my previous visit that he was 78 years old because Andy had told me she went for a younger man the second time around as she was 84. Before I entered the living room where Andy was, Charlie stopped me to whisper that Andy “just hadn’t been herself” for about the last week and he was getting worried.

Andy was sitting up in a recliner with her feet propped up and quickly shut the TV off when I entered the room. A big smile greeted me as she recognized me from visiting before. Charlie was in the kitchen preparing our coffee so we casually chatted about how she had been feeling and how much pain she had been having while I did her vital signs. Everything checked out perfectly. Before Charlie came back into the room she motioned for me to bend over she had something private to tell me. She proceeded to tell me that she suspected Charlie of “messing around” with their cleaning lady. As Charlie served the coffee, I asked her how her appetite had been and she said fine. However, Charlie told me that she hadn’t been eating as much as she normally did but guessed that since she wasn’t as active that it was okay. To my knowledge I had heard nothing so far that made me feel uncomfortable with Andy’s mental status. While inspecting her incision site, I mentioned to Charlie that their housekeeper really did a nice job keeping things straightened up. He chuckled under his breath and said “thanks, I try.” Quizzically looking at him I asked how the housekeeper assisted him. Slapping his knee and laughing he said, “Girl where in the hell would we get the money for a housekeeper.” Inside my head a warning bell went off.

I continued to work and assess and, hidden under several blankets at Andy’s feet, I saw the foley bag that she had went home with and there was only a small amount of dark amber urine in the bag. I questioned them both when the bag had last been emptied, and Charlie said that he didn’t have to empty it that much because Andy had not been putting out much urine. Another warning bell went off in my head. There was about a cup of urine in the bag and he stated that he had not emptied it since yesterday. Andy swore that she had been drinking plenty of water or iced tea. I went to the phone and got an order for a urinalysis and culture and sensitivity from Andy’s primary doctor. I explained to them both that Andy may have an infection and sometimes not all the warning signs show up at once. But loss of appetite, confusion or mental state alterations and decrease in urinary output could be our “red flag warning.” Sure enough, several hours later her doctor called me and said that Andy was septic. He had already called in an antibiotic that would be delivered to the house, and Andy already had a regular appointment with him tomorrow and the foley would be removed.

Sometimes we have to go back to the basics of what we were taught in nursing school and learned along the way in our profession. Great praise to the Home Health Care Nurses and staff who solve these mysteries everyday working alone from house-to-house.

written by Linda Dawson

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