A Visiting Nurse Pays a Visit

One of my patients broke his leg a few weeks ago and ended up going to short-term rehab. He has been a favorite of mine. Each week I’ve checked his vital signs and blood sugar, listened to his heart and lungs, made sure he had no problems with his medications, and checked to make sure he is getting his Meals on Wheels. At 89, he was content to sit in his recliner all day. He looked forward to receiving communion each week from a volunteer that stopped at his apartment in a low-income senior housing building. Although he is nearly blind, he found comfort from having photos of his family on a wall near his chair. He’d tell me stories of his brother who was killed in WWII. There was a photo of his mother who raised seven children alone. He always talked of her with reverence. He liked our visits and told me that it always made him feel better when I came to see him. He always asked how my family was. I always asked about his family. He asked me if I thought I would be able to come to his 90th birthday party. No way would I miss it I told him.

Yesterday I decided to stop at the facility where he was recieving short-term rehab. Although it isn’t part of my job, I like to check in on my patients when they have gone into the hospital or rehab. When I walked into his room, I expected to see him sitting up in a wheelchair with his his leg elevated. I thought he would tell me how they never keep the room warm enough. Instead I found a man that looked much different from the one I knew. In fact, I walked back out of the room to check the name on the door to make sure I was in the right room. My patient was asleep. Mats were on the floor next to his bed which I assumed was to protect him in case he fell. As I stood next to his bed, I saw that his face was drooped on one side. I called to him but he was barely arousable. He’d try to open his eyes but couldn’t. His hands flailed randomly. I took hold of one hand and sat quietly next to him. His face was drawn. He had lost a lot of weight since I last saw him. Since I hadn’t had any reports about him, I thought perhaps that he had been heavily sedated or that he had stroke since I last saw him.

My Mother’s Rising BNP

My mother’s BNP is up to 301. Last year it was 201. She has had congestive heart failure for some time now so I’m not surprised that her cardiologist regularly checks her BNP. I am concerned that it is going up. That means her medication isn’t working the way it should or that her congestive heart failure is worsening.

The BNP (B-type natriutetic peptide) assists doctors in making a diagnosis of CHF in the context of shortness of breath. (See my January 4th post). It can also track the responsiveness of CHF to treatment. That’s why my mother gets tested.

I couldn’t remember the normal values for this test so I checked out the patient library at Quest Labs. Here is the breakdown:

Brain natriuretic peptide

Normal:	0–99 picograms per milliliter (pg/mL) or 0-99 nanograms per liter (ng/L) SI units. No heart failure is present.
Abnormal:	100–300 pg/mL or 100-300 ng/L (SI units) suggests heart failure may be present.
	300 pg/mL or 300 ng/L (SI units) or higher is considered mild heart failure.
	600 pg/mL or 600 ng/L (SI units) or higher is considered moderate heart failure.
	900 pg/mL or 900 ng/L (SI units) or higher is considered severe heart failure.

So my mother’s 301 reflects mild heart failure. As much as she won’t like it, she is going to need a change in her medication. Probably her doctor will increase her diuretic in order to pull fluid out of her system and relieve the burden on her heart. If it works, her BNP should go down the next time she is tested. Let’s keep our fingers crossed!

In the Care of a Sister

Today I saw a patient of mine who has been through a difficult illness requiring much help. Her sister rose to the occasion. She left her grown family and moved in with her sister for the duration of the illness which lasted for several months. It was just the two of them. The sister became a caregiver as she bathed and dressed her sister, washed her clothes, and cooked her meals. She became a nurturing presence in this household.

These sisters are in their seventies. It’s been more than half a century since they lived together. Illness gave them the incredible opportunity to be with each other in ways they haven’t been since they were children. As my patient gained her strength, the two of them took time to look through old photo albums and spend quiet moments talking about bygone days. They learned new things about each other. They had moments when they got on each others nerves but later laughed about it. When my patient was almost at the point of full recovery, these sisters had a hard time saying good-bye.

I learn something from every patient I take care of. These two sisters taught me about the unique opportunities we have in life that are hidden like treasures within a sometimes tragic or challenging health experience.

Give the Elderly More than Photos

What really gets to me in my job as visiting nurse is the raw loneliness that many of my patients face every day. Last week I went to see a eighty year old woman who had a small but pleasant apartment. There were family photos on the walls and every flat surface. She knew the name of each of her fourteen grandchildren and seven great-grandchildren. We talked about her family for a little while before I took her blood pressure and give her an injection of Vitamin B12. She told me that her large family all lived locally but no one visited her. That used to bother her alot but now she is resigned to it. They are all so busy she adds with tears in her eyes.

When I was young, we often went to see my grandparents on Sunday. There was no choice. We just did it. In today’s complex world, children are over-scheduled and parents are over-worked and the elderly are left out of the equation. As I drove away from this woman’s home, I thought about the photos in her home. There were school photos, studio portraits, wedding and graduation photos. Lots of my elderly patients have the same kind of family photos. It is almost like the family is saying ” I can’t visit you but here’s my picture so you know I care”. But photos are no substitution for the real thing. And the elderly know it.

The elderly speak of the world that they grew up in where  mothers cared for elderly relatives and visits to grandparents were often and expected. They are puzzled by today’s world now that they are the senior member of the family. I see them alone and sad. They fill their days watching game shows on TV and doing search-a-word puzzles. Women, like my eighty-year old patient, just want what we all want: the love and support of their family. I truly believe their families love them but it almost seems as if they have forgotten them. We need to assure that our family life  includes time for our elderly members.

Take my Blood Pressure Right Please!

Since May is Blood Pressure Awareness Month I have to tell you about my pet peeve: blood pressures that aren’t taken right.  How often have you had the experience of rushing to keep a  doctor’s appointment during a busy day in your life, be brought into the exam room, directed to jump onto the table, and immediately have your blood pressure taken by the medical assistant? You figure the person taking your blood pressure knows what they are doing. You think she didn’t make the cuff tight enough but you don’t want to say anything. You are nervous about being at the doctor’s office where your blood pressure is always higher than when you take it at home but the office routine is the office routine. No one ever comes back to repeat a reading. You notice that the medical assistant takes your blood pressure over the sleeve of your sweater even after you offer to push your sleeve up but you aren’t sure if that is right or not.

Now please don’t think I’m singling out medical assistants as being incompetent in blood pressure taking.  I have seen doctors and nurses take blood pressures wrong. My own doctor would often take my blood pressure with my arm way above my heart….wrong, wrong, wrong!

Hear the Lung Sounds

Mr. Donovan was a 76 year old man who was just in the hospital for congestive heart failure. When I listened to his lungs, I could still hear some fine crackles at the bottom of his lungs. Peggy Rowley was a 52 years old recovering from pneumonia. Except for a little congestion in her upper airways, the rest of her lungs were clear. John Shaffer, age 61, has emphysema. I struggle to hear breath sounds when I listen to his lungs. The sounds are very diminished. He asks me what I’m listening for when I listen to his lungs. Good question, I tell him.

BNP or BMP??

My mother had a blood test this week to check her BNP level. A few weeks ago, she went to the lab to have a BMP done. When I talked to her on the phone tonight, she wanted to know what the difference was between the two tests. Good question since the tests sound so similar but in fact they are quite difference. A BNP is B-type natriutetic peptide, a blood test that helps doctors determine if people with difficulty in breathing, edema, or fatigue have lung or heart disease. An elevated BNP is associated with congestive heart failure (CHF).  A BNP can also be used to track the progress of CHF patients. A BNP that remains elevated suggests that the treatment the patient is receiving for CHF is not effective.

Visiting Nurse Journal: Christmas

I’m glad Christmas is over. As I visited each of my patients during this holiday season, I saw how hard it was for them to celebrate Christmas. For the elderly, Christmas is a harsh reminder of the losses they have faced in their lives. Most of them don’t bother with decorations now. Only two of my patients had Christmas trees: one was in the home where my patient lived with her son and another was in a home of an elderly couple who was looking forward to their only child spending Christmas with them. Christmas is a lonely time for the elderly who live by themselves. Some of my patients had places to go for Christmas but didn’t feel they had the strength to be a part of a large family gathering. Loneliness, isolation, and sadness keep the elderly company during this time of year. During my visits, I encourage them to share their memories of past Christmas’. One lady told me of the excitement she had as a child when she received a stocking filled with an orange, an apple, some walnuts, and two pennies. She recalled that time as being such a happy one. Another woman told me of Christmas in Austria where she grew up. Children would go house to house at Christmas to ask for candy. These memories bring a smile to their faces. I laugh with them as they tell me a funny incident from their childhood. I hug them as I leave ever in awe of the time we have just spent with each other.

Please Santa, Bring Some Presents for My Patients

I wrote out a Christmas “wish list” for my patients today since we were told to get it in to the social worker by November 1 this year. Anonymous donors in our community go Christmas shopping for the patients that we have selected for gift-giving. I’ve chosen three patients that meet the financial need criteria that we go by.

My patients have either no family or family that sporadically pops in and out of their lives. They don’t stay long enough or seem to care enough to make a difference. One of the patients on my list finds more comfort from the birds in her yard than she does from the people in her life. For her, I put bird seed on her list. More than anything she wants her birds taken care of. 

The other woman on my list sleeps on an old sleep sofa surrounded by piles and piles of bags. I have never been able to figure out what is in those bags. She never wears more than an old nightgown and a stained sweater. I worry about her being cold. She needs soft flannel sheets for her bed.

The last person on my list is a man I’ve been taking care of for about a year. He always has a big smile for me when I visit him but he has trouble speaking because of a stroke. Most of his basic needs are met by an assortment of community services. He just doesn’t have any one who will bring him anything special. I think he’d be thrilled with a simple food basket with fresh fruit, small boxes of cookies, and a bag of hard candy. We don’t have as many donors as we used to. Times are hard. I wish we could do even more to make the holidays special for these folks. Oh Santa……

Obama Supports the Nursing Profession

 Obama has a long history of supporting the nursing profession. As an Illinois senator he worked on such issues as limiting mandatory overtime for nurses and improving nurse-patient ratios. His commitment to improving health care and addressing issues close to the heart of nurses has won him the endorsement of the American Nurses Association. Obama for Nurses issued this statement as one of many that shows just how Obama plans to improve working conditions for nurses. This will have a direct impact on the delivery of health care.

The nursing workforce shortage ranks as one of the most pressing issues facing our health care system. Nurses play a critical role in every aspect of patient care and also serve as administrators and executives in clinical and policy settings. Yet, too many young adults are choosing not to enter the nursing profession, and a significant number of current nurses are switching careers or retiring early. Barack Obama will improve working conditions including limiting mandatory overtime,improving nurse-to-patient ratios, providing additional support to training and incentive programs, and con tinuing to recognize and support nurses’ right to organize. In addition, Obama supports reauthorization ofTitle VIII training programs with greater financial incentives for students and nurse faculty, including scholarships and loan repayment. Obama also supports adequate funding of the Nurse Reinvestment Act.