This week one of my patients, an elderly woman in her 80’s, told me how useless she feels. This isn’t the first time I heard someone tell me that. Usually it is a woman used to a lifetime of being very busy around the house. Now they can’t walk without a walker, they need someone to clean their house, and they get their meals from Meals-on-Wheels. Arthritis, balance problems, general debility keeps them from being able to do the kinds of things that were always part of their life.

Some of these women live with their children. They see their daughters rushing around trying to balance work life with home life, a home that includes an aging parent. The patient I talked with this week said she used to help out by often cooking dinner for her daughter and son-in-law. Now she can’t.

I honestly don’t know what to tell these women. I encourage them to do things like folding laundry but that just doesn’t seem like enough to them. My heart breaks for them. Everyone wants to feel useful. I did get one woman to crochet squares that she gave to a charity organization. The squares would be joined, made into an afghan, and be given to someone in need.

Does anyone have any suggestions on how incapacitated elderly women can still feel useful? What can they do to help their families? I’d especially be interested in hearing from anyone who has lived with an elderly parent or grandparent. I’d love to be able to compose a list of suggestions that I can give to the women or their families of activities they can participate in. So please help me out if you can.

 I was back on the road today after a week-and-a-half vacation. One of the nice things about vacation was not having to drive thirty or forty miles everyday. I drove when I wanted and stayed home when I felt like it. Very nice.

Today was a beautiful day and I was feeling well-rested and ready to get back into the swing of things. I passed a thermometer on a bank as I drove to work. It read 64 degrees. I wore a short sleeve top and didn’t bother to bring a sweater knowing it would warm up as the day passed.

I arrived at work one-half hour early so I would have time to go through my paperwork and get report on my patients. The pile of papers in my “in box” wasn’t too bad and I got through them rather quickly. Nurses who saw my patients while I was away left me written reports on their status. Most of my patients remained stable although there was one that now needed daily wound care because a blister she had broke and was raw and oozing. I had a voice mail message from a daughter of one of my patients requesting that I see her mom since she had fallen two days ago and had a skin tear on her elbow. It looked like I was going to have a busy day. That was okay. I was feeling good!

There was one patient that I wasn’t going to see today or actually ever again. Usually I saw him on Monday’s but he hadn’t been home for awhile. After falling at home, he entered rehab and didn’t do very well there. He just lost his spirit. Home was where he wanted to be and no amount of encouragement could make him accept the fact that he needed to be in-patient for at least 6-8 weeks. He never made it home. He died while I was on vacation and I went to his wake to say my last good-bye.

I noticed alot of goldenrod along the roadside. Some homes already had fall wreaths on their front door. The leaves are still green though and when the day gets its warmest, it is hard to remember that it is September and not the beginning of summer.

When I’m on the road, I have a small collection of snacks next to me. I’m not one to give in to the temptation of stopping at any number of fast food places that dot my route around town. Instead, I bring a few things to munch on. Last week when I was on vacation I went to “Whole Foods”. I found a big container of dried green beans that really seemed ideal for my daily snack. The green beans are crunchy, slightly salty, and easy to munch on while driving. I carry a bottle of water to sip on. Sometimes I have bags of dried almonds. I’ve even made my own trail mix with dried almonds, sunflower seeds, and dried cranberries.

The day flew by. My failing 92 year old woman seemed frailer and more lethargic than ever. I did wound care on two of my patients. My COPD patient required a call to her doctor to report a side effect to one of her medications she was having. One of my patients was doing just great and that made me feel terrific.

A few clouds moved in by the end of my work day but the air was still very comfortable. Maybe it will rain tomorrow. That wouldn’t be so bad since we have had outstanding weather for about a week. I logged in 38.2 miles today. And even though I went into work a half-hour early and left an hour late, I still feel the vacation spirit. I’m hoping that feeling will last at least one more day. Wouldn’t that be great!!

Carefully I opened the package that contained the equipment I needed to drain a PleurX catheter.  A PleurX catheter goes into the pleural cavity and remains there where it can be used intermittently to drain fluid out of the pleural space. I was going to do this in the rather cluttered and small bedroom of my patient’s apartment. My patient was dying of lung cancer after years of heavy smoking. Now he lay in his bed with the ornate mahogany headboard. Oxygen ran through a soft green tubing into his nose. Before I began I left the room to scrub my hands at his bathroom sink. When I returned to his bedside, I picked up the drainage kit that was packaged in a blue wrapper. The inside of the wrapper was sterile and became my sterile field. That means anything that came in touch with it must be sterile. On the field was already gauze for the dressing I would put over the catheter when I finished. There were alcohol wipe that I would use to clean the tip of the catheter. A new cap to cover the tip of the catheter was also part of the kit. I touched nothing with my bare hands.  My patient waited expectantly for the draining to begin. The trouble he was having breathing was caused by the build-up of fluid in his pleural space. Once I was done, his breathing would be slower and easier. I expected that at least 200cc of amber fluid would be drained off today. He held his flannel shirt up so I could remove his old bandage which I did with non-sterile gloves. I threw the bandage and my gloves into a plastic bag I had set out for garbage. I now turned to put on the sterile gloves that lay across the blue sterile field. I gingerly picked up one and using sterile technique I put first one and then the other on. I was ready to begin. Just then a flash of black crossed in front of me and landed in the middle of the blue sterile field! It was Nicky, my patient’s devoted and very fluffy cat who now sat grooming himself  oblivious to the fact that he just contaminated something that I had been so careful about maintaining sterility. But I now had a cat in front of me, one who wasn’t about to move. Of course now I would have to #1 get Nicky out of the room and #2 start all over again. Later when I told my clinical supervisor about my feline helper, she laughed and said “Welcome to Home Care! You just never know who in the household will want to assist you!!”

The rain was pouring as I ran across the parking lot of the convalescent home. I headed into the lobby where several residents sat in wheelchairs watching me as I came through the door. Two young women behind the front desk were talking about the weather when I stopped to ask them to direct me to Mr. R.’s room. I did as they told me. I went down the hall, found the elevator on the right, and took it to the second floor, then another right and his room should be right in front of me. I didn’t see his room but I did see him. He was one of about ten elderly men and women in wheelchairs who lined the hall. The last time I saw Mr. R. he was in a short-term rehab facility. When I went to visit him there, I found him in the midst of having a stroke. Now he was here at this convalescent home sitting in a reclining chair with an untouched lunch tray next to him. A blanket was scrunched up on his left side. His pajama bottoms were ones I had seen on him so many times when I went to his apartment to make a home visit. Today they were pushed up and his scrawny legs dangled off  the edge of his wheelchair.

Mr. R. was sleeping as I approached him. I called to him and his eyes fluttered open. He took my hand and held it close to his chest. I heard him whisper “I’m not good Chris”.  He’s hard of hearing so I had to lean close to talk to him. I tell him how I miss our Tuesday morning visits. I ask him if he is eating and he replies no. “Would you like a drink?” I ask him and he shakes his head “yes” in reply. I hold the milk carton so he can sip the straw that sticks out of it. He begins drinking and soon finishes it. I decide to really push the limits by filling a spoon with ziti and sauce and offer it to him. I apologize that the sauce isn’t as good as the sauce his mother used to make but after a few bites he tells me that it wasn’t that bad. A nurse stops by and asks how I know Mr.R. I tell her that I was his visiting nurse for the past two years. She asks me what he was like at home and I tell her that he was a great guy with a big heart. I tell her how he sent a neighbor out to buy me a mother’s day card. I tell her that he sat quietly in a recliner surrounded by photos of his family. He loved our visits and visits from his big Italian family.

I have to leave since I was due at another patient’s house in a few minutes. Fortunately, my next patient lives down the street. My visit with Mr. R. was an unofficial one since he is no longer my patient. (We don’t see patients in the hospital or nursing facilities) I think of him often especially when Tuesday morning comes along. I lean down now and give him a kiss on his forehead. “I’m praying for you” I say to him. He tells me that he prays for me to. He closes his eyes as he lets go of my hand. It’s still raining out as I exit the building. The rain camoflages the tears that well up in my eyes as I get in my car and leave.

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.

I gave him a kiss on his old bald head and went out to the nurse’s station to ask his nurse how he was doing. When I asked when he had a stroke, she told me that he hadn’t had a stroke. I told her about the facial droop, the difficulty in arousing him, the random movements of his arms. A look of concern crossed her face. She turned to a doctor standing near-by and asked her to come check my patient. Suddenly about four people surrounded his bed, checking his blood pressure, putting oxygen on him, calling to him, and telling me that this was all new. An ambulance was called for and off he went to the local hospital for treatment of a new stroke.

As for me, I walked out to my car with a heavy heart. I sat for awhile in my car thinking about him, thinking about the two years I saw him every week, thinking about him now going off to the hospital. I don’t think there will be a 90th birthday party. I doubt I will see him again. Good-bye dear man.

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:

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!

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.

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.

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!

So here’s what I want to see when blood pressures are taken. No drinking coffee, no smoking, and no exercising before you have your blood pressure taken. Those are the things you can do to assure accuracy. I remember when I was a smoker. I’d always have a cigarette on my way over to the doctor’s appt.. Was my blood pressure higher then normal then? You bet! And think about exercise. Taking your blood pressure immediately after an aerobics class is not the best time. And what about those older men and women who struggle to walk down a long corrider using all the energy they can to make the distance to the exam room and then their blood pressure is taken as soon as they park their walker. Why can’t we just tell the nurse or the medical assistant to come back when we have caught our breath!

Patients always ask me if it is okay to have their blood pressure taken over their clothes. The answer is no. You just don’t get the most accurate blood pressure over clothes. I admit that I have on occasion taken a blood pressure over clothes. Usually it is when the person is healthy, has no history of hypertension, and the clothing is very light. Or I may take it over clothes if it is just impossible to get the sleeve up and it isn’t appropriate for them to undress. This doesn’t happen often. I always strive to take it on a bare arm.

Now the part that really gets me is when the position of the arm isn’t correct. When my doctor lifted my arm way up I always felt like telling him to please don’t take my blood pressure that way. I never got up the nerve though. I’d just stew after the visit. The arm should be at the level of the heart and well-supported. Any higher or any lower affects the accuracy of the reading.

The cuff should be snug but not tight. The cuff shouldn’t be popping off as the blood pressure is being taken. If you have very muscular arms or obese arms, make sure the right size cuff is being used.

Finally, if there is a need to take your blood pressure more than once, and actually that is a good idea according to the American Heart Association, then the taker should wait at least one minute between readings. That assures time enough for the blood vessels to return to normal before the blood pressure is taken again.

I came across two websites that have credible information about the process of blood pressure taking: http://www.steeles.com/catalog/takingBP.html#hearing and www.americanheart.org. Speak up. Insist on having your blood pressure taken the right way.

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.

When I put my stethoscope on a patient’s back, I expect to hear the sound of someone breathing in and out. Nothing else. I work from the top of the lungs to the bottom of the lungs because abnormalities can be heard throughout the lungs or in just one area. I complete my listening to lung sounds by listening to the sounds in the upper airways in the front of the body. Generally, abnormalities start in the lower lungs and progress upwards. Take Mr. Donovan. Typically a person with congestive heart failure may have fluid in the lung bases. This sounds like rubbing your hair between your fingers. When congestive heart failure is left untreated, the fluid could fill the lungs.

John Shaffer doesn’t have fluid in his lungs. His disease is nasty. When he breathes, his airways are narrowed, inflammed. Breathing for him is like breathing through a tiny straw. Not much air gets in. And because not  much air comes into his lungs, his lungs don’t expand very well. And so I hear very diminshed breath sounds. Emphysema is a chronic, progressive disease. Many emphysema patients end up on oxygen so they can take in

When lungs are infected,  I can hear a variety of sounds. There can be wheezing, one side of the lung could have lung sounds that are more diminshed than the other side, or I could hear noises that get better or worse with coughing.

So when I listen to the lungs, I am listening for sounds that tell me that there is congestion from infection, sounds that tell me there is fluid that shouldn’t be there, and for sounds that tell me the lungs are fully expanding or not.