A Typical Day in Home Care

7:00 AM The nurse starts her day at her Home Care office to review new home visits assigned to her today. One new patient lives in a high crime, poverty-ridden area. The nurse calls for a security guard to drive her and remain with her during that visit. She packs food stamps and donated medical supplies with her for this family. The nurse then uses the telehealth equipment in the office to "visit" one of her diabetics. The nurse "sees" this patient's insulin syringe with correct dose.	Home TeleNurse Visits (click for larger image)
7:30 AM The woman used an oxygen concentrator to maintain oxygen at 4 L/min while awake, and slept with nasal continuous positive airway pressure (CPAP) to increase oxygenation and overcome sleep apnea. The nurse undertook a cognitive assessment to determine if the patient's poor affect was related to low oxygen saturation. There are two ventilator patients that this nurse follows using the in-home telehealth monitors. These women are sisters who in their 40's had MI's related to sleep apnea related hypertension. The electronic data measurement from the hand held spirometer is transferred across the telephone line to the sleep apnea clinic. The data is fed into a computer which alerts the sleep physiologist to the sister's decreased lung volume. The nurse increases the positive pressure and instructs the patient to use the nasal airway during daytime naps and in addition to sleep throughout the night. The nurse refers to patient for a respiratory therapist home visit to assess CPAP equipment. She also re-teaches the sisters care of patient and working with equipment. She leaves short teaching videotapes to guide care.	Home CPAP Ventilators
The nurse arrives at the home of a 60-year old Caucasian man suffering from congestive heart failure, obesity, and sleep apnea. This patient and his family were indigent, living in a low-income neighborhood ravaged by unemployment, illicit drug use, and burglaries. The security guard stays with her during the visit. The nurse also assesses psychological status of all family members because being housebound due to personal safety has created social isolation and often leads to reactive depression. Depression can mask physiology-based fatigue and poor cognition.
8:30 AM The nurse also uses this time in the office to make an interactive 2-way live video linked house call (see monitor). The nurse can see the patient and the patient sees her. She directs the patient to use her the spirometer to obtain an FEV1 lung volume. The patient holds the spirometer up to the wireless T.V. remote camera and the nurse can read the dial, the measure is within normal limits for the patient. This patent smiles each time she visits with her "T.V." nurse.
8:45 AM The nurse arrived at the home of a newly diagnosed insulin-dependent diabetic, who had recently experienced a cerebral vascular accident with left-sided weakness. This patient was a divorced, 40-year old, middle-class woman, who lived alone in a two-storied home. The patient's sister visited daily to administer medications through a pump to regulate insulin and to provide help with activities of daily living. The nurse reinforced patient teaching about medication orders with her sister, and reviewed the signs and symptoms of hyperglycemia and hypoglycemia with her. This morning the nurse reviews the oral intake and urine check records she asked the patient to keep. The previous day the patient voided approximately 500 ml of cloudy/dark yellow urine. Her blood pressure today was 180/90 mm Hg, her pulse was 100 beats per minutes, and her blood glucose was 200 mg/dL. The nurse administered the patient's medications which she had not taken that day. The patient's sister was given instructions about symptoms that would indicate the need to contact the nurse. This visit included obtaining a blood and urine specimen to take to the laboratory and notifying (via laptop computer electronic email) the physician of hypertension and potential urinary track infection. Her blood pressure had decreased and fluid intake increased. Because the sister can't always be present, the next visit was scheduled to be telehealth robot for the end of the day.
9:15 AM-9:45 AM The nurse observes a mother complete TPN (Total Parenteral Nutrition) asceptic procedures for central vennis catheter infusions. The mother has excellent technique - but needs to include this 13 year more in his own care. Completes Point of Care blood laboratory. Takes specimen from child's central catheter and then drives the specimen down to the laboratory. She uses her laptop computer to send a memo to the CQI (Continuous Quality Improvement Team). The team is a group working to review various processes to improve these. All staff are represented on the team and several tasks have been streamlined saving nurses time for patients. The nurse notes very inefficient time use to drive to laboratory.
9:45 AM On the way to out of the lab, the nurse was paged by the home care office. The wife of a postoperative patient of 3 days called to say that his left abdominal incision line had opened and was draining a large amount of fluid and blood. From her car, the nurse returned the call to the wife and told her to wash her hands very thoroughly then place a newly laundered cloth on the area and press on the wound. The nurse informed her that she was in the area and would arrive shortly.
10:00 AM The nurse came to the home of the patient and found a 1-inch opening to the fasica, although internal sutures appeared to be holding. The wound was draining a copious amount of serious fluid with old clots but no bright blood. Vital signs remained stable. The patient was assisted to a comfortable position and a pressure dressing was applied to the site. The physician was called and informed of the patient's status. The nurse helped the wife ambulate the patient into their car to be transported to the office to avoid emergency room or hospital charges.
11:00 AM The nurse completes lap top computer charting and goes to lunch. During coffee break she thinks of her afternoon schedule where she'll visit patients she has followed in her case management disease specific population (oncology and nutrition supplements) over the past 6 weeks. This nurse case manages patients who are on enteral and parenteral nutrition. Included in her case load is the patient and family she visits now. This family is in the photographs shared with their permission. The patient wrote under each before and after photo, of her life on TPN (Total Parenteral Nutrition).
11:45 AM Nurse takes lunch break.
12:45 PM She looks at the record of a patient referred for hospice care. Later she will assess that family's ability manage the patient at home. She discusses the patients living will with the patient and family. Because of her clinical expertise and experience with ethical and legal issues related to hydration and nutrition, this nurse was invited to present her opinions and research data from records she maintains. She will present her decision-making ethics approach for the local medical-legal community group.
1 PM The first family she sees this afternoon are a young couple in their early 40's. Mr. Johnson began his own business in home remodeling and repair several years ago. His business has done well, allowing his eldest son to become employed after the first year. Unfortunately at this same time he was diagnosed with stomach cancer. Six months past his chemotherapy, he was tapered from total parenteral infusions on to enteral tube feedings with no debilitating diarrhea. He has had no recurrence of cancer symptoms in past 5 years. He was being visited monthly, however, because of consistent poor nutrition intake and low weight. This month the nurse has returned for an extensive nutrition assessment including blood drawing for laboratory measures. The patient has lost more weight but has no nausea, vomiting or diarrhea symptoms. When queried, the patient states, "I just can't afford that feeding 6 times a day, it costs $32 a day! I am on self insurance, I can't turn those bills in, that just can't be!! I still can take watered down baby food - that's cheap." The nurse tells the patient she appreciates his sharing his financial concerns and that she will call the social worker and dietitian to see if he was getting enough calories in baby food. The nurse sends an e-mail to the dietitian and to the local cancer society who may be able to supply some enteral liquid feedings without charge. she leaves food stamps for the family.
2:00 - 2:30 PM The nurse drives to local park to take a slow paced, restful walk for her afternoon break.
2:30 PM Back in the Home Care Agency Office. She calls dietitian about Mr. Johnson's low calorie intake and enteral feedings. She sends an e-mail to the MD's pager via her wireless handheld computer. This computer program automatically sends the latest laboratory results of the patient. This nurse used her computer chart entry to chart her physical assessment data. A summary of this patient's data is sent automatically to the medical record and to billing department for nurse charges to be submitted.
3:00 - 3:30 PM At the close of the day instead of driving to the office an hour away, she revisits the diabetic patient by the telehealth link from her house. The MD has ordered fasting blood glucose for the morning - which the nurse tells the family she will get by telehealth glucometer in the morning. The nurse the documents this day's patient conditions and the outcomes of her nursing care using the laptop from her home. She leaves information and reports for the evening and night home care nurses including a short videotaped section from a telehealth visit and the cardiac rhythm monitor strip for tracking of the new MI patient. The videotape is when he was starting to have PVC's on the cardiac monitor. On the video you hear his teen-aged grandchildren visiting and explaining about a robbery of the grocery across town. The nurse councils the family to keep the patient stress free while his heart stabilizes. The nurse wonders how she would ever do without the technology she has to visit and help patients today. 4:00 PM Nurse finishes her day by visiting her patients is assisted living using Robonurse.