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Home > RNJ > 2007 > May/June > Perspectives: The Voices of Rehabilitation Nursing

Perspectives: The Voices of Rehabilitation Nursing
Louise Harmon, RN C CRRN C

Many years ago while living in a small community, I decided to shift professional gears from rehabilitation to home health nursing. My new career path provided many rich experiences, enabling me to use my rehabilitation expertise as well as to develop a strong sense of autonomy. Resourcefulness became a very important skill in my new specialty.

My home health client, Irma*, was a 73-year-old retired nurse who lived with her daughter, son-in-law and teenaged grandson in a lovely home in my small town. She was very active in the community with volunteer pursuits and was a much cherished member of her family. During my visits, she fondly recounted her days as a “maternity” nurse at our local hospital where she assisted many babies into the world, some now prominent members of our community. With an air of motherly pride, she recalled how her daughter, Margaret*, would stop by her unit every day after school, to help put away supplies or run errands for the head nurse. As she told her stories, I tried to imagine how much simpler and perhaps a bit more human the nursing experience was during Irma’s career. *names have been changed.

Irma was recovering from dehydration related to a recent viral infection and, as she was doing quite well, I planned my discharge visit to be fairly short. However, when her daughter, Margaret, greeted me at the door, I sensed from her demeanor that something was terribly wrong. Leading me quickly down the hallway to Irma’s bedroom, she gave me a synopsis of the previous day’s events.

All was fine until the family gathered around the dinner table the evening before. Irma was eating and participating in the family conversation, as usual, when suddenly, she tumbled off her chair. Her son-in-law helped her back up, but Irma seemed to be listing slightly to one side and having a little difficulty speaking clearly. Instead of calling for medical help, the family decided that Irma was simply tired from her active day, and helped her into bed for the night.

Shortly before I arrived, Margaret attempted to help Irma up to the bathroom, but she was having difficulty walking and kept stumbling to one side. When I entered Irma’s bedroom, the change in her condition from my previous nursing visit was readily apparent. Instead of her light-hearted bantering, Irma could barely verbalize an intelligible word. As Margaret assisted her to sit on the edge of the bed, she leaned significantly to the right. I safely placed Irma into bed and pulled Margaret into the other room.

“I need to call her doctor and have her transported to the hospital. I think your mother may have had a stroke”.

I made the necessary phone calls and answered Margaret’s questions, as the ambulance arrived to take Irma to the hospital. I reassured Margaret that her mother would be in good hands and promised to call her the next day to see how she was doing.

To my surprise, when I phoned the next morning, Irma had been discharged home the previous afternoon. Margaret had been told that Irma sustained a stroke, and tests had showed evidence of an older, previous stroke as well. Irma’s physician decided not to admit her to the hospital, as he felt that there was little anyone could do for her and made the decision to send her home to die.

When I called the doctor to ask for additional skilled nursing visits, he was rather abrupt with me, stating he could not see the point of continuing home health, as he was certain that Irma would expire shortly. After much wrangling, he agreed to three more nursing visits to teach the family ‘terminal care’. But he was very clear: no more than three visits.

As I entered her bedroom, Irma was lying flat on her back, with her daughter attempting to give her sips of water. Not surprisingly, Irma was choking. I sat her up in bed, and very carefully spooned a little water into her mouth, but she choked on this as well. Margaret and I went into the kitchen and after rummaging through the cupboards, we located some applesauce and gelatin. Irma was able to swallow the applesauce fairly well. Next, I thickened some water with a little of the gelatin, and this, too, went down without difficulty. Over the next hour and a half, I gave Margaret a crash-course in caring for a post-stroke patient. We were able to borrow a bedside commode and a wheel chair from a neighbor who recently lost his wife. I showed Margaret how to transfer Irma and toilet her safely. Together we created a diet of soft foods and thickened liquids, and I demonstrated how to help Irma improve her ability to swallow by cueing her to tuck her chin. I told Margaret to call me if she had any concerns whatsoever, and planned to return the following day.

When I arrived, I half expected to see Irma lying in bed, further declining. However, I was pleasantly surprised to see her sitting up in the wheelchair, looking at me with recognition. Margaret reported how Irma ate some scrambled egg and applesauce shortly before I arrived. Although it was a slow process, she was able to swallow her breakfast without choking. As I did my assessment, I could see that Irma was getting stronger, regaining some of the function which she had lost. I spent the remainder of my visit instructing Margaret on ways to help Irma continue her progress. I suggested that starting the next day, she dress Irma in her normal clothes, and take her into the dinning room for her meals. I demonstrated techniques to encourage Irma to use her affected side and emphasized the importance of Irma participating in the familiar family routine of the house as much as possible. “Do not baby her”, were my parting words.

When I returned to the office, I called Irma’s doctor to update him on her progress, hoping he would reconsider and allow our physical and occupational therapists to evaluate her. I was crushed by his response.

“I told you….three nursing visits. That’s all!”

Although I felt he was being terribly unreasonable, I knew I had few options. The area in which I lived was very rural, with individuals remaining quite loyal to their family physicians. It was never a consideration to challenge their medical advice, and the local doctors were not terribly fond of listening to suggestions from nurses. I resigned myself to only one more nursing visit.

I decided to call Margaret the next day and strategize with her how to best use my remaining visit. Irma was doing better, and Margaret felt that for the next several days she could handle her needs quite well. I told her I was only a phone call away, and would be happy to answer her questions anytime. We kept in contact for the remainder of the week, and I directed Irma’s care via the phone.

When I walked into the living room a week later, Irma was dressed and sitting in her recliner, feeding herself breakfast. Her right hand was still weak, and her smile was slightly crooked, but, it was just so wonderful to see her smile. When she managed to say “hello”, I felt a tear roll down my cheek. It was obvious that Irma was not ready to depart from this good earth just yet.

I kept in touch with Margaret for some time after I discharged Irma from our agency, and helped her to connect with services in the community which would encourage Irma in her rehabilitation efforts.

My home health experience had been quite a departure from working in a big city rehabilitation center. There were no specialists or therapists to perform evaluations and no case conferences to help plan care; there was no ‘state of the art’ equipment. There was only good basic rehabilitation nursing to rely on, which coupled with resourcefulness, can work well anywhere.

About the Author

Louise Harmon, RN C CRRN C, began her career as a rehabilitation nurse over 30 years ago at Kessler Institute in New Jersey. Over the years, she has applied her rehabilitation experience in a number of practice settings, including home health and pain management. Currently she is working as a nurse case manager consulting on short term disability claims for Standard Insurance in Portland, OR and can be reached at LouiseHarmon@comcast.net.