When appearances deceive

Nursing, Jun 1999 by Keener, Sherry

IN NURSING, FIRST IMPRESSIONS CAN BE MISLEADING. HOW WOULD YOU HAVE HANDLED THESE THREE CHALLENGING CASES?

Inside the hospital, life is highly structured, built around medication regimens, physical therapy strategies, nutrition plans, and the like. During their stay, most patients accept the structure imposed upon them. But once they're back on their own turf, these same people dare to be themselves. Living their own lives, they may ignore our carefully crafted nursing plans.

Home health care nursing calls for a brand of nursing that's more innovative, less structured. Let me tell you some stories to show you what I mean.

SAVING FACE

"About time you got here!" barks Mr. Turner. "The sink's full of dishes, the bathroom's filthy, and the laundry's piled to the ceiling. Dora's not managing things at all since she came home from the hospital."

I follow him into the kitchen, where my new client stands unsteadily at the sink, leaning against her walker as she juggles dirty pots and pans. She turns awkwardly toward me, tears in her eyes.

I'm appalled, but I try not to show it. After introducing myself, I say, "Mrs. Turner, you shouldn't be standing on that new knee very long or doing things that can throw off your balance. Can't your husband take over some of these tasks until you're stronger?"

Mr. Turner snorts. "Me, do women's work? Dora will just have to cope. If you're so concerned, why don't you pitch in and help her?"

Mrs. Turner bites her lower lip, then lifts her chin and looks me straight in the eye. "I'll manage," she says. "But can you ask the doctor to give me more pain pills? I have only a week's supply, and they're going to run out a lot sooner than that."

I want to tell off Mr. Turner, but I hold my tongue. Instead, I get on the phone and find household help through the couple's church. I also convince her physician to prescribe pain medication for 1 more week.

Mrs. Turner's knee heals, and her dignity remains intact.

AFFAIR Of THE HEART

"What am I going to do with you, Mr. Goodwin?" I ask, exasperated. I set the medication vials back on the table. I'd just counted the tablets and, once again, my client had taken only half the prescribed doses.

Mr. Goodwin's eyes twinkle and he leans forward in his wheelchair. "I'll tell you a secret, dear. Did you know that my Lillian and .I have been married 69 years?"

Secret? He tells me this every time I visit.

"My Lilly loves flowers, and each day of our marriage, I gave her one," Mr. Goodwin continues. "Sometimes, it was only a dandelion or a bit of clover, but it meant something special to us both.

"Now that she's in the nursing home, I can see her only once a month. But I always take her a bouquet of flowers, one flower for each day of the month. I pay for them with the money I save by taking half of those heart pills. The doctor says my heart may just quit without those pills, but the day I can't take flowers to my Lilly is the day my heart will truly stop."

Do I tell Mr. Goodwin how important his medication is, remind him that he needs to take care of himself so he and Lilly have more time together, ask if his physician has prescribed a generic drug to save money...then report his noncompliance to his physician? Sure. But we both know that ultimately the choice is Mr. Goodwin's. The needs of the heart go beyond Cardizem.

BLESSING IN DISGUISE

"You think I'm awful to leave him alone, don't you? You think I'm cold and selfish. Well, I don't care."

Frances White stands defiantly before me in her coat and hat. I've just finished caring for her husband, who's confined to bed with advanced cirrhosis and a recent stroke. He's totally dependent, unable to change position or even scratch himself. Dementia has left him confused and barely able to speak.

Although he's reasonably clean, with intact skin and adequate nutrition and hydration, I suspect that his wife leaves him home alone a lot. In fact, the home health care assistant has already called me twice with safety concerns. But whenever I try to discuss this with Mrs. White, she tells me to mind my own business. Now I have to tell her that I must notify adult protective services.

Her eyes fill with angry tears. "Go ahead, call them," she snaps. "I knew it couldn't last. For the first time in 40 years, I can go out and not be afraid of being beaten up when I come home. I keep him clean and fed-I have to! I can't keep this trailer if he goes to a nursing home.

"See this dress? It's the first new one I've had in 10 years. I bought my clothes at secondhand shops while he spent all our money on drink. Do you see how bare this house is? He broke everything during his rages.

"Well, I have a life now. I even have a friend. If he doesn't have a life anymore, it's his own fault. But I do, and I'm not sorry."

Do I report Mrs. White to adult protective services? I have to; they're coming down hard on neglect and abuse in my state. But it's a blessing in disguise. Although Mr. White goes into a nursing home, the caseworker finds financial help for Mrs. White so she can keep the trailer. In the end, both she and her husband are better off.