To begin this story, you are a home-care nurse, and a good one at that!
You receive your initial intake referral form. The internist has asked you to go admit a 76 year old woman on 4 liters of oxygen, with shortness of breath and low oxygen saturation due to Congestive Heart Failure. She was just discharged from the hospital yesterday. On the drive over you are thinking about what kind of mobility and assistive devices she might benefit from, whether a home health aide will be of help, etc. ( This will be a quick in and out visit, you think to yourself).
You get to the home and ring the doorbell, and are invited in by a overweight gentleman in his 50's who smells of cigarettes. Being the astute nurse that you are, you look around as you are escorted to your patient. While following the long trail of oxygen tubing, you see empty fast food containers, caffeinated soda cans, ashtrays, a jar of bacon grease next to the stove.....oh my! You enter the room where your patient is and find at least 5 people reclining watching "the judge shows". The whole family has shown up to meet the nurse!
So much for getting in and out in a timely fashion.
As you are taking your history and physical you realize that Mrs. Smith (who is so fragile and sweet by the way), lives here with her son and their family. Mrs. Smith is a lifelong smoker, with Type 2 diabetes and hypertension. Her husband passed away suddenly of a heart attach a few years ago which prompted her to move in with her son. You review her lengthy medication list which includes every thing from insulin to anti-hypertensives, diuretics, blood thinners, inhalers etc.
On exam she is short of breath at rest, "junkie" lung sounds, blood pressure is elevated, 3+ pitting edema in her lower extremities, her heart rate is controlled and she has an 02 saturation of 88% on 4 liters of concentrated oxygen. You can see the revolving door of the hospital moving as you continue to assess. (As the well read and current nurse that you are, you know that CHF has a high rate of hospital readmission and can be prevented.)
You take a deep breath and open up your mental Mary Poppins bag of cardiac education tools to keep sweet Mrs. Smith home with her family and for that matter maybe impact her family members health as well.
You take out a balloon (great tool for nurses to keep in their pocket especially any heart health nurse). Comparing the balloon to the heart, blow up the balloon to over inflation and then let the air out a few times. This gives a visual demonstration that the balloon walls weaken and become flimsy with bunches of less toned muscle that create a decrease in the ability to squeeze out the blood your body needs for energy and oxygenation. There are a few reasons for that. Just like every other muscle in your body, it needs exercise, good nutrition and care.
You continue by scaring the stuffins out of the patient and her family with your smoking around oxygen lesson. You tell her about the patients you have cared for that have burned their nasal hairs and nasal passages while smoking with oxygen via nasal cannula. In case that didn't effect them all, you share the story of an elderly smoking patient who set her apartment on fire and sent the lady in upstairs apartment to the burn unit . She fell asleep with her cigarette lit and the tanks exploded! Softening things up, you go on to explain that smoking not only affects your lungs, but also is a vasoconstrictor which worsens the hypertension and workload of your already tired heart.
Next you ask about nutrition and diet. Mrs. Smith's daughter-in-law proudly states that they made Mrs. Smith's favorite dinner last night as a welcome home celebration....baked ham, mashed potatoes with gravy (of course), and collard greens with fat back and sweet tea! Holy sodium batman!!
That explains our edema already this morning! Sigh....so you dig out the cardiac/ heart failure diet pamphlet packed full of low sodium, low fat, caffeine free, lean meat, high veggies and fruit and fiber filled alternatives to the family's recipes from Great Grandmama. (you hope it doesn't just get used as a good spot to place your coffee cup on).
After many grumbles and eye rolls, you explain that caffeine is also a vasoconstrictor and that the fats produce sludge in the arteries making matters of the heart worse. Sodium pulls in fluid and since the heart is not strong enough to manage that extra fluid, it hangs out in the legs, feet, hands and worst of all the lungs. You take out a scale from your bag of tricks to leave with Mrs. Smith and ask her to log her weight daily to keep track of how much fluid she may be retaining.
You go on to demonstrate some very light physical exercises, (perhaps cardiac rehab may already be initiated), that can be done in the chair and encourage movement around the house to help with fluid reabsorption and also to prevent blood clots from sitting still too long. Blood clots can also form in the heart since the heart muscle is weak and may not be squeezing all of the blood out of the chambers each time leaving pooled blood prone to clots.
You review the importance of taking all of her medications on time each day and encourage a pill box to help keep track of what she has and hasn't taken for the day. We all forget! Review the protocol for chest pain including nitroglycerin sublingual tablets in the discussion, if prescribed, and of course when to call the home health nurse, doctors office or in emergency, 911.
You realize that somewhere along this education session, you have all sets of eyes on you and the "judge show" has been silenced. Maybe, just maybe you affected some of the family members health choices in this process. You have provided all the tools Mrs. Smith AND her family can use to help her heart function to the best of its ability....and made some bonus listeners say "hummmm.....maybe i should cut back on fats, sodas and get a walk in a few days a week".
So to wrap up this tale, you place a "NO SMOKING! OXYGEN IN USE!" sign on the front door as you leave that visit. You continue to follow and care for Mrs. Smith and her family. You modify treatment plans as you communicate with her physician when needed and begin to notice the lifestyle changes necessary to optimize your patient and family's health.
Good work home care nurse extraordinaire!
Check out these Resources!
A great website for grocery shopping tips and info: Family Grocery Shopping Tips, 5 Easy Ways to Find Healthier Options at the Grocery Store.
For Your Patient Education Library
Patient Education Resources for Healthcare Professionals.
How about a Blood Pressure Wallet Card for your patients?