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Giving Patients the Tools They Need to Stay Out of the Hospital and In Control

Posted by Meaghan Starling on Nov 18, 2014 12:32:00 PM

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real-world-banner-Giving-Patients-Tools-They-Need-141118Did you know that the oldest person to climb Mount Everest was eighty? That a sixty-seven-year-old once rowed across the Atlantic? That an eighty-two-year-old completed the Ironman triathlon in Hawaii? Seniors are capable of amazing things. Too often, there is a mentality that age and weakness go hand in hand. Even if setting a world record is off the table, empowerment and encouragement can help boost patients to achieve goals that once seemed equally unimaginable.

Read on to discover how Jodi, a Residential RN, helped a patient find her confidence and voice by getting answers to tough questions and giving her the tools she needed to advocate for herself and improve her health.

Some Background

When “Wendy” began home care, she faced a mountain of physical and emotional issues. Health wise, she suffered from acute asthma/bronchitis, acute respiratory failure, and waves of uncontrolled pain. Wendy’s living environment was unsafe and filled with hazards because her husband was a hoarder, and this was paired dangerously with multiple medication issues and poor stability when walking. Her husband’s hoarding also inflicted emotional distress on Wendy. Combined, these challenges caused Wendy to be a “frequent flyer” – regularly in and out of the hospital.      

Care Plan at a Glance

The medical social worker helped get the clutter and hoarding in Wendy’s home under control. The physical therapist trained Wendy on safety and obtained a multi-wheel walker to encourage mobility. The occupational therapist assessed her ability to perform activities of daily living (things like getting out of bed, getting dressed, cleaning the home) and helped make adaptations to increase her independence. Jodi, Wendy’s registered nurse, identified goals, addressed medication issues, empowered Wendy by encouraging her and withholding judgment, and coordinated care with physicians.

Residential Nurse Jodi’s Story

When I first met Wendy, she was frequently fighting through “devastating” attacks that caused severe back and stomach pain. She had constant hypersalivation throughout the evenings with an elevated temperature and low blood pressure. Until the care team started to break down the pieces of the puzzle, these "episodes" resulted in multiple rehospitalizations.

As Wendy’s nurse, I questioned her hypotension and the amount of medications being used for hypertension. I was able to show Wendy’s physician that she was being overmedicated and helped resolve her hypotension by discontinuing certain medications and improving diet and hydration.

Despite our progress, Wendy continued choking on mucus at night. She had several doctors involved in her care, but there was a lack of communication between them. I was able to help Wendy identify and record her symptoms and triggers. She was able to share these with her multiple doctors: gastroenterologist, pulmonologist, cardiologist, and primary care physician.

Once Wendy’s doctors were all on the same page, she finally had the appropriate testing completed. The mystery was solved: Wendy suffered from GERD/Barrett's Esophagus, asthma, and hypotension. She had been aspirating her stomach contents into her lungs, which caused the respiratory symptoms and aggravated her asthma. It also explained the fevers, pain, and increased blood pressure changes. The patient’s control was restored, and after months without answers, she finally had one.

Clinical and Emotional Success

Wendy went from feeling ashamed to have people in her house to finally having a cleaner home she could be proud of. With fewer aggravating environmental issues for her asthma triggers, new medications to control the GERD, no more blood pressure medications, and normalized blood pressure – Wendy had no more ER visits or hospitalizations. With our support, she gained both physical strength and the inner strength to stand up and tell her doctors what she needed.

At my last visit with Wendy, she had her hair cut, was standing dressed, was not short of breath, and was smiling. She gave me a card thanking me for listening and advocating for her. I thanked her for allowing me to advocate for her and being so determined to take charge of her emotional and physical concerns. The impact that Residential Home Health had for [Wendy] is one of the best outcomes I could have asked for.

Thank You

When Wendy was discharged from Residential’s care, she was moved to express her thanks in a note:

Jodi,

How do I say goodbye to you? You have become such a large part of my life in the past few months. I was so nervous when you came to visit the first time. I didn't know what to expect. I was so ashamed of myself and my home. Right from the start you put me at ease and let me know you came to help me, not criticize! I'm not used to someone concentrating on what I need and making sure it gets done.

You contacted doctors, got meds changed, and even got some dropped when I didn't need them. I was so depressed and meek, I was just going along in a fog. You were my voice and gave me back my strength.

My doctors now work as a team. I no longer feel lost and hopeless. I could go on about how much you've done for me, both physically and mentally, but I'll stop now. You are a beautiful, caring person, and a great nurse. Thanks for bringing sunshine into my life.

We are so proud of the progress Wendy and so many patients like her have made. Rather than accepting a certain set of conditions or health issues as inevitable or “the new normal,” it’s time to take action and conquer your challenges. Find providers who can help maximize your quality of life and reach your goals. You are capable of great things!

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Topics: Real World Stories, Medication Management