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Thinking Like a Nurse

Tracy Enfinger

Auburn University Montgomery

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Thinking Like a Nurse

Along my journey of working as a nurse I have worked in several different settings,

hospital, home health and clinical. The home health setting allowed me to meet many wonderful

people and care for them in their home which allowed for more time to address their needs. My

most memorable patient in the home health setting was an elderly lady that was approaching the

time in her life to enter into nursing home care. My reflection on this experience highlights my

nursing philosophy and values.

I met a sweet lady, who I will call Mary, not long after becoming a home health nurse. I

was a specializing in psychiatric home health nursing and Mary was a dementia patient so she was

added to my case load Mary had many diagnoses and in addition to the dementia. Mary also had

congestive heart failure, hypertension, diabetes, atrial fibrillation with coumadin management,

neuropathy, macular degeneration, depression, paranoia, and she was frequently falling. Marys

dementia was not severe, in fact she seemed to have a rather good memory.

Marys home was a single wide mobile home that had a handicap accessible porch and

ramp. Upon entering her home It was clear to see that Mary had a problem with hording. The

pathways were barely big enough to pass through, and I would have to remove clutter just to find

a place to sit. The windows were covered with blankets so that no light from the outside could

come in and more importantly to Mary no one could see in. The home smelled of urine, was

extremely warm, and Mary had a bug problem. Florence Nightingale (1960) states, fresh air, light,

warmth, and quiet are vital to a patient. Mary did not have the most idea environment for health

and healing, but she was at home.

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Mary had no living family members and was being cared for by herself and a team of home

health professionals that included a nurse, a physical therapist, and a home health aid. The nurse

was responsible for management of Marys health needs and medications. The physical therapist

was helping Mary to build strength and balance with biweekly exercise sessions. The home health

aid gave Mary a chair bath and helped her change into clean clothes two times a week. This team

was keeping Mary in her home and out of a skilled nursing facility.

Getting to know Mary I realized that as hard as she tried to cover up her memory defecate

and her fear of being at home alone, these were very real safety concerns. Though Mary wanted to

remain in her home it quickly became clear that this was not the best setting for her. In addition to

Marys medical needs, which were very serious in nature, Marys mental health was posing a threat

that was equally as serious. One time I arrived at her home to find her at the mailbox, she appeared

to be dressed like a man in a heavy coat, scarf, hat and heavy boots. I asked her why she was

dressed this way, it was July and very hot outside, Mary replied I cant let them see me outside

of my house or they will come in and steal my medication. I asked Mary who they were, she

replied I dont know. Mary then explained she has been being watched and robbed on a regular

basis, this is why she was disguising herself to go to the mailbox.

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The home health care of Mary went on for over a year and at case conferences we often

spoke of how much better off Mary would be if she was living in a nursing home setting and our

concerns for her safety. No one wanted to approach this subject with Mary due to the fact that she

so desperately didnt want to leave her home. She had become a Grandmother like figure to us and

we cared deeply for her and her well being. Over time I had asked Mary why she kept her home

so cluttered. Mary said for two reasons, first if Im falling I will have something to grab on to,

secondly I need to keep my valuables hidden away. She infect would hide her medicine box in her

dish washer and often her purse would be under her bathroom sink.

I tried to have discussions with Mary about the risks she faced living alone with her medical

conditions, while at the same time trying not to set off her paranoia and increase her fear of the

people that are watching her and stealing her things. I tried to educate her on importance of having

a life alert system to summon help if needed and avoiding tele market type calls and scams targeted

at the elderly. Mary did not cook and it seems that Marys primary diet came from a local church

group that delivered one meal every day. Mary wouldnt budge , she wanted to remain at home.

As more months past Mary began to call rescue squad more frequently with various

complaints. She would be treated and released only to be back on the rescue squad in another day

or two. I finally decided I needed to have a talk with Marys primary care physician as well as case

management at the hospital to work toward placement in a nursing care facility for Mary. After

explaining my concerns to her doctor and the case manager at the local hospital a plan was put into

place. The next time Mary presented to the hospital she would be staying.

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I thought the process would be speedy but it ended up being drawn out for weeks. Mary

was sent to two different hospitals, ones with senior care units for dementia patients and then

finally placed in a nursing home. I felt a since of relief but at the same time felt as though I had

taken part in betraying Mary by helping facilitate her placement in a nursing home. The guilt I felt

brought me to tears at times. I put off going to visit her for fear she would be angry. Finally I

decided enough time had gone by and maybe she had enough time to settle in to her new life. I

went for a visit. Flowers in hand I presented at the nursing home to see Mary. I was advised of her

room number and sent on my way. I didnt find her in her room, that was bright and cheerful, but

she was in a group room sitting playing cards with some other ladies laughing and glowing. She

looked up at me and tears filled her eyes and she reached her hands out to hug me while she was

introducing me to her new friends as her best nurse ever. Mary said she had been afraid she would

never see me again and also asked about the other team members who had become her family.

Mary was thriving, she had gained weight and had color to her cheeks, her mind was sharp and

see seemed more normal that ever. I had made the right decision.

Looking back on this I would have acted sooner and I realize that I knew what I needed to

do all along but the guilt of taking away a persons independence blocked my judgment. In the end

the very things I was helping my patient facilitate the very things that were contributing to her

declining health and instead of making her made she ended up idolizing me for helping her help

herself. Dewey (1938) states that while we cannot learn or be taught to think, we do have to learn

how to think well and especially to acquire the practice of reflection.

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References

Nightingale, F. (1860). Notes On Nursing: What it is, what it is not, Available

http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html Kearney-

Nunnery, R. (2016). Advancing Your Career, (6th ed.). Philadelphia: F. A. Davis

Company.

Dewey, J. (1938) Experience and education New York: Touchstone

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