1. Wheeler, Lovie MSN, RN

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8:00 a.m.: I arrive at the office. As a home care case manager for the John Dingell Veterans Medical Center, I proudly serve veterans in their homes across the greater Detroit area. First I retrieve my phone messages. "Nurse Wheeler, this is Mr. P. My medications arrived in the mail and I need you to give me call." Next message, "I take care of Mr. C. The doctor told us to call for home care. We need someone to teach us about this feeding tube." Third call, "Hi Nurse Wheeler, this is Carmen from Urology. Mr. K. will be coming in today for a Foley catheter, and I'm letting you know he will need monthly catheter changes in his home."


9:00 a.m.: The staff and clinical nurse manager gather for our weekly huddle. The agenda for today includes National Patient Safety Goals, documentation requirements, and the importance of increasing our census for the third and fourth quarters of 2014. We are also reminded to attend the Nursing Grand Rounds this afternoon; diabetes is the topic.


I schedule visits with three veterans who live in downtown Detroit. I prepare my nursing bag making sure I have extra syringes, exam glove, sterile gauze, and hand sanitizer. I print current medication profiles from the VA electronic medical record, which I will leave with the veteran or caregiver as a reference. This form also includes any upcoming appointments with providers at the medical center.


10:00 a.m.: My first patient, Mr. H., a World War II (WWII) veteran, lives in a high-rise apartment in the heart of downtown Detroit. While still in the car, I call Mr. H. to inform him I have arrived. He comes to the door, short of breath, with oxygen at 2 L via nasal cannula. Military in WWII were provided with free cigarettes as part of their K rations, so many became chronic smokers and now suffer from chronic obstructive pulmonary disease (COPD). "Hello, Mr. H. How are you?" His response is simply "I'm good now that you're here." We catch an elevator to the sixth floor making small talk until we arrive at his apartment. Once inside I proceed to wash my hands, using hand sanitizer, and take my supplies out, placing them on a barrier. In addition to COPD, Mr. H. has a history of Vitamin B12 deficiency and hypertension. I glove and draw up the cyanocobalamin. As I wipe his upper arm with an alcohol swab he jokingly yells ouch! "Mr. H., really, I have not given you the injection yet!" After the injection I complete an assessment related to falls, skin integrity, lungs sounds, bowel sounds, and diet. I take a set of vital signs and assess his pain level. We reviewed oxygen safety measures, falls prevention, and the importance of taking medication as ordered. I provide Mr. H. with a copy of his upcoming appointments and ensure he has made travel arrangements. I gather all of his medication bottles and complete the medication reconciliation. As I check for expiration dates, doses, and frequency against the medication profile I quiz Mr. H. on the purpose and side effects of his medications. Mr. H. asks, "When will I see you again?" "Next month" is my reply.


11:00 a.m.: Back in the car and off to see Mr. M., a Veteran of the Operation Iraqi Freedom conflict. "Hello, Nurse Wheeler," he says, "how are you doing?" I respond "fair for a square" and we both laugh. Mr. M. has multiple sclerosis (MS), chronic pain, posttraumatic stress disorder, and depression. He ambulates with a slow unsteady gait using a walker. He often forgets his limits and needs frequent reminders. His caregiver is present. I address safety measures to prevent falls, and discuss the need for additional equipment like a bedside commode, grab bars, and a Hoyer lift. Then I proceed to complete a set of vital signs with pain levels, measure his lower extremities, lung sounds, bowel and bladder pattern, skin integrity, and diet. I provide Mr. M.'s caregiver with a copy of his upcoming appointments and medication profile. As I complete the medication reconciliation the caregiver provides updates on Mr. M.'s mood and behavior. She whispers as she shares her concerns that he doesn't want to leave the house. We discuss making a referral to the psychologist for an evaluation in the home, and also a follow-up appointment with his provider to get a referral for physical therapy, which can promote reeducation of the muscles in his lower extremities. The VA provides healthcare services to Veterans with MS from the time of diagnosis throughout their life, whether they have a service-connected or nonservice-connected status.


12:00 p.m.: I arrive at Mr. B.'s home, a historic building converted to an assisted living facility. He is a Vietnam-era veteran who suffers from diabetes, thought to be related to Agent Orange exposure in Vietnam. I am here to teach him about glucose monitoring, but once inside Mr. B. complains about pain in his right great toe. His pain level is reported 8 out of 10, great toe tender to touch with +2 nonpitting edema. Mr. B. states "please don't bump it." I suspect Mr. B. is having a gout attack. We discussed food choices to avoid, the importance of taking medication to relieve pain, and I offer Mr. B. the option to report to the emergency room for evaluation. He refused, stating "I will have a few more drinks of my favorite juice." I advise him that alcohol is a risk factor for gout and recommend he increase his water intake. I reiterated the option for a walk-in appointment. Mr. B. said "OK, I will call my granddaughter for a ride." I leave the apartment thinking he will not show up as requested, not today, anyway, as he can barely put pressure on that foot, or get his foot into a shoe. I will definitely add the primary care physician to my nursing note to make him aware of the current gout attack.


1:30 p.m.: I head back to the hospital for lunch and nursing grand rounds. I attend the monthly conferences to stay current on best practices and show support of my nursing colleagues who present the research and evidence-based practice information. After the presentation I walk back to the home-based primary care offices where I can be found until my "tour of duty" ends. There, I chart my notes and reach out to Mr. B.'s primary care nurse practitioner and discuss his unrelieved pain. I review notes from other members of the home care team to assure coordination of care. I also have to address the voice mail messages from this morning. I call Mr. P. and set up an appointment for this week to help with his medication management and contact Mr. C.'s caregiver about his feeding tube. I inform the urology clinic nurse that the consult for Mr. K. has being received and I scheduled him for monthly Foley catheter changes.


5:00 p.m.: I leave the office, thankful and proud to serve those who have served.