1. Facente, Alice C. MSN, RN, BC


Home care nursing isn't for the faint of heart.


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The convalescent-home referral said that Loretta was 71 years old with the usual health problems related to stroke and diabetes. It also said that her husband had a gun and "wasn't afraid to use it." Fiercely protective of his wife, he'd had many disputes with the nursing staff about her care. The discharge planner who'd referred her to our home care agency insisted that two nurses make the initial home visit.


When I arrived at the home, the admitting nurse was already in the driveway, embroiled in a discussion with the husband. Insisting that he'd take care of Loretta himself, he refused to allow us in the house. Although we told him that his wife's personal physician, whom he claimed to trust, had asked for our help, he remained adamant. Finally, after I said that we'd have to call 911 for a police escort, he let us in.


An overpowering odor of urine hit us as we entered the living room. We soon discovered it was from the couple's 14 cats and two dogs. The litter box was overflowing. It was so dark and dirty inside the house, we couldn't tell if the floor was linoleum or wood.


Loretta was sitting on the edge of a hospital bed in the living room, smiling. We introduced ourselves and told her we were there to take care of her. "I'm so happy to be home," she said, hugging her husband and two of the nearest cats. With her husband hovering nearby, we began a complete physical assessment.


Her husband had just filled all of her prescriptions and purchased an alternating air pressure mattress for the hospital bed, three sets of bed linens, pads for the bed, and an assortment of incontinence briefs.


We offered the services of Meals on Wheels, but he refused. The kitchen counters were grimy and cluttered. The kitchen sink was plugged, full of black, stagnant water and greasy pots. The only thing on the large wooden table was an aluminum baking pan filled with dry cat food. A cat lounged on every flat surface: the kitchen cabinets, counters, hospital bed, even the wheelchair. We didn't try to reason with the couple about sanitation issues surrounding these pets, at least not on this first visit.


We gave Loretta a sponge bath with her husband watching our every move. We taught him how to empty the urinary drainage bag and monitor her blood sugar, and instructed him on her medications, simplifying procedures wherever possible.


Each step of the way, we praised him for his fast learning. We told him we appreciated how devoted he was to Loretta, and that our goal was to help him continue to take good care of her. Loretta seemed oblivious to the dirty environment and her husband's intimidating manner, and accepted all of the care we provided.


By the time we were ready to leave, he hugged us, thanked us, and said we could come back anytime.


During my visit the next day, I convinced him to allow a home health aide to come and bathe Loretta. He agreed-but only if I made my nursing visits at the same time. When I arrived for the third visit, the husband showed me how he had unclogged the toilet, mopped the kitchen floor, and thrown all the dirty dishes in the garbage; he bought paper plates and plastic utensils to use.


The house never became what could be described as clean, but Loretta and her clothing always were. Loretta never developed pressure ulcers, pneumonia, or deep vein thrombosis. She had frequent urinary tract infections from the indwelling catheter, but her husband phoned me immediately when he recognized signs of infection, just as I had taught him.


At the end of every visit he always thanked me, and I never did see that legendary gun.