“HERE'S YOUR NEW REFERRAL,” my home health agency supervisor said. “It's the patient's second hospital discharge this year for heart failure. The cardiologist isn't sure what's going on.”
The patient, whom I'll call Jim Allen, was a 66-year-old widower who lived alone in a suburban community. Besides heart failure and type 2 diabetes mellitus, Jim had hypertension and osteoarthritis in his lower back. His mobility was further compromised by obesity. He was taking prescribed medications to treat his heart failure, lower his BP, and address his elevated blood glucose levels.
Jim was my first patient to see the following morning, a chilly day in early spring. Flyers lying on his driveway and several letters that filled the mailbox on his porch indicated that he hadn't been outside in the last few days. I rang the doorbell and waited. From a side window on his porch, I watched him inch his way to the door, leaning on his wheeled walker.
He grunted as he opened the door and invited me in. I noticed that he was short of breath after coming to the door. “Not sure what you can do for me. Never had a nurse before,” he said. “Only reason I let you come was that the doc said he wouldn't keep me as a patient anymore unless I tried this.”
As I introduced myself, I realized I needed to keep my tone upbeat. “You never know. Maybe we'll come up with simple ideas to make your life better.”
He nodded. “I like the word simple. I've never been one for doctoring.”
“Let's sit down and talk a bit,” I said, happy that his home appeared tidy and well maintained. “How about at your kitchen table?”
“Works for me.” He shuffled to the small round table in the back corner of the room. We sat across from each other. Several penciled technical drawings lay on a side chair.
“It looks as if you do drafting work?” I asked, knowing that today's conversation needed to be nonthreatening so we could develop a therapeutic and trusting relationship.
He smiled. “Those are for a patent I'm working on. I used to do construction and have eight patents to my name. This new one is to improve the fittings for new air conditioning unit installations.”
I reached over and picked up one of the drawings. “I'm impressed. Takes a lot of smarts to come up with these ideas. How do you do it?”
“I don't know,” he shrugged. “Just comes into my head. I think in pictures and designs.”
I leaned forward. “I'd like to talk more about this later. Since it's my first visit, I need to ask a lot of questions. It helps me figure out the best plan of care for you.”
Jim took a deep breath. “All right. Shoot.”
Talking about his son, grandchildren, and his wife's death 8 months previously came easy to Jim. Since then, he'd done little cooking, relying on frozen dinners and pizza and take-outs from a local deli. He denied problems with housekeeping. But as we moved to a discussion of his medications and medical history, his mood changed. Shifting in his chair, he began tapping his feet.
“It looks as if we've had enough questions for today,” I said. “We'll finish next time. Can you walk to the bedroom, so I can see how you manage your walker?”
He liked my suggestion of taking smaller steps and slowing down, which lessened his shortness of breath. Once in the bedroom, he sank onto a quilt over his queen-sized bed.
“Before I go, I'd like to take your blood pressure and listen to your heart, and then check your medicines.” I washed my hands before pulling my stethoscope and BP cuff from my nurse's bag.
I auscultated a third heart sound as well as crackles at the bases of his lungs. His BP was not an issue today, but the edema in his lower legs and feet concerned me. After instructing Jim to keep his feet elevated as much as possible, I picked up a shoe box filled with medications from the floor and handed it to him. “Tell me about your pills and how you take them.”
He coughed. “I take one from each bottle in the morning. Elsie used to help me with my pills. I don't worry about them so much anymore.”
“Hmm. Is it getting too hard?”
“Nah. I don't believe much in medicines. Elsie did though.”
“The pills keep your heart working right. Taking them correctly might help you feel better. Which pills did you take this morning?”
He rummaged through the box, stared at each bottle, and pointed to three of them. After checking the labels on each one, he'd taken only two of the three correctly. I corrected that misunderstanding and set Jim's pills for the rest of the day in cups and placed them on the kitchen counter. The medication schedule was complicated, requiring him to take tablets five times during the day. “I'll be back tomorrow with a pillbox to organize your medication by the time and day you need to take them,” I told Jim.
“Whatever,” he replied. “This is too much for me to think about now.”
“Let's make it 10 o'clock tomorrow then.”
I contacted Jim's cardiologist to confirm and simplify the medication schedule so that Jim's medications could be taken at just three times during the day instead of five. The cardiologist wanted Jim to remain on a 2,000-calorie and 2-g sodium diet per day. I was eager to help Jim set up the pill box, teach him the actions and adverse reactions associated with his drugs, and instruct him on his diet.
The next day, after I checked his vital signs and lung and heart sounds, we sat at his kitchen table to discuss his medications. The shoe box of pill containers lay in the middle of the table. “Let's line up your medicine bottles and put the pills in the right slots.”
He grimaced. “Will you put the pills on the cups for me like you did yesterday? Elsie used to do that, and it worked out fine. I don't need anything fancy.”
“How about giving this a try for a week? While you watch, I'll fill up the pill box. You read the names, and I'll put them in.” I handed him one of his medication bottles to start.
He rolled the container between his hands. “I should tell you now, I can't read. I grew up on a farm, never went past the sixth grade.”
I looked at him in surprise, realizing the main reason for his seeming lack of interest in self-care likely wasn't due to cognitive decline.1,2 “That's an important thing you told me.”
He bit his lip. “I try to hide it. It's embarrassing.”
I squeezed his arm. “Not a problem. We'll just need to do this differently.”
And we did. I taped and labeled each of his tablets to a different index card, using universal symbols such as a heart, miniature photo of the ocean for his furosemide, and a small sugar cube for his metformin.2
On another visit, we discussed his low-sodium diet. Stacks of canned fruits and vegetables, single serving packages of cheese and crackers, and several boxes of sugared cereal filled his pantry. “I'm not much of a cook, but I like to eat.” He rubbed his belly. “My neighbor brings me hamburgers, and I love strawberry sundaes.”
I attached small magnets of different foods to a magnetic white board and separated them into three columns—foods to avoid, foods to eat sparingly, and foods to eat without restriction.2 These new diet guidelines, a list of recipes that I coded for him, and a referral to Meals on Wheels improved his blood glucose levels and helped him lose 5 lb in the next 6 weeks. His vital signs remained stable, and, over time, his leg edema and shortness of breath improved.
On various visits during the following weeks, Jim showed me drawings of each of his patents and explained how each one improved the heating and air conditioning units in new construction. He regretted his inability to read the fine print of his patent application and other business and personal documents, and he was never sure if his lawyer had taken advantage of him. “If it weren't for my patents, I'd be a poor man. I depend on him to be honest.”
Assessment tools for depression and cognitive decline had proved Jim's abstract thinking and his cognitive skills remained strong, but he declined a referral to the Adult Literacy League and the volunteer services it provided.1,2
A way forward
On my last home visit, Jim met me at the door and led me into the kitchen. A plate of muffins sat on the table. “I made these for us from one of your recipes. No salt or sugar. And I have good news. The government just approved my ninth patent.”
Then he smiled and said, “I just might check with that volunteer service about learning to read the new contract.”