Rehabilitation Nursing • Vol. 32, No. 3 • May/June 2007 93

Many years ago while living in a small commu-

nity, I decided to shift professional gears from reha-

bilitation to home health nursing. My new career path

provided many rich experiences, enabling me to use

my rehabilitation expertise as well as to develop a

strong sense of autonomy. Resourcefulness became

a very important skill in my new specialty.

My home health client, Irma*, was a 73-year-old

retired nurse who lived with her daughter, son-in-

law and teenaged grandson in a lovely home in my

small town. She was very active in the community

with volunteer pursuits and was a much cherished

member of her family. During my visits, she fondly

recounted her days as a “maternity” nurse at our lo-

cal hospital where she assisted many babies into the

world, some now prominent members of our com-

munity. With an air of motherly pride, she recalled

how her daughter, Margaret*, would stop by her unit

every day after school, to help put away supplies or

run errands for the head nurse. As she told her stories,

I tried to imagine how much simpler and perhaps a

bit more human the nursing experience was during

Irma’s career. *names have been changed.Irma was recovering from dehydration related to

a recent viral infection and, as she was doing quite

well, I planned my discharge visit to be fairly short.

However, when her daughter, Margaret, greeted me

at the door, I sensed from her demeanor that some-

thing was terribly wrong. Leading me quickly down

the hallway to Irma’s bedroom, she gave me a syn-

opsis of the previous day’s events.

All was fine until the family gathered around the

dinner table the evening before. Irma was eating and

participating in the family conversation, as usual,

when suddenly, she tumbled off her chair. Her son-in-

law helped her back up, but Irma seemed to be listing

slightly to one side and having a little difficulty speak-

ing clearly. Instead of calling for medical help, the fam-

ily decided that Irma was simply tired from her active

day, and helped her into bed for the night.

Shortly before I arrived, Margaret attempted to

help Irma up to the bathroom, but she was having

difficulty walking and kept stumbling to one side.

When I entered Irma’s bedroom, the change in her

condition from my previous nursing visit was read-

ily apparent. Instead of her light-hearted bantering,

Irma could barely verbalize an intelligible word. As

Margaret assisted her to sit on the edge of the bed, she

leaned significantly to the right. I safely placed Irma

into bed and pulled Margaret into the other room.

“I need to call her doctor and have her transported

to the hospital. I think your mother may have had a

stroke”.

I made the necessary phone calls and answered

Margaret’s questions, as the ambulance arrived to

take Irma to the hospital. I reassured Margaret that

her mother would be in good hands and promised to

call her the next day to see how she was doing.

To my surprise, when I phoned the next morning,

Irma had been discharged home the previous after-

noon. Margaret had been told that Irma sustained a

stroke, and tests had showed evidence of an older,

previous stroke as well. Irma’s physician decided not

to admit her to the hospital, as he felt that there was

little anyone could do for her and made the decision

to send her home to die.

When I called the doctor to ask for additional

skilled nursing visits, he was rather abrupt with

me, stating he could not see the point of continuing

home health, as he was certain that Irma would ex-

pire shortly. After much wrangling, he agreed to three

more nursing visits to teach the family ‘terminal care’.

But he was very clear: no more than three visits.

As I entered her bedroom, Irma was lying flat on

her back, with her daughter attempting to give her

sips of water. Not surprisingly, Irma was choking. I

sat her up in bed, and very carefully spooned a little

water into her mouth, but she choked on this as well.

Margaret and I went into the kitchen and after rum-

maging through the cupboards, we located some

applesauce and gelatin. Irma was able to swallow the

applesauce fairly well. Next, I thickened some water

with a little of the gelatin, and this, too, went down

without difficulty. Over the next hour and a half, I

gave Margaret a crash-course in caring for a post-

stroke patient. We were able to borrow a bedside com-

mode and a wheel chair from a neighbor who recently

lost his wife. I showed Margaret how to transfer Irma

and toilet her safely. Together we created a diet of soft

foods and thickened liquids, and I demonstrated how

to help Irma improve her ability to swallow by cueing

her to tuck her chin. I told Margaret to call me if she

had any concerns whatsoever, and planned to return

the following day.

The Voices of Rehabilitation Nursing Louise Harmon, RN C CRRN C

Rehabilitation NURSING

Perspectives Winner of the 2006 RNJ Writers’

Contest

94 Rehabilitation Nursing • Vol. 32, No. 3 • May/June 2007

The Voices of Rehabilitation Nursing

When I arrived, I half expected to see Irma lying

in bed, further declining. However, I was pleasantly

surprised to see her sitting up in the wheelchair, look-

ing at me with recognition. Margaret reported how

Irma ate some scrambled egg and applesauce shortly

before I arrived. Although it was a slow process, she

was able to swallow her breakfast without choking. As

I did my assessment, I could see that Irma was getting

stronger, regaining some of the function which she

had lost. I spent the remainder of my visit instructing

Margaret on ways to help Irma continue her progress.

I suggested that starting the next day, she dress Irma in

her normal clothes, and take her into the dinning room

for her meals. I demonstrated techniques to encour-

age Irma to use her affected side and emphasized the

importance of Irma participating in the familiar family

routine of the house as much as possible. “Do not baby

her”, were my parting words.

When I returned to the office, I called Irma’s doc-

tor to update him on her progress, hoping he would

reconsider and allow our physical and occupational

therapists to evaluate her. I was crushed by his re-

sponse.

“I told you….three nursing visits. That’s all!”

Although I felt he was being terribly unreasonable,

I knew I had few options. The area in which I lived

was very rural, with individuals remaining quite

loyal to their family physicians. It was never a con-

sideration to challenge their medical advice, and the

local doctors were not terribly fond of listening to

suggestions from nurses. I resigned myself to only

one more nursing visit.

I decided to call Margaret the next day and strat-

egize with her how to best use my remaining visit.

Irma was doing better, and Margaret felt that for the

next several days she could handle her needs quite

well. I told her I was only a phone call away, and

would be happy to answer her questions anytime.

We kept in contact for the remainder of the week,

and I directed Irma’s care via the phone.

When I walked into the living room a week later,

Irma was dressed and sitting in her recliner, feeding

herself breakfast. Her right hand was still weak, and

her smile was slightly crooked, but, it was just so

wonderful to see her smile. When she managed to

say “hello”, I felt a tear roll down my cheek. It was

obvious that Irma was not ready to depart from this

good earth just yet.

I kept in touch with Margaret for some time after I

discharged Irma from our agency, and helped her to

connect with services in the community which would

encourage Irma in her rehabilitation efforts.

My home health experience had been quite a de-

parture from working in a big city rehabilitation cen-

ter. There were no specialists or therapists to perform

evaluations and no case conferences to help plan

care; there was no ‘state of the art’ equipment. There

was only good basic rehabilitation nursing to rely

on, which coupled with resourcefulness, can work

well anywhere.

About the Author

Louise Harmon, RN C CRRN C, began her career as a re-habilitation nurse over 30 years ago at Kessler Institute in New Jersey. Over the years, she has applied her rehabilitation experience in a number of practice settings, including home health and pain management. Currently she is working as a nurse case manager consulting on short term disability claims for Standard Insurance in Portland, OR and can be reached at LouiseHarmon@comcast.net. GO BEYOND

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