This visit gave me a first hand view of a career path I may want to explore in my future as a nurse. The rapport with the client seemed more personal than in a hospital setting or SNF because it is their “space”. I also enjoyed the lack of chaos and gossip which has been noted at the majority of nurses stations in any location.
The true value was to see how important it is to be well prepared for each home visit. The necessary knowledge, skills, documentation, and medical supplies as it pertains to a specific client.
Principles learned were the importance of verification of current doctor’s orders for treatment, prescribed medications, and follow up visits required. Observations for client safety included, placement of furniture, unobstructed floor space for walking, medical equipment, cleanliness, proper food storage, compliance with medications and instructions. The practice of proper hand hygiene before and after the visit, client assessment, teaching and education.
Proper documentation of the visit was written in detail and a copy provided to the client. The following factors may be considered in all areas of nursing care in any setting: level of self-care, ability for activities of daily living; level of nursing care needed; prognosis; education needs; mental status; level of compliance with instructions from healthcare professionals.
Ways in which the nurse adapted care to the home setting are briefly stated in the following: Changing a Foley catheter on a male client, setting up a sterile field while kneeling on the floor as the client was sitting at the edge of the bed; setting up an IV without an IV pole or pump using a clothes hangar and a curtain rod over the bed to attain the necessary gravity flow; writing out new requests for doctor to write orders for special procedures such as toenail trimming to be performed by a podiatrist and requiring a referral from the PCP, client nor spouse able to provide foot care; inspecting oxygen concentrator of the certification sticker and writing a request for a reinspection and recertification prior to expiration; writing request for home health aide to come and assist client in bathing or showering. Spouse can no longer support husband in shower, client cannot shower himself due to weakness and fatigue impaired gas exchange.
One specific client is an 87 male, age 87, awake aware and oriented x 4. He has a history of smoking tobacco for 50 years approx 1-2 packs per day, denies alcohol abuse, denies use of street drugs. Developed impaired gas exchange which led to four coronary artery bypass graphs (CABG) approximately 4 years ago. Recovery has been unremarkable. Respiratory disability, COPD, emphysema, places restrictions on client who is physically capable of being mobile however, due to impaired gas exchange, client limits his activities, lives and sleeps in a recliner in his bedroom. Client’s spouse helps with meals, laundry, medications and of course, companionship, love and nurturing. PCP ordered a foley catheter with a leg bag due to, incomplete emptying of the bladder, related to side effects of certain medications. The physician orders the change once per week and to inspect for infection.
The nurse performed a quick full body assessment, and relocated the client from his chair to a bed for the Foley change, field set up, inspection, disinfection and insertion of foley. Nurse did a complete review of all medications with client, verified with PCP orders, confirmed with client understanding of the medication purpose, dosage and time, plus possible side effects. The nurse inquired about any herbal supplements or OTC being taken along with prescribed medications.
Client is very knowledgeable about his medications and his medical condition, very compliant and proactive in his healthcare. Oxygen concentrator and oxygen tubing has been installed throughout the house for client accessibility to all rooms within his home.
Client and spouse live in a clean, orderly home, which is uncluttered, appears very well organized for medications, documentation. There are two steps at the front door, and a step down into the garage that is risk for falls. The nurse discussed with client about installing side hand rails and being escorted down steps by an able bodied family member.
The spouse and client expressed concern regarding showering. It has become too much of a burden on the spouse to shower or bathe the client, and the client is too fatigued to bathe himself. The spouse requests assistance for bathing, and the nurse responded by writing a request to the Kaiser social worker and stated she would call and speak with the social worker explaining the need for assistance in bathing. As a nurse I would have responded much the same way, explained what is and is not covered by their health insurance and Medicare.
Two of the eight functions, listed in Timby, observed were the hanging of an IV piggy back with medication using a clothes hangar and the curtain rod for height and gravity flow. The saline lock was already in place and appeared clean, dry, and patent, with no signs of infection. The second observation was removal of a foley catheter, assess for infection and pain, and setting up the sterile field to prep and insert a new sterile foley.
The client’s spouse provides all documentation to the nurse which has accumulated between home visits, records for all physicians appointments, and provides information about psychological health. Spouse provides a clean and safe environment for client and is compliant with instructions. The client’s son calls and checks on them and drives them their doctors appointments and assists the spouse with grocery shopping.
The reimbursement for nursing care through Kaiser has 3 types of coverage or ways to pay. One is commercial—called KP (Kaiser Pay). Members will have to pay the co-pays and has nothing to do with Medicare. Risk is the second form of reimbursement. Risk is a Medicare client, and the member has signed over their Medicare to Kaiser. Medicare pays Kaiser a lump sum for all the patients who have signed over their Medicare, whether or not the clients have been in the hospital one time or ten times. Kaiser does not submit a bill to Medicare for this client. The third form of payment is called Cost or unassigned and is also a Medicare client. The client has not assigned Medicare over to Kaiser, therefore Kaiser must submit billing each time the client receives services. This client is Hispanic and his diet has been mainly beans, rice, corn, and meat. I would encourage more fruits and vegetables for nutritional purposes, fiber and also to alleviate the clients complaint of constipation.

Head to toe quick examination, auscultation of lungs, noted congestion, then abdomen noted peristalsis. Observed skin integrity and noted small wound on little toe, the client and spouse were unaware. The client was advised to keep the wound clean and dry and exposed to air as much as possible until complete healing, also wearing clean socks everyday as necessary when walking.
The nurse demonstrated how to use the nebulizer properly for the best effect. The demonstration of use of the nebulizer, insertion of medication, and proper placement on face, with proper breathing technique for best effect. A written teaching plan is provided by Kaiser and kept in a three ring binder in the clients home. No handouts on this visit. The spouse was also present for the demonstration and explanations, she asked questions and demonstrated herself how to use the nebulizer. The nebulizer was set up in a permanent location close to clients chairbed to be convenient for use. Explanations on use were kept in simple language, level of understanding was complete as evidenced by demonstrating and repeating the instructions.
It would have been nice to have their son available for teaching and explanations. The son is the one who checks on them and drives them to their doctors appointments.