AGNP in aRetirementCommunity

Residents accept the GNP as the one who willfollow their health most closely, whether theyare in the hospital or health center, or at home.

How she functions,what she feels,and how residentsuse her many services.

MARTHA HENDERSON

Geriatric nurse practitioners are,first of all, nurses. As nurses wecare for patients during both acuteand chronic illness, counsel, teach,promote health, help families solveproblems, and offer support andcomfort when death is near.

In addition to those skills, theGNP is a specialist in the care ofolder adults. Knowledge of the ag­ing process and how it affects theonset and course of a person's ill­ness, metabolism of drugs, and in­teraction with the environment areessential to the clinician in a geriat­ric setting such as the retirementcommunity where I work.

Nurse practitioner skills-com­plete history taking, physical as­sessment, and diagnosis and man­agement of common illnesses-fa­cilitate the early identification and

Martha Henderson. RN, MSN, GNP,C, isdirector of clinical services at Carol Woods,a residential retirement community inChapel Hill. North Carolina.

treatment of serious problems. Thesame skills enable the GNP to reas­sure an anxious person that recentchanges are part of the aging pro­cess and no cause for worry.

In North Carolina the practice ofnurse practitioners is approved by aJoint Board of Medical Examinersand Board of Nursing, after appli-

cants present proper educationalcredentials. Once approved, thenurse practitioner can operate onstanding orders, written jointly bythe NP and physician who sharesthe practice, and prescribe medi­cines for various common problemsof the elderly. Easily accessiblephysician backup for consultationand referral is essential for ethical,medical, and legal reasons.

Carol Woods, "a nonprofit retire­ment community of 320 residents,is located in Chapel Hill, NorthCarolina. The residents live in cen-

tral and garden apartments. Theircontract provides for one to threemeals daily in a central dining halland for care in the health center. Ashort walk from residents' apart­ments, the health center includesan outpatient clinic managed bythe GNP and a nursing home with30 beds for residents who need

skilled care, and 30 rest homebeds.

This setting is ideal because resi­dents may receive care in theirapartments (which most callhome), the outpatient clinic, therest home, or the SNF, dependingon their needs at any given time.Hospitals are nearby and hospitalstays are often shortened becauseof the nursing home, where rela­tives and friends, plus a staff espe­cially sensitive to problems of theelderly, can provide care and a sup­portive community close to home.

Geriatric Nursing March/April 1984109

In this retirement community, amedical director is present two halfdays a week. The GNP is the pri­mary provider on site full time forthe health needs of the residents.Doing so may be as complex as con­vincing a woman with normal,short-term memory loss that she isnot "going senile." Or it may be assimple as diagnosing congestiveheart failure in a man who thinkshe has merely a persistent cold.

A primary function of the nursepractitioner is coordination of care.Because the resident may have aprivate internist or psychiatric so­cial worker in town, a neurologyspecialist at the university, and adistraught adult child many milesaway, the nurse practitioner oftenbecomes the one who pulls ele­ments of care together, keepspeople informed, prevents frag­mentation of care, and eases com­munication among different pro-

. viders.The private physicians in Chapel

Hill work closely with me and seemto trust me as a complementaryprovider-s-one who can keep an eyeon "their" patients, inform them ofchanges, or call them when neces­sary. Because we can consult bytelephone about proper manage­ment of a problem, a sick elderlyresident often is spared a tiring tripto see a physician. And the physi­cian often is spared a trip to CarolWoods.

Continuity is the nurse practi­tioner's other primary responsibili­ty. Because I've been at CarolWoods since its beginning fouryears ago, the residents and I arewell acquainted. They accept me asthe person who will follow theirhealth needs most closely and try tohelp them wherever they are.

I first meet the new resident inhis or her apartment. There I re­view the preadmission medicalform, gather more informationabout health and psychosocial andfamily aspects, and explain ourhealth services. Soon after this ini­tial visit, the new resident comes tothe clinic, where vital signs andweight are taken as a base line, andto sign appropriate releases so thatwe can obtain a more complete

110 Geriatric Nursing March/April 1984

A Day in the Life of a GNP

9:15 I came directly to clinic to review the day's schedule, seewhich residents had called in sick,and take care of urgentproblems.

9:30 Mary Jones stopped to talk with me about discharging hersister from the nursing home, and about what she can and can't doin caring for her sister in her apartment.

9:40 Mr. Barker phoned. Hopes his wife can be discharged fromnursing home tomorrow. Told him I'd see her today and let himknow.

9:45 Ann Moore came in with a sore throat. I examined her,advised extra fluids, rest, saline gargle.

Discussed plans for the day with clinic staff, answered 2 phonecalls, then to nursing home to see Ms. Barker.

10:00 Ms. B. has been having diarrhea and back pain. Afterexamining her, talked with her doctor about reducing Chronulacand trying a rectal tube for her distention. Caned Mr. B. to let himknow she won't be discharged tomorrow, but probably soon.

10:20 Two quick home visits, one to evaluate a resident who felland hit her knee. No evidence of fracture. Advised ice, elevation,and Ace bandage. Visited Ms. Cooper, who returned from thehospital yesterday after a total abdominal hysterectomy. She neededreassurance, a dressing change, and advice about medication forconstipation.

10:35 Returned to clinic. 7 patients on morning schedule.Ms. Smith: discussed chronic arthritis of knees, ulcerative colitis,and her array of doctors. With whom should she continue? Howcan she consolidate? She confided that her weight problem is due tosnacking in the evenings because of loneliness. Because her kneepain was not acute, I reinforcedher present regimen of 12 aspirin aday, moist heat, and mild exercise. Referred her to the dietitian fordiet counseling to lose weight. I listened to her talk about herloneliness and suggested several activities she might take part induring the evening.

11:00 Mrs. Walters: symptoms of urinary frequency and nocturia.She had no suprapubic or costovertebral-angle tenderness. Herurinalysis revealed over 100 white blood cells and moderatebacteria. Sent urine culture and, per standing order, started her ondouble strength trimethoprim and sulfamethoxazole (Septra DS)BID for 10 days, pending urine culture results.

11:20 Ms. Brown: She didn't feel she needed another visit this soonwith the surgeon who's been following her after a lumpectomy forbreast cancer. I examined her and promised to consult the surgeonabout the wisdom of postponing this follow-up visit another twomonths. Also evaluated mer cardiovascular status, because she hascardiac disease and is on several medications. She is stable.

11:45 Ms. Capps: Follow-up of congestive heart failure and COPD,following her stay in the hospital and nursing home. She is betterthan ever!

12:15 Dr. Smith: Has full-blown case of shingles. I talked with herphysician about his approach with this particular patient, sinceshe is already on several psychotropic drugs.

12:40 Mr. Ellis: Check on a recurrent, rather persistent URI. Examnegative. After finding his symptoms had improved, I could see thathe needed reassurance that infections in the elderly take longer toclear. Reassured him and scheduled a follow-up check by telephonein seven days.

I:00 Dietary employee: Dropped a large tray on her rt. footyesterday, now worried about pain on weight bearing. After exam, Ireassured her I did not think she had a break but could not bepositive without an X-ray and advised such. She did not want to goto an orthopedist or for X-ray today, so I advised elevation, Tylenol,and heat and said she could give the foot 24 hours to see if itimproved. If not, she will see her physician.

1:15 Lunch-15 minutes. Patient in the nursing home to see-Ms.Leve-e-before my 2:00 P.M. appointment.

1:30 Ms. Love had had a morning of diarrhea and nausea, and thenurse had asked me to see her. With a history of ulcer disease, herproblem was potentially worse. After history, exam, and hematocrit,I felt safe in treating her conservatively with clear liquids, antacids,and time, especially because the diarrhea and nausea had subsided.

I:50 Message that a resident had fallen in the central apartmentand cut her lip. When I arrived, Ms. Spencer was bleedingprofusely from the mouth, apparently having severed an artery.Applied direct pressure to the bleeding site, positioned her so shewouldn't aspirate blood, and had the LPN call the rescue squad.Within minutes, Ms. Spencer was en route to the hospital.

2:10 On the way to an appointment with the executive director,met Mr. Jones who had just been discharged from the hospitalfollowing a myocardial infarction.·Told him we'd arrange meals inhis apartment for a week and that a nurse would be up to see himlater today or tomorrow morning.

3:10 After the executive director and I discussed my performanceand ptogram goals, I went to the nursing home to say goodbye toMs. McDowell, who has terminal cancer, and to see that allarrangements were in order for discharge to her home in ChapelHill tomorrow.

3:30 The nurses asked me to check Ms. Russ. She had a verysmall perirectal abscess that seemed treatable with warm soaks TID

as the first step.

3:45 Received telephone message. Ms. Spencer's artery was ligatedand multiple stitches taken; now returned for admission to thenursing home. Conference with head nurse of SNF. She suggestedputting Mr. Long; terminal Ca, on Brompton's mixture instead ofcodeine injections. I agreed to call his physician.

4:00 Ms. Currin: returned from hospital yesterday, following bowelsurgery. She has a gastrostomy tube for supplemental feeding, a hipreplacement about two months old, and is confused. I wrote ordersfor an egg crate mattress, cleaning around the gastrostomy tube,assistance in taking oral fluids and food, decubitus prevention, andreality orientation.

4:30 Back to clinic to talk with M.L. about her terminally illfather. She was concerned that her-frail mother didn't realize theseriousness of his illness. We went together to speak with hermother.

5:00 Back to clinic for appointment with Ms. Cash, who couldn'tCOme to the clinic this morning. She has bursitis in her shoulders. Ireinforced her.need for regular aspirin therapy and heat, andordered physical therapy ultrasound.

5:20 Dictated notes on patients seen in clinic (notes on nursinghome patients written while there). Looked over the day's mail andlab reports, made 3 follow-up phone calls to residents, and tookreport from clinic LPN on her day's activities.

6:30 Left clinic at the usual time.-MH

health record from other SOurces.New residents soon learn that Ispend most of my time in the clinicand see them by appointment or ona walk-in basis for urgent prob­lems. They also know that if theneed arises, I can admit them to thenursing home for a short or longstay and continue to be involved intheir care. If illness prevents theircoming to the clinic, I go to theirapartment. If they need hospitali­zation, I help arrange this in coop­eration with their physician, seethem in the hospital, and talk withthe staff about their admission,ongoing care, and discharge.

Each day is different at CarolWoods Health Center. There is noroutine day or routine patient. Ex­cerpts from my log illustrate thekinds of things a GNP might doany day (see box).

While the log shown reflects onetypical day, others may include aninformal conference with individu­al nurses or a continuing educationsession with the whole nursingstaff.

Besides physicians and nurses,the providers with whom I collabo­rate include occupational, physical,and speech therapists, a socialworker, and patient care associates.Resident care is distinctly a teameffort.

The demands are many, the chal­lenges varied. The variety is fun,but the relationship with each tesi­dent is my primary satisfaction. Alongitudinal view of Mr. Long'scare may cast light on this aspect ofthe GNP's job.

We met onTanuary 30, 1980,·during my first visit with him andhis wife; Mary. He had lived manyof his 90 years in Chapel Hill,which he had served as a public of­ficial for several years. The Longshad been married 60 years and hewas now "more devoted to Marythan ever."

That day I collected necessaryinformation, made out his problemlist and medication sheet, learnedwhom to notify in emergency, andnoted some details about healthhabits, past illnesses, and a littleabout his adjustment to this newhome. Except for some trouble be-

Geriatric Nursing March/April 1984 III

cause of cataracts, being "a littleunsteady" on his feet and thereforeusing a cane, he described hishealth as really quite good.

Mr. Long came to the clinic verylittle over the next four months de­spite chronic osteoarthritis andatrial fibrillation, an atonic colonand chronic constipation. In Junehe began to come more regularlyfor help with his bowel problem orto check his weight, which he al­ways feared was dropping. At 127pounds he really couldn't afford tolose. We coped with these problemstogether, and he also came for sev­eral acute illnesses: sinusitis, ver­tigo, and an arterial leg ulcer,which became a chronic problem.

After his cataract extraction inDecember and a one-day stay inthe nursing home, he often came toclinic for ajustrnent of his soft con­tact lenses, which never felt as ifthey were in the right place. Heneeded either an adjustment orreassurance that they were prop­erly positioned. His ophthalmolo­gist had determined previously thatthere was no substantial problemwith his lenses.

In July '81, he was admitted to arest home bed in the health centerbecause his wife had a fall that re­quired keeping her under observa­tion, and he really could not toler­ate their separation. It was easyenough to move her to a doubleroom and admit him as her room­mate and helper until her dischargeto their apartment.

In early October Mr. Long wasworried about an enlarged cervicallymph node. Because of its non ten­der, firm, unilateral nature, I re­ferred him to his general practi­tioner, who sent him to a surgeon

.for evaluation. The node was diag­nosed as a sebaceous cyst and wasnot biopsied.

A month later, Mr. Long said hewas passing black stools. Evalua­tion through history, exam, hemat­ocrit, and stool guaiac disclosed GIbleeding. After consulting his phy­sician and observing Mr. Longclosely in the nursing home, I re­ferred him to the University Hospi­tal, where he was evaluated, trans­fused, and stabilized. During that

112 Geriatric Nursing March/April 1984

admission, the neck node was biop­sied and diagnosed as metastaticcancer. He was told of the diagno­sis and returned to Carol Woodsfor a weekend stay with his wife be­fore a further hospital workup. Hewas discharged when no primarysite was found.

Mr. Long stayed in the healthcenter 20 days, where I watchedhim increase in strength. His wifehad been readmitted to the nursinghome during his hospitalization.She was unable to stay in the apart­ment alone because she was almostblind, quite frail, and at risk of fall­ing. Knowing his diagnosis, Mr.

Each day is different,with varying demandsand challenges.The variety is fun,but this GNP'srelationship witheach resident is herkeenest stimulationand best reward.

Long wanted more than anythingelse to go home. I knew this wasrisky and consulted his physicianand daughter. I told Mr. Long myfears that he or his wife might fallbut promised to support them intheir care at home if they were de­termined to make the move.

Getting home was their numberone priority, so, with arrangementsmade for daytime help in the apart­ment, I discharged the Longs at theend of November. Right after theyhad enjoyed a good supper to­gether, Mr. Long stood up, turnedquickly, and fell, fracturing his leftfemur.

When I met him in the emergen­cy room, he was smiling and reas­suring me that letting him andMary go home had been the rightdecision! He survived a pinning op­eration and amazed the hospitalstaff with his endurance and lucidi-

ty. I visited frequently, carryinglove messages back and forth tohim and his wife. After a 10-daystay, he returned to the nursinghome. The reunion with his wifewas touching. He was glad to behome in the retirement communityagain where he could be with her,have unlimited visiting hours withhis family, and see familiar staffand friends.

Mr. Long knew he was dying andwe had some good talks aboutdeath. He often wondered aloudwhy he had been permitted to stayon this earth so long, but he alwaysconcluded that it was for .cornpan­ionship for his wife. A "good Pres­byterian" minister once told himthat God had a plan for everyoneof his children. Mr. Long believedand took great comfort in this. Hisonly concern was for his wife, be­cause "she's not as well and able asmost people think." He had pro­tectedand cared for her and fearedthat she might not get what sheneeded after he died. I assured himthat she would be cared for.

During Mr. Long's final days hebattled pain and 'confusion, aspira­tion pneumonia, and bladder dis­tention. Then would come a goodday, when he was clear, recogniz­ing family and staff and sharingspecial moments of closeness.

Christmas was a good day. Heasked for a beer, something he hadnot had in many years. He got thebeer and he had family with him allday. By this time his wife knew hewas dying, and she was beginningto grieve. Two days later Mr. Longdied.

We still miss him very much. Formonths after his death, his 90-year­old widow stopped by the clinic tomourn with me. Because I was soinvolved in his care, she still cannotpass the clinic or see me withoutthinking sadly of her Jim. Her feel­ing about me is bittersweet, shesays.

As you can see, a geriatric nursepractitioner acts as a primary pro­vider of health care to patients. Tome and to most nurses, I believe, itis the patients who provide thekeenest stimulation and the mostsatisfying reward. GN