Nursing in the community is varied, busy and demanding. It’s like the weather……so unpredictable. Many people would be unable to live at home without the support that they get from community nurses and their teams. Nursing people in the community involves providing complex patient care at home including care at the end-of-life. We can be asked to deal with any care situation; we have a high skill set and are experts in delivering holistic care. On a day to day basis our visits can range from managing long-term conditions to dealing with acute or chronic wounds.
The demands on District Nurses are growing as more complex needs patients are being cared for at home. The skill set required to keep patients at home is immense, challenging and ever changing. It is through dedicated care and commitment that the patients are able to be cared for in their own homes
This morning I visited a new patient for wound care to both legs. A full holistic assessment of his physical and psychological needs was required along with the assessment of the wounds to his lower legs.
On arrival to the patient’s home I immediately observed that the home was unkempt and the patient was having difficulty caring for himself at home. I carried out my initial assessment using our ‘ever friendly’ RIO system. During the assessment, ticking boxes and typing between answers, I felt it was only fair to stop and allow the patient time to express himself fully and listen to his stories of the past and his family. As part of my role as a District Nurse I need to show compassion and listen to the patient so that they feel valued as an individual. After a short chat I had to guide the conversation back to the assessment questions.
The assessment process is always in-depth and lengthy. It includes all of the past medical history, medication checks and assessment of how the patient manages his activities of daily living. The patient’s psychological wellbeing is also assessed using the PHQ9 and GAD7 assessments. It was clear that this patient required input from social services for assessment of his care needs and a benefit check. He also needed assessment by the community matron as he had had frequent admissions to hospital for exacerbations of chronic obstructive pulmonary disease. Podiatry input would also be required as he is diabetic and his toenails were overgrown and GP review as his blood pressure was elevated and medications needed reviewing. I was expected to complete the visit in 90 minutes but this visit, as many others, was going to take a lot longer than anticipated. The patient had not been caring for himself adequately, as he had had several falls over the last few months which required me to complete a falls assessment and referral to the community falls team.
A District Nurse cannot be task orientated. Although the referral was for wound care my assessment opened up a multitude of problems that needed to be addressed. If I didn’t address these concerns then I would be failing my patient.
A risk assessment, manual handling assessment, nutritional assessment, frailty assessment, and skin assessment was also required. The patient was provided with health promotion advice which included diabetes, dietary, skin care and advice on prevention of pressure ulcers.
Eventually it was time to move on to the assessment of the patients leg wounds; the reason he was referred to the District Nurses in the first instance. Photographs were taken with consent and uploaded to the system. The legs were holistically assessed. Wounds were measured and the wound bed and surrounding skin thoroughly assessed. Using evidenced base practice a decision was made on what dressings were required for the type of wounds the patient had. The legs were then dressed accordingly. A care plan was written, skin assessment and wound assessment charts were completed. A prescription request was completed and emailed to the GP and uploaded on to the system.
The visit was becoming much longer than anticipated and I was starting to feel the pressure on my time as I had a list of patients still to be seen. I completed the referrals to the community matron, the podiatrist, the falls team and the letter to the GP. I then documented all the details and actions of my visit and booked the patient in for subsequent visits on the RIO daily team planner.
I felt a sense of achievement as the patient profusely thanked me for caring and listening to him. The total visit time for this one patient took 3 hours but I left the patient’s home feeling like I had made a difference and after all that’s what nursing is about.