Skilled nursing facility admission after hospitalization

DRMrs. Wilkinson? I'm Dr. Okafor, the attending physician here at Riverbend. I'll be the one looking after you while you're with us. And you've brought company, I see.

FAMILYI'm Denise, her daughter. I followed the transport van over from the hospital.

PTShe hovers. Seventy-five years old and I still get hovered over.

DRA little hovering never hurt anybody. How was the trip over?

PTLong and bumpy. For a ride that's supposed to be twenty minutes, it wore me out something terrible. And that's the whole trouble, doctor, if you want the honest truth. Everything wears me out these days.

DRThen that's exactly where we'll start. Let me first tell you what I know from your hospital records, and you correct me where I get it wrong. You were just in the hospital, and they've transferred you here for skilled nursing care — to build your strength back up before you go home. You have type two diabetes, and it has started to touch your kidneys — stage one chronic kidney disease, the earliest stage, but we take it seriously. Your blood pressure runs high. You have anemia, and you receive vitamin B12 injections for it. Your triglycerides run high as well, part of what we call metabolic syndrome. Am I telling your story right so far?

PTThat's my story, told better than I usually tell it. The diabetes is the one they kept circling back to at the hospital.

DRThen tell me about that part in your own words. What has your body been doing lately?

PTWell. I'm thirsty all the time, for one. I keep a glass by my chair and a bottle by the bed and it's never enough. And what goes in comes out, so I'm up to the bathroom all night long. Four, five times a night. And here's the strange part — I'm hungry too. I've been eating more than I ever did, and still I feel emptied out. Weak.

FAMILYTell him about your feet, Mama.

PTI was getting to my feet, Denise. They tingle. Both of them, and my hands some too. Pins and needles, like they fell asleep and won't wake all the way up. It's worst at night when I'm trying to rest.

DRHow long has all that been going on — the thirst, the bathroom trips, the tingling?

PTThe tingling crept up over months. The thirst got bad these last few weeks. Denise noticed I was refilling my glass every time she turned her back.

FAMILYShe was also napping half the day, which is not my mother. My mother reorganizes other people's kitchens for entertainment.

DRThen we'll keep the kitchen locked for now. Mrs. Wilkinson, those symptoms — the thirst, the hunger, all the trips to the bathroom, the tingling in the hands and feet — those point straight back at the diabetes, and they tell me your sugars have been running higher than we want. A big part of this stay is building a steady routine around that. Regular meals, medicines on time, and nurses keeping a close watch every single day.

PTThe hospital doctors said much the same. I'll confess it to you like I confessed it to them — I let things slide at home. Cooking a proper diabetic meal for one person is a sorry business.

DRThat's honest, and honesty is useful to me. It's also very common, so you'll get no scolding here. Now, your medicines. Tell me if this list matches what you know. Clopidogrel, seventy-five milligrams once a day — that's a blood thinner.

PTThe little pink pill. Yes.

DRSimvastatin, twenty milligrams at night, for the blood fats. The long-acting metoprolol, one hundred milligrams, for blood pressure and heart rate. The vitamin B12 injection on a schedule for the anemia. And a nitroglycerin spray you keep with you, for under the tongue if you ever feel chest tightness.

PTThe spray lives in my handbag. I haven't needed it in a good long while, thank the Lord.

DRMay it stay that way. But hear me on this — if you ever feel that chest pressure while you're here, you press the call button first. Don't just quietly reach into the handbag. We want to know about it, every single time.

PTI promise to make a proper fuss.

DRPerfect. Now allergies, because your chart lists several and I want them exactly right. Aspirin, peanuts, and animal dander — and a note that you're generally an allergic person all around.

PTAlways have been, since I was a girl. Aspirin swells me up. Peanuts are the dangerous one — even peanut dust starts my throat itching. And I can't be around cats or dogs for long, which is a pity, because I do like a dog.

DRThat last one matters here, believe it or not. We have a therapy dog that makes rounds on Thursdays, so we'll keep him off your hallway. The kitchen gets a peanut-free flag on every one of your trays, and the aspirin allergy goes in large letters on the front of the chart.

FAMILYI was going to ask about food. She barely touched anything at the hospital.

PTDenise, the food there was gray. All of it. Even the gelatin managed to be gray.

DRWe will aim considerably higher than gray. A dietitian is part of your team here. Meals will be diabetic-friendly and built around the peanut allergy, and she'll come sit with you about what you actually like to eat.

PTNow that's civilized.

DRLet me lay out how today and the next stretch will go, because admission day is a busy one. This morning I'll do a complete history and physical exam. The nursing staff will do their own initial assessment. And then the whole team sits down together and writes what we call an individualized plan of care — that's the map for your entire stay.

PTA map. All right. And what's drawn on this map?

DRTherapy, mostly, and watchfulness. Physical therapy will work with you several times a week — walking, balance, getting out of a chair without it becoming a production. Occupational therapy comes too, and they handle the daily-living side — bathing safely, dressing, kitchen tasks. And a speech-language therapist will see you as well.

PTSpeech? There is nothing wrong with my talking. Denise will vouch. She'd tell you there's too much right with it.

FAMILYI would tell him exactly that.

DRIt's broader than talking. The speech therapist checks swallowing safety, and runs through thinking and memory exercises. After a hospital stay, and with sugars running high, plenty of folks feel a bit foggy. It's one more set of eyes on you, that's all it is.

PTFoggy is fair. I've been losing my word for things lately. It comes back, but it takes the scenic route.

DRThen she'll be a good visit for you. On top of the therapy, the nurses will check on you every shift, every day — vital signs, blood sugars, medicines, skin checks, the whole picture. That daily surveillance is the backbone of a stay like this. And once a week, the full team — nursing, therapy, the dietitian, social services, and me — sits down and reviews how the plan is working, and we adjust it as you go.

FAMILYAnd how long are we talking about? She will ask me the minute you walk out of here, so I'm asking while you're still in the room.

DRA fair question, and I'd rather give you honesty than a number on day one. It depends on how the therapy goes. Some folks need a couple of weeks, some need longer. What I can promise is this — when you're getting close, we do a formal pre-discharge assessment. Can you manage your medicines, your meals, the stairs, is the house set up safely. Nobody goes home on a guess, and nobody stays a day past ready.

PTAnd nobody sends me home a day before ready, either. I live alone, doctor. Denise is forty minutes away with a family of her own. If I go home, I need to be able to do for myself.

DRThat is exactly what the whole plan gets built around. Anything else on your mind before I examine you?

PTTwo things. My B12 shot — I believe I'm due soon, and I don't want it forgotten in the shuffle. And I want my own nightgowns brought from the house. These hospital gowns are an indignity.

DRThe nurses will get the B12 onto the facility schedule today so nothing lapses. And yes to the nightgowns — label them, that's the only rule we have. Denise, anything from you?

FAMILYVisiting hours, mostly. And whether I'm allowed to bring her decent coffee.

DRVisiting is generous here — the front desk has the sheet with all the times. Coffee, yes, within reason. Cream and sugar we'll negotiate with the dietitian.

PTThey will pry the sugar from my cold stubborn hands.

DRThen we'll open the negotiation gently. All right, Mrs. Wilkinson. Let's do that exam, and afterward I'll let you rest before lunch comes around. Welcome to Riverbend. Our whole job here is getting you strong enough to go home and reorganize your own kitchen again.

PTAnd maybe somebody else's after that. Thank you, doctor. You may hover now, Denise. Briefly.