My day begins early in the morning, checking my computerized schedule to see if any patients were added during the night. Even if my schedule is the same as when I went to bed, I know to remain flexible throughout the day as I leave to see as many as 20 patients.
I am Dr. Teresa Cating, Adult and Geriatric Nurse Practitioner and I provide primary care to older adults living in the community. Most of those 18 patients I will see reside in an assisted living facility. I manage their chronic diseases, but also focus on wellness-helping them to live their best and most healthy lives.
As I arrive at the assisted living facility, I am greeted by the director of nursing or medication aide or both. They are eager to give me their reports or to add someone to my schedule. Everyone at the facility can provide important information about the patients; therefore, I make friends with everyone including housekeeping, dietary, and most importantly the nursing assistants. The staff can provide valuable input into how patients are walking, eating, conversing; as well as their level of orientation.
I begin to see patients, one by one in their apartments. I am notified by the facility, the patient, or the family about which patients need to be seen due to signs or symptoms they are exhibiting. I bring the complete office visit to the patient's home and am able to complete a physical exam as well as needed labs, and x-rays or ultrasound. In addition, minor suturing, and other minor procedures can be completed right there, reducing the need for older, frail patients to be transported (often by wheelchair transportation) to an office or emergency room.
After the "office visit," I discuss any necessary information with the staff (and/or family) and write orders. Then, it's on to the next patient. Many times, there are urgent situations that occur and I stop to attend to those-a patient falls, chokes, or is having a hypertensive crisis.
Nurses deciding to become nurse practitioners often imagine they want to be acute care nurse practitioners partly because they believe they may "lose their skills" if they practice geriatrics. It is, in reality, quite the opposite. As practitioners, we are faced with a list of diagnoses such as chronic kidney disease, chronic obstructive pulmonary disease, heart failure, hypertension, anemia, cancer, Parkinson disease, and chronic urinary tract infections...and that may be all from the same patient! In addition, many have dementia, depression, chronic pain, and a history of repeated falls.
Attempting to obtain the history from an older adult who has poor recall of events is difficult at best. Upon review of systems, the patient with dementia may state "everything is wrong" or "nothing is wrong." You need to have outstanding interviewing skills to get the patient to tell you how they have been feeling. The physical may not be as challenging as obtaining the history; however, it can be. Patients with dementia may not want to be touched and/or may be aggressive. Developing plans for older patients who have multiple comorbidities is perhaps, the greatest challenge of all and requires the full use of abilities and resources. I grapple with writing a prescription when the patient has poor renal function, is on an antidepressant that interacts with most antibiotics, and has a host of allergies.
Do you see where I am going with this? Geriatric care is one of the most challenging areas you'll face as a nurse practitioner. Patients are getting older, frailer and sicker, and need caring, committed providers to see them through the last stages of their lives. I am able to spend quality time with my patients, focusing on their physical and mental problems while making a plan for their last stages of life to be of the highest quality possible. This is the most rewarding career I could have dreamed of.