Home Health Nursing

Describing what a home health nurse does might be easier if we take one example of a recent admission and look at what the nurse might be expected to do. In this case, we’ll look at a patient who was just released from the hospital after having heart surgery.

When patients are discharged from the hospital, they arrive home with a lot of paperwork, bottles of pills and instructions from the physicians and hospital staff.  The patient may have heard what the doctors and nurses in the hospital said but for a variety of reasons, it is extremely difficult to remember once back at home.  The instructions, however simple, are difficult to remember. Medications are missed or, worse yet, taken with another medication that it should NOT be taken with (because the physician is usually unaware of what medications the patient actually has at home)! Instructions do not always translate well from hospital to home. Someone needs to follow-up with recently discharged patients. This is where home health nursing comes in.

  1. On the first visit, within a day or two of hospital discharge, the home health nurse goes to the patient’s home, does a physical assessment, checks the patient’s understanding of medications and treatments and his or her disease process, and does any teaching necessary.
  2. The nurse then assesses for mobility and physical environment problems such as throw rugs a patient could trip on or any obstacles that should be cleared.
  3. A care plan is created to address issues if there are mobility problems, and a physical therapist is arranged (this will involve getting orders from the primary care or treating physician).
  4. The nurse meets with the patient, this is called the ‘admission process’ and it takes a couple of hours to do.  Instructions are reviewed to make sure the patient fully understands their care plan.
  5. On each subsequent visit, an assessment is done and progress is checked (especially with the medication regimen).
  6. Most patients are compliant and can be discharged after a few visits. The goal of the home health nurse is to get the patient to be independent and not need their services any longer!


Over time, a good home health nurse learns a few things:

Older people tend to have vision, hearing, and memory problems. Sometimes they will not tell you if they can’t see the pill bottle label or did not hear what you said.

Some patients have to be watched more closely like a forgetful person with diabetes or a person with a questionable caregiver.

Caregiver problems may require a social work referral.

Our nurses are often welcomed by many frantic spouses who were trying to figure out “what the doctor wrote” or “what the doctor said”, or “which medication bottle to use.”

Care doesn’t stop with a hospital discharge and for that, there are home health nurses!

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