Sunday, June 7, 2009

Nursing Considerations

Nothing's simple. If we had a Maseno Mission Hospital manual for nursing care, it might include a few extra NB's, or caveats, to accommodate our fragile infrastructure here:

(1) "Encourage nutrition and ambulation" sounds like a simple enough medical order to implement. But it can be a challenge to coax a sick and weary patient to eat and walk, even in the U.S. It is a very tall order for 66-pound Ritah in rural Kenya. She is 38 but looks 68. Although she is on ARV's, Ritah remains frail and bedridden after recovering from miliary TB. She also suffers from HIV-wasting, painful genital and decubitus ulcers, and concomitant depression. She has had no visitors since her admission ten days ago. Ritah's adult daughter is the full-time caregiver for her own brother who suffers from dementia.

Ritah must struggle to sit up in bed to feed herself, but we are reluctant to resume IV fluids and are trying instead to help her regain strength via oral medications and nutrition. She must also struggle to get to the bedside commode, but we are equally reluctant to catheterize her. She might otherwise not get out of bed at all. So we sit and talk quietly with her while she eats, buy occasional extra treats to supplement her hospital diet (beans and rice, porridge and "eggnog," an egg-enriched soy formula), and assist with her personal care -- a laborious task when there is no water on the ward, and a painful one for her, regardless. Bed linens are changed as needed. So far, so good. But we are short-staffed with only 11 nurses for three 8-hour shifts.

Because of her muscle-wasting, it is also painful for Ritah to stand. We began with dangling, of course, and then progressed to daily trips outside in a wheelchair. We wrapped her in a sheet because there are no "johnnies" on Wards I, II and III. They cost money. (There is something to be said, after all, for those much-maligned hospital gowns in the U.S.) The first day we helped Ritah walk, we needed to find her some clothing. She had only the shirt and soiled kanga/wrap she had worn upon admission. My size-4 skirt swam on her. There were no safety pins anywhere, so I appropriated adhesive tape and strapped the skirt almost double at her waist to make it fit. (Photo below shows her in a gown borrowed from Maternity!)

Although pleased with her new skirt, Ritah protested the walker mightily and asked for "an injection for strength" instead. Injections are often perceived as the only answer to illness here. Ritah clearly didn't believe we were taking proper care of her without them, and no amount of "education" helped. The first day with the walker, she ambulated two bed lengths before collapsing and insisting she be returned. We coaxed her to "return" herself. The next day she progressed to four bed lengths, and today she made it the length of the ward and back -- neatly sidestepping two scavenging chickens underfoot. Ritah thinks she's getting better because of the injection of sterile water that was finally administered to her by a frustrated staff nurse. We know it's because she's eating and using her muscles. Whatever works...

(2) "Encourage socialization" sounds equally straightforward, but family and community dynamics are sometimes complicated. Repha, 24, was admitted with a high fever and cerebral malaria. She was considered by her family to be "bewitched" because of her delirium. Before admission, Repha had twice been treated by a local practitioner with blood-letting and herbs. Two dark circular bruises on her forehead surround undoubtedly non-sterile incisions. "Everyone was disappointed when snakes and cockroaches didn't come out," explained our clinical officer.

When that didn't happen, and when Repha didn't improve, her family brought her to the hospital as a last resort. Had she been a child, she probably would not have survived her prolonged fever and dehydration. (Little Vincent, age 3, didn't live long enough to be admitted from Outpatient today.) Fortunately, Repha is now on the mend, after three days of IV fluids and quinine. Thank goodness they were in stock this week. She still needs a blood transfusion, but there is no blood at the Kisumu blood bank again. (It runs low whenever school is out and the donor population disappears.) Repha was also given a tetanus shot because of her head wounds. She smiles weakly at us, but her family still doesn't visit. We will ask Matron to intervene. Her family needs to witness Repha's recovery. Seeing is believing...

(3) "Administer oxygen via nasal cannula" is another fairly routine nursing order. But if we have cannulas in stock (no money again), they are often poorly-packaged, kinked and unusable. Fortunately, thanks to St. Barnabas, Falmouth (Cape Cod, Massachusetts), parishioners, we have a wonderful new oxygen concentrator that has saved several lives since Christmas. But we also have four wards -- Male, Female, Paediatrics and Maternity -- in separate buildings at Maseno Mission Hospital. Even a dual-capacity oxygenator can't help a patient on another ward.

So who gets to breathe? The 70-year-old grandmother with CHF who cares for three orphans? The 35-year-old father with PCP pneumonia who is the sole family wage-earner? Or the infant with malaria-induced anemia? And who decides? And, oh, by the way, what happens when the power goes out -- which is becoming the rule rather than the exception in Maseno? Nothing's simple. Except prayer. Yours and ours together. Thank you/Asante, Everyone!

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