Exactly what does a nurse do anyway???

There we were, a bunch of people that I love, sitting around the table discussing our week, and the subject turned to jobs...then somehow it turned to college and why education was or was not important.  The subject then turned to nursing education and just how much was truly needed in order to "become a nurse." 

One of those people that I love (and of course still do) gave the opinion that "nursing education has turned into something so ridiculous and hard...mostly you just need to know how to follow doctor orders...it truly would only take half the time to educate someone to be a nurse"...and on and on it went. I will spare you all the "in depth" conversation that followed~~ BUT what this conversation did do for me was cause me to reflect on a lay person's idea of what the job of nursing entails...

Educating people to become a nurse entails so much more than teaching the technical skills required to be a nurse. 

Yes we teach them how to wash their hands properly (to not spread infection) take vitals signs (Blood pressure, pulse, temperature, count respirations, oxygen saturation and assess pain), insert foley cathetors, IV lines, nasogastric tubes, and trachs, give a bed bath and change linens, safely move people in bed and safely ambulate someone or move them to a wheelchair etc, to "wipe butts" and empty bedpans, hang IV drips and give medications in many forms...and on and on and on.

AND YES we could teach just about anyone to do these things.

BUT we also teach them anatomy, physiology, pathophysiology, biology, microbiology, immunology, algebra, chemistry, English grammar, sociology, psychology, developmental psychology, abnormal psychology, pharmacology, health and wellness/assessment across the life span, science of nursing, alterations in health/ illness, nutrition, nursing theory, research, informatics, clinical decision making, transcultural diversity and relations, ethics, professional behaviors, spirituality, death and dying processes, nursing management, leadership, community health, interpretation of lab values....and on and on. 

We also teach all of the above through concepts of human caring, basic human needs and teach the nursing process. 

We teach them all of these things in order to prepare the nursing student for the art and science of nursing. We educate them properly so once they are in the work setting and "following doctors orders" while performing their technical skills, that they will do so safely. The subjects that are taught give the nurse the ability to use the technical skills as a compass to asses the true health status of the patient. Without the knowledge base~~the technical skills would have no meaning.  

So~~ while the nurse is talking to their patient they are studying them and assessing their neurological status and assessing their oxygenation. During the communication with their client they are also assessing the patient for knowledge level, home safety, patient advocacy, illness insite, inside information to shed light on present situations and to develop a relationship of caring so that healing can occur. 

While the nurse is checking the patient's vital signs they are learning about their cardiovascular, respiratory and thermo-regulatory states.  

When the nurse is giving their patient a bed bath they are assessing their skin integrity, their ability to assist (their strength), fluid balance, nutritional state and infection/ skin breakdown risk. 

While assisting someone to a wheelchair the nurse is providing safety while assessing their patient's strength, cognitive ability, safety risk and spatial awareness. 

When inquiring about their patient's med list the nurse is assessing the patient's knowledge around their disease processes as well as their safety regarding how, when and why they take the medications. 

During the process of changing a patient's dressing the nurse is assessing the wound healing stage, the surrounding tissue state, as well as checking for odor/infection...they are also assessing whether that type of dressing that was "ordered by the doctor" is actually working.  

While "wiping butts" the nurse is assessing skin integrity, assessing the color, odor and consistency of the stool to detect disease states or healing. 

When a nurse is "following a doctors order" and medicating their patient, that nurse does 6 checks in order to ensure the patient is receiving that medication correctly~~ but more importantly the nurse has to know why that med was ordered, and they need to know if it is the right dose for that patient, and they need to know what side effects to watch for...and on and on and on.  

I could go on!!  The bottom line is that the nurse is with the patient far more than the doctor is. The nurse is the front line (bringing their thoughts, assessments, interpretations and communications to the doctor in order for the proper care to be given to the patient) and safety net for their patient (ensuring that the doctor's orders are indeed safe for the patient and not given if they are not!). If the nurse isn't educated but merely taught technical skills, then that nurse would not be able to do the above I just mentioned and the health of the patient would be in jeopardy. 

How educated do you want your nurse to be???? 

The wisdom of reflection

He sat on his mother’s lap clinging to her for dear life as he screamed in fear.  The hospital bed seemed to hug them as they sat in the center of it, leaning against the head of the bed that was at a 75 degree angle. His little body was shaking and his large dark eyes darted from one nurse to the other as they prepared to take out his existing IV and replace it with a new one. “No, No,” he cried. “Mom, mom,” he pleaded between screams and sobs.  His young mother was desperately trying to sooth his fear while suppressing her own.  She was tired, and her eyes betrayed her calm exterior as they were filled with sadness and protective instincts for her child. 

I watched them.  I prayed for them.  I desperately wanted to take this experience away from them.  This young patient is only 21 months old.  He is my grandson.  She is my daughter.  I was not there to be his nurse but to be their protector and guide through this experience and I felt like a failure.  I wanted to grab him and run away.  I wanted to cry. 

The nurses approached them cheerfully and tried very hard to sooth him by explaining things and by quickly and skillfully doing their job.  He would have none of it!  While he was a good trooper he was scared.  Fear is hard thing to watch your grandson and son struggle with.  The doctors were very good at providing us with timely updates and filled us in often of their concerns and thoughts as treatment progressed.  Added to the current fear of being in the hospital with a sick 21 month old, was the knowledge that the doctors were concerned that possibly our amazing little man “might possibly have lymphoma” because of his lab values…something they were looking into…

He was hospitalized after a week of strept throat that wasn’t treated or diagnosed by his pediatrician despite my daughter visiting the office 2x that week with her child who had a fever of 101 every day, consecutively all week.  As a result, he developed a large abscess posterior to his parotid gland that was drained of 15cc of bacteria after the second admit day.  He had to receive IV Vancomycin until they knew what the cultured drainage was growing.  He was sick of being sick and sick of being trapped in a small room with people accosting him! 

My daughter is a wonderful mother, she gets her protective instincts from me…anyone who knows me will know that I take protecting those in my care very seriously…as does she.  I watched her with awe and admiration as she loved, protected and cared for her son.  I watched in awe at my grandson who could still show curiosity, kindness and have fun during the times he wasn’t in pain or fearful.  The ability of being able to adapt to his situation was inspiring.  My son-in-law was equally strong as he provided his own brand of presence to the situation.  Watching them together parent their child in this very stressful situation gave me peace as I saw the strength and love they have for their child and one another.

Being an ER nurse I of course understood why all the medical interventions were needed.  As his grandmother, and my daughter’s mother, I was scared, angry and protective.  My husband and our family that was home in Maine were also sitting on pins and needles as they waited and worried about this precious little boy of ours. The experience reinforced a few things for me.  As a nurse it is our job to skillfully and compassionately provide our patients and their families with the treatment and care they are prescribed.  It is our responsibility to bring them accurate and knowledgeable information in a timely and routine fashion; giving them time to ask questions and to answer those questions without impatience or judgment.  It is our duty to care about the situation they are in and to convey that with a kind presence, a caring touch and to give them moments of our uninterrupted time to show them they are not alone. It is our calling to see the patient and the family as human beings in a scary situation.  There is also a piece that hit home for me…those family members and friends that continually come in to see their loved one are coming out of concern and they offer hope and distraction from fear for the patient and family. I challenge anyone reading this who is a nurse to reflect on your practice and be sure that you are truly the nurse you were meant to be.  Your presence is vital to the mental and physical wellbeing of your patients and their families. 

Lynchburg General Hospital in Lynchburg Virginia has an amazing pediatric unit filled with compassionate and truly skilled nurses who did all of the above with grace and humility.  The doctors were equally skilled at their job and also did it with much compassion.  My grandson fully recovered and is now running around at breakneck speed as usual!  He does not have lymphoma! Thank you Jesus.

 

An exercise of compassion

The ER is in total chaos today.  All 23 rooms are full, the behavioral health suite is full, the waiting room is full and even the hallway is full. Full of sick patients.  The nurses are frazzled, working as hard as they can delivering treatments, hanging IV medications, soothing fears, charting and carrying out each order on every patient. There are 23 rooms in our ER.  The waiting room has 12 triaged patients waiting for a room, the hallway holds 5 stretchers with sick patients on them and the behavioral suite has 5 patients in there (3 counted for in the room number).  We are currently in a crisis situation~ we have 2 doctors, a PA and 6 nurses.  Its only 9am. 

At this point another behavioral health patient is brought into our ER by the state police.  He is psychotic and half-dressed and screaming at unseen people.  He was found in the park yelling at a tree.  As the charge nurse I go out to assess him (the triage nurse is busy).  I find him to be completely in need of psychiatric help and not suitable to be allowed to stay in the waiting room, (as you can imagine the other patients and their families were getting an eye full!!) BUT where can I put him to him safe and to keep the staff and other patients safe???  Shuffling of patients begins…

Our ER, like every ER across the country is facing these situations every day.  The budget cuts to the mental health programs have resulted in catastrophic cuts in the community resources that our patients need to stay healthy and out of crisis situations.  The ER has become the place to send all of these patients. Once with us, the truly ill might be kept in our ER for days while waiting for a bed to open up in a psych hospital. 

Behavioral health/mental health patients are especially frustrating for us ER nurses for a few reasons.  We are not psych nurses, so many times we feel overwhelmed with how to help them, they are hard to manage both medically and emotionally and at times they have multiple outbursts that are unsafe and scary, they take up many of our limited resources (staff and beds) so we again feel overwhelmed, and the frustration level rises every time we present their situation to another hospital hoping they can be seen and helped in the fashion they need~~~ and they get declined due to “that patient just doesn’t fit our milieu.” 

With all of that said~~ how can we as nurses see these patients through a new lense??? Since we have no control over the red tape of the Psych world maybe there is something we can do to see the patient as we do the chest pain, the trauma and the septic patient; we might have less frustration and feel less overwhelmed.  I decided to try something~~ and it was an exercise in compassion. 

I decided to be a mental health patient to walk a mile in their shoes~~ to see how it feels on some small level.  With the ok from my supervisor and the help of the staff, I came into the ER and “signed in.”  At first it was silly and giggles erupted from myself and the triage nurse…but then as I was asked the multiple intrusive questions, and brought to a room to change out of my clothes and given the blue paper scrubs to change into, things were not so funny.  Out of respect for me the nurse didn’t stay in the room and watch me change~ BUT if I were truly in crisis she would have had to do that… once changed, all of my belongings were taken from me, bagged and locked up.  I had to be without my bra and undies…NOT COOL…and I couldn’t keep my cell phone either.  I was then moved into the behavioral health suite~ scary……….  I wanted the full experience so I was then put into 4 point restraints for “an unsafe outburst that put myself and the staff at risk of harm.”  At that point I was scared… something happened. 

I always knew that putting someone in restraints made me sick to my stomach…I knew on some guttural level how awful it must feel for that person.  Now, I know why we do it and I’m not saying we do anything wrong, I am just saying that it is WORSE than I ever imagined it to be.  I stayed in them for 15 minutes, and I was with people I trust… and at one point I had to tell myself to not freak out!  My nose itched and I couldn’t scratch it.  I didn’t like the way the shirt was slipping up off of my stomach… I felt so out of control… when I was released from the restraints I felt like crying.  I had the luxury of saying, “ok this little experiment is OVER!! I honestly can tell you that it was a good experience, in the fact that I got just a little taste of how the patient must feel…and it opened my heart as well as my eyes. 

There may not be anything I can do to get the mental health patient to a psych bed any quicker…BUT I can have a better understanding of their situation and a bit more compassion. 

Tears and being present.

The call came in from EMS as “72 y.o. man with end stage Lung Cancer in respiratory distress~ vitals stable~”.  Family requesting transport to the ER for evaluation. He is on Hospice~ the nurse tells us the family is no longer able to cope with him at home.”  I went to room 7 to prepare for my patients arrival.

My patient arrived 10 min later on the EMS stretcher~ His gaunt frame fought to hold up his head~ his skin was dry but pale, respirations were labored but controlled at approx. 32 bpm~ his eyes were open wide and they never left my face as the paramedics brought him into the room and moved him to the bed.~ The venti mask covered his mouth so I couldn’t quite understand what he was saying to me. The paramedic was delivering his report but I was so distracted by the look in my patient’s eyes that I went to him and removed the mask so he could talk to me. 

“My wife is coming (breath) with my son (breath) please let her (breath) in when she gets (breath) here…she (breath) has Alzheimer’s (breath) disease and she (breath) is easily scared (breath).” 

I placed the oxygen mask back on his face and reassured him “My name is Bobbi~ and I will be your nurse tonight~ I promise you I will let your family in the minute they get here.”  With just that simple promise I watched his shoulders relax, his head rest on the pillow and his eyes close.  As I worked to deliver a Nebulizer treatment to him, get him on the monitor and draw his labs I asked him some questions.  He nodded yes or no to most but did tell me “I do not (breath) want to be saved (breath)if I die here (breath) please just keep (breath) me comfortable (breath)…I have a DNR.”  He assured me that his family was aware of this wish, “all except (breath) my wife who (breath) just doesn’t understand (breath) what is happening.”

10 min later my patient was much more relaxed and breathing easier post DuoNeb, Ativan, Morphine and repositioning.  His wife, son and daughter had arrived and were now in the room. I found a rocking chair for his wife and brought her a cup of tea and a warm blanket.  As I talked with their children about what had transpired in the last few hours I watched his wife tend to her husband.

Her brow was furrowed as she moved to the head of the bed and rested her hand on his forehead.  He smiled at her. She said to him, “see… you’re okay now…” She picked at his blankets and smoothed out his pillow. 

“My mother is in and out with her thoughts…she has Alzheimers but all in all she is in the present moment lately,” her son told me.  “Our sister died of a rare lung disorder when she was 40 and my mother has never been the same. I think my father’s breathing issues are reminding her of that because she is talking about her a lot.”

As the evening progressed my patient grew more agitated and anxious with his increasing respiratory distress… despite our interventions.  The doctor and I talked with the patient and family and the decision was made to increase his morphine for more comfort.  My heart ached as I watched his wife struggle with the information…she understood in one minute but in the next minute she did not…she paced and cried…she tended to him by readjusting his blankets, offering water, kissing his hand. She on several occasions would get up close to her husband’s face and cry to him, “don’t leave me…please don’t leave me…”  His daughter left the room often in tears and his son tended to his mother.  He reassured her often with his hand on her shoulder, “Ma, it’s okay…dad isn’t in any pain and the nurse is helping him…don’t be afraid.” 

Two hours later my patient passed away~ more peacefully than when he arrived…His family struggled to let him go and to be present for one another.  His wife at first didn’t believe what she was seeing…she begged me to help him…how could I make this woman understand that I couldn’t…tears fell from my eyes as I watched her son hold her as she cried for her husband.  She came to me and put her arms around me and I hugged her back…she cried long deep cries of sorrow~ My heart broke. 

As I write this I continue to cry for this woman.  They were married 50 years and now her husband is gone. Her house is empty and her mind is clouded…what will become of her?  My best friend lost her husband to cancer 3 months ago and I know the pain she is in…deep dark pain~ I pray for them both. 

Being a nurse is at times a painful job…Even though I know that giving a patient and their family my heart is needed; it at times is overwhelming.  I saw this patient’s son yesterday in Subway~ he approached me and thanked me repeatedly for the care I gave to his father and his mother.  He told me that my compassion was worth more to them than anything else I did that night… I guess for the families being present is exactly that….a present!

Transpersonal caring relationships in Nursing

I walked into room 15 to introduce myself to my new migraine patient and I found her rocking back and forth on the stretcher.  Both of her hands were firmly pressed into her forehead and covering her eyes.  The chart says my patient is 17 years old but her tiny frame all curled in a ball made her look 10 as she rocked in pain.  An older woman sat in a chair in the corner of the room and looked at me with pleading eyes. 

I quietly closed the door and moved to the stretcher.  I sat the chart down on an empty chair and softly introduced myself to my patient and her mother. 

“Hello (name), I am Bobbi and I will be your nurse today…I promise I will get you feeling better soon.”

“Please help me,” my patient answered without moving her hands from her head.  I asked her to rate her pain on a scale of 1-10 with 10 being the worst pain.  She whispers “9”.  I asked her an acceptable level of pain and she whispers “not a 9.”

Her mother informs me that my patient has a 4 year history of migraines since suffering a major trauma…she mouths what the trauma was to me with a look of great distress.  I nod to her that I understand and move to my patient.  I tell her that I will start an IV and hang some fluid to get started while we wait for the doctor to come in.  I turned the light off as I left the room.

I put her chart in the doctor’s rack and went to gather supplies.  My patient was fourth in the rack to be seen~ hence about an hour.  I had one other patient at this time so I went to check on them and then returned to my little teen’s room. 

I entered her room and softly told her, “I need to turn the light on while I start your IV but I will turn it off as soon as I’m done.” I covered her with warm blankets and put my supplies on the bed. 

She continued to rock back and forth without answering.  I quickly started her IV and hung the saline wide open for a 500cc bolus.  I got two washcloths out of the closet and ran them under cold water.  I placed the cloths on her forehead and the back of her neck.  Tears leaked from her eyes.  I went to ask the doc for some orders for pain meds… the doc said, “I have to examine her first.” 

I went back into her room and asked her permission to give her a hand massage.  I explained to her that it would help relax her and ease her pain. I asked her if she was allergic to the scent of peppermint and if she minded me using the essential oil while I massaged her hands… She agreed.  Her mom remained sitting in the corner watching my every move. 

I slowly and deliberately massaged each of her hands for 10 minutes with the peppermint oil.  After the first few minutes she visibly relaxed and tension began to release from her body.  After the first hand was finished I moved to the other side of the bed to massage her other hand~  she was completely still and her face was relaxed…her mother patted my shoulder as I sat down in front of her and whispered “thank you so much” into my left ear.  I finished the massage of her second hand and just sat quietly for a moment observing my patient.  She opened her eyes and smiled at me.

“I didn’t believe that was going to help but I feel so much better!”  She then rated her pain a 5 on the pain scale.  I smiled, refreshed her cold cloths and told her, “I will let the doctor know what we have done and he will be in soon.”  I left the room and went to doc…I informed him of my nursing intervention…he looked up and said, “Cool.” 

The end result of this encounter~ a happy patient~ hugs from each lady in room 15~ and a satisfied nurse~ a patient who only required a bolus of fluid, hand massage and an injection of 30mg of toradol before going home a very happy girl.  For me ~ another example of the power of nursing presence, alternative therapies and transpersonal caring relationships!