holistic nursing and the surgical patient

A category 2 abdominal pain patient was brought into room 5 from the waiting room of my ER…She was an early 20 something who happened to be 17 weeks pregnant…she was complaining of diffuse belly pain, fever and nausea that had escalated over 48 hours.  I watched the tech wheel her by the nursing station to go into room 5.  She was petite in stature, and even smaller in appearance as she hunched forward guarding her stomach with her arms.  A very worried looking older woman accompanied her. 

I quickly exited out of my charting on the computer, grabbed her triage information and scanned it.  I went to the med room and collected an IV tray, saline, and a Doppler.  As I entered the room I quietly laid my equipment on the counter and walked to the stretcher.  Worried eyes looked at me from the face of this attractive young woman.  She sat on the stretcher in a semi-fowler position with her knees drawn up to her stomach.  She held the older woman’s hand and barely changed expression as a tear fell from her left eye. 

I outstretched my hand to her as I introduced myself to them both.  “My name is Bobbi and I will be your nurse tonight, I promise to take very good care of you and make you more comfortable as soon as possible.” 

“Thank you…and my name is ***** and this is my mother….I’m pregnant” she tearfully answered.

After she finished telling me about her abdominal pain I examined her, assessed her vital signs again and started an IV, drew blood and hung NS at 150/hr.  Using the Doppler I found her baby’s heart beat to be a bounding 176…this brought a fresh tirade of tears from both women as they visibly exhaled with relief that the baby was okay.  Her temp was 102, respiration's 22, heart rate 122 blood pressure 126/70, lungs were clear bilaterally with a room air sat 100%.  Her skin color was pale and very warm to touch.  She rated her pain 8/10.  She had positive bowel sounds all quads and was extremely tender to the slightest touch with positive rebound tenderness. 

As the next couple of hours went by with tests and the diagnosis of appendicitis ~ I carefully took care of this patient as we awaited her trip to the OR.  She was quiet but strong…she was childlike when the pain intensified and somewhat soothed by her mother’s reassurance.  I administered morphine often in small doses to alleviate her pain…I gave her cool cloths for her forehead, dimmed the lights and sat with her.  I offered her constant reassurance that her baby would be okay~ when my interventions for her and my other patients were completed,  I was able to give her a hand massage and Reiki as we waited. 

What I noticed, as did her mother, was that during the hand massage and during the Reiki treatment her pulse significantly lowered and her breathing slowed as her face relaxed.  The pain meds helped of course but the visible transformation of her facial and body features during the relaxation therapies was so obvious that her mother commented on it several times.  As I wheeled her to the OR she again asked me for reassurance of her baby’s safety…I gave this to her.  Before I left her in the care of the OR team she tearfully took my hand and thanked me for caring about her and her baby…she thanked me for the way I cared for her in the ER… “the touching therapy helped me so much…thank you…Can you come and take care of me when I’m in labor? She asked with a grin”…

Walking back down to the ER I felt so thankful that I was able to take care of this patient in her wholeness…body/mind/and spirit.  I have been blessed these last few years to have my nursing skills enhanced with the knowledge of holistic care and the learning of alternative therapies like hand massage and Reiki.  My BSN classes included a Reiki course to which I became a level 2 practitioner… I now have the awesome pleasure of teaching Nur. 101 and I’m able to pass on the teachings of holistic care with real life examples of what it looks like.  Being able to nurse someone holistically positively affects not only the patient but me as well… I have a very grateful heart.

past and present reunite

I could hear her crying and screaming in pain as I entered the ER for my evening shift.  The door to her room was closed but the bone chilling cries echoed out beneath the wooden door and filled the airspace of the nursing station.  I inquired of her... “She got here almost an hour ago and we cannot seem to get a handle on her pain…”  I looked at the board to see her name~  I knew her…  My heart raced and I felt a lump gather in my throat…I hadn’t seen her for almost 9 years now.  My mind sped back to a time that our paths had crossed. 

I was doing home health nursing then and she was a teenager with a newly diagnosed sarcoma…I was to care for her while she received treatments.  I was in her home several times a week for a several months…we bonded and I cared about her.  She knew my daughter~  I wanted her to live…I prayed for her day and night.  She was tough…strong and determined.  She had spirit and spunk far beyond her years…I wanted to take care of her… her case brought out the best in me but also that part of me that wanted to take over and do it all…  I struggled with my sense of ego and pride…I struggled to not let her into my heart…it was a losing battle.

Life changed for me and I took another job~  I left her in the hands of my co-workers and I cried for days…I battled with the feelings that I had abandoned her … I had crossed the line with her~ I knew that my feelings for her were deeper than they should have been.  I took on more of her care than I should have or at least more than was professional… when I left it broke my heart.  I did not know that it broke hers too….

I was pulled back to the present by the day nurse wanting to give me report…I would be getting this girl that so long ago claimed a piece of my heart…  I listened to the report and then went in to meet with her.  As I opened the door the crying and begging for pain relief hit me in the heart.  I looked at her and saw a grown woman whose pale face was contorted in pain. Tears soaked her face as she twisted and rithed on the stretcher.  “Please help me, I can’t stand this pain any longer…”  I left the room, went to the orders and saw she could have another dose of dilaudid now…I retrieved it from the med room and quickly returned to her. 

As I sat on the stool next to her bed and injected the pain medicine I prayed for relief for her.  Her mother sat close by holding her hand.  I introduced myself as I cared for her…she looked at me and started a fresh tirade of tears… “Oh my god, is it really you Bobbi?” 

“Yes it is” I replied with a smile. 

She reached across the stretcher and put her arms around my neck and pulled me close as she cried into my neck.  We stayed like this for several moments.  I let myself feel the heart wrenching feelings that I had let go so long ago.  “I think of you so often,” she said between sobs.  “you were the best nurse I have ever had…I measure everyone next to you.” 

I smiled and let the compliment enter my heart.  “I missed you terribly when you left,” she said.  I told her that I had missed her as well and so often had prayed for her.  I told her that I watched her in the newspaper and from afar at school…I told her that she was one of those patients that never left my heart. 

I managed to get her pain under control with meds, hand massage and presence…and we enjoyed catching up with one another.  She was admitted and I went home …  As I thought about the encounter I realized that as a young nurse I tried so hard not to let anyone into my heart for fear of being unprofessional… I knew she had entered my heart deeply and it scared me.  I always thought of her, prayed for her and worried for her, and struggled with the feelings that I had abandoned her…as I let myself feel the rush of emotions that occurred when we reunited I realized that I was wrong all those years ago… It wasn’t the fear of being unprofessional; it was the fear of not being able to help her that kept me bound…

Jean Watson’s theory of human caring talks about caring moments and allowing our hearts as nurses to be present with our patient’s heart.   I did not realize what was occurring way back then BUT I do know the power of presence now.  Being present with this patient gave her and I both healing that night in the ER… allowing myself to care for her all those years ago touched her and in return in touched me.  As we reunited and told one another the power and effect the other had on our lives…healing happened.  Watsons theory came alive for me that night in the ER and I will never be the same.

The mind/body/spirit connection

I went to room 13 to check on the patient I had just received report on… the ER was CRAZY but for some reason I felt the need to check on him first.  Late teens, sick for 3 weeks with diarrhea, waiting on a stool sample (all other labs were back and relatively normal), loss of 20 pounds… I found him asleep on his left side with his left arm outstretched to expose the 18 gauge needle in the anticube with IV tubing attached to NS running at 400/hr (second liter).  He was a handsome boy but pale and thin with dark hair all messed up, skin was dry and monitor showed a normal sinus with a rate of 96.  His oxygen sat was normal at 99, blood pressure also normal at 120/76.  The room was empty except for him of course and a purse…pink with brown trim (I’m assuming not his). 

History was that he had been experiencing diarrhea several times (5-8) a day for 3 weeks, no fever and no vomiting.  Pt. does however have pain in his lower abdominal region that is intermittent but ranges from a 7-8/10 on the pain scale.  Pt. had a prior bout of this diarrhea last year around this time.  No other medical history…otherwise healthy.  Pt. comes from an intact home of original parents and he is the oldest.  

I went into the room and tidied up.  His mother arrived and I introduced myself.  She told me that she was concerned her son was dehydrated.  I reassured her that his vital signs were now normal (he was tachy upon arrival at 126)and that his orthostatic vitals revealed he was a bit dehydrated to start but that this liter of saline hanging was the second one and we would assess those vitals again shortly to show her his improvement.  I told her I would be back and left to check on my other patients.  She thanked me and sat down next to him.

After I finished my rounds I returned to room 13 to check on my boy.  He was awake and in fact had just returned from the bathroom where he had left me a stool sample.  “Oh joy,” I remarked with a laugh and went to collect the sample… I’ll save you the details but I will say it was very foul smelling and it left me suspicious of C-diff.  I brought the sample to the lab and returned to the room.

My boy needed something for nausea and pain so I checked with the Doc in charge and then medicated him with Zofran and morphine.  As I sat on the stool to the right of his bed and slowly administered his meds, I began to ask the questions that nagged at my brain.  “Tell me about the day this diarrhea started…” 

After several minutes of talking I found out that this young man was under tremendous stress at home and school…he was the oldest of 3 and his dad was out of work…his mother tells me that he is “OCD” about stuff and “worries about everything”  to which he agrees with her.  He tells me that he lies awake at night worrying about the family with money…that he is afraid of not measuring up at school and in sports…about how his dad is angry all the time now that he isn’t working and how he fears that they will lose their house…I also find out that for several months he has been taking Advil, 600mg twice a day for headaches… I bring this info to the Doc. (The Doc addresses this with them in the seriousness of such a dose so often and how it may contribute to his issue and instructions are given to not take any more for now). 

After his second IV has finished I cap the INT off and sit down.  I tell my patient that his labs are normal and we want him to come back for a follow up in 2 days if he is no better.  His mom begins to cry… “So what is wrong with him?” she asks.

As I looked into the eyes of this mom and then her son I saw fear…We talked for the next 15 minutes about the stress going on in the home and how her son was internalizing it…and now the compounded fear that her son has about having to start school and play golf with the added pressure of having diarrhea multiple times per day~ he then began to get teary.  He told me that he just felt sick all the time lately and his stomach was in knots when he thought about the family and school issues… I told them that of course stress is very real and it can turn into illness in the body because we are made up of mind/body and spirit not just body..., but that they of course needed to come back for a follow up if he was no better in a couple of days…

I remembered what helps me to get problems off my mind…writing…I offer some advice ~ “carry a small notebook around and leave it on your bed at night~ write all your worries and concerns in it as they float into your mind…when your mind relaxes close the notebook…do this as often as you need to and if you are a Christian you then can ask God to take that notebook full of fears from you and carry the load himself.”  My boy…the patient and his mother both thank me through tears.  “We are Christians and that advice is well received I can assure you” she said and “I’m going to do the same thing myself.”   

I prayed for them several times that night and again the next day as I felt so heavy hearted for them both…Another day with another patient I just knew was in my path for a reason.  J

A vessel of Hope

She came to the ER for complaints of dizziness, intermittent nausea and fatigue x 5 days.  She denied vomiting, diarrhea or pain. She told me that she is never sick and that this is “really bothering me because I play field hockey and I have to be able to practice…preseason.” Her skin was warm, dry and pink and her eyes were bright. Pretty girl… I evaluated her in the routine way…heart sounds, lung sounds, and vitals.  I put her on the monitor after doing posturals and then had one of our techs do an EKG.  This patient’s mother was glued to her side, so I asked her to leave the room for a few minutes of what I assured her were just routine questions we ask every teenager.  Her mother reluctantly left the room.  I sat on the stool to the left of the stretcher and asked the routine questions regarding drugs, alcohol, abuse and sexual history.  Pt. has a new boyfriend and yes they had sex, “but only once and with protection.” I collected a urine sample and left the room after I let her mother back in.

An hour and a half later after all test results were back, the only thing that was “wrong” with my little 17 year old girl was that she was pregnant.  I sat at the computer and tried to gather my thoughts. The PA on duty was not a usual for us and he was being quite flip about the fact that this young woman’s life was about to change…big time.  His answer, “you play you pay.”  I told him I that he was being as ass and that I would go and talk to them if he wanted…”ya, sure, whatever.”  I took her chart and went to the far end of the hall.  I leaned against the wall and closed my eyes…I was cheering at a tournament game for basketball and my boyfriend was playing.  I was 17 years old as was he.  The next day I was going to take a pregnancy test…the memory hit me hard, and I knew this girl was already concerned she may be pregnant and she was scared. 

I asked God to meet me in this patient’s room…to comfort this young woman~ and her mother ~as this news was going to change lives today.  Taking a deep breath I opened the door and went in.  I once again took the stool seat to the left of the stretcher.  I again asked the mom to step out of the room…(now this was difficult for me because I know that as a mother I would have wanted to be there…but far too often in this job do I see parents that do not support their children in these circumstances~  and the patient by law has a right under these circumstances to privacy.) I knew in that moment that this mother feared that I would be saying her daughter was pregnant…I saw it in her eyes and in the way she got up to shaky feet and left the room~ just before closing the door she told her daughter she loved her and in that moment I knew she would be a help to this young woman.

Her eyes were fearful as she sat there biting her fingernail…she looked so young in that moment.  I told her everything was medically fine but that the blood and urine samples confirmed that she was about 3 months pregnant.  Tears immediately filled her eyes and sobs escaped her mouth.  I sat on the bed and held her…she clung to me tightly and continued to cry.  I rocked her and just let her cry…I knew this pain and I knew the fear that was now slithering into her mind.  “thank you,” she said as she reached for a tissue~ when she stopped crying and blew her nose I asked her if she wanted her mother.  “will you stay in here with me?” 

I went to get her mother and we went back into the room, “Your pregnant, aren’t you?” she asked hesitantly… “yes,” she answered with her head down.  I stood off to the side and prayed.  “This is going to kill your father.”  A tirade of tears assaulted my young patient and I tried desperately to stay silent.

“Mom…please, don’t you think I know that…” she cried.  In that moment the mother began crying herself and went to her daughter and gathered her in her arms and wept with her.  I started to leave and my patient asked me to stay.  I stopped and just sat on the stool.  I took a deep breath and cleared my throat…I, in that moment, told them my story~ My teenage pregnancy and beyond.  The fear that turned to joy as my daughter blessed my “husband” and I’s life in ways that we never thought possible and how God used her to grow us into the people he wanted us to be…I told them that it was painful, embarrassing and life altering BUT that it was truly a blessing and I wouldn’t go back and change one bit of it…I told them they had many options to consider and that I could help with anything they needed.  They thanked me and I was thankful that I had that story to share, because in that moment their lives looked black and fearful~

Sometimes I wonder why I stay in bedside nursing…the hours are long and working every other weekend gets really old…the ER is a beast that just roars continually with pain and suffering ~~ but every once in a while I know that I was placed in a patient’s life that day for the purpose of hope and healing.  I received a thank you card yesterday from this patient…she was keeping her baby and going to go to a local college and stay home to have help.  Her parents are being supportive and she has hope for a nice future…Amen!!

Gone but not forgotten

The room was dark and quiet as I finished up my nursing note.  My patient was tucked into her own bed and finally asleep as her daughter slowly ran her fingers through her mother's white curls.  I nodded good bye and stepped out.  Once in the car I checked my phone and found a message from the hospice intake worker that I had another patient to go and see...and urgent open.  I read the directions and something tugged at my brain telling me I knew this address.  I ran into the office to retrieve the paper work.  Once back in my car I opened the file.  The name was that of my friend... my friend that was NOT in the end stage of breast CA with mets.  "what is going on?" I muttered to myself.

I called the intake nurse and asked about the call for this patient.  "I got an urgent call from her doctor telling me that she had just returned from Boston after recieving trial medications that failed...and she is days from dying~  and she wants to die at home...she asked for you."  My heart raced and my stomach clenched...tears ran down my face as I heaved in deep breaths...this cant be true...I just talked to her a couple weeks ago and she said how well she was doing...

I prayed for the 20 min drive for courage, wisdom and strength...I prayed it wasnt true. 

I arrived to be welcomed at the door by my friend's husband who was in tears.  "Thank goodness your here...she cant breathe!"  I rushed into the bedroom to find my friend gasping for breath.  Before I could even hug her and find out what happened, I turned up her oxygen (since when did she start using oxygen, my brain yelled!!!) to 5 liters and turned the fan onto her, then started talking softly to her as I stroked her hair off of her forehead.  "Just breathe in and out slowly...thats it, nice and slow...Im here now and its all going to be okay...slow in and slow out...thats it, just relax and let the oxygen reach your cells...its okay, its going to be okay."

As I comforted my friend I surveyed the room.  She was lying on a hospital bed, oxygen was being fed to her by nasal cannula from the compressed air machine and there were a dozen pill bottles lined up on the bed stand.  My eyes found her husband and I gave him a questioning look.  He motioned me to meet him in the other room.  I continued soothing and calming my friend until she fell asleep and then went into the living room.

Between great sobs of anguish he told me, "She was sent home last night by ambulance from Brigham's and Woman's...to die.  They set up the home 02 and the bed.  They ordered her lots of pain meds and stuff for anxiety...how are we going to do this?  She was fine last week and then she just got so weak and couldn't breathe...they xrayed her and said the cancer was all through her lungs now..."

4 hours later, after her sister arrived, I was driving home with an ache in my chest that truly felt like I would stop breathing myself.  I could not stop crying. I had prepared my friend and her husband as best I could.(she didn't have long)..I told her I loved her and that I was so sorry for what was happening.  I told her how much her friendship had meant to me and that she was a wonderful mother to her children.  I told her that she taught me how to relax and that she showed me how to laugh with abandon~  I told her she would be greatly missed.  She couldn't talk but she nodded with tears streaming down her face...she grabbed my hands and mouthed  "I'm not ready." 

5 hours after that I was called to the hospital to be with her.  She was too air starved to stay at home comfortably and her family couldn't take it.  I arrived to a room full of family~ her 2 children (my kids ages) and her husband, sisters and friends.  She was getting hooked up to a morphine drip and she was no longer in the present . Her eyes were closed but she gripped my hand when I knelt beside her and kissed her face...I wept.  I was no longer her nurse...I was just her friend... I prayed for her and her family.  I then did something Ive never done before... I just knew I was suppose to sing her favorite song...I softly sang to her, Jesus lover of my soul, and I watched as her breathing slowed and a peace entered the room and her faced relaxed.  I was aware that all eyes were on me but I didn't care about being embarrassed, I cared about my friends comfort...her soul.  I sang the song 2 times and by the end of it she was gone...

It was one of the hardest, saddest and most incredible days of my life.  My daughter and I sang that song at her funeral because her husband requested we do so. It was a privilege to honor her in that way.  I tell you all this because I have been thinking alot about her lately. I miss her and I honestly miss working at a job that allows me to connect deeply to a person and their circumstance. 

How does your job allow you to connect to another human being???  Are you using your talents to make another person more comfortable??? What is your story of human connection???