Exemplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 098 - 100
Article Text
The Unresponsive Person
David Evans - RGN, ICU Cert, BNsg
In the middle of my shift in the Intensive care Unit (ICU) the cardiac arrest beeper sounded and the resuscitation team quickly responded. On arrival at the scene, the team continued the cardiopulmonary resuscitation initiated by ward staff. The elderly woman, who had suffered a cardiac arrest, was intubated and defibrillated into a normal cardiac rhythm and then transferred to the ICU for continued management.
On arrival, one doctor inserted an arterial line while another inserted a pulmonary artery catheter. Nurses took observations and attached machines to monitor the client's heart rate, blood pressure and oxygen levels. An electrocardiograph was taken and sedatives and analgesia were administered at regular intervals.
I was the nurse allocated to care for this seventy-five year old woman. Throughout this activity, as is normal practice, I explained what we were doing.
This took the form of simple statements such as 'you are in the Intensive Care Unit' or 'I am measuring your blood pressure'. Despite the person being unconscious, this one-sided conversation continued, attempting to provide some information of events as they occurred.
Her condition improved and she spent the remainder of the day drowsy and sleeping. The next day I visited her and she described events from her perspective. Despite being apparently unconscious she was able to recall some aspects of the activities. She remembered being unable to move, and having people 'ouching and jabbing' her. She could recall people talking around her bed, although not what was said.
She said 'I wanted everyone to leave me alone, but I couldn't even move my little finger'. While she shared her fears and feelings about the events of the previous day I was able to offer further explanations and answer questions.
On reflection upon the conversation, I was reminded of how important it is to talk to the patient when providing care. Within the intensive care unit, as in many other areas, this conversation can be more a habit of practice than a clear attempt to inform.
I have often had the relatives of patients comment, 'you still talk to them when they are sleeping' or 'can they hear you?' I have also observed their self-conscious attempts to maintain this one-sided conversation to their unresponsive relative. I have always encouraged this activity on the basis that it requires little effort and the person may well be able to hear what is being said.
While this woman could not recall what was said, she had some awareness of the events that had occurred. For me, this demonstrates the importance of talking to all people. This communication provides information to help put order into what can be a confusing and intimidating environment. Most importantly, it provides the human contact and the human caring components for the therapy.
Talking to the unconscious person is an important part of the nursing care. In practice it can be hard at times to maintain a one-sided conversation in the absence of signs of listening or understanding.
Explanations and simple statements take little time or effort but may have a significant impact on the person. While it provides information about what is happening, it also conveys the caring and supportive aspects of the treatment. Even the unresponsive person may be receptive to talking, touching and genuine caring.
Primary Health Care in Nursing Practice
Carol Coombs - RN, RPN
Dip App Sci (Comm Health Nsg), BNsg (Prim Health Nsg)
One aspect of my role as a school-nurse was to carry out health assessments of all reception grade children commencing school in a defined geographical area. The health assessment comprised a physical examination as well as a psycho-social assessment of the child's health. During the assessment the child was usually accompanied by a parent so that a comprehensive health history could be obtained at the same time.
It was during one of these yearly visits to a local school, that I came across a little boy named David. Unfortunately, David was one of those children whose reputation often precedes them due to what is often referred to as 'unacceptable behaviour'. Before I had even met David, I had been informed by the staff of their concerns and asked if I would able to assist in trying to find solutions for David's problems. The problems identified were mainly behavioural ones, such as disruptive and destructive classroom behaviour, refusal to talk, refusal to mix with other children, soiling himself in the classroom and running away from school.
David seemed to be the main focus of conversation and attention in the school at that time. I was quite anxious to meet David to find out whether his behaviour warranted all the attention that was being directed towards him.
I did eventually meet David, accompanied by his mother, when he came to see me for his health assessment. Unfortunately I have to admit that his behaviour on the day certainly lived up to its reputation! Within minutes of him entering, the room took on an appearance as though a whirlwind had just passed through. It did not take me long to establish that David was unable to cooperate with the criteria set for the health assessment procedure. After sending David back to his classroom, I had a very long chat with his mother and she was able to provide me with a very comprehensive account of David's past medical history.
I discovered during the interview that David's mother had taken him to see a number of paediatricians in the past, all of whom had given him a clean bill of health. His developmental milestones had been normal throughout his infancy, except for an unwillingness to talk. By the age of two he had not been heard to utter a word. It was also at this age that he started to become very naughty and as a consequence of this was referred to a paediatrician (the first of many) by the family doctor.
Numerous tests were carried out on David but to no avail and his mother was eventually reassured by the paediatrician that everything was fine and that it was just a stage that David was going through. His behaviour continued to deteriorate and as he had started to repeat words in parrot fashion by the time he reached four, it was surmised that his lack of speech was not a contributing factor.
Because of David's behaviour he was unable to attend kindergarten as staff were unable to control him. Once again he was referred to a paediatrician. The results were much the same as before, although some assistance was given to the parents in the form of a parenting skills programme, to enable them to manage David's behaviour.
David did not commence school until he was seven, as it was hoped that by then he would have developed appropriate social skills to handle a new environment.
On entering school David was unable to adjust to his new surroundings and his behaviour became worse. He was eventually referred to the Child Guidance Officer attached to the school and placed on a behaviour modification programme which had to be administered by his teacher. She had 20 other children in the class and the extreme behavioural problems displayed by David provided an untenable situation.
I was also amazed to discover from David's mother, that he had never had any formal type of psychometric testing done, not even by the Child Guidance Officer. It seemed that most of the health workers he had seen, considered his problems to be a result of poor parenting. The focus of their intervention was in overcoming these problems by advising his mother on how to become a better parent.
Although David's mother did blame herself for his problems, she still felt that there was something drastically wrong with him, since he was not improving. He had gradually become worse since starting school. The situation had become so bad that it was now affecting the whole family, including her relationship with her husband.
It was obvious from listening to what David's mother was telling me that something quickly had to be done to alleviate the situation. I felt that the whole family's future was at stake if some kind of assistance could not be given immediately, and to ignore the mother's plea for help was to put the whole family at risk.
By this stage I was also having some thoughts as to whether David might be intellectually impaired after listening to what others had told me about his behaviour and from what I had observed for myself. After consulting with David's mother and letting her know of my concerns, I asked for and received her consent to have David undertake a psychometric examination. I then approached the Child-Guidance Officer who was responsible for David at the school, to see if he would be willing to perform the testing and gave my reasons as to why I thought this was a good idea. Unfortunately, my request was refused. The reason for his refusal to perform the testing was a desire to not label the child as intellectually-impaired at such an early age.
Although I appreciated his concern, I was more concerned with what might happen to David and his family if help was not forthcoming in the short term. I was also given a very clear message that it was not my domain to concern myself with these types of problems. Although I appreciated what the officer had to say, I was determined to press on for the sake of the family, as I could see that the mother was at breaking point.
Fortunately for me, the organization in which I worked had child psychologists attached to it and they were extremely approachable people. With David's mother's approval I contacted them and spoke to them of my concerns and the urgency of the referral. Thankfully they were very responsive to David's case and arrangements were made for him to be seen urgently, much to his mother's delight.
David's psychometric process was a difficult one, due to his unpredictable behaviour and it took a number of sessions involving two psychologists to be completed. The results did however, prove to be worth the effort as it was discovered that David had a receptive language disorder, and it was felt that much of his behaviour was a result of this problem. During communication processes it was thought that he was unable to interpret incoming messages and was not able to respond in appropriate ways. Although I knew nothing of these types of language disorders it certainly made sense to me having observed David's behaviour which was often erratic and inappropriate.
After seven years we had come up with an answer but how to treat the condition was another matter! Although the psychologists who had assessed David had recommended that he attend a special oral school where he could receive one-to-one care, the School Child Guidance Officer was totally opposed to this suggestion. This was even after David's parents had also stated that they wanted David to attend an oral school.
By this time I felt like the meat between the sandwich. I was totally powerless in that I could not refer the child myself and the two psychologists were reluctant to impose their views on the guidance officer. At that point there was an impasse. Even the school principal had little influence over the officer! Eventually my patience ran out and I decided to take the situation in hand and went ahead without any authority to arrange a meeting involving all parties. By this time the principal had also lost his patience and with his assistance it was arranged that the guidance officer, David's teacher, the parents, the two psychologists, a representative from the oral school and I would attend. The meeting went ahead with everyone being present. To start with the meeting was very tense, but it did turn out to be very successful. I believe this was due to the presence of the expert from the oral school who was able to put David's case into perspective. As a result, everyone at the end of the meeting was in total agreement that David would benefit by attending an oral school· and that he should start immediately.
David did go off to the oral school the following week much to his parents delight and also to mine! Some six months later I received a phone call from David's mother, who was overjoyed at David's progress. Apparently he was now able to ride to school in a taxi accompanied only by the taxi-driver and his behaviour had improved markedly. He was starting to talk at last, not just in a parrot-fashion but starting to construct sentences, much to everyone's pleasure. He was no longer soiling himself and his concentration span was improving. She also thanked me for my involvement and concern for the family and believed that if I had not come to their aid at that time, their situation would not have improved and it was only now that she could fully appreciate what they had all been through.
The reason I chose this exemplar is that recently (some seven years on) I ran into David and his family at my local shopping-centre and to my surprise the family remembered me. I would not have remembered them if they had not approached me first. Amongst the members of the family was a good looking young man able to converse with me in a very normal and appropriate way. David now attends a normal high-school. The family are still together and coping well as a normal happy family.
My recent association with them made me reflect on the time I spent as a school nurse and appreciate the small part I played in this family's life for which I admit I felt most gratified that I had the privilege!
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