Exemplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 131 - 134
Article Text
The importance of assessment
Gaynor Keenihan RN, BN
The following experience helped me to review my own techniques for gathering client data at the initial health interview and throughout hospitalisation.
I was working night shift in a post-acute surgical unit where several clients had undergone surgery during the afternoon shift. Mr A had returned from the recovery room an hour prior to the shift handover and was to be monitored closely. Information presented at handover revealed Mr A had undergone an intra-optic lens implant. All data and observations pertinent to his post-operative monitoring were stable and showed no cause for concern.
I commenced my round of the ward; settling clients and monitoring the vital signs and other data of all of the post-operative clients. On first assessment, Mr A was lying in the supine position, breathing deeply, with noisy inspiratory wheezing, and was not responsive to verbal stimuli. Physical stimuli awakened the client, and he responded to questioning. His respiratory phase was bilateral, with a long pause between expiration and the next inspiratory phase, and the respiratory rate was elevated to 26 breaths per minute as he attempted to converse. It was at this point that I began to feel uncomfortable with the data I was observing and collecting.
I switched all the overhead lights on and noticed that there was a suggestion of colour change in Mr As face, his lip colour was slightly pale and his face was quite flushed. I could see in terms of body type that Mr A was of the heavyset 'endomorphic' build. My initial thought was that he might have asthma, and that a ruddy complexion may be normal in relation to his build. I started to wonder if anyone else would think the same. At this stage I was not overly concerned about his status and I left him for a moment to fetch the case-notes and bring them back to the bedside to continue my observations.
I was reluctant to alter the positioning of the bed at this time, as I was weighing up the effect of this action on the surgical area. A potential outcome of this action could be to increase the intra-optical pressure thus compromising the success of the lens implant. The admission data revealed limited information on current or past health history, and I searched the records for further clues. There was mention of asthma as a chronic condition in other documentation and I checked this with the client. Mr A confirmed the information by saying that he had 'empty asthma for many years'.
Further exploration and questioning revealed a history which was congruent with a state of chronic respiratory illness, or emphysema. With this additional information I was able to consult with other members of the health team to alter the postoperative care given to Mr A and to monitor him within the new parameters of his health status. Two years later, with the introduction and widespread use of nursing diagnosis tools, nurses were encouraged to expand and fine-tune their assessment and observation tools to new levels.
The experience of nursing Mr A was frightening at the time and left a lasting impression on me as an evolving clinician. It gave me cause to reflect on a range of previously unexamined base-line skills and procedures.
Reflective practice in critical care nursing
Diane Chamberlain RN, Crit Care Cert
During the course of my Bachelor of Nursing Studies I have learnt to reflect on nursing practice and what this means to nurses and patients, and what this achieves in defining the practice of nursing.
As a critical care nurse, the skills that I wish to discuss in particular are those which are perhaps metaphysical in origin, and consequently develop when experience and maturity allow caring for a patient in a natural and fluid manner, relying on mature understanding and a highly developed sense of intuition.
Then one has the mental and nervous capacity to develop highly tuned skills of emotional and spiritual origins. They are skills which are not listed in competencies but are ones beyond basic day-to-day care and include higher values such as a highly developed sense of responsiveness, exceptional sensitivity to the interpretation of patients' needs, and because of dealings with life and death and suffering on an everyday basis, a highly developed sense of spirituality.
A highly developed sense of responsiveness
This particular skill can be explained by knowing what patients and their families need without having to ask. I am able to tune into what they are feeling, and the energy that exudes from them is received and interpreted by me with the consequence that there is a compulsion to fulfil their need.
One particular evening at a bedside handover I saw our new admission. His name was John. He was brain dead. His features were perfect; not a scratch on him. The family had been kind enough to donate his organs. I looked at his mother and smiled. I empathised with her. How could she see him there; pink, chest moving up and down (ventilated), cardiac rhythm, and watch him as if he is asleep? Later tonight he would go to theatre and the family would see him dead in the recovery room. When caring for John and his family, the air was filled with grief and shock. I have highly tuned senses that pick up the energy from the family and it imprints on my brain like Morse code. In a strange sort of way they know I understand, and turn to me for support and caring. Few words are needed because I am tuned into their energy fields due to a highly developed sense of responsiveness.
The compelling thing about this phenomenon is that there is no choice in how I may follow my body's lead to this skill. It draws me like a magnet. I have no choice; I do what the body leads me to do. It is distressing if I do and distressing if I don't. An example of the compelling nature of being able to interpret people's energy fields was when I went to retrieve a young woman who had been violently stabbed. She had eighteen of the most violent wounds I had ever seen. She died later.
This was a very distressing experience for me. My ability to sense the violent energy at the scene of the stabbing was as if I was there when it happened. This experience remained unresolved for a good while, and after many nights of bad dreams it finally released itself into the environment. It occurred to me much later that there was a need to follow through and share the energy with someone else such as a member of her family, but in that case there was no-one. The doctor with whom I went on the retrieval didn't have the sensitivity or highly tuned senses to experience it in the same way as I did, and instead dealt with it in a very clinical way.
I have no choice in the use of this skill of responsiveness and it does not have anything to do with how good my nursing practice is. Equating it with good nursing practice may seem logical; but having experienced my responses to a person's energy, I can only conclude that there is no choice. It is something that is predetermined. It holds more power than something I can choose. I am bonded to share the energy I feel with another. It almost equates with the meaning of life. This is one skill which some of us practice in our care and which gives nursing its special meaning. But does this then have anything to do with notions of 'good' embedded in nursing practice? Personally, it is hard to decide.
To the observer it must be seen as doing good. I have an aversion to the label of a 'good nurse'. It evokes thoughts of passiveness, of powerlessness and doing nice things. In contrast, the phenomenon of sensitive response to a person's energy levels can only happen if the nurse is tuned into these energy levels. They are too powerful and real to be even considered in the same light as passiveness and niceness.
Following one's destiny is more powerful than following role expectations of being good. So by possessing this highly developed sense of responsiveness, the involvement with the person for whom I am caring extends beyond the physical to an almost undefinable dimension. The difficulty is that it tends to be rather unique and as such, it is hard to find other nurses with whom to share the experience. Consequently, the stress to which I am exposed is at an almost metaphysical level and needs unique ways to cope with it; usually in my own way.
A sense of spirituality
A sense of spirituality is closely aligned with the highly developed sense of responsiveness. Spirituality does not mean religion or moral controlled behaviour but means to me a phenomenon of sorts. The spirit is the other part of the person that makes him or her complete. To me it is not a matter of belief, but a matter of knowing it's there. I have the skill of knowing the patient's spirit and spiritual health and it is aligned with their physical healing.
Many other nurses are tuned into spiritual awareness especially at sacred times of birth and death. Another nurse, who didn't find critical care nursing as fulfilling in his life, once asked me if I got sick and tired of using all those gadgets. I looked at him and realised that he would have no idea or value the reasons why I am compelled to work in this area. I simply answered that there was a lot of fulfilment in caring for these people and their families, without explaining further what keeps me here. If I had, it would have taken several hours.
Sensing spirituality is ideal in a critical care environment because the patient is usually unconscious and if not unconscious, then heavily sedated and at times paralysed. In such instances the quietness is ideal for feeling a person's spirit. It doesn't always happen instantly and I often need to care for a person for several shifts before I get to know his/her spirit, almost as if it was shy or hesitant to know me. It is in this special relationship that there may be the chance to help the person heal. The transferring of healing energy to the person is possible at this stage and it often precedes being able to reduce into tropic drugs or oxygen requirements. This is another special skill which gives nursing its special meaning. It is often possible to begin a shift and start a patient's physical assessment when they are very critical and sense that their spirit has gone.
All that is left is a ventilated body. Strangely enough, the doctors soon decide to withdraw treatment and the family are more than willing to be part of that decision. So perhaps these people are aware at a subconscious level that a person's spirit has departed but for various reasons don't discuss it if the topic is raised. Some family members who have very strict religious beliefs often sense it too, but because of the nature of their religion don't accept it as possible.
One person for whom I cared became known to me at a spiritual level. He was in renal failure after the repair of a burst abdominal aneurysm. He was so weak he couldn't move his arms or legs but at times I could look in his eyes and see his communication, feel his spirit talking. It was frustrating at ward conference time when the doctors discussed treatment, not at the bedside but away with all the chest x-rays and biochemistry results, and made decisions about this man that were different from what he wanted. The doctors had not taken the time to watch or feel his responsiveness and started discussion toward withdrawal of therapy. My protests were met with deaf ears and it worried me that they couldn't sense his urgent fight for life. A few days later he had given up his fight for life and I could sense this strongly.
The next day his spirit had departed, and he then died. Another lady for whom I cared, was admitted late one evening shift, suffering from respiratory failure. When I was alone, assessing her physically and completing the admission procedures even though she was too exhausted to talk, she communicated non-verbally her near death, not as a fear but as a destiny. When the time came to intubate, heavily sedate and ventilate her, I got her husband and asked him to express anything final that he wished to say to her. He was shocked at my request. I couldn't explain the reason for requesting it. However he did give her a big hug and kiss and said farewell should anything happen, and then treated me suspiciously for the rest of the time.
She died peacefully the next day, and he would not otherwise have had the opportunity to say goodbye, which is a recurring regret of many loved ones in intensive care units. It did, however, compromise the client/nurse trust and as a result of this I will always be careful, even though he may have appreciated it later.
Caring for Aboriginal people is an overwhelming experience when I am able to know them spiritually. Their physical health is so acutely aligned with their spiritual health that one often becomes the other. One particular man from northern Australia, who was critically ill, had his wife and some of his cultural group visit him for the first time since his admission. It was a strange experience as the elders walked into his room. They didn't even look at him or his supporting equipment but stood facing the walls and exuded spiritual energy which I couldn't understand or interpret, but only feel. They left quickly, and later that afternoon the man went into irreversible cardiac arrest without any physical warning, but I could sense as we went through resuscitation procedures that this man's spirit had departed and could see that attempts at resuscitation were in vain. Sometimes having a sense of spirituality needs to be endured because it complicates the many stresses I need to deal with, within myself.
Usually it is the accumulation of stresses which may lead to burnout, as I am usually able to deal with each situation adequately on my own. I don't cry easily any more. I turn off when I get home because the balance is there with children and a life of my own. Critical reflection aids the wind-down process, but there is still a need to say goodbye to all the people I have come to know very personally and have died. I have a small garden in a special place which has a plant for each of those people and in this way I can continue to practice at levels beyond the physical and yet survive. It is truly rich and rewarding because it is indeed extremely difficult.
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