Examplars
Critical nursing incidents where you made the difference
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 031 - 033
Article Text
Closing the communication gap
It was 0715 when I arrived on to the ward where three of my students were working. As I was speaking with one of my students about the care she had planned for her patient, I noticed that at the next bed lay an Asian-looking lady with a frown on her face. Next to her sat her husband with a concerned look on his face. They both looked worried and anxious. I immediately left my student and went across to enquire what the problem was. As usual, I introduced myself to the couple and proceeded to ask them what was wrong. The gentleman just nodded and his wife who began to mumble in something that sounded to me like the Chinese language. I realised then that neither could speak English.
At that moment the RN responsible for the patient walked in and I asked her if we could get the interpreter to find out what was the problem and to explain things to the couple if needed. The RN stated that the patient had had an abdominal hysterectomy and the interpreter had been up the previous day to explain all about the surgery and its outcome. The patient was Vietnamese and was day one post surgery. She had been vomiting during the night and was still nil by mouth with an IV line in situ. The RN did not think there was any further need to get the interpreter.
I was in a difficult situation, as the students were supernumerary and I was from the University. Yet, I felt I had to do something to help the patient. As my good fortune would have it, I quickly remembered that one of my students in another ward was also from Vietnam. So I politely asked the RN if it was alright with her if I brought the Vietnamese student to explain things to the patient and her husband. I followed this up by stating that the student would only interpret what the RN wanted to ask the patient and to explain to the patient what the RN wanted her to explain. This was important as the student did not know the patient and the RN did. The RN agreed to this.
The student came down and as soon as she greeted the couple in Vietnamese, their faces lit up. What followed next was very exciting as the patient and her husband became very vocal and expressive. The outcome of the conversation was that the patient was in pain and was worried about getting up for a shower by herself. The patient was reassured, through the student, that she would be given something for the pain before being assisted with the shower. The nil by mouth and IV therapy were also explained. It turned out that the couple were boat people who had only just arrived into Australia three months ago.
To help improve care for the patient, we asked the Vietnamese student to write down the English equivalent for the Vietnamese phrases for 'I want to sit up', 'I need to use the pan', 'I am in pain', 'I am uncomfortable' and so on. We put a card up on the bed so every nurse could use it to care for the patient. For the rest of that shift, every time I walked into the patient's room I could see that she looked as if a load had been lifted from her shoulders. She was more relaxed and responsive to the staff around her.
This incident highlights the importance of explanation and reinforcement in caring for patients. Patients do become worried and frightened and they need to be reassured. As nurses, we need to remind ourselves that a single act of explanation, even if patients speak the same language is often not enough. Almost every agency in Australia has an interpreter service and we should endeavour to utilise this service to the fullest to provide optimum care for all patients.
Saras Henderson RN, BScNsg, Med
Don't be afraid to trust your intuition
After being sent to relieve on a busy morning shift on the neurosurgical ward of a large public hospital, I took a phone call informing me that one of the ward's patients was ready to be transferred from the high dependency unit. This patient's status as a particularly unstable diabetic had necessitated admission to high dependency for three days post-operatively following a laminectomy. I was assured that there was nothing about the patient's condition that should cause any concern. Thirty minutes later the patient, who was also totally blind, was brought to the ward and placed in a side room. During the quick verbal handover, I was again assured that her postsurgical recovery had been uneventful.
I turned my attention to the patient, who was lying on her back, and who seemed utterly unaware of my presence. What struck me most was her absolute lack of motion; no limb movements or facial expressions, and what I can only describe as an almost 'deathly' stillness. When I spoke, her responses were whispered and she initiated no conversation herself. Her observations were within normal range, as was her blood sugar level, but all my instincts told me that something about this lady was 'not right'. As I completed admission procedures, I noticed that a Medic Alert bracelet included on her clothes list was not on her wrist, nor could I find it in her toiletry bag which had accompanied her from the high dependency unit.
So great was my concern, that I rang the registrar, requesting that he come to check the patient. When I told him that all observations were within normal limits, and that my concerns were based only on her withdrawn and motionless state, he assured me that blind patients often exhibited this pattern of behaviour, especially post-operatively. He asked me to 'keep an eye' on her, and to call him again if I had further cause for concern. I also rang high dependency seeking information about her Medic Alert bracelet, but it could not be found. As the shift progressed the patient remained utterly still and, unless spoken to, completely non-interactive. I telephoned the medical staff in charge of her care again, as she had not been visited by them that day. Again, I was only able to report that the patient was totally withdrawn and, if anything, even more lethargic than previously although she was still responding in a whisper if spoken to.
I was still absolutely convinced that something was wrong, and carefully checked her medical and nursing notes and a previous drug chart which, in line with usual procedures, had been folded in half with a new chart placed on top. I discovered that since admission, the patient had been on fairly high doses of oral hydrocortisone, which had been replaced with intravenous hydrocortisone for 24 hours after surgery and then ceased. There was no order for oral hydrocortisone on the new drug chart. A sudden alarm bell rang, as I recalled a mention of adrenal insufficiency in her medical history. Memories of anatomy, physiology and pharmacology studies were stirred, especially the implications of an abrupt withdrawal of long-term corticosteroid therapy. I paged the registrar, and this time was able to give him full details of the sudden cessation of hydrocortisone. Within fifteen minutes intravenous hydrocortisone therapy was re-commenced, and shortly after this a call from high dependency informed me that the missing Medic Alert bracelet had been located. When I picked it up I opened the envelope to check it, and under the inscription 'diabetic' was a second inscription, 'cortisone dependent'. Whether this experience highlights the importance of accepting the value of intuitive nursing judgement, or is an example of a clinical picture not 'fitting' available information or cases experienced previously, is not really the issue here. The reader can judge. What is important is that nursing staff persist in the face of initial dismissal of their concerns by medical staff if they feel there is a real need to do so. Also highlighted is the importance of full information being given at handover, especially significant details of a patient's medical history. Had I been aware of the patient's history of adrenal insufficiency I may have had an earlier insight into the cause of her condition. Finally, even seemingly insignificant details like ensuring that articles listed on a clothes list are accounted for when patients are transferred, can contribute to the overall picture of the patient. It was fortunate that my intuition, or my past experience-call it what you will-guided me in my belief that all was not well with this patient.
Judy Zollo RN, DipT, BNsg
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