I heart Travelbee...

I spent the greater part of this morning working on my first journal about my clinical experience in adult health. We are encouraged to participate in "reflective journaling" (which is fun, because it's a lot like my blog posts, but with a bit more structure). In the first part, we should "consider and apply a nursing theory". I went onto a website to peruse different theories throughout nursing history (there are some really interesting ones- including one, a woman named Peplau, who was born at the turn of the century in Reading, PA where I went to church as a kid!) I kind of geeked out for awhile reading through different theories of nursing care- it's way more interesting than i previously thought... But anyways, I thought I would share my journal entry in this post. It might not be that interesting, but I know my mom would care, and i swear she's one of the few people that read this blog anyways. So, here you go, Mom-- read over my homework!

Journal #1

While perusing through a summary of various nursing theorists, I was struck by Joyce Travelbee's Theory on therapeutic human relationships. While her work appeared to originate in psychiatric nursing, she began to expand on the importance of existential values in the care of chronically ill patients. While the patient that I worked with is certainly not chronically ill at this point in his life, I think that his self-care improved as our rapport grew throughout the shift.

Travelbee believes that “nursing is accomplished through human to human relationships”. At the start of my shift, I introduced myself and he was sort of indifferent to my presence (other than the flippant remark about having such pretty nurses). As the day went on, I taught him about his blood pressure and what the numbers meant, I expanded on his knowledge of the incentive spirometer and the importance of mobility in his healing. Towards the end of the day, when I would hand him the IS as I left the room, he would remark, “well, i'll do it, but only because you asked me to.” Now in retrospect, perhaps all my teaching didn't exactly sink in (especially if he only did self-care to appease me). However, it really did seem that all our conversations throughout the shift helped him to understand more about his recovery and that my empathetic remarks and explanations about sacro-iliac joint pain (I also suffer from this occasionally) helped our relationship and improved his care. Travelbee also talks about how ongoing feelings of empathy and sympathy help to build rapport between the patient and nurse. Even if he only did the IS because I asked him, he was still doing it regularly (I told him to do it on commercial breaks). Furthermore, his mobility improved pretty dramatically throughout the shift. When I came on, he could barely stand for more than a minute or two, and by the end, he used the walker to ambulate to the bathroom! By the end of my shift, I would certainly say we had built a profound rapport- he even seemed sad to see me go- asking who would take care of him. I reassured him that his primary nurse would be in regularly to check on him.

When I first took this patient, I was kind of disappointed in my choice, because it seemed like it was “too easy” of a patient, but it turned out to be fairly challenging. Even though his care was pretty standard, he was having a particularly hard time managing his pain and therefore not doing the things he needed to do to get well. His immobility could really pose a problem if it didn't improve significantly while I was on shift (especially since he was already 24 hours post op). I guess that just goes to show that you really can't judge a patient by his/her chart!

After searching both Cochrane and guidelines.gov, I was disappointed in the lack of information about post op standards of care. There were some article about treatment modalities three weeks after back surgery, but no information about immediate care. I resorted to looking in Lewis' Clinical Companion, and found basic information about care following spinal surgery. My patient had a discectomy at L5-S1 and was over 24 hours post op when I cared for him. One of the main points was to maintain proper spinal alignment by using the log-rolling method and supportive pillows. The patient did a good job of using the log-rolling technique as he was taught by physical therapist. Since he remained primarily on his back most of the day, we did not utilize extra pillows to keep spine aligned (that is used if the patient is in a side-lying position- a pillow between the thighs helps keep the spine aligned). It is also important to assess and monitor peripheral neurologic signs in the extremities. Both the primary nurse and I assessed his circulation, sensation and motion in his feet and lower legs. His circulation and motion was good, but he did have some problems with decreased sensation in his left leg compared to his right. That is not something new, however, and the research shows that sometimes neuropathy is not immediately corrected after surgery.

As with all surgery, it is crucial that the nurse check for ileus or other interference with bowel function. The patient was already on a full diet, and had passed gas as well as having active bowel sounds in all four quadrants.

The patient was prescribed 2 tablets of Norco to control his pain. Judging by his problems with mobility, I am not sure this was adequate. However, with regular dosing (q4hrs) his pain was better controlled. When I first got on the floor, it was 3pm and he was yelling out in pain while working with the physical therapist. Upon looking at the MAR, I was surprised because his last dose of Norco was at 10 that morning. I would think, especially if he was scheduled to work with PT, the nurse would want to make sure he was properly medicated for pain. His missed dose obviously set him back, because after his painful experience with PT, he was reluctant to try ambulating again. We really had to goad him into trying to stand up and walking to the chair. By the end of the shift, we had kept his Norco administration constant at q4hours, and he was able to ambulate to the bathroom (albeit with some pain) with moderate assist as well as using a rolling walker.

The dressing site on his lumbar area was assessed by both the primary nurse and I, however, there were no orders in the chart for changing the dressing. Although there was a moderate amount of dried blood, there was no active bleeding. I deferred to my nurse, because she said we couldn't change the dressing without an order. I left the floor before she heard back from the doctor.

Travelbee's theory gets a little more existential than i mentioned here, and i fully anticipate using her ideas on suffering and how a nurse's spiritual beliefs and philosophical values may improve a chronically ill patient's ability to find meaning in his/her illness. Definitely going to use that in my concept paper this semester on Spirituality and Terminal Cancer Patients. more to come...