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.
Maternity Clinical Journal
Day One
Monday was our first day on the floor at Seton Main's Maternity Unit. I started the semester off with a rotation to the Mother/Baby unit. I think it was a really gentle introduction to maternity for me. I had been concerned with my emotional stability because of my somewhat traumatic personal maternal history. But our first day was really great, and I think things will go just fine. I was paired with Patty, who is a fantastic nurse, and we got to talk a lot about nursing, maternity, hospice, and everything in between. It turns out that her senior paper for nursing school is nearly identical to the topic I just chose for my concept analysis paper! It was really neat to connect with another nurse like that.
We started my shift by going through and checking on her two patients. The first one had a c-section so we were helping to manage her pain. She was hesitant at first to take the 'heavier' pain medicine because she said she didn't want to get addicted. Patty did a really good job of explaining to her that as long as her body needs it, she won't get addicted. She also explained that we need to keep her pain managed so that we can get her up so that she will recover quicker. I also got to watch her help the new mom with breastfeeding. She was teaching her that it is best to wait until her baby opens up his jaw really wide before latching so that he gets a bigger part of the breast, and not just the nipple. Patty was a wealth of information, and had such a great demeanor and easy rapport with the patients. One patient's husband made a comment asking if she could just stay for another 48 hours until they left!
Throughout my shift, I mostly followed my nurses, but I did get to feel a fundus (two of them, actually!) when my second nurse was doing her assessments at the beginning of her shift. The first fundus was a little boggy, so I massaged it and, sure enough, it tightened up again! I think that is one of those things that doesn't seem like it works until you see it. (or feel it, rather) Later in the evening I watched one newborn assessment and saw a little petichiae on one of the baby's faces. Other than that, there were no irregularities. I also held a newborn baby boy that was being given up for adoption. The mother had already left the hospital, but the adoption wouldn't be finalized until the end of the following day, so the baby was just being watched in the nursery. It made me kind of sad that he was just sleeping in his basket with no one holding him or even touching him. When my nurse left me in the nursery for a minute, I decided to pick up the little boy and give him a little human contact. I held him for a good five minutes, and I would like to think it might have given him a little comfort.
All in all, I really enjoyed my clinical day. I was impressed with how pleasant and encouraging most of the nurses were. Both of the women I worked with had years of experience, and were just so gentle and knowledgeable. To borrow a term from psych- you could really feel the difference in the milieu of the floor compared to other med/surg floors. It was a nice change, and I can see how it would be really great to work in maternity.
PS. The same cute little girl who told us that the breast gave white milk, not chocolate was also pretending to be a nurse and checking her mom. She kept rubbing her belly and inspecting her arm. Then she said, “now I'm going to check your booby stars,” and started to try to lift up her pajama top. The mom had inverted nipples (we had talked about it earlier because she was having a hard time breastfeeding) and I guess that 'booby stars' is the term their family uses to describe it. I thought it was really cute! (cuz the nipples did sort of look like little stars!)
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