Sunday, July 31, 2005

A First-Year Story Resurfaces

Today I've been packing up nursing school books to send to my sister-in-law who starts her nursing classes this month (Yea!). While going through some old folders, I found this little paper from very early in first year. This was an extra-credit psych assignment to describe an experience where I used a method of therapeutic communication with a patient from clinicals. Exchanges like this are what keep you going when you're in nursing school. I think it might be an inspiring story for students and can also show more experienced nurses that nursing students can find awe even in the simple task of bringing someone a blanket.

D had been an unrestrained passenger in a motor vehicle collision. He was ejected and thrown 30 feet through the air and into the side of another vehicle. He had been badly injured and in the hospital for a month already when I cared for him.

He had a tracheostomy with a tent, and was completely unable to speak. His eyes often stared off into some unknown space, and then come back to rest on me, wide with anxiety and fear. Because of his neck brace, he was unable to nod or shake his head “no�. His level of consciousness was diminished in such a way that he did not attempt to mouth words, and even with the attentions of rehab care and speech therapists, could not communicate using any reliable yes/no method such as eye blinking or hand squeezing. But he could wave his hand.

The first time I saw it, I had no idea what to do. He was looking at me – his eyes wide like a terrified child. His right hand shook in a banjo-strumming motion. I asked him if he was in pain. No change. I asked if he needed to use the bedpan. No change. Still the hand shook, and I was becoming worried about what he may be trying to communicate. I asked the nurse to hurry in because I thought D needed something.

She said he was anxious and that he got this way when he was worried. She asked him to point to where the problem was, and the strumming moved lower. She asked if he needed to use the bedpan, or if he needed to be cleaned. The strumming got faster. More urgent. “OK� she said, “we’ll clean you up.� And when we rolled him over, there was a small poop down there. It sounded to me like during certain times he was more oriented than others, and the idea of soiling himself caused him a great deal of distress. Now that I had seen it, I felt I could try to communicate if it happened again.

The next time he started waving his hand, I asked questions. “Do you have pain?� No change. “Do you need suctioning?� No change. D put his hand on his chest and then up in the air again to banjo-strum. “Does your chest hurt?� “Do you want another blanket?� The hand moved furiously and his eyes opened wider. “Ok, so you want another blanket, you are cold?� He reached over toward me with the strumming hand. I took his hand and said “Let me go get you a warm blanket.�

When I returned with two pre-warmed blankets, I rolled one out over him pulling it up near his chin, and put another over his feet. “Is that what you wanted?� “Does that feel better?� The hand no longer shook. In answer I got the biggest smile I’d ever seen (think of the guy on the Enzyte commercials). I had to laugh. “I’m so glad that was it. You just let me know whenever you need something, and we’ll work it out until I can see you smile like that all the time.�

There are no communication methods I could recommend for use with D. The easiest way to communicate was to take the time to get to know him and learn how he used his body to tell a story. I was happy to see him two weeks later on the day he was headed to rehab. He still had the trach tube in, but he could whisper. He seemed much more oriented, and recognized me when I went in to tell him hello and how happy I was for him that he was recovering so well. I had enjoyed caring for him, because I was able to be with him one-on-one and he gave me a great learning experience (both in communication and practical skills), and I was able to give him the attention he needed to help alleviate his anxiety and fear. Even though communication was always tough, with practice I became familiar with his different states. I was pleased, and felt I had given him good care.
Posted by HypnoKitten at 11:06 PM

Blogger shrimplate, at 8:14 AM  

My 1st hospital job was as a nurse aide on a "nursing home" floor. We had permanent assignments, so I worked with "L" every day I was on the job. Because of his stroke he could only say "masoo" but he could say it a little differently to indicate different things.

Sometimes masoo meant "can I please have the newspaper" and sometimes it was a bathroom indicator, as just two examples. We all just learned what he meant in various contexts/situations.

Astonishingly, he was able to sing the words of entire songs, like "Bye Bye Blackbird," but he could not talk. A neuro nurse might be able to explain this to me, but my guess is that singing doesn't come from the Broca area.

Anonymous marj, at 2:11 PM  

Great story. :) And by the way, thanks for organizing links to nurse blogs. I'm starting to feel a real sense of community from nurses online!

Blogger Nurse Practitioners Save Lives, at 2:21 PM  

It is amazing what we can accomplish if we take the time to pay attention to our patients. Being unable to communicate has got to be a living hell for patients. We must be aware but by graces that we may be there ourselves one day.. Great job!

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