[CLINICAL ROTATION] Patient by Patient

 

 

Patient by Patient

On busy days, it can be easy to flit from patient to patient with a laser focus on what our patients “need” in the moment, meeting that need, making sure the call bell is within reach, and heading off to the next patient, or call bell.  On those days, it is important to remember that what all of our patients needs is personalized care, therapeutic communication and the feeling that they have been listened to and heard.

This week we seemed to have a number of crotchety and uncommunicative patients.  That kind of patient can really make the day longer and more challenging.  Talking with patients who just want us out of their space for whatever reason can be difficult.  I had a wonderful conversation with my patient’s partner who was also a cancer survivor.  She had popped in on her way to Rochester for a biopsy.  Her boyfriend, my patient, was a completely different story.  He wanted nothing to do with me.  He was relatively tolerant of my necessary assessments, but wanted to lay back, enjoy the morphine drip and nap in peace.  Even his physicians wanted him to go home, but –with no roommate- the hospital environment was pretty chill riding the opioid pony.  The only real distraction was me.

In these situations, I think that it is important for me to remember that all patients have individualized needs.  Although I have an assessment sheet that I am anxious to fill with details that are important to personalize my care, that sometimes that means care from a distance.  Re-approaching, re-framing, and re-phrasing during hourly rounds to address questions and concerns sometimes doesn’t draw a patient out.  In those cases, providing care with respect to their desire to be left alone is also part of nursing and frees us up to pop into other rooms and ask how people are doing and if they need anything.  Nursing care is determined patient by patient.

It was comforting to hear some of the other stories from fellow students in post-conference of their patient experiences.  It seemed like it was just “that kind of day.”  It was also encouraging to hear about some of the brilliant successes that fellow students had, as well. 

Going into next week, I am looking forward to the opportunity to take on more patients, to get in another med pass and to have my observational experience.  So much to look forward to as I reflect on the near-misses and successes of the week.

Wishing you a wonderful weekend. 

Be well.

 

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New Semester, New Rotation Venue & Excitement vs. Nervousness

Student NurseOn a physiological level, excitement and nervousness act very similarly in the body.  Starting clinical rotation in a new venue with a new instruction and a different group of students produces both…

Our car-poolers were no different than I was heading up to the medical center.  Were we going to find our way there?  How were we going to navigate the car park, the supply rooms, the med-surg floor?

Fortunately, we were met with a great deal of help and support.  There was less nail-biting once we met our preceptor, our guide-nurse and received our fancy student badges.  (Huzzah!)  We were reassured that we were not in it alone, that we would encourage each other and come to rely on the strengths and support of our cohorts who will, inevitably, become some of our closest allies this semester…

It is an exciting semester that we begin.  Fresh.  Newbies.  Probies.  Attending to the needs of our clients and delving into unexplored areas of learning.  It is a challenge and an opportunity and reframing our nervousness as excitement is the first step to walking confidently into a patient’s room and being the support that our clients need us to be

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[OPPORTUNISTIC LEARNING STRATEGY] Pharm-mercials & Pharm-marketing

ImageThey’re everywhere.  You’ve seen them, ignored them, recycled them and changed the channel on them.  They… are pharmaceutical ads.

Pharmaceutical companies spend exponentially more money and other resources on medico-marketing then they do on research.  Over $57 billion per year (that’s billion, with a “b”) in 2005.  “Pharmarketing” is highly controversial.  However, it’s ubiquitous nature can be a beneficial to the opportunistic student. 

When a moment (or ad) presents itself, read, or listen up.  Review the drug trade and generic name, side effects, contraindications… Repetition via different media, at different times, in varied locations reinforces learning and memory. 

Another benefit?  Some of the most frequently prescribed drugs and those that are being pushed out the hardest by pharmaceutical companies are the meds in the media that also end up in your med pass. In nursing, learning must be continual to stay up to date on changes and advances in evidence based practice, in protocol, in research… New developments  arise every moment of every day.  Creating a habit of catching learning opportunities can be a powerful tool to keep in your nursing bag throughout your career as a nurse. 

So next time a pharm-mercial pops on, or a full-page magazine ad presents itself; listen up, give it a quick scan and solidify your learning on-the-go!

Human Connection in Oncology: The Importance of Empathy in Nursing Care

When contemplating social events, we will commonly ask each other, “Are you going to be there?” We like to know that individuals whom we enjoy will likely be present at the same events. When we anticipate life events that have uncertainties to them, we like to know that someone whom we trust and who we have reason to believe cares about us, will be in the life event with us. Treatment for cancer is one of those life events. Patients want to know who will be there with them. Patients are most assuredly interested in the forms of treatment available to them, but they especially want to know that they matter to others, including those who are administering their cancer treatment. Part of what makes an oncology nurse’s care effective is the nurse’s willingness to be there with a cancer patient, to connect with and care about the patient and about the patient’s life and illness. This human connection between an oncology nurse and a cancer patient and the patient’s family is now being identified in studies as what is most memorable about treatment and what is most sustaining to families whose family member did not survive the disease. Patients and families describe oncology nurses with adjectives including kind, supportive, informative, and trustworthy.1-3 What is it about the oncology nurse and the nurse’s care that is so sustaining to patients or to their survivors that it is reported as a source of comfort by patients and families for years after the actual care experienced?

Fortunately, what patients and families refer to is the most common of all elements of oncology nursing care: the human connection. This connection is the interface between nurse and patient; nurse and family members; nurse and other clinical care team members; nurse and ideas about care; and between the nurse and self-images, including self-compassion and forgiveness. A desire to form human connections is a motivation for becoming an oncology nurse; the human connection between the oncology nurse and the patient and family can offset difficult relationships with peers, disappointments with leaders, and even the irritations of inconsistently available resources and supplies for care.4 The disappointment in self for not being able to form such connections well (or to be there for patients and for families) has been one of the reasons for oncology nurses choosing to exit oncology nursing. This human connection between the oncology nurse and the patient and family is sustaining for the patient, the family, and for the nurse and is a treatment intervention. Amazingly, we know some of the outcomes of the human connection as a treatment because of patient and family reports, but we do not know the critical components of this human intervention in fine detail or the factors (environmental, personal, professional, or clinical) that influence the ability of the oncology nurse to deliver this treatment.

There is no form of mainstream cancer treatment (chemotherapy, radiotherapy, surgery, biotherapy) and no level of cancer prevention that is unaffected by the human connection between the oncology nurse and the patient or family. Cancer treatments have focused increasingly on the smallest elements of the human body (ie, genes, polymorphisms), but the usefulness of these smallest elements in cancer treatment will be dependent on oncology nursing care and the human connection between the oncology nurse and the patient. To be effective, treatment needs to be acceptable, understandable, and described in a way that resonates with patients’ life priorities. The acceptability of treatment relies on the ability of the oncology nurse and that of other clinicians to make a human connection with patients such that we can prepare them well for the experience of treatment in terms of what it could mean for their lives.

When we reflect on the human connections in our oncology nursing practice, our reflections include clinical interactions that were remarkably positive (the peak experiences) or memorably negative (the nadir experiences). The emotion that accompanies these reflections can be powerful enough that we reexperience the emotion with the recalled memory and move quickly and with purpose to end the reflection and instead focus on the next life event. By suppressing the memory and the emotion and moving doggedly to the next life event, we miss a sure chance to learn from ourselves the mystery of how it is that oncology nursing makes the human connection with patients and their families that proves to be the sustaining, memorable part of treatment. Instead of not attending and analyzing the human connection, let us study this element of our practice that gives such sustenance to others as well as to ourselves. How and when are such human connections made? What are the patterns across such human connections? What are the common elements in these connections, and are they common enough that they could be titrated to benefit different patient situations? How are these human connections maintained between a nurse and a patient? What environmental, personal, professional, or clinical factors influence the human connection in positive or adverse ways? The human connection in oncology nursing needs careful study, but in the interim we will continue to be there for oncology patients and their families, for our colleagues, and for ideas that will improve our care.

 

References

1. Zamanzadel V, Azimzadeh R, Rahmani A, et al. Oncology patients’ and professional nurses’ perceptions of important nurse caring behaviors. BMC Nurs. 2010;9(10). http://www.biomedicalcentral.com/1472-6955/9/10. Accessed November 14, 2010. [Context Link]

2. Masood J, Forristal H, Cornes R, et al. An audit of patient satisfaction with uro-oncology nurse specialists-a questionnaire study. Int J Urol Nurs. 2007;1(2):81-86. [Context Link]

3. Van Rooyen D, le Roux L, Kotze WJ. The experiential world of the oncology nurse. Health SA Gesondheid. 2008;13(3):18-30. [Context Link]

4. Steen B, Burghen E, Hinds PS, et al. Development and testing of the role-related meaning scale for staff in pediatric oncology. Cancer Nurs. 2003;26(13):187-194. [Context Link]

CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT

SKIN, HAIR AND NAILS
Skin pink, warm, dry and elastic.  No lesions or excoriations noted.  Old appendectomy scar right lower abdomen 4 inches long, thin, and white.  Sprinkling of freckles noted across cheeks and nose.  Hair brown, shoulder length, clean, shiny.  Normal distribution of hair on scalp and perineum.  Hair has been removed form legs, axillae.  Nails form 160 degree angle at base, are hard, smooth, and immobile.  Nailbeds pink without clubbing.  Cuticles smooth, no detachment of nailplate.  Hands well-manicured with clear enamel.                                                           

HEAD AND NECK
Head symmetrically round, hard, and smooth without lesions or bumps.  Face oval, smooth, and symmetrical.  Temporal artery elastic and nontender.  Temporomandibular joint palpated with full range of motion without tenderness.  Neck symmetric with centered head position and no bulging masses.  C7 is visible and palpable with neck flexion.  Has smooth, controlled, full range of motion of neck.  Thyroid gland nonvisible but palpable when swallowing.  Trachea in midline.  Lymph nodes nonpalpable.

EYE AND EAR
Acuity by Snellen chart O.D. 20/20, O.S. 20/20.  Visual fields full by confrontation.  Extraocular movements smooth and symmetric with no nystagmus.  Evelids in normal position with no abnormal widening or ptosis.  No redness, discharge, or crusting noted on lid margins.  Conjunctiva and sclera appear moist and smooth.  Sclera white with no lesions or redness.  No swelling or redness over lacrimal gland.  Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities.  Irises are round, flat, and evenly colored.  Pupils are equal in size and reactive to light and accommodation.  Pupils converge evenly. 
Ears are equal in size bilaterally.  Auricles are aligned with the corner of each eye.  Skin smooth, no lumps, lesions, nodules.  No discharge.  Nontender on palpation.  Small amount of moist yellow cerumen in external canal.  Whisper test : patient repeats 2 syllable word.

MOUTH, THROAT, NOSE, AND SINUS
Lips pink, smooth, and moist without lesions.  Buccal mucosa pink, moist, and without exudates.  Stensen/s ducts visible with no redness or swelling.  32 white to yellowish teeth present.  Gums pink without redness or swelling.  Protrudes geographic tongue in midline with no tremors.  Equal bilateral strength in tongue.  Ventral surface of tongue smooth and shiny pink with small visible veins present.  Frenulum in midline.  Soft palate smooth and pink.  Tonsillar pillars pink and symmetric.  
Nose somewhat large but smooth and symmetric.  Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does not obstruct airflow.  Inferior and middle turbinates dark pink, moist, and free of lesions.  No purulent drainage noted.  Frontal and maxillary sinuses  are nontender to palpation and percussion.

THORAX AND LUNG
Respirations 18/minute, relaxed and even.  Anteroposterior less than transverse diameter.
Chest expansion symmetric.  No retraction or bulging of interspaces.  No pain or tenderness on palpation.  Tactile fremitus symmetric.  Percussion tones resonant over all lung fields.  Vesicular breath sounds auscultated over lung fields.  No adventitious sounds present.

BREASTS AND LYMPHACIC
Bilateral breasts moderate in size, pendulant, and symmetric.  Breast skin pale, pink with light brown areola.  Nipples everted bilaterally.  Free movement of breasts with position changes of arms and hands.  No dimpling, retraction, lesions, or inflammation noted.  Axillae free of rashes or inflammation.
No masses or tenderness noted on palpation.  Bilateral mammary ridge present.  No discharge noted from nipples.  Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable.  Demonstrates appropriate technique for BSE.

HEART AND NECK VESSELS
Carotid pulse equal bilaterally, 2+, elastic.  No bruits auscultated over carotids.  Jugular venous pulsation disappears when upright.  Apical  impulse palpated in the fifth ICS at the left MCL.  Apical pulse- 70 beats/minute, regular rhythm, S1 heard best at the apex, S2 heard best at the base. 

ABDOMEN
Skin of abdomen is free of striae, scars, lesions, or rashes.  Umbilicus is midline and recessed with no bulging.  Abdomen is flat and symmetric with no bulges or lumps.  No bulges noted when patient raises head.  No peristaltic movements seen.  Soft clicks and gurgles heard at a rate of 15 per minute.   Percussion reveals generalized tympany over all four quadrants.  No tenderness or guarding                                 in any quadrant with light palpation.  Umbilicus and surrounding area free of masses, swelling, and bulges.

MALE GENITALIA
pubic hair growth pattern is normal for adult male: pubic hair and base of penis are free of excoriation and infestation.  Circumcised penis is free of rashes, lesions, and lumps and is soft, flaccid and nontender on palpation.  Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no discharge is palpated from urinary meatus.  No masses or swelling noted in scrotum and left side hangs slightly lower than right side.  Skin is free of lesions and appears rugated and darkly pigmented.  Two descended testicles palpated.  No swelling, tenderness,or masses palpated along the testicle.  No bulges or masses palpated in inguinal or femoral canal. 

FEMALE GENITALIA
Normal hair distribution, no lesions, masses, or swelling.  Labia majora pink, smooth, and free of lesions, excoriation, and swelling.  Lania minora dark pink, moist, and free of lesions, excoriation, swelling or discharge.  No discharge from urethral opening.  No malodorous discharge noted from vagina. 

ANUS AND  RECTUM
The anal opening is hairless, moist, and closed tightly.  Perinanal area is free of redness, lumps, ulcers, lesions, and rashes.  No bulging of lesions appear when the patient performs the Valsalva maneuver.  Patient can close external sphincter around gloved finger.  Anus is smooth, nontender, and free of nodules and hardness. 

PERIPHERAL VASCULAR
arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally.  Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally.  No epitroclear lymph nodes  palpated.  Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers or edema.  Legs are warm bilaterally.  Femoral, popliteal, dorsalis pedis, and  posterior tibial pulses strongly palpated bilaterally.  No apparent varicosities or superficial thrombophlebitis noted.

MUSCULOSKELETAL
Gait smooth, with equal stride and good base of support.  Full ROM of TMJ with no pain, tenderness, clicking or crepitus.  Sternoclavicular joint midline with swelling or redness.  Normal curves of cervical, thoracic, and lumbar spine.  Paravertebrals nontender.  Full smooth ROM of cervical and lumbar spine.  Upper and lower extremities symmetric  without lesions,nodules, deformities,or swelling.  Full smooth ROM against gravity and resistance.

NEUROLOGICAL
Cranial Nerves:
1. Identifies correct scents
2. Vision 20/20 OS, 20/20 OD, full visual fields
     intact.
3,4,6 No ptosis, full extraocular movements (EOM)
    pupils equally round, react to light and   
    accommodation (PERRLA)
5. Temporal and masseter muscles contract                  

                   Bilaterally.  Able to identify light, sharp, dull
            touch to forehead, cheek, and chin.  Corneal
            reflex present.
        7. Able to smile, frown, wrinkle forehead, show
            teeth, puff out cheeks, purse lips, raise eye-
            brows, and close eyes against resistance.
        8. Wispered 2 syllable words heard bilaterally.
        9 and 10.  Uvula and soft palate rise symmetrically
           on phonation.  Gag reflex present.  Swallows
           without difficulty. 
        11. Equal shoulder shrug against resistance;
               turns head in both directions against
               resistance.
         12. Protrudes tongue in midline with no tremors,
               able to push tongue blade to right and left with
               no difficulty.

Motor and Cerebellar System

No atrophy, tremors, weakness, full ROM of all extremities.  No fasciculations, tics, or tremors.  Gait and tandem walk normal and steady.  Negative Romberg test.  Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs each heel down each shin with no deviation.

Sensory System

Identifies light touch, dull and sharp sensations to trunk and extremities.  Vibratory sensation, stereognosis, graphesthesia, two-point descrimination intact.

Reflexes

Reflexes 2+ bilaterally, except Achilles 1+.  No Babinski
present.