A male patient, age 66, had been admitted to the hospital for heart failure and sepsis. He had been in the hospital for over a month and had recent CABG2 when I came to the Critical Care Unit clinical day for my first experience as a senior nursing student.
The patient had an extensive medical history including hypertension, diabetes mellitus, and coronary artery disease with lesions more than 75% occluded. The patient had been extubated two days prior to my clinical day, due to some improvement of his condition. However, his O2ox had started to steadily fall again and the doctor re-intubated the patient a couple hours before my arrival.
The patient also had hand restraints applied due to past attempts of tube removal. Hospital policy was that restraints were to be removed for at least 5minutes every hour. It was obvious from the moment I met the patient that he did not like the restraints as evidenced by pulling, attempting to furtively gesture and overall restlessness. He looked very uncomfortable and fearful. His eyes were darting around and he continually pushed the call bell for pain medication. He had been documented by previous shifts as being combative and confused.
Aside from medication administration during my shift, I had the opportunity to have quite a bit of spare time, as the census in the CCU was lower than normal. Having just one patient, who was relatively stable, is a luxury not normally experienced! With that spare time I rediscovered the skill of a complete bedbath and skin assessment.
I explained to the patient that I was going to remove his restraints and get him washed up. He nodded his head in understanding and was extremely cooperative. He could not talk, of course, due to intubation, but he could nod or shake his head. I kept up a steady stream of conversation as I went along. I noticed he had quite a few tattoos, which I commented on -- knowing that normally tattoos are a source of personal beautification and pride. I also noted that above his TV, which was not turned on, were a few hand-made construction paper cards with words of encouragement. "DON'T GIVE UP!" "WE LOVE YOU!" in very large letters. I remarked on those as well, asking if the cards were from grandchildren. He nodded yes and closed his eyes.
The patient noticeably relaxed during the bed bath, skin, cardio and neuro assessments. His heart rate had dropped a bit as well. I remarked that the incision on his chest was healing well. By the end, an entire hour had gone by! The patient was getting a bit drowsy. I asked him if he had any pain and he shook his head no. I let him know that I was going to re-apply his restraints and he just closed his eyes.
After I tied the restraints and adjusted his sheets and blankets, the patient grabbed my hand and did not let go. He looked me right in the eye. My first reaction was to let go after about five seconds, but he did not let go. He held on for (what seemed like) quite a while. I just let him do that. He then closed his eyes and breathed a deep breath. We stayed like that for quite a while.
I wondered why this patient had been called combative and confused. Granted, my time on the unit was short and rather "special", being a student, so perhaps it could be chalked up as a mere exception to the norm.
Shortly after, a respiratory technician came in to do a nebulizer treatment with the patient and immediately started shouting at him to CALM DOWN CALM DOWN! What was going on! I popped my head into the room, drew the curtain around us and asked what was up. The technician said that this patient was known to fight his treatments and he was just helping the patient to relax. His voice was not at ALL calming! I looked at the patient, who was looking at me, slightly bewildered and DEFINITELY confused and said to the technician, "he seems pretty calm to me -- why don't I stay here and give you a hand in case you need it?"
I stayed in the room, close by, not hovering but just being present. The treatment seemed to go well but the silence from the technician was uncomfortable as he went about his work. After the technician left, I again fluffed up the patients' blankets, wiped his face from sweat and gave him a smile. I gestured to the pretty construction paper card that advised: "Don't give up!" He gave a small smile in return.
As nursing students, we do many nursing diagnoses about Anxiety and our interventions include helping the patient to relax, utilize visualization and deep healing breaths. To my shameful admittance, I have never actually done any of my own interventions prior to this 5thsemester of nursing school.
It appears that a lot of seasoned nurses do not truthfully have time to acknowledge the human beneath the tubes and machines. Workload and required documentation seem to now define the patient in the bed. Words like "combative and confused" can lead to a correct diagnosis of compensatory shock but can also be an incorrect assessment of someone who is terrified, uninformed and shut off by the inability to speak.
What ways have you attempted / succeeded in treating the human response in a critical care situation?
