Week 5

The framework I am using is based on Doane, G. and Varcoe, V. (2005). Family Nursing as Relational Inquiry. Developing Health-Promoting Practice.

This situation occurred recently at work. This patient was a 42 year old man who was originally admitted for ETOH overdose and epistaxis (nosebleed). As his labs came back it was determined that his platelet count was 66 on admit, and had dropped to 43by the time I was assigned to his care (a normal platelet count is 150,000 - 450,000). Quite obviously, this guy was at serious risk of bleeding to death. However, he didn't seem to absorb this. He kept ripping out his IV lines, tearing off his cardiac monitor and wandering out of his room partially dressed, telling the staff he needed to go "check on my stuff, I'm going to be pissed if it's gone". I should add that by this time (day 5 of his hospitalization) he was no longer officially detoxing... that process had occurred mostly during the 3 days he spent ventilated in the CCU. When first assigned to him I was neutral on the situation, I'd just had 7 days off and didn't "know" any of the patients. During report nothing was said that would make me think he was going to be a "problem", in fact he'd slept most of the previous shift. I started my assessments with other patients who appeared to be less stable and figured I'd leave sleeping beauty till last for assessment. Of course, as I leave another patients room after assessing them, my patient is standing out in the hall dressed in a pair of jeans and a very bloody hospital gown.

"Hey W, what are you doing?" I call as I hurry over to his side. "I'm going to the ER" he replies. I'm looking at him thinking, why???? I'm busy (I have 5 other patients) and I can feel my stress level rising. "What'cha going to the ER for?" I say. "To get this fixed" he tells me, as he holds up his left arm, blood dripping steadily off of it onto the floor from his former IV site. "I can fix that for you here" I say, taking his right arm and trying to guide him back to his room. "Nope, I know them" he states as he heads off down the hall. I trot after him, talking a mile a minute, my attempts to get him back into his room futile as he swings into the ER, which is REALLY busy this particular evening. By now I'm frustrated. Everyone in the ER is looking at us as I try to explain what's going on. I catch the looks between a couple of ER nurses and interpret them to be saying, "sheesh, these Med-Surg nurses cannot control their patients", and I start to feel embarrassed. Finally one of the other nurses takes pity on me and helps me talk W back into his room.

I get him cleaned up, another IV started, (hospital regulations state only 2 pokes per nurse, it took 4 nurses before one of us could get a 2nd IV started), check the protocol and give him a healthy dose of lorazepam for agitation and anxiety. After taking his vitals and assessing him I check the clock. It's been 2 hours settling this guy down and I still have the rest of my patients to see, not to mention my charting, MAR checks, tele strips, etc..... needless to say I'm waaaay behind schedule and feeling frustrated, distressed and downright angry.

A couple of hours later and it starts all over again, but this time he wants to leave, go home and check on his "stuff". After a lengthy talk with me explaining over and over that he has a potentially lethal platelet count and could seriously bleed to death, it turns out that he really wants to go outside and have a cigarette. I don't have time for this but neither does anyone else.... so I capitulate and tell him I'll take him outside if he'll go back to bed afterwards and try to get some sleep. He agrees and sits down in a wheelchair for me to give him a ride.

We go out and as I stand waiting for him to finish smoking I'm literally steaming. My night is shot, it'll be a miracle of I get out on time in the morning, I'm tired, my feet hurt, and I'm spending my break watching this guy smoke. Can you say stressed out???? But then, he started to talk. "I appreciate your taking me out here. I haven't had a cigarette since I came in and I've really been wanting one" he tells me. "It's ok, but don't forget you promised to lay down and rest when we go back in" I say. "I remember", he sighs, "I've been having trouble relaxing because I'm worried that my stuff will be gone when I go back to my room". "I've been staying in a motel down the street and I don't know if they'll kick me out after a week of not paying the bill" he tells me. "Can you call someone to check on it for you?" I ask. "I can't call my friend from the room, it's long distance" he replies. I offer to call his friend for him and he actually smiles at me. "If you could do that I promise I'll lay down and behave" he says. All this poor guy wanted was for someone to go check on his stuff. I did as I told him I would, getting the number for his friend and calling and leaving a message for them. He held up his end of the bargain and laid down and behaved for the rest of my shift.

I'd felt frustration, anger, embarrassment, stress and more during this situation. Most of these emotions were contextual, and I think most of them were what most nurses would feel in the same situation. They did inform me of what other shifts probably felt while trying to take care of this particular patient, and they helped me decide how to relate this incident to the next shift, explaining to them that this patient was not bent on being non compliant, but he was concerned about his belongings and if they would take a few minutes to see if the message I left was answered then he would probably relax and allow his treatment to go forward.

In reflection, I didn't listen to my feelings during the situation. Had I done so, I probably would have let this patient leave the hospital AMA and go wandering down Highway 2 at 4 in the morning. Instead, I bit my tongue, put my work on hold and took the patient outside to smoke. By doing so I showed him that I cared how HE felt, I listened to his story, I empathized with his feelings and I did my best to alleviate his concerns. I think that most nurses value their patients feelings though often we don't have time to validate those feelings. By making the time for this patient I did the right thing, even though it put me behind on my other work.