Nursing histories for better patient care

The article about patients not recalling their medications brought back many memories from when I was working in the hospital. When patients are admitted, nurses do a nursing history that is quite similar to the medical history, but with a different goal. Although the patients have already been asked many questions, our questions were geared towards helping us understand our patients to be able to give good patient care. The more we learned about our patients, the better we could care for them.

One question that would get a lot of confused answers would be “what medications are you on?” So many patients, especially the older ones, would say, “the white one for diabetes, the blue one for high blood pressure…” Trying to track down which medication and which dosage wasn’t always easy. Challenging would be a good word. :-)

Other questions we asked were sometimes met with suspicion. We would ask what the bowel and sleeping habits were normally. I remember some families members getting really upset over these questions. The stress of their loved one being ill, the stress of the admission and all that went into it, and now they were being asked questions that seemed useless to them. I would explain knowing what is usual at home helps us a lot in the hospital. For example, if we have admitted someone who only has a bowel movement every three days, we’re not going to start pushing laxatives after 24 hours. If a patient usually stays up until 2 a.m., we’re not going to worry if they’re still awake at midnight.

Even questions such as if someone lived alone, if there were stairs in the home, and about living arrangements. These are all important issues. Nurses need to know what people are like at home in order to judge if they are having problems in the hospital. Equally important, nurses need to know what type of living situation the patient is going to be discharged to.

Most of us are aware that by the time we are doing the nursing assessment and nursing history, the patients have been poked and prodded more than they thought was humanly possible, and they have been asked questions until they can’t think straight any more. But, it’s also important to remember that nurses have a different take on patient care and the answers patients give nurses are for different goals than the answers patients give doctors.

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What do nurses really do?

When I went to college to study nursing in 1978, my brother’s friend, a bright engineering student, asked me in all seriousness, “What do nurses do?” Not long ago, someone I was chatting with told me that she had never realized what nurses did until her mother was dying in the hospital. This person was in her early 50s. From 1978 to 2007 is a generation and yet there are still people who don’t know what nurses are do.

I guess it can be expected. People don't usually encounter nurses unless they're in a stressful situation and they only see the obvious, not anything that happens behind the scenes. On TV, nurses receive very little true attention. Either we’re portrayed as bimbo sex objects, doctor hand-maidens, or non-existent (as in the show House).

It’s funny because I do enjoy House very much – it’s a show I don’t like to miss – but in that show, it’s not only nurses who are non-existent, it’s the orderlies, the radiation technologists, and all the other healthcare professionals who help a patient recover while in hospital.

When was the last time, in real life, that doctors in a hospital knew exactly where the medications were and gave them to patients, did all the tests that they do in the show (for example, without any assistance in the cath lab or while the patient is having an MRI), transport patients from place to place, and all the other stuff they’re portrayed as doing on that show? I do recall one scene when one of the doctors told a nurse to do something and she countered with a question; she was told to just do as she was told. Oh boy.

On other shows, nurses are portrayed as women (almost always women) who do only what they’re told, without question. The only exception I recall is the series ER, where nurses, men and women, show that they have a brain.

So, what *do* nurses do? Unfortunately, because of the severe nursing shortage, whatever they are supposed to do, they often don’t have the time to do it all, or to do it as thoroughly as they would like.

The big difference between doctors and nurses is that doctors treat the illness and nurses treat the person. If a person has broken leg, the doctor is concerned, and rightly so, about getting that leg healed. It could be through surgery, casting and traction, casting only, or whatever the orthopedist feels is the correct way. The nurses have other priorities.

Nurses are concerned with the patient’s pain level, the correct placement of the traction as ordered by the doctor, the cast being fit properly and not causing problems with the foot and toes, the immobility causing problems with skin integrity (bedsores), lack of appetite, difficulty going to the bathroom, psychological well-being, and numerous other things. They report back to the doctor the patient's progress and if they notice any problems that they can’t handle or they need medical interventions.

It’s the nurses who observe the patient 24 hours a day, 7 days a week. They keep the records and are able to tell the doctors if there is increased pain, decreased pain, if the patient seems to be getting depressed, if he or she isn’t eating properly, if a foot seems to be getting a bit more swollen every day, and anything that is observed for more than just a few moments.

Nurses don't only care for people, but prevent complications from happening. That is probably the best way I can describe it. When they can, nurses also provide emotional support by being there and listening. They teach and try to help people who have just learned they have diabetes or cancer, or they help someone learn how to cope with a newly dependant parent. Oh yeah, and nurses save lives. Literally. From performing CPR until the crash team arrives to noticing subtle changes in a patient’s status, nurses save lives. Many of them.

A nurse is a person of all trades. When the dietician isn’t around, it’s the nurses who have to convert meals for the patients with diabetes, when the physios aren’t around, it’s the nurses who help the patients with their exercises, when the respiratory techs aren’t around, it’s the nurses who help the post-operative patients do deep breathing and coughing to clear the lungs. There is so much that a nurse does that isn’t seen by the public and probably never will be.

I do admit that there are men and women who shouldn’t be in nursing and give the profession a black eye – just as there are in every profession. The problem is that we’re so visible and out there that if a nurse or nurses give bad care, it gets broadcast quickly. If a nurse does a good job, it often goes unnoticed because everything has gone as smoothly as possible.

So, I guess this is a plea for a bit of understanding. Nurses are not miracle workers but they have been known to perform what could be seen as miracles sometimes.

Work injury for writers?

When we think of injuries in the workplace, we often think of lifting something and hurting your back, or a traumatic type of injury for construction workers. As a nurse, many of my co-workers had back injuries (as I did), but also managed to hurt various limbs from getting a bad bang against a piece of equipment or something like that.

Writers – and others who use the computer for long periods of time – can also get hurt if we’re not careful. Carpal tunnel and repetitive stress syndromes cause a lot of workplace pain and absence.

According to the US Department of Labor, repetitive motions such as those made by people who use computers or tools, or who are cashiers, have the highest rate of lost work days per year due to repetitive stress: a median of 23 days in 2002. That’s a significant number of lost work days, especially if you compare it to other injuries such as falls to a lower level (14 days), fires and explosions (12 days), transportation accidents (12 days), falls on the same level (9 days), over exertion (8 days) and so on.

Most times, repetitive motion disorders are easily prevented but not many people, including myself, take the proper measures to prevent it. Carpal tunnel syndrome itself isn’t always caused by repetitive stress though. The median nerve, which controls the palm side of the thumb and the fingers, runs from the forearm to the hand. When pressure is placed on the median nerve, it can cause irritation, swelling, or compression. The pressure can be caused by a variety of things, such a sprain or fracture to the hand or wrist, diseases like arthritis, or by work stress and repeated use of the hand in the same manner.

As with most injuries, the earlier carpal tunnel or a repetitive stress syndrome is diagnosed, the better it is for successful treatment. To check for carpal tunnel, besides a regular physical exam, a doctor checks for tenderness, swelling, and warmth in the area. Strength is important as well. There’s one way that a doctor can check on the spot as well. By placing the fingers on the median nerve, or tapping it, if you have carpal tunnel, you should feel a strong shock-like sensation, or at the very least, a tingling sensation.

A nerve conduction test may be an option. Electric shocks (small ones!) are sent to the nerve and the conduction time is measured.

Sometimes medications can help reduce the swelling and pain. Some doctors may inject a steroid or anesthetic medication directly into the painful area. Physiotherapy may be helpful for some people, to help stretch and strengthen the wrist. Surgery for carpal tunnel now is very common. It’s done with a local anesthetic.

Of course, the best treatment is for it not to happen at all, right? That means taking the advice of the experts who are trying to keep us from injuring ourselves. Don’t type non-stop for hours on end. Take frequent breaks and stretch your arms, hands, and wrists. Be sure your keyboard is at the correct height for your hands. Wear splints to keep your wrists straight if you have to. Keep your hands warm, even if it means wearing fingerless gloves. Be careful, if you’re pounding out the articles to make a living, unless you want to use speech recognition software exclusively, take care of those hands!


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