Clinical Narrative
During my interview for the 2011 Graduate Nurse Residency Program, the interviewer posed the question, “How would you define yourself as a nurse?” Totally unabashed and with uncharacteristic confidence, I responded, “That I’m a rock star.” One might wonder how being a rock star translates to nursing, but that term encompasses every aspect of being an expert nurse (Benner, 1984). The rock star nurse understands the big picture. Her performance is fluid and flexible. Based on experience, the rock star anticipates what to expect and easily modifies plans to best care for the patient (Nursing Theorists, 2013).
Despite my brazen declaration of rock stardom, I was a novice. I relied on book knowledge and followed procedures to formulate treatment plans. My patients were adequately cared for, but I craved to be the nurse that performed in a show-stopping manner. After working in the Intermediate Medical Care Unit and transitioning to the Post Anesthesia Care Unit, I gained experience and developed an invaluable nursing sense that acted as my compass through torrential seas.
Despite my brazen declaration of rock stardom, I was a novice. I relied on book knowledge and followed procedures to formulate treatment plans. My patients were adequately cared for, but I craved to be the nurse that performed in a show-stopping manner. After working in the Intermediate Medical Care Unit and transitioning to the Post Anesthesia Care Unit, I gained experience and developed an invaluable nursing sense that acted as my compass through torrential seas.
Embracing my rock stardom became evident on a call night when various situations pulled me in multiple directions. A coworker and I were called in at 7:00 P.M. and after seeing the list of surgical cases, I knew a storm was brewing. On a typical call night, two nurses have one to three patients. Tonight, six patients were already scheduled. I took a deep breath and said, “It’s go time.”
Immediately, I assumed care of a laparoscopic cholecystectomy whose recovery was smooth. Then, the night grew busier. My colleague was preparing to recover another laparoscopic cholecystectomy while I was getting ready to receive a man in his 80s who had an intramedullary (IM) nailing for a broken hip. At the same time, a patient arrived to PACU from the Emergency Department for an appendectomy. I helped my coworker by anticipating the patients needs after a cholecystectomy, looked up my IM nailing patient who seemed to be a straightforward case, and figured I would assist the OR nurse by gathering the pre-operative paperwork and taking vital signs.
The patient was a young woman in her 30s. Her vital signs were temperature of 39 degrees Celsius, oxygen saturation of 86%, a systolic blood pressure in the low 90s, heart rate in the 120s, and mild pain (unbeknownst to me, she had received morphine in the ED). Even though I was merely helping the OR nurse, I knew the patient required speedy interventions. Intuitively, I put her on oxygen and titrated to keep her saturation greater than 92%. Then I asked the surgical team if they would like me to give the patient fluid based on the heart rate and blood pressure, and possibly some IV Tylenol and/or antibiotics for the temperature. The surgical attending agreed and the interventions were put into play.
A few moments later, I had a family member call from the waiting room and express that he was very angry due to unfair treatment and “blatant” disrespect, even threatening to take legal action. I listened to his concerns, realizing that he was frustrated. I asked him if there was anything I could do to help. He simply wanted to know the plan. I called the surgical team and OR nurse so that I could give him an estimated timeline. After I knew the plan, I shared it with the patient and family member, which diffused the calamitous situation. While the family member was still upset, dealing with his frustration in a calm and collected manner was somewhat appeasing.
Then the patient in his 80s with a broken hip wheeled into recovery. He was suffering from post anesthesia delirium and attempting to climb out of bed. I reoriented him repeatedly, but his confusion was not improving. I sent my coworker to find family, but in the wee hours of the morning, nobody was available. At one point, he looked at me with ravenous eyes exclaiming, “I’ve got to get out. I’ve got to get out.” He was not sweet-talking his way out of the bed. Seeing as he was grimacing, I concluded that the patient could be in pain; I judiciously administered pain medicine. He calmed down for moments at a time, but then grew restless again. After bladder scanning, I knew the patient did not have urinary retention. With a menacing laugh, he continued to try to climb out of bed. Realizing that it could take hours or days for post anesthesia delirium to resolve, I knew the patient would not be safe returning to his room without being monitored. Still, restraints should be avoided because experience taught me that impulsive patients become agitated and more confused when tied down. I called the charge nurse on the floor and said that the patient would need a sitter.
While keeping my IM nailing patient safe and in bed, more patients transiently passed through the recovery room. At 3:00 A.M. our last patient finished surgery. The resident wanted to write discharge orders, but the patient was having a considerable amount of pain requiring high doses of opioids. I reasoned with the resident that it would be unsafe to discharge her. The patient also requested to stay. After advocating for the patient, she was admitted. At 4:30 A.M., I went home exhausted, but satisfied with the how I diffused multiple tremulous situations. I had achieved rock star status.
Immediately, I assumed care of a laparoscopic cholecystectomy whose recovery was smooth. Then, the night grew busier. My colleague was preparing to recover another laparoscopic cholecystectomy while I was getting ready to receive a man in his 80s who had an intramedullary (IM) nailing for a broken hip. At the same time, a patient arrived to PACU from the Emergency Department for an appendectomy. I helped my coworker by anticipating the patients needs after a cholecystectomy, looked up my IM nailing patient who seemed to be a straightforward case, and figured I would assist the OR nurse by gathering the pre-operative paperwork and taking vital signs.
The patient was a young woman in her 30s. Her vital signs were temperature of 39 degrees Celsius, oxygen saturation of 86%, a systolic blood pressure in the low 90s, heart rate in the 120s, and mild pain (unbeknownst to me, she had received morphine in the ED). Even though I was merely helping the OR nurse, I knew the patient required speedy interventions. Intuitively, I put her on oxygen and titrated to keep her saturation greater than 92%. Then I asked the surgical team if they would like me to give the patient fluid based on the heart rate and blood pressure, and possibly some IV Tylenol and/or antibiotics for the temperature. The surgical attending agreed and the interventions were put into play.
A few moments later, I had a family member call from the waiting room and express that he was very angry due to unfair treatment and “blatant” disrespect, even threatening to take legal action. I listened to his concerns, realizing that he was frustrated. I asked him if there was anything I could do to help. He simply wanted to know the plan. I called the surgical team and OR nurse so that I could give him an estimated timeline. After I knew the plan, I shared it with the patient and family member, which diffused the calamitous situation. While the family member was still upset, dealing with his frustration in a calm and collected manner was somewhat appeasing.
Then the patient in his 80s with a broken hip wheeled into recovery. He was suffering from post anesthesia delirium and attempting to climb out of bed. I reoriented him repeatedly, but his confusion was not improving. I sent my coworker to find family, but in the wee hours of the morning, nobody was available. At one point, he looked at me with ravenous eyes exclaiming, “I’ve got to get out. I’ve got to get out.” He was not sweet-talking his way out of the bed. Seeing as he was grimacing, I concluded that the patient could be in pain; I judiciously administered pain medicine. He calmed down for moments at a time, but then grew restless again. After bladder scanning, I knew the patient did not have urinary retention. With a menacing laugh, he continued to try to climb out of bed. Realizing that it could take hours or days for post anesthesia delirium to resolve, I knew the patient would not be safe returning to his room without being monitored. Still, restraints should be avoided because experience taught me that impulsive patients become agitated and more confused when tied down. I called the charge nurse on the floor and said that the patient would need a sitter.
While keeping my IM nailing patient safe and in bed, more patients transiently passed through the recovery room. At 3:00 A.M. our last patient finished surgery. The resident wanted to write discharge orders, but the patient was having a considerable amount of pain requiring high doses of opioids. I reasoned with the resident that it would be unsafe to discharge her. The patient also requested to stay. After advocating for the patient, she was admitted. At 4:30 A.M., I went home exhausted, but satisfied with the how I diffused multiple tremulous situations. I had achieved rock star status.
References
Benner, P. A. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley
Nursing Theorists (2013, September 9). From novice to expert: Patricia E. Benner. Retrieved July 12, 2014, from http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html
Benner, P. A. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley
Nursing Theorists (2013, September 9). From novice to expert: Patricia E. Benner. Retrieved July 12, 2014, from http://currentnursing.com/nursing_theory/Patricia_Benner_From_Novice_to_Expert.html
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