The Science of Nursing Meets the Art of Nursing
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* By Ellen Hill
I am telling this actual story from my perspective to give you the opportunity to envision the world of acute healthcare through the eyes and brain of a Registered Nurse (RN).
I have one hope: that it helps you to understand and appreciate the powerful contributions to healthcare that RNs make.
We are SO MUCH MORE than “the pill pushers” or “the person who follows the physician’s orders.”
We have a perspective of unparalleled breadth and depth that is steeped in SCIENCE (e.g., mathematics, chemistry, biology, psychology, and the like).
But we are also so much more, exemplifying the holistic ART OF NURSING (Body-Mind-Spirit): fierce patient advocates, tireless action-takers, endless strategizers, and dedicated team players.
How will you recognize us? We’re the ones wearing our hearts on our sleeves!!!
The young U.S. Army trainee, PVT Donnelly, lay drenched in sweat in a bed in the Intensive Care Unit (ICU).
He had sustained a traumatic injury several days previously while rappelling down a towering 50-foot wall. The combination of his improperly-fastened safety harness and his losing his footing while he was still 32 feet in the air resulted in a catastrophic fall. The horrific results included a closed head injury, a fractured pelvis, and a compound fracture of the right femur, which included shearing off of the head of the femur (aka, the acetabulum, or the “ball” part of the hip joint’s “ball and socket”).
He’d lay in the sleeting rain on the half-frozen muddy ground for nearly 45 minutes, becoming hypothermic, while the Drill Sergeant held pressure with his full body weight over the femoral area to staunch the bleeding. The Emergency Department (E.D.) had been contacted with the request to urgently send an ambulance and a few first responders were summoned STAT.
Upon arrival in the E.D., CPT Norris, the E.D. Physician immediately assessed and stabilized PVT Donnelly, then expeditiously contacted MAJ Finney, the Department Head for Orthopedics. He needed to refer the soldier’s care to MAJ Finney and to seek a decision from him pertaining to the PVT’s disposition (i.e., where PVT Donnelly was to be admitted and whether or not MAJ Finney would be taking him directly to the Operating Room (O.R.) or to the ICU instead)? MAJ Finney ordered a few imaging studies to determine the full nature of the injuries and grimly entered orders for PVT Donnelly to be admitted to ICU.
For starters, he required careful monitoring, including hourly vital signs with core body temperature, hourly neuro checks, hourly pulse checks of his right leg and foot, continuous EKG and pulse oximetry readings, transfusions of 2 units of packed red blood cells (PRBCs) and IV fluids, serial blood draws for lab tests (Complete Blood Count [CBC] and a panel of 21 Chemistry blood tests [Chem-21]), administration of IV antibiotics, careful tracking of urinary output, oxygen at 2 Liters Per Minute (2LPM) flow rate, and pain management.
Shortly after PVT Donnely’s transfer to ICU at nearly 7 PM, MAJ Finney greeted me warmly,
“CPT Douty, I’m so glad that you’re still here! Please gather your nursing staff and meet me in the Report Room in ten minutes. It’s best if we verbally discuss the orders that I’ve written for PVT Donnely’s care, giving everyone a chance to ask questions and provide input. I’ll ask you to have additional pain medication on hand. After our discussion, we’re going to have to take him to the Procedure Room to irrigate and pack his open hip wound. We’ll have to repeat the debridement procedure twice daily, morning and evening. We can be somewhat flexible in scheduling that according to your staff’s availability, the ICU’s census, and the patients’ acuity levels.”
As the Vietnam war was ending, I submitted my “Dream Sheet,” indicating my top five desired assignment locations. Months later, I looked at my orders in disbelief: Patterson Army Hospital at Ft. Monmouth, New Jersey! I ruefully muttered under my breath,
“So much for ‘Join the Army and see the world!’”
My three years there flew by and I again submitted my Dream Sheet. This time, someone was listening, as I was stationed at Ft. Sam Houston, Texas, at the Army’s Academy of Health Sciences. I spent three years at the Field Medical Support Branch’s Basic Combat Medic Training Course!
My next assignment brought me to Ft. Lost in the Woods...er, I mean Ft. Leonard Wood, Missouri, where I was assigned as Nurse Manager of the ICU and Post-Anesthesia Care Unit, with the concurrent assignment as Chief Nurse of the 93rd Evacuation Hospital!
My career was really taking off, as I was being assigned to three locations simultaneously! This is where I was stationed as we resume my story about PVT Donnelly.
As I summoned my ICU staff, I intuitively realized that there would be an unknown duration of time (likely weeks) during which my staff and I would be assisting the Orthopedic physicians with PVT Donnely’s twice-daily debridement procedures.
The procedure was similar to what burn patients must endure having their charred flesh removed while deeply submerged in a Hubbard tank. These debridements would likely elicit a Pain Score of “8” to “10” for PVT Donnelly (on the 0-to-10 Pain Scale, with 0 being no pain and 10 being unbearable pain).
My mind leaped into overdrive as I quickly reviewed the many considerations that I wished to review with MAJ Finney and my nursing staff:
PAIN:
Discussion: During the debridement procedures, general anesthesia would not be used, due to the frequency (twice daily) and anticipated duration of time (2-3 months) that the procedure would be carried out, both of which would increase the risks associated with general anesthesia.
Considerations:
1- Have Orthopedic physicians administer local anesthesia in the area of the hip wound and allow 15-20 minutes for it to begin taking effect before beginning the debridement procedure.
2- ICU RNs and Orthopedic physicians coordinate the administration of IV pain medication for maximum effect as the procedure was about to start.
3- RNs must perform pain assessments (using the 0-10 Pain Scale) pre- and post-procedure and every 5 minutes during the procedure to evaluate changes. The goal would be to maintain PVT Donnelly’s Pain Score at or below 4. Also need to discuss additional appropriate intervention, beyond the scope of pain meds, to be performed at that time to effectively manage his pain.
4- MAJ Finney to contact the Pain Management Team for advice for fine-tuning the Pain Management for this young trainee. Might maintaining a continuous level dose via PCA pump prove more effective? Would his needs be best met by having spinal/regional anesthesia?
5- Teach PVT Donnelly the techniques involved with progressive relaxation and Lamaze childbirth exercises (breathing, concentration, focus) and coach him through applying the techniques during the debridement.
6- Assure PVT Donnelly that he is encouraged to express his pain in the moment, within reason Let him know that he’ll be given physical and auditory privacy as possible.
The ICU environment consists of two semi-circular bed configurations with monitoring equipment consoles between. Each bed has a privacy curtain that can be pulled closed for visual privacy; however, we may have to consider unorthodox solutions for auditory privacy (e.g., provide PVT Donnelly with an extra pillow that he can use to cover his face and muffle his screams and moans and tissues to dry his eyes and blow his nose).
DRESSING CHANGES
Discussion: Under these conditions, wound debridement would be carried out using a “wet-to-dry” dressing approach. The outer thick ABD pad is removed and discarded.
The next layer of 4X4” gauze dressings are removed individually. When they were applied, they were moist with sterile saline; however, as the gauze dried out from the heat of the body, it adhered to the margins of the wound.
When lifted out, any wound exudate and adhered tissue would be removed with it. The deeper the layers of 4x4s and gauze being removed, the greater the adhered tissue that was removed with it.
As that was accomplished, the wound bed would be packed with sterile gauze impregnated with petroleum, then layers of moist 4x4s, then finally one or more ABD pads, depending on the wound’s outer dimensions The premise was to continue to remove adherent tissue until the innermost wound bed had no necrotic tissue remaining and exhibited pink granulation tissue.
This would allow “healing by intention,” (in this case, tertiary intention) meaning that the initial traumatic, infected wound would be allowed to heal from the deepest, innermost layers first, then eventually upwards to the outermost layers.
Considerations:
1- Although PVT Donnelly’s open hip wound is contaminated, the debridement procedures are to proceed as sterile procedures.
2- The Wardmaster (SFC Higgins) must increase stock levels and maintain them for twice-daily use of the following supplies: Sterile debridement tray (obtained from Central Materiel Supply (CMS) prior to each procedure and the used tray must be returned to CMS upon completion of the debridement), large abdominal (ABD) pads, 4x4s, packing gauze, and Normal Saline for wound irrigation.
CMS is closed on Saturdays and Sundays; therefore, the debridement trays for the four debridement procedures performed over the weekend must be brought to ICU before the end of the day shift every Friday.
3- Placement of an abdominal binder* to avoid taping dressings to PVT Donnelly’s fragile abdomen skin. The abdominal binder is a support band that encircles the patient; it is closed at the back and is open in the front.
The opening consists of rows of rivets through which lengths of gauze strips would be laced and tied securely along the edges of the large ABD pad. The gauze strips are cut and removed for easy removal of the ABD pad and packing; new gauze strips are easily threaded through the rivets at the end of each procedure and tied securely.
.
MOVEMENT/POSITIONING/TOILETING
Discussion: PVT Donnely’s right hip has been repaired with a partial hip arthroplasty; however, his wound was not surgically closed due to the increased potential for infection. Therefore, nursing staff will need guidance from MAJ Finney regarding his postoperative positioning and movement.
Considerations:
1- MAJ Finney to consult Physical Therapy for a regimen of strengthening, stretching/range-of-motion, and the like for PVT Donnelly to be provided in ICU 7 days per week and to encompass upper and lower body routines Ensure that all PTs are made aware that his hip wound remains open for healing by intention. Note: Only a small amount of PT equipment may be stored at bedside; the rest must be transported to the ICU by PT sessions with PVT Donnelly.
2- How high may the head of his bed be raised to allow him to eat and drink?
3- May he be turned to the operative side at all, or must position changes to be restricted to his back and his non-operative side? Nursing to begin a q2 hour WHILE AWAKE position change schedule and post at the head of the bed.
4- PVT Donnelly would have to urinate into a urinal; however, we’ll need guidance regarding how much he can be moved (with his hip repair) when he needs to have a bowel movement? Will he be allowed to use a bedside commode?
NUTRITION
Discussion: PVT Donnely’s needs for additional calories from protein and fat are increased due to tissue repair and wound healing.
Considerations:
1-MAJ Finney to consult with the Dietitian. Specify that PVT Donnelly is to be given input into meal selections (including drinks) within the limitations of the Dietary Orders.
Please also specify that he’ll be given between-meal supplements (milkshakes, etc.) and an assortment of healthy snacks.
PSYCHO-SOCIAL
Discussion: PVT Donnely is an 18 y.o. young man who sustained a traumatic event with significant physical injuries and potential psychological implications. It is natural for him to go through a full spectrum of emotions. \He’ll require access to appropriate leisure activities (within restrictions of the ICU).
Considerations:
1- Consider referral to the medical center’s Psychology Department to request assessment and ongoing interventions (e.g/. Trauma Counseling) for PVT Donnely. Encourage PVT Donnelly to express his feelings. He may be at risk for depression.
2- MAJ Finney to consult with Occupational Therapy regarding PVT Finney’s O related needs (hygiene/grooming/upper body dressing/use of upper extremities for leisure and work activities).
3- SFC Higgins to assess PVT Donnelly’s leisure activity preferences while ICU-bound. Discuss available resources (Canteen; Library; Portable phone; Bedside TV; other). Please inquire with his Basic Training Drill Sergeant if he can have brief visitations by 2 buddies who entered Basic with him from his home state.
4- MAJ Finney to contact PVT Finney’s NOK (parents) and provide an update on his medical-surgical status, prognosis, and the like. Please assure them they are welcome to come to see him.
5- MAJ Finney to contact Patient Administration Division (PAD) to discuss PVT Finney’s likely disposition: to be medically-boarded out of Army, then transferred into VHA system for determination of disability rating and availability of ongoing healthcare and subsequently into VBA system for processing of disability payments.
It’s time for me to join MAJ Finney and my ICU nursing staff for our impromptu meeting to discuss PVT Donnelly’s care needs, to agree upon a division of labors (who will be responsible to do what?), and to begin to construct a holistic framework of Body-Mind-Spirit considerations around him that emphasize he is a unique, multi-dimensional, living, breathing PERSON who deserves the best care that we can possibly give him.
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* Ellen Hill (Douty) is a CPT in the Army Nurse Corps with nearly 11 years on Active Duty as of the time of this story (the 1980s). She entered the U.S. Army directly out of high school: She’d won an Army Scholarship to a 4-year BSN Nursing Program, after which she would be required to remain on active duty for three additional years. The Walter Reed Army Institute of Nursing, in conjunction with the University of Maryland, became her life for the next four years. The Vietnam War was drawing to an end; however, she was very excited about the opportunities that she would have to care for soldiers and their dependents at many locations worldwide.
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