Caroline Mayberry, RN; Jolanta Sojka, RN OCN, CN-2; Glynis Cox, RN, OCN, CN-2


May 14, 2008

This patient was no stranger to the 5 North unit. Our oncology nursing team first met her when she was diagnosed with ALL (acute lymphocytic leukemia). Since that time she was frequently re-admitted for chemotherapy and transfusions. However, despite frequent exposure to the hospital, each readmission was marked by extreme anxiety regarding procedures and absence from home. On this day she had come to the Same Day Treatment/Urgent Care Center located on our oncology floor for lab work and possible transfusion. This treatment room was designed to address the frequent emergent needs of the oncology outpatient to avoid prolonged stays in the emergency room that can complicate the care of the often neutropenic patients.

The same day treatment nurse immediately noticed the woman's pallor and fatigue. Vital signs indicated BP 74/43, HR 127, respirations 24, temperature 101.6, O2 sat 89% on room air. She was dyspneic on exertion and not oriented to time. We were already aware from previous hospitalizations that establishing IV access on this patient would be a challenge and that she was often anxious regarding any change in her condition or treatment. The patient had started shaking with rigors and the all too familiar signs of a patient becoming septic.

Other nurses from outside in the inpatient area secured their own groups of patients and provided assistance to the same day treatment nurse. Oxygen was administered while a nurse notified the physician of the patient's condition on admission and received telephone orders. Immediately, our best IV nurse was able to start large bore IV access and draw lab work and blood cultures. Tylenol was administered, a bolus of 1000 ml normal saline was given and the antibiotic was started all before the physician had walked down to assess the patient from another unit. As one nurse documented and updated the patient's health history by speaking with the husband, another nurse provided frequent vital signs assessment and contacted the charge nurse to secure an inpatient bed. When the lab called with WBC 0.3 Hgb 7.4, Plt 4, K 3.2 and Mag 1.6, we assisted the nurse with transitioning the patient to inpatient status while executing the resulting multiple transfusion and electrolyte replacement orders.

The primary characteristic of a good nursing team is the ability to work together when a crisis situation arises. The hallmark of a great nursing team is when the team identifies each nurse's particular strength and utilizes them during an event to create the most holistic plan to care for that patient. That is what differentiates a Magnet nursing facility from other institutions and helps raise the bar for what we all strive to be the standard of care in nursing.

While the standard hierarchy of needs always keeps the nurse repeating the mantra "airway, breathing, circulation," as Magnet nurses, we know that by providing emotional support to the physically unstable patient and family, we can improve the overall outcome ten-fold. When a patient feels trustful and at ease with their caregivers and treatment plan, we can save costly minutes in the struggle to stabilize the patient's medical condition. As each nurse performed their care they explained to the patient the need for each medical intervention and asked about how the woman's daughter was doing, what was new in her life outside the hospital, and related to the woman on a personal level. Many of our patients are such familiar faces we often walk up and down the hall as if we are all in the same neighborhood greeting our friends on the street. By creating a feeling of a home away from home it can ease the depression and anxiety that accompany the abrupt change in lifestyle that accompanies a cancer diagnosis.

The patient's BP 102/58, HR 98, respirations 20, temperature 99.0 and O2 sat 98% on 3 liters nasal cannula. The rigors had subsided and she was admitted as an inpatient with neutropenic precautions. After transfusion her lab findings improved and the next day she greeted us with a smile (that we could detect under her mask) as she ambulated with physical therapy in the hall. As nurses, we first evaluate the vital signs and lab values to assess the daily needs for our oncology patients. As Magnet nurses, we look beyond the numbers to provide for the whole person that is behind the mask and inside the body often ravaged by illness.

This patient recovered from this episode of bacteremia, but eventually succumbed to leukemia further down the road. It is very telling that despite her initial fear of hospitalization, she eventually chose to spend her last days in our hospital on our unit rather than on hospice care at home. During her final inpatient stay when we heard she was to be admitted we prepared the room for her down to the amount of pillows she always liked to have in bed. Though I had heard she was minimally responsive, when I came to see her the last time she smiled and was able to squeeze my hand.

During one of our hospital's continuing nursing education classes I attended, there was a segment on caring for the death and dying patient. We were given an exercise to draw a picture of what we want our surroundings to be like when we die. We all drew beautiful islands, picturesque mountains, and even our own bedroom surrounded by our family. Not one of us drew a picture of a hospital room, which is so often the reality for our patients. We then discussed how our patients might have also dreamed of that scenario as a healthy person before being stricken by illness. As Magnet nurses, our goal is to care for the individual to improve health. However, when this is not an option we can certainly provide the same holistic care to improve the quality of one's death.

This delicate balance is achieved through the knowledge, dedication, compassion, and teamwork that characterize our Magnet nursing team. The ability of the nurses at our institution to assess and reassess then subsequently develop individualized interventions is evidenced by the quality of care across the lifespan. From the beginning of life in Labor and Delivery, to the need for immediate life saving intervention in our trauma ICU, the nurses at Robert Wood Johnson University Hospital exhibit their Magnet worthy excellence every day. This is just one Magnet story.


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