Nursing 101: Back to Basics
There are two things you learn immediately upon entering nursing school:
1) You’ll never stop learning.
2) Always look at your patient.
They may sound simple, perhaps even obvious, but they are crucial to being a great nurse. Working one night in the emergency department, both statements proved themselves to be abundantly true. I was receiving a new patient from triage who had only been assigned ESI level 4, or what we called “basic care.” There are five ESI levels for patient triage, ranging from 1, being extremely critical such as a patient in cardiac arrest or requiring emergency intubation, to 5, needing a band aid or ice pack and requiring minimal resources. The triage intake nurse made a brief, simple note with the patient’s chief complaint: Allergic reaction. The nurse wrote that the patient had “felt funny” after eating some shellfish at a restaurant but showed no signs of a serious, life threatening reaction. There was no other description of any patient symptoms in the note. The story didn’t make much sense to me, but the intake nurse initially laid eyes on the patient and deemed him basic care, so seeing this new patient was not my priority. With night-after-night of cold symptoms, headaches and nausea, I had found myself questioning the stories, and severity, of most patients I came across.
When I went into the room to assess my new patient, I began asking my usual questions. Why are you here? What symptoms are you having? When did this start? Are you having any pain? I immediately noticed the patient’s wife was answering most of the questions for him, although he seemed perfectly capable of responding on his own. This piqued my interest; but it is not uncommon, especially among older men who may try to brush off their symptoms.
As the patient’s wife began telling me what was concerning her, I realized this was very much a different story than was described in, or rather, omitted from, the triage note. Did the triage nurse misunderstand? Was she dismissive? What did the patient initially say? Did the patient downplay his symptoms? The patient’s wife was sharing with me that he got up to use the restroom at the restaurant and came back “completely different.” She said his speech changed, and he seemed off balance. My patient then chimed in and said he felt like it was harder to walk “all of a sudden.” His wife kept saying, “Something is just not right with him.”
My wheels started turning, and the more the patient and his wife began to talk, the more concerned I became. When I asked the patient a question directly, it took him a few moments to answer. He would look at his wife, puzzled, and say “why can’t I think of the answer? Why can’t I remember?” Minutes later the nurse practitioner arrived in the room, and we completed the assessment together. When we made eye contact, I realized she was thinking what I was thinking: this patient appeared to be having a stroke.
Doctors were immediately notified, a stroke alert was called overhead, and ER staff began rushing into the room. The patient was quickly put on the gurney and rushed to have a CT and perfusion scan of his brain.
I was reminded of those nursing school days when I was taught to take the time and talk to my patients and why it was so important. I was reminded never to take another nurse’s (or doctor’s) word for it. I was reminded that something presenting as one thing may in fact be something completely different. I was reminded to trust family member’s instincts, one of the things I swore I would always do, having been in those shoes myself.
At the end of my shift, my patient was stable and would be going for further testing as well as being admitted to the stroke unit for continued observation. The scariest thing was, I had taken my time going in there. The note didn’t raise any suspicion and the situation seemed very much non-urgent. I probably would have taken longer to go in there had the patient’s wife not stopped at the desk for a glass of water. What if we were busy, and this patient waited hours before seeing the nurse and physician, simply because his triage level was low? What if I had taken the other nurse’s word for it and delayed this crucial assessment?
My mind has been reeling since caring for that patient, and I expressed my frustration to my colleagues. I felt the need to share this experience, for it could happen anywhere, to any nurse, at any hospital. I don’t think the nurse who triaged him is stupid or incompetent. Perhaps she was told a totally different story than I was. Maybe she wasn’t asking the right questions, maybe she was, I don’t know. But I do know it could happen to anyone.
It can be so easy to get wrapped up in the flashing numbers, laboratory results and diagnoses. But what really matters is the patient. Not every patient is going to present the way you expect them to. Someone who is sitting up talking to you one minute can crash the next. Spend the extra minute and look at your patient. Always remember to trust your gut, and always do your own assessments.
