Originally Posted: 5/17/2011
As my husband will tell you, one of the things that drives me crazy is the general public misconception of the role of the registered nurse. I feel that often times that many people think if you work in a doctors office or hospital and are not the doctor, then you must be the nurse!
At the beginning of every appointment, before my Dad sees his oncologist, he has his labs drawn. Usually between 8 and 13 tubes of blood each visit. Last week was no different. However, when the nurse practitioner reviewed his labs a short while later, she looked puzzled. “Give me a minute to call the lab, I think they might have lost your CBC,” she told us. A few phone calls later, the puzzle was solved. The standing order for Dad’s complete blood count (CBC) had expired, and so the phlebotomist had not drawn it. A CBC monitors components of the blood- white blood cells, red blood cells, platelets, among others- and is one of the most essential labs for oncology patients, especially stem cell patients, as it allows basic monitoring of immune system function. It is common for hemoglobin or platelets to continue to drop for several months after the transplant and as a result, my Dad occasionally needs to receive blood products to correct those. Of the multiple tubes that are drawn each visit, it’s one of the most important. His doctor laughed. “A nurse wouldn’t have forgotten the CBC,” he said to me. It’s true. Nothing against the phlebotomist, but she’s not a nurse. A nurse would have called to verify the order, because a nurse knows that anyone coming into a cancer center probably needs a CBC. It is the difference between learning a skill, and understanding the theory and rationale behind it.
Skills are just one small piece of the nurses role, and many of these skills can be delegated by the RN to assistant personnel. For example, the certified nursing assistant (CNA) or medical assistant (MA) may take your vitals, the phlebotomist may be the one to draw your blood. Each state board of nursing regulates which tasks may be delegated to a nursing assistant, and which must be performed by the RN.
Indeed, family members often learn to perform many of these skills at home as well. I remember my Mom crying the first time she had to change my Dad’s dressing on his back after his surgery last August. She hates putting tape on skin (we never used band-aids much as a kid for this reason), and therefore Tegaderm, a huge sticky sheet of tape used to dress wounds, is basically her worst nightmare. But after the first or second time, she had dressing changes down. When he had his port implanted in January, she also had to learn how to flush that. Here is a picture of her releasing the air bubble in the syringe prior to flushing.My Dad also had to learn a few skills of his own, when he was started on Fragmin after he was diagnosed with a blood clot soon after his surgery. Fragmin is a medication that is given as a subcutaneous injection (SubQ), meaning that it is injected into the layer between the skin and the muscle. He gives himself a Fragmin shot every day. A home health nurse came the first few days he was home to help him, but since then, he has been on his own. At first he hated the idea of daily injections, and had a bruised up stomach to prove it, but as time went on, he became a pro (although he did have me come over to give him his Neulasta shot before the transplant. At $7000 a pop, he did not want to risk missing on that one!).
In addition to learning nursing skills, registered nurses must use critical thinking skills to assess for changes in functioning, understand what these changes may mean, and know when to call the doctor for further intervention. I was reminded of this again today when talking with a good friend, whose sister is set to receive a stem cell transplant on the same unit my Dad was on. When I asked who her nurse was today, she told me it was the same nurse who I believe is responsible for saving my Dad’s life. This nurse took one look at my Dad on the morning he was sent to the ICU and immediately called the rapid response team. “Something just wasn’t matching up,” she told me later. It was true. And I had been trying to tell every other nurse and doctor this for quite some time. She actually listened. At first glance, he looked fine. He did not look like someone in imminent respiratory failure. But his oxygen saturation was only measuring 85% on the maximum amount of oxygen available by face mask. And if you really listened, he was having trouble finishing a sentence without getting short of breath (even though he denied it). Had she not used those critical thinking skills, as well as taken the initiative to call the rapid response, there is a good chance my Dad would have gone into full arrest from respiratory failure.
Nurses do all this with compassion, building relationships with families as they provide care. Nurses help to empower families by serving as the patient advocate when the patients are not able to advocate for themselves, ensuring that questions are answered, and that families understand the treatment plan. Nurses provide education about disease process, medication, and yes, empowering families to be able to change the dressing, flush a port, or give an injection without fear and anxiety.
Last week was Nurses Week- did you thank a nurse?