10 Random Tips for Nurses

9 08 2010

There is no real theme for the next Grand Rounds, but the host Jackie Fox of Dispatch From Second Base is hoping to get posts on doctor-patient communication in any of its forms. She adds that nurses play a critical role in communication.

I’ve had nurses explain what the doctor is talking about. One of my family doctor’s nurses let me know that the surgeon he recommended for my first-ever surgery was a great guy and that all his patients really like him. This was good to hear, and she was right.

Most of my experiences with nurses are similarly positive and I “love” the once-yearly visits to my endo-nurse, who just needs half a word to know how I’m doing.

But I also have some not so good or even bad experiences with nurses. Here are some serious, and less serious tips, merely based on my own experiences. I won’t deal with the normal etiquette: shake hands, listen etc, but most tips are pretty obvious anyway. At least in my view.

1. Never reprimand patients, and certainly not in front of others.

My worst experience dates from 11 years back, when I stayed at the hospital after a massive postpartum bleeding. I had all symptoms of an Addison crisis, but this was not recognized as such. The nurses at the pediatric department found I had to try harder to give milk (but lactation failure is one of the first symptoms after giving birth), or to nurse the baby (weakness is another symptom: I couldn’t hardly walk or stand on my feet). They started to take me serious when I vomited all over the place (vomiting and the absolute dislike of food are another sign). Another nurse saw it differently, and gave me a sermon about the importance to do my best and break the circle to eat, etcetera ….in the presence of a fellow-patient. I was so ashamed. It hurt very bad, because there was nothing I could do about it, but I felt like someone who faked it all.

Two other “rules” follow from this one:

2. Try not to judge patients and take them and their illness seriously (unless proven otherwise)

3. Don’t step into the doctor’s shoes (never mind how often you may be right)

Certain doctor’s receptionists also like to act like they are the doctor. I know one who asks things in a snappy way, like: “Why do you need those pills anyway?”

4. Respect the patients privacy.

5. And don’t go partying at the ICU (of all places).

Yeah this happened. It was just a small party: some cake, coffee and loud jolly conversations at appr. 07.00 am. I wouldn’t mind otherwise, but “parties” ain’t what you need after one night ICU, where you’re too weak to respond to signals like all kinds of beeps, voices, panic, intubations, and regular rough hawk-ups. Your damn ill, that’s why you are in the ICU.

6. Don’t offer technical solutions to non-technical problems

I had trouble feeding my first child because she was too small and didn’t have the power. A got “support” from a nurse who offered all kinds of technical solutions (all kind of exotic things, like nipple shields), that were not at all required. Everything went smoothly as soon as I was home, alone with my baby.

7. Don’t treat a child as an adult, even if it tries to act like one.

It is their way to cope. Just let them.

8. Try to be honest. Don’t say “it doesn’t hurt a bit”, when it does.
On the short term it may help to use a trick to get unpleasant things done, but in the long run people -and especially children- may no longer trust you or any of your colleagues in a similar situation. At least consider this.

9. Be open, nice & friendly

10. Always remain professional

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Nursing Myths (1): Post-operative Temperature Measurements.

21 09 2008

Patients recovering from surgery at the ward, are frequented by nurses taking their blood pressure, pulse and temperature. What would happen if nurses wouldn’t routinely measure temperature? Would infections be missed? Could this lead to more serious infections and other complications?

Hester Vermeulen and colleagues have performed a study that shows that routine measurements of body temperature in postoperative patients is of limited value. This study was published in Clin Infect Dis. 2005 May 15; 40(10): 1404-10, (see here for HubMed-citation). Previous studies have also pointed in the same direction, but were less robust in design (retrospective, unblinded studies and/or surrogate endpoints). (for study designs see previous post here)

The study of Hester Vermeulen et al. was a prospective, triple-blinded diagnostic study, which means that groups of patients were followed from the beginning and neither the patient, the treating physicians nor the nurses responsible for daily care were informed about the outcome of the measurements. Independent nurses not involved in routine care did the temperature readings. Only patients with non-infectious diseases were included.

Of the 284 enrolled patients, 60 (21%) had a temperature of ≥38ºC, but only 7 out of theses 60 patients really had infections. The sensitivity did not improve for higher febrile temperatures (38,5-39ºC) or when the febrile temperature was measured on more than one occasion.

On the other hand, of the 223 patients (79%) who had a temperature less than 38ºC, 12 patients (>5%) did develop an infection.

Overall, in 19 patients (7%) a postoperative infection was detected (14 on basis of bacterial culture, 5 on clinical/laboratory grounds). Only 7 of these patients had a febrile temperature beforehand.

Eight patients developed a serious infection (pulmonary, intra-abdominal and sepsis), but six of them had no febrile temperature, meaning that infection is often not accompanied by a previous increase in temperature.
Thus routine temperature measuring might even be misleading to nurses and physicians: relying on body temperature might delay diagnosis and subsequently treatment (because a negative result reassures, but does not exclude an infection).

Experts in diagnostic accuracy studies would say that routine temperature measurements in post-operative patients have a very low sensitivity, a low positive predictive value and meaningless likelihood ratios (see Wikipedia)

Freely translated, this test performs lousy.

The study of Vermeulen et al. is part of an continuing program for the development of evidence based local guidelines. On the basis of these results Vermeulen et al adviced to abandon routine postoperative temperature measurements, but to perform these measurements only when indicated.

Still, as I understand, it is not easy to implement the guidelines. Nurses still find that they ought to check temperatures daily -it is in their routine-. And if they do adhere to the protocol many doctors still ask for the temperature data during ward rounds. Last but not least, patients find temperature measurements reassuring and rely heavily on information about the measured values. Furthermore, it is also pleasant that the nurse visits you regularly, if not for the temperature, then for the caring.

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Patienten die op zaal liggen om van een operatie herstellen worden op gezette tijden bezocht door de zuster, die hun pols opneemt, de bloeddruk meet en hen even ‘tempt’. Wat zou er gebeuren als verpleegster niet routinematig de temperatuur zou meten? Zouden infecties over het hoofd gezien worden? Zou dit tot méér ernstige infecties of tot andere complicaties kunnen leiden?

Hester Vermeulen en collega’s hebben in hun studie (Clin Infect Dis. 2005 May 15; 40(10): 1404-10; zie hier voor HubMed-citatie).aangetoond dat routinematige bepaling van de lichaamstemperatuur in geopereerde patienten weinig zinvol is. Eerdere studies wezen hier ook al op, maar hadden een minder goed onderzoeksdesign (retrospectief, niet geblindeerd, surrogaatmarkers) (voor een beschrijving van studie designs, zie eerder bericht hier).

De studie van Vermeulen et al. is een prospectieve, triple-blinded diagnostische studie. Dat houdt in dat patienten vanaf het begin gevolgd worden en dat noch de patient, noch de behandelend arts of de verpleger (die de patient verzorgt) op de hoogte is van de uitslag. Onafhankelijke verplegers doen de temperatuurmetingen. Alleen patienten zonder infectieziekten werden geincludeerd.

Van de 284 geincludeerde patienten, hadden er 60 (21%) een temperatuur gelijk van 38ºC of hoger. Maar slechts 7 van deze 60 patienten hadden ook echt een infectie. De sensitiviteit van de test ging niet omhoog als men alleen mensen van een hogere temperatuur (38,5-39ºC) of met een herhaalde hoge temperatuursmeting in beschouwing nam.

Aan de andee kant: van de 223 patienten (79%) die een normale temperatuur hadden (lager dan 38ºC), kregen er 12 (>5%) toch een infectie.

In totaal, werd in 19 patienten (7%) een postoperatieve infectie geconstateerd. Slechts 7 van de 19 patienten had tevoren koorts.

Acht patienten kregen een ernstige infectie (long- of buikinfectie of sepsis), maar slechts 2 van hen hadden tevoren koorts en 6 dus niet. Hetgeen betekent een infectie niet altijd voorafgegaan wordt door koorts.
Routinematig tempen kan dus zelfs misleidend zijn. Als verplegers en dokters zich hier teveel op verlaten, kan dit een snelle diagnose en therapie in de weg staan (omdat een negatief resultaat ten onrechte geruststelt).

Epidemiologen zouden zeggen dat de routine temperatuurmetingen in post-operatieve patienten een erg lage sensitiviteit, een lage voorspellende waarde en een nietzeggende likelihoodratio hebben. (zie Wikipedia)

Vrij vertaald: knudde met een rietje.

Bovengenoemde studie is er éen uit een reeks, bedoeld om (locale) evidence based richtlijnen te ontwikkelen. Op basis van de resultaten is het advies van Vermeulen et al. om postoperatieve patienten niet langer routinematig te temperaturen, maar alleen als daar aanleiding voor is.

Een duidelijke stelling, maar toch blijkt de praktijk weerbarstiger. Verplegers vinden dat ze toch dagelijks horen te tempen -dat zit in hun routine. En als ze de regels wel opvolgen, vragen sommige dokters tijdens hun visite er toch naar. Last but not least, patienten vinden temperatuurmetingen en andere vaste rituelen geruststellend. Ze hechten ook veel waarde aan de uitkomst van de meting. Verder vinden ze het gewoon prettig als de zuster op vaste tijden bij hen langskomt. Was het niet voor de tempeartuurmeting, dan toch voor wat extra aandacht en zorg.