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The contractual approach to nurse patient intervention
The contractual approach to nurse patient intervent ion Marjorie Bowden
Severely burned patients suffer not only devasting physical complications from the injury, but also overwhelming psychological stress as a result of trauma and treatment.
there is no magic formula to relieve stressful nurse patient relationships. We have, however, developed guidelines which can help the nurse in her overall approach to this problem.
Because the nursing staff shoulders the majority of the intensive, specialized care required to return the patient to health, much of what they are required to do for the patient is painful. The nurse, recognizing her role in therapy, is frequently distressed by the demands which must be made upon the patient in this continuously taxing encounter. In caring for these critically and emotionally troubled patients over a number of years at the University of Michigan Burn Center, we realized
The basis of this approach is an acceptance of the patient as an individual, and the understanding that each individual has learned to handle crises with his own coping mechanisms. The nurse, in working with the patient, attempts to guide his reactions in a manner that will help him deal more effectively with this traumatic period of his life. The mechanics of this approach involve establishing on going “contracts” between the nurse and the patient which identify achievable, short term goals that help both the patient and the nurse reduce frustration and promote a mutual feeling of trust, Respect for the patient’s integrity and a consistency in approach to each new crisis will help maintain a feeling of self worth for both parties and
~~
Mariorie Bowden,
BS, MSW, is
a clinical social
worker a t the University of Michigan University Hospital in Ann Arbor. She received her degrees from
Bluffton College,
Bluffton,
University of Michigan, Ann Arbor.
October 1972
Ohio,
and the
65
set the stage for constructive nurse patient interaction. Caring for a severely burned patient demands the solving of everchanging problems. Burn care can be divided into three definable but overlapping categories: the “emergent”, the “acute”, and the “rehabilitative”, each of which has inherent physical and emotional difficulties. The first period of care, the erne?‘-
gcnt phase, begins at the time of the accident and continues until life sustaining measures have resolved the immediate problems resulting from the injury. The patient, during this period, is overwrought with anxiety. He most likely has a sharp memory of the accident and guilt feelings because it was not prevented. In the rush to the hospital, he begins to realize that he is critically injured and many unanswered questions flood his mind. “HOW badly am I hurt? How soon can I go home? What will they do to me? How much will it cost? Who will take care of my family?” When he arrives in an area of specialized care, such as the burn unit, his fears are heightened by the completely foreign environment. Strange people, strange equipment, a different nomenclature and no familiar face to turn to for assurance increase his fears. The nurse, in the midst of this seeming chaos, must fill the patient’s need for security. Her initial contact must provide not only a feeling that the patient is being cared for, but that someone cares for him. A possible dialogue a t this time might be, “Mr. Smith, I am Shirley SchindIer and I am your nurse. You have
66
had a severe burn to a large part of your body. There are procedures that we will begin shortly that are necessary for your recovery. Other staff people and I will explain to you as best we can what we are doing. We are all here to be of assistance to you. We have cared for many severely burned patients and know how confused people become by so many things happening all a t once. Please feel free to ask questions and tell us how you feel.” A conscious effort on the part of all staff members to sincerely and simply answer the patient’s questions and requests and give on going explanations help reinforce the feeling that someone cares. It is especially helpful during this stressful time if consistent nursing assignments can be given and that the trusted, familiar, nurse introduce the nurse who will be taking over the care.
In the days that follow admission, the patient attempts to figure out what has happened to him, what will be happening to him in the next few hours, days, or weeks, and what effect all of this is going to have upon his life. It is a time of emotional, and physical, pain and confusion. This is a crucial period in the development of useful nurse patient relationships. The nurse’s verbal recognition and understanding of what the patient is going through can be reassuring and can make the patient to feel understood and accepted. An exchange that might take place during this time might be, “You seem very quiet this morning Mr. Smith.” (No comment) “I imagine you have quite a bit on your mind since the accident.”
AORN Journal
“You know, Mr. Smith, if people are unhappy, sometimes it helps for them to talk about it. You can talk to me about it if you like.”
“Dreams and some confusion in thinking are fairly common in burn patients. It can be upsetting when it happens. It’s caused by the changes in your body chemistry and fluid balance. As that improves so will your thinking.”
“It’s silly, Shirley, for a grown man to cry. I haven’t cried so much in my whole life as I have these last two days.”
“It scared me,” said Mr. Smith. “I thought I was going crazy. That’s all I need on top of everything.”
“You have had good reason to cry Mr. Smith. You’ve been through a lot.”
“It is scary. Don’t be afraid to talk to me about it. I will explain to you what is happening as best I can.”
(Still no response but tears are seen to be forming in his eyes.)
“Not as much as some of the others in here. And you know what I’m crying about? My wife. I miss my wife. I know she had to go home last night to take care of things but . . .” And Mr. Smith continued to talk about his wife, his family, his job and all the things he was missing. The nurse usually only has to say a few words to indicate she understands and accepts the way he feels. Explanations about changes in behavior are also helpful t o patients during this time. Part of an individual’s ability to master a crisis comes from his understanding of what is happening to him. “Nurse, did I just say something?” “Yes, Mr. Smith. You have been talking. I couldn’t understand. Were you dreaming?” “I guess so.” said Mr. Smith. “I must be going crazy. I keep hearing things and seeing things that I know aren’t there. Just now I was back on the job. It was so real.”
October 1972
After fluid and electrolyte balance have been stabilized, the patient enters what is termed the acute period. This is a time of constant wound care, dressing changes, debridement, and grafting, a time when complications of any and all organ systems are the rule rather than the exception. The patient begins to realize h e is indeed severely injured and that hospitalization may be prolonged and a t best uncomfortable. At present, debridement of eschar and preparing a clean granulation tissue for autografting is a n arduous and tedious task for both the patient and the nurse. This is the period of greatest physical pain and emotional stress. A method of communication should be established by the nurse to help all involved to deal effectively with day to day tasks. Establishing and using a contractual approach to daily activities can be a helpful method of communication. A contract with a patient is an on going, daily and hourly understanding between patient and nurse about what must be done and the responsibilities of each. The patient is
67
given an understanding of why the procedure is necessary and why his cooperation is desired. He is helped t o realize that he, too, is a member of the care team. He is not an object, but has self worth and a choice of behavior. A contract might be stated, “Mr. Smith, remember the doctors explaining to you this morning about why you should start sitting up. I am going to help you get up in a chair this afternoon. Would you prefer to do it before or after your afternoon nap?”
“Well, I guess I’d prefer it now so I can rest afterward.’’ “Good, I will get the orderly to come and help us. Now, the chair is here by the bed. We know you are weak but we would like you to t r y to stand for a few minutes as we transfer you from the bed to wheelchair.” The nurse then explains carefully the steps involved in transferring and what Mr. Smith will be required to do as well as what she and the orderly will be doing. “You won’t drop me will you? I’m a big man. Even the two of you aren’t big enough to hold me.” The nurse takes time to recognize that Mr. Smith is scared and that new experiences are frightening but reassures him. The procedure is carried out as stated. A contract is also used with patients who find it difficult to cooperate. An example might be that Mr. Smith chooses to get up in a chair after his nap but then refuses. The exchange might be,
68
“Mr. Smith, we are ready to get you up in your chair now.”
“I’m not getting up. I can’t get up. I’m too weak.” “You have to get up Mr. Smith. You can help us. We will all work together. 1’11 explain . . .”
“I’m not getting up!” “Mr. Smith, I have to get you up. It will be easier and quicker if you cooperate. By not cooperating you will only make it more difficult for all of us.”
The nurse then goes on to explain reasons for increased activity and the steps involved in transferring. If Mr. Smith expresses feelings, the nurse recognizes them but continues on. She then carries out the task as stated. Contracts have proven helpful when patients have to be limited in some way, such as in fluid intake. The patient’s cooperation is enlisted by setting up a contract. This should be a contract that he can maintain. For example, a patient may be limited to only 300 cc’s per shift. The nurse then may say to the patient, “Mr. Smith, your fluid intake today is Iimited to 300 cc’s. Yesterday you had difficulty in keeping within the limit and for the last two hours you were unhappy with me because I couldn’t give you anything to drink. Would you like to plan with me on how and when you might like your liquid so that the same thing doesn’t happen today?” The nurse then goes on to talk about the ways in which the fluid amount might be distributed over the shift.
AORN Journal
Variations of the dialogue may be used for all procedures and treatments. However, in adopting the contractual approach, it is of utmost importance that the nurse fulfill her part of the bargain. If she cannot do this, she will relinquish the trust that she has strived to gain. Consistency of approach is also essential in utilizing this method. It is necessary for all members of the team to use the same approach once i t has been established. Changes will result in confusion on the part of the patient as to his role in therapy and he may attempt to manipulate the nursing staff.
A frequent mistake by the nurse is to imply a choice to the patient when there is none. It is better to consider which procedures or activities allow options for the patient and which do not. This will help eliminate endless discussion as to whether o r not a particular activity is necessary.
It is also exhausting and useless to attempt to argue with a patient about the way he feels. If he is convinced an activity or procedure is painful or frightening, an intellectual discussion is not going to change his mind. Patients should not be made to feel guilty or threatened for verbal expression of emotions. They should be encouraged to express aggressive and hostile feelings, even though they may be difficult for the staff to accept. It is important to remember that the hostility is not directed at the nurse personally but against the situation in which the patient finds himself. Some patients always seem to be stalling for time. If the request is legitimate and if time allows, it should
October 1972
be granted, but only for an established period of time. Prolonging the period before a painful or fearful procedure generally raises the anxiety level of the patient. The patient under a great deal of stress may be preoccupied with his own feelings. Fear and anxiety may color the meaning of even the simplest exchange. For example, words which imply harm should be avoided. “I’m going to cut off your dressings” is better said, “I am going to remove your dressings”, or, when debriding eschar, it is better to say, “There is some skin here which will not heal and I am going to remove it”, instead of, “I am going to cut off some dead skin.” These concepts were once graphically illustrated to us. A patient who had been extremely docile during wound care and who had denied any discomfort, confided to the social worker that he feared that if he complained during this time, the nurse might become angry with him and it would be much easier for the scissors to slip and cut him. Praise of actions and accomplishments is almost mandatory in maintaining a good relationship with the patient. For example, “I know it is difficult for you to raise your arm, but look how high you are holding it today.” In caring for a patient over a period of time, the nurse might also add, “I think you did better than yesterday,” or, “Today’s dressing was a little more difficult than yesterday”.” This allows the patient a chance to express his feelings about the procedures. Comments which attack the patient’s integrity, such as comparisons with other patients,
69
abusive or belittling adjectives and sarcasm should be avoided.
team meetings that will hopefully guide the patient’s return to reality.
Treatments should be arranged so that a rest period follows. When a painful procedure is finished, the patient may then be given a choice of something to do. “Would you like to rest or watch television?” or, “would you like something to drink?” This is a way of helping the patient regain control of himself and his situation. It should not be a time when other activities are immediately forced on him.
When grafting is well under way, the patient enters the rehabilitation period. He has by this time come to depend on the nursing staff for most of his daily activities. He must be weaned from this dependence and encouraged to care for himself. This should not be sudden, as if the staff were neglecting him as some patients may feel, but through a gradual process. As soon as the nurse notes that the patient has the capability of doing the most minor activity for himself, he should be encouraged to do so. It should be stressed that this independence is now as important to him as medication, surgical procedures or intravenous therapy once were.
Because of the continuous anxiety with which the patient copes, it is not uncommon for him to share his feelings with a “nonhurtful” member of the care team, such as the social worker, the chaplain or the dietician. For this reason, it is necessary for all members of the care team to share information (unless the patient specifically requests it to be kept confidential) so that a constant supportive approach may be developed. It is not unusual, in view of the terrifying nature of the accident or injury and prolonged, painful hospitalization, that the most common fear for burned patients is of death. The reality behind these fears should be recognized and discussed with him. When appropriate, all possible hope for survival and positive outcome should be extended. In the event that the patient may appear to become temporarily psychotic and/or develop serious behavior problems, a psychiatrist may be called upon to assist in interpretation of the behavior and the defense mechanism being used by the patient to cope with his situation. An approach should then be developed in
70
During this return in independence, the patient begins to realize that he must plan for his future. This frequently represents a new crisis. Thoughts of disfigurement, deformity, economic worry and his future role in society may overwhelm him. The members of the care team may need to work long and hard to help the patient channel these feelings into constructive planning and activities. It is not uncommon for both patient and staff to become discouraged and fatigued during this period of care, especially if the course has been difficult. To reduce the disappointment that may develop and become problematical, the entire team needs to work closely to set up a realistic rehabilitation program for each patient. The nurse plays a key role in seeing that this program is implemented in a consistent manner which will meet the needs of the individual.
AORN Journal
Again, the contractual approach is useful. It is necessary that the patient understand the goals and be aware of the importance of his cooperation and participation. For example, if one of the current rehabilitation goals is to have the patient use his arms, the following exchange might take place. “Lunch time Mr. Smith. Now that the grafts are healed, you may begin using your right arm again. I would like you to try feeding yourself today using your right arm as much as possible. I shall help you as I know your arm must be very stiff. If it seems to cause you a great deaI of difficulty, perhaps you may want to speak with the occupational therapist when she comes this afternoon. She may be able to make specific suggestions to ease the task.” Patient fears and anxieties continue during the rehabilitation stage. Considerable support and encouragement need to be given t o overcome these fears and to establish achievable goals. The contractual approach is one way the nurse can gain an understanding of the rapidly changing needs of the patient and recognize the improvement. Throughout all care periods, the patient’s family must be taken into consideration. They, too, will be experiencing a great many fears and
anxieties. Simple explanations and constant reassurances are necessary in helping them to reach an acceptance of the patient’s condition. Experience has shown that if the family can be involved in establishing some of the patient’s goals they are more likely to cooperate in maintaining these goals. By involving the family in this process, they too will be able to set goals for themselves in their role of supporting their loved one.
In summary, it is understandable that nurses may find difficulties in dealing with the day to day problems of caring for the severely burned patient. The nurse, in guiding the patient to understand, accept and cope with this situation as he passes through the three phases of care, will benefit from the use of the contractual approach. Establishing on going contracts with the patient assists both parties in identifying achievable, short term, goals which will help them recognize progress, reduce frustration, share a trust, and maintain integrity. Consistency in approach by all team members will minimize the chance for confusion and misunderstanding of expectations. If the nurse is successful in adopting the contract to deal with her patients, both will find their relationship less stressful through the periods of burn care. I
I
Ocular palsy halfed Full return of regular eye movement t o patients with ocular palsy is possible in cases involving a pituitary tumor, according to Cavett M. Robert, Jr., MD, Joel A. Feigenbaum, MD, and W. Eugene Stern, MD, o f the hospital of the University of California at Los Angeles. Seven of nine patients studied had full return of eye movement after intracranial surgical removal of the tumor. The third cranial nerve was the most commonly affected of the ocular motor nerves, the investigators said. All operations involved an intracranial subfrontal exposure with removal of pituitary tumors.
I
October 1972
I
71
Severely burned patients suffer not only devasting physical complications from the injury, but also overwhelming psychological stress as a result of trauma and treatment.
there is no magic formula to relieve stressful nurse patient relationships. We have, however, developed guidelines which can help the nurse in her overall approach to this problem.
Because the nursing staff shoulders the majority of the intensive, specialized care required to return the patient to health, much of what they are required to do for the patient is painful. The nurse, recognizing her role in therapy, is frequently distressed by the demands which must be made upon the patient in this continuously taxing encounter. In caring for these critically and emotionally troubled patients over a number of years at the University of Michigan Burn Center, we realized
The basis of this approach is an acceptance of the patient as an individual, and the understanding that each individual has learned to handle crises with his own coping mechanisms. The nurse, in working with the patient, attempts to guide his reactions in a manner that will help him deal more effectively with this traumatic period of his life. The mechanics of this approach involve establishing on going “contracts” between the nurse and the patient which identify achievable, short term goals that help both the patient and the nurse reduce frustration and promote a mutual feeling of trust, Respect for the patient’s integrity and a consistency in approach to each new crisis will help maintain a feeling of self worth for both parties and
~~
Mariorie Bowden,
BS, MSW, is
a clinical social
worker a t the University of Michigan University Hospital in Ann Arbor. She received her degrees from
Bluffton College,
Bluffton,
University of Michigan, Ann Arbor.
October 1972
Ohio,
and the
65
set the stage for constructive nurse patient interaction. Caring for a severely burned patient demands the solving of everchanging problems. Burn care can be divided into three definable but overlapping categories: the “emergent”, the “acute”, and the “rehabilitative”, each of which has inherent physical and emotional difficulties. The first period of care, the erne?‘-
gcnt phase, begins at the time of the accident and continues until life sustaining measures have resolved the immediate problems resulting from the injury. The patient, during this period, is overwrought with anxiety. He most likely has a sharp memory of the accident and guilt feelings because it was not prevented. In the rush to the hospital, he begins to realize that he is critically injured and many unanswered questions flood his mind. “HOW badly am I hurt? How soon can I go home? What will they do to me? How much will it cost? Who will take care of my family?” When he arrives in an area of specialized care, such as the burn unit, his fears are heightened by the completely foreign environment. Strange people, strange equipment, a different nomenclature and no familiar face to turn to for assurance increase his fears. The nurse, in the midst of this seeming chaos, must fill the patient’s need for security. Her initial contact must provide not only a feeling that the patient is being cared for, but that someone cares for him. A possible dialogue a t this time might be, “Mr. Smith, I am Shirley SchindIer and I am your nurse. You have
66
had a severe burn to a large part of your body. There are procedures that we will begin shortly that are necessary for your recovery. Other staff people and I will explain to you as best we can what we are doing. We are all here to be of assistance to you. We have cared for many severely burned patients and know how confused people become by so many things happening all a t once. Please feel free to ask questions and tell us how you feel.” A conscious effort on the part of all staff members to sincerely and simply answer the patient’s questions and requests and give on going explanations help reinforce the feeling that someone cares. It is especially helpful during this stressful time if consistent nursing assignments can be given and that the trusted, familiar, nurse introduce the nurse who will be taking over the care.
In the days that follow admission, the patient attempts to figure out what has happened to him, what will be happening to him in the next few hours, days, or weeks, and what effect all of this is going to have upon his life. It is a time of emotional, and physical, pain and confusion. This is a crucial period in the development of useful nurse patient relationships. The nurse’s verbal recognition and understanding of what the patient is going through can be reassuring and can make the patient to feel understood and accepted. An exchange that might take place during this time might be, “You seem very quiet this morning Mr. Smith.” (No comment) “I imagine you have quite a bit on your mind since the accident.”
AORN Journal
“You know, Mr. Smith, if people are unhappy, sometimes it helps for them to talk about it. You can talk to me about it if you like.”
“Dreams and some confusion in thinking are fairly common in burn patients. It can be upsetting when it happens. It’s caused by the changes in your body chemistry and fluid balance. As that improves so will your thinking.”
“It’s silly, Shirley, for a grown man to cry. I haven’t cried so much in my whole life as I have these last two days.”
“It scared me,” said Mr. Smith. “I thought I was going crazy. That’s all I need on top of everything.”
“You have had good reason to cry Mr. Smith. You’ve been through a lot.”
“It is scary. Don’t be afraid to talk to me about it. I will explain to you what is happening as best I can.”
(Still no response but tears are seen to be forming in his eyes.)
“Not as much as some of the others in here. And you know what I’m crying about? My wife. I miss my wife. I know she had to go home last night to take care of things but . . .” And Mr. Smith continued to talk about his wife, his family, his job and all the things he was missing. The nurse usually only has to say a few words to indicate she understands and accepts the way he feels. Explanations about changes in behavior are also helpful t o patients during this time. Part of an individual’s ability to master a crisis comes from his understanding of what is happening to him. “Nurse, did I just say something?” “Yes, Mr. Smith. You have been talking. I couldn’t understand. Were you dreaming?” “I guess so.” said Mr. Smith. “I must be going crazy. I keep hearing things and seeing things that I know aren’t there. Just now I was back on the job. It was so real.”
October 1972
After fluid and electrolyte balance have been stabilized, the patient enters what is termed the acute period. This is a time of constant wound care, dressing changes, debridement, and grafting, a time when complications of any and all organ systems are the rule rather than the exception. The patient begins to realize h e is indeed severely injured and that hospitalization may be prolonged and a t best uncomfortable. At present, debridement of eschar and preparing a clean granulation tissue for autografting is a n arduous and tedious task for both the patient and the nurse. This is the period of greatest physical pain and emotional stress. A method of communication should be established by the nurse to help all involved to deal effectively with day to day tasks. Establishing and using a contractual approach to daily activities can be a helpful method of communication. A contract with a patient is an on going, daily and hourly understanding between patient and nurse about what must be done and the responsibilities of each. The patient is
67
given an understanding of why the procedure is necessary and why his cooperation is desired. He is helped t o realize that he, too, is a member of the care team. He is not an object, but has self worth and a choice of behavior. A contract might be stated, “Mr. Smith, remember the doctors explaining to you this morning about why you should start sitting up. I am going to help you get up in a chair this afternoon. Would you prefer to do it before or after your afternoon nap?”
“Well, I guess I’d prefer it now so I can rest afterward.’’ “Good, I will get the orderly to come and help us. Now, the chair is here by the bed. We know you are weak but we would like you to t r y to stand for a few minutes as we transfer you from the bed to wheelchair.” The nurse then explains carefully the steps involved in transferring and what Mr. Smith will be required to do as well as what she and the orderly will be doing. “You won’t drop me will you? I’m a big man. Even the two of you aren’t big enough to hold me.” The nurse takes time to recognize that Mr. Smith is scared and that new experiences are frightening but reassures him. The procedure is carried out as stated. A contract is also used with patients who find it difficult to cooperate. An example might be that Mr. Smith chooses to get up in a chair after his nap but then refuses. The exchange might be,
68
“Mr. Smith, we are ready to get you up in your chair now.”
“I’m not getting up. I can’t get up. I’m too weak.” “You have to get up Mr. Smith. You can help us. We will all work together. 1’11 explain . . .”
“I’m not getting up!” “Mr. Smith, I have to get you up. It will be easier and quicker if you cooperate. By not cooperating you will only make it more difficult for all of us.”
The nurse then goes on to explain reasons for increased activity and the steps involved in transferring. If Mr. Smith expresses feelings, the nurse recognizes them but continues on. She then carries out the task as stated. Contracts have proven helpful when patients have to be limited in some way, such as in fluid intake. The patient’s cooperation is enlisted by setting up a contract. This should be a contract that he can maintain. For example, a patient may be limited to only 300 cc’s per shift. The nurse then may say to the patient, “Mr. Smith, your fluid intake today is Iimited to 300 cc’s. Yesterday you had difficulty in keeping within the limit and for the last two hours you were unhappy with me because I couldn’t give you anything to drink. Would you like to plan with me on how and when you might like your liquid so that the same thing doesn’t happen today?” The nurse then goes on to talk about the ways in which the fluid amount might be distributed over the shift.
AORN Journal
Variations of the dialogue may be used for all procedures and treatments. However, in adopting the contractual approach, it is of utmost importance that the nurse fulfill her part of the bargain. If she cannot do this, she will relinquish the trust that she has strived to gain. Consistency of approach is also essential in utilizing this method. It is necessary for all members of the team to use the same approach once i t has been established. Changes will result in confusion on the part of the patient as to his role in therapy and he may attempt to manipulate the nursing staff.
A frequent mistake by the nurse is to imply a choice to the patient when there is none. It is better to consider which procedures or activities allow options for the patient and which do not. This will help eliminate endless discussion as to whether o r not a particular activity is necessary.
It is also exhausting and useless to attempt to argue with a patient about the way he feels. If he is convinced an activity or procedure is painful or frightening, an intellectual discussion is not going to change his mind. Patients should not be made to feel guilty or threatened for verbal expression of emotions. They should be encouraged to express aggressive and hostile feelings, even though they may be difficult for the staff to accept. It is important to remember that the hostility is not directed at the nurse personally but against the situation in which the patient finds himself. Some patients always seem to be stalling for time. If the request is legitimate and if time allows, it should
October 1972
be granted, but only for an established period of time. Prolonging the period before a painful or fearful procedure generally raises the anxiety level of the patient. The patient under a great deal of stress may be preoccupied with his own feelings. Fear and anxiety may color the meaning of even the simplest exchange. For example, words which imply harm should be avoided. “I’m going to cut off your dressings” is better said, “I am going to remove your dressings”, or, when debriding eschar, it is better to say, “There is some skin here which will not heal and I am going to remove it”, instead of, “I am going to cut off some dead skin.” These concepts were once graphically illustrated to us. A patient who had been extremely docile during wound care and who had denied any discomfort, confided to the social worker that he feared that if he complained during this time, the nurse might become angry with him and it would be much easier for the scissors to slip and cut him. Praise of actions and accomplishments is almost mandatory in maintaining a good relationship with the patient. For example, “I know it is difficult for you to raise your arm, but look how high you are holding it today.” In caring for a patient over a period of time, the nurse might also add, “I think you did better than yesterday,” or, “Today’s dressing was a little more difficult than yesterday”.” This allows the patient a chance to express his feelings about the procedures. Comments which attack the patient’s integrity, such as comparisons with other patients,
69
abusive or belittling adjectives and sarcasm should be avoided.
team meetings that will hopefully guide the patient’s return to reality.
Treatments should be arranged so that a rest period follows. When a painful procedure is finished, the patient may then be given a choice of something to do. “Would you like to rest or watch television?” or, “would you like something to drink?” This is a way of helping the patient regain control of himself and his situation. It should not be a time when other activities are immediately forced on him.
When grafting is well under way, the patient enters the rehabilitation period. He has by this time come to depend on the nursing staff for most of his daily activities. He must be weaned from this dependence and encouraged to care for himself. This should not be sudden, as if the staff were neglecting him as some patients may feel, but through a gradual process. As soon as the nurse notes that the patient has the capability of doing the most minor activity for himself, he should be encouraged to do so. It should be stressed that this independence is now as important to him as medication, surgical procedures or intravenous therapy once were.
Because of the continuous anxiety with which the patient copes, it is not uncommon for him to share his feelings with a “nonhurtful” member of the care team, such as the social worker, the chaplain or the dietician. For this reason, it is necessary for all members of the care team to share information (unless the patient specifically requests it to be kept confidential) so that a constant supportive approach may be developed. It is not unusual, in view of the terrifying nature of the accident or injury and prolonged, painful hospitalization, that the most common fear for burned patients is of death. The reality behind these fears should be recognized and discussed with him. When appropriate, all possible hope for survival and positive outcome should be extended. In the event that the patient may appear to become temporarily psychotic and/or develop serious behavior problems, a psychiatrist may be called upon to assist in interpretation of the behavior and the defense mechanism being used by the patient to cope with his situation. An approach should then be developed in
70
During this return in independence, the patient begins to realize that he must plan for his future. This frequently represents a new crisis. Thoughts of disfigurement, deformity, economic worry and his future role in society may overwhelm him. The members of the care team may need to work long and hard to help the patient channel these feelings into constructive planning and activities. It is not uncommon for both patient and staff to become discouraged and fatigued during this period of care, especially if the course has been difficult. To reduce the disappointment that may develop and become problematical, the entire team needs to work closely to set up a realistic rehabilitation program for each patient. The nurse plays a key role in seeing that this program is implemented in a consistent manner which will meet the needs of the individual.
AORN Journal
Again, the contractual approach is useful. It is necessary that the patient understand the goals and be aware of the importance of his cooperation and participation. For example, if one of the current rehabilitation goals is to have the patient use his arms, the following exchange might take place. “Lunch time Mr. Smith. Now that the grafts are healed, you may begin using your right arm again. I would like you to try feeding yourself today using your right arm as much as possible. I shall help you as I know your arm must be very stiff. If it seems to cause you a great deaI of difficulty, perhaps you may want to speak with the occupational therapist when she comes this afternoon. She may be able to make specific suggestions to ease the task.” Patient fears and anxieties continue during the rehabilitation stage. Considerable support and encouragement need to be given t o overcome these fears and to establish achievable goals. The contractual approach is one way the nurse can gain an understanding of the rapidly changing needs of the patient and recognize the improvement. Throughout all care periods, the patient’s family must be taken into consideration. They, too, will be experiencing a great many fears and
anxieties. Simple explanations and constant reassurances are necessary in helping them to reach an acceptance of the patient’s condition. Experience has shown that if the family can be involved in establishing some of the patient’s goals they are more likely to cooperate in maintaining these goals. By involving the family in this process, they too will be able to set goals for themselves in their role of supporting their loved one.
In summary, it is understandable that nurses may find difficulties in dealing with the day to day problems of caring for the severely burned patient. The nurse, in guiding the patient to understand, accept and cope with this situation as he passes through the three phases of care, will benefit from the use of the contractual approach. Establishing on going contracts with the patient assists both parties in identifying achievable, short term, goals which will help them recognize progress, reduce frustration, share a trust, and maintain integrity. Consistency in approach by all team members will minimize the chance for confusion and misunderstanding of expectations. If the nurse is successful in adopting the contract to deal with her patients, both will find their relationship less stressful through the periods of burn care. I
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Ocular palsy halfed Full return of regular eye movement t o patients with ocular palsy is possible in cases involving a pituitary tumor, according to Cavett M. Robert, Jr., MD, Joel A. Feigenbaum, MD, and W. Eugene Stern, MD, o f the hospital of the University of California at Los Angeles. Seven of nine patients studied had full return of eye movement after intracranial surgical removal of the tumor. The third cranial nerve was the most commonly affected of the ocular motor nerves, the investigators said. All operations involved an intracranial subfrontal exposure with removal of pituitary tumors.
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October 1972
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