The Nursing Experience (page 5)

The best way to find out if nursing is for you is to shadow a nurse. Contact your school of interest and ask if they allow it. High school students can also attend nurse camp at a local college and spend a few days immersed in the nursing experience. Nurse camp allows you to practice on computerized mannequins and use nursing equipment. You'll also get to talk to students and instructors, which gives you a chance to ask questions about your potential career.

Nurse Camp

• Attend nursing classes taught by nursing faculty.
• Learn about the student experience from nursing students.
• Learn and practice skills in a nursing laboratory.
• Utilize computerized mannequins that simulate real patient illnesses.
• Observe nurses in a hospital unit.
• Find out about nursing specialties.

If time or distance prohibits you from firsthand experience, or if you'd rather read about nursing before jumping in, here is an inside look at the nursing experience. The skills noted here are by no means all-inclusive. They were chosen to give you an insight into the world of nursing, and are intended to give you a brief overview, not to teach you the skill. As they say on television, nurses are professionals—don't try these skills on your own.

Health Assessment

As the first component of the nursing process, assessment encompasses a number of skills that let you do some detective work. Nurses assess clients' four domains: physical, psychological, social, and spiritual. Physical health involves basic functions such as breathing, eating, sleeping, and walking, while psychological health involves a person's intellect, self-concept, emotions, and behavior. Social health encompasses the client's relationship with family, friends, coworkers, and society, and spiritual health refers to a person's meaning of life, attitudes toward moral conduct, and belief in a higher power. Nurses consider all these dimensions when performing a comprehensive assessment.

Assessments include both subjective and objective data. Subjective data, also called history, are the symptoms, feelings, perceptions, and other information that the client states and validates. Objective data, also called physical, are the signs directly measured, observed, and felt by the nurse. Nurses need to be able to assess all types of clients, and to modify their assessment to meet the client's age and health status. Children are not just small adults; their bodies are different, and they don't have an adult's level of understanding. Thus, nurses learn skills to both assess children and communicate with them. Older adults require skill modification as well, as do critically ill persons. You need to move faster if a client is in a life-threatening situation, and you need to alter the order of your assessment. Nurses thus learn both assessment skills and assessment modifications. However, before they assess, nurses initiate the nurse-client relationship and discuss confidentiality.

Nurse-Client Relationship

The nurse-client relationship is a helping relationship that differs from social relationships. It focuses on the client, is goal directed, and has defined parameters. The nurse-client relationship begins with the orientation phase, which consists of introductions and an agreement between the nurse and client about their roles and responsibilities. The second phase is the working phase, during which the nurse and client participate together in the client's care. The nurse acts as the client's advocate, caring for his or her physical and emotional healthcare needs. The final phase is termination, which is the closure of the relationship. Here the nurse reviews the client's aspects of care and how they have dealt with physical and emotional responses. Termination is also the time for discharge planning.

Confidentiality

Confidentiality requires that client information remain private between the client and the healthcare team. No one else is entitled to the client's information unless the client signs a consent for release of information. Nurses need to tell clients about their right to confidentiality, and they need to avoid discussing clients outside the clinical setting. Telling friends or family about clients violates the client's right to confidentiality and could result in disciplinary action for the nurse.

In respect to confidentiality, nurses are required to adhere to the Health Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was enacted to ensure health insurance coverage after leaving an employer and to improve the efficiency and effectiveness of health care-related electronic transactions. The Department of Health and Human Services (DHHS) developed the Standards for Privacy of Individually Identifiable Health Information, better known as the HIPAA Privacy Rule. The privacy rule regulates how certain groups or persons can use and disclose individually identifiable health information. The privacy rule:

• grants client patients more control over their own health information, and sets boundaries on the use and release of health records.
• enables patients to make informed choices and to know how, when, and for whom their protected health information is used.
• limits the release of protected health information to the minimum necessary for the purposes of the disclosure.
• establishes safeguards that most healthcare providers must achieve to protect client health information, and allows civil and criminal penalties to be imposed on those who violate the rule.
• allows for disclosure of protected health information for public health, safety, and law enforcement purposes.

Subjective Data

Once nurses establish the nurse-client relationship and discuss confidentiality, they are ready to begin assessment (even though nurses actually begin their assessment when they first see and hear the client). Nurses first collect subjective data using therapeutic communication techniques. Communication is a powerful tool, and therapeutic communication techniques are some of the most important skills in a nurse's toolbox.

Examples of Therapeutic Communication Techniques

• Broad opening statements allow clients to set the direction of the interview: "Where would you like to begin?"
• Active listening is more than hearing; it involves the nurse's ability to focus on and decode what the client is saying.
• Open-ended questions require more than a "yes" or "no" answer: "How would you describe your pain?"
• Focusing helps to keep the client on topic: "You were telling me about your heart problem; can you tell me more about it?"
• General leads encourage the client to continue: "And then?"
• Silence may be the best response. It slows the pace of the interview and allows the client to reflect on his or her feelings.

Once nurses establish the relationship and confidentiality, they begin the interview, usually asking about the chief complaint, which is the reason why the client sought healthcare. The nurse then obtains the client's health history, which includes medications, allergies, nutrition, elimination, sleep patterns, hospitalizations, injuries, and family health. Nurses then ask questions about each body system—for example, they will ask about breathing problems and coughing to assess the respiratory system. Since nurses use a multidimensional model, they will also ask about the client's psychological, social, and spiritual health. The main purpose of the history is to focus the physical assessment, but the history also provides insight into the client's healthcare teaching needs, which may include nutritional counseling or smoking cessation.

Vital Signs

At some point during or immediately after collecting subjective data, nurses assess vital signs: blood pressure, temperature, pulse, respirations, and what is now called the fifth vital sign, pain, which is discussed later in this chapter. Vital signs reflect the client's overall health and changes can indicate serious illness. Therefore, nurses need to know both technique and interpretation. For example, you need to know how to use different types of thermometers, as well as know that an increase in temperature can signify problems such as infection, increased stress, heat stroke, and some types of cancer. Pulse and respirations are more than just numbers. Did you know there are 17 pulse sites? Both pulse and respiration have characteristics such as rhythm and quality, and respiration characteristics also include depth. A slow pulse (under 60 beats per minute in an adult) is called bradycardia, while a rapid one (greater than 100 beats per minute in an adult) is tachycardia. Dyspnea means difficult breathing.

Blood pressure may be measured directly with a catheter placed in an artery, a measurement monitored by critical care nurses. But most nurses use the indirect and more commonly known method, using a stethoscope and sphygmomanometer (blood pressure cuff). For those people with hard to hear blood pressures, nurses use the Doppler method, an electronic system similar to home blood pressure machines. Blood pressure assessment takes skill. An overly wide cuff can cause a falsely low reading, while a cuff that's too narrow can cause the reading to be falsely high. Readings are typically documented in fraction form, with one number over another. The top number is the systolic blood pressure; the bottom, the diastolic. Normal adult blood pressure is 120/80.

Measurements

If you're health conscious, you know about measuring height, weight, and basal metabolic index. But you'll go beyond the bathroom scale as a nurse—you'll learn to use chair and bed scales, as well as standardized height and weight charts. More importantly, you will learn how weight provides important information about clients' nutritional and hydration status. Weight can also help evaluate treatment response, particularly in clients who are receiving diuretics (water pills).

According to the Centers for Disease Control and Prevention (CDC), body mass index (BMI), a number calculated from a person's weight and height, is a reliable indicator of body fatness for people. While there is a mathematical equation to determine BMI, most nurses rely on a BMI calculator, such as the one on the National Institutes of Health's website: www.nhlbisupport.com/bmi. BMI is used to screen, not diagnose, weight problems, using standardized weight status categories that are the same for all male and female adults 20 and older.

BMI Categories

Physical Assessment

Physical assessment involves using your senses to obtain objective data from clients. The physical boils down to four assessment techniques: inspection, palpation, percussion, and auscultation. Inspection involves careful observation of behaviors and physical features, such as inspecting the skin for rashes. Palpation is the use of the fingers and hands to gather assessment information through touch. The nurse palpates the abdomen to see if the liver is enlarged. Percussion involves listening for specific sounds while tapping the fingers on certain body areas. The nurse can percuss the bladder to determine if it is filled with urine. Auscultation is the listening for the sounds of movement within the body using a stethoscope. The nurse auscultates the lungs to assess the quality of air movement.

All nurses perform some level of physical assessment, but complete head-to-toe assessment is usually reserved for registered nurses who attained the baccalaureate and/or a higher level of education. Bachelor-prepared nurses take a course in health assessment, where they learn both technique and interpretation. They use their assessment skills as part of the nursing process. Advanced practice nurses, prepared at the master's or doctoral level, use advanced physical assessment skills to make diagnoses.

Client Hygiene

Nurses assist clients with their most basic needs: eating, toileting, and sleeping. Nurses help patients eat regular meals or special diets, and they feed patients through devices, including nasogastric (nose to stomach) and gastrostomy (directly into the stomach through the skin) tubes. Nurses certainly handle their share of bedpans and urinals, but they also maintain elimination by inserting and monitoring urinary catheters, and care for ostomies, surgical openings created to allow clients to urinate or stool through an opening in the abdomen. Healthy sleep begins with a comfortable bed, and nurses develop bed-making skills that allow them to make beds while clients occupy them.

Infection Control

Infection control involves hand hygiene, preparing sterile fields, and using standardized precautions. You're probably wondering why something as everyday (hopefully, more often!) as handwashing is listed as a skill. But proper handwashing is the most important defense against spreading infection, and once you learn proper handwashing, you'll never go back to your old way again. Hand hygiene also includes the proper use of alcohol-based rubs, which can substitute for handwashing in some situations.

Sterile fields provide aseptic (germ-free) workspace. Nurses prepare sterile fields to dress wounds and perform sterile procedures. Standardized precautions prevent the spread of infectious diseases through the use of personal protective equipment (PPE) that includes gloves, masks, gowns/aprons and eye shields that form barriers between the nurse and client. The type of PPE used varies based on the type of exposure anticipated or category of isolation determined by CDC guidelines. Nurses also use standard precautions for all clients, in all settings, regardless of suspected or confirmed infectious status. These precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. The precautions include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. For some procedures (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary.

Specimen Collection

Specimen collection aids in the screening and diagnosing of illnesses, directing of treatment, and monitoring of progress. Nurses collect a number of specimens, but the most common are blood, urine, and stool. They regularly perform glucose monitoring on diabetic clients, check urine for specific gravity, blood, and bacteria, and check stool for occult (not visible) blood. Pediatric nurses regularly swab children's throats to test for strep throat, while women's health nurses may collect specimens during a gynecological exam to assess for sexually transmitted diseases and cervical cancer. Forensic nurses collect specimens for DNA testing.

Medication Administration

Medication administration is a common but crucial function that requires defined skills and considerable knowledge about pharmacology and clients' health status. Nurses need to know drugs' generic and trade names, classification, action, indications, dosage, delivery method, side effects, precautions, contraindications, effects on laboratory tests, drug-to-drug interactions, nursing considerations, and client teaching needs. Here is some of what nurses need to know about aspirin, a seemingly simple medication:

Generic name: Aspirin and acetylsalicylic acid.

Trade names: At least 18, including ASA, Bayer Aspirin, and Ecotrin.

Classification: Nonopioid analgesic (pain reliever) and antipyretic (fever reducer). (Nurses need to know that aspirin is also used as an anti-inflammatory and anticlotting medication.)

Action: Aspirin is thought to relieve pain by inhibiting prostaglandin and other substances that sensitize pain receptors. It may reduce fever by acting on the hypothalamic heat-regulating center and may exert an anti-inflammatory response by inhibiting prostaglandin and other substances. Low doses of aspirin seem to interfere with clotting by keeping a platelet-aggregating substance from forming.

Indications and Dosages: For mild pain and fever in adults and children over 11 years old: 325 to 650 milligrams every four hours as needed. For the inflammation of arthritis in adults: 2.4 to 3.6 grams daily in divided doses, followed by a maintenance dose of 3.2 to 6.0 grams daily in divided doses. To reduce the risk of stroke in adults: 50 to 325 milligrams daily.

Delivery method: Orally (tablets or chewing gum) or rectally (suppositories)

Side effects: Tinnitus (ringing in ears), hearing loss, nausea, gastrointestinal bleeding, upset stomach, prolonged bleeding time, leukopenia (low white blood cell count), thrombocytopenia (low platelets), hepatitis, rash, bruising, hives, angioedema (allergic skin disease), Reye's syndrome (potentially fatal disease in children), and hypersensitivity reactions.

Precautions: There are multiple precautions, including use with caution in persons with impaired kidney function, vitamin K deficiency, or low platelet count.

Contraindications: Aspirin is contraindicated in clients who are hypersensitive to the drug and persons with certain gastrointestinal problems or bleeding disorders.

Effects on laboratory tests: May interfere with urine glucose analysis.

Drug-to-drug interactions: There are several, including: anticoagulants (increases risk of bleeding), oral antidiabetics (may increase low blood sugar effect), and antacids (decrease aspirin effect). Some herbal drugs interact with aspirin, increasing the risk for bleeding.

Nursing considerations: Enteric-coated and slow-release tablets should not be used for acute pain or fever because these preparations are slowly absorbed.

Client teaching: Some over-the-counter (OTC) preparations contain aspirin; read labels carefully to avoid overdosing. Alcohol may increase the risk of bleeding, and caffeine may increase aspirin absorption. Clients on low salt diets should be aware that buffered aspirin contains 553 milligrams of sodium. Because there are so many drug-to-drug interactions, clients taking prescription or herbal medications should speak to their healthcare provider before taking aspirin or OTC products containing aspirin.

Medications are administered orally, rectally, vaginally, intravenously, and topically, as well as under the tongue and via injection. Nurses also administer eye, ear, and nose preparations. When administering medications, nurses adhere to the client "Rights to Medication Administration": right medication, given to the right patient, in the right dosage, through the right route, at the right time. Additional suggested rights are giving the medication for the right reason and ensuring the right documentation. Nurses also assure that clients understand their responsibilities about their medications, especially if the client will be responsible for self-administration.

Pain Management

Nurses ensure clients' comfort in a number of ways such as fluffing a pillow or holding a client's hand. But pain management is the most important and complex comfort mechanism. No two people experience pain the same way since people have different perceptions and responses to pain, necessitating careful assessment. When assessing pain, nurses consider location, intensity, quality, and temporal pattern. Superficial pain emanates from the skin or just below it, allowing the client to easily demonstrate where it comes from. Internal pain, however, may not be localized and may actually be felt in an area distant from the affected organ. For example, a patient with a heart problem may feel the pain in his left arm. Clients may describe their pain as mild to severe or on a scale of 0 to 10, with zero being no pain and 10 being the worst pain they ever experienced. Quality refers to how the pain feels, such as sharp, dull, or stabbing. Clients may find an analogy easier to describe their pain and use phrases such as "like a knife went through me" or "being hit with a hammer." Pain from a heart attack may be described as "It feels like an elephant is sitting on my chest." Temporal pattern stands for when the pain started (onset) and how long it lasted (duration). Clients may have pain all the time, for one occasion, or intermittently, as pain may be acute or chronic.

Nurses manage pain through physical, cognitive, behavioral, and pharmacological therapies. Physical pain relief includes repositioning, hygiene, and cutaneous stimulation. Repositioning a bedridden client can relieve pain from pressure spots, while simple cleaning can decrease discomfort from irritated skin. Cutaneous stimulation refers to heat, cold, massage, vibration, and the application of pain-relieving ointments. All help to relax and distract clients and create an analgesic (pain relieving) effect. Cognitive techniques work well with certain types of pain. Distraction (looking at comforting pictures or listening to music) helps with brief periods of pain, such as those experienced when undergoing a procedure. Guided imagery can minimize pain or act as a pain substitute, while anticipatory guidance teaches clients how to minimize pain before it happens. Behavioral techniques such as relaxation and meditation can enable clients to feel a sense of control over their pain. Pharmacological pain management relies on analgesic medications, some of which are potent and highly regulated narcotics, requiring the nurse to monitor for adverse effects such as respiratory problems, tolerance, dependence, and addiction. Nurses administer analgesics and evaluate their effectiveness.

Perioperative Care

You may have no plans to ever set foot in an operating room after graduation, but chances are that you will spend some time there doing a clinical rotation when you are a nursing student. Many illnesses and injuries require surgery, which may be minor or major, planned or unplanned, and may involve one body part or a whole system. Surgical procedures may be performed in a hospital, physician's office or clinic, or an ambulatory surgical center, and many surgical procedures create stress, necessitating physical and psychological adaptation for the client and family. Surgery can affect activity, nutrition, temperature regulation, urinary and bowel function, sleep, body image, and relationships. Most postoperative clients will experience pain, and most are at risk for bleeding and infection. Client recovery commands knowledgeable and skillful nursing care, referred to as perioperative care when it encompasses care before, during, and after surgery.

Preoperatively, nurses perform a comprehensive assessment to look for risk factors that can contribute to complications from the surgery or the anesthesia. This assessment includes a history and physical assessment, as well as monitoring laboratory tests such as blood studies (including type and cross match in case transfusion is needed), urinalysis, electrocardiogram, and chest x-ray. Nurses also teach clients what to expect during the surgical phases and how they can participate in their own recovery. Surgical preparation can be extensive as some clients needing IVs, medications, stomach decompression, bowel cleansing, and operative site cleansing and shaving. During surgery, nurses may act as either a scrub nurse who provides the surgeon with equipment or a circulating nurse who protects the client's safety and health needs. Operating room nurses also assure that equipment functions properly. During the postoperative phase, which begins when the client enters the recovery facility, nurses perform continuous monitoring to detect possible complications and assure the client's comfort.

Client Teaching

Give a man a fish; you have fed him for today. Teach a man to fish; and you have fed him for a lifetime.

—Author unknown

Learning empowers clients to manage their healthcare problems and possibly achieve a higher level of wellness. Nurses frequently teach clients and reinforce information from other healthcare providers. Hospital nurses teach illness management; school nurses teach nutrition; occupational nurses teach work safety; psychiatric nurses teach coping skills; and forensic nurses teach about violence prevention.

Hospitals seem like great places for illness teaching, but the stress of illness and hospitalization can hinder learning, creating challenges for the nurse. Added to this is the increasing knowledge level of today's healthcare consumer, thanks to the Internet. Clients can google practically every disease and health topic known to mankind and find a plethora of information. Unfortunately, clients may not be able to differentiate fact from fiction because some web sites provide inaccurate information. To meet these challenges, nurses apply the nursing process to client teaching and begin with assessment of clients' learning needs. Nurses first analyze the client's baseline knowledge with broad opening statements like, "Tell me what you know about your diabetes." This gives the nurse someplace to begin. Nurses next assess the client's health and cultural beliefs as well as their language skills, since these factors can impact on the teaching-learning process. For example, some cultures utilize folk medicines and nurses need to accept client beliefs and integrate them into the teaching-learning process. Nurses identify client priorities and motivation. For example, a postoperative client with newly diagnosed high cholesterol may be more interested in learning how to get back to work than learning about a low fat diet. Nurses can teach this client about his priority need and still develop a discharge teaching plan that creates an opening for him to later learn about the diet. Finally, nurses assess the client's literacy level and physical state. The client's ability to read and write guides how the teaching will proceed, and the client's physical state determines the client's ability to process information. Pain and other issues may diminish concentration.

Once nurses complete their assessment and diagnose the client's knowledge deficit, they identify outcomes, then create a teaching plan and implement it. Most nurses teach clients on a one-to-one basis, using teaching aids such as pamphlets, DVDs, and models; others teach client groups. The latter is typical of nurses who teach clients to care for their diabetes, chronic lung disease, or heart problems.

Nurses teach about all illnesses, but they also teach about health, helping clients to attain and maintain an optimal level of wellness. Health teaching spans the lifecycle, requiring nurses to know development. Infants are not ready for formal education, so nurses teach parents and encourage them to provide their infants with safe, developmentally enhancing toys. Toddlers and preschoolers learn though play. Toddlers like to imitate and preschoolers ask lots of questions. Preschoolers are usually proud of their accomplishments and thus respond well to teaching that is accompanied by praise and stickers. School-age children enjoy learning about their bodies, and can understand cause and effect, allowing nurses to help them set goals. Adolescents strive for independence and appreciate having some control over their healthcare. Adult learners respond well to straightforward teaching that allows them to apply their newfound knowledge immediately. Knowledge does not decrease with age unless affected by illness, and older adults usually have as much to teach as they do to learn. Healthy lifestyle teaching pertains to the whole lifespan, thus nurses continuously teach about proper nutrition, normal sleep and elimination patterns, exercise, and stress management. But each developmental stage presents with its own health needs as exemplified in the following table.

Examples of Wellness Topics Taught by Nurses

Counseling

Nurses do not provide psychiatric therapy, unless they are advanced practice psychiatric nurses, but they do counsel clients. Nurses counsel clients as they adapt to changes in life, body image, role performance, self-esteem, and personal identity. They counsel families about relationships and the changes in those relationships, including divorce. Nurses counsel about loss and grief. Loss can be anything from empty nest syndrome to the death of a loved one, and grieving manifests differently in every client. Nurses counsel by helping people identify their strengths and mobilizing their resources. They teach coping skills, stress management, and problem solving, and they enable clients to work through the stages of grief.

Informatics

Informatics evolved over the last four decades to assist nurses in all areas of nursing practice. Thus today's nurses need to be as savvy with a computer as they are with a ventilator. While this field has become a nursing specialty in its own right, most nurses work with some form of computerized system. Computerized systems aid in assessment because many programs prompt nurses to ask clients further questions as the nurses enter data. The program then analyzes the assessment data to generate possible nursing diagnoses and potential interventions. Computerized nurses' notes sort and print out client data, including vital signs, medications, and treatments to make documentation more efficient and accurate. If you're concerned that you lack the technology skills to be a nurse, don't worry. Most nursing programs have resources to help turn the novice computer phobic into a proficient computer techie.