RN Tips: Do You See the Whole Picture?

After several memorable incidents with task-oriented nurses, I decided it was time for action. I wanted to know what nurses actually observed when entering a patient's room. Some nurses arrive at the bedside without seeing anything else in the room, without seeing the whole picture.

The Incidents

Although some of these incidents involve LPNs, they are not the only nurses who fail to recognize sudden condition changes a patient may be experiencing or whether dangers are lurking in the environment. I personally witnessed some of these incidents.

• An LPN was delegated to check blood sugars for the team. His focus was only on performing the finger stick; he failed to notice the patient had become unresponsive in the process of a cerebral stroke.

• An LPN was inserting a foley catheter on a male patient who had turned bluish purple and stopped breathing. We were not able to revive the 45-year-old patient during the code.

• An overzealous nightshift RN who checked oxygen saturations on every patient, including her patient with COPD. The results was 88%, which, had she reviewed his records, was normal for him. After applying oxygen, the patient began to lose consciousness. Fortunately, it was noted the patient lost his drive to breathe because of the oxygen and higher saturation. When the oxygen was removed, the patient returned to his baseline level of 88% and was fine. The incident could have killed him.

• A woman admitted to the ICU after surgery was noted to have a low oxygen saturation level despite oxygen therapy. The patient received sedation as the doctor prepared to intubate her. I walked in to assist when I informed the respiratory therapist that she inadvertently connected the patient to air instead of oxygen. Once on oxygen, the saturation improved to high 90s. The patient was not intubated, another near-miss incident.

• An elderly man went through two shifts before anyone noticed he was using a bread bag as a colostomy bag.

• An elderly woman on our unit for more than 12 hours before anyone noticed she had a stage 4 sacral decubitus. Even the emergency room staff failed to assess and document the ulcer.

• The patient whose wrist restraints were improperly attached to the side rail suffered a broken wrist when the rail was lowered.

• The patient admitted for chemotherapy who constantly complained of leg pain. He was on home injections of a white blood cell booster. After his third admission day, someone finally looked at his leg, it was noted he suffered from the flesh-eating bacteria. He eventually underwent amputation of the leg.

• Several incidents of patients receiving chemotherapy or other IV fluids at the wrong rates and doses. Patients who were instructed to silence their own IV pumps. One incident involved a poorly spiked IV bag, which caused a portion of the chemotherapy infusion to slowly leak on the floor. Chemotherapy spills in the patient's environment are hazardous to anyone who enters the room.

• A patient who suffered arm necroses due to an infiltrated chemotherapy drug. My husband suffered from infiltrated IVs daily because his inexperienced nurses did not recognize the signs until at least 500 cc of IV fluids infused (initially, they did not recognize he had an infusaport.)

• One of the worse incidents led to the nurse being fired and her license suspended. In the mid-90s, I admitted a gravely ill AIDS patient who suffered multiple skin lesions, Kaposi Sarcoma. When the patient died within 12 hours of admission, the nurse told the doctor that he appeared to be breathing when she observed him on rounds. Because of her comments, the incident was investigated and she was removed from patient care. It was later learned, she was so afraid of contracting the disease that she failed to go past the door during her shift.

• A patient fell and broke his hip attempting to reach his bedside table.

• My husband's colostomy bag unattached with stool covering the entire front portion of his body after the nurse should have performed an initial assessment. The nurse was angry because he had a new complaint of back pain that was unrelieved by analgesics. I discovered that his air mattress had deflated and he was actually lying on the metal bed frame for 8 hours.

• There were also incidents of nurses and prison guards leaving dangerous items at the bedside. For instance, a patient swallowed two caps used to plug IV tubing, thinking they were pills; an inmate saved syringes (overfilled needle box) to inject his pain medications. On our hospital prison ward, an officer left his mace on the patient's bedside table, an inmate removed the metal strip from a flashlight to use as a weapon and an inmate saved and used his sheets to escape our hospital ward (no one noted he did not have dirty linen). He was found hiding under a house in the neighborhood.

The Whole Picture

Because of these incidents and many others, I discovered that

• Many nurses failed to look under the blanket to assess patients

• When a nurse is task-oriented, they may fail to see the whole picture

• Patients have been seriously injured or died when a nurse has tunnel vision

• It would be interesting to know exactly what a nurse see (or don't see) when he enters a room.

• Patients and others can be injured by environmental dangers

I decided to test nurse's skills of observation. I used an empty room to set up a scenario I named, "Seeing the Whole Picture". I placed a CPR full body mannequin in the bed with the blankets pulled up to her neck. I wanted to see if nurses paid attention to the environment and patient safety in addition to monitoring the patient. Each nurse would have to list anything out of the ordinary while in the room. Head nurses actually sent their nurses to my ward because they were having the same problems. Examples of the scenario setup include:

• Notes were placed on the "patient's" back for collapsed lung; on her arm-an "infiltrated IV" site; on the heel- a "skin breakdown".

• A sign on the floor at the other side of the bed-"fluid spill".

• Oxygen is not turned on but patient was wearing nasal prongs (at least in one nostril).

• Empty glove box and full needle box

• Wrong IV fluids and rate

• Isolation Precautions

Each nurse was to "make initial rounds" and write a list of things they found wrong. The list should have included at least 15 items but amazingly, many nurses missed the collapsed lung, oxygen, and fluid spill. Some removed the blanket but failed to look at the whole patient. No one noted the dangers of an overfilled needle box or the lack of gloves on a patient who was on isolation.

The experiment was a real eye-opener and learning experience for all involved. I gave each nurse small potted plant cuttings for participating. Do you see the whole picture? Try it on your unit.