The husband called, introduced himself and explained the malfunction. The connector portion of the tube had lost its elasticity and whenever his wife coughed, stomach contents came out of the tube. Further interview helped me gain information about the family unit function. The husband was sole care-giver of his wife, a stroke victim with damage to the nerves necessary for swallowing. I assessed the family dynamic so I could work to maintain a therapeutic community (HELPING ROLE). It was unsafe to give nourishment through the mouth since an absent gag reflex made aspiration a danger. The husband understood all this. All his wife's nourishment/fluids came to her through the G Tube and immobile patients need adequate nutrition/hydration to combat the hazards of immobility (MONITORING THERAPEUTIC INTERVENTIONS). My initial thought was to bring the patient into the GI clinic for adjustment/replacement of the adapter. I asked the husband to give me a few days to arrange the visit/ambulance/doctor for replacement of the broken parts. He agreed and seemed relieved to be able to speak with someone who knew just exactly what his problem was and was willing to arrange a solution.
I was impressed by the great deal of concern the husband had for his wife and told him so. I offered encouragement for his continued attention to his wife's care (HELPING ROLE - EMOTIONAL AND INFORMATIONAL SUPPORT TO PATIENT'S FAMILIES). I made use of this opportunity to reward a family member for efforts in maintaining healthy behavior in the face of what may seem like massive disease, i.e., stroke victim.
I discussed the facts of the case with the MD Team Leader (GETTING TIMELY RESPONSE FROM PHYSICIAN - ENSURING QUALITY HEALTH PRACTICES). We agreed on the intervention and both felt it was a shame to waste the time and effort to bring the patient in when ten minutes was all that was needed to replace the part in the hands of an experienced GI Technician. "You could do it, Tony", he said.
It occurred to me that most CVA patients have some contact with our Home Health Agency to assess the after care needs of a patient able to live at home. My hunch was right. I confirmed the interface with Home Care and asked to speak with the nurse assigned to this case (ORGANIZATIONAL AND WORK-ROLE COMPETENCIES). Paul, an H.H.N., returned my call advising me the case was closed to his department. I discussed the problem with him and we both felt we should re-open the case. I filled out the necessary forms; however, there was yet another snag holding up things. Paul had never seen a placement or change of these devices. "No problem", I said, "find some time to drop by my clinic and I can inservice you in 20 minutes." (BUILDING A THERAPEUTIC TEAM)
That afternoon Paul came by and I showed him a video on Percutaneous Endoscopic Gastrostomy Placement (PEG). We opened a PEG kit to get the parts we needed and used the rest of the kit for "hands-on" teaching. Paul stated he felt comfortable with this plan and would arrange a visit within 2 days. One day after our initial contact I phoned the husband to discuss our plan. He remembered Paul and agreed it would be better not to bring his wife in by ambulance. He thanked me for my concern and help. I replied with praise for his attention to care. I explained that it was my privilege to assist his remarkable efforts.
A word now about cost. We solved this problem with a $125.00 PEG kit, plus a Home Health Nurse visit. The standard plan would involve an ambulance (@ $300), an Endoscopy procedure (@ $350), and risk to the patient. Saving money is okay, but the thrilling part is to know my ingenuity and resourcefulness combined with clinical knowledge got the job done right.
A few days after his incident Paul called to report that everything went as planned. We discussed how easy it was and I encouraged him to survey the Home Care patients to give us some idea as to how many PEG's were in place in our population. He reported that there were about 10 patients maximum. I have subsequently managed to obtain the PEG replacement parts, without opening a kit, bringing the cost down to $4.00 plus a home visit.
Earlier, I described my feelings about putting this deal together as thrilling. It really is a charge! There are no needles, no drugs, no sheets or bedpans, no signs of nursing involvement. But, to think my involvement as anything other than nursing would be an error. Management of the "human experience" of disease or loss is nursing, and that is what I do best.
Anthony Dombroski, RN
My role in G.I. includes proficiency in all procedures as well as advice. I know that if we can do this now in the office, we can perform a safer, more complete exam. and possibly save a hospital admission. I call home and arrange my personal plans as this all will keep me in the clinic far after my shift ends. It is worth my time to provide expert care to the patient, as well as protect our investment in very costly equipment. The cost of repairs and frequency of breakdowns is minimized when only trained personnel assist is the feeling expressed in the G.I. literature (ORGANIZATION AT WORK ROLE COMPETENCIES).
After setting up the room and preparing all the widgets we used to disimpact an esophagus, I run to E.R. to meet Mr. S. Dr. G. is in discussion with the E.R. physician. I interrupt, tell him we're ready and that I'll go see the patient first. Mr. S., emesis basin in hand, is clearly in distress. I close the doors, pull the curtain, gain a little quiet, introduce myself, and begin to explain this rather bizarre procedure. I can see that my explanation is sinking in as my patient nods and agrees at all the proper junctures in our conversation. He states he understands. I also can see his shoulders and posture relax as my message of confidence and competence is understood. Compliant, cooperative patients need less meds, suffer less complications, and ensure successful procedures (TEACHING COACHING FUNCTION).
Dr. G. comes in and dovetails his explanation with mine. The procedure goes as planned. We push the meat impaction through the esophagus and continue with a complete esophagogastro-duodenoscopy. Mr. S. has a particularly rigid esophagus with normal mucosa. It appears as though he may have an extra-luminar process affecting his swallowing. In his age group this usually means cancer; inoperable, fatal. To further visualize this area, Dr. G. has ordered a CAT scan after informing Mr. S. that this may mean he has a tumor in his chest. After recovery, I offer to walk Mr. S. to Radiology and facilitate this booking process. The news of cancer has taken Mr. S. by surprise. Being with him now helps even though he moves with a leaden slowness and stares at the floor in front of him (HELPING ROLE).
As we walk to the elevator silently, he turns to me and asks, "So this is cancer, eh?" "That's one of the things we are trying to determine with this CAT scan", I reply. More silence. As we reach the basement he says, "This doesn't have anything to do with me swallowing lye when I was a kid, does it?" Stunned, I reply, "It sure does, Mr. S., it sure does!" I'm elated to be there when the missing piece of information is revealed. Back on the elevator to more talks with Dr. G., revise our grim outlook, and allow us to send Mr. S. home that day without the specter of cancer hanging over his head.
The question of lye ingestion is no longer standard, thanks to society's safety efforts. Days or
weeks of worry were avoided by having me be available to listen patiently to Mr. S. Expensive
tests were avoided and, best of all, the patient left with a smile on his face understanding
completely what his problem was all about.
Anthony D. Dombroski R.N.