The patient lifts his shirt and lightly touches his belly; his abdomen heaves and recedes. In my 26 years as a nurse, I have never seen anything like it. Snakes-that's what it looks like, and I am reminded of the line from Raiders of the Lost Ark: " Indy, why is the floor moving?" His abdominal wall is stretched so thin that a student nurse and I can see the peristaltic waves crossing the intestine.
Timothy Jeffries was admitted with acute abdominal pain three days ago; now his pain has resolved and bowel sounds are present. He has been restricted from oral intake for days, and last night his IV line blew. No one seems to be able to find a vein. Mr. Jeffries just wants to go home.
Before we can consider that, I talk to the student about assessing Mr. Jeffries. The stress of the hospitalization and the resolved intestinal obstruction, along with the rocking and rolling of his innards, indicate his potential for gastrointestinal bleeding. Having been without food or drink for days and with no IV infusion for 10 hours, he is dry as a chip. I know this, but I must teach the student to collect the data that inform diagnosis.
"What's his urine output?" He has not voided yet, but Mr. Jeffries says he might be able to "squeeze out a few drops." I ask about his tongue. "Moist," the student says. His pulse and blood pressure? "Normal," she replies. Next, we look at his skin turgor: it's delayed. "Let's see," I say. "Some symptoms say his fluid balance is fine; some say he is dry. What could we do to gather more data?" Immediately, the student says, "We could check his urine for specific gravity." Off we go to get what we need, and why not get the stool guaiac test, too?
But there are no urine dipsticks to check for specific gravity. No stool guaiac or gastric bleeding tests, either. I ask the head nurse, "Where's the stuff we need to do patient care?" She tells me that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made ensuring competency in these simple tests so difficult that having them is now cost prohibitive. The irony is that no one complains about the expense of putting almost all surgical patients on H2-receptor blockers-it's easier to medicate than to diagnose.
Who has decided to take away tools that have such practical value? Why would JCAHO, created to ensure the safety of care, enforce stringent guidelines that raise the cost of such important tools? I call three hospitals and find that other nurses have been pressured to give up such tests but had suggested other ways to cut costs. Decisions that affect practice are made without involving caregivers, and some bedside nurses simply gave up the fight.
If you are a hospital administrator or a patient care manager, ask nurses before you toss away an essential tool. You may have just undermined the very thing you sought to protect-patients' health-by removing my stuff!! It's time to involve bedside nurses in boardroom decisions.
Nurses, we can and should influence decisions. It's time to find our voices, but doing so requires confidence, competence, and comfort-things not possible if we don't value our work or the roles we play in health care.
When Mr. Jeffries is discharged he is still dry. We wheel him to his car and overhear him and his wife talking about the chicken soup waiting at home. We can only hope that the tensile strength left in his abdomen is enough to prevent the snakes from roaming.