Yesterday my patient’s skin peeled and pulled away from her fingers and toes. In the past week she had gained twenty pounds from water retention. The swelling stretched her skin until it radiated a watery sheen. As the swelling began to go down, the skin rebounded, dried, and flaked. I took off her anti-embolism hose and her sequential compression devices and released the smell of dirty gym socks. She was depressed, withdrawn, un-communicative, because a surgery she expected to earn her a brief hospitalization had incurred Murphy’s Law. She entered her fifth week in ICU with a tracheostomy and a surgically inserted feeding tube. I understood her frustration.
After trach care, catheter care, blood sugar checks, and adjusting IV drugs to a prescribed blood pressure parameter, I wanted to do something for her, not to her. I warmed up lotion and lavished her hands with it. Every finger got special attention. I remembered how pressure to my fingers during stress reducing massages seemed to release the tension in every muscle of my body.
I dialogued in an effort to break her silence. “You know why I’m doing this don’t you? If my mother were in your place, I would want to come in for a visit and know someone had cared enough to do it.” I moved to her legs and feet. I washed them warm wipes, slipped the disposable cloths between each toe. I slathered lotion on legs where lines of dryness mapped her skin in white. She grimaced when I rubbed lotion into her right ankle. “That really hurts.” No response. “What about the left one?” She actually nodded in response to my question.
Then for a dignified, mature woman, whose best friend told me she was meticulous about her appearance, disaster struck. She passed an enormous bowel movement, something the general surgeon would celebrate. It added to the patient’s humiliation and loss of her sense of self. How could I convince this stoic, regal woman that just this once, normal human bodily function meant she was one step closer to getting well.
I gathered cleaning supplies, linens, and another set of hands. “Now I’m going to bore you with some stories.” I warned. Stool puddled between the woman’s legs and housed itself in any crevice it could find. I had used stories before with a young male patient to pass the time when he found himself in a similar situation.
I talked about my grandmother, widowed after World War I, she raised four children on her own. “My grandmother worked to provide for her girls. When I knew her, she never was in anything but a skirt, her strawberry white hair in a chignon, and her nails long and perfectly polished.” I think grandmother resonated with my patient. I could tell she was listening. My helper and I started to mop and wipe and clean and contain the flood of excrement.
“For supper one night, the family enjoyed a roast, probably a rarity in that day. The oldest sister cut and served while the others ate. Before she could sit down to eat, one sister was back for seconds. The eldest picked up the roast and threw it at the offender. All my grand-mother could say was: ‘Girls. Girls.’” What I was trying to tell her was that we are all human, subject to human frailties and that this moment would pass. She smiled.
A week before that I cared for an octogenarian who lived alone. He began to hallucinate and provided intricate details of what he saw. He realized he was seeing things. The anxiety left him restless. He hollered for someone to come and kept punching the call light. I knew his daughter was coming. I pulled up a stool and sat beside him. “Tell me what you see.”
“Right now I see you encased in a sheet of water. It’s all around you.”
“I believe that’s what you see.” I held out my hand, not to deny him, but to share what I saw.
“I know there’s no rain, but I see it.”
“What else do you see?”
For the next forty minutes he created what I interpreted as his view of Heaven. He detailed with the precision of an engineer, a lift. It had a broad platform and inched upward toward Infinity. He talked about pulleys and cogs and people. “You were there too.”
He looked straight at me when he said this.
I shuddered like I had has a child, when other children who noticed me shake, said: “A rabbit just ran over your grave.”
In all the time he spoke his visions, I just listened and wondered what it all meant. Then the man uttered the words that explained it all.
“I think I’m dying.”
I sat with the man until his daughter arrived.
It is a cliché to refer to long standing definitions, but Florence Nightingale defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery.” (1860) I added the italics. Our patients come to inhabit bland, functional rooms, filled with outlets, equipment, monitors, electric beds, television, climate control, negative pressure, and, if they are lucky, a window. But they also come with an inner environment which constructs the essence of who they are. The greatest privilege in nursing is being allowed into that most private place. Entering there may be one of the most important parts of a patient’s survival. The ability to gain entry is one element of the unquantifiable art of nursing.
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