1. Laskowski-Jones, Linda MS, APRN, ACNS-BC, CEN, NEA-BC, FAWM, FAAN

Article Content

MANY YEARS AGO, I worked as a critical care nurse internship instructor in a year-long program open to newly graduated nurses. Along with three other instructors, I taught nurse interns the art and science of caring for patients in emergency and critical care settings. We always began their initial clinical rotation on a step-down unit to let them gain experience and confidence before going into higher acuity areas. I sought patient assignments that offered them ample opportunities to learn new skills and refresh ones they were taught in nursing school. One particular patient really fit the bill. I will call her Nettie.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Nettie was in her early 70s when she was admitted emergently after an abdominal aortic aneurysm ruptured at home. Despite an aggressive resuscitation and an emergent aortic repair performed by the cardiothoracic team, she was hypotensive for so long that she was thought to have a brain injury. She spent at least 2 weeks in the ICU before being transferred to the step-down unit with a very poor prognosis for a functional recovery.


Nettie did not open her eyes or respond to voice, but she did grimace and move purposefully to pain. Because she developed a transmissible infection, she was given isolation status and placed in a private room. She had a tracheostomy and was on a mechanical ventilator. Devastated, Nettie's husband visited her every day. Knowing that she would likely never return home, he sold Nettie's car.


I selected Nettie for my two new nurse interns as their very first patient assignment. In the first week, I had both nurse interns work with me in a team effort as I assumed direct care responsibility for Nettie. With this arrangement, I could take the necessary time to teach them how to properly don and doff their personal protective equipment, perform a comprehensive physical assessment, prepare and administer a myriad of medications through her feeding tube and vascular access devices, care for the surgical wound, and manage her ventilator and other critical equipment. We bathed Nettie, tenderly applied moisturizing lotion to her skin, turned her regularly to prevent pressure injuries, and moved her extremities through their range of motion to avoid contractures and to keep them flexible.


As we cared for Nettie, we continuously talked to her in a conversational manner and told her about current news and world events. I stressed to my interns the importance of never leaving patients out of bedside conversation and to always talk to patients as if they are hearing and aware of everything. When we stepped away from the bedside, we turned on Nettie's TV for additional stimulation and made sure she could hear and see it if she opened her eyes. After a few days of this regimen, my nurse interns gained confidence and began to perform much of Nettie's care under my watchful eye. Then something miraculous happened.


Unexpected response

Nettie opened her eyes and made real eye contact with us. In short order, she started to follow simple commands. Within another day, she began mouthing words, but her tracheostomy tube prevented speech. We immediately notified her physician, who reevaluated her and initiated more aggressive ventilator weaning measures. Nettie's husband was elated.


Returning to the unit after a weekend off, I assigned one of my nurse interns to provide more of Nettie's care by herself under my supervision. Upon receiving the morning report on Nettie, I learned of her incredible weekend progress-she had been taken off the ventilator and had received a new tracheostomy tube with a speaking valve. Nettie's first words were strung together in a full sentence that I will never forget: "The queen of Africa died."


The step-down unit nurses were delighted with this new development, but they chalked up her odd statement to "confusion" and hoped it would resolve as she recovered. I did as well-until we turned on Nettie's TV and heard the morning news as we began her daily routine. A queen in Africa had indeed died in recent days. Nettie smiled and simply stated that she had once met her.


When Nettie's husband visited that day, I related this unusual story. He broke into a wide grin, nodded, and regaled us with tales of their travels in Africa and around the world. It turns out that Nettie was not at all confused; she was just relaying current events to us as we had to her.


Perhaps the most telling moment that showed Nettie's indomitable will to recover occurred when her husband sheepishly admitted that he had sold her car. She indignantly informed him that he was going to have to go buy her a new car because she intended to drive again.


Driving ahead

Over the years, a mutual acquaintance kept me posted on Nettie's life after hospital discharge. Nettie never forgot us and wanted us to know that she did indeed resume driving. Following months of therapy that included inpatient rehabilitation, Nettie got that new car and drove again for nearly another decade. I am forever grateful that Nettie showed all of us that great nursing care, hope, and a strong will make a difference.