Professional Caring

Abstract

On the CCRN and PCCN test plans, 80% of the questions are based on clinical knowledge, and 20% of the questions come from a category called Professional Caring and Ethical Practice.1 Why is clinical knowledge not enough to pass a certification examination? Clinical knowledge is one aspect of excellent nursing practice, but it is not the only thing necessary. A great nurse not only has expertise but also uses caring communication to translate clinical information into clinical meaning for patients and their families. For example, a family member with limited medical knowledge may see a blood pressure value on the monitor and think that because the number looks better, the patient is doing better. However, a nurse with good communication skills can compassionately explain that the blood pressure number has only normalized because the patient is now receiving multiple vasoactive agents and in reality the patient’s condition has worsened. The nurse’s clinical knowledge may stabilize the patient in the moment, but the nurse’s professional caring can have a greater long-term impact by preparing the family for a realistic discussion about next steps. The patient in this scenario has classic signs of meningitis, which include nausea, headache, nuchal rigidity, photophobia, fever, and leukocytosis. Seizures may occur. A lumbar puncture to obtain cerebrospinal fluid for testing and cultures is necessary to confirm the diagnosis. Meningitis is life-threatening, so it is imperative to diagnose and treat it quickly. A ventricular drain (A) would allow collection of cerebrospinal fluid for testing, but there is no indication for an indwelling catheter (eg, for cerebrospinal fluid drainage to decrease intracranial pressure if the patient were stuporous). An ophthalmologic examination (C) to evaluate for papilledema, a sign of high intracranial pressure, may be performed. Less than 1% of patients with meningitis have papilledema. Because papilledema is neither sensitive nor specific for meningitis, an ophthalmologic examination would not be a priority. An electroencephalogram (D) detects seizure activity in the brain. Approximately 30% of adult patients with meningitis experience seizures. Treating meningitis will help decrease the seizure risk, so confirming the diagnosis and beginning treatment is the higher priority. Although electroencephalography may be performed, it would not be the first diagnostic test.The patient needs treatment for malignant pericardial effusion; pericardiocentesis is necessary to remove the fluid compressing the patient’s heart. Common symptoms of a pericardial effusion include shortness of breath, tachypnea, and orthopnea. This patient also has the classic presentation of Beck triad (jugular venous distension, muffled heart tones, and a paradoxical pulse), which indicates a pericardial effusion. Pleural effusion (A) and pulmonary edema (B) are less likely given the clear lung sounds. A pleural effusion would likely present with unilateral crackles and diminished air flow on the affected side. Jugular venous distension may be present in a patient with cardiogenic pulmonary edema; however, auscultation would likely reveal bilateral crackles. Although the patient is at risk for radiation-induced pneumonitis (D), this complication would not occur this early in the course of treatment. Radiation-induced pneumonitis (also called fibrosis) commonly occurs 1 to 3 months after treatment.The best response to the patient’s and family’s reluctance to have the procedure done on a certain date is to ask an open-ended question that allows them to discuss their concerns and fears. Discussing their concerns can help alleviate anxiety and allow them to feel heard. Although the patient needs the procedure to prevent heart muscle damage (A) and the surgeon has determined the date to be appropriate (B), neither response addresses the patient’s and family’s concerns. An interdisciplinary approach involving the chaplain (C) and other members of the health care team may be beneficial, but more information is needed before engaging staff members from other disciplines.The patient has rhabdomyolysis, according to the creatine kinase level of greater than 5000 U/L, tea-colored urine, and hyperkalemia. Femur and tibia fractures are risk factors for compartment syndrome, which is confirmed with compartment pressure measurements. Compartment syndrome is a surgical emergency. Fasciotomy is indicated to prevent neurovascular compromise and worsening muscle damage. Although bladder catheter irrigation (B) can rule out bladder catheter obstruction as a cause of oliguria, and renal ultrasonography (C) can identify causes of acute kidney injury, such as hydronephrosis or trauma, neither evaluates the cause of rhabdomyolysis. Serum myoglobin levels (D) are elevated in patients with rhabdomyolysis. However, serum and urine myoglobin levels are not useful for diagnosing rhabdomyolysis or monitoring response to treatment because they are not specific for rhabdomyolysis and myoglobin has a short half-life.Acute pancreatitis is the most common complication after endoscopic retrograde cholangiopancreatography. This procedure evaluates and treats blockages of the common bile and pancreatic ducts. The causes of pancreatitis after endoscopic retrograde cholangiopancreatography are not well understood. The literature suggests that acute pancreatitis may result from ductal inflammation caused by instruments during the procedure, pressure during contrast dye injection, or an allergy to the contrast dye itself. The resulting duct edema can block pancreatic enzymes from leaving the pancreas, leading to the release of enzymes that break down protein (proteolytic enzymes) and inflame the pancreas. Removal of the obstructing stone should lower serum bilirubin levels, not cause acute liver failure (A). Perforation of the colon (C), the gallbladder (D), or other biliary structures can occur but is uncommon. Best practice when caring for a child with autism includes soliciting the family’s input about the child’s unique signs of pain and anxiety and then integrating their preferred therapeutic approach into care. For a child with autism, hospitalization can create an overwhelming sensory and cognitive experience, especially when multiple staff members approach the patient (B). Distraction techniques may not be effective with this child (C) because their brain may have trouble processing the movements of multiple people, which could lead to cognitive-behavioral aggression. It is important to avoid moving too quickly around children with autism because it can lead to overstimulation and self-injurious behaviors (D).Williams-Beuren syndrome is an illness characterized by typical facial features, growth delays, mild intellectual disability, congenital heart defects, and hypercalcemia. A child with a new diagnosis of Williams-Beuren syndrome is at risk for hypercalcemia, although the cause is unknown. Children with DiGeorge syndrome often experience hypocalcemia (A). Hyperphosphatemia is typically found in patients with chronic renal disease and hypoparathyroidism (B). Hypophosphatemia may be observed in children with nutritional deficiencies or failure to thrive, and it can occur with diuretic use (D).This child’s symptoms are consistent with heparin-induced thrombocytopenia and thrombosis. The initial treatment is to stop all heparin administration and replace it with another anticoagulant. Decreasing the infusion rate (A), pausing and then restarting the infusion (B), and continuing the infusion while monitoring coagulation study results (D) are not indicated because all heparin products must be stopped to remove the offending agent. Prophylactic administration of platelets (A) is not generally recommended for patients with heparin-induced thrombocytopenia and thrombosis.The priority response in this scenario is to initiate manual ventilation and oxygenation while assessing airway patency. Elevated peak inspiratory pressures indicate increased airway resistance, which can occur when the airway is obstructed by secretions, bronchospasm, or kinks in the endotracheal tube or ventilator circuit tubing. The acronym DOPE (displacement, obstruction, pneumothorax, and equipment failure) can be used to remember the most common causes of postintubation hypoxia or acute deterioration. Adjustments to the ventilator settings, such as increasing the minute ventilation (A) or positive end-expiratory pressure (B), may be needed, but the priority is initiating manual ventilation while determining the cause of the acute decompensation. Sedation medications (C) may be indicated if patient agitation is determined to be the cause of airway obstruction.An epidural hematoma can develop after spinal fusion surgery and, if large enough, can compress the dural sac, nerve roots, or cauda equina. Symptoms may include decreased or absent motor function and symptoms of sensory dysfunction such as pain, numbness, tingling, or a complete absence of sensation. The key diagnostic test is a computed tomography scan, and the patient may then need emergency surgery to evacuate the epidural hematoma. Adjusting the epidural medication infusion rate (B), increasing the frequency of neurological assessments (C), and initiating passive range-of-motion exercises (D) do not facilitate diagnosis of this postoperative complication.AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.