7. Terri’s medical condition was systematically distorted and misrepresented. When I worked with her, she was alert and oriented. Terri spoke on a regular basis while in my presence, saying such things as “mommy,” and “help me.” “Help me” was, in fact, one of her most frequent utterances. I heard her say it hundreds of times. Terri would try to say the word “pain” when she was in discomfort, but it came out more like “pay.” She didn’t say the “n” sound very well. During her menses she would indicate her discomfort by saying “pay” and moving her arms toward her lower abdominal area. Other ways that she would indicate that she was in pain included pursing her lips, grimacing, thrashing in bed, curling her toes or moving her legs around. She would let you know when she had a bowel movement by flipping up the covers and pulling on her diaper.
8. When I came into her room and said “Hi, Terri”, she would always recognize my voice and her name, and would turn her head all the way toward me, saying “Haaaiiiii” sort of, as she did. I recognized this as a “hi”, which is very close to what it sounded like, the whole sound being only a second or two long. When I told her humorous stories about my life or something I read in the paper, Terri would chuckle, sometimes more a giggle or laugh. She would move her whole body, upper and lower. Her legs would sometimes be off the bed, and need to be repositioned. I made numerous entries into the nursing notes in her chart, stating verbatim what she said and her various behaviors, but by my next on-duty shift, the notes would be deleted from her chart. Every time I made a positive entry about any responsiveness of Terri’s, someone would remove it after my shift ended. Michael always demanded to see her chart as soon as he arrived, and would take it in her room with him. I documented Terri’s rehab potential well, writing whole pages about Terri’s responsiveness, but they would always be deleted by the next time I saw her chart. The reason I wrote so much was that everybody else seemed to be afraid to make positive entries for fear of their jobs, but I felt very strongly that a nurses job was to accurately record everything we see and hear that bears on a patients condition and their family. I upheld the Nurses Practice Act, and if it cost me my job, I was willing to accept that.
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