I am seeking the opinions and advice of some of you experienced hospice nurses
I work nights in an ICU, and occasionally care for patients who, during their ICU stay, are changed to comfort care only and stay with us until we can place them in hospice. Sometimes I find it hard to get out of the ICU mindset and instead focus on comfort, and I feel like I usually do a fairly good job of that, at least the best I can.
So the situation.... elderly man with multiple comorbities admitted to our unit for altered mental status (on top of underlying dementia) & some really jacked up labs(missing dialysis) He had a recent AKA of one leg, and the other was completely cold and pulseless, and per the family, had been for about 2-3 weeks. The legs were causing him severe pain with even the slightest movement. He was to leave first thing in the morning to an inpatient hospice facility, and would probably pass away in a week or two.
During the day shift, he was very combative, vomited X2 so the nurse inserted an NG tube(?), and then had to be restrained. He was started on Morphine 4mg Q2hr prn and Ativan 2mg prn. Pt was given both shortly before I came in that night and was resting very comfortably, even snoring. He hadn't slept in a couple of days so we were all so happy to see him finally comfortable.
So, my goal for the evening was comfort. I kept the lights off in the room, curtain pulled as much as I could without blocking the monitor, and slid the glass door shut to keep it quiet. Honestly, though I checked on him frequently, I only repositioned him one time & cleaned up a bowel movement. Even with premedication before, it caused him a terrible amount of pain and he screamed so loud he woke up his family and you could hear him down the hall. I just couldn't bring myself to do it to him again.
Well, the charge nurse (who was the patients nurse during the day) came in that morning and basically accused me of neglecting him and being lazy because I told her that I let him rest and only repositioned once.
We are supposed to turn our ICU patients Q2hrs so she was livid about this. But I just don't think it was appropriate to wake the poor man up and cause him tremendous pain every other hour in the middle of the night!! The family told me they wanted him to rest, and I did everything I could to enable him to do so.
Did I do the right thing? What would you have done differently? Thanks for all you do!
Sep 24, '12
by loriangel14 Guide
I would have/have done the same thing you did.I have read and I believe that it takes at least an hour for a aptient in pain to get comfortable again after being turned.Where i work, if the goal is comfort then turning q2h is abandoned.4mg of morph q2h is a poor order for palliative measures. Our standard order for our palliative patients is 2-10mg q 15 minutes. Most of our patients end up on PCA pumps.Like the previous poster says, sometimes just a little pillow tuck is enough. Scopolamine patches are usually used as well.
Last edit by loriangel14 on Sep 24, '12