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NRSKarenRN, BSN, RN Moderator 116,314 Views

Joined Oct 10, '00 - from 'RN Spirit from Philly Burb'. NRSKarenRN is a PI Compliance Specialist, prior Central Intake Mgr Home Care Agency. She has '35+' year(s) of experience and specializes in 'Home Care, VentsTelemetry, Home infusion'. Posts: 27,289 (22% Liked) Likes: 13,347

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  • Dec 5

    YES to extra undies. But also pants/socks/shoes. Kiddos this age take naps and that's when I see the most wet pants, which tend to leak down to socks and shoes because they were sleeping and didn't notice. I would send a letter home to encourage parents that keeping a whole set of clean clothes at school might be beneficial.

    I also see a lot of littles come to me because they are too tired or hungry. There is a lot of teaching going on here about bedtimes, and playing video games too late, and eating a proper breakfast.

    OH! and homesickness. I never let them call home just because they miss Mom/Dad/Auntie/Grandma/Grandpa/whoever. They will start coming everyday. I usually tell them "We all miss people when we go to school or work, but that's what makes it so much better when we see them later! And (whoever) will be soooo proud of you when you get home that you stayed at school all day and they'll love to see all the work you did!"

  • Dec 5

    I have worked in Hospice for many years in many roles. I have seen situations like this story so frequently and also feel there is huge room for improvement. There are several ways we can improve and prevent stories like this from happening.
    We need to have honest, open dialogues about end-of-life care and caregiver needs BEFORE family members actually start to decline. This means we need to start writing to Reader’s Digest, AARP, and other visible sources read by the public and start bringing up the topics of “How much does caregiving cost?” “How will we afford care for Mom/Dad?” “Who will care for Mom/Dad 24/7 should paid caregiving not be an option?” Hospitals could even hold monthly workshops on the topic and cover important questions like “What is involved with caregiving?” “How much is intermittent paid caregiving?” and “What does outpatient Hospice offer and cover?” We offer this for new parents, why not families of the elderly?
    I would love to see more families having open conversations about decline and what the plan will be when someone does decline and need constant care.
    I agree with the previous posted who mentioned media portrayals of aging and death. It seems like when we do portray death, it is rare, fast and clean. And that there are way more portrayals of miracle cures and success stories than honest portrayals of dying.
    I think if more families had a chance to prepare, end of life could be less traumatic.

  • Dec 5

    As a palliative nurse in the hospital setting, I deal with the emotional and other fall-out of a terminal illness constantly. I also worked in the community.
    I could probably write a book about this topic as there is so much to consider, think about and such.

    My suggestions are:

    1. Upstream work - meaning when a patient is dx with a terminal illness or chooses to forgo treatment, there should be a referral in the community asap to a palliative care consult or meeting with a hospice liaison with the goal of looking at a plan. Even though the patient might be "still ok" it is important to start planning. That means advanced care planning and also financial planning. Perhaps the patient needs to see an elder lawyer, perhaps they need to apply for medicaid, perhaps the kids need to plan and save time so they can take time off when the time comes. This is the part that is hardest to realize because there is not real good set up in most communities and patients may be reluctant to plan ahead.

    2. Be honest and put out all information up front.
    This is the biggest thing in my opinion.
    Nowadays, nobody can die in an acute care hospital, unless death is imminent. If the person has more than 2 days left, we want to transfer them out. Sometimes it is not possible due to weird circumstances but in most cases, we are pretty accurate in estimating imminence of death.

    Now comes the hardest part and that is why you end up with the fall-out in the hospice house:
    Families are highly emotional and often angry at that time.
    Once a patient/family considers comfort measures only, we have to sit down and talk about what that means in terms of care plan but also what comes next. It is very important to be honest and to say that if CMO is initiated, the work in the acute care setting is done and we help the family to make a plan to transfer out. I explain the three options (home hospice, hospice in the nursing home, hospice in the hospice house), sometimes a person would like hospice in assisted living (which would be the fourth option) and I also talk about the financial piece.
    It is vital for everybody to understand that if there is no medicaid in place that covers longterm care or an insurance that will pay, that medicare does not pay for longterm care. I talk to them about the "room and board" and down spending.
    That is usually when they ask about the hospice house. And I explain up front what GIP really means and that it is a pay by day decision - that it can also generate costs because patients are not always GIP level and if they are routine for some days, it will create costs.
    When I talk about home hospice, I point out that the family needs to provide 24/7 care and the patient can't be left alone.

    It is important to be up front and understanding but also firm. And everybody has to give the same information.
    Those are hard discussions because the families who do not want to pay are often angry - home hospice is "free" though and if they feel that they can not provide 24/7 care at home that is their choice.

    All of this should be pointed out with the CMO discussion especially when it is clear that the patient is not imminent.
    A different story is when we know that the patient most likely has more than 24 - 48 h. Still, I never promise anything. I will say that usually once symptoms are managed and the patient appears stable and "has more time left" we will work on a discharge plan. However, if I feel that this is highly unlikely to happen - terminal extubation, taking off bipap/highflow, clear signs of imminence, I will also point out that this is highly unlikely and we will see how things go and to prepare that there is probably not much time left.

    The bigger struggle is to ensure that the overall plan and goals for care are clear.
    Sometimes case managers have a hard time with those discussions and revert to a plan that makes less sense and will result in the patient not receiving the care they want or need. If the patient would like to be comfortable and taken care off with a terminal illness, but the case manager suggest "rehab" so that "he can get stronger before going home" - this plan fails easily. Especially when the patient is already symptomatic with SOB/pain/ other and has very limited capacity for "rehab". Even if the case manager and family talked about "some days of rehab" and "go home" - chances are the patient is unable to participate and gets symptomatic , which means the rehab facility will send back to the ER. And we are back at square one because the plan was really not good.
    Also, if the patient is at rehab and wants to go home with hospice after, it is essential that the hospice liaison comes out before the patient is D/C to meet with the family and patient to talk about the plan and set up for hospice. Otherwise, rehab discharges and often enough, the patient is back after staying at home for less than 24 hours.


    When the family and patient want hospice it is usually not a good plan to go to "rehab" first - there are few exemptions. If the patient has a Medicare Preferred plan (managed medicare), that case manager will sometimes have the patient go to a skilled facility for a few days if there is a problem to set up hospice right away - for example if the family member has to work 2 more days before a family leave, or the room is not set up , or there are long holidays and hospice can not admit the patient asap. The difference is that the Medicare Preferred CM will work on a firm plan with the family and facility - the main point here is the communication piece. If I see a patient who has such an insurance, I call the CM from the doctor's office and discuss a plan, once we agree I connect that CM with the hospital CM to carry out the plan.

    Whatever plan is made in the hospital - people need to put out all the information. Yes, I get a lot of anger (which is often just an outlet for the other emotions and stuff that is going on - grief, sadness, disbelieve...) but I also hear that families are glad I talked about everything up front and that there no surprises afterwards. It is important to guide families through the process and outline what is going to happen once a CMO decision is made.

    Such a plan can look like this:
    First the doctor will put orders in place to ensure the patient is comfortable and does the POLST.
    Then we work on managing any symptoms that are distressing, we also will call the chaplain (if the patient /family would like support).
    Because your loved one most likely has some more time left that he/she can spend with the comfort of hospice care, we will refer to the ...agency who will come out and evaluate your loved one for the hospice house. If they evaluate and you and the agency agree on that plan, we will put everything in place to transfer. If they come out and you do not wish to go forward with the hospice house, but wish the nursing home option with hospice, we will ask you to pick at least three facilities from this list and we will ask them for a bed, at the same time we will let the hospice agency know that this is the plan so they know (sometimes the hospice house agency also offers hospice in the home or nursing home - in that case it is a one stop shopping place).
    Once there is a bed offer and you want to accept it, if there is private pay the nursing home will ask you to pay at least 2 weeks up front, they will contact you, please know that you have to be prepared to write a check at that time.
    If you want to see the facility first, you can tour the facility.
    Once everything is set up, we will organize the ambulance ride.


    It is very important to be clear on everything. If somebody decides for the hospice house, I will always point out that if it turns out that symptoms are controlled and there is "more time left" that they will also work with the family and patient on another plan like home hospice or nursing home.

    All of the above is written with Medicare in mind.
    Commercial insurances and federal blue cross blue shield etc may have different rules. If the patient is 40 y old and was working prior to illness with a commercial insurance and now after going through cancer treatment is terminally ill or has a sudden event and moving towards end-of-life, the commercial insurance may pay differently for the hospice house. The only way of knowing in those cases is to refer and have them evaluate the patient, run the insurance and call for a pre-approval.


    There are patients where I know the first time I am seeing them in the hospital that they are not doing well but they are not ready to focus on their comfort and they do not wish hospice. They often chose an approach where they can continue all treatment options but also start some palliative measures and may continue to see a palliative care provider in addition to help with advanced care planning/symptom control etc.
    Typically, those patients start to circle at some point between hospital, rehab, and home - with the time at home or rehab very short and more time in the hospital. A typical example is the patient with end-stage COPD and CHF who now perhaps has something else as well like lung cancer or worsening dementia.
    Those are the patients who often decided to seek aggressive treatments in hope to extent their life span and they are willing to go through a lot in order to get there (including ICU, intubations and so on and forth) plus they often hope that a new treatment comes along next week that will "turn everything around".
    Those are also the patients who often live more in the hospital at some point than anywhere else and are resistant to discuss end-of-life with their providers. For those patients, it is typically the family who will have to make decisions one day when they are not able to recover anymore, can't come off the ventilator, are in the ICU on drips and maxed out treatments or when they have a sudden event and now are unconscious. While I would like to talk with them about their goals for care I can't if they do not wish to do so. In that case, the only thing I ask them to do is to fill out the HCP form and if they think that they are "low income" to have the family help them apply for Medicaid / get an elder lawyer. I tell them that this is to help the family and patient to prepare in case "things do not go well".

  • Dec 4

    Bypass the scheduler- call the DON and tell him/her no dice.

  • Dec 4

    So perhaps this is a bit of a diatribe, but I really do believe nurses can be just as scholarly as any other profession. And to be quite honest, I am very tired of hearing nurses talk about how there is no need to further their education or at the bare minimum keep up-to-date on CEUs or the latest journal articles because it 'just doesn't have anything to do with being a nurse or being xyz,' or quite frankly any number of other statements or attitudes that put down or otherwise discredit the need to engage in academic or scholarly pursuits.

    I cannot tell you how many times I have heard a professional discharging one of my patients, and going over the instructions and hear them give ludicrous explanations about medications, diagnoses etc. only to think to myself "where did you get that hogwash from?"

    I have really been trying to instill in my students and new NP graduates that follow me a love of learning, to never be stagnant in their clinical practice, and to always look for the answers to questions they develop throughout the day (not that I have 100 years of clinical practice, but I digress). I really do believe that this is the best way to practice as a nurse, whether advanced practice or at the RN level. I tell my students that as an RN you should never do things just because they are ordered. If there are no reasons not to perform an order, fine, do it, but take the time to find out why things are done the way they are, listen to the doctors on rounds, read physician notes, multidisciplinary notes, go the extra mile.

    For my advanced practice colleagues, puh-lease let's not be satisfied with the status quo. Sign up for conferences. Go to lectures. Go to skills courses. Author journal articles. Get that next degree. Let's step up our science background and take extra courses and represent the very best that nursing has to offer.

    I do worry sometimes about the quality of our graduates from APRN programs. As for me, I am going to try to be the best role model I can. I have just completed my DNP degree , and I have just been accepted to a Neuroscience Ph.D. program here locally at a renowned university.

    I signed up as someone willing to be a preceptor in the national databank of whatever with the ANCC for NP students, but have yet get any requests, but I love to take on students as teaching is one of my main passions, so if anyone here needs a preceptor and serious about their stuff, I'm willing. I'm in the Philadelphia area.

    I guess I write this long post just because I grow tired of seeing so many members of my profession who are OK with lackluster. I feel that this is not something seen in other professions to this degree. I suppose I could be wrong.

    The grass on the other side of the fence very well could be brown instead of the plush green I sometimes see. Just my two cents.

  • Dec 3

    I think nursing as a profession is very unfair to its members when there's a complaint about staff. We are called into the office and "they" say something that the manager passes on, frequently pretty vague so the complainant cant be identified. The nurse is supposed to change base on what someone said, no context provided, it's impossible to defend because they wont tell you specifics. Nurses are left going out to work on the floor wondering who has their back, and what statement could be misinterpreted by someone passing by.

    The law (including employment law) has a basic right to face your accuser. You should be given the opportunity to defend yourself, or add context, and question the person who is making the complaint. I've been called to the office for tone of voice...but not a specific instance, just generally told to be nicer, and it was a serious complaint, put in my employee file. How does one remedy that, especially in an ER where a stern tone, or loud voice might be appropriate to the situation.

    My father is a teacher, and their union has a policy, that if the complainant is not willing to sign the complaint, they consider it non actionable. Sounds scary at first, but if a problem is serious enough, and you are a professional person, you should be ready to stand behind your words. Its childish to do what so many posters suggest, send an anonymous note to a supervisor when theres a problem. If you were a supervisor, who would you respect more, someone sending anonymous notes, or a signed letter? If you were the person with performance issues, what would help you improve...a fairly vague anonymous complaint, or specifics, and the opportunity to discuss the issue? We need to start respecting our own knowledge, and giving respect to our coworkers as they try to improve.

  • Dec 3

    Well, from a nurse manager's perspective...

    I have had to have that conversation with employees. Usually starts with "There have been some concerns brought to me by other staff members about x, y, z..."

    No, that's not gossiping. That's addressing an issue that other staff members have with a coworker's performance or attitude or whatever. Nurse managers often do not work on the floor, thus they must rely on other staff members' observations regarding any performance issues.

    However, I will say that I typically would not have a discussion with someone without concrete examples. And if an employee came to me with complaints about a coworker, I would insist they come back and talk to me once they have specific examples, including dates and details.

  • Dec 3

    You were directed by the attending physician via a telephone conversation to NOT send the resident to the hospital ER.

    As long as you documented your observations, interventions, and conversations with the physician and supervisor, you should be fine. You did what a prudent LPN would do in a difficult no-win situation.

  • Dec 3

    I have had multiple nursing home residents with orders for HS alcoholic beverages over the years. This type of order is nothing new, nor is it outside the realm of possibilities. It is for their comfort...

  • Dec 3

    My CPR course I was taught to begin chest compression if you are in doubt, even if there is a weak pulse.

  • Dec 3

    Hi everyone, new grad here on my own after my first month orientation. I have not experienced a code blue before but went through a basic mock CPR during orientation.

    Details: Came back from break, was doing my nursing rounds when one of my patients who was ‘stable’ all morning suddenly began seizing so I quickly ran for the pt. My supervisor happened to be around and was by the bedside as well and said "pt is seizing call a code!". Pt eyes began rolling backwards, unresponsive to name and touch as she was seizing and decreased LOC. I checked for breathing and radial pulse (should’ve done a carotid pulse) and only felt a weak pulse. I initiated a code and began chest compressions and pt woke up after a couple of them and began vomiting blood etc. Pt never had an epileptic episode before and pt began stabilizing after medical intervention.

    I am just reflecting on my nursing practice and judgment.. My question is whether we are supposed to call code blue for seizures? No one questioned my actions of calling a code and even said I did a great job. Thoughts?

  • Dec 3

    Decreased LOC, unresponsive when I shook her shoulders and name albeit it appeared to be a seizure that lasted a few seconds. Couldn't hear her breathing and weak pulse. Also partly due to my nursing supervisor telling me to start a code.

    We have an ICU nurse outreach team.

  • Dec 2

    On the other hand: I had one come in right off of the bus and say "I know this isn't a medical issue, so it's not your problem, but do you have something that I could clean the dog poop off of my shoe with?"
    I gave him a toothbrush, he cleaned everything by himself, wiped down the sink after, and washed his hands! I could have hugged him

  • Dec 2

    Wow, I am not a school RN but you guys have the most interesting posts. Is there a way to support my local school RNs? I'd love to kick in for some granola bars and a microwave, etc.

  • Dec 2

    I'd like a skeleton. Then I could dress him/her up for holidays!!!

    More outlets.

    An easier way to get food for my office. I just buy granola bars, saltines, and gummies out of my own pocket.

    A bulletin board. Thinking of asking for one for next year.

    Uninterrupted lunch.

    More color in my office.

    A quieter bell/announcement speaker. Holy cow, I can't hear myself think some days!!

    A slightly bigger office so I could have a waiting area and another cot.

    A cot that is not the ugly brown color I have right now. Our school colors are blue and gray- how I ended up with a poop brown cot I will never know.

    A color printer.


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