tnmarie, LPN 9,999 Views
Joined: Aug 23, '12;
Posts: 283 (44% Liked)
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geriatrics, hospice, private duty
One of my new patients has a severe oral aversion. There is no physical reason the pt can not eat PO. Any tips on getting a peds patient with severe oral aversion to eat? The child is 8 y/o and I'll be caring for the child in a home environment. Thanks in advance!
Thanks for all the replies. I still haven't decided what to do yet. Gonna see how much continued coverage through COBRA will be before I decide anything and also gonna find out when exactly my coverage through previous employer ends. I do know that my maintenance meds are going to cost over $300 without insurance! Still it may be cheaper to just pay that amount and not carry insurance until February...
...Also, be aware that people are still being denied certain tx due to "pre-existing condition." You can get health coverage, but the specific condition itself can be denied coverage for pre-existing conditions. I've seen it 3 times in the past year in my asthma clinic, so it is still out there.
My daughter had short term insurance for a while, it was not expensive but after signing up she got a letter pointing out that the coverage did not meet the guideline for Obama's definition of insurance, so she will still have to pay the tax penalty!
Main duty is keeping the pts comfortable and helping the family and pts cope. Pain management is a biggie. The skills I used in hospice weren't that different than LTC or other places; you just focus more on palliative care. It can be emotionally draining, but I loved hospice nursing. Good luck if you decide to go for it :-).
We have a younger res that acts out when you don't do what they want when they want. S/he sits down and then lays back in the floor. If we don't actually observe the res in the process of laying down, we have to chart it as a fall. We also have another res that gets down on their hands and knees and crawl around in the floor. Again: fall.
Our policy is that if any part of their body touches the floor, it's a fall. Legs hanging out of bed touching floor mats with bed in low position: fall; assisted to floor: fall; rolling out of low bed to floor mat: fall; lying in floor throwing tantrum: fall. We had a resident in a low bed in isolation that would "fall" every 10-15 minutes while awake (onto the floor mat of course).
That being said, I don't get the whole "when no part of the body is near the floor" thing you are talking about.
Also, just because it is supposed to be counted as a fall, I have a sneaking suspicion that they aren't always documented as such. More than once I was told by the CNAs that res x fell but the nurses didn't write it up as one. I never had the cahones. If they touch the floor: fall packet, period.
Wow, I think you are working at a place I recently left! I was determined to stay a year. I made it 10 months. I bought the supplies. I loved the residents. After buying barrier cream and other supplies, our pressure sores cleared up (imagine that). However, it got to the point where I could no longer afford to buy supplies. Skin was already breaking down again when I left. I was trying to make it the year but now I wish I had just moved on. The place is probably going to get closed in the next little bit anyway so how is that going to look on the ole resume? The up side is that maybe my residents can move somewhere where they will receive better care.
As an added bonus, the job ended up making me physically ill! I had several ER visits and ended up in the hospital for almost a week on one occasion (I never had health issues prior to this job).
Anyway, if you are staying, I second the advice above. Keep all communications; write them, don't just do verbal complaints; get malpractice insurance YESTERDAY; chart like a fiend to CYA. I always CC'd the administrator, DON, ADON, dept head if applicable that way no one could say "we didn't know" or "she never said anything". I STILL have all that documentation today because I figure some serious depositions are going to start rolling in in the next few years....
Good luck. You are going to need it! Just remember that you can only do so much. Be gentle with yourself.
Hello all and happy New Year!
So here is my situation: I went directly from one job to another at the end of December. I am not eligible for insurance through my new employer until February. I have a chronic condition and maintenance meds so I can't really afford to be without insurance, even for a month.
It seems like my only two options are short term insurance or COBRA but I read that short term insurance does not cover pre-existing conditions. I think COBRA may be my best bet, but I quit voluntarily d/t "drastic change in working conditions" (which I can easily prove). I did carry health, vision and dental through my previous employer since March and I will still be paying the premium up until the middle of January via paycheck deduction.
Has anyone been in a similar situation? What did you do and how did it work out? Any input or advice would be greatly appreciated. I have contacted the benefits department of my previous employer regarding COBRA but I'd just like other input to consider :-)
@Dana: that is why we do neuros after unwitnessed falls. It is safer to proceed as if they did hit their head since we don't know. As far as getting the nurse in the situation, I don't think I understand what you are asking. Just call the nurse for help and they should take it from there. Finally, there are physical indicators during neurochecks that won't be affected by dementia AND res with dementia can STILL have mental status change.
Tab alarms and pressure alarms do help quite a bit because these devices let us know when someone is getting restless (often because they need to toilet or need a brief change) so we can hopefully prevent the fall.
We have a whole fall packet: pain assessment form, change of condition form, neurochecks, investigation report, ect. We do the same as everyone has said: CNA stays with patient and calls for nurse. The CNAs take VS while the nurse assesses and then we all get the res in to bed. If the CNA doesn't appear to be getting VS, I'll just politely ask for them :-). Yes the nurse can get them but I find it more efficient to be assessing the res while CNA gets VS simultaneously. Our CNAs also have to write a witness statement of their account of what happened.
Make sure as you are assessing that you are noting everything: what kind of footwear, how is the res positioned, what did they say happened, is the floor cluttered, etc. We have to figure out why they fell and place an immediate intervention.
We do scheduled (and frequent!) neurochecks on every unwitnessed fall. Over the years, I've only sent one res out after a fall d/t abnormal neurochecks. Luckily most of my peeps have been unscathed after a fall. That CT scan after every unwitnessed fall seems excessive. You can generally catch a problem with good assessment skills, imo.
Finally, I've been told to never chart that you "found" a resident in the floor. It makes it sound like you lost them. Instead, chart "observed resident supine in floor ...".
Back when I was living in a more rural area, I worked PRN at LTC to help offset some of the bumps in the PDN road. It had the added bonus of keeping more more marketable because in my area, facility experience is valued over HHC experience for the most part. It also made me appreciate the pros of working at each job even more.
Now I am working at a larger company in a large metropolitan area and I've quit the LTC gig for now (I also got very burnt out on LTC after a while). I'm hoping I won't have to return to that again, but If I do, I'll do LTC or agency. We have several agencies that staff PDN cases so that is probably what I'll do if needed.
My question is are they aware and simply don't care? Or are they disconnected from what really goes on in the unit and really believe it's our fault for not getting a lunch?
My former employer took away the only other nurse in the building on my shift. This of course meant that I could not leave the floor and would not get lunch. I promptly called my state board of labor thinking it was illegal to not be able to take lunch. The board of labor clarified for me that in professions like nursing, it was acceptable/legal that we did not receive a lunch (whole other thread, I think) but that if we weren't paid while working through lunch, that was illegal. So basically, I wasn't going to get a lunch but I would be paid for it. As an added bonus, I had to fill out a missed punch form every shift stating why I did not get a lunch even though EVERYONE knew I didn't and exactly why (Lunch: NA-only licensed staff in building). Our time clocks had a missed lunch option, btw!
I left that job ASAP but not before I ended up in the ER for a flare up of a chronic condition that was exacerbated by lack of proper nutrition/proper time to eat.
BTW, even if you get a full 30 minute lunch, if you have to eat it at the desk because you can't leave the floor for whatever reason, that does not count as a full, uninterrupted lunch and employers must pay you.
I have rarely heard of an instance of a PDN doing "a little extra" that didn't end like this. Once they see you will do the little extra, they will expect more and more. Then when you put your foot down, they throw you under the bus. That is why it is so important to keep boundaries and remember that you are NOT part of the family no matter how long you have worked with your pt. It sucks that this is a frequent consequence of doing a little extra to help out from time to time.
Sorry it happened to you and hope that it all works out for you. Keep us posted.
The skills you use are going to depend on where you end up and even the shift (night shift did all the U/As, colostomy and PEG care in my last SNF). My last SNF didn't let LPNs do IVs but most SNFs do. See where I am going? You may want to see where you end up to get a better idea of what skills you need to review.
I wills say that if you do end up at a SNF, the primary thing you will be doing is passing meds! Seriously. Hours on a med cart. You give lots of insulins and lots of tube feeds so insulin administration and PEG feeding and care would be good skills to review. Also lots of U/As and Foleys if you are on night shift.
I don't think many hospitals hire LPNs now and again the skills you use would be dependent on the type of floor you end up on.
I've never worked at a doctor's office as an LPN but in clinical it was mostly VS, paperwork, and talking on the phone to labs and pharmacies. Most offices in my area use MAs instead of LPNs. If you end up at a specialist, your tasks will vary widely.
Is there a particular area that you WANT work?
What medications absolutely must be given daily?
All medication MUST be given as ordered. Unless it is PRN, it must be given daily as scheduled. If it is not given, it is a med error. "Borrowing" from another resident is technically insurance/medicare fraud and hence a big no-no. Your facility should have e-kits (warfarin is almost certainly in the e-kit). If a med isn't in the e-kit, you can call pharmacy and get meds from emergency back up. If there is no way to get the med there to be given as scheduled, then you must call the MD and let them know. They will usually order to hold it and/or give a one time dose of something that is available in the e-kit. TL/DR: if a med isn't on the cart: 1. check the e-kit. 2. Call the pharmacy. 3. Call the doc if med unavailable through e-kit or pharmacy.
What should I be looking for before I send a patient to the ER?
Too many specific scenarios to list! Basically any change of condition from the patient's baseline should be reported to the MD and the MD will decide if they want an ER visit. So you will call the doctor, notify them of the change in condition and they will order the ER transfer (or they may opt for labs, xrays, meds ect.). If the patient is unresponsive, coding, or in a life threatening situation, our policy is to call 911, get them out, and then call the doc after the fact. On the other hand, if the change in condition is minor, we wait until morning to call the doctor. TL;DR: In most cases except the most emergent, the MD will be letting you know who and when to send to ER (though you pretty well know who will be going out based on s/s).
What would you include in a good progress note?
Depends on what is going on with that particular resident. I use my head to toe assessment cheat sheet as a guide:
There is also a great tool floating around on all nurses that deals with charting on specific issues called "daily skilled documentation guidelines" that I also use but can't find a link to at the moment.
Basically if there is anything going on with a resident (UTI, URI, ABT, PEG, FOLEY, TRACH etc) you will want to chart about it.
I'd also be checking to see when his last BM was as well....
Edit: whoops, the above poster already mentioned that.
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