Race Mom, ADN 13,999 Views
Joined: Jul 2, '05;
Posts: 812 (10% Liked)
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8 year(s) of experience
NICU/L&D, Hospice, and back to Mom/baby!
OP, I just want to say how terribly sorry I am for the way your sisters passing was dealt. I myself am dealing with a sister (only one) who has a terminal diagnosis. I am so fearful that her death will be treated the same way. My advice is to file as many grievances/complaints that you can. Maybe you complaints will prevent these things from happening to another person.
OP, it sounds like she may have gotten referred to a for-profit agency perhaps? Either way, if the patient has difficulty swallowing, cannot take their medications, and family is requesting to open to comfort kit for EOL symptom management, you do it. I cannot think of any reason in that situation that it would be appropriate to say no. Also the response time is very questionable. Usually Condition of Participation dictates we respond within an hour. Now as an ON-Call RN for Hospice, this is becoming more and more unreasonable to ask of us considering the work load we are carrying, but it should never take 5 hours for a visit of that nature. Scheduled dressing change, maybe, but not for symptom management issues.
I am so sorry that happened to you and your family. As a hospice nurse I've seen way too many messed up passings due to the incompetence of the hospice team. Burns me so badly that many people have to have a horrible experience. Your sister knows you tried and still loves you.
I would file a complaint. And I would absolutely put this down on the survey. Also bring it up with their ethics committee.
Two days before she passed, she had a seizure (only time she ever did). At that point, she transitioned to active dying. When we got her into bed, after calling hospice (which took multiple tries...getting voicemail but it didn't allow you to leave a message) I made the quick decision to open the kit. Her seizure was at 3am and it was about 6 am before the OC nurse arrived. He said "who opened this kit?" I told him I did (although I didn't use anything, just got it ready and looked to see was in there). He said "well, I don't know if there could be any legal ramifications for you since there isn't an order for those meds." I told him I didn't care. I couldn't get ahold of them and she was non-responsive. He was a really nice RN, but that just hit me weird. Then next night, when she was in a large pain crisis, I called the oncall (this is after her CM wouldn't come and open her kit). I asked her, when she called before making the visit), if I had permission to open the kit. I was told no. It took over 3 hours for them to arrive. So, while waiting the 3 hours, I opened the kit. If they weren't going to take care of their hospice patient, I certainly was. I pulled out enough morphine for 3 doses, giving her one, and fridging the other syringes. Taped the box back up, and put it in the fridge. I made this decision after I was told the OC nurse was in a town 1.5 hours away and wasn't done with that visit yet. So unacceptable.
I really did see my sister's death as being something more peaceful and spiritual, but it was the opposite. I will struggle with this for a long time, I'm sure. This went against everything hospice was supposed to be.
Sorry for the confusing way I typed this. As you can tell I was a little angry. I have been a hospice RNCM and have worked for two really good hospices. Unfortunately, my young sister went on hospice (in another state) and this is the story of her death. No one would open the dang kit! I was so mad! It would take 3-5 hours to get the oncall RN there for a crisis at nighttime. Her CM refused to come over and open the crisis kit when I called and asked her to please come and do this. Her response was to crush what can be crushed and give her MsContin rectally (they don't supply gloves or lube, even though they supplied suppositories PRN).
So, in a nutshell, my intent was to ask if any of these situations were ok and I was just being out of line by requesting them. The whole hospice experience for my sister's death was a horror story. (They wrote on FMLA paperwork that her hospice dx was brain cancer, and CM verified it with me when I questioned it, only to tell me a week later she didn't have it but offered not one glimpse of an apology for what that did to our family. She discussed her "next pt visit" with the SW while sitting at our table during the visit, mentioning how difficult the pt was.) There is SO much more that is even worse than these examples, but I'm not going to mention all of it, cause it would just be a rant. Thanks for your reply. It is greatly appreciated
When I was an L&D nurse, I would always advocate for my pt. Docs would come in and want to AROM the pt and up the Pitocin. The pt would just nod in agreement. When the doc would leave, I would tell my pt "you don't have to have your water broken. You can let this go more natural. All you have to do is tell the doc that you want to wait for interventions." The pts always expressed gratitude but allowed the doc to AROM them. Nurses need to really be strong and not worry about what the doc thinks. I always advocated for my pts. After that, it was their decision. Of course, this means that I have gone head to head with a few docs. I don't care if they don't like me. I have seen too many poor outcomes from wanting to deliver in the 9-5 world.
So, if you have a pt that is within 1-2 days of end of life, has thrush causing difficulty swallowing, when do you change meds to liquid vs crushed? What would keep you from opening the comfort kit at EOL? Is it ok to give pt the [COLOR=#444444]Hyoscyamine[/COLOR] from the comfort kit, even though it "causes urinary retention"? If a family member calls you on a Friday at 1630 with c/o pt having pain crisis and family requests visit to utilize EOL kit, is it ever ok to say no and direct family to continue to crush all meds or give them rectally vs visit to open comfort kit for liquid meds and not visit? Yes, your guess is correct, this happened. It makes you want to open your own hospice in that town.
part of hospice care is providing PRN visits per family request- if the family has not opened the comfort kit, a visit should be done to provide instruction on how to utilize these meds. I also would not give po meds per rectum unless you have contacted the MD and got an order to do so. Also, a pain crisis is in itself adequate reason for a visit, let alone if pt is imminently dying and family is unsure what to do.
Pt has private insurance. Is hospice required to provide incontinence supplies for a pt on hospice with need for incontinence supplies (chux, etc). No other dx other than what pt is on hospice for. Young pt with no previous need for incontinence supplies.
Any supplies needed to provide care for the pt are covered under hospice- hence all the hoopla about wound care supplies and not using a $4.oo dressing if a 75 cent dressing will do the job.
Phew! Wears me out just imagining it........I've seen plenty of terminal agitation, but nothing I couldn't handle with an aggressive medication schedule using the normal dosages and calling hospice when the patient needed a higher dose. Hope for your patient's sake that she passes quickly---it surely can't be any fun to be her right now.
Just wondering if her spiritual/emotional needs have been addressed adequately, since she's still experiencing so much anxiety and anger about dying. That can hold up the process for quite a while and contribute to horrible anguish. I once had a patient who was actively dying for over a week, yet kept fighting it tooth and nail.....she was comatose, yet remained agitated despite doses of morphine and lorazepam that would have put me beyond any further worries after the first go-round. Her family kept telling her it was okay to go, but for some reason she just could not relax and let it happen.
Then one day the hospice brought in a volunteer who sat down in the room and began to play her harp. The patient's daughter and I were in the room at the time. Within five minutes a look of inexpressable peace came over the patient's face, she smiled one last time, and then she was gone. I like to think she was lifted up to Heaven on the music of the angels.
Western Governors University (WGU) is an immensely popular online virtual university because it offers an array of aspects that attract adult learners, such as reasonably priced tuition, nonprofit status, a respectable assortment of majors and concentrations, regional and national accreditations, and an innovational competency-based format that promotes expedient degree completion.
I am an ASN degree holder and my first six-month term at WGU officially started on May 1, 2014. Even though my first term technically does not conclude until October 31, I have decided to take a two-week break until my last term begins on November 1. In a nutshell, WGU's transcript evaluator allowed me to transfer 86 previously-earned credits, which left me needing to earn 34 credits in order to receive the BSN degree.
Since May, I have earned 27 of those 34 much-needed credits. Therefore, I need to earn 7 more credits before I will be able to sign my name TheCommuter, BSN, RN. I quite possibly could have earned all 34 credit hours in the span of one six-month term but I work full-time 12-hour night shifts, and to be completely candid, my motivation waxes and wanes like the four seasons. Without further delay, here is a breakdown of my first term in WGU's online RN-to-BSN completion program.
Care of the Older Adult
This course was fairly straightforward. I worked in long term care for six years, so I already had some real world experience with the course material. This class covered topics such as the different types of aging, theories on aging, Medicare, Medicaid, gerontological nursing assessments, determining level of function, and the Healthy People campaigns. A third party genetics course was required.
Biochemistry consisted of five different PowerPoint presentations that were graded by TaskStream, which is a third party grading company. Two of my presentations passed on the first attempt, two passed on the second attempt, and one finally passed on the third attempt. Essentially, I crafted models of hemoglobin using yarn and created two models of fatty acids using toothpicks connected to peach ring candy. Topics covered included lipids, hemoglobin, myoglobin, metabolism, enzymes, fatty acid synthesis, cell death, and other interesting themes.
The organizational systems course consisted of two papers and a third party course offered through the Institute for Healthcare Improvement. One of the required paper assignments required the student to formulate a root cause analysis and other required that I furnish a detailed resolution to a multifaceted ethical situation involving an elderly patient.
The health assessment course was comprised of an objective final exam and an applied assignment that required me to record myself as I performed a full head-to-toe assessment on someone. I assessed my best friend from head to toe as my laptop's webcam recorded the 36-minute affair. I became spooked and dragged out my studies for the final exam, but the testing was straightforward.
Nutrition for Contemporary Society
Since my knowledge base in nutritional issues is relatively strong, I easily passed the final exam for this course. Topics included lipids, carbohydrates, proteins, vitamins, minerals, water balance, nutritional diseases, deficiency symptoms, obesity issues, and exercise physiology.
Professional Roles and Values
Essentially, this course covered topics such as the role of boards of nursing, professional organizations, nursing theories and theorists, the history of nursing, historical nursing figures, interdisciplinary and multidisciplinary teams, leadership, management, and differing levels of educational attainment in the nursing profession.
Information Management and the Application of Technology
In essence, this course was a survey of introductory nursing informatics. It discussed the history of nursing informatics, information systems, networks, interfaces, operating systems, hardware, software, electronic health records (EHRs), clinical decision supports, and the various levels of informatics nursing professionals.
Community Health and Population-Focused Nursing
Students must pass an ATI final exam with a satisfactory score in order to pass this course. Topics included the differences between community-based nursing and community health nursing. Moreover, the different types of community-based nursing were extensively discussed, including public health nursing, parish nursing, hospice nursing, home health nursing, school nursing, disaster response nursing, and ambulatory care/clinic nursing. Principles of epidemiology were also introduced.
Introduction to Probability and Statistics
This very straightforward course consisted of seven modules that were formulated by a third party company called Acrobatiq, which is a subsidiary of Carnegie Mellon University. StatCrunch, a software program for data analysis and calculations, was an optional component of the course. Topics included exploratory data analysis, descriptive statistics, analytical statistics, theoretical probability and empirical probability.
In summary, my time spent in the Western Governors University RN-to-BSN completion program has been enjoyable. My self-efficacy has blossomed with each competency test that I have passed. In addition, I am pleased that this degree will cost me less than $7,000. Feel free to ask any questions.
You're welcome Tanaciou and missamelissy8! I forgot to mention perfusion. In newborns sometimes you see acrocyanosis, where the hands and feet are somewhat cyanotic in appearance. This is a normal occurrence. But they should be pink and well perfused otherwise or this is an abnormal finding that needs to be further investigated (eg. pale, cyanotic throughout, or differing colour i.e.. well perfused in trunk but pale legs).
2. b) Mother assessment- Assess general mood and coping, provide support and encouragement as it is a difficult time with little sleep and it's always important to let them know how they are doing such a great job
- you can auscultate air entry, heart sounds and bowel sounds although a lot of maternity nurses don't do so, it's good practice for a new grad.
-VS of course
-Breasts- if breastfeeding assess nipples for any broken areas, bleeding, bruising etc. Emphasizing with mom the importance of ensuring a good latch and how to break the suction before removing baby if the latch is poor. Also assess the softness/firmness of the breasts and ask the mom if she's noticing a change/feels her breasts are heavier etc. If she is not breastfeeding, encourage her to wear a firmly supportive bra and avoid any stimulation of the breasts including letting hot water run onto them a lot in the shower, etc. This can help prevent milk from fulling coming in when they don't want it.
-Fundus- Fundal height should always be checked. Lay the patient flat on their back in the bed and palpate starting near the umbilicus. After delivery it is usually at or below the umbilicus and should continue to go down. If it is higher than previous assessments you need to figure out why and what is going on. If you can feel it at the level of the umbilicus (it feels kind of like a ball under the skin, for some women it is harder to feel than others - women with more adipose tissue usually) it is called u/0. If it is 1 finger below the umbilicus it is u/1 and so on. If it is a finger above the umbilicus its 1/u. Also assess for fundal tone. It should be firm. If its note, it's called boggy. Sometimes it may become firm with massage. If it is boggy you should always try to firm it up with massage. The funds should be central in the abdomen. If it is off to one side you need to ensure the patient is flat on her back and that she doesn't have a full bladder. Get her up to try and void if you are unsure. If a uterus is boggy, there may be clots inside, etc. and bleeding is definitely a risk here.
-Lochia/flow/bleeding- Assess bleeding. Hemorrhage is a risk so you always want to ensure you are educating the patient what to report (soaking more than a pad in an hour, saving clots larger than a toonie to be checked for tissue, etc). Rubra is the initial red bleeding, serosa is when it turns to more of a pinkish and alba is the final step, whiteish/yellowish, which you don't see in the hospital usually. The flow should be stopped by the 6 week checkup appointment, usually lasting 3-6 weeks. Make sure mom knows not to use tampons, pads only at this time.
-Perineum- inspect perineum for bruising, swelling, intactness of sutures if applicable, appearance of episiotomy if present, and also check if hemorrhoids are present (and if so get ointment for her). It is very normal for some swelling to be present. We have ice pack peri pads that help a lot with this. Just always be cautious with unilateral swelling, we have had a few hematomas form under the skin where it initially just looked like swelling but it quickly became quite large and very firm, not to mention the patient was in an immense amount of pain so we got the doc in, and he ended up having to take her to the OR to drain it (no colour change to skin). So just something to keep in mind! Also make sure she changes pads regularly, and does her sitz baths (or applicable hygiene method your hospital uses).
-Legs/feet- assess legs and feet for swelling/edema, and also check homan's sign (for DVT) by having patient flex foot out against your hand (sorry little hard to explain, google it if unfamiliar).
-VS- obviously same ranges for any other adult
-Hydration/Nourishment- If breastfeeding especially, these are veryy important. Encourage the mom to still take multi vits as the baby will draw from Mom and her bones even for it's nutrients if not supplied. Eating a good balance of healthy foods.. also drinking an adequate amount of fluids will help with milk production
Education- is a biggg thing on mother baby. Some topics to brush up on : the importance of DTAP vaccines for herself and close family members to help provide a "cocoon" effect of safety from pertussis (whooping cough). I really emphasize this as I mostly work as a meds nurse and it is a horrifying disease to see, and can be fatal, and there are current outbreaks, so very important to educate re: this!!
- importance of keeping sick people away from baby, and the importance of good hand hygiene for everyone who touches or is near baby
- "Back to sleep" and the prevention of SIDS (sleeping on stomach/side biggest risk factor, other biggest ones are sleeping in bed with parents, or 2nd/3rd hand smoke.Educate to all of these topics)
- Second hand/3rd hand smoke- preferably no smokers around baby at all but if not possible- definitely no smoking in the house or car!! Person should remove their coat/sweater they smoked in, wash hands, arms etc. and put a blanket over clothing if going to be holding baby. This smoke does increase risk of SIDS so make sure they are aware of this.
-Proper bathing technique for a newborn
-Formula preparation if applicable, and emphasizing not using powder until 6 months for safety (even though they say 0+ months..)
-Car seat safety- never add anything to the car seat- ie. strap paddings, head rests, cover that also goes under the back and around the straps. All of these just decrease the fit of the suit (As does large puffy clothes ,don't do it! Dress them when you get out, or put it on backwards after all buckled in. Discuss importance of keeping baby rear facing as long as possible for the seat and that it is very important for preventing neck/spinal cord/head injuries and this greatly outweighs any risk of leg injury which has been shown to be very smlll ( a lot of parents feel they have to turn because of their leg length). Also of having food or other objects in trunk secured so it's not possible for the baby to be hit with this in an abrupt stop or car accident.
-General safety- no hot liquids while holding baby, no bumper pads, extra blankets, pillow etc in crib. Not leaving baby unattended on changing table. Once a bit older, start having chemicals locked away, including cleaners, and baby proofing sharp edges, door and outlets, etc.
-Crying- watch the period of purple crying and educate yourself re: same. Our hospital implemented this and hopefully yours does too, but if not its still a great learning and teaching tool. Teach everyone re: shaken baby syndrome and the importance to know you can just set the baby down in a safe spot if you are getting frustrated and try to have a break, as it's normally people reaching their absolute peak of frustration that shake.
Hope this helps! It's meant as a guide so if I forgot to mention something, forgive me I'm very tired :P Tons more education areas you will cover with families. We have checklists we have to have completed on topics before they leave. These were just some off the top of my head lol.
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