what can you say

AngelGirl · Mar 15, 2003

Greer128

Thanks for the insight, both in your comments and in the lines you have listed below your post. Very provocative.

Hellllllo Nurse, BSN, RN · Mar 16, 2003

Originally posted by RainbowSkye
.......Do any of you nurses who work in long term care have any suggestions?

I used to work LTC, did it for years. But I gave up. I will never go back. As the only nurse for 65 pts (9 tube feeders, two trachs w/ MRSA, all the rest demented, frequent falls, total care, etc). I had 3 aides usually, sometimes 2.

Many of the charts do not even contain the residents' code statuses, or even their allergies.

Many times, I've called res' "next of kin" or "responsible party" as listed on face sheets to find that the phone #s are disconnected, or are incorrect.

Many charts do not have an H&P.

I once had pt who had a clogged G-tube. I removed it and inserted a foley, it worked fine. However, I was written up. I was told this was against policy, and that I should have sent the pt to the ER.

As for FOS pts- Often CNAs will lie, and falsey document, saying a res had been having daily BMs, when they have not.

Because if I give a laxative, Fleets or whatever, the pt will then really be having BMs, and the CNA might actually have to be involved in cleaning it up. So, they tell me the pt is not constipated. Some elderly pts always have hyoactive BS and distended abds. That's usual for them. You may not feel any stool when you check for impaction, either.

Some CNAs also do not want to be bothered with actually taking V/S. So, they just write in fake ones.

Also, many res are so combative that it is nearly impossible to get a decent assessment on them. These factors combined with the huge number of pts LTC nurses have to take care of, and you can see how problems w/ some pts are often overlooked until they are rather far along.

I've had a few pts fall and break hips. Restraints (chemical and physical) are not permitted in most nursing homes. Adm feels that the nurse w/ 65 or so pts should be able to keep close enough tabs on all of them to prevent any falls/injuries.

Yes, I've sent pts w/ hip fx to the ER. Even though I knew they were too old and frail for a surgical repair, I will not be able to get any pain med orders for the pt unless I have proof in the form of X-rays and documentation (from the ER) that the hip is really fx.

I will also not be able to prevent adm from ordering the pt up and dressed in their w/c by 4am (w/ all the other poor souls) unless I have proof of the fx.

Adm in LTC does not recognize nursing judgment. If you try to keep a pt in bed because they are ill or injured, adm sees it as you trying to get out of doing the work of getting the pt up and dressed.

I have had pts returned from hospitals (many times) with bed sores that they did not have when we sent them out. I've also had an ER D/C a res back to me at 2am, w/ a temp of 102. This pt had hx of sz disorder and craniotomy.

Even though I worked at one LTC for almost 3 years, I was unfamiliar w/ the baselines for many of my pts. Why?

Because when you have such overwhelming numbers of people to care for, there some that always have something going on and take all your time. These especially needy and demanding ones prevent you from ever getting to know much about some of the other residents.

I worked at one LTC where phone service was cut off as someone had "forgotten" to pay the bill. One of the CNAs lent me her cell phone so I could call 911 and call the ER to give report.

Most LTC "medical directors" are a joke. Some have been the "provider" for years to residents that they've never even laid eyes on. They just come in, read the nurses' notes, write a progress note of their own, and leave.

As for pt "dumps", often hospital attendings will D/C LTC pts from the hospital back to the nursing home on Fri afternoons, even if the pt is still acutely ill. This is because they will have fewer pts to round on over the weekend if all their nursing home pts are D/C.

I have worked in a hospital, in med/surg. It was an awful hospital, and working conditions weren't much better there.

My closest friend has been an RN for 25 years. Mostly in hospice and psych. She recently quit a job in LTC. She was the only nurse for 120 residents on nocs. She had 3 CNAs and one med aide.

I worked with her in inpt hospice, and I know she is a fabulous nurse. However, she told me the LTC position made her feel "so inadequate and incompetent" because she struggled and struggled, but could not possibly provide good care for her 120 pts.

I really enjoy elderly people, but I couldn't do it anymore. Trying to provide good nursing care in a nursing home is like trying to bail out a lake with a teaspoon.

Leaving LTC really lifted an unbearable burdon off of my shoulders.

RNCENCCRNNREMTP · Mar 19, 2003

My favorite...

Nursing home sends in a lady for evaluation after a fall.

Has a knee prosthesis.

Acutely has a distal femur fracture just above the prosthesis.

I call nursing home to let them know patient is being admitted and tell the nurse...

"She broke her femur just above her knee prosthesis"

Her response....

"OK, she broke her femur below her knee!"

????????

"Noooooooooooooooo, the femur is that big bone ABOVE the knee"

One of medic friends said it best..

"When I get old and my family puts me in a nursinghome, every morning after breakfast, bath and new/clean clothes, I am going to S**T my pants!"

eldernurse · Mar 23, 2003

I hate it when they send patients to the ED with change in mental status and we have to ask "How could you tell?" But one of the latest reasons to be admitted to our ED is "inability to ambulate!" Just because a person needs to be placed in a nursing home does not mean they need to get there via the hospital.

We house many patients who really need to be admitted because our hospital is clogged up with patients waiting for placement. Something needs to be done.

flashpoint · Mar 23, 2003

How do you all handle after hours transports BACK to the nursing homes? Here if a patient comes to the ER via ambulance "after horus," one of out NHs expects the ambulance to take them back. Had a gentleman a few weeks ago that the NH called 911 for because he fell, NH thought he broke his hip, so...we show up and transport him to the hospital. We got him settled in his room, gave report to the RN, and sat down to do our run report. I looked up and saw our patient walking down the hall toward the snack machines. We went back to quarters and the hospital did a full workup on the paitent. A couple hours later, we got the call to transport him back. Our EMS Captain refused to do the transport becasue there was no medical necessity and there were other means of trasnport available. NH staff threw a fit because their tranport people had to get up at 0600 to come get him. It just seems like a no win situation to me...yes we are available to do the transports, but why should the NH resident pay $400 for a ride across town when they have no problem sitting in a car?

AngelGirl · Mar 26, 2003

eldernuse:

I think that the idea of a family member placing aloved one in a nursing home is still a hot button for many families.

To have the patient SEEN IN THE ER first seems to warrant more of a need for the loved one to "be placed," as far as the family is concerned.

It's as though they think "Sissy did ALL she could with Uncle Tody, but when he had to GO TO THE HOSPITAL!! then, it was time to put him in a "home."

Sometimes the heart won't accept what the mind already knows.

TazziRN, RN · Apr 6, 2003

Our local NH called and told me they were sending me a woman with SOB and low sats in the 60's.

Me: "IS ANYBODY BAGGING HER????"

NH: Oh yes, a paramedic is at the bedside now.

Me: (relieved) Oh, okay.

Pt gets here and the medic is so mad his ears are steaming. They got to the pts room at the NH and found her with no RN in sight, two CNA's there cleaning the pt up after incontinence, the pt was very altered and cyanotic. That's when the medic took charge and started bagging the pt! I was also told in report that the lung sounds were clear. The medic found her to be full of fluid (we eventually pulled off nearly 1 liter after Lasix and the pt perked right up). We have one board and care home in the area that is excellent; the owner usually brings her residents to us herself unless an ambulance is needed, and stays until a disposition is decided. If for some reason she or one of her relatives can't stay, they leave us a number at which they can be reached. This place is definitely the exception to the rule.

ERNurse752, RN · Apr 6, 2003

Originally posted by TazziRN
Our local NH called and told me they were sending me a woman with SOB and low sats in the 60's.

Me: "IS ANYBODY BAGGING HER????"

NH: Oh yes, a paramedic is at the bedside now.

Me: (relieved) Oh, okay.

Pt gets here and the medic is so mad his ears are steaming. They got to the pts room at the NH and found her with no RN in sight, two CNA's there cleaning the pt up after incontinence, the pt was very altered and cyanotic. That's when the medic took charge and started bagging the pt! I was also told in report that the lung sounds were clear. The medic found her to be full of fluid (we eventually pulled off nearly 1 liter after Lasix and the pt perked right up). We have one board and care home in the area that is excellent; the owner usually brings her residents to us herself unless an ambulance is needed, and stays until a disposition is decided. If for some reason she or one of her relatives can't stay, they leave us a number at which they can be reached. This place is definitely the exception to the rule.

That sounds like what tends to happen at the ECF's near me...there is a critical pt and no nurse at the bedside...or a pt with sats in the 70's, and they've been placed on 2 L per N/C.

:rolleyes:

teeituptom, BSN, RN · Jan 6, 2004

Arent you glad nursing homes never change, just comsider them job security due to their ineptitude.

Had a patient brought in from NH the other night. Nurse at nursing home called 911 and started cpr on a patient that she couldnt feel a pulse on. All the while the pt was yelling at her to stop. Paramedics had to pull her off physically.

Yes the pt had several broken ribs.

athomas91 · Jan 6, 2004

:roll :chuckle

i guess NH are the same everywhere!!!

ours will send us a DNR because "they won't eat" - what do they want us to do - shove food down their throat?!?!

Medic946RN · Jan 7, 2004

Originally posted by TazziRN
Our local NH called and told me they were sending me a woman with SOB and low sats in the 60's.

Me: "IS ANYBODY BAGGING HER????"

NH: Oh yes, a paramedic is at the bedside now..

Been there, done that, got the tee shirt and baseball cap!

One of the last runs I took before going to nursing school was at an ECF for the famous difficulty breathing call. On arrival the EMT crew was trying to bag a pt though her stoma, the nurse(and I use that term very lightly) was standing there with an aid and her hands on her hips.

Me: What's going on?

Nurse: Well she does this.

Me: Define this as it applies here.

Nurse: When she codes, she codes.

Me: (to EMTs) Is she in arrest.

EMTs: No she's just having trouble breathing, we can't bag her that well.

Me: Attach the bag to her trach tube.

EMTs: She doesn't have one.

Me: No prob we'll make one outta 7.5ett. (A good medic can make anything out of a ET tube some o2 tubing and tape)

I go to place the ett into her stoma and guess what, it won't go in past the cuff.

I look at the nurse

Me: Did you suction her?

Nurse: We have the equipment

She did. It suspiciously still had the dustcover on it.

I whip out my suction, squirt a saline bullet down the stoma and suck out the biggest, nastiest mucus plug I have ever seen.

The patient coughs, smiles and motions for me to lean over to her. I do and she kisses me on the cheek and whispers thank you.

I hold her hand and say "C'mon sweetie, lets get you to the hospital before they kill you here." (I was a real smarta$$ in my younger medic days)

On arrival to ED pt was sitting up and smiling, conversing well and had an 02 sat of 99 with 2lpm 02. The ER doc told me. "You fixed her, so go ahead and take her back, but unfortunately, the ECF's in that area wouldn't accept a patient back once they left by ambo until they were medically cleared by a doc. So she got to sit in hallway and the NH got rid of one those bothersome, labor intensive pts who might need to checked on more than once a day.

(climbs off soap box)

Thanks, I needed to get that one out.

BRANDY LPN · Jan 7, 2004

I do not work LTC anymore and never will again (if that were the only choice I had You would find me at the local diner serving cheeseburgers) Because like another poster mentioned you have about 50-60 patients you have to do meds and treatments and charting on ALL of these pts some of these pts receive 10-20 differnet meds at a time and they have to be crushed in applesauce ect. also you have to check CBGs on the diabetics. Put out fires all over the place ect. this does not give time to get to know the residents, or to do much nursing care. You have to relie on what the aides tell you and that is not always acurate, but you dont have the time to check yourself when you have that many pts. I dont beleive that this is a problem caused by nurses but rather admin. and the laws that allow this to continue, to the OP if you really want to see change please contact your representitves.

On another note this issue cuts both ways (prob. because of all the unneeded transfers) I once sent a lol to the ER with sats in the 70s (with 02 via non rebreather) and with full report (including v/s) and got her back in like an hour with dx of sinus infection. (she was long time copd and full code) and two hours later had to call EMS back to get her in the middle of code she was on vent for two weeks and ended up coming back fine. This same day had 2 res fall and had to ship both for fx , plus continue with all the other duties I was still passing 6am meds at 12 when it was time to start next med pass and the RN supervisor would not come help me, she did eventually send someone else to do my treatments but that didnt really help with the fact that I was 6 hours behind on the dang meds. So before you judge too harshly try to put yourself in the shoes of the LTC nurses can YOU imagine being the only licensed personell to give all the nursing care to 50-60 pts? This is not intended as a flame just hopefully an eyeopener.