Interment cath and trach suction per pt request limit

[Rvanurse2012]

So I recently switched jobs , and I went from acute care ( critical care and step down units) to long

term care but not your usual nursing home patients , these are Pts with mental and physical disabilities and considered young adults -ages 18-50 being oldest. The majority have CP and a few traumatic brain injuries. I have two patients that require prn nurse intervention one being str8 cath as needed per his request and one that has a trach. Requiring suctioning. Let's address first dude ... He will request that you straight cath him numerous times a shift despite timing between last cath times. Request we'll over what I think you would need to cath someone who is not able to urinate without nursing intervention ... Is there a limit to this the order states as needed within no limits and I have asked staff and they say they just do it when ever and how many ever times he request... Now here's the trach dudes story .... He request suctioning numerous times a shift. He request prior to neb tx , then after and then will request again in between the last neb and then again prior to ha neb and after and then again .. Each suctioning you hardly get anything but a scant amount of clear secretions , he wants you to hold the suction catheter down until he nods to pull it out. Is there a limit to this and how can I approach the fact that this seems to me as a behavior problem almost a stimulation type thing because he is a quad that doesn't feel anything from shoulders down. Any suggestions ???

[wooh, BSN, RN]

I'm surprised at all of the recommendations to just convert the cathed patient to a foley. We're really pushing to avoid foleys except when absolutely necessary to decrease CAUTI rates.

There comes a point where q hourly straight caths can't be any more of a risk than indwelling. All the trauma to the tissue, the constant in and out?

I'd bet he feels like he needs to pee because he already has a UTI (even if it isn't showing up on a UA.)

I'd also bet that if he had a foley, he'd find some other aspect of care to demand on an hourly basis.

[Pepper The Cat, BSN, RN]

There comes a point where q hourly straight caths can't be any more of a risk than indwelling. All the trauma to the tissue, the constant in and out?

I'd bet he feels like he needs to pee because he already has a UTI (even if it isn't showing up on a UA.)

I'd also bet that if he had a foley, he'd find some other aspect of care to demand on an hourly basis.

or maybe a Supra-pubic cath

[GrannyRRT]

Did this patient have a bad autonomic dysreflexia episode from bladder distention?

Basically there are 3 options for emptying the bladder especially if bladder retraining is not possible. But, this patient should be presented with the pros and cons of the options. This will allow him so control in his life.

From the OP it seems this is a nursing home which probably does not see many quadriplegic patients and the other patients sound as if they are functioning with some mental impairments for a variety of reasons. Now not only is he trapped in his body, he probably has few to no options for socializing and groups activities.

The fact he is in a nursing home which does not have a quad program means he is probably insurance challenged. He also probably did not have someone in his life who could be a primary. Those two factors mean he would not her home care. Depending on the state insurance he probably did not get into an Acute Rehab post SCI. Many of these issues are addressed during Acute Rehab.

If we knew our SCI or TBI patients were getting placed on our Intermediate unit with a lower nurse/patient ratio and take advantage of whatever OT, PT and RT services we could squeeze from the insurance in an attempt to better prepare him.

A lot of hospitals (and staff) just want the patient out as soon as the trach is placed. The label "chronic" comes with a trach.

Sometimes we can squeeze 5 days for prepping before placement. That is barely enough time for the first trach change.The patient is still spinning from learning he is a quadriplegic for the rest of his life which means not many decisions are processed.

If he gets tossed out too soon before spasms and some of the AD potentials are addressed, he is off to a bad start in a nursing home. Readmissions to a hospital might mean having to start over in another nursing home with staff who don't know him and may not be happy about all the care a quadriplegic patient requires daily. Heavy patients in many ways.

Unfortunately too many quadriplegic patients end up on this path of feeling let down by his family or alienating himself from them to not be a burden. They are also caught in the mess of the US healthcare system which would rather warehouse a young person rather than offer rehab. The patient essentially becomes a foster child moving with too few advocates in a broken system.

Advocate for the patient to have the appropriate care. I have seen good things happen with persistence and patience.

I am also a passionate advocate for children who are at the mercy of our healthcare system if anyone wants to start that discussion.:)

[blondy2061h, MSN, RN]

There comes a point where q hourly straight caths can't be any more of a risk than indwelling. All the trauma to the tissue, the constant in and out?

I'd bet he feels like he needs to pee because he already has a UTI (even if it isn't showing up on a UA.)

I'd also bet that if he had a foley, he'd find some other aspect of care to demand on an hourly basis.

Right, but if they're getting less than 100 ml, he doesn't need hourly cathing OR an indwelling catheter. He almost certainly has some type of cystitis going on and need a urologist if the ua isn't showing it. He also probably need psychology.

[LadyFree28, BSN, LPN, RN]

Did this patient have a bad autonomic dysreflexia episode from bladder distention?

Basically there are 3 options for emptying the bladder especially if bladder retraining is not possible. But, this patient should be presented with the pros and cons of the options. This will allow him so control in his life.

From the OP it seems this is a nursing home which probably does not see many quadriplegic patients and the other patients sound as if they are functioning with some mental impairments for a variety of reasons. Now not only is he trapped in his body, he probably has few to no options for socializing and groups activities.

The fact he is in a nursing home which does not have a quad program means he is probably insurance challenged. He also probably did not have someone in his life who could be a primary. Those two factors mean he would not her home care. Depending on the state insurance he probably did not get into an Acute Rehab post SCI. Many of these issues are addressed during Acute Rehab.

If we knew our SCI or TBI patients were getting placed on our Intermediate unit with a lower nurse/patient ratio and take advantage of whatever OT, PT and RT services we could squeeze from the insurance in an attempt to better prepare him.

A lot of hospitals (and staff) just want the patient out as soon as the trach is placed. The label "chronic" comes with a trach.

Sometimes we can squeeze 5 days for prepping before placement. That is barely enough time for the first trach change.The patient is still spinning from learning he is a quadriplegic for the rest of his life which means not many decisions are processed.

If he gets tossed out too soon before spasms and some of the AD potentials are addressed, he is off to a bad start in a nursing home. Readmissions to a hospital might mean having to start over in another nursing home with staff who don't know him and may not be happy about all the care a quadriplegic patient requires daily. Heavy patients in many ways.

Unfortunately too many quadriplegic patients end up on this path of feeling let down by his family or alienating himself from them to not be a burden. They are also caught in the mess of the US healthcare system which would rather warehouse a young person rather than offer rehab. The patient essentially becomes a foster child moving with too few advocates in a broken system.

Advocate for the patient to have the appropriate care. I have seen good things happen with persistence and patience.

I am also a passionate advocate for children who are at the mercy of our healthcare system if anyone wants to start that discussion.:)

I'm RIGHT there with you!

Rehab from Peds to Adult health is my mainstay specialty...that's all I know, and the dynamics that go with it.

[sistrmoon, BSN, RN]

I'm surprised at all of the recommendations to just convert the cathed patient to a foley. We're really pushing to avoid foleys except when absolutely necessary to decrease CAUTI rates.

In our hospital, straight cathing is almost always preferred due to lower infection rates. However this is sometimes taken to an extreme and the whole picture should be assessed. I had a group of urologists wanting me to straight cath(and teach to self cath) a dying patient every 4 hours who was in excruciating pain with leg movement. Not appropriate in that case.

[sistrmoon, BSN, RN]

There seems to be a subtle dig here. I'm not saying every patient doesn't deserve the best quality care regardless of nurse/patient ratio. I'm saying I'm one person, and I do my best each shift for each patient, but I'm still one person and the more patients I have with more acute and complex needs, the less I can address each patients' needs. The sickest patient and most immediate needs are going to be prioritized. I work Adult Oncology(with med surg overflow) so I don't purport to know what it's like to work Rehab or Subacute Rehab. I do deal with quads and trachs infrequently, but I certainly don't know them like I know my leukemics. The bottom line is, though, that more patients and less support, is going to limit your realistic ability to address frequent needs like this. I don't think it makes me a bad or less caring nurse to recognize that these factors are going to limit the kind of care I can give all my patients, and I don't like the implication. In an ideal world, I would have all the time and resources to address each patient's needs thoroughly. This is one of my biggest frustrations of my career.

[GrannyRRT]

Long Term Care is about the long term whether the condition is chronic or will improve with healing or rehab. You don't have to rush like in Acute care where all the care begins and ends sometimes on the same day. LTC is where you get to make care plans which are actually customized goals rather than to satisfy busy work charting requirements. It should also be done as a team with the patient. If the patient agrees to a certain plan with the team, it can influence behavior. But, from a nursing and allied health viewpoint, it is rewarding to be able to mark off goals like getting the appropriate catheter or strengthening the respiratory system enough to clear his own secretions.

Extubating a challenging patient in ICU is cool but decannulating_ a trach from someone who was given up on is awesome. The same goes for having someone use a urinal for the first time since his life changing event.

[LadyFree28, BSN, LPN, RN]

Long Term Care is about the long term whether the condition is chronic or will improve with healing or rehab. You don't have to rush like in Acute care where all the care begins and ends sometimes on the same day. LTC is where you get to make care plans which are actually customized goals rather than to satisfy busy work charting requirements. It should also be done as a team with the patient. If the patient agrees to a certain plan with the team, it can influence behavior. But, from a nursing and allied health viewpoint, it is rewarding to be able to mark off goals like getting the appropriate catheter or strengthening the respiratory system enough to clear his own secretions.

Extubating a challenging patient in ICU is cool but decannulating_ a trach from someone who was given up on is awesome. The same goes for having someone use a urinal for the first time since his life changing event.

PREACH!

[imintrouble, BSN, RN]

Long Term Care is about the long term whether the condition is chronic or will improve with healing or rehab. You don't have to rush like in Acute care where all the care begins and ends sometimes on the same day. LTC is where you get to make care plans which are actually customized goals rather than to satisfy busy work charting requirements. It should also be done as a team with the patient. If the patient agrees to a certain plan with the team, it can influence behavior. But, from a nursing and allied health viewpoint, it is rewarding to be able to mark off goals like getting the appropriate catheter or strengthening the respiratory system enough to clear his own secretions.

Extubating a challenging patient in ICU is cool but decannulating_ a trach from someone who was given up on is awesome. The same goes for having someone use a urinal for the first time since his life changing event.

"You don't have to rush like in acute care" simply rolled over me like a mack truck. You don't have to rush in LTC?

The above post bears absolutely no resemblence to any LTC I've ever worked.

[GrannyRRT]

"You don't have to rush like in acute care" simply rolled over me like a mack truck. You don't have to rush in LTC?

The above post bears absolutely no resemblence to any LTC I've ever worked.

Of course you run around all shift doing patient care. We are all over worked in LTC but still get to know the patients to be part of the team helping to make the decisions to improve care. And, there will always be exceptions with caregivers who just need a job. There are also facilities which are just storage units doing the bare minimum to keep the bills paid. Some will not even attempt weaning someone who is a steady cash cow with few other needs.

But, the decisions for the long term don't need to be made RIGHT NOW.

For acute rehab we do weekly care meetings. This gives the caregivers an opportunity to get to know the patients but time is a factor since we may have only 100 days or a lot less to form and achieve goals with the patient.

For Subacute the meetings are initially biweekly then monthly.

In the meantime everyone discusses care options with everyone from the CNA to to MD having an input.

Sometimes it takes a little while to decide on the most appropriate care. In long term it takes longer to get approval for a procedure, find an accepting doctor and hospital and arrange for transport. Some procedures may be denied regardless of the need.

[imintrouble, BSN, RN]

Of course you run around all shift doing patient care. We are all over worked in LTC but still get to know the patients to be part of the team helping to make the decisions to improve care. And, there will always be exceptions with caregivers who just need a job. There are also facilities which are just storage units doing the bare minimum to keep the bills paid. Some will not even attempt weaning someone who is a steady cash cow with few other needs.

But, the decisions for the long term don't need to be made RIGHT NOW.

For acute rehab we do weekly care meetings. This gives the caregivers an opportunity to get to know the patients but time is a factor since we may have only 100 days or a lot less to form and achieve goals with the patient.

For Subacute the meetings are initially biweekly then monthly.

In the meantime everyone discusses care options with everyone from the CNA to to MD having an input.

Sometimes it takes a little while to decide on the most appropriate care. In long term it takes longer to get approval for a procedure, find an accepting doctor and hospital and arrange for transport. Some procedures may be denied regardless of the need.

Thank you for your clarification, but I still don't recognize most of what you've posted.

I imagine there are more like me, than you. That's too bad, because I think I would've stayed in LTC if I'd been lucky enough to work in your facility.

I've hijacked this thread enough.

Back to the catheter and trach.