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 ???

[GrannyRRT]

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.

Cuts in CMS have hurt LTC.

What you are saying is heard loud and clear. There is not always time to really work with a patient individually for some goals. You hope others can carry out the plan in as many pieces as possible.

CMS does not reimburse for Respiratory Therapists for therapy anymore. Even OT, PT and SLP services are limited.

Reading the OP about the trach makes me want just 15 minutes for an assessment to see what could be strengthened to get the patient's mind on that instead calling.

[GrannyRRT]

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.

Cuts in CMS have hurt LTC.

What you are saying is heard loud and clear. There is not always time to really work with a patient individually for some goals. You hope others can carry out the plan in as many pieces as possible.

CMS does not reimburse for Respiratory Therapists for therapy anymore. Even OT, PT and SLP services are limited.

Reading the OP about the trach makes me want just 15 minutes for an assessment to see what could be strengthened to get the patient's mind on that instead calling.

[ICURN3020]

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.

Thank you! I think a lot of the differing opinions throughout this thread stem from the fact that an ICU/acute care nurse and a long-term care nurse have very different perspectives based on their roles in the patient's care and their available resources and abilities while the patient is in their care.

An ICU nurse may have a patient for a few days and doesn't not have the opportunity to get to know the patient on a deeper level like a long-term care nurse would.

ICU nurses aren't heartless, we are just maybe more focused on critical, life-threatening issues the patient has in the short time they are with us and aren't effectively able to address every possible psychological issue or personal preference the patient may have due to the nature of our role. This also frustrates me because I really do care about patient's fears and worries, yet I am not Superwoman and can only do so much. I too love to see a patient make positive progress such as being extubated when all hope had been lost or turning the corner and stabilizing after a touch-and-go period of time.

We are all important in the patient's care! I respect all the care that all specialties of nursing provide to our patients. I cannot do my part effectively unless you have done yours effectively. We just have different priorities and time constraints.

[blondy2061h, MSN, RN]

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.

No, definitely agree with you there. In fact, "for end of life comfort" is an indicated reason for an indwelling catheter. This isn't an extreme or self limiting problem, though. This is an issue that should be addressed to make the evidence-based best practice work.

[ICURN3020]

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.

If my patient is desaturating, exsanguating or having suspicious cardiac rhythms, you can bet my priority is not going to be making sure they have the appropriate urinary catheter. Now maybe if they go from normal to no urine output, that would be considered.

Acute care nurses are not just satisfying "busy work charting requirements". Are you kidding me???? I care and therefore chart what the patient's VS or urine outputs are every 15 min or hour because I am watching the trends to spot changes so that I can intervene in a timely manner and prevent trouble. I must admit that comment sent my BP up momentarily. Come to work with me for one shift and you'll see that you're priorities will change significantly, just as if I spent a shift with you in long-term care.

What we do is not "cool", it is life-saving. And that's pretty rewarding too.

[GrannyRRT]

Thank you! I think a lot of the differing opinions throughout this thread stem from the fact that an ICU/acute care nurse and a long-term care nurse have very different perspectives based on their roles in the patient's care and their available resources and abilities while the patient is in their care.

An ICU nurse may have a patient for a few days and doesn't not have the opportunity to get to know the patient on a deeper level like a long-term care nurse would.

It is the ICU which can get the patient's long term goals started. I think I mentioned this before that we will know in ICU through our rounds what the patient will need for care and learn from CM how screwed he will be for rehab days and placement due to insurance. Multidisciplinary rounds can be a blessing. Everyone will strive to get as much done prior to discharge such as a new trach(including custom), possibly a supra pubic cath, g - tube and make decisions for appropriate long term vascular access since that can be facility dependent. Our units consist of mostly neuro patients (SCI, TBI, CVA) and we are fortunate to have long term and rehab attached.

Our Case Managers and Social Workers are awesome and will let us know which facilities the patient might land in. We then can prepare for the best or the worst.

We are huge on both the acute and long term sides of the hospital. Once the medical directors pulled the teams together and insisted on Multidisciplinary planning, we have less bounce back and do not have the reputation of "dumping" just to be rid of a patient. We get dumped on in our rehab and long term but welcome the challenge. The doctors accepting these patients may even try for an acute to acute transfer to buff up the patient instead of wasting rehab days.

So, it is not who is better but who understands THEIR system the best and can make it work. This takes a team and not just nurses. You shouldn't feel like you are supposed to carry the load but try to get the right resources in the game. Hospitals have to get their own care teams better organized for discharge planning which makes life a little better for long term staff with very limited resources and the patient will be lost in a mess from our healthcare system fragmentation.

Next time you are with a Case Manager ask how hard it is to get just a shower chair for a patient.

[ICURN3020]

As far as "goals" go, while your goal may be making sure the patient gets a shower, my goal is to keep my patient alive throughout my shift.

Both important, just different.

I must bow out of this thread now

It is what it is. To the OP, sorry for sidetracking your thread. My input regarding the original topic can be found in my first few posts.

[imintrouble, BSN, RN]

GrannyRRT,

Are you a nurse? Your name would indicate otherwise. I thought maybe you're both an RRT AND a nurse. You certainly have the RRT knowledge.

It would go a long way in explaining the disconnect some of us who have LTC experience are getting from your posts.

[sistrmoon, BSN, RN]

I work in Oncology and often see patients for months at a time for inpatient chemo and waiting for their counts to go up. We heavily involve them in their plan of care and get to know them. My charting isn't busywork. Tried to give the benefit of the doubt but the digs keep coming. I'm bowing out too. Sorry OP!