Latest Comments by andre

andre 3,886 Views

Joined: Sep 12, '03; Posts: 143 (7% Liked) ; Likes: 54

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  • 1
    AtlantaRN likes this.

    Our agency is on an EMR so it's really only consents, port DNRs/copies of advance directives and pharmacy auths to turn in. The expectation is to turn everything in within 24 hours of the admit. Or 24 hours of the revocation/discharge. And ok to fax and then turn the originals in next time you're in the office.

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    I can't possibly be the only one trying to figure out how we're supposed to have any time left to see patients with all the new documentation requirements??????

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    What we have done in these scenarios is explain to the pt and family that if they call 911 or go to ER without calling us first, they are revoking their hospice benefit as that is outside our plan of care. There are occasions where we will ok hospitalization if the diagnosis is treatable and clearly outside of their hospice diagnosis (such as a recent patient with new onset seizures.....hospice diagnosis is cardiac).

    I think rather than making a blanket decision to discharge the patient in 30 days, now is the time to once again educate the pt and family about hospice philosophy, reevaluate patient goals, and establish a plan of care where it is clearly documented that all are understanding that 911 calls/ER visits without first discussing with hospice team means you are choosing to revoke the hospice benefit.

    Hope that helps,

  • 9

    Quote from Michiganag
    I just called in this morning for the 2nd time in my life. While I hated to do it, I’m miserable and in no way should be around patients. I was told to make sure I go to the doctor to get a note. A note? What, are we in Jr. High? This is my profession. You expect me to make clinical judgments regarding the welfare of my patients but you don’t think I can determine when it is appropriate to come to work? While I may have strep and end up going to the doc (I seem to be a strep magnet!), I probably don’t, it’s probably viral, and I can’t image crawling out of my house to sit in a waiting room at some Urgent care just to get a note. What a waste of healthcare resources!
    I had this same experience when I had the flu a few years back....missed two consecutive days of work and was required to get a doctor's note. I went to my MD's office but saw a covering MD who, when I told her why I was there shook her head and said, "Wow, what are you, three? I can't believe they're making you do this....I'll be right back".

    She did no physical exam, just left the room, wrote my note, came back in and said "Feel better....go home and go to bed." Her note said: "Andrea has the flu. She may return to work tomorrow if she is feeling well enough, otherwise she may return at her discretion. Thank you for wasting an office visit by making her come in."

    It just makes me burn....I agree with you completely. We take care of incredibly sick patients--why is it so difficult to see that we do, in fact, know when we just have the sniffles and are capable of safe care versus when it is unwise, unsafe and generally a lousy idea for us to come to work?


  • 30
    sharpeimom, Mikey31079, ShifraPuah, and 27 others like this.

    Ok. I totally understand that nursing is a 24/7/365 operation. Really. And I knew when I went to nursing school that I'd be working weekends and holidays, and planning my vacations six month in advance, at least while I worked in the hospital setting.

    But seriously, why bother even giving people the opportunity to earn sick time if you are going to punish them for using it? I myself, though never warned or terminated for it, was routinely "dinged" on my annual evals for "excessive absenteeism".....though I only took sick time I had earned. Every year I had the same response for my manager: "I understand your policy, but I disagree with it. If I am sick or I have a sick child, and I have sick time to take, I am going to take it. I call in well in advance of the shift so I don't leave anyone in a bind. I have also been known to come in when asked on my day off because of other staff sick calls, or to help cover vacations. I disagree that it's excessive absenteeism if it's within the limits of the time I earn." And every year we'd agree to disagree, and I'd go back to the floor....

    Now I work in hospice. I work very few weekends, I have paid holidays, and if I call out sick I am told "Feel better....take care of yourself." In fact, the few times I have gone to work sick because of the expectations I had absorbed that that's just what you do as a nurse...and I was told "Go home! You're sick! We don't want you seeing patients like that!".

    It just makes me so angry that so many of us are made to feel like criminals or bad employees for taking more than 2 or 3 sick days per year! Sometimes life just doesn't work that way! And no one should be made to feel bad about that!

    Ok, rant over.


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    I'm not case managing any longer, but when I did I carried a caseload of 12 and generally did 4 visits and several phone calls per day. Five visits was BUSY and happened sometimes, but I never did more than that.

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    What a nice thread!

    I've been a vegetarian for about six years now, never really liked meat but of course was always expected to eat it as a child. Was mostly veggie all through high school and college before going "all the way" and never will go back....I feel sooo much better (really think meat is impossible to digest and "heavy") and love ALL kinds of veggies! The only exception seems to be the one you can ALWAYS find in your hospital cafeteria: brussel sprouts

    My other half and my kids eat about 50% veggie,and although I hold out vague hope that someday they'll join me, I know better than to push them...

    My favorite cookbooks: Fields of Greens, The Mediterranean Vegan Kitchen and A Year in a Vegetarian Kitchen. I like Veganomicon too, and the postpunkitchen forums are great for recipes,too!

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    Our agency is now on Road Notes, which is fine but is not terribly intuitive. I hear GREAT things about HealthWyse (have a friend who is a project manager for that company). I've heard very mixed reviews about McKesson, but have never seen it.

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    LOVE my Ultrascope! I hear much better with it than my (double the cost) Littman.

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    Anyone work in a clinic that has a Patient Navigator? Any experiences to share with how that model works?


  • 8

    One of my assigned patients is dying of metastatic liver cancer. I was told in report, "he's full of mets". The day before I took care of him, Hospice was consulted. He had a significant amount of pain, but if we kept up with his Oxy (he also has a Duragesic patch) he was comfortable.

    So my usual morning routine goes like this: print my report sheet, and start putting in my little boxes for med times, assessments, etc (yes, I'm the OCD nurse), while I wait for the night nurses to be ready for report. Get face-to-face report from the off-going nurse(s). Then we do walking rounds, so we can meet the patients....and make sure they're still breathing (true story: not long ago in walking rounds we discovered a palliative patient had just died...imagine if we had skipped rounds and I hadn't gone to assess her first?). As soon as I've met my patients and made sure there's nothing that needs my immediate response--patient crashing, in pain, etc--then I go back to my computer. At this point I take a good 20 minutes to look at the last set of vital signs, any a.m. labs that are back, and the last nursing note. By this time I feel "ready" to decide who I need to see first, and start passing my meds. And it's probably 8am by now.

    Generally I find it helpful to have looked at vitals and labs before pulling meds, so that I know if the patient's BP is low enough to hold meds, for example. Or I know what their K+ is before I pull out a big dose of Lasix. So anyway, I pull my first patient's meds, and do my first assessment when I go to give them.

    Lather, rinse, repeat. I usually pass all my morning meds and cover fingersticks before sitting down to document any assessments. Of course, by this time docs are rounding and writing new orders, too....

    So. Back to my patient. After hearing in report that he's full of cancer, we go to see him first and he needs pain meds. So right away I pulled his Oxy and gave it. He said to me, "you girls are soooooooooooo nice".

    About a half hour later, after seeing my next patient, I went to re-assess his pain, and he was much more comfortable. I asked him if he needed anything, and he said, "oh just a few ice chips if that's ok". I said of course, and then suggested some ice cream. His whole face lit up, and he asked, "I can have ice cream?"

    Oh lordy, you can have anything you want.

    As far as I'm concerned, when you're dying of cancer, ice cream for breakfast is not only ok, it's medicinal.

    So I went to see all my other patients, gave meds, sent folks for xrays, talked with some docs. Then I went to see him again. With an ice cream in hand.

    He beamed from ear to ear.

    All day he kept thanking me for being so nice. Honestly, he was an easy guy to like, grateful for the most trivial of things. One of the things I like most about palliative patients is that the focus really is on the small things--fluffing pillows, backrubs, clean sheets, cool cloths. Pain meds. Ice cream. Lather, rinse, repeat.

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    I graduated in NH (NHCTC Stratham) in May of 2005. Took my boards June 7th, 2005. Could have tested sooner but I wanted a few more days to study. It is do-able, IMHO.

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    Clearly I didn't read your first post very closely! Somehow I thought you had said she was moaning with care.... Your other post about not being able to auscultate heart sounds, along with the wet breathing would lead me more toward fluid overload.....still, if she's that "wet", and even with no grimace but some moaning, I might use the morphine more often than q3hr.....

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    I'd rather suspect she is either in pain or anxious--anxiety may be r/t dyspnea. Is she on any morphine? I think she needs to be medicated!

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    I went to hospice directly from tele! Well, unless you want to count the 8 weeks of misery in outpatient oncology before I ran screaming to hospice (oh I loved onc--the patients, the work itself--it was the nastiness of the other staff I just couldn't stomach)...

    Actually, my experience sounds a lot like yours....spent five years as a unit secretary on tele, then was a new grad on tele--had just under two years as an RN when I went to hospice. If you've got any experience on your unit with palliative/comfort care only patients, that will be helpful.