Kittypower123, ADN, BSN, RN 4,981 Views
Joined: Feb 13, '09;
Posts: 144 (65% Liked)
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I've been away from this site for awhile. But I would like to clarify. I do not do my documentation after the admission visit. I do it on-site. But, I do a thorough evaluation of the patient to determine whether or not they are appropriate for hospice. By this time, I know much of their medical history as well as what is going on with them now. During the admission assessment, I am required to document on each system (cardiovascular, respiratory, etc.). When doing a thorough evaluation, I gather information such as cardiovascular disease and symptoms the patient is experiencing at that time as well as over time. So, when I get to that portion of the admission assessment, I already know that the patient has an irregular heartbeat, they require O2, experience dyspnea with exertion. All this is information I obtained during the evaluation portion of the visit. I do not need to re-assess the patient in front of me just because it's been 30 minutes or so. It's the same visit and information is still valid. I would document if the patient had taken any medication since I got there and what the effect was, or if their symptoms had changed in that short time. Typically, however, they are not in an acute care setting and are not experiencing such rapid changes to their condition. All our admissions include an evaluation as that is not done before hand.
There are a few things that help your patients and their families to have positive experience. First, don't promise anything that you can't personally deliver on. If it's not up to you, don't promise. Be honest about what you and hospice can and cannot do. Second, check meds at every visit and order any refills needed. If you wait for them to tell you, they will be calling after hours and on the weekend. Third, educate. The patient and family need to know what's coming. They need to know what changes will occur. When they don't know what's coming, they panic needlessly. That doesn't do anyone any good. They need to know which things they can and should do something about (and what to do) and which are natural and do not cause discomfort. Don't make the mistake of educating once and figuring they'll remember. They won't. Educate again, and again, and again. Finally, don't rush. Things will come more naturally and will take less time as you gain experience. That being said, don't rush a visit. Even when you feel rushed and are trying to get out as quickly as possible, take a breath and focus on what's in front of you. The patient and their family deserve your best.
Back when I was working in a SNF, I had a patient on Coumadin. The INR came back at 5-something and there was blood in the foley bag. Called the MD and he said to give the Coumadin and retest in the morning. Um...No. Sorry, not going to do that. Got him to agree to hold and retest in the morning. What the patient really needed was some Vitamin K.
What is this for? How long is the lesson supposed to be? Who will you be teaching? Can you give more information please?
I'm so sorry you're struggling with grief. It does come with the territory, as much as we try to be professional and have boundaries, some of our patients just get to us. Your hospice company should have chaplains, they can help you too. They're there for the staff as well as the families. Also, there is probably a bereavement coordinator who may be able to help. The chaplain or bereavement coordinator can help you talk through what you're feeling as you deal with the grief. If that's not enough, seek out a professional therapist. I have had a few patients that I cried over when they died. Thankfully, I can talk to the chaplains at work. I also have a wonderful husband who will hold me and let me cry it out. I hope and pray you find the right person to help you through your grief.
Time management can be difficult. You can plan your week, but it won't turn out that way! One thing I do is front-load my week. I plan to get almost all of my visits done in the first three days of the week. I know it won't happen, but if I plan for 4 visits on Friday, I know I might end up with 8. As I plan my week, I try to cluster visits geographically. I also think about which visits should be pretty straightforward (patient is stable, not much in the way of education needs, etc) and which will likely take more time. I think about which visits can be moved to later in week if something comes up and which can't. Having this information in my mind helps me change plans as I go and still be sure patient needs are being met. I'm constantly reviewing my schedule to check my progress and any changes I've had to make. If I have a CC or GIP patient, I see them first. I know they can take more time and I want get them taken care of. Most of time, if something else comes up with them after the visit, I can handle it by phone. It's tough to get time managed well in hospice, it takes time and practice. Use the frustrations with time management to learn. It will get easier.
As for documentation, that takes practice too. Remember to document decline. For example, on admission patient ambulated with rolling walker, now confined to wheelchair. Also, you don't need to write a narrative for every system. Focus on what is an issue for that particular patient. For example, if you have a CHF patient, what is their b/p, hr, heart rhythm, do they have edema, is it better/worse/the same, are they on oxygen, are they compliant with meds, what education did they need, etc. For us, the assessment is mostly checking boxes and imputing certain stats like vital signs, last BM, Diet and % eaten, pain rating, that sort of thing. The narrative itself doesn't need to be long, just focus on the reason for the visit or the particular issues for that patient.
I'm have found that working by myself such as a hospice case Manager or home care help a with the sensory overload part of it. I am responsible for my work with very little drama from other nurses. The families we work with are over the top sometimes but with some time by myself at the end of the day i did it for almost 6 years.
Regarding your concern about morphine: as a hospice nurse, I just die a little every time someone says that morphine kills people. IT DOES NOT. Used appropriately, comfort care measures such as morphine have been shown to actually extend the life of terminally ill patients in some cases. Their bodies aren't being as worn down by pain, and they have a greater quality of life for their remaining time. I have had several patients who were breathing 40-50 times per minute (normal being 12-20) who received morphine (or Dilaudid, or whatever) specifically to decrease their work of breathing. If a patient's goal is to be comfortable at end of life, morphine is often a very helpful tool to meet that goal.
I and my coworkers wonder a lot lately...
Granted, I work in end-of-life care and there is a lot of symptom management related to terminal illness. There has always been the group of providers who are very hesitant to prescribe narcotics for symptom management pain and would not prescribe liquid morphine to deal with SOB unless the patient decided to be CMO.
Pain management is not that easy to begin with if a person has more than the standard pain issues or prior substance use. When we see patients who have a prior narcotic history or are already on high doses they may do better with methadone but many prescribers do not have the experience and do not like to deal with it for example. I had a patient basically screaming out in severe pain because of cancer and the patient had a prior tolerance history with taking up to 200 mg of morphine a day. What can I say? methadone fixed the problem but it was an act to get there....
I do think that providers need to be more educated about prescribing narcotics and also utilize other medications and methods.
I just want to put this out there - "Normal" is a setting on your washing machine. Everyone is unique. As others have said, there is no stigma with taking medication for diabetes, allergies, hypertension, sleeping disorders or whatever. There shouldn't be with ADD either. Figure out what works, learn to work the way you need to. Just because someone else organizes themselves a certain way doesn't mean you have to. I get teased a bit at work because of how I do things, but I also get compliments for the results. I laugh with my coworkers (it really is all in fun, we get along great) and keep on doing what works for me.
I've had a few patients with sudden and quickly worsening wounds. Not all were sacral though. The first was actually her heels. I did a full skin assessment in the morning and was called back in the afternoon to by the aide to find both heels had large black areas. I don't recall them being butterfly shaped though. She was gone by morning.
Another was a gentleman I saw in the afternoon who had several existing wounds. I noted blanchable redness to both hips. He was being repositioned frequently and the care was good. When I came back in the morning both hips had large black areas. He was gone within the week.
In both cases I had heard of Kennedy ulcers and believed that was what I was seeing. My supervisor had never seen one. I have seen other cases, but those two stand out in my mind. It is an interesting phenomenon and definitely needs more attention in literature and education programs.
I work in hospice too and am going to pursue wound certification. If you go the WOCNCB website and look at the eligibility for the exam, it explains that there are two different pathways. Taking a course and successfully completing it make you eligible to sit for the exam (you must apply to take the exam within 5 years of completing the program). The other option is to qualify through experience. This pathway requires 50 CEs for each specialty (wound care, ostomy, and continence) you wish to test for and 1500 direct patient clinical hours within the last five years (at least 375 within the last year). I am opting to take the course. I am only pursing certification in wound care at this time, not ostomy or continence. You can look at the requirements at Eligibility | Wound, Ostomy and Continence Nursing Certification Board. Hope this helps.
A mass email saying "Thanks nurses! etc." At least it came out at the beginning of Nurse's Week this year, instead of the last day like last year (I think they forgot last year...oops). No reference at all the theme of the week though. From some of these posts, sounds like it could be a lot worse.
That wasn't a suppository!
As soon as I finish this assessment I need to change the dressings in rooms 5 and 7, change the foley in room 6, help Susan in with the wounds in room 8, do my next med pass, and finish my charting.
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