New hospice nurse with questions

toomuchbaloney · Sep 4, 2014

Tell them you don't know how long.

heron, ASN, RN · Sep 4, 2014

Good job!

Does "wet lungs" mean rales or crackles? Robinul has to be given iv or im, but can be quite effective in controlling bronchial secretions (rales). Lasix is a possibility if he has iv access (many cancer pts have implanted ports or Hickman caths.) The morphine you're already using is also helpful due to it's effect on cardiac function. It used to be the first-line treatment for pulmonary edema (crackles).

Keep an eye out for caregiver fatigue now that the patient is total care. Initiating or increasing CNA visits can give them a little bit of a break. Teach them about positioning and the non-verbal signs of pain/distress. Encourage them to use the morphine liberally, as it addresses dyspnea as well as pain. Reassure them that the cancer is killing the patient - not the morphine. Help them figure out parameters for holding it. On my AIDS unit with actively dying patients, our hold point was a resp rate of 4/min or less. That could be higher if the caregiver(s) are anxious about overdosing.

If they haven't already accessed bereavement services, do it now. CMS requires that such services be available and continue up to 13 months after the death.

One strategy I used to use when talking about timing is to relate it to childbirth. Most people have experienced waiting around for a pregnant woman to "pop". You know it's going to happen, just not exactly when. The speed, course and timing of a labor is completely unpredictable. The difference is that, in childbirth, we have ways of speeding up the process or entirely taking it over (C section). Can't do that when someone's dying. More often than not, when I explained it this way, people would get it.

Hang in there and take care of yourself.

QuiltDog · Sep 6, 2014

Remember to use the other members of the team, such as SW and SCC to help you meet the patient and family's needs. One of my biggest learning curves when I first became a hospice nurse was to think it was "all on me". Of course, coming from the hospital environment, it usually was! However, in hospice, you work as a team. Good luck to you

heron, ASN, RN · Sep 10, 2014

OP - are you there? How are things going?

Kerber · Sep 10, 2014

Hi I am hanging in there. I had my frist death last Friday am and 2 nd same day later that afternoon! This my 3 rd week now and I am enjoying it. Right now I have couple patients with problems I am trying to learn about. One is on Pca pump he has bone cancer and in a lot pain other is older lady with CHF he lower legs very swollen and red. I see her again today she won't keep them up though!

westieluv · Sep 10, 2014

Are you still required to be on call 24/7 for the entire month? I've worked for two hospice companies and I've never heard of that. Even if you don't get called, that is still being on duty and you can't relax or go anywhere. Everyone needs his/her share of days where they are not on call or scheduled to work. You know...days off? Used to be a common thing.

Maybe things are changing for the worse faster than I realize. I know things are bad in corporate dialysis these days, hence the reason why I'm getting the heck out of Dodge and coming back to hospice. No more running critical dialysis treatments on patients after already having worked 14-17 hours that day. Dangerous and unfair to patients, to say the least.

heron, ASN, RN · Sep 14, 2014

Hi I am hanging in there. I had my frist death last Friday am and 2 nd same day later that afternoon! This my 3 rd week now and I am enjoying it. Right now I have couple patients with problems I am trying to learn about. One is on Pca pump he has bone cancer and in a lot pain other is older lady with CHF he lower legs very swollen and red. I see her again today she won't keep them up though!

Thank you for getting back to us. It's great that you're starting to get some good feelings about your work.

The patient with bone cancer might benefit from NSAIDs (toradol IM if he can't swallow). Bone pain is notoriously resistant to opioids.

CHF lady could use a recliner, if there's someone in the home to help her with it. Ace wraps can help, too.

Kerber · Sep 14, 2014

The CHF lady had a lot water retention in lower legs. She has recliner and we up LASIK to 80 mg bid. The legs weep with water. Wouldn't a ace wrap just get wet? Should I put some ABD pads and then wrap the ace around that? She can't afford ted hose either. She also has small hole in lower leg she bump a bed she put bandaid over it and now the skin tore around that it's red but doesn't look infected. I left it open to air to heal. Her legs are so swollen ! Suggestions?

QUOTE=heron;8121211]Thank you for getting back to us. It's great that you're starting to get some good feelings about your work.

The patient with bone cancer might benefit from NSAIDs (toradol IM if he can't swallow). Bone pain is notoriously resistant to opioids.

CHF lady could use a recliner, if there's someone in the home to help her with it. Ace wraps can help, too.

heron, ASN, RN · Sep 14, 2014

My experience with that kind of weeping edema is that it's a fairly terminal phenomenon. You're not going to fix it. The best you can do is ward off further skin breakdown. Keep an eagle eye out for signs of infection and skin breakdown. Cutaneous pain is very hard to treat. She might need frequent CNA visits. Does she have a caregiver in the home? If so, they could probably use some support, too.

On my inpatient units - AIDS in the 90s and hospice in the oughts - we used either abds and chux, changed as soon as they get wet, or rigged something out of pillows and soaker pads. Not a lot of good options out there.

And please don't be insulted, but is the patient a DNR? Don't assume that they are. When I worked in the industry, hospices were specifically forbidden to require DNR status in order to be admitted. The industry isn't unhappy about that since admissions, especially long ones, equals profit margin.

heron, ASN, RN · Sep 14, 2014

Additionally - the social worker, spiritual care person and bereavement counselor should be involved now, if they're not already.

Kerber · Sep 18, 2014

They hired another hospice nurse we take turns each week to be on call this week I am off call next week mon-sun iam on call does that seem right? We only have 7 hospice patients and 2 RN

westieluv · Sep 18, 2014

Are you seeing patients next week, or does that alternate with being on call? The company that I just accepted a position with does it like this: week one, nurse 1 does visits but isn't on call. week two, nurse 1 doesn't do visits but is on call. Nurse 2 has the opposite schedule so that someone is always on call and someone is seeing patients, but you don't have to do both in any given week. We also have a low census as this is a relatively new branch office. As we get more patients, we will have more nurses.