oxyjen

Thanks Cin for contributing your experience in witnessing what happens with a person removed from the vent. I was so afraid she would suffer from air hunger, and that being medicated, and unable to move, she wouldn't be able to ask for help. I pictured that even if she wanted to ask for more O2, or more medication, she would not be able to. I learned yesterday that she spent another day with all of her family, and that it was very hard for them to visit her. I guess she died a few hours after being taken off of the vent, but did die peacefully. I'm grateful to have heard this, I did want her to have her wish, and to not suffer either. I'm relieved this horrible time is over for her family and I hope they do feel they did everything they could do, and that she had her wishes met.

Just an update to this thread. Thanks for the thought provoking opinions! The students discussed this at length too. One said this woman's condition hadn't declined enough, if this was her mother, and still able to communicate like this lady could, she would never allow her to be taken off the vent yet. I couldn't help but feel myself agreeing a little with her. When I 'personalized' this, and imagined myself in this situation, it became harder for me. Yet, the woman didn't agree with her family and got her wish on Monday. I heard that she died a few hours later. Again, thanks for suggestions and opinions.

We didn't have this lady as an assignment today. I did visit with her before I left, and I also spoke with the staff, it was hard because everyone was so busy, but I managed to ask a few questions. She will be transfered to a Hospice, supported by an Ambu bag, they'll admit her, medicate her and stop Ambu-ing. What she has chosen is called terminal weaning. Get this. Hospice can't/won't take her as a patient while she is on the vent. So they have taken a preliminary history (probably by phone/fax) but she is not allowed daily visits by them. I didn't ask why, I bet I know why. Their visits are nonreimbursable if she is on life support. If you think this isn't true, ask any hospice approved by Medicare/Medicaid, I think they'll tell you. Why would they send an employee to visit her if they won't be paid? While she is in the nursing home Medicaid is paying for her care, and they won't pay for two agencies to care at the same time, it's one or the other. Medicaid and Insurances (I think) are the same, doesn't matter. It's considered double billing, am I right? Anyway, that said, She told me she was allowed an outing with her family a few days ago, accompanied by RT. She seemed to be rather unimpressed by this outing. Maybe it is a mental weapon not to make a big deal about it, or thing about it too much. She was able to talk so that I could understand her today (no writing!). She is quite certain of her decision, and comfortable with it. She knows she is doing what is best for her, she said that, not me. I won't go into all that she said, but I felt better, I think she is comfortable and she said she isn't too afraid, just a little. I told her goodbye, and that I'd not forget her, and she thanked me and said to thank the students. We did say a few more private things to each other. I've had a really busy full day and I'm too tired type more right now. Google "terminal weaning" to learn more about this process. From what I read, there aren't any standards of care with this. I mean, no set amount and type of medication so that the feeling of air hunger isn't felt 100% of the time.

I agree too, indigo girl. Again, this board has helped me deal with something I encountered in nursing that I couldn't do very well on my own. I honor you who helped me here. I'll see my lady tomorrow. It might be the last time I see her, but I'll make time for her for sure.

Thanks for your opinions. It is indeed a very tragic situation, and has become harder as I got to know her more personally. I really like this lady and never have cared for an ALS patient before. She still has limited movement of one arm, that is IT. Even her tongue is paralyzed. It is a blessing for her that she can still write short notes. Her chart doesn't include what happened before she came. She wrote the story, best she could. So I had to figure it out best I could. I agree she needs a psych eval, she is depressed, cries a lot. I know who the social worker is, and will talk with her. I guess I am afraid that suddenly, everything will happen very quickly, psych eval, hospice admission, admit to an ICU somewhere and turn off the ventilator, without giving the poor thing a chance to have her say, to be guided in talking with her family. She needs an advocate present when she is talking with them. That is what I'm going to tell the social worker. I need to hear that someone is LISTENING to this lady, especially her family. CDK, I understand your shock. Please try to remember, if God wants her to live, she will live after the vent is turned off, right? He's given us the knowledge to keep loved ones with us awhile longer than we used to be able to, but he gets us all in the end. No one's soul never wears out. I just hope I can make a difference, that's all.

Hi gr8rnpjt, I avoided saying in my original post how I came to be slightly involved here, and did present myself as her primary caregiver but I'm not. I apologize to anyone who reads this. I'm not an employee and it's not within my scope to be coordinating this. I come with students and we were asked 4-5 times if we would like to care for the lady. Sometimes we are asked if we would like to gain experience in certain areas, sometimes we are asked not to take on certain assignments. I was told that a social worker and hospice 'would have to be contacted', and that it was taking much longer than they thought it would. After that the patient told me 'she would be gone in 2 weeks'. I'm hoping all of this coordinating has been established by the time I see her again. I just will listen to her and offer my time and support, along with my students.

I have had limited occational contact with a 50 yo patient who has been brought to the facility with ALS or Lou Gerhigs disease. She is ventilaor dependent. She communicates by writing on a board, very slowly and hard to read. My heart goes out to this woman. Her mind is perfect, but she is trapped in this body and is 5 years with this disease. She was brought to this facility because no one else in her area would take a ventilator patient. So she is an hour away from her family, who comes on the weekend. She says she was put on the ventilator without her permission, the family insisted. She has decided to end her life. She told me she'd be gone in two weeks. I've questioned the two Respiratory Therapists who work with her. One explained that the wheels to begin this process have begun. she and her family will need visits from social workers and hospice. Then she'll be transfered to an ICU closer to her family and sedated with MS and taken off of the ventilator. One says she will be snowed and completely comfortable and have an easy death. The other said it doesn't always come easily, the MS helps some but not entirely. The patient and I had a limited conversation about this and it left me rattled. I found I had trouble talking with her about her death. She obviously is having trouble with her decision. She said her family says she owes her grandchildren to stay here. I responded that I was so sorry she has this terrible disease and was so rattled I don't know what else I said. She cried and I hugged her. I had to leave, I'd already spent so much time, communication from her is very slow. I don't know that religious counsel has been in, or if she even wants it. I worry that this lady isn't recieving the emotional attention she needs (from myself or anyone else). I would think that hospice would be coming every day to start this process but I've not seen anyone visit her yet. I feel guilty that I've had her as my patient 4-5 times but spent my time with her concentrating on tubefeeds, meds, ventilator, treatments, and haven't taken the time to be there for her emotionally. I'll see her again later this week, dont' know if I'll be assigned to her, but wondered if you could help me with a few thoughts on how to do a better job this time? It might be my last time to see her. How do I say goodbye?

Thanks guys, today, after asking about this, I went about my day and didn't think about it in the same way. Sometimes I have to really stop myself from thinking I did something wrong, no matter what or how stupid. Now that I have my head around this I realize it is nothing, nothing, nothing. Relief is a GOOD feeling.

Absolutely, even though I wasn't REAL upset, I realized it was on my mind too much, feels good to just talk it over a bit. Nurses pay, though better than lots and lots of jobs out there, doesn't reflect what we think we go through. I always said if nursing were a male dominated world I'd be making double or triple what I make. (This is getting off track of my original post!) My nurse friends husband worked all his life in maintanence at our hospital, same as she. She told me he made 'as much as I do'. Never forgot that. And not putting down maintanence men, for goodness sake!

Well! I just had a visit from a friend, who lives next door to the respiratory therapists sister. What a coincidence. Turns out he tells me that there has been arguing between these two sisters. Their father was very ill for a long time and the one who is moving drove 30 miles a day to visit him, pretty much was the main source of support to the mother, and that she has always complained that the RT would show up once a month and climb on the staff, doctors, demand medical records (which they wouldn't give her), and generally stir things up. After the father died, who is helping the mother? not the RT. At least this is the story I was told. So, there is a rift, and now this sister is moving and leaving mother, who will need the RT more than ever. I've probably made this sound complicated, and I'm really not all that interested, I don't know these people all that well anyway. Thanks for a few kind words, and reassuring me I didn't do anything wrong. I'll see what happens next week when I see the RT. If I could handle respiratory secretions I would take that training in a heartbeat! They do make good $$$$ Mucous, It is the one thing I can't handle too well, lol.

What everyone else said. Sounds like you could use a bit of Xanax to smooth the rough edges too. We're all on your side!

I'm still a bit upset since Friday. I teach clinicals to PN students. We were at a skilled floor of a LTC facility. There is a new respiratory therapist there, I've been learning from her and she is helping my students learn about aerosol treatments, ventilators, oxygen. I don't know much about ventilators, so I bow to her to teach a bit once in awhile. She seems to enjoy this. She is very busy, and hardly has time for lunch with alarms constantly going off. We were in a patients room working, the students were changing a dressing and she had finished working on the patients trach. I didn't think it was especially stressful at the time and I asked her about her sisters plans to move, just making idle chat. She didn't know what I was talking about, her sister moving. (I know her sister, she knows I know her sister, so that's why I brought it up) She looked completely blank, and I said isn't your sister Brenda? She nodded then she said 'unprofessional' and looked away, dismissing me I guess. She then asked a couple questions, like where is she moving, but I was so stunned by the 'unprofessional' comment I didn't want to say anymore. I said, look, I don't usually carry tales, I was just curious about how their moving is going, and I'm sorry if it upset you. I was embarrased in front of my 3 students. Later I planned to go to her privately and apologize again, but decided to heck with it. I didn't do anything unprofessional. Did I? I know we aren't to speak of personal things in front of patients? Maybe that was what she was thinking. If so, I do feel sorry I said anything. I'll be extremely careful around her in the future. Sheesh.

Well, I heard a cute one in report Friday. Night nurse gave report on cute Mr Jones, who had been A&O in the hospital before being transferred to LTC. She said he had been confused all night. Several times he had been trying to get out of bed. Finally he was found standing in the door way to his bathroom. He had been incontinent of stool and when found was urinating on the floor. The NA said to him, why don't you turn around and go in the toilet?" He replied "I CAN'T do two things at ONCE!". He was returned to bed and Betty NA was in and out of his room the rest of the night trying to keep a close eye. In the morning he said to the staff "Boy, that aide from last night, named Betty? Shes a real nervous person, isn't she!"

AnnemnRN, bless your heart for going to the trouble to help me with my little problem! I really, really appreciate it very much!

Hi and thanks for the comments. Well, the order is to irrigate the wound, I guess it is to both flush and clean it both? I need to make this care plan for students who need step by step instructions? Order is irrigate with normal saline and pack wet to dry. Routine measuring is twice a week. So on the days of measuring they would add that step. So am I saying to put on the sterile gloves at the right time? Would you put them on after flushing or irrigating with normal saline? Sorry, I am old school, maybe toomy is an old term for catheter tip syringe, or maybe I am wrong about what a Toomy is? :imbar Thank you!

Hi, I need to write a plan of care for a wet to dry dressing, lots of steps and I'm not sure when the sterile gloves go on. Could you help? Here is the scenerio I've come up with: position patient pad bed, emesis basin handy for later irrigation open and arrange supplies nonsterile gloves remove old dressing measure wound with cotton applicator tip irrigate wound with NS and Toomey stringe apply sterile gloves pack wound with 4x4's dry skin which is wet with irrigant apply ABD pad and tape Please rearrange these if they aren't in the right order. Add your rational so I'll understand better. Thank You!

Hi, can someone help me remember the steps to the following procedure, changing a wet to dry dressing with wound measurement using a cotton tip applicator, irrigation with a Toomy syringe, and packing a tract? I need to write a plan of care and it has been awhile. Specifically, I can't remember when to take off the non sterile gloves and go with the sterile ones? Is it after removing the old dressing and before measurement, or after measurenment? Or, is it after measuring and after irrigating. (since you have to dry the surrounding skin before the sterile packing and new dressing begins) Or do you measure, then sterile gloves, then irrigate, pack, apply wet to dry, then, being done with the sterile part, dry the skin which would contaminate your gloves but it wouldn't matter at this point. Briefly, I have: position patient with basin and padding open and position supplies apply non sterile gloves remove old dressing measure wound irrigate dry skin with 4x4's apply sterile gloves pack wound abd then sucure Rearrange these steps if you think they are out of order, maybe add your rational so I understand the reason. Thank you!

Major, I never thought about the amount it takes to fill the channel!

Thanks for responces. I surveyed several nurses last night from different facilities and they were about 50/50 on the over/under question. (I always put it over myself, btw, with the bag always below the bladder) maladi, thanks for your input about filling the bulb.

I'm embarrassed to ask this, it's a tiny, detailed (dumb) question. Most Foley catheters are 5cc balloons and the tray comes with 10cc of sterile water. The leur cap (orange) says 5cc/10ml. My foundations book says to inflate with 10cc. I have always filled the balloon with the full 10cc. Why is it called a 5cc balloon if it holds 10cc and you are supposed to inflate it with 10cc? Why isn't it called a 10cc/10ml? (I warned you this was a dumb question.) Thanks if anyone knows the history of why this is so. One other one. Some say the tubing goes under the leg because it is to be below the bladder level Some say over the leg, to avoid skin pressure (under the leg). How do you do it?

Thanks, this resident has been in vegatative state for 15 years, and has a trach. Her admission weight was 99 pounds. I don't know if she was underweight on admission, she looked beautiful in the pictures in the room. It's too bad. I know the dr has to maintain labs so it doesn't appear he is doing any harm.

Two residents in a LTC home in my area are so obese! One has been there 15 years and adm weight was 99 pounds, now it's 190. Abdomen huge and very firm, hard is a better word. Trouble breathing too. Another R isn't as bad, but close. I asked a nurse about it and she said the DR goes by the lab values. They have to maintain those. If they decrease the feeding they go down, so they have to keep it like it is. LTC is new to me, is this your experience that tube feeding leads to obesity?

WooWoo! Lets hear it for BSNGRAD2B:yelclap::yelclap::yelclap:

I think it's extremely low. Come to Ohio!

All I can say is I sympathize. What a horrible night. It isn't your fault, Take your minutes to cry out this frustration and day shift will be there soon to help you in any way they can.