zuchRN

I think you will love recovery. I have been working it for a year now after working in long term care for 13 years. If I can adjust, anyone can!!! I was really apprehensive about extubating patients, but as it turns out, it is the easy part. I would make sure that you truly empathathize with your patients reports of pain. Start asking as soon as they start to rouse and medicate as often as possible without desaturating or dropping the BP. Making sure that you do this will help in a shorter PACU stay and a happier patient. Good luck...you will love it.

I was just wondering what your thoughts are on BP post op. I work in stage one PACU. Some of our patients have low bp's for various reasons. The last 2 days, I have had 3 ortho nurses not want to take patients because of decreased bp, despite being within 20% of the pre-op level. One person was running 100/50 consistently with a preop bp of 110/60. Another person had a pre-op pressure of 138 and they were running 110. Is there something that I am missing???

I picked up a night shift at our local hospital. I was placed on CCU. The agency told the hospital that I was able to do Coronary Care.....WELL, I have been a DON in LTC for the last 7 years, this is my first week doing agency...I have never worked in a hospital let alone CCU. This week I have worked tele..which is fine once you know the requirements. I was scared to death to go to CCU. I have to tell you though, I had a blast. I titrated nipride drip and admitted a lady on a nitro drip. I did more IV pushes tonight than I have done my entire nursing career combined. I really don't have a point, I was just excited that I was able to do this and wanted to share with people who actually understand. I am glad that I have solid assessment skills-that got me through the night. Thanks for listening.

Well said Triage and southern. I agree whole heartedly that professional nursing staff does not demand the respect they deserve. I have had to talk with nurses about gossiping and not liking each other and he said she said stuff. What a collosal waste of our time and energy. How can anyone respect us when we so obviously don't respoect each other? I took the time one week to account for all the time I spend dealing with interpersonal issues between professional nurses. Between my time, the 2 parties always involved, there was a total of 42 hours in one week. This is just mindless. This is 42 hours that could have been devoted to better resident care. I was absolutely mortified today to have 2 nurses come to me to complain that they hated the other nurse because she was a "close" talker. I was so completed dumbfounded that I told them, "so what?" Why do people complain when someone sneezes the wrong way? I would like to believe that this is isolated, but I am sure that you have all been a part of this at some time in your career, and every minute we spend doing these mindless things is one more minute we are not focused on the resident. Also, in Indiana the DON hours worked on the floor do not count as part of the ppd as far as state is concerned unless your bed occupancy is less than 60. However, as far as patient care is concerned, we very much count.

In reading the replies to this post, I am hearing that mandated staffing ratio's are the "answer" to our problems. I encourage everyone to ask what their facility ppd is. We have a ppd in our facility which is higher than the proposed state minimum and is higher than the mandated ppd in California. Usually it is not a question of the facility having the hours--it is a question of finding the staff to fill those hours. As a DON, I am not afraid to work the floor and do not hestitate to do so. I make a point of helping in the dining room etc. You also have to remember when the BOH comes in, they must link poor clinical outcomes with inadequate staffing. Very difficult to do in some cases. I have to say that I do not know one DON who wants to "screw" the staff when someone does not come to work. Realistically, you can only work so many hours in a day. However, I also firmly believe that the residents are number one and if it is needed I will work the floor. I would venture to say that most people have absolutely no clue what they are getting into when they accept a DON position. I keep thinking that there has to be a way for us to work together rather than being a us v. them issue. We could accomplish so much more working as a team rather than bickering. How can we accomplish this? I know that everyone is always going to have a boss--I don't like listening to the administrator pretend to be a nurse anymore than you like the DON talking about overtime. I still think there must be a way to evercome this way of thinking that DON and adm is lazy and doesn't understand versus their point of view of the CNA's and nurses taking too many breaks or they just don't understand what management goes through. Also, I recently took a trip sown to our state capitol and was able to lobby to our legislatures..actually talked to them in person. I would encourage everyone to personally visit the people rather than write. Sometimes it is easier to ignore the written word.... Thanks for listening.

What is it that people like or dislike about in-services? I frequently do the in-servicing and have been experimenting with different types of presenting styles and activities. I would appreciate any good suggestions on things that really capture your attention or tune you out. Not having in-services is obviously not an optiojn. Just looking to make them wothwhile for everyone involved.

Right now, we do weekly skin assessments on all residents. We rare;y deve;ope in-house pressure ulcers. I think we have had one in the last 6-months. obviously, our focus is prevention, because it is obviously too much work if one does develop!!! ha ha. I am blessed with wonderful nurses and aids who really understand and get it!!! I also do rounds on all shifts and rather than rant and rave if a heel isn't perfectly rfloated, I educate. I find that this works wonderfully and usually the same error in judgement does not occur again! However, we do admit people who have wounds. We complete pain assessments every shift, we complete documentation every shift: if the dressing is in place we document peri-wound and then if dressing is changed we document periwound, wound bed, wound edges, drainage and all the other wonderful wound stuff. We also complete the Braden scale on each residetn with a pressure ulcer weekly. The Braden scale is also done weekly upon admission. We now have to document the resons that they score low in a particular section of the braden scale and what interventions we are goingto put into place to help maximize the score in that category. I know that it sounds like a lot, but it takes minimal time. I do believe we probably spend a total of 1-2 hours a week on wound documentation. Hope this helps.

would you feel the same way if bonus's were based on clinical factors rather than keeping costs down? What if the measurement for bonus was a percentage of prussure ulcers, weight loss, restraints, antipsychotics, CMI?

we have now implemented a walk to dine program for appropriate individuals. I was also just reading a study from medscape that was saying that balance activities in restorative decreased falls more than strengthening or endurance exercises. we have also really focused on our exercise program and grouping people for restorative care (1:4 ratio). They play games like basketball, bubbles, velcro darts and variace ball toss games. This dropped our falls from 30 per month to about 15-20 per month. A lot of the resident's falling were those resident able to actively participate in restorative and hence, restorative activities take up more time, energy, and provide closer supervision. I don't know what state you are in, but where I am we can have a physical therapist train non nursing personel to ambulate lower risk individuals and also count this as a program. I have also ordered hipsters to prevent injuries post fall, they seem to work (i guess we will know that they don't if there is a hip fx) We utilize low beds...not my favorite thing to do...alot of undue stress on nursing staff backs. I have not tried this yet, but i saw in the fall prevention catalog that they have infrared beams that will alarm when someone is gettingout of bed. Our regional nurse has utilized them and has found it helpful. Pull tab alarms are great but we are phasing them out and going strictly to pressure sensitive alarms...9 times out of ten, the resident is remopving the alarm. Another one of the tools that we utilize to assure that we are doing all that we can for fall prevention is a fall log form. The fall log is a briggs form that has a check off list on the front and a nurses notes on back...it is very useful in tracking and trending falls. The 2 things that we should stress the most is not utilizing antipsychotics or benzodiazepines.....not good at all. we have also stressed the pain management component involved in falling---often, having a good pain management regime for a resident prevents the falls altogether. :chuckle

I have a good sheet. it is for site assessment. If you would like a faxed copy, you can e-msil me @ [email protected]. I am a DON and have seen and utilized many different forms. This one seems to satisfy the needs for surveys and is the least time consuming.

I know that if you ask your DON for a copy of the regs and tell her that you just wanted a copy so you can make sure you are following the rules...or you want to brush up for survey to be sure that you are doing things correctly...some bs like that, she should give you a copy of the regs no problem. There are federal regulations, which is what you are surveyed on so it is best to get the feds regs. The IN regs are just a little different with things more specific like you have to have telephone orders signed in so many days, 2 step mantoux's......stuff like that. what you are tagged on is actually the f-tags or the federal tags. You can get a state tag, but usually don't. As far as IN with staffing, if a complaint is called to the state with regards to staffing, the surveyor will come in and eval the last 3 months of schedules and then look at pressure , weight loss and ADL issues to determine if the facility should be tagged. In IN you are only tagged for staffing if the short staffing resulted in negative patient outcomes...example is pressure areas.....fallls etc. It is actually very difficult to prove inadequate staffing related to megative patient outcomes. If your DON does not give you a copy of the regs....email me and I will get you a copy of federal and state...I have multiple copies....

I would also like to point out that this resident may be on depakote for behavior management issues. We are using depakote and klonopin more and more for behaviors, this may explain the low dose and being used in combination...Just anopther thought.

The "money" is printed on our copy machine. The funds for the Treasure chest come from petty cash and whatever other budget the administrator sees fit. We also are able to buy the dvd players through HH gregg for 49$. I love it and it works well. We have all the department heads that keep stocked with them and hand them out all the time. It is fun. We probaly hand out 200-300 bucks every week. This is spread over about 110 employees in the facility. The beauty of it is that you don't have to be special friends with anyone. Everyone can get them everyday from a variety of people. We also have exercises every morning at 11am. It has been tuff getting everyone there when they are supposed to be. We started to reward the staff that was present with these bucks. If you are at exercises every day for the week...that is 5 bucks right there. We hand them out at inservices. we give them out for picking up extra hours, for having a positive attitude on bad days....etc, etc, etc. That is one of the things I like about it, you are not confined by strict rules of when you can or cannot give them. If you or anyone else feels that a person is deserving, you can hand them out!!!!!!!!!!

We have implemented a program that actually has worked wonders at the facility I work at. I work in long term care. This program benefits all employees and not just nursing. The staff development cordinator and myself have developed a program called "one in a million". It is a reward program for giving good care..doing something that goes above and beyond the call of duty. We have fake money printed up and all the managers hand this "money" out to anyone they "catch" doing something good. It may be that when I do rounds, I see someone answer a call light that is not on their assignment, or it may be that everyone on the assignment was positioned correctly to avoid pressure ulcers. It may be something as simple as calming an agitated resident. Whatever the deed, they are rewarded. I come in on nights and weekends. I also keep a supply in the med rooms so the nurses have access to them to hand out to employees. Also, cnas and various other departments will come and get them to give to someone for helping them with a particularly difficult transfer or something to that efect. Once they collect 5 of these, they can redeem them in the "treasure chest". The treasure chect has everything from food and snacks to toys to bath and body products to tools. You name it we have it in there. We also have an item list that people can save up for. We have a DVD player (it is 250), dinner with the administraor, uniforms, pedicures, dvd's, cd's. These range anywhere from 75-250 dollars. We do not limit the amount of dvd players we give out. Anyone who saves enough for one---gets one!!!!!!!!! We have already been able to give 2 away to the deserving employees!!!!!!!!!! It is not a lot---but it is effective and fun!!!!!!!!!!!

oregon--- MDS is a minimum data set. The MDS is ahuge thing for long term care. basically you have a huge amount of questions to answer...everything from does the resident wear glasses, is there long or short term memory impairment, to projecting how many therapy minutes someone will have. It is meant to drive your careplans. But it has a huge financial impact. In IN we have RUGS for medicaid as well as medicare and depending on the casemix for medicaid will determine our re-imbursement from medicaid. The rugs aslo drive the reimbursement for med a. It is a huge process. you cannot just answer all the questions...you have to assure that the info is documented and sometimes examples provided --in a seven day reference period to be able to answer the question. It is a huge undertaking and requires a loy of patience and tremendous organizational skills. A few things to ask prior to accepting this kind of position is: 1. how often will you be pulled to the floor to work 2. how much on-call time will ou have? 3. if a larger facility, will you have an assistant? 4. will you be responsible for any other programs? the answers to 1,2,4 should be no and you shouold get this in writing.

At my facility I have a program in place called aler charting --I have found that no matter how much inservicing I do on charting accurately and thouroughly it doesn't happen. I know that it doesn't happen because of time!! let's face it, charting is the last thing everybody wants to do!!! So I put out the alert charting list and it includes all the every shift documentation and the med A documentation. I write down exaclty what needs to be assessed--for example: Jane- URI- Document lung sounds, temp, respiratory rate/quality, o2 sats and orientation. I keep this on until the URI is resolved. It improves the follow through. If you would like the form you can e mail me and give me a fax number. I also have a few other documentation inservices that I have presented that I could fax you.

Pre-setting meds is always a bad idea. It is the cause of more med errors. For those of you unable to complete a med pass in the allotted time, have you talked to your DON about changing med pass times so that half the cart would be 8-12-4-8 and the other half being 9-1-5-9? This is a very easy thing to do. The pharmacy consultants should also work with you to decrease the number of meds being given (by eliminating duplicate therapy and unnec. meds). It is also a function of pharmacy to help you to redistribute meds over the day to help even out the med pass. Pre-setting meds is considered a bad practice and against regulations for the following reasons>>> as the nurse passing the med, you have to be able to identify all the pills that you are giving with name dosage and expiration date at the time you are going to pass the medication, pre-setting the meds 3 hours ahead of time ensures that you are not able to identify those 3 core items at the time you are giving the med.

I have been reading the posts here and felt compelled to reply to what everyone has said. I have a slightly different perspective than some of the others who have poated. I can look at this situation from the point of view of the director of nursing. I have been the DON at the same facility for 2 years now. I really love this job, but dealing with CNA and nurse relationships is frustrating. If there is a problem with a CNA, I expect the charge nurse to handle the situation. I handle disciplinary action in the following manner. I will not write someone up on the first offense unless it is just a blatant disregard for the rules. The first instance, I chalk it up to lack of knowledge. I educate....you have to give someone the proper knowledge to be able to complete a task. If after this the CNA is still not meeting expectations...it is a write up. I think someone said that the DON doesn't do anything when the charge nurse has written someone up. That is not necisarily true. By writing the CNA up, you have done something. tHIS SHOULD BE PUT IN THE EMPLOYEE FILE AND AFTER AN ACCUMULATION OF WRITE UPS TERMINATION WILL OCCUR. yOUR EMPLOYEE hand book should have the particular guidelines for your facility. However, if a charge nurse is writing someone up, and the DON is just throwing it away, that is wrong. Now I must also say that charge nurses cannot just go write up crazy. They need to try and investigate what the problem is. Talk with the CNA. Maybe something happened and they are having a really bad day and you ended up being the person that it was vented to. Use compassion. I am sure you have had a bad day and rolled your eyes at your DON or have had some smart remark for your supervisor. Never ever tolerate a CNA or anyone yelling at a resident. Sometimes, it is needed to send someone home for the night. If someone is having a horrible attitude, you have to write them up and they go off on you---send them home. They don't need to be there throwing attitude--who knows what will happen when they go in a resident room. I would also like to say that it is not always the CNA that is at fault. You have to set your expectations and hold people to those expectations. I have only really used CNA's as examples...but remember, all these disciplinary issues happen with everyone...nurses, housekeeping, maintenance...everyone. Remember to treat others as you would want to be treated and you should be ok...also you should expect people to treat you with dignity and respect.