Wildbriar

Me too, thanks everyone for the great insights!

I've run into this with various SNF controlled-substance committees, wanting to lower, or even eliminate someone's antipsychotics or antianxiety meds just to meet guidelines. Usually if I talk with the administration of the SNF they are agreeable to leaving things as-is if the primary physician will write a note and corresponding order that reflects the potential harm to the client if meds were reduced. Basically, just a statement from MD that says the person needs it at current dose and why.

With our hospice, if someone leaves our service area they are no longer on our service and generally must be discharged and e-admitted when they return. It is either a discharge or a revocation depending on your state and company's policies. If we know someone will be leaving for a trip, etc. we do our best to coordinate a short-term admission to a local hospice if at all possible. We had one pt who wanted to go on a cruise with her family and cruise ships won't allow "hospice" pts on board (at least this line wouldn't) but we could d/c her, and confirm that DNR status would be honored by the ship's medical status, packed up her meds with her family and away she went. -Erin

We have an LPN/RN team for weekend on-call. Our LPN takes the calls and triages, RN does the admissions and home deaths and they both do visits that need doing. I know in Colorado an LPN cannot do the intake nursing assessment. We don't use PCA's much but the one time we had a pt on a pain pump his primary nurse was an LPN. She would coordinate pain dosages with the MD and our DON. I agree, its best to check your state regs, they can vary widely from state to state. -Erin

Leslie, thanks for the suggestions. This pt does not want to do any palliative raidiation and wishes to remain home so we are doing what we can. I think my frustration is that this is not a typical wet, draining wound. She had some significant bleeding when the erosion really started to go below the skin but since then things have slowed down to what looks like cappillary bleeding only. Someone else mentioned a vac, but this is not a wound that a vac would help, only create more pain and tissue damage. I've never seen anything quite like this but obviously this wound has no chance of healing. No signs of infection present either. In fact, with the exception of this nasty hole in her chest this woman is doing remarkably well, good appetite, cheerful disposition, and still ambulatory. I have discussed this with our Med Dir and his thought was that this was likely to cause an arterial bleed if it continues so we have tried to prepare her husband as best we can. I may have to approach the idea of inpt care again with them if the idea of her bleeding out at home is too much for him. Thanks again. -Erin

I'm am running out of ideas and could use some new inspriation... I have a client with radiation induced spindle cell sarcoma from a previous mastectomy and breast cancer treatment. The sarcoma has caused a nasty wound and is eroding the skin and muscle on the left side of the chest, beneath the axilla and is moving deeper and deeper into her chest wall. It is so deep I can now visualize fascia and her collarbone. We've been controlling small bleeds with silver nitrate. This client is absolutely petrified of bleeding to death but i think that is where this is headed as the erosion continues toward her brachial artery. The area is so tender and difficult to dress that it is generally left open to air, with any eschar formed left in place to prevent large scale bleeds. Does anyone have any ideas of what I can do with this wound, or where it might be going? I've never seen anything like it before and feel at a bit of a loss. Thanks, Erin