jerseyRN

Call back if you need to. They have some amazing pharmacists picking up the phone. Call back until you get one of those.

Hey RNkitty, Sounds like you're ready for a break.... even though we've been through it all before, it's probably the first time for the family you happen to be seeing that day.

Need to take issue with your rule of thumb about sx not being "normal" if they're not seen in healthy people. The dying don't look like healthy people. Noisy secretions are normal at end of life. We reposition the patient, treat them with atropine etc, and assure the family the secretions don't disturb the patient as much as they distress the family. Along with the other s/s of active dying, talking about what to expect and why these sx develop helps.

sounds like you are assessing and doing all the right things for your patient, and also that she is actively dying. Tell the family the disease is taking their loved one, and the goal now is to keep her comfortable as this natural process progresses. Tell them the disease is going to take this lady no matter what action they or the hospice team or anybody does, and do they agree that the goal now is to make her comfortable, and do what we can to ensure she passes peacefully? If so, that is what the medication will do. Assure them that the hospice will give no more medication that is necessary to keep her comfortable. And remind them that the hospice will be there for them when they need it.

I agree with previous posters. It sounds like an ominous turn. Remember the goal of wound care is comfort at this point - keeping her clean and dry, and medicating for comfort. Mouth care for comfort/ relief of dry mouth. Glad you have hospice coming. They can reinforce these issues with the NH staff so you don't have to. Use the hospice team as much as you can for not only your grandma's comfort, but also for you and your parents.

ps- one thing I wish was different is there's limited opportunity to commiserate with other students. There is a part of the discussion board where you can post anonymously - allegedly. Nobody used it. I wanted to discuss content and instructors but didn't find a way to do that.

I started this semester with the Nursing Informatics course. It was a lot of work, but do-able. I was disappointed in that the course was more about following APA style than Nursing Informatics. The instructor was nitpicky and more concerned with form than content. I'm registered for a Leadership/MGT course in January and hoping it will be better. Two courses at a time is a lot to tackle, especially if you have a life.

You could contact NHPCO or HPNA and see what they say. Who employs you and this director RN? She must have a supervisor. Maybe you should seek out that person if you can't approach her directly with your concerns?

I love my little Maglite super-bright flashlight (under $10). Bandage scissors. And I have never have enough pens! Be sure to have some chocolate in there.

We wear street clothes, business casual. Would rather be able to wear scrubs ... hate getting dressed every morning, especially when it's >100 degrees as it is this week. We also are prohibited from wearing open-toed shoes or going without socks or stockings. Ugh, it's hot.

OK, let's get this straight - over 50 is not "older". Over 70 is "older'. Don't take my denial away from me! We all know it can be an effective coping mechanism....

Well, hmm. What to do? I think I would be sure to document very carefully... especially about the contradictions in her self-rating of pain and her behavior, such as reporting her pain is better, she's sleeping more, she laughs with caregivers, etc. I would also be noting the adjustments made in her pain meds and dosages. I'd get the lock box and count the pills. I think I would have a straightforward conversation with the patient about all of the above. I would tell her I want to act as her advocate and do everything I can to make her comfortable, but I also have to rely on my own experience and judgment and assessment skills, and that I won't participate in providing her with more meds than needed to control her pain. I would keep the SW coming! After all that if she continued to report pain of 10, I would increase her dosages. What is her dx, BTW? Good luck. What a vexing case.

Yes, I wondered about this case too. Not to say limiting her meds is the wrong action, because I didn't see the patient and don't want to backseat-drive my colleague's instincts and decisions. But I wonder: What about increasing the MS Contin to 90 mg q12h (compensating for the QID Lortab), and tweaking the anxiolytic to either Valium 5 mg q 6-8h, or lorazepam 1 mg q4h (depending on pt preference)? I agree, if she's asking for it, and is terminally ill, she needs it. Try to manage it in a way that gives her what she needs in medically appropriate dosage and schedule. Nobody on hospice should have to watch the clock. Not that we should turn a blind eye to abuse, but we have to be willing to give pts the benefit of the doubt.

We're required to wear street clothes ("business casual" is what I do). I'd prefer to wear scrubs because it's easier and tax deductible, but it's not the policy of my agency. I wouldn't choose a lab coat... they always strike me like an affectation ("I have a lab coat, so I must know what I am doing"... I remember having to wear them in nursing school so we wouldn't look like the neophytes we were).

Oh, Leslie, sorry for your losses, and sorry you encountered such an emotionally inept doc at such a sad time. Personally, no matter what the loss, I find no comfort in, "It's a blessing." No matter the circumstances, I can't imagine it ever feels that way to the next of kin hearing of the death for the first time.

No problem with a few tears, but if the nurse is so emotional that the family needs to comfort HER, it crosses a line.

Agree with all previous posters that it's ok to be sad, share a few tears, feel loss and grieve. But in my life I've only gotten mascara on the shirts of guys who were holding me while I was sobbing. If that's the picture.... I think you need to try harder to remember that in the end, it's their loss, not yours, and respond accordingly.

Wow, monkeymind... "heart of stone"? Just the opposite! I tell people it's rewarding to be a part of helping families keep loved ones at home and comfortable when hospitalization won't help and a cure is not possible. And that it's a privilege to witness the great love of families during the trying time of terminal illness.

For programs I've been looking at, you need a bachelor's, but not necessarily in nursing.

Get your social worker or chaplain to stand fast with you to make it clear to the boss you're not the right nurse for this case. Suggest to boss she make a home visit to "help clear the air" ... sounds like it's been awhile since she crawled out from behind the desk.

I went right to your post because my situation is somewhat similar. I am also a second career nurse (bachelor's in journalism), diploma school grad, working the last 7 years in hospice. I can't get excited about going back for a second bachelor's, and not just what it would get me anyway. I am 50.... like being at the bedside... don't see myself in nursing management, yuck. I've had the pleasure to work with the WOCN at one of the nursing homes where I have hospice patients. She's been a great mentor and I can see what a difference her skills and training (also she has the kindest personality) bring to the residents. She helps heal wounds, but also inservices the staff and as a result there are fewer pressure ulcers and skin issues at this place than other NHs I visit. On the business side, she has the NH job and prior to that was a wound specialist at a medical center. Also she sees ostomy clients for a GI doc. Also met another WOCN who works for Convatec... inservices nurses on wound care and Convatec products... M-F 9a-5p. So it seems to be a certification you can do a lot with. Truthfully after 7 years in hospice, it excites me to think of being part of patients healing and getting well! Wow! I'm researching online programs now. Leaning toward webWOC. Good luck to us both!

Using levsin all the time but never heard of buscopan. Ditto for nozinan. As for the octreotide, it makes sense, but it's a pricey drug. Which makes me wonder.... are you practicing in the US? I might consider ABHR (ativan-benadryl-haldol-reglan) supp or gel for the N/V (leaving out the Reglan if there's evidence of obstruction). You can also add "D" - decadron to this compound... sometimes that will help if there is obstruction, depending on cause. Like compazine better than Phenergan. Have a hard time finding phenergan nowadays anyway. If this lady is a hospice patient, I wouldn't be quick to give IV or SQ fluids unless that was the only option to relieving the nausea. Does she want things possibly prolonged, or simply symptom mgt?

Just got my annual $500 bonus for certification.

It's different for everybody... Calm before the storm? Try to enjoy it.

My guess is your boss is not a nurse. She places both you and the sw in the uncomfortable position of exceeding/ignoring your scopes of practice. Yes, in hospice we work as a team, and there have been a few times when I've needed a sw to take the other side of the draw sheet and help me lift someone in bed, or order the 02 concentrator. But in the circumstance you were dealing with, the sw's I know would have had the good sense to excuse themselves and leave the room, or at minimum, turn away and use that time to offer support to family members while the nurse did her thing.