Chris81

My use of the word incompetence arises from the basic floor- nursing checklist for skills all nurses are expected to perform,sometimes on an hourly basis,sometimes once every 5 years(vital signs to how you hang TPN&lipids,with a long running IV-ABX). I have been assigned RN students who were very enthusiastic and eager to put their hands on a patient,and the equiptment needed to perform a task and it was a joy to watch them deconstruct a task I had long ago integrated. New nurses I elevated to a higher level,as as evidenced by their graduation and passing NCLEX demonstrated their mastery of content,but to my surprise were unprepared to perform those skills that were maybe done once in a nursing lab. At first I thought they were kidding,no-really,I thought they were just trying to blow my mind. After the first few orientees I came to accept the fact that no,they had never inserted a foley catheter into a male pt.,did not know how to obtain a BP on a female c a complete mastectomy on one side and IVs on the other,or how to transfer a pt.c a CVA. Having worked in a facility that liked to "grow our own" nurses,I worked side by side c CNAs who went onto to school with the intention to return to LTC(yay!),so I heard from them throughout school about what they were not being taught. As The Commuter as sagely noted,nurses graduated from school with all kinds of floor experience,volunteering for procedures big and small,embracing any opportunity to DO something. I fear the nurses of the past decade have been educated to pass NCLEX only. Most environments require competencies be demonstrated yearly by staff nurses,and we expect those newly minted nurses to do it best!-no shortcuts,every step textbook. I've reset my expectations and realize that when I'm orientating a new nurse,I'll be showing you HOW to apply everything you've read,studied and tested on. No insult intended,just disappointment expressed.

Funny-the crisis when I was a year-old nurse was the introduction of DRGs-veteran nurses were warning us we'd get "fresh radical necks","chest tube with glass bottles on the floor,grab your hemostats" being admitted to nursing homes,booted from hospitals by the "bed counters". Never did see a radical neck,mostly hips,amputations,worse wounds(ST III-IV PUs),post CVAs and plain old OBS(prior to Alzheimer's as a diagnosis).Staffing then same as now-2 nurses,7-8 aides,60 pts. Difference now is higher admission/discharge rate,higher technical education/profiency for nursing and despite efforts to reduce/eliminate it,the silo mentality persists in management reducing productivity,efficiency and engagement with our elders. Enough said for a Saturday morning-punching out!

Spot on,Commuter.Have also followed your posts regularly and agree. SNF 34+ yrs myself(started at the starry-eyed age of 19) and have recently(thankfully) had the opportunity to continue in LTC in AL/MC 1 month ago,when present SNF taken over and expanded to CCRC. Couldn't have come at a better time,as my generally upbeat self was being eroded by increased acuity,decreasing age of admits,increased incompetence in new nurses,decreased education from management,increased QAPI,decreased resident face time,increased hours spent at work,well,you completely get the picture. Signed-Beaten down,but not out!

Bravo! You grew your judgement that day-don't feel like a moron,feel like your nursing education(classroom content+clinical rotationsxREAL LIFE EXPERIENCE= a well rounded nursing student,who will be up to the tremendous task of being a nurse. Go ahead,flex that judgement-doesn't it feel bigger and stronger?

This may be one of those rarely seen" probationary period" Do Not Hire situations. She sounds like she really doesn't want to be working there,despite many efforts to address real concerns. OR-give her enough rope.....

Research validation. The core of this very humanistic approach to cognitive impairment(acute or chronic) is to accept an invitation into someone else's heart and mind for awhile. Accept that this person is frightened,angry,in despair,lonely,lost,searching,and they are looking to you for some assistance in reorganizing their thoughts. Instead of focusing on particulars"you're husband's dead,you're children are grown,you live here now...",affirm the emotion they're expressing"you must miss him,tell me about all those kids,what was your house like..."while attempting to redirect physical energy-keep walking with them(if searching or pacing),sit them down with you if they keep coming to you(you may remind them of someone,or just have good energy!). Sometimes the driver is physical-pain,elimination,hypoxia,infection. A LONG time ago we used to do something called"REALITY ORIENTATION'-yeah,just as it looks-too rigid,truth based,one size of REAL for everyone. Validation feels so much better now. Redirection is less about lying than it is about getting them off an unfamiliar path they've wandered onto,and back to a more familiar place.

At our facility,we've made a concerted effort to:reduce/eliminate waking elders from sleep to administer meds. MDs are completely on board with this,and nurses will ask if something ordered q4/6/8 could instead be given close to this while awake?ABX would be exception,and only for course of TMT. We specifically asked on 2 elders to change Sinemet from similar dosing times because of the awakening issue AND because both elders were "midnight ramblers".We were trying to promote sleep and stimulate motor function at the same time!?! Guess what-reduction in falls,more daytime alertness(better engagement,eating,ambulation-LIFE!) and 2 less doses per person.

Our MDS coordinator laminated heavy copies of these and PERSONALLY handed them out to all nurses in our facility to guide our charting. After years of SOAP,narrative,checklist and general meandering around trying to capture the past 8 hrs.of this person's life in our SNF,these guidelines really help narrow the (reimbursable) focus on the nursing care delivered. PT/OT/ST chart their own notes,so no repititon in NN.Also emphasis on the lowest level of skills demonstrated by pt.and ANY performance of nursing assistance provided.

In our LTC located in Colorado where MMJ is legal on the state level,we do not permit the (state) legal possession,consumption or self-medicating of MMJ on our non-smoking campus because we receive federal dollars through CMS,and marijuana still criminalized under federal law.

VS immediately with grips,speech,pupils,mentation. Repeat q 15 minx1hr,q30minx2hrs,q4hrsx24hrs,q shiftx72hrs. restart sequence c each fall(even when multiple falls occur within this time frame. Labor intensive c frequent faller(65

NOTE-[this is from a LTC perspective] I did the end of month recaps for a 59 bed facility on paper for the past 8-9 yrs,noting every order,d/c,edits(time changes,preferences,etc),carry-overs,dx/med.on a 59 bed unit with and average of 7-9 med sheets per pt. I'd go in @ 0300 just to get my hands on the med books,had 9 printing runs (meds/notes/prns/notes/tmt/notes-you get the picture) for about 600 pieces of heavy vellum paper,then print monthly MD orders. With eMARS,all of the important content of those orders comes down to ORDER ENTRY,whether it is done by unit sec. then noted&verified by nurse,or entered by nurse herself. In our program,what the med nurse sees to administer is driven by the times entered for administration,whether by hour,shift or day of wk. If an order is obtained during the time frame the med would be administered ie"lasix 40 mg.po daily in AM",an overide to start time has to be entered(0800) so it can be started the day the order is obtained,otherwise the nurse has no idea she has a med to be give. As we continue to shift from paper to EMRs, the challenge will be to remember-THE MACHINES ONLY DO WHAT WE TELL THEM TO DO! We've been doing computerized charting for 2 yrs. now,added the eMARs recently and I"ve come to realize how much of our day to day communication regarding our care has been verbal,conversational and anecdotal. The shift from one form to another is time intensive(short-term)but the intention is to keep all pt. info in one place(EMR),and once you learn how to navigate it,it's A LOT easier to find out why Mrs.X was ordered Pamelor q HS in June 2005[migrane management],rather than digging out folder #6/12 in the med records room.

Don't see too many of these anymore(thankfully!) I'd try to manage exudate first-alginate rope for packing-loosely!-foam as secondary. This will help odor as well. Karaya paste as perimeter to secure dressings to helps in difficult spots. Skin prep to periwound to protect from maceration. Shoot for manageable and realistic outcomes first-try to keep from getting larger,esp. tunnelling. Fortunate pt. preferring to remain in bed,keeps area offloaded. If drainage copious and becomes unmanageable,considering pouching? Also remember pain management prior to dressing change,sounds like you're trying to take this into account. She may already be determining her outcome- Good luck to her and you!

LOVE how you think! Though not a newbie,practicing 30 yrs.,LTC, I'm grateful that I've been able to work in a field that encourages critical thinking every shift. My mind has been sharpened year by year,enhanced by experience and balanced by a hunger for knowledge in my profession,applied to living,breathing human beings every moment. While I am well aware of the rise of regulations,Pol.&Proc's and litigation, I deeply resent the dumbing-down of an undervalued yet highly skilled vocation. "You better get an order..." is beginning to make my skin crawl. Thinking on your feet and seeing the big picture used to be assets,now you're viewed as a wild card,lone wolf, practicing outside your scope of practice. Keep asking questions-draw on your education and knowledge-and apply them to the person in front of who needs your help RIGHT NOW.

Just had visit from our V.A.C. rep yesterday,good to get refreshers/updates/tips! You can cut more than one piece of foam for a wound, if you're not good at eyeballing the shape. Better to have 2 pieces that fit,rather than in/out, or worse-too big. ALWAYS document # in/# out in EMR, also note on drape number of pieces in. Supported in "Clinical Guidelines"-Reference source for clinicians-KCE 08/10.

As scope of practice varies from state to state,so does the elusive and much sought "IV Certification" for LPNs. I was certified in Colorado in '80,at the urging of my administrator in my newish job in a LTC. She was reluctant to hire an LPN c 11yrs.experience in LTC without it! There was 1 other LPN in the class,the others were RNs and it was 44hrs. long. BON issued cert.,and I became LPN-IV. 2 futhur updates over next 15 yrs. enabled me to hang ABX and utilize central venous access devices for fluid/drug delivery and draws. Each state should have its' own definitions of what IV cert. means in that state and what you can/cannot do. We got an LPN from Florida a few years back who said"sure,I'm IV certified",which turned out to be a 1 hr.demonstration from a pharmacist,1 observed start on the floor and off she went,"certificate" in hand! That didn't fly here in CO. Also,paramedics,military medics,EMTs who have been certified in their scope of practice are NOT certified under nursing practice in LTC in CO. Do your homework,and GO GET IT!

Luckily for me,and the elders whose home I work in(yes,it's a LTC/SNF),what you all are describing is at the heart of the Eden Alternative. I began working at a traditional(institutional) LTC 21 yrs. ago. About 6 years ago,we began the Eden Journey,without any physical remodel,or drastic upscheduling. But-not without a LOT of frustration,re-education(of staff,families,PCP's and elders themselves),stops,starts,lofty ideals, and deep,DEEP evaluations of ourselves as caregivers-"What am I as a nurse,supposed to do if they refuse meds,baths,meals etc.",families expectations"DO EVERYTHING FOR MOM-she's 87,you know",MDs'"Do you mean you don't want him transferred to the ER?". Management has steered this change,surveyors are now looking for" culture change" and maybe the next generation will see it as the norm. In the meantime,my perfect LTC would have everything everyone else has described, AND an anonymous philanthropist who whould like this happen NOW, and shower us with $$$$$$$$!!!!!

::up::::yeah::::bow::hug::hug::balloons::balloons::clpty::clpty::clpty::dancgrp::hpygrp::w00t::redpinkhe:redpinkhe:redpinkhe:redpinkhe:redpinkhe Thanks to you for recognizing your staff in such a cool way! Every day(and night) we go to work and expect our staff to rise to meet everyone's needs. Our standards are high, and when a shift pulls together we turn to each other and say "Yeah!". Just another day @ work for us.

Wondering if anyone is using liquid adhesive ie Mastisol,et al, to additionally secure Tegaderm drape with KCI V.A.C.? Problem isn't air or fluid leak, but corner of dressing is in a rather mobile section of skin-perineum/scrotum of highly active young man-paraC5-7./bilat. AKA/self-transfers bed-w/ch.,with a St.IV undermined PU,dx.osteomyelitis (L) ischium,on IV Vanco. 98% of this dressing is beautifully intact except this problem spot. Requires additional reinforcement almost each shift until next complete dressing change. Restricts his transfers to just daily,but is in constant motion in bed,repositioning himself-is fiercely independant. I'm familiar c wound vacs,but am unsure if the use of additional adhesive is contraindicated c this brand. Any tips would be greatly appreciated!

Don't forget pain management. During a survey, we had a PT/WCC perform a dressing change on a pt. who stated "OUCH", with the surveyor present. Needless to say,we recieved a MAJOR citation,which resulted in a change in policy/procedure. We now make every attempt to pre-medicate prior to dressing changes,explain we'll suspend procedure until adequate pain relief obtained(yes,this will take time), and document the above on the Wound Doc. Alternative measures-ice,massage,topical analgesia,etc. can be utilized,as well as PRN po pain relief. Maybe short-term routine analgesia for duration of wound? With upcoming changes to MDS 3.0,attention to pain/relief is an essential component. Good luck!

Well, while I was fully aware that the only people who get to put their hands on my body are those who are invited to, or are falling over, I didn't really take it as a sexual harrassment thing because I'm about 5'10, and @ that time, weighed 175lbs. I was twice his size. And no surgery yet! Couple of threatening discs in neck, low back pain,yadda yadda yadda. Oh, and the "Chris" in Chris81 Is in the femenine. Not girly. Just feminine. K?

WAAAAAYYYY back in the earyl '80's,before those lovely mechanized lifts, I was attempting to manually transfer a resident from his very low comfy swivel chair to his bed for our medical director to examine. Instead of assisting me, the rather smug Dr.xxxx stood behind me,ran 2 fingers down either side of my vertebral column as I was bending down to lift and said"All GOOD nurses have them...". When I inquired as to WHAT "them" are, he said"incisions, from your spinal fusion"! I was young,flustered, and SPEECHLESS.

Agree c assessment that 12 hrs.LTC is 4 hrs. TOO much! Physically and emotionally demanding, whether slinging med cart for ENDLESS med passess, assisting CNAs c direct care,responsibility for care team(elder/CNAs/therapies/"spontaneous family phone calls/care conf"/)treatments,inservices,meetings, for your 30 or so pts,THEN DOCUMENTING ALL OF IT-EVERY BIT! It's darn hard to get it all in during the 8 hrs. you're sched. for, rarely leaving @ the stroke of 3:00. But hey,we come back in and do it again the next day! Seems newer/younger nurses prefer 12's. We find it harder to cover a 12 hr shift, esp. if the noc. nurse calls in.

Stand tall-be VERY proud of your decision to become a NURSE. That is what you will be. You'll graduate from an accredited school,pass a difficult board exam and have the initials LPN after your name every time you chart. You will be the bedside nurse who knows her pts./residents/elders/clients better than anyone because that is what you'll be trained to do. You'll absorb an amazing amount of information from everyone around you,and if you're curious,intelligent,respectful and professional,maybe one day someone will turn to you and say"I didn't know you're not an RN! What is an LPN anyway?" And YOU WILL TELL THEM!:redbeathe:redbeathe

No policy? No monitor? NO WAY! Somethin's gonna give on this one...Better keep those vitals and documentation up to the minute,and MD on speed dial...........Good luck!

I believe IV cert. varies by state,and compensation by employer. I got certified by the state of Colorado 20 yrs. ago,taught by an accredited provider. It was a 44-hr. course,with classroom and practicum. In 2006 an upgrade was required,covered central lines,and was needed to maintain licensure. I'm paid a differential based on a certification above and beyond basic LPN licence,work in a SNF,and use those skills more often than I ever thought I would.