RN4ustat

Wow!! Thanks for the links.......looks like some really good info!! I was very fascinated by the dementia prognostication info, specifically the mention of the Mortality Risk Index as the company I work for has recently started to use it in determining eligibility. Thanks again for the info!! -------------------------------------------------------------------------------- This could lead to serious problems for your agency if you're not using the tools the same (which means at least one of you is using it wrong!) And I'm assuming these instruments are being used as part of the continuing certification as well as to document decline from a clinical stand point. I'm attaching "Fast Fact #150, Prognostication of Dementia" it should help with your documentation. I found it pretty easy just by putting into Google "Dementia Prognostication FAST score" it was the first hit. I guess I've just gotten good at doing searches. But you should also know about the "Fast Facts" in general -- there's even a downloadable version for a PDA! You can find them here: http://www.eperc.mcw.edu/ff_index.htm And there's even a search function now. The PPS is discussed in FF #125 Also, Growth House has a link to various tools here: http://www.growthhouse.org/promotingexcellence/ Good luck. I hope these documents help Concept 150 Dementia Formatted.pdf

Actually, you don't want to initiate atropine eye gtts too early...if the patient is actively dying then it is appropriate to use to manage congestion and secretions. However, if it is started too early, it can actually cause pyschosis.

I do 20-22 visits per week and I try to always give myself a day in the office for recerts and other paperwork. I usually see about 5 pts per day but that depends on how much windshield time is required to see them all. I have several patients that are only located within a 2-3 mile radius of each other, so I can easily see 6 on that day and I have several that all live in one facility so that makes it easy to see 6-7. My schedule is in an uproar at the moment however because I'm currently trying to transition my patients to other case managers so that I can move to another position.

I currently have 15 and have had as many as 25 but my company utilizes LPNs to assist with the visits. We set our frequencies of course to meet our pt needs and we only have to see our pts q 14 days to do the supervisory visit, but most of us try to see all our pts at least once a week. They want the RN's to do 20-22 visits a week and the LPN's to do 28-30. This is really a fairly decent caseload....I even have one full day that I can dedicate to recerts and updating charts, etc and my team director will either let us come into the office on our "paper day" or work from home!! I've never had so much flexibility!! Its awesome!! We have a full-time after hours team and a full-time admit team but we do take backup call approximately one night a month and are back up for admits about once a month. Our service area is pretty large and there are days when we have 5 or 6 admits. It really isn't too often that we have to do a backup admit however. And if we do an admit voluntarily after hours or on a weekend, we are compensated VERY well for it!!

No, not all hospices are like the one you're working for. I worked for a large, nationally known hospice last year and can truly feel your pain because it sounds like a carbon copy of the scenario I experienced!! Our Executive director and Patient Care Manager were ignorant to our problems/concerns!! We begged desperately for more help and were promised multiple times that help was on the way but it never really was. The PCM promised to come out into the field to help ease our load but never did!! After nearly a year, I couldn't take it anymore and I went to work for a hospice 9 miles down the road. At first I was afraid that it would be the same situation but I've been with this company nearly 9 months and I've given up waiting for the other shoe to fall because I truly don't think it will!! I am truly amazed by the teamwork with this company. Everyone pitches in to help when there is a crisis and our team director is so supportive!! Hang in there!! Oh by the way, none of the nurses I worked with at the other company are still there..........imagine that!! I think the burnout rate is about 3 months........Sad isn't it?!

I recently attended a teleconference regarding terminal restlessness/agitation and was a little surprised to learn that often times, ativan is to blame for increased restlessness/agitation. The physicians that were giving this seminar recommended haldol or even risperdal which doesn't cause as much euphoria. I'll have to find the documentation from that seminar and post the specifics. It was VERY interesting actually!!

LOL!!! That just might work.......but may get me fired!! I have tried telling her that I can't discuss any other patients with her........she knows that. I think she just wants to test her boundaries. But its very frustrating. Like I said, I've never encountered a pt or family member that was SO nosy!! I hide my care when I go to the neighbors homes so that she can't see I'm there otherwise she'll call them on the phone during my visit!! She's amazing!! Loves to gossip and claims to be a Christian......it really disgusts me. And her poor husband can't get a word in edgewise (he's the one I'm there to see). Nothing else has worked so far so I'm going to continue to try diversion and if that doesn't work then I'm going to start changing the subject when she starts to ask. Thanks for the great ideas and if anyone has anything else they'd like to share, please feel free!! You guys are a great sounding board!!

That's exactly what I say but she persists. Any other ideas??

Bear with me while I try to explain this.....never encountered anything like this before and not sure how to deal with it. My hospice covers several very small rural towns that are all about 8 - 10 miles apart. In these little towns, everyone knows everyone and probably knows folks from the surrounding towns as well. I have 1 patient in particular that makes me insane. Well it isn't really the pt but rather his wife. She is very nosy!! I call her "neighborhood watch". The neighbors on either side of these people are on service as well as their daughter and the daughter's mother-in-law. When I arrive the wife always asks if I've been to the neighbors or if I'm going to the daughters etc. I've explained until I'm blue in the face that I can't discuss it with her. She just looks at me like I'm being mean or lying and continues to ask. Tuesday one of my co-workers had a very serious car accident on her way home from work. Yesterday, I had to call this patient and the wife was asking me about my co-worker's accident (not sure how she found out about it unless it was from the front page of the local news paper......they showed a lovely picture of the accident with my friend being cut out of the car!!) I told her I wasn't able to discuss it with her and she continued to gossip about it. I am to the point that I hate going to this home!! What would you/should I do?? Any ideas on how to handle this would be great!! Thanks!!

Yes, we tend to order things like O2 concentrators/portable tanks, nebulizers, etc if there is a potential that the patient will need it. Its better to have it on hand and not use it than need it in a crisis and not have it available.

I just resigned from a hospice that informed me I was not "organized" because I never got finished on time. On a daily basis, I would have 5 or 6 patients with at least 30 mintues drive time in between each one. The boss never took windshield time into consideration when making assignments and advised me that I could do it in 8 hours because my colleague could do it in 8 hours (all her patients lived in the same town which was also conveniently her home town.) Being salaried, I got tired of donating my time to the company.

Wahoo!! I passed too!!

I feel the exact same way!! I concentrated on studying the core curriculum/study guide as well as a couple of symptom management books that I have and I felt very ill-prepared. i took the exam with my PCM and of course we compared answers afterward (I know you shouldn't) which made me second guess myself and feel very stupid!!

I have been taught that the admission must be done by an RN, but the RN only has to see the patient every 14 days. My hospice uses LPN's and it allows me to have a higher case load than the other case managers (not necessarily a good thing) but it can be very advantagous for all parties if the RN/LPN are a good working team.

Have you found any online resources?? If so, where did you find them?? I have the core curriculum and study guide but I am struggling with the core curriculum as I find it very dry. I am very nervous about the test this weekend.........hope I will do well and good luck to you!!

Last year I worked for a very small rural hospital based hospice. I loved the work I did but never had enough work to keep me busy. I was seeing 1 or 2 patients daily and using my PTO time to make up my regular hours. So, I was very excited when I became an RN case manager for a very large, well-known hospice company because I knew there would be enough work to keep me busy. We have been working short handed for so long that I'm beginning to feel very frustrated. I know that there has to be a happy medium somewhere so I would like a little input from other case managers regarding caseloads and on call before I make a decision to make a change. Thanks in advance!!

I am curious if any of you nurses have ever helped start a hospice from the ground up. If so, what exactly does that involve. I currently work for a VERY large, well-known hospice company but I was recently offered the position of Patient Care Coordinator with the responsibility of helping get this new hospice off the ground. I'm probably not going to accept the position but I was curious if any of you have any insight. Thanks in advance for your replies.

The hospice I previously worked for would not allow this under any circumstances. My current employer allows chemo or radiation for palliative purposes such as pain control.

What's funny about the for-profit vs not-for-profit hospice debate is that all hospices, regardles of their profit status, are paid the same reimbursement rate by medicare; therefore, it stands to reason that ALL hospices potentially make a profit. I have worked for both types of agencies and I have to say in all honesty that my patients at the for profit hospice receive better care because we can provide more for them. We also accept indigent patients because it is the morally correct thing to do. I'm not saying all for-profit agencies do so, I'm simply stating that the one I'm currently employeed by does.

Actually, only 3% of ALL patients (including those in LTCF) that are hospice eligible, ever utilize hospice services!! Sad statistic huh?? Sounds like we need more education all the way around.

The patient's church's position on medicine "is based primarily on a Bible verse from James 5:12-16. The citation reads in part: 'Is any sick among you? Let him call for the elders of the church; and let them pray over him, anointing him with oil in the name of the Lord.'" I spent a lot of time with him today asking him about his beliefs and why his church believed that they had to suffer. I explained to him that I wanted to understand his beliefs better so that I could better understand him and figure out a way to help him that supported his beliefs but allowed me to do my job. I also explained to him that there were various types of healing and that perhaps when his church elders prayed over him, the answer to their prayers came in the form of a nurse or doctor with the knowledge, technology and medicine capable of making him feel better. He didn't agree with that because "it doesn't say that in the bible". I asked him if he felt that the Lord worked through people and he said yes. So I asked him if he thought that nurses and doctors could be doing the Lord's work and he also said yes. Not sure if I accomplished anything or not but it was at least worth a shot. We'll see how this plays out. If anyone has dealt with a similar situation, I sure would appreciate some advice. Thanks again.

I have a sweet little patient with prostate cancer that has more than likely metastasized to the bone. He c/o frequently of severe pain in the hip, thigh and pelvis region. We have lortab 7.5mg available for him to use and have offered him a duragesic patch, but he refuses both. The problem is, the use of medication is against his religion. He is a member of the Church of the Firstborn. He feels strongly that it is a weakness of his faith if he takes the pain meds. I understand that it is not my job to change his beliefs but to support them. I'm just not sure how to deal with his beliefs when they keep me from being able to do my job. Has anyone else ever experieinced a situation like this?? How did you handle it?? Do you think that non-medicinal pain management techniques would be helpful and if so, what do you suggest?? I appreciate any advice or suggestions!! Thanks in advance!

I work for a small rural hospital based hospice. We are trying very hard to grow our census but recently we've run into some problems. We were given a handful of referrals at the local nursing home and after our PCC evaled them and decided the patients didn't really meet criteria, they were picked up by another nearby, larger hospice. After they had been on board a few weeks, the hospice promised the nursing home they would buy them all new minis blinds and refurbish some of the rooms in return for more referrals. Is this marketing or something more sinister? Yesterday we received a referral from a hospital discharge planner for a patient that had a cva and was coming home unresponsive. The family chose us over the larger hospice because he had heard good things about us from his co-workers who happen to have a family member on our service. The only fly in the ointment was the patients PCP, he is the medical director for the other hospice. My PCC took the orders to the doctors office for him to sign and he said "Oh no this will never do. We can't use these other hospices, they write too many orders and it will be too confusing." He called the family and then he had his office staff inform my PCC that the family had decided to go with another hospice. How can he do that?? Is this legal?? And what if anything can we do about it?? I realize that hospices are a very lucrative and competetive business right now but some of their actions seem a little unethical. Any advice would be appreciated here. Thanks!!

I am interested in any and all information I can get about this subject. We recently admitted a patient with advanced idiopathic pulmonary fibrosis. We've tried nebulized morphine solution on her without a lot of success so very interested in this topic. Thanks in advance for any advice!!

I can sympathize. When I was a student, there was a seasoned nurse who complained to our instructor that we asked too many questions. And my very own preceptor had the same attitude. We sat down to take report on my first day on the floor with her, she looked at me and said "I promised myself I'd be nice to you today". I am usually very happy to have students on our unit but I was pretty disgusted with one we had the other day. I walked up to the desk to check for orders to note and she was sitting on the desk with her shoes off text messaging her friends on her cell phone. We asked her to get down and informed her that wasn't appropriate or professional. If I had seen her instructor, I would have visited with her about it as well, but she never came to the floor. Do instructors still go to the clinical settings with students??