mlolsonny

Scrubbing the hub was never in question. Pulling blood through the lumen of the PICC was. This was not how most of our RNs were taught, so we were asking for expert opinions. Thanks for your responses.

Big discussion at nursing home. Single lumen PICC. Educator says aspirate for blood prior to every flush and infusion. A couple of us think that's asking for trouble. What is best practice in home care or outpatient setting? We're measuring exposed length and arm circumference daily. Aspirate for blood or not?

Don't slam the door behind yourself! You may just need a new boss!

MDS (Minimum Data Set--nothing minimum about it) is the federally required Resident Assessment Instrument for nursing homes that drives further assessment, care planning, reimbursement, and nursing home quality measures. It's a Long term care sub-specialty, as most MDS coordinators are first and foremost nurses, but also detectives, teachers, reimbursement specialists, and documentation pros!

Anticoagulant works with clotting factors, not just platelets as ASA and Plavix. christinaxrn hit the nail on the head!

Your assumption is correct. Because supervision occurred 3 or more times, code as supervision. With the information presented, there is absolutely NO justification to code as extensive.

and nowadays, Gero-psych won't even take them without a bed hold...

Also a difficult lesson to learn, but until you can get your own work done on time, you can't do anyone else's work. I.e. helping with transfers, bringing people to the BR, etc. Your scope of practice is much broader than a CNAs, so anything that they can do, you can do, but they can't do your work for you.

My Trifecta patient for complexity has had CVA, CHF, COPD. Add in DM, renal failure, Parkinson's, chronic infections, immunocompromise...

Rails can help confused and agitated people be more mobile and help them get out of bed!!!

The first two questions with rails, grab bars, assist bars, etc. are restraint and safety. Looking at safety is much more broad than the aspect of acting as a restraint. Here are the questions from a side rail assessment that we developed after a survey tag r/t safety. Physical restraint: Any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones' body. Does side rail use meet the definition of a restraint for this resident? Yes/ No STOP HERE-SIDE RAIL USE NOT INDICATED FOR THIS RESIDENT Mark rails with Red tape or remove from bed. Is resident immobile (comatose, paralyzed, no spontaneous movement)? *Yes/ No If primarily immobile, does the resident have enough mobility to turn or slide to one side? *Yes/ No Has resident ever sustained bruises, skin tears, lacerations or fractures from a side rail? *Yes/ No Has resident ever become entangled in the side rail or entrapped between the mattress and the side rail? *Yes/ No Is the resident able to turn from side to side independently with use of rail? Yes/ *No Does side rail use increase resident's physical mobility? Yes/ *No If any starred answers chosen, side rail use indicated only with presence of staff. Mark rails with Yellow tape. If mobile, does resident make any attempt to get out of bed? Yes/ No If mobile, can resident get in/out of bed safely without any human assistance or assistive device? Yes/ *No If mobile, is the resident at risk for orthostatic hypotension or does resident have difficulty with balance/trunk control? *Yes/ No If mobile, does resident have decreased safety awareness due to confusion or judgment problems? *Yes/ No If starred answers chosen, rails increase risk for falls. Document increased risk and informed consent from resident/ family member (include name of family member giving consent). Does side rail use increase resident's risk for falls? Yes/ No Is this resident safe to use rails when they wish? Yes/ No If yes, mark rails with Green tape. Is OT/PT evaluation needed for transferring and/or ambulation skills? Yes/ No After completing assessment, please mark side rails with appropriate color tape: Green= Go-may be up at any time the resident wishes. Yellow= Use with caution- staff presence required for rail use. Red= STOP-Do not use Side rail(s) for this resident. Analysis of risk factors: RN Assessor: Date:

Unless your start time is absolutely set at 2000, try starting earlier. Group some tasks together, like starting nebs, giving supplements to people that are getting only supplements, etc. Don't get hung up on going to rooms in order. I suspect that some of the difficulty is because as it gets later, you're needing to wake people, sit them up in bed, etc. That was a huge issue when I was a new LPN on PM shift. Talking to the other nurses is helpful, but don't forget your biggest asset....talk to the CNAs! They know that Mrs Jones likes to go to bed at 1830, while Mrs Smith doesn't go until later. They can help you get to people while they are still awake. If there are certain residents that are very difficult to get meds into (or unsafe), closely look at admin times and discuss with the clinical manager. They may just need admin times adjusted.

In the simplest: Preventable Problems. Think pressure ulcers, contractures, weight loss, non-healing wounds, medication errors, decline in mobility/ ADL ability. Rationale: If adequate care is provided, most of those are prevented. Certainly you're going to have patients or residents that surprise you, and develop/ decline in condition. If you're diligently monitoring and putting interventions in place, you won't have big problems with these things that are supposed to be prevented. Look at your staffing patterns. If you don't have enough registered nurses to assess, and plan care ; enough LPN/LVNs to monitor, implement, and notice the daily changes; enough nursing assistants to provide the hands-on care, declines will happen. Talk with your residents: Use the QIS Resident Interview and Observation form. The surveyors will ask these exact questions. Don't be surprised by your resident's answers.

200 hours of staffing for 53 residents @ 1.16 MCM per 24 hours. 24 hours RN (one AM charge, One PM charge, One with focus for the day-- Assessments, Wounds, MD rounds, Mood/Behavior monitoring, Restorative, etc.) 12 hours MDS 40 hours LPN (16 hours AM and PM and 8 hours night) 8 hours TMA (on LT unit) 115 hours CNA (16 nights, other shifts flex with census)

We use EMR and ours uses Events as "to do" list for charting. We open a Clinical Charting Task event and put in what we want documentation on. Our nurses love our events.

Use the Seven Habits quadrants to help you prioritize?? I'm amazed at how much more I get done with this type of prioritization. Q1: Upper Left is Urgent and Important-- These are the fires that need to be put out! (80% of your day) Q2: Upper Right is Important, but not Urgent-- After Q1, then work on Q2. (They recommend 20% of your time daily) Q3: Lower Left is Urgent, but not Important-- Delegate!!! Q4: Lower Right is Not Urgent, Not Important--IGNORE! Use your Outlook to it's fullest. I'm using Tasks now and am able to prioritize them. I had no idea how much more organized I could be. It's a lifesaver. If one of my nurses asks what she can help with today, I share my Tasks. Get to know your staff and their strengths. Use THEIR strengths to YOUR advantage. I have a really picky, OCD RN that is awesome at collecting data for Infection control and QA. Once I taught her the process, she's continually collecting the data, so it's not a ton of work at the end of the month (or the day before QA if you're a reforming-procrastinator like me). Sounds like you may need a day just to sift through and figure out where you're at. DO IT! and start your priority list.

Our LTCF has a Comfort Care Directive that spells it out in writing about hospitalization, transfusions, suctioning, IV fluids, meds, antibiotics (oral, injectable, or IV), labs, other testing, even oxygen, etc. Ideally if the patient is alert and oriented and able to express their own wishes, we ask them to discuss it with family and physician, fill it out and sign it. If not, we ask the family to discuss it and fill it out if they wish with the explanation that making decisions now when Mom or Dad is not ill is likely MUCH easier than an emergent situation. We've had situations in which we sent a resident to ER d/t acute change in mental and physical status. We sent every page in Advance Directives section of chart including Comfort Care Directive (CCD). This gentleman was septic, and because he had documented HIS wishes on CCD, family and MD were spared the difficult decision-making at that time. His family and the ER MD were very appreciative that we knew exactly what HE wanted for his care, and were able to communicate that very concisely. Our medical director shared this with us as it was shared with him by the ER MD. Our facility is now a part of a multi-facility chain and we've shared this with other facilities and our local hospice. If you're interested in developing your own, I'm absolutely willing to share what we have. Just let me know.

We certainly can't be the only ones tho....... I was just wondering about how you judge when to start, if you make it retro (i.e. change in condition on Friday, expect it to resolve over the w/e, Monday comes and still not resolved-- Would you use Friday as the first day (if the MD was notified of the change)? Our docs have been pretty supportive, and I think we're capturing more $ for the monitoring, etc. We just haven't had the opportunity to talk with many others about how they do things.

In one of my nursing classes, it was presented that if a patient asks for prayer, we should all know a very "generic" prayer that wouldn't be offensive to any faith. Although I am a practicing evangelical, it isn't my place as a nurse to evangelize, but to minister to all the broken people with whom I work (Patients, family, AND staff). It has been a very rare occasion that I have offered prayer, but when asked, I do my best not to offend.

Only the first of many faux pas :omy:

We don't accept orders like this unless it's a situation or trying to determine minimal effective dose for a new med. Then we use the smallest dose, and assess effectiveness; if not effective, give more (in this instance, initial dose of 5 isn't effective, give 5 more, and repeat if needed to max dose). The the trick is to figure out how much the pt need routinely (and frequency) to keep pain well controlled and follow-up with the MD for a set-dose order. I agree with drmorton2b above, but the order needs to be clarified as soon as you know what your pt. needs.

If the MD told you to cut it in half, if it's an error, it's the MD's error.

I can honestly say that if I could place my mom in the facility where I work, she'd drive me crazy , but I'd see her more than if she was anywhere else. I had the honor of caring for my DON's mom for the last couple years of her life. I learned a lot about how great our staff are during her stay.

How about alcoholic father's first child ), OCD Mom's 3rd??? Dad was absent for most of my formative years- but I didn't go to nursing school til I was 33 tho. He was well resurfaced by then. I think my love of all things medical came from Mom's colitis which reared it's ugly head when I was in 5th grade. I was fascinated with learning more about how it (and everything else) worked.

Are any of you MN LTC nurses utilizing MSHO for your residents that have a change in condition? We attended an inservice in January, and have really increased our MSHO utilization. Just wondering if any other facilities are "skilling" people for changes in condition, med changes, etc. How do you decide when to implement, etc.