soapynurse@adel

In Virginia, RN's out in the field do the pronouncing. We also made all other necessary calls and disposed of drugs. If the patient is in the hospital, a house physician can do it. The facility usually makes the calls, but often they forget to call hospice about the death. I have made visits to the hospital when they had failed to call us.....urghhhhhh. Keep up the good work. Alice in VA

I can't for the life of me think of the name of this scale, but it is often used in patients with dementia/or who are unresponsive. You gauge it by moaning, grimacing, restlessness, etc. I'll try to dig out a copy and post it here. If I had staff in a facility or a family who couldn't tell if the patient was in pain, I made a copy of this scale to leave with them. The hospital nurses didn't seem to thrilled, but agreed to post it at bedside. Keep up the good work ladies and gentlemen. I wish I was still in the trenches with hospice. I had one very sad situation one time when a patient was transported to the hospital for terminal care. His wife felt she couldn't take care of him at home. Admittedly, she was a tiny lady, and this gentleman was a big guy. Finances were not an issue, but they didn't follow up on getting help into the home. He had made it very clear he wanted to die at home. The wife stood at the end of his bed and said, "I want him transferred to the hospital, he'll never know it anyway." So much for the patient hearing this. To make a long story short, the transport company can not transport narcotics, so the man arrived at the hosp sans his meds. Would you believe the hospital had neither the MSIR or the lorazepam intensol??????? I ended up going to a local pharmacy to pick it up and carry it back. I could have rung the neck of that hospital pharmacist. It all worked out in the end and he died very peacefully, though before his family got there that day. I did manage to catch them before they got to the room to break the news. All were very well prepared as this man had had a wonderful life and was ready to go. Ahhhh, the memories. Alice in VA

We used morphine or oxyfast on a regular and frequent basis. We always got titrate to comfort oders, so the sky was the limit. We used usually lorazepam in conjunction because as pain increases, so does the anxiety level, respiratory rate, etc. I had one guy who was on up to 1600 mg a day of combined long acting MSContin and MSIR for breakthrough pain. We also administered lorazepam as needed, also with a titrate to comfort order. Along with those measures, we used scop patches and recently added on Robinul tablets which work faster than the scop and dries them up pretty quickly. I would often place a patch and at the same time, give Robinul for it's almost immediate effect. It comes in tablet form, can be crushed on put in applesauce if they can swallow, mixed with a minimal amount of water to drip into their mouth, or crushed and sprinkled under the tongue. Didn't take long for it to dissolve. I've even just tucked a tablet into their cheek as it dissolves easily. I didn't have so much trouble with nurses, but in assisted living facilities, the med techs can't use a titrating dose, it has to be a fixed dose and time period. So we just made the prn order so that it could be given very frequently. I did actually have some med techs, though, who were afraid to give the morphine. I had one tell me one day that I wanted her to go back and give the morphine so the lady would die. Then on a more positive side, we had patients in a local nursing home and they, the nurses, were very much on board as far as pain control and they could use titrating orders. One nurse had a patient who was not hospice, but obviously needed some of the meds we often used. She called the primary MD, told him what she needed and he agreed immediately. Yay for her!!!!!!!!! It's very much a struggle sometimes, but I was very committed to keeping my patients comfortable as well as sticking to a very rigid bowel program. We had one assisted living who adapted their bowel program to our recommendations so that no one would end up being impacted on their unit, hospice or not. These girls in the particular facility were very much on board with our program and they never hesitated to give meds. A little bit off topic, but still important....we used a topical phenergan gel for nausea and sometimes also lorazepam. It didn't work for everyone, but it usually worked in my patients. Sorry to be so long winded. Hope this info is helpful. Alice in the beautiful Shenandoah Valley

From all the researching I have done, it seems that you need to be proficient in Microsoft office....access, excel, etc. You will be doing a lot of database work, spreadsheets, etc. You also need to know presentation software...Powerpointe. Hope this helps. Luckily my teenage daughter just finished a computer program at her college, so I get the textbooks to work from. Guess I know what I'll be doing next week. Good luck. And also, make sure you have enough memory on your machine so programs will run efficiently. Alice in VA

Hi Angela, I had actually read about this and it sounds very interesting. It sounds so valuable and could be a great source for networking. Guess I'll have to come up with some money for the opportunity that sounds too good to miss. Thanks so much. Alice

I was wondering if anyone has had experience with either Excelsior or Canyon College. Canyon's program seems very brief compared to Excelsior. Any suggestions, support, etc. would be greatly appreciated. Alice in Va

I absolutely believe it is better to stay ahead of the pain than letting it rear it's ugly head. And it can happen so quickly. I tried very hard to keep my patients comfortable for them and for their families. I often encouraged the family to stay with the patient, crawl in bed with them to comfort them, whatever it takes. I had a gentleman pass away one day with his family, two cats and a dog at his side. Can't get much more peaceful than that and yes, he was comfortable. Happy Nurse's Week everyone. Alice

Was just wondering if anyone else has had trouble getting info from Excelsior? I sent a request for info, director of admissions responded, but apparently dropped the ball. Got a response from a second person in admissions that it would take 7-10 days to get info out. This all makes me a little leary of their program and I'm just looking for a certificate!!!! Have also looked into Canyon College....almost seems too simplified. Good luck everyone and Happy Nurses Week. Alice in VA :balloons:

We had several ALF's who used our services. We did not provide continuous care unless symptoms were out of control. Luckily, over time, the staff became very well educated and appreciated our help. This was especially good because they followed our protocol and the patient was allowed to stay in familiar surroundings. Family members often chose to stay with the patient, often around the clock. Luckily, this worked out very well for all concerned. Alice in VA

Our team meetings would often get out of control until we went to having a nurse scribe. This person documents all pertinent discussion and then the appropriate people sign the document and all is done. We used to have to fill out our team sheets ahead of time and that was generally a pain the you know what. Our hospice is very spread out, so for those of us who worked in the very southern part of the area, it was often difficult to get back to where the charts are. Now, the scribe documents and suggestions for changes are made during the meeting. Usually the nurse manager or social work supervisor ran the meetings, but now the music therapist does. Don't know how that came about and not sure I approve. Just always make sure your documentation evidences decline or improvement to help the team decide if the patient remains eligible. Alice in VA

"I've had the experience a few times of starting my shift and finding the dying patient with a mouth thickly coated with dried secretions. " Of course in hospice, this is a very common problem. We usually use toothettes (pink swabby sponges) maybe moistened with water or water with a little drizzle of mouthwash to make their mouth feel better and smell better. This works fine if carried out on a regular basis. We also encourage chapstick as the lips do get very dry. Again, think of what you would want done for yourself or family members. Good luck. Alice in VA

Sounds like you're on the right track. Yes, I think he'll get over the side effects, but he probably doesn't realize that. Duragesic can make some people very fuzzy. He'll decide when it's necessary to take the breakthrough med. when he needs it. Some people, though, are very stoic about their pain and resistant to additional meds. Keep up the good work. Wish I was still doing it. Alice

Before I would even begin to offer any suggestions, I would want to know if the person is on any long acting narcotics and what do they have for breakthrough pain. Maybe it could be time for a clysis. Is the patient eating, ambulatory, having BM's? Alice in VA

Sadly, I'm retiring from hospice where I had really found my niche. But that's another story entirely. I absolutely agree that the patient should be given whatever it takes to make them comfortable (titrate to comfort). Our docs were very good about that and families understood that, yes, the meds may hasten things, but they preferred their loved ones to be comfortable, bottom line. I did work with some nurses who were almost stingy with the MSIR & Lorazepam. I tended to be pretty aggressive and it worked for me. I was also very aggressive with bowel regimes as I hated to dis-impact someone because 1. It is so indignant for the patient, so invasive and 2. it's not necessary to do this if following a good bowel regime from the start. Oh yes, the magic poop pills were wonderful, but didn't always work. I learned so much and really wish I didn't have to give it up. I leave it with some wonderful memories and confidence that I did a good job. Keep up the good work everyone. Alice in Virginia

Yes, your patient is your number one concern, and I absolutely advocate that. I always tried to treat my patients as if they were my own family. They appreciate it and their families do also. I attended a lady last fall who was actively dying and in great respiratory distress. This was my first visit with her, so we knew nothing about each other. She was on her living room couch laying down, thus increasing the difficulty with breathing. My only alternative that I knew of was to get up behind her, sit her up and then lean her back on my chest...then I was able to administer the morphine and lorazepam she so desperately needed. She died about an hour later, but she was comfortable. Her brother said to me how grateful he was that I just came in and treated her like she was my sister. That made my day. We all have our own methods, techniques. You will find your niche. A few nice words, a gentle touch, holding the hand are sometimes all that is needed. I wish you luck. Alice in Virginia