5150dx

Aloha, I recently graduated and have begun to work in a local hospital. My only experience with Hospice was when my dear friend was dying of leukemia and complications last year -- the Hospice was great! I am 38 and have worked as an EMT on fire dept. and ambulance so am not new to dealing with pts. and family at time of death -- just not the long drawn out kind. I am finishing my first month, with a preceptor, on the medical unit. 3 CA patients whom I met early on, have all returned, in varying stages of condition. Yesterday, a dear man with lung ca with mets to spine, brain and probably abdominal organs appears to be nearing death. He had been going into Hospice when I met him first, but then a family member convinced him "you cand just do nothing" so he changed his living will to include all efforts. My pt. is mostly unable to respond, no oral intake to speak of for a week, on iv fluids, getting decadron ever 6 hrs and iv ms every 2 -- ativan appears to increase moaning and thrashing so I stopped using, seeing him mellow more and be more restful with just the ms. HOB elevation, relieves his acute respiratory distress. 2 days ago his feet ballooned up and he and I joked about when they would "pop". Now, they have improved because we have a "compliant" patient who has ended his efforts to sit on the edge of the bed -- of course the fluid appears to have just gone to his belly, sacrum and lungs. As long as he doesn't get moved (which we still have to do to avoid decubs), he seems mostly comfortable. The poor doctor is so frustrated with the patient's code status, and is even considering interpreting the pt's living will which says he wants the "normal standards of care for his disease process" to mean no cpr or artificial feedings. I feel for him and am impressed that he cares enough to think this way, even if he ends up not risking it for fear of being sued by distraught family. The other pts. both will likely be called terminal soon -- advanced small-cell lung ca with mets to brain upon diagnosis, doing poorly with chemo and radiation and a lady with met ca to lungs, uterus, bladder and more. Yet another is fighting met. cervical CA, at a point with bi-lat nephrostomies, bili bag and now dialysis, and tpn. She already did chemo and other options which doctors could offer, with no great success. I guess I am struggling with my own feelings that they should be working with hospice -- trying to balance that with patience that each person needs to figure it out in their own way and time -- and some may never choose it. It just saddens me and I know I will find a way to choose the best words to help the families and not color them with my frustration about THEIR denial. Thanks for listening!

Hello all :) So sorry I did not respond back sooner -- The training was great! Gunter Klose is an excellent teacher of the skills and extremely experienced. After the training, however, I had to focus on passing my NCLEX, selling our home and moving to another state. All of that is finished and I am just beginning to explore the possibilities that lay before me. I will follow up later! Thanks again for these forums! Kristin

I just finished this winter, ADN, and am very thankful for the opportunity. I had a strong background in emergency medicine/ambulance and passed the NCLEX at 75 questions - with no study for that particular test. Now, I am having no trouble finding work. I agree with whoever said that the NLN has stringent standards for schools which want to be accredited... and EC has met them time and time again! There will be the occasional "mistake" that happens to make it through the EC program but, I suspect, no more often then those produced by traditional "programs"... yegads! I could point out quite a few nurses who went the traditional route and can't think themselves out of a corner OR have any real experience with patients.... sigh.... I strongly support the programs that Excelsior College offers. Kristin

Well, I leave in an hour for the airport -- looking forward to the training experience, though I have never been away from my husband and son for two weeks I have also found an AHA BLS Instructor course for the week after I return. I am trying to give myself options... The neat thing was that this instructor has a business in northern California providing safety training to people in the community. Apparently some years ago she injured her back as an R.N. and could no longer lift pts. So she told me she searched ideas and decided to teach one CPR class per week. Then it became more involved and she has become "The" resource that medics, docs, nurses, firefighters, etc. can go to for training on a regular schedule. In fact, that is how I found her... a medic friend of mine also teaches a medic course, 4+ hours away from this instructor, but knew to suggest I contact her.... she has earned the reputation far and wide. Now, there is another entrepreneurial idea. I was a little surprised that no one had responded to my first post -- I guess it sounded like I was advertising... but I was not. I was simply posting a business idea that is open to nurses and is something that I have found to be actually working for several nurses, some as independent nurses, others describing it as a wonderful skill when working as an oncology nurse, in hospital. Anyhow... I love reading the posts here! Thanks, especially, to Lois Jean -- I have since printed out copies of the diabetic foot survey form - I think it was from a government website -- to use with my (future) students! Kristin Graduating Feb. 20th!!!

Hello, Cheerfuldoer, I feel like you do about the uniform. At almost 40 I have not viewed those wearing whites as slutty, sex kittens, subservient hand maidens or such. They can look clean, crisp and professional looking and it seems very unlikely that would not be to the liking of our "clients" and professional peers. When I wrote about my thoughts about client/patient I was trying to point out the fact that it can, with some people, make them feel a bit more empowered to stand up for their rights as a consumer of our services. Now, will it make ALL the difference? No, of course not. But over 8 years of working with "clients" in their homes I found that, once I got over my initial resistance to using the term, I understood the significance. I realize that there are many great nurses and they are providing excellent, professional nursing care to their patients/clients. Also, I realize that there are (perhaps) more clients who are realizing that they don't have to take such a passive role in their in-hospital care. It seems, however, that this would be a minor thing that we could do to "take the high road" but I see that some others see it as just another "politically correct" rule being churned out by the powers-that-be and they resent that. Maybe I am just sad that I see the career of nursing as being something that fewer and fewer good people will want to pursue, and for good reasons. There are so many problems with understaffing, bad attitudes from docs and others, etcetera. I guess I am just in the camp of looking for ways we can use to portray us as a more (united?) professional force "to be reckoned with". It makes me sad that so many leave the role they loved because they hated the awful "job". I don't have all the answers (now THAT'S the understatement of the century ) and I guess I am old-fashioned but I just hope that we can find ways to help our profession be one that we can find more satisfying and true to our hopes. There is such bitterness from so many nurses about things like nursing diagnoses, whites, terms like client vs patient, and more. I realize that it can be difficult to see how those details might be valid when you are in the trenches, day after day, understaffed and frustrated. I guess I just had my vision tweaked by several dear friends who are those "crazies' who envision something better. A while back, I called a friend who had been a bedside nurse for 15 years before going into education and contributing to nursing research for several years now. I asked her about these "semantics" and she convinced me they were important to our role as professional nurses and to the continued autonomy we are supposed to enjoy. Another nurse I am lucky to call a friend, told me not to be discouraged but to keep on visualizing that it will get better. She has her doctorate in nursing, is a respected authority on the care of terminal patients and is out on the pioneering edge of defining what nursing can be. An advocate of change she, among other things, is building a wellness center that will utilize complementary and traditional medicine for her clients. I found her when I was desperately seeking protocols on providing massage to my friend with leukemia. One of the studies she had published covered just that subject. My point (is there one? ) is that perhaps, just maybe, these semantics might help us, and incidently the public/docs/hospital administrators/etc, to see nursing as the profession that it can be and to ascribe (?) more value to those who choose that path. I have to believe that there is hope. Thanks all :kiss

Hello all, First of all I want to say how much I appreciate the feedback. Second: to the person who wrote, "Plus, when I wear white it seems to attract coffee. I can't remember a day when I wore white that I didn't dribble some coffee on myself. Don't do it any other time except when I wear white.", I certainly understand :) Please know that I wasn't implying that anyone not wearing whites was dirty -- just that, if your scrubs are getting so nasty during a shift, try to take a fresh look at the situation... either we should be making more use of the disposable protective gowns and such, because the fabric of your scrubs is not stopping blood from soaking your skin and/or a change is needed. Believe me, I understand how easy it is to get whites soiled.... I also want to make it clear that I am not in love with the color white -- it's just that the public identifies whites with professional nurses. My point about "uniforms" designating a profession identity still holds .... call them monkey suits if you want but folks recognize them. I disagree that the public perceives the whites as you described ... that the public expects us to give up our seat for doctors, etcetera. Repeatedly patients are allowed to remain vaguely confused about the various people who care for them, often lumping them all into the role of "nurse". I absolutely value each team member I work with HOWEVER I still hold that clients/patients are unaware how few nurses there are on duty. Maybe that's not such an important point, but my gut tells me otherwise. And in no way am I saying that it should be mandatory to wear whites -- Thanks you all!

Hello again - well, now that I am not shaky from low blood sugar, perhaps I can participate a little more thoughtfully Deb, you wrote: "wearing whites is NOT practical in all clinical areas...." -- now, I am sure you can give me some examples however the ones I think of all would still benefit from the wearing of light or white clothing. Meaning, if you get dirty, it is obvious and you know you must change before going to your next patient... dirty. I have read and heard nurses say things like "I'm a slob -- I can't wear white". Now, outside of the hospital setting, I can tend to agree, which is why I don't include it in my civies wardrobe But, at work, to me, it just seems "clean" to wear whites -- if blood or some nasty bodily fluid ends up on them, it is very clear they are soiled and not to be worn until washed. Yes, I realize that means keeping extra whites in a locker. If big spills are happening often then that means we should be wearing disposable protective gowns more frequently... right? As far as respect goes, I mention the wearing of whites because it is something most of our customers/clients and peers/coworkers will recognize. Even though it should not matter, the fact remains that it does. If how we dress didn't matter we would not see every other profession having their own sense of "proper" attire. Think of business black, the whole red tie/orange tie thing, white collar, shined shoes, 3 pc. suit versus friday casual. Would most attorneys show up in court dressed in a washed out t-shirt or Goofy print shirt? Very unlikely, though we can all think of exceptions. Why do firefighters wear uniforms? Police officers? Believe me, they wouldn't if it wasn't very beneficial to them. I still believe we would appear more professional and would make progress towards the public becoming more aware of how few R.N.s are on duty AND that there is a distinction between the professional licensure of the staff. You also wrote: "In some areas, this is true, as healthcare is NOT a right, but a PRIVELEDGE in the USA, anyhow." Shouldn't clients/patients still have the right to good "customer service" even if it were a "right" (which I wish it was, too)? MJLRN97 wrote: "we're supposed to be thinking in business terms, e.g."customer service", but the truth of it is, most of us are not business people---we're NURSES, and we take care of patients!" -- I understand where you are coming from but if we DON"T think and portray ourselves like professional business people we will continue to be taken for granted. We are professionals who are partnered with the other healthcare professionals and the clients. The care/service we provide is unique from the rest. We are not simply "following orders". If we continue to allow the public to see us that way I am doubtful that we will make as much "professional" progress as we might hope. I think we need to look at the whole "customer service" issue from a variety of angles, not just blasting it because it reeks of "money" -- Must go... thanks so much for the thoughtful responses!

Oh, and another thing -- considering ourselves as "professionals" working with "clients" might shift our thinking and the way we present ourselves so that we aren't just "part of the room charge". Maybe that and more of us wearing whites would heighten our clients awareness of who the registered nurses are and why there is a difference in titles, duties and responsibilities. I know that your ability to provide excellent care doesn't rely on the color of clothes you wear or the length of nails (yikes, perhaps it does!), but over and over, I read posts from nurses who comment on the increased respect they get from patients when they wear their whites. I think it would be good for non-hospital staff to realize how few R.N.s are actually on duty. Yegads... I will stop now...

Hello, I personally prefer the use of the word "client". For all of you who don't like to think of the "patient" as having contracted with you so you will provide them a "professional service", I am sorry that is how you see it. I have been hospitalized several times and saw a great difference in the attitudes of the various nurses who provided my care -- several of which provided LESS THAN professional service. Those same nurses were the ones who acted like I had no business asking them to contact my doctor when I kept vomiting and dry heaving post adominal surgery (laparotomy (sp?)) -- they kept telling me they had given me "everything" they could. Luckily the anesthesiologist looked in on me, found me drenched in vomit, crying and crouched in the chair the nurse had insisted I sit in... he quickly ordered something more effective and I was immediately relieved. Or the time my son was hospitalized and was becoming over-hydrated and after 1 hour of my mentioning it to the nurse I finally reached over and wheeled the da*ned thing closed -- oohh did that piss her off! All she could think was to be angry at me instead of noting my 3 year old's puffy lids and doughboy arms. Patient implies that we are suffering and blessed/lucky to have someone to care for us. Physicians have long had a terrible reputation of having god complexes and many still intimidate their "patients" into procedures and treatments because "doctor knows best". We should be doing what we can to encourage our "clients" into working with us to improve their health -- and maybe if we think of them as clients and, as such, entitled to good "customer service" we would provide better nursing care. I could go on but that would not be productive. They really are clients of ours. Sorry, anything we can do to improve the attitudes of nurses like that, I welcome... within reason of course Rant mode off... I do appreciate reading the different opinions. I guess I just see a terrible lack of professionalism in a significant number of the nurses I encounter. Maybe some will say it is just political correctness but that is what many still say about the "n" word. Sorry if I stepped on toes... or appear rash... I just get heated up when I think of how sarcastic and snide some nurses can be as soon as they think they are out of their patient/client's hearing. Okay, I'll shut up now

Hi Dave, I read you post with interest but am wondering if that would be most appropriate for someone who had a history of using large amounts of opiates - either legitimately or abusively - not a current addict. If a self-admitted heroin addict is hospitalized for surgery, when do we make sure he gets the opioid he needs to avoid withdrawal and heightened sensation of pain? By the time he/she is post surgery, hours have passed since his last "hit"... possibly bringing all sorts of complications related to withdrawal... I don't have the answers and am new to this but it still seems a little uncertain to me. Thanks for your feedback. Kristin

Hi there, I just wanted to make you all aware of Manual Lymph Drainage and Complete Decongestive Therapy. I just finished nursing school and want to have skills that may allow me some freedom in the setting I work in. My focus is oncology and this training will complement it beautifully. There is one nurse I have been talking with who has made a very successful business in the Sacramento metro area. Some healthcare plans she is able to bill directly, others get billed through the Physical Therapist she opened the clinic with. It's the end of a long day so I can't think clearly to write out more detail but will list several links for you to research. I am signed up to attend a 2 week training intensive in Santa Monica, beginning on Feb. 9th. I chose to go with Guenter Klose's program as it was highly recommended by several R.N.'s I spoke with and it is a short, intense training instead of spread over 3-4 weeks. http://www.klosetraining.com http://www.lymphnet.org http://www.lymphnotes.com http://www.clt-lana.org There are more... just do a search. There is one training group headed by a Physical Therapist who is irritated that others (I.e. Nurses and Doctors) are being allowed to be trained and bill medical insurance for this therapy -- I am glad her view is the minority Keep in mind that the main client base will be anyone who has gone through cancer treatment and or surgery, or burn injury that involved lymph vessels. It is also important that patients receive education on this as a preventative measure, accompanying their procedure so they will know how to minimize their risks and recognize early lymphedema. To me this has some serious entrepreneurial potential. Email me if you have any questions and I will try to help. Kristin beautifulbooks@@Hotmail.com (just drop the extra @) ?

Wow! I will stop laughing now and tell something I learned from a patient... 1.a. Don't follow your bosses instructions to pour a half-gallon of gasoline on that rubbish pile.. and THEN wait 5 minutes to approach it again and set a match to it. 1.b. Then DON"T drive yourself home and climb in a cool bath as you are in denial about the increasing difficulty you are having breathing. 1.c. THEN DON'T expect your wife to handle it very well when she is working as an EMT on an ambulance, happens to be driving and gets dispatched CODE 3 to her own house to pick up her own husband who has burns to his face and crispy nasal hairs. Thankfully my supervisor came at the same time, meeting me at my home and offering to swap vehicles with me so HE would drive my husband to the E.R. Yeah... the things we learn from our patients - my poor husband will never live that one down. Kristin

Hello, Please realize there is a big difference in protocols for treating Lymphedema (either primary or secondary) versus edema caused by cardiac "issues". Diuresis as a treatment to reduce Lymphedema is absolutely contradicted because though it dehydrates the fluid buildup it leaves the remaining interstitial fluid even more concentrated with protein which makes infection, fibrosis formation and other complications even more likely. Lymphedema is mostly seen in patients who have undergone surgery which either removed or damaged a region of lymph glands -- commonly seen with breast cancer pts. Others are secondary to severe burns or radiation treatments. Still a few more were born with missing or malfunctioning lymph vessels and organs -- this would be Primary Lymphedema. Please take a look at this website: http://www.lymphnet.org/ and remember there are a growing number of nurses, physical therapists and doctors who have undergone specialized training for this problem and are certified to do so. Also beware of some massage therapists who claim to do "lymph massage" -- this has nothing to do with the medically oriented and clinically proven Manual Lymph Drainage combined with Complete Decongestive Therapy which these patients need. CDT will include the Manual Lymph Drainage with restorative exercise, skin and nail care of the affected limb, compression bandages throughout the initial treatment and then the professional fitting of compression garments to keep the lymphedma in check. The patient will also be educated about caring for the limb, including, but not limited to, not allowing invasive procedures to be performed on it (ie: blood draws, injections, blood pressure cuff, and more). The use of mechanical compression devices is becoming rapidly more controversial because of its ability to actually damage the lymph vessels, among other things. Kristin

I just realized that the placement of my prior post might make you think I meant Narcan for Ketamine or Versed reversal... nope. Meant to refer to earlier posts where using Narcan was mentioned. Thanks!

Please just remember that you can titrate Narcan during the procedure, definitely no need to jolt the pt. completely with viscious return of pain. I am new to all of this but thought I would share that reminder. It disgusts me that there are docs who perform painful procedures on pts. without including adequate analgesia. If no narcs are the goal, then how about parenteral ketorolac??? I think we are seeing way too much dependence on causing (and relying on) amnesia in our patients. Just my not-so-humble opinion. As a newbie, I should probably tone my expression down but this subject is a biggie for me Kristin Waiting for Feb. graduation!!!

Hello, I am a new graduate so don't have any real experience to share with you. HOWEVER I just purchased Margot McCaffery's most excellent book "Pain: Clinical Manual" and here is little from that: Pg. 455: Opioids must not be withheld from persons with pain who are suffering addictive disease. No scientific evidence exists that providing opioid analgesia to these patients in any way worsens the disease, or conversely, that withholding opioid analgesia increases the likelihood of recovery.... When possible, a single opioid agent shoud be used. Mixed opioid agonist-antagonists should never be used in the opioid-dependent patient because these will precipitate withdrawal. Analgesics should be ordered on an around-the-clock basis to avoid decreased opioid blood levels with associated breakthrough pain and withdrawal because both are risks for increased drug use." Elsewhere she points out that "No need exists to contribute to discomfort while the patient has acute pain, and during this time of acute stress detoxification should be avoided." My thoughts are: Document that the patient is NOT opioid naive and make sure the doc understands that much - I am uncertain of the legality or appropriateness of stating the actual addiction ?? but the term "not opioid naive" might be okay? Then target titrating until the patient is comfortable. My understanding is that Dilaudid is more potent (some say 7:1 or 10 mg. ms = 1.5 dilaudid) but what I am reading states that it is uncertain. It does have a short duration (3-4 hours), if that helps. I have worked with so many patients who had poor pain management from staff who were "scared" or "ignorant" about providing care. So, I am doing what I can before even working as an R.N. to gather resources to help me learn more. I am impressed that you are trying to as well. Sorry I couldn't give you more specific info. Kristin All done and waiting for graduation in Feb.!!!

Okay, I just finished nursing school (A.S. Registered Nurse) and want to go to massage school and then attend NMT workshops (either St. John or Delany). I can't see any other time I can have it so available to me so.... the big question is "Can I justify the additional expense and time not working as a nurse?" Yes, I can see ways I can benefit my patient by providing more skilled massage with my nursing care but it is difficult to justify spending another $4K and 6 months to gain a licensure that doesn't seem to offer me any additional pay at a hospital working as a med-surg nurse or even in ortho. I really get excited by the idea of working either independently or in a pain/ortho/chiro/rehab/? clinical setting and getting paid as a massage therapist as well as blending it with the care I provide as a nurse. I was just in a vehicle accident, head-on, both cars totalled, thankfully not my fault and no broken bones for either of us. Today I will go to physical therapy and I chose an office that employs several certified massage therapists. Now, I understand the insurance will pay if the doctor ordered physical therapy and that includes massage... Any information you can provide will be appreciated! Thanks! Kristin

Eagleriver, I just wanted to say thanks for your post - I just shared my friend's last days and I came away feeling like that - a total positive... that is once I got hospice involved who helped make the doc face reality. .... I just finished nursing school and look forward to working in hospice as soon as they feel I have enough med-surg experience. I used to work on an ambulance and so am not totally green... Thanks again! Kristin

Congratulations! I just finished yesterday, graduation scheduled for January. Oh my, what a relief. Of course, now my mind races to think of the future Enjoy the feeling of accomplishment! Kristin

Thank you all for your replies and support. At one point, during the wee hours of the morning, holding her hand and resting on the siderails and listening to her breathing I was overwhelmed with a sense that I was in exactly the right place in the world right then... that all the crazy twists and turns our lives take somehow put us right where we needed to be. Most of the time I didn't think that way but this really hit home. I had been mourning the loss of another good friend the week before but this really put things in perspective. Now I remind myself to see these folks as gifts to me... the time we have is so precious... try not to waste time wishing they weren't gone... instead focus on the gift that the time together was. Now, if I can just KEEP that thought I will be forever grateful for the lessons I learned and have no doubt that it will affect the care I am able to provide as a nurse. I love the idea of working in Hospice but am afraid they won't hire me until I have some experience in med-surg first.... we shall see. If that is the carrot dangling in front of me then I can probably see myself getting through some time there. Thanks again to you all! I am so grateful for the stories and feel connected to others who are sharing this roller coaster ride. May we look out on the world with a fresh perspective. Thank you. Kristi

Hello, I am almost finished with an ADN program... I just wanted to share a bit about what happened over the past several weeks. I learned alot about the differences among various nurses and doctors and became more cynical about certain aspects of care. Nine months ago, a dear friend asked if she could name me as her power of attorney for healthcare. I agreed. She was in remission with AML, 52 y.o. and with a family who she was afraid would be unwilling to "let go" if they faced a decision to cease care. Easy enough, it seemed. Two weeks ago today, I received a call from her daughter stating that Mom was on her way to the hospital via the ambulance. She had been ill with bronchitis and a "cold" for about one week. They discovered her barely breathing and barely able to open her eyes. I called the E.R. and asked them to contact the staff on the ambulance to tell them she takes morphine and to consider Narcan to rule out overdose. The charge nurse sweetly assured me she would do so. The transport time was going to be approximately 50 minutes. I then headed for the hospital. I arrived to the E.R. and spoke with the Medic who transported her. I had worked with him before, while I was an EMT. He told me he had intubated her enroute. I mentioned the morphine and he looked at me in shock... no one had called him about that. Of course he would have given Narcan. As it turns out, Narcan would not have helped. When I found her in the E.R. she was "circling the drain". BP of 38/16, temp down to 99 (after days of spiked temps), pulse 130 and thready. As far as we knew, her leukemia was in remission so, when faced with suspected bacterial pneumonia, treatment was started. Turned out sepsis had set in. The E.R. staff were simply outstanding. Hours later, we were able to get her to the ICU. Again, fantastic care! Though the first ICU nurse made some insulting remarks about the IV line in the scalp... I smiled when I later heard her report about her inability to get a better line for hours! By the 5th day the infection was beaten, and we began preps to wean her off the vent. It took more than 24 hours for the Versed to wear off enough for her to wake and become reasonably responsive. Thankfully, I was able to ask her if she wanted the tube back if she was unable to breath without it... she very clearly shook her head "no". She was extubated at about 10 am, kept breathing and by 3pm was moved to a general med/surg floor. I had left, prior to the move, to return to work. When I called at 3:45 to check in, the poor nurse admitted that she didn't even know if there was an IV running. I left work and went to the hospital. I slept there. The day nurse was sweet and kind but was severely overloaded... I think she had 9-10 pts. My friend was so weak she could not remove the mucous she coughed up. Lack of coordination and weakness kept her from being able to raise her hand, much less push the call button. Her family members were there but were pretty immobilized by the situation. She couldn't suck through a straw so I would dribble liquid into her mouth by holding some in a straw with my finger over the top. She showed me she could swallow so we went against the orders of the doc to wait 14 hours till the next day when she could get a "swallow evaluation" by a therapist. By 5 am she was able to suck through a straw, soothing her throat. My friend had asthma and owned a nebulizer. Using it gave her more than just physical relief... it was a psychological "control" factor, which helped her relax... The doc had ordered one breathing treatment every 6 hours. She asked for one ever 4 or so... Imagine my frustration when I would request one and be told that doctor's orders did not allow more frequent treatment. Or the amazing disappearing RT who later said he saw she was whispering to a family member so assumed she would not want a breathing tmt right then... only returning when a 2nd call was put in. The night nurses were great... and seemed to have more time because of so many pts sleeping. By midnight the breathing tmts did slightly more than nothing to relieve my friends breathing difficulty... she was "gurgling".... CHF worsening. I called the on-call and explained the situation and he ordered 40 of Lasix. Within 45 minutes she was breathing much more easily. But the nurses were too nervous about her lower BP... which Diane and I both told them were WNL for her. Nope... no more Lasix. Then later, 20 mg.... once again doing nothing helpful.... but her BP was up... especially when she was clenching the siderails, panting for breath. At 1:30 am she finally fell asleep... I settled into a two chairs (!) to try to nap. At 3 am the lights were switched on and a lab gal came in saying "Rise and shine, I need some blood". Aarrgghh!!!! I asked her to join me in the hall and demanded an explanation. Turned out ALL pts. have blood drawn at 3 am so the docs can have the results by 6:30 if they happen to want them that early. I told her about my friends exhaustion and need for sleep and was told that she had to have the blood drawn. I went to the charge and he explained that the only other option was for him to document that I refused to allow it. "Fine with me..." I answered. He smiled and said he respected that We had already talked about her situation and that she only wanted comfort care. Of course, the lights and discussion while the blood was drawn from the other pt. in the room woke my friend. I explained to her and suggested we go ahead with the draw since she was awake.... she asked "How bad is my blood?" and I explained the dire details... platelets really low, white count 30 k and rising... so blood was drawn. No more sleep for us. By 6 am, neither of us had slept, as she needed almost constant help with clearing mucous and incontinence care. I can't say enough about the wonderful compassion and caring I witnessed in her night nurses! Prompt, professional care provided with a kind smile. At 8 am I called the doc.. he had not seen her yet but her white count was up to 88 k... her leukemia was back. I mentioned hospice... he answered that he thought more days of the iv antibiotics might help. I explained that the cultures were showing the infection licked... he said he would check on that. He then spent approximately 2 minutes in her room and then told her that if she would stay in until Monday (4 more days) and stay on the IV antibiotics he might "be able to buy her a week or so more but if she goes home tomorrow she will likely be dead in a day or so". Hospice nurse came in.. Wow!!!!!!!!!!!!! I talked to her and explained my concern about the CHF and the reality of her time left. Within 15 minutes she had reviewed the situation and returned to me with a frown. I started to say something about not wanting the doc to feel we didn't trust him.. she leaned to me and whispered in my ear "F(*&^ the doctor... she is not being told of the reality" - thankfully a daughter overheard and laughed at the audacity! The hospice nurse began prep for my friends possible homecoming the next day... I stayed that night as well, because my friend asked me to, and she never slept. I caught a nap but she was even more wiped out by 6 am. It had taken almost an hour to get an RT in for a Breathing tmt... and then he was rude... she didn't want suctioning. The day before she had rested in feces for an hour and half though the family had asked for help twice... she was obese so they were uncertain how to help her themselves. I met that nurse and she always acted annoyed when we tried to talk to her - no way around it.. she was a royal B(*&^^^! I heard her visiting about her upcoming vacation, new shoes she had bought and more... and heaven forbid I ask about when her last meds were given! Yech! As I left that morning I cried and told her that I was afraid that if she stayed until Monday she might not have any quality time at home wth her family and that I didn't think the doctor was being realistic about the potential benefits of more IV antibiotics... as she had already been on them for 9 days.... and could continue oral ones at home if she wanted. I asked her to think about it and give us her answer when the doc would come in later. Thankfully I had been able to have a frank discussion with her night nurses who stated that my friend couldn't get the care she needed here... that only hospice could provide it. They were worried that she wouldn't make it through the weekend with no sleep and with her resp. status deteriorating so much. Friday am the hospice nurse got hold of the doc... he came in singing a different tune and my friend was home by 1:30 pm - reclining on a low air loss bed and surrounded by the comforts of home. The sublingual morphine and ativan helped her to relax and the 40 of Lasix she kept getting meant she only wanted her nebulizer once or twice per day. She slept and had wonderful visits with her family... enjoying the halloween costumes of her grandchildren, playing cards with her son and eating "real" food. I saw her Monday and could see she was declining.. but still able to have a wonderful visit. Tues.... slept alot... passed away Wed. evening. The family called the Hospice nurse and she stayed on the phone, coaching them to give her the morphine and ativan since Mom was in distress as her breathing was shutting down. She went to sleep. She had told us all that she did not want to die in a hospital and we were able to help her accomplish that goal. Thanks for listening... Kristi

Hello, I just want to second Jadednurse's post... and others that recognize that while this is inconvenient and has legal ramifications which must be addressed, it is extremely important to many pts to be able to smoke. I haven't smoked for 9 years but when I hit a stressful moment the craving returns! When I went for a divorce, long ago, that first cigarette after 5 years of "recovery" was pure relief. I hate nicotine, I hate the addiction but we must be realistic. Maybe I am a bit "militant" about it right now as I just helped get a friend OUT of the hospital and into home hospice. She just passed away a day ago. Last week I had to sleep several nights at the hospital because "hospital policy" endangered her. Sometimes "routine" can hamper a pt's recovery. As a student nurse I am also becomming rapidly wary of many nurses being unwilling to call a doctor when needed, to change orders.... or still letting a pt. sit for 1.5 hours in feces.... Grrrrr..... Sorry (a bit) for the rant! Kristi

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Hello, I checked at the website for the CA BON and read the information about which are considered independent nursing procedures (those relating to comort, hygeine, etc.) compared to those which require a doctor's order (foley cath, etc.). I followed up with a phone call to BON, was transferred to a nurse education consultant who confirmed this for me. Have fun researching! Kristi