Donnagg123

We give IV vanco PO. The pharmacists swear it is cheaper to reconstitute and give PO than to give the PO pills.

see if you can change to a crushable form of something similar. My pharmacy usually recommends senna.

What about a patient that has dementia and management is saying this person "has to" get up for day on night shift as therapy supposedly does this resident 1st when it is very obvious the person does not want up on night shift. Don't they still have a right to refuse?

I know the answer but want opinions. What to do when a patient family is insistent that the person is in pain, yet the patient consistently denies pain and no symptoms of pain when family says resident is. Here is what happened. A patient who is hospice but still able to talk / make decisions etc. When one particular family member is there they are telling nursing that resident is in pain. Yet when patient is asked if in pain res denies it. Family says patient moans out, says resident tells them is hurting, hallucinates, and is awake off and on (while family sitting next to bed hovering over while patient sleeps), sits up and moans. NO ONE sees these "displays" of pain that they say they are seeing even when observing resident for long periods. When resident does actually have occasional complain of pain tylenol is effective. Yet particular family member is insistent that he needs morphine. What to do? I know there are times residents feel more comfortable telling family they are in pain versus nursing but we cannot force someone to take pain medication, right?

Thank you for that. :) She implied it was a law and she said "legally" and I was like ??? I did not think it was.

I did not mean to imply that you would never use nursing judgement to decide when to hold or not. I was just curious where she came up with the "3 dose" rule. If that was just a standard or some law I had never heard of. Of course if I held say colace because a resident was having diarrhea no I am not going to call an MD at NOC to tell him LOL But I agree with the others that if there is something in the vitals dramatic enough to warrant you holding meds like BP dropping etc then you need to get to the root cause...is there something more going on? I got the impression from the person that even still they felt it is okay to hold for 3 doses before notifying MD. Implying that I was overreacting. The person also believe that pretty much there is NO reason to call MD at NOC.

Even with parameters you can only hold so many days / doses then you have to notify md right?

In a discussion today it was brought up about holding meds. A nurse said legally you can hold 3 doses without notifying MD. I thought you have to let MD know asap if you are going to hold meds? Legally how many doses can a nurse hold (if there are no parameters) before notifying MD?

Besides passing midnocs meds (frequently) and 5-6 am meds lots of nebs sometimes accuchecks in the AM if they get no coverage. In the meantime finishing up everything 2nd did not get done in regards to processing orders and finishing admissions. Monthly summaries and medicare charting. Glucometer checks and checking temps on fridges. We get med deliery on 3rd. Doing change-over monthly. Dealing with all of the sundowners and bed alarms answering call lights taking everyone to the bathroom atleast 50xs. Other than that well (at least according to day shift) we do nothing....

I know this is old, but ...do you work where i work?? It sounds awfully familiar... LOL

Never assume things because it does not work that way where i work. For CII they have to have a copy or the original valid script or you are not allowed to get into the EDK. It is illegal. period. They used to be able to send us a 3 day supply without a script from back up. Not anymore since the rule change. I would NEVER intentionaly let someone suffer, but what are we supposed to do? Also, It is not like we give them NO pain meds but if they are to the point of needing a CII (which now includes all hydrocodones!) you are screwed with no valid script. Here they do not accept scripts from PA's either. We can do tramadol without a script but that is as far as it goes narc wise.

you are correct! so you don't know they do not have the script till too late. OR if someone has increased pain at noc (even for established residents) if you do not have a script you still cannot get into narc edk. So yeah these new rules may be helping to control abuse or whatever but it really hurts the ones who need it and can't get it and as a nurse to see a resident in pain and not be able to help is heartbeaking

I just need to vent. I am very frustrated with the new narcotic rules. The rule is now even Norco's we have to have a valid script and a code before getting into the E-box. Some may say well that is not unusual. BUT when you work nocs and new admits come in or a med is out.....it really ties your hands. You cannot get their pain meds etc so if they are hurting or cannot get their routine anxiety meds etc then the resident is punished and you may get in trouble for not controlling pain etc. Your damned if you do and damned if you dont. You may also say that the ones that have been here SHOULD had it already taken care of or the ones that come from hospital SHOULD have a valid script with them, but the sad fact (as those who work LTC know) this just does not happen. To me, THAT is what the E-Box is for! Maybe you might have to get a code etc, ok I understand. Nope, now they are saying if you do not have a valid script it is a NO and illegal. What are you supposed to do for your patients? Very frustrating....

how about "shortness of breathe" ..... it is shortness of breath!

How many people are you guys responsible to give the lax to and how many do you usually leave for her? Depending on how many I would say that she probably feels like you are doing it on purpose at 1300 so then she is responsible for the next step at beginning of her shift. Not saying you are but that might be why she is getting angry. You say your med pass ends at 10:30 is there any way you could stagger some of them out after that instead of waiting till 1300? But I also agree that it is a 24 hour facility so sometimes she will have to understand that some things will get passed on. JMHO Also i as well am surprised that Aides can give a fleets. I would think you would have to assess, what if it inadvertently triggers the vagus nerve?

sorry to say this is sooo not true. I work 3rd and we do all of the above and then some. I have learned more on 3rd because there is a lot less staff to help so you are forced to learn it all.

Here Here! I work noc's and it seems like if I get 15 minutes to sit and do nothing I would consider myself lucky (same for the CNA's).

You are very lucky! I work 3rd and we get 2 nurses for 3 carts, and also have to do census, sending meds back to pharmacy, processing orders, ALL the cleaning, not including a laundy list of meds and treatments and more. I would have the nurse do like you are and maybe get the extra charting done (VS/medicare, ATB charting etc.).

Okay, first I think I need to clarify. I was not trying to make sweeping judgments on the CNA profession as a whole I was just talking about where I work. I am sorry if I offended some but it was not an attack on the CNA profession. Was I saying that all CNA's gossip...NO. I have some very good CNA's but they as individuals tend to gossip...I was not making a wide spread judgement on all CNA's. Also, I understand that CNA's care for residents and are very close to residents. But in our facility it is policy that the nurse call family etc. Also do I think CNA's are stupid and have NO knowlege base in nursing? ...a resounding NO. I just meant they are not licensed by the state to know these things. Background info: I work in LTC, the care plans are not hidden, any charting they have to do is in an electronic system seperate from the nurses station, they all have "tickets" pieces of paper that are kept in a drawer with free access to all CNA's that list diet, mobility, etc etc. for all residents "in the system". Whenever there is someone new they are given report every shift of everyone so they can ask the CNA caring for them before them any questions or the nurse. Edited to add CNA's atour facility do not do vital signs, the nurse do. They do not do any treatments of any sort on the residents. What I was asking is that aside from need to know information to care for residents (which they have plenty of other areas to access this information) are CNA's from a HIPAA standpoint allowed to look in residents charts? I hear of people getting fired all the time for HIPAA violation and ignorance of the law is not a good excuse (from a court standpoint). I am NOT trying to block CNA's from giving good care to our residents, I just want to make sure form a legal standpoint that I would be covered because I worked too hard for my license to have it taken away because of someone else. That is all.

Oh no! I would never say it hateful or mean or berade a CNA. If I had to discuss this it would be in private quietly. But the CNA's I work with just pick up charts and start looking in them without asking me or anything. I do tell the CNA's certain things, because you are right it would be important to know, but they get royally PO'd at me when I don't tell them EVERYTHING about the residents like why did we send so and so to the hospital etc. I just feel they do not have the knowledge base to back up everything they look at AND they tend to gossip.

Okay, I am curious if I am right or are other co-workers right. Are CNA's allowed to look in charts? I question this for two situations - one was a CNA who went to look in her grandmothers chart for information (curiosity reasons) and when I told her not to she got very upset. I told her it was a HIPAA violation. She (weeks later) told me that where she used to work the CNA's used to get in charts all the time and a nurse who works with us backed her up. They stated maybe it is a facility thing but I said HIPAA is federal and CNA's are not allowed in charts. We also got into an argument about what I should tell the CNA (like if a person had AIDS, etc) and I said technically that is a HIPAA violation. And she stated that she should have a right to know because they (CNAs) are the "primary caregivers", and I said HIPAA would say if you use universal precautions that should cover everyone no matter what a resident has. and if there was anything that didn't I would tell her what equipment to use. Another situation was a similar one, a CNA was looking in residents chart on behalf of another worker (it was her friends aunt). And she also got mad and stated I had never said anything before and I told her that was because I had never saw her do it. My point is that I think that CNA's should not be in charts. There is nothing in there that they need to know and if they do it should come from the nurses (me). Other people, even nurses, disagree. I feel like if they are caught doing it on "my watch" then I would be the one in trouble, and I feel it is my job to vigorously protect patients info as I would my own. I know they are not allowed to look in charts of relatives or curiosity reasons for sure, but what is the law when it comes to HIPAA and CNA's?

I can see both sides of the issue. I have seen people end stage brain cancer and the family still refuse him to be a DNR. Another example was a woman who before her stroke was lively and would look at people who are just laying around like lumps and shake her head and say she would never want to be in that shape. Well. lo and behold, she had a massive stroke that basically left her paralyzed and she was unable to speak or move. Instead of letting her pass, her sister decided to put a g-tube in as she was the POA. You can see it in her eyes she is alert and able to understand what you say and she moans out and cries a lot. All she does is lay there like 3rd base. I know that is not what she would have wanted as she has 0 quality of life. On the other hand , several times I have called MD's about a resident and the first thing they ask is what is their code status? Hello! They have pneumonia/flu (or whatever). Something that could be treated with ATB or maybe they just need a breathing tx or two. If they are terminal I could see that but sometimes MD's cause part of the problem too by just brushing them off ("well they ARE 80 or 83" etc.). I think it is about quality of life. If the person no longer has a potential to have any quality of life why let them linger and suffer?

as I work 3rd - we see a lot of thyroid mediciine / stomach medicine - IE levothyroxine/synthroid, Prilosec/omeprazole, protonix, Reglan/metaclopramide, etc. Also we usually give the osteo pills: Boniva (monthly) actonel or fosamax (weekly). I have seen a lot of the men on flomax, and a lot of people are on the statin (cholesterol) meds. Pain meds can vary - we have quite a few on Percocet right now, but Lortab/vicodin are pretty common, so are darvocet and ultram. We also have quite a few with prn/rountine nerve pills like xanax, ativan. Hope this helps :)

I personally have not had to deal with it too much as I work third shift but I have a few examples for you. There was one family member who said well we don't want so and so to see dad (when the so and so is a close relative to the dad). Or there was one family member that would say well we don't want (the residents) ex-wife to know anything. I think it makes it so hard when families have conflict and decide you to be the mediator because they cannot get along. A lot of it is usually childish too. The focus should be on the patient and what they want, but sadly, especially in LTC what the actual patient wants doesn't matter it is what the family members want. example "Mom doesn't need to be on lasix" even though moms feet are +4 pitting, or "Dad has to have pain medicine around the clock!" Even though dad has never shown any s/s of pain and refuses the pain medicine the majority of the time. Sorry to digress, but it is just sad how some families behave.

I agree with everyone else. Do what your heart says. I am an RN who works LTC and the whole timein nursing school I hated every other area of nursing but geriatrics. You get to know every detail about the patient, it feels more like a home, there is never a dull moment, plus I get way more hugs and thank yous than I would at a hopsital :) Besides if you decide to do hospital work or LTC work or pediactrics or whatever, as long as you have love for what you do that is all that matters. I feel like I make a difference in peoples lives in what I do so my job satisfaction is very high. Eveyone told methe same "oh you should do hospital work or you will lose your skills". Let me tell you I use plenty of nursing skills in LTC. Foley catheters, G-tubes, IV's, trach care, suctioning, CPR, critical thinking, PICC lines, ports, wound care, etc. etc. Working in LTC there is always something you could learn. I still find everyday there is a lab or a diagnosis or pill I am not familiar with so I look it up and learn. I think a lot of times LTC facilities are overlooked in not only nursing schools, but in general nursing community. Which is sad.