RyanSofie

Your reply was well worth quoting! "As an Oncology NURSE and Hospice NURSE" Thank you! My question was " if this were your loved one what would you suggest". As nurses we are patient advocates. It is not beyond reason to suggest Hospice/Palliative care to a patient who is as ill as the one I described. My point was NOT to give MEDICAL ADVICE but to give COMPASSIONATE NURSING ADVICE . Thanks again for your response.

My friend's patient has a tumor large enough in his neck that he has dysphagia, a PET scan has shown several "spots" on his lungs.He has end stage COPD. He is anemic and severely underweight. He is 76 years of age. The "team" has told him he needs to have an immediate tracheotomy and a peg tube.They also have advised radiation. No biopsies have been done. He has had a caratoid blockage and has two cardiac stents. I have spoke several times to his nurse who is a dear friend of mine asking her to address Hospice with this patient and his family. I foresee this man having alot of suffering ahead and a poor quality of life for the remainder of his life . The physicians of course will suggest all possible interventions as their first priority is to preserve a life. Life is not merely breathing (in his case the liklihood of a vent is very high) nor is life a chemically sustained heart beat. The patient did sign a DNR and I am concerned his 6 daughters will also convince him to forego this. If this were your loved one ,what would be your suggestions?

You will develop a method to pass medications more efficently. Each nurse tends to do this so don't worry. I suggest you start as early as possible setting up your cart ( right after report if possible). Check to be sure your well stocked with cups/spoons/applesauce etc. As you get report note any abnormal blood sugars/B/p's/Temps etc from prior shift and if patient recieved coverage,those you should assess first ( I used highlighter on my sheet for those. Start BS/VS as early as possible also. Also note patients who need narcs/crushed meds/tube feedings/IV's. Once you have your rhythem set you'll be a pro in no time. I worked LTC many years and it can be very daunting. You can do it..it will take time and remember don't be hard on yourself.

I have had this happen and it can make you question yourself. I now see it as the family looking for a better outcome of a situation they cannot control or change. You were correct in requesting family sit with an anxious patient. Your intervention was correct . Many times the unfamilarity of an enviornment or people escalates anxiety.Family can provide a familiar comfort.

The "TOTAL" work hours are as long as it takes to complete visits, open cases,recert cases,discharge cases ( assessments) and make routine visits or prn visits. Then...complete Oasis, med sheets, careplan, orders,Braden scales,pain assessment forms forms and more forms...If patient cancels one day then squeeze him/her into the next or the next. Then there is driving time between patients, to labs, to office etc etc. Time for phone calls to Physical therapists,HHA,OT,Doctor blah blah blah...All for about 65,000/year base pay.Weekends,holidays etc included in hours to be worked. Piles of paperwork that never seem to end. Keeping track of 30 patients recerts, resumptions,discharges...lab dates. No overtime, straight salary...hours worked ENDLESS...Hospital nursing 8-12 hours, complete paperwork (notes on patients) admits ,discharges...labs, surgeries...etc etc..at designated hour punch out and go home. Nursing ahhhhhhhhhhh such an easy profession...anyone can do it. LOLOL

Ask if clinicians are allowed contact with physicians if orders are needed. Do physicians see patients if change of status occurs? Commuting/road warrior is the norm for home health. Expect alot of travel time and reams of paperwork unless company has computerized system. Are clinical supervisors involved in field visits ( or are they just administrative and hands off? How often are clinicians required to take on call rotation? How many patients are you expected to carry and does clinician also do case management with assigned patients.

R.N. B.S.N PHD Phooey....I sign my name 20000000000000000000000000000000000000000000000000000000000000000000000 times a month...D.S. R.N is enuf !

Sept/Virgo: HH is a 24/7 commitment without the compensation to reflect the amount of time consumed from your life. The companies know the time required and the managers,adminstration are appropriately compensated for putting the whip at the field staffs backs to complete the reams of documentation needed for billing purposes. I went to per diem status because I was literally overwhelmed at the 'productivity! requirements of seeing 5-6 patients daily or more if pts cancelled or refused that particular day. In addition to completing documentation which required hours more of (work @ at home). We do not get "administrative office day". We had a turnover of administration as a matter of fact and the "office was rearranged "to make it exceedling difficult for clinicians to work there at all. Charts are under lock n key...there is no desk space for clinicians...no pc to utilize etc. To staple papers together one must ask to get stapler from office manager. my home has therefore become free office space for the company. Complain away because I sincerely understand your frustration. May I add one positive to this? I enjoy my patients and their families. I feel I can make a positive impact in health care management for the patient through teaching. I enjoy getting in my car and traveling away from my city into the countryside here. Those families who so lovingingly care for their loved ones at home face so many challenges in the day to day of life. I know what we do is time consuming and poorly compensated financially for us but my compensation is when a family member takes the time from her busy day to bake me a loaf of homemade bread which she wraps warm from the oven to send with me. To see the parents of two very ill adult children sitting on their front porch waiting for me, lifts me from my fatigue in a way that is incomparable to any day in a hospital. I believe as nurses we give of ourselves beyond what most do in any profession but our rewards are also beyond what most recieve as well.

Age has many benefits in nursing as the response above indicates. Life experience and having learned the skill of prioritizing and the ability to accept and utilize constructive criticism are key to making a long day survivable. There is no doubt that being a new grad and putting theory into practice is overwhelming. The experienced nurse will not hold your hand through the process but if you are open to learning the "real" way things are done the experienced nurse will demonstrate those skills daily. Observe and if you do not feel comfortable attempting a new skill , be honest and ask for assistance. The patient should not know your apprehensive . If your in a situation you need assistance with,inform the patient that you would like another nurse to assist without going into an explaination of being a new grad to the patient. You will survive and at the end of this new experience be amazed at what your capable of achieving. Welcome to nursing !!!! :yeah:

:nurse::nurse::nurse: We are advocates for our patients. We will use our critical thinking skills at solve issues with intelligent, experience based knowledge that we have diligently worked to aquire in our professional settings. Why then do we as NURSES simply "HOPE' things will improve ? We as nurses must begin to recognize our VALUE to healthcare. We fail to use our voices where they count in the legislative halls of the government. We are millions strong across this nation and we can make the changes that need to be made through our united efforts. Physicians are heard ,pharmecuetical companies, insurance companies etc. We are an integral part of healthcare and I say NURSES stand up...be counted and recognize your place in healthcare is VITAL.:nurse::nurse::nurse::yeah::yeah::yeah:

Who has even heard of a weekly meeting running THREE HOURS late? If my med pass/shift started at 2:30 I would have gotten up, excused myself, and got out on the floor. That place sounds insane. If the meeting ran that late...did the previous shift have to stay on the floor? Most NH facilities (LTC or Skilled) are for profit and cut staff to the marrow . I would have filed a complaint with the area labor board and asked for compensation for being unfairly terminated. I speak from experience as I was in a situation such as yours and terminated ( not due to med errors but due to not "washing out" nebulizer cups for reuse). I was also left with a very unsafe situation. I fought them legally and won. Nurses need to stand UP and stop cowering when faced with these circumstances. If we want to be recognized as essential professionals providing professional medical services we need to STAND up and SPEAK out to those making these decisions that allow organizations to break the law. Nurses need to get into the political forums and start uniting agains't these types of employers.

The company I work with rotates call between clinicians. One week on usually a month which includes a weekend ( Friday to Friday). We have no "shifts". If you work in the field you work until you finish your required "quota" of 5-6 visits. You set the appointment times with your patients and that determines your work hours. Typically I say "I have an opening in the morning between 8am and 12 noon or afternoon between 1p.m and 6pm. I have learned not to set precise times for appts because of the variables that can occur ( traffic, previous patient in crisis ,etc). I can see typically 4 routine visits between 8am and 12noon if all goes smoothly which is rarely the situation. If I have SOC's ,RC's or ROC's they consume at minimum an hour and a half excluding travel time because of assessments,wound measurements, report to physician ,etc etc. Of course the other factor is mountains of paperwork and that is many times hours in addition to my day. Home care is not an easy task by any means. My team and I have calculated our true rate of pay based on hours invested and we would earn more at McDonalds. On call is another thing, typically you can triage on the phone and if the patient is having a critical situation the advice is 911 EMS to hospital. If the call is in regard to cath coming out or something a nurse can address you get in your car and hit the highway to that patient. We are paid 50.00 /week for on call and per visit for visits. Weekends or evenings may also include late referrals or hospital d/c's that require immediate SOC or ROC. I have had to drive 160 miles round trip to see "1" patient and make that daily quota of 5-6. We are given points for visits...routine (1 point) SOC (2 points) ROC (1.5), D/C (1.5 ). If clinician must drive 10 miles or 200 miles to see a patient the points are the same. A nurse must make "productivity" that is "30-32" points per week. We are expected to work Mon thru Sat every single week. So? What do you think? Beneath all this...frail elderly many living alone in financially and support lacking circumstances. patients with numerous chronic disease procesess in addition to the acute problem that results in home care eligibility. Good luck nurse...hold onto your hat its a heck of a ride...

if it were a perfect world a hh nurse could work an eight hour shift and see one patient every hour. unfortunatley that is never the situation..a start of care oasis..requires an hour just in paperwork ( at the home) in addition to the reams of additional documentation ( poc, clinical pathway overview. variance tracking. medication list with all meds numbered for reference for the patient , physician notification with orders, contacting any other disciplines you access are indicated, hha poc, writing out your visit calendar and noting dates for recert window etc etc etc etc...multiply this x 5-7 visits a day. not only paper work but crisis ( i recently had an entire family flipped out because mom was "boiling towels on the stove" which physical therapist informed the family was due to possible "appendicitis" because mom had flank pain. i was called and went immediately as ordered to do prn on patient and methodically unraveled the situation , calmed the family and patient. the diagnosis? uti. i obtained a simple urine specimen , calmed the family and patient and went about my business for another 10 hours . time invested: 2.5 hours ! my quota required by my company 5-6 patients a day...if crisis occurs and you miss appointment...continue the day until you reach quota or add to the next day to make quota. . needless to say the treadmill was too fast for me...i had to go contigent i simply could not work 14 hours or more everyday . in the end earning less than i would at mcdonalds flippin burgers. driving? try 86 miles for one patient...then another 100 plus that day to see the remaining..an hour drive to that one:eek: patient and an hour drive back to see the remaining ...:eek::eek:

If I thought it not worth my time or attention...I would not comment on it...

Ridiculous conversation.

Logical deduction! That is what is called "critical thinking" , a nurse/CNA or the dog catcher can surmise this solution. The original contributor to this post is lacking simple common sense.

I agree about engaging patients and families in conversation regarding advanced directives when we are admitting them. Making a decision as important as DNR or specific wishes in the event of a terminal outcome should be done when the patient/family are not in a crisis situation. Emotions run high during terminal events and prevent the patient from recieving the care and comfort they need from their loved ones. We are in the business of life and promoting comfort , what better way than helping patients and families through the process of choosing the way they wish to be treated. :redbeathe

I have a patient whom I believe is a victim of Munhausen by proxy. The patient is not a child but an elder. The patient is ventilator dependent at home, is on tube feedings and is cared for by a daughter. The daughter has cared for this patient for many years at home and prior to that cared for her father who was also vent dependent at home. The daughter has manipulated the patients medications frequently and has caused the patient significant crises. The latest is with holding thyroid medication and as a result the patient going into severe hypothyroidism , and hyponatremia. The daughter then refused to have patient transfered to hospital and instead began adminisitering a teaspoon of table salt vis the feeding tube every 6 hours . The patient has CRF Stage 3 and as a result of this also had anasarca. The daughter has removed medications for blood pressure causing the patients B/P to soar. All those involved in the medical care of this patient know this daughter is intentionally creating crisis with the patient . The daughter spends her time vocalizing her theories and "treatments" to family members and insists it is the medical providers fault the patient is in crises. It is heart breaking to see this patient suffer but how does a practioner intervene in such a situation. APS ( adult protective services are useless) and physicians have not voiced any alarm despite their knowing of the medication manipulation and with holding of prescribed interventions.

You will get "better" with time. Nursing is a monumental profession...we step into the midst of suffering..willingly. We must be the advocate for our patients in a competitive society whose goal is the almighty dollar. I cannot describe what it requires because until you live it no description will suffice. You alone must decide if you can take the stress and are willing to see it through.

At the suggestion of my mentor, I spoke with my unit manager (again) today and told her straight out I was leaving a lot of things not completed. There just isn't time in the day for it all! She suggested if we get 2 more pts they may hire another nurse. I gave her many suggestions such as someone to answer the phone and take off orders, etc. and she said she'd try to get us a charge nurse. While those things may or may not happen, the admissions keep coming. I agree...tell the supervisor/unit manager/DON/ADON/Administrator to put on some scrubs, roll up their sleeves and hit the floor! The unit manager can take off orders, ansewer the phones, make appts etc. The DON can do those skin asessments, change that wound vac and do those dressing changes.Administrator can handle the admits...do the entire head to toe assessment,H&P, write the orders and verify them with the doc, order labs, talkwith the pt and family and even give em a cup of coffee!!! OR...the State can waltz in and start tagging. Maybe remove the facility accredidation for Medicare. Give the State a ring anonomously. These facilitites are the reason Medicare is getting bled dry and the center of our healthcare issues. If your a new grad..it is no place for you to be. Blow the whistle nurse...you cannot be fired, or treated unfairly for whistle blowing. Protect your patients.

My beloved husband was diagnosed with a terminal illness at age 41. As difficult as it was for me as a nurse , he chose Hospice soon after his diagnosis. Hospice allowed him to "live" the remaining year of his life without the stark white walls of hospitals or the constant invasive procedures of attempting to stop the inevitable outcome. He was at home with us and he was as free of pain as was possible. We did not limit his pain medications as would have been done in a hospital. We allowed him to choose what medications he wanted . We had the opportunity to spend the time with him talking about his life and things that he loved. We were able to take a trip together which we called our "second honeymoon". He and I watched the sunrises and sunsets on the Gulf of Mexico. We took strolls on the beach . We enjoyed his favorite meal in a romantic setting that overlooked the Gulf. I treasure the photos I have of that journey and the smiles we shared. He passed away peacefully a few months later. I wanted him to stay. I miss him every day but I am so thankful he did not have to suffer because of my need to hold on to him. My memories are not of him laying in a hospital bed full of IV lines and machines beeping and buzzing. My memories are of his hand holding mine as we strolled with warm sand betwen our toes and watched the sun set.

Can Dankins be used on a diabetic heel ulcer with an eshcar over it? The eschar is split and the heel smells necrotic. The patient cannot afford the Santyl ordered by the podiatrist for her foot. We did get her on an oral antibiotic but how to deal with the wound now? I am using a hydrocolloid to keep the wound moist and loosen the eschar but I suspect this heel wound is deep. I was wondering if Dankins would help decrese the bacterial load in the wound.

In my humble opinion the greatest satisfaction in nursing is empowering our patients in a time of health care crisis and need. Illness and/or caregiving is a major change in the lives of the patient and/or family members caring for the patient at home. Assisting them in learning how to take control over the circumstances and seeing tangible proof when they return a demonstration of your teaching is so rewarding. I have went to do an SOC and the weight of the situation is palpable when a family member or patient has been inpatient and had a major change in physical health. Through the process of teaching and offering support the weight lifts , the family member or patient are then able to begin the healing process and have a better understanding of the disease processes,medications etc. At the end of a cert peroid when I do a discharge Oasis and can state "goals met" and can see in black and white the progress it is so satisfying. Of course we all have patients or caregivers who see our presence as another set of hands and do not accept the responsibility of learning. All in all at the end of a long day those who choose to empower themselves provide the reward to the clinician and make it all worthwhile.:)

A "mold"...you have too much paperwork!

Take a deeeep breath and blow it out slowly....You have passed the "honey-moon phase of those 1st 2 weeks". Now comes the challenges. First, organize visits before going out to see patients. Prioritize according to acuity and difficulty ( family challenges). See those with highest acutity first, eg: b/p issues, wound care etc. See those with pcg issues last if they take more time. At least that is how I do it. I keep a rubber made storage container in my trunk with wound care supplies, cath kits, extra drain bags, anything I may need for visits and I restock weekly.I also keep folders with extra paper work forms I may need. I also keep a file with basic written teaching materials I can give to patients..I give them a copy and keep one for chart. I then note what I gave and teaching I provided. I find organization is the best way to decrease stress.. Each week I update my frequencies and my five day windows for end of cert periods on my schedule for the week that way I am not caught by surprise. The other neccessity is time for yourself. You need down time...do something for yourself. Rekindle your strength....