scribblerpnp

Just to update. I did talk to the director, who was mortified and agreed that this was inappropriate behavior. I did find out that this nurse was new to Hospice care (worked less than 6 months). Next thing I know, I find out that she called the family member and told him that it would be better if they waited a year until they went out. Phew! Hopefully this sounds like she got some much needed re-education. I know that in hospitals, this may happen, but Hospice is different. The director told me that direct family members (i.e. spouses) are considered as much as the patient as the dying person is. So she assured me I wasn't over-reacting in being upset about this. So sad. With Hospice, you anticipate the staff to help you grieve for your loved one in an appropriate manner, not aid you in dysfunctional behavior.

What type of clinic will you be working in? I work in out pt clinic as a PNP (but still do my own nursing duties). We don't do IV's or blood draws. The most invasive procedures we do are st caths, IM injections (vaccines), glucoscans, and maybe an I&D of a small abcess. I have done all of these on multiple age groups, and can say that 90% of the time the kid isn't upset by the time they leave the office (giving out treats helps a lot, as well as being very speedy). And some things we provide education on: Development (physical and mental) of your child/infant Basis child/infant care S/S resp dist S/S dehydration Care of teh child with a cold and common peds illnesses Dietary needs Prevention of illness Yes, there are going to be kids that have severe stranger anxiety and who cry the entire time they are in the office, but it is the minority. And I have seem some 16 year olds be more whiny and PIA with vaccines than a 4 year old- once we had to have four people hold down a 16 year old to give her her Gardasil vaccine (!!!). The MOST frustrating part of the job are parents who are either high strung or who aren't providing their best care to their child (you do deal with CPS). As well as bratty kids who aren't behaving appropriately and who act out while the parent just sits and watches. Most peds nurses (who are honest) will admit that SOMETIMES and to SOME PT's, deep, deep down in your Bad Place, you enjoy giving a shot now and then to an onery kid. As far as critical- I have seen it maybe 4 times in 6 years. In Out Pt, usually you don't code people. Those critical situations were kids in resp distress who were sating about 60-70 on RA and were put on O2 while we waited for the ambulance to come to take them to PICU. There are quite a few threads under Peds concerning out pt clinics, try looking around there for some more info. You aren't the first to ask this question.

If you are interested in taking pictures of babies as part of post mortem care, there is an organization set up for free pics. . You could register as a volunteer for your local hospitals. Now I Lay Me Down is very reputable. http://www.nowilaymedowntosleep.org

I thought it sounded like adenovirus, but that could be the peds person in me!

Since developmentally it appears she is an infant, I would stick to trust vs mistrust. At this time it looks obvious that she will never advance through the second stage. By assessing her as a toddler, she will definitely fall short, though she has obtained the highest developmental level she is Traditionally trust vs mistrust lasts the first year of growth, and it sounds like your pt is in that developmental age group.

In general, you can give ear drops to children under 1 year,. Was there a specific medication you are referring too?

What about inpatient Hospice? The two local to me have massage therapists part time. I would think being a CNA and a massage therapist would be a plus for them. But not everyone is cut out for Hospice. Just a thought.

Chocolate milk and rice crispies cereal!

My main concern is the time frame. I wouldn't think so much about it if it were 3-4 months from now, but two weeks after the death seems a little skeevy to me. You have to wonder about a woman who is willing to go ona date with a man two weeks after his wife's death. It does bring up the idea that her intentions may not be honorable.

I'm having a friend (who works at the facility) get me the policy. If there isn't one (and there should be), I'm going to write a letter addressing the lack of policy and asking a policy be written as well as a yearly inservice and inservice for all new employees. So if any of you DO have a policy where you work, I would be greatly indebted if you could post it here or IM me with it. I would like to find HH with actual policies to include in the formal complaint as examples. I would be suprised if there isn't SOMETHING somewhere that addresses this (either in a policy or employee handbook), as I am sure it is not uncommon for Hospice families to have trouble detaching themselves from the nurse relationship due to the extreme closeness that can develop. And this is where the professional nurse is responsible for making that transition occur in an appropriate manner. And no, it might not make her go away (especially if her motives are questionable), but it MIGHT keep it from happening to someone else. All I can think about is that I know this type of thing is not appropriate because I am a nurse, but what about the families who don't realize that this is not a good relationship to continue? I would think that teaching the nursing staff about the letting go process that families must go through with their Hospice relationships after the pt has passes would be something that is taught and reinforced. ANd at the two major hospitals where I have worked (pediatric and a psych) there WAS a policy and it was definitely reviewed during orientation as well as in the employee handbook. There hsould be some kind of structure in place to protect those grieving from possibly being taken advantage of or developing inapproriate attachments. I DO know that this Hospice does have a policy that family members of the dying pt may not volunteer at Hospice until one year has passed from the date of death.

Let me start out by saying that I am a HUGE proponent of Hospice and the Hospice philosphy, and I am sure that my recent experience is FAR from the norm. But I still feel the need to share as both an education to others and as a way to deal. Recently I have had a close family member die while in the in-patient services of Hospice. During that time she and the immediate family received the best of care. The husband of the woman (married for 45+ years- seemingly happilyy) is obviously going through a dysfunctional grief process (AEB recent events). The husband became very close to the nursing staff due to the length of stay (approx 60 days). After the wife's death, the husband had a very strong need to reach out to one nurse in particular for comfort. Here's the cincher: Within less than one after the death of the spouse, the Hospice nurse (single and 20 years younger than the new widower) gave this man her home phone number and agreed to meet with him for dinner and a movie on a weekend evening to "talk" (about two weeks after the spouse had passed). Hmmm, sounds like a "date" to me. OBVIOUSLY this is a no-no. I have made the director aware of the situation and am hoping this RN receives some re-education and I plan to continue to go further if the RN continues in this behavior. Also obviously this has caused family conflict at a time when family interpersonal relationships need to be at their most open. So, what policies/in-services does your Hospice facility provide to the staff about boundaries and appropriate termination of the nurse-pt/family relationship and these types of situations? It totally sucks that I have to deal with this now too, as it was totally unneccessary. What sucks even more is that I will never forget it, and it will always leave that sour taste in my mouth.

Libra and Peds all the way. I also teach nursing and some of the most common statements students make about me is that I am extremely fair- Very Libra-ish I think

Good luck for your endeavor! What our school has found to be the biggest problem with grants are that as a faculty we are understaffed. Barely enough people to teach and then grant-writing gets moved to lower status because you can't do everything. Also a lot of grants focus on giving money to schools with low NCLEX pass-rates (which isn't our trouble) or schools who are willing to do some type of research related to the grant- and again- faculty who are overloaded teaching don't have time to do research. I don't have a lot of advice to give other than finding another local nursing school who has an awesome tech dept and see what they use.

Thanks for the clarification. I would think those two things could be easily managed in a single time slot. SO def sounds like a money only issue. The main problem I get that deals with 1+ issues are if they are completely unrelated. I have lots of parents coming in for sick visits and "by-the-way" wanting to discuss their child's overweight issues as well. NO go for me, that is a separate appointment altogether because of the level of teaching and time it takes to talk about diet and obesity. Same with parents bringing in their kid with a cold and wanting them checked for ADHD.

Yup, no big back strain from lifting those 16 lb babies!

I will warn you that older infants and toddlers can be the worst pts to assess! With a toddler, go in the room at first and completely ignore them and don't get close. I start out as far away as possible and talk to the parent. If at all possible, let them sit in the parent's lap and have the kid hold your equipment before you use it on them. Don't go straight for their head or chest. That is their center and they are very protective of it. I start listening to heart sounds with my stethoscope at their shins or feet and move it up to the right place. Sometimes demonstrating on the parent first can help (with the older toddler) Also make lost of funny noises to distract them (or bring in a new toy for them to play with while you are doing your assessment). I like to do animal sounds while I'm listening to them because then they look at ME and not what I am doing. Save anything that could potentially hurt until the end so you can hightail it outta there right after. And in infants and toddlers you usually want to listen to the HR and RR for a full minute when doing VS, otherwise you can get some strange numbers. Also, you might want to get a pocket-sized bubble soln and wand (or a pinwheel would work too). This is great for distraction AND for getting the preschoolers to deep breathe when you are trying to listen to lung sounds. It also is great for doing IS for the younger kids. I love bubble soln and would be totally impressed by a student that showed up with it on the first day to use for the above reasons. You might want to get more than one because the kid might not let you have it back though! One more thing, in peds a good developmental assessment is just as important as a physical assessment. Make sure you have a good cheat sheet that goes over important developmental milestones from birth to 5 years of age. Oooh, and one more thing, kids don't circle the drain like adults, they will crash and burn (upside is they also improve faster), so keep a close eye on those resp distress kids (it is RSV season).

Maybe they want two appointments because the time that would be necessary to cover the two issues appropriately would take up two appointment slots? If it would make a 15 min appointment go 30 minutes I could see why the office would want you to schedule two appointments. And two dx versus one does not equal a higher code for the most part. The diagnosis doesn't really matter, the level and procedures determines the cost. Sometimes seeing a pt for more than one thing would increase the level of the visit if it means that you did more stuff. But often not enough to justify the time spent with the pt. For example, if I see a pt with an ear infection and it takes me 15 minutes, that is usually a level III. And charges for that visit would be say 60.00. If the same pt came it with an ear infection AND pneumonia with wheezing (1st occurence), I could check their pulse ox, administer a breathing treatment, teach them how to use an inhaler plus everything else I normally do. This level of care usually takes 30 minutes and would be coded as a level 4. Some ins won't pay for pulse ox or inhaler education or neb tx in out pt, so I am out that money. The level 4 code would increase to charges of maybe 80. So in that 30 minutes I have lost 40.00. I could have seen two level III at 60/each for a total of 120, but I saw one level 4 for 80. Maybe someone else could explain it better, but this is the easiest way I could explain. Sucks for you, but I can understand why the doc wants two appointments.

WIth flonase and nasonex, the instruction packet actually states for the pt to lean forward with the head bent downward and to point the tip of the nasal spray bottle towards the ear

Thanks for the great information! I really appreciate it. Now she is on cont of 40 with q15 bolus of 20. Conc is 50/ml. The percent increase was an interesting read. The hospice where my mom is is not following that but increasing usually by 2 mg at a time. Truthfully this seems to be working well for her, so I have that to be thankful of!

I've worked child and adolescent psych as well as adult and I liked the child/adolescent better. Mainly I do better with peds because I have more empathy/patience. With kids, usually it isn't their fault, they have had a traumatic experience due to some adult screwing them up in one way or another. So I don't have any anger issues towards them like I would have with the non-psychotic adult psych pts. (The PARENTS on the other hand..... but they weren't there that much at least) Psychotics I am OK with and can do well with the empathy, the drug abuse, gen depression and bi-polar or personality disorders I don't care for much. The major downside with peds is you can see them in some kind of cycle that is difficult to break and how at times it feel slike they don't have a chance of ever being normal. It is hard to D/C them back home in some cases putting them in basically the same environment they were in prior to admission. I did work on a teen rehab unit, and while some went back to using, I am fairly confident that it did work for many. One of the grads is now living on her own and going to college, so that story so far has a happy ending. BUT at the same time, they are still kids and still need kid activities. So it was nice to be able to offer then some sort of "normal" life and stability while they were inpt's. But often times I worried or thought about them post D/C more than the adults. It isn't for everyone. The biggest + for peds/adolescent psych for me was the increased ability to empathize.

Blows my mind that this student, who was apparently in the early stages of a nursing program was hung out to dry by the instructor. Really, how is this supposed to be a learning opportunity with no instructor to reinforce the lessons? I've taught at three sepparate institutions from ADN to BSN accellerated, and I've never heard of leaving a student alone for long periods on the floor unless it was the semester or quarter prior to graduation. I wonder if this instructor's dept chair realizes that this is going on? Sounds sort of fishy on the instructor part. But then again, not how I was taught and is not how I teach. And I agree to that to an extent we don't prepare our students for the real word, but with 8 -10 students, two pts each (totaling 16-20) that I'm responsible to make sure care and meds are given to, it is no wonder that they don't get it until orientation. though they certainly see ME multitask and prioritize (i.e., no I cannot watch you give your scheduled zantac yet, I've got a 8yo post appy who needs his morphine!)

Ouch! What a terrible teacher! I'm so sorry, but that was very unprofessional. Student nurses are responsible for their practice, but as an instructor, they are still working under my licsense, so you can BET I'm not leaving the floor. Besides, how can you teach your students from the cafeteria or other department?!?!?! During an 8 hour clinical, I even bring my lunch and don't leave the floor (students split lunches) so I am always there for my students. This type of instructor behaviors shouldn't be common practice in a nursing program, and we don't tolerate that kind of junk where I work. Anyway, the origonal student will one day figure out that you can't be everywhere at the same time. It just hasn't happened to her yet. Still, VERY frustrating for the staff nurse!

Any instructo worth their salt would see through this in a minute. I can always tell when my students blatantly copy a care plan from a book, because it isn't individualized to their pt. And when this happens, they have to re-do it. Usethat stuff as a guideline, but your care plans should be as individual as your pts.

Thanks for your reply! Now she is up to 35mg/ cont per hour with 15mg bolus q15 min. I imagine the bolus will increase over the weekend, as one or the other goes up about every 2-3 days.