Larrythenurse

Excellent comment. Indeed, in Oregon there is a specific section in our nursing rules, Division 47, that covers Delegation. Other intricacies include that the RN must individually observe the staff's performance, within 60 days of the initial delegation and no more than 180 days thereafter. And the BoN is very clear that the observation must be done individually for each task performance. So, for example, if in an ALF and the delegated staff is doing insulin on a dozen folks, the RN must observe each one. Now, CBG can be trained, so it does not require as intensive a supervision process. Indeed, for task performance, the BoN has told me that when delegating for G-tube medication administration the RN must observe the actual med being administered; using a placebo or water is not acceptable.

Most of my DD/ MR and physically impaired folks either can't or won't clean themselves. I not only wash 'em, (male and female) I make sure they are well washed! And I do very clear teaching with staff as to what I expect. This can be embarrassing direct- retract the foreskin and clean underneath the member, if an erection occurs either finish the job or return later, clean between the labia, wipe front to back, etc. For some of the staff I get in there and clean the patient 1:1 with the staff observing, then I watch them do it and offer advice on technique. And any time I find a patient with poor pericare I follow up and retrain the staff involved. Having said that, I want to emphasis that I think we as nurses should strive to be holistic, taking into consideration the cultural/ religious/ spiritual/ ethical issues our patients may have and considering these as we offer care. :jester:OK. So much for being the total professional: I hate doing a physical on my folks and finding, how shall I put this gently? Well, as we used to say many years ago in the ER: "Lady in bed five needs her cat well cleaned," or "Gentleman in bed five has a particularly dirty rooster." While we are on the subject- clean those orificees, folks! Wipe until the wipe comes back clean! A final note- when I worked geriatric units and had to help my "little old ladies" get undressed I used to tell them: "Now, if you have something I have never seen, I will let you know." This element of humour helped often helped relax the person a bit. (That is, until undressing a lady who had been a WAC during WWII found some rather interesting tattooed reminded of her, hmmm, let us just call it service to the airmen!) Oddly, I found the older female usually less modest than younger ones. Likewise, the older gentlemen seemed comfortable enough with me doing personal care. It is younger folks (30 down) who seem to me very inhibited with their bodies.

Hi there. I am an RN consultant for DD folks in group homes and day program settings. In Oregon we have a process of formal delegation described in our nurse practice act that defines how we can train unlicensed staff to do tasks of nursing care. The staff is trained to do the task only, not any of the nursing or support details. In most of my facilities unlicensed staff, trained in this by other non-licensed staff, do a lot of traditional nursing duties. These include transcribing orders and administering medications. I don't like it, to be sure, but that is the reality of the situation.

Good for you- we should not only do what we love but most importantly love what we do!

Yikes, sounds like a tricky position for a new grad. I would check your Practice Act to see if this training is covered. Here in Oregon we have formal process for delegation and nurses need to be aware of it. I agree with the comment that having Unlicensed Assistive Personal doing an increasing amount of nurse work jeopardizes the patients, not to mention our professional integrity. However the reality is there are some practices UAPs can safely do, and healthcare is moving toward a more task intensive approach.

What specifics of licensure are you worried about? If you have made earnest and repeated attempts to understand this person's non-verbal communication and determined this is what he wants, his treatment team should come up with a way to support this. Your documentation should reflect a multidisciplinary approach to determining and meeting the client's needs, considering factors of productivity, integrity, safety, integration, etc. It may be that this person's life-style choices are such to preclude meeting certain licensure issues, in which case proper documentation to support this should be used when applying for a variance. I would also question why this person is in a nursing home. Is there really no other community based setting more appropriate for him? Does he also have medical needs?

Good question- I have not yet explored the MAR application in Therap; my agency is still rolling it out. I have general concerns about Unlicensed Assistive Personal (UAPs) giving meds. How much is the RN considered to be responsible for the adherance to non-RN agency training by UAPs? I certainly correct and intervene proactively when I see bad practice... it is just that that happens so darn much! Also- who is doing the actual transcribing of the orders into the Therap datebase? Is there RN oversight in this process?

Great post Brother Nurse! I wear my "male nurse" title proudly. Whenever I meet a teenage male I always ask them if they have thought of nursing as a career option. Twenty years ago none of them had, now I find some of them have considered it. Mike, you forgot one of of the other interesting aspects of a the Murse's life: years ago as a newer nurse I took a three month temp job replacing a charge nurse out on leave. All of the nurses on this unit were female and had all worked together for years and... yep, their periods were in synch. Those ladies taught me more about management than any course or lecture I have ever had!

Here is a story: I was sitting with my mother in the cool clear Medina River in central Texas bemoaning the fate of an English major looking for a job. Mom asked me what I wanted to do. I said I wanted to to practice the ethic of good work, be employable anywhere city or country, be able to travel lightly, make a decent income, and work within an organization or independently. She thought for a moment and suggested nursing. That was 1987 and I have never looked back. Thanks, Mom.

Ouchee. But there are several thing to be done if the person has a potential for this: 1. Ask your MD how necessary the cath really is. Sometimes the person is cathed because of incontinence so try to just d/c it (with all other attendent risks) and put them in Attends instead. 2. If you got to have it, use the smallest lumen possible and underinflate the balloon! That way there is less trauma. (Of course increased ease to pull it out also!) 3. Keep the member as clean as possible! Especially with direct care staff, get right in there and show them how to retract his skin if need be and clean all around the head of the member. 4. This one is my favorites: Hide that thing! Put your guy in a Attends with a couple of pair of underwear and the hose threaded out back. Put his pants on backwards. ('Course check to make sure the line is patent, etc.) Give him an elastic band attached to his pants to yank. If pica is not a risk give him silly putty or other textured material to hold. Put something else in his hand to stimulate him! 5. Make darn sure the thing is loose and not pulling! Consider using KY (with xylocaine is great) on the urethra to cut down chaffing. 6. Make sure hairs are not getting wrapped up and pulled on the tube. 7. Folks, watch out for erections! Men get them naturally during the sleep cycle (and at other times, not always sexual.) If cathed, this can cause great discomfort. Examine behaviorial issues around the incident; could it have been sexually induced?

By coincidence, I have a community based patient discharging with a new one of these today. The Gastrostomy port should be used for medication (and med flushing.) You can also use it to vent air from the patient's stomach and/or aspirate stomach residual. The Jujostomy port should only be used for feeding. Generally the person will be on a low rate (not more than 50cc/hr) continual feeding with a water flush. You will want to get them on a pump, Kangaroo is a common brand. The pump ideally will allow for continuous feeding with water bolus, like the Joey model does. Finally, the "Bal" port inflates a balloon that secures the device. DON'T mess with it. And it is probably best to have the MD explicitly state this on the orders.

Anyone ever develop a medication class for a day program? The program serves developmentally delayed folks who are medically stable and may have the occasional routine or PRN med to take during the day. The agency is state certified as providers but they have minimal licensing standards for medication administration due to low medical accuity. The staff have no medical brackground. Meds would only be in blister packs. Their current written guidlines are barely intelligable. They have asked me to do a training for their staff and I've agreed if I can also write their policy. Now I'm trying to guestimate how many hours this might reasonably take. Training will be for about 30 staff and I'm alloted 4.5 hours. Thanks! Larry

Sorry it took me a bit to get back to you. Thanks for the tips. I had already done most of your advice. So far it is going well. There is a DD nurse program here in Oregon but there are not too many of them. And they are, to put it nicely, not too competent or complete with their work. I continue to work 40 hrs a week with my full time insurance-paying job and have all the private consulting work I can currently handle. Be well! (And if you have any money left over at the end of the year, PLEASE send some to a disaster relief agency.)

Hi there! Great forum here. I serve a DD population residing in group homes in the Portland, OR area. I work full time for a company and make visits to the homes where I do assessments, write care plans and protocols, and teach staff. Recently the OR Dept. of Human Services, Seniors and People with Disabilities Service started to solicit RNs to work as contract RNs for them, essentially doing the same thing I am. Through my contacts I have been offered similar contract work directly from an agency serving DD folks. So, long prelude, but here is my question: What should I charge? And a bunch of sub-questions: Charge differently for profit vs. non-profit? Flat rate for teachings? Fee for delegation? Milage outside of a certain area? Any advice would be most appreciated.