nancynurz

Just need to plunk down my 2 cents here :) Any and every person who is breathing meets the DSM-IV criteria for SOMETHING-- night terrors, various forms of insomnia, nicotine addiction, caffeine addiction/ abuse, dyslexia, dysgraphia, sibling rilvary, phobias, fetishes (I admit to a serious pen fetish!! Also veins. I do stop to admire a total stranger's veins-- never stooped to actually palpating yet, just coveting them for my next lab draw orders LOL). Some of us just have more visible "issues" than others and quite frankly, I'd rather work with someone who's been labeled and treated than someone who has the symptoms but is in denial (I'm sure we can all conjure up the OCD or Narcisstic Personality supervisors we've had). I'm adult ADHD (at least the adult status has come thru age alone other people I know would debate use of that title when referring to me).

Doesn't the CMS stress use of objective observation on the OASIS? How many patients tell you "Oh, I can shower juuussstt fine honey" but when you ask them to show you how they get in and out of the tub, they can't lift their leg over the edge?! Was she able to tell your supervisor exactly what you didn't ASK her? You are per diem, why not just refuse to work with this patient? You are not obligated to service a patient that is unsafe unsupervised due to environment OR noncompliance. If the agency wants to keep beating their head against a wall, you don't have to offer your noggin! This is why I write books on some of mine; I include lots of juicy quotes to support my observations. Saved my rear many times and my old agency had been named in a lawsuit for "abandonment". I was a supervisor at the time and I documented EVERY message this person left, right down to the last one where we were told we were "fired-- I have another agency coming in now" (not a news flash as I worked my fanny off to link her). The attorney reportedly read my last few communication records and apologized for wasting our time. Now ask me if I got a bonus for this :rotfl:

If you want to play it low-key, what about the old "It takes two to argue" approach. If she gets absolutely NO response other than "Thank you for your insight; I'll take it into consideration" it takes the power and control from her. You have acknowledged her opinion and you didn't lower yourself to obnoxious behavior. Kind of like when your older sibling teases you; without any response, they quit. It will frustrate her to no end if you brush it off like a pesky fly. She can rant, rave, fume, stomp and scream but if you don't give a response (not even an eye roll or a grimace, gotta think your "happy thought") you will watch her deflate. She flat out admits that she likes feeling powerful and manipulating things . . .

Not impressed by the "cannabis dependence" implications-- this is a psychological dependence and no pill can alter your belief that you need it BUT I wonder if it has any potential for AIDS and cancer; maybe even pain management. As for weight loss WHOOOHOOOO!! Not only could I use a tweak (if I lay off the fast food grab and run lunches, it would help LOL), I have many DM II patients who'd benefit from this. The cost of obesity, smoking and drug abuse is pretty high, even if you just consider the loss of life from accidents.My aunt was killed at the age of 15 in a MVA where the other driver was intoxicated. Not legally drunk but no doubt her reactions were slowed from the ETOH. It seems our society wants a magic pill to take the responsibility off our shoulders. The pill may work in scientific studies, but what can we do about continued poor decision making? With all I've seen, I still can't manage to quit smoking! I'd want to see the "fine print disclaimer" before I'd take this myself. As a friend used to tell me, "Someday they're going to find that saliva causes stomach cancer, but only if swallowed frequently and in small amounts!"

Call your state ombudsman. I know there are times when the nursing home has to take him back. They cannot discharge him without making arrangements for further care needs-- your dad was dumped! If he is not doing well and home health can't come out due to lack of physician coverage, you can always go back to the start and use the ER. The home health campany was not supposed to accept the admission without confirming there was a primary care physician to sign their orders for service. We NEVER use the facility doctor unless an appointment has been set up to see the primary or for a visiting physician. Depending on the type of MRSA and the teaching that was done for you, the family, you are all at risk of infection! You should be able to find the number for the state hotline on his facility paperwork.

The "sweet" elderly and blind IDDM tells you that they used to work in a funeral palor and "see" (OK, here it comes . . .) dead people. Not only are they visible, they are audible. I have seen too many things to discount this, but on the next question, I discovered they "sometimes" give commands for violent acts. Turns out the doc missed a history of mental health treatment for "anxiety"-- treatment was with Zyprexa. Don't forget that their food is "poisoned" at times and adult day care is out because "people talk about me". Guess it is a good thing I'm a psych nurse!!! No current risks and very involved family (thank goodness) so referrals are being lined up. How about the open for a "venous stasis ulcer"; stasis dermatitis is soooo bad there is no visible wound until the third visit. On plantar surface of the heel and the pt swears the doc never looked at the bottoms of their feet!!! You want an odor story . . .

This has always been difficult for me. I can understand the high number of substance abusers in psych-- if you have the choice to experience side effects like blunted emotions, weight gain, diabetes, muscle stiffness, tremors, drooling, etc., or your can get high-- I understand the choice some make. Some patients are flat out lonely and sadly, their hallucinations are company. I have seen patients become functional but they are then able to recall severe abuse or just plain see how little they have accomplished in life. They prefer to be lost in their illness. Think about the smokers who carry their portable O2 or smoke through their trachs, the diabetics who want insulin rather than change their eating habits, the morbidly obese who want the CPAP & refuse to admit their weight causes their apnea and joint pain . . . I think everyone is negligent with personal responsibility for their health in some way; just some are more obvious than others. You do your best to teach and then support them. I've seen some patients make complete turn-arounds, you never know when kindness and a non-judgmental front (no matter what you may feel inside ) may make the difference.

I currently work as a behavioral health home care nurse and I entered nursing in a communtiy mental health center. This was pure luck-- single mom, new grad, 8-5 M-F, on-call q6 weeks and all major holidays off. Because it is a specialty, I started out making almost $4/ hr more than a friend who worked 12 hour shifts in the ICU!! As a nurse case manager, I had the best of both worlds. I had to help consumers with securing and maintaining benefits, create budgets when the agency was the payee, shopping, attend appointments, socialization-- only I could also carry the Decanoate and syringe with me to admin in the home. I filled weekly med planners, ordered meds, filled med packs for daily to twice daily drops, completed health assessments, behavior mod, symptom management groups, did teaching on health conditions and the impact on mental health, and tons of dual diagnosis stuff. The treatment teams functioned like an extended family and most of my interactions were one-on-one. I get this in home health too but less of the social work function. I also worked in a crisis center and when we were short staffed, I did the entire assessment-- RN & SW. I could diagnose (of course with the doc's review and signature) from the DSM and even got trained to complete involuntary hold orders on my own assessment. Many of the SW would tell me they wished they had gone through nursing school-- wages are incredibly low for an MSW in my area. Some of the things I hear make me wonder about the future of humanity, but most of the time I wish I could write a book about the things my clients do/ say!! If you like working with AoD, you can obtain CCDC certification without a master's degree. I enjoy psych nursing and you couldn't pay me enough to be stuck on a floor running from one end of the hall to the other-- been there, HATED IT. I like being able to learn about my clients and just know when something is wrong; you also have time to work with a weakness and turn it into something with positve outcomes. You also learn to appreciate how good your life is. When I get caught up in what the Jonses have, the next day, I see how little the Smiths have to work with.

I started working home health on weekends and finally took 1/2 days on Friday-- there is little hope of contacting doctors for anything not considered urgent outside office hours. Plus, recerts can become a hassle when they fall outside your work days. However, visit nurses are in high demand during these times. For a while, we would "co-case manage" clients; what you can't catch, your partner can. JMHO

The longer you stay in the hospital, the more risk you have for noscomial infections. Plus, I know I just plain feel better in my own home and on my own schedule with my own food :)

I knew about the pineapple reactions, but the tomato/ salsa thing was new. Hmmmmm, I had a horrible reaction to one brand of salsa but thought it was justsome odd spice. About 3 years ago, I put on my gloves, took them off and had this burning ache in my hands. After a few hours, I had welts that itched and my skin sloughed for a week! Someone told me that the alcohol ahnd gel predisposes you to a latex allergy-- anyone else hear this? Don't use lambskin if you are wanting protection from HIV. They sell vinyl condoms (at a huge price hike). Can your nursing school get in touch with a Litmann rep? We got a student discount on ours.

Hooboy! I have no idea where I got SN is primary from :imbar I've had it placed in my brain and gold-plated, so now I've gotta train myself back out of it! Even the Palmetto GBA manual CLEARLY states: "The HHA enters the ICD-9-CM code for the principal diagnosis. This code must be the full ICD-9-CM diagnosis code, including all five digits where applicable. When the proper code has fewer than five digits, it is not zero filled. It may or may not relate to the patient's most recent hospital stay, but it must relate to the services the agency is rendering. If more than one diagnosis is treated concurrently, enter the diagnosis that represents the most acute condition and requires the most intensive services." Sorry Monica-- I've seen that passage tons of times, yet that mental block is still there. It took a year before I remembered to use N/A for the therapy MO item on my Medicaid patients and a good two years for the skin lesions.

http://www.cms.hhs.gov/oasis/usermanu.asp This is where I get my information. It states in the manual that nursing takes precedence over PT, you can show it in black and white. There is also a list of State contacts for OASIS questions. Most states offer OASIS 101 training; very helpful to be trained by the same people who audit you submission errors :)

If nursing is a skill, the nurse has to "complete" the OASIS and the primary diagnosis is the one driving nursing service. Order for skilled services by priority are: SN, PT, OT, then ST. PT can recert and be a primary skill. OT can be primary after SN &/or PT discharge.

I wan't diagnosed until 6 years after I got my BSN and passed the Boards. I am able to multi-task better than I can focus on one task, I can bounce from one crisis to another and fill more than one role at a time. I've done community mental health and home health for years as I HATE the structure and confinement of facility based nursing. I found that because there is so much to learn in a limited time, I didn't have time to get bored and foggy during class. I was also the single parent of an infant/ toddler with severe ADHD (I swear he had it in utero) while I went through school. It can be done and if you define your weak points, you may see they are strengths if you look from the right point of view. My impulsivity has been trained into "quick thinking" and I do great in crisis situations. Hyperfocus has become an ability to dig into a patients seemingly unrelated complaints until I get the puzzle together. I used to be bull-headed, now I'm a "strong patient advocate." Try the book "You Mean I'm Not Lazy, Crazy, or Stupid". It can really help you develop insight and change your negative beliefs about yourself.