pammyf

Hi Nameste (BTW-I have spent YEARS in India!) I totally relate to you about "hello they are dying....", And as for the glycerine suppositories. Now, that it a GREAT idea! Our hospice is connected to a massive hospital-based center with over 10000 employees. As such, the "Jayco" warriors, as well as the FDA, tend to target every little thing. We try to be very careful to adhere to the fear-based principles of modern medicine and conform to all the appropriate standards of care. As we know, in hospice, when there are times creativity, love, and good old fashioned nursing far outweigh "standards" (not). Butter bullets fall into the category "creativity, love and make it work in the home setting when our patient needs quick symptom management without the frills". Patients come first. Thanks for your support and the glycerin idea! PS Have you seen any articles supporting your glycerin action? I am on a literature quest for my hospice. I am NOT a student (although I am considering an MSN)..

They work well. The thing is the FDA has not given it its stamp of approval. Methadone is well documented to work rectally. But not in butter--although quite frankly unless they have a allergy to milk I cannot imagine it being any different then "surgical lube".If your pharmacy will put the tablets in a capsule for rectal administration then go with it. Some of the higher doses will obviously not work in capsule size, like you understand. When going above 4o mg of methadone I admit they look like monsters. At least they have a cooling effect! I too have used the capsules with pain meds inside but the capsules have to be the kind that easily "melt" into the rectal vault. Cheers.

Story one: I had a patient with some sort of civil war gun by his bed. I requested that his family removed it. I was assured they did, but guess what, he used it on himself. He was a very old man and it was so very horrible for us all and most of all his family. He was alone at the time, thank the lord. We think he could see "the writing on the wall" in terms of his increasing weakness, need for increased pain meds, etc. He did not have a depressed affect. It was hard. Story 2: Another guy years ago (in Home Health actually) who had another civil war revolver --yeah I live in South West Virginia! And he just had to show it to me, loaded of course. I was a little nervous since I had to drive over cow grates and fields to get to the house and I was ALONE. Turns out he used it to shoot deer and then drag the deer to the front step for his dogs to chow down. And yes, there was a carcus on the front steps! Story 3: Teenage Aides pt (about 20 years ago) who was on lots of dope and he had to show me his gun. I was really upset and told him I would never come back until it was locked up. His parents locked it up but not before his dad brought him out to kill a wild boar! I am a rural nurse, and the idea of guns totally scares me and I do not look for such things but they make fine stories:uhoh3: mind you, when in doubt leave and alway, always get your team involved, and if danger lurks then of course you must discharge.

I am certified. The test is about 300 bucks if you join the hospice and palliative nsg association....which is about 75 bucks to join...My work place reimbursed me, and they gave me a thousand dollar bonus. But as far as a raise goes: hmmm....I suppose it depends on your place of employment. There should be some monetary reward. There is the "reward" of solidifying your knowledge base, being up on the newest information etc. I really enjoyed studying for it (maybe for 10 hours on and off total). Good luck.

When I give a pill or two of course I just use lubrication from a water based thing like lubriderm. But if a patient has 300 or 400 mg of morphine or 40mg plus of methadone (they are horse pills!) which requires administration then I think about an easy way to give it! The families where I work are usually OK with rectal administration ONLY if the patient is actively dying or near coma... (we all prefer a non rectal route of course). Ivs are so darn expensive and we try to use oral when possible as well.... SO if you take a little butter and put the pills in it (or crush for huge methadone tablets) make it shaped like a suppository and place it in the freezer then it easily slips in. It is easier then administer 5 or 7 pills in rectally as they get so slippering and families wig out over it. The family can administer every 8 or 12 hours and give roxanol or whatever PRN. The amt of salt is negligible and these are actively dying patients so salt is not an issue. Our hospice has done this for years. Again, this is only in the last days of life and would never be considered at other time. Just wondering if anyone has seen any literature about it....maybe it is our own hospice thing! Thank you for responding!

Works really well in some cases. Remember to always have patient take po prior to first nebulized administration. There is a potential for a very bad reaction so if roxanol goes into the lungs death can and has occured. Copd pts really like it. The systemic effect is 10 to 15 percent thus less constipation and mental changes. Is lovely for helping couphs with the lung cancer pts --and obviously helping shortness of breath! Avoid color roxanol and obviously the purer (mroe sterile) it is, if available, the better.

Have any of you used butter, which when cold molds like a suppository? When a patient is no longer able to swallow, but still requiring larger doses of pain meds, and when IVs are too costly, I use this route. I mix the pain meds such as methadone (for the SRs we do not crush obviously). The family is told to administer every 8 to 12 hours and the patient is comfortable, the family relieved, and the hospice nurse happy the symptoms managed. There may be a first pass issue: ie the oral route goes via hepatic so the pain effect is reduced. The rectal avoids this so the pain effect may be potentiated. On the other hand, it is a valid and cost effective way to manage pain at the VERY end of life (usually only the last few days are when the pt cannot swallow the larger doses and the pain itself peaks) Any takers? I am looking for journals to support this since my work place is asking for more literature. IS ANYONE FAMILIAR WITH LITERATURE TO SUPPORT BUTTER RECTALLY AS A VEHICLE FOR ENDSTAGE PAIN MANAGEMENT

Golly, when you have to deal with a 3d party such as a nursing home, and the nursing home is trying to look good even though they are negligent of pericare, and dump that on as your responsibility it is quite pathetic. Changing a care plan to increase aide visits is appropriate but...I think the nsg home is remiss and they are using you as the fall back so the daughter will not blame them! Your boss/ and IDT should be made aware of this dynamic to reinforce you! ...take a deep breath and realize you were perfectly in the right..... tell me more about menopause brain,,,i think i have it too but I do not exactly know which symptoms you are referring to: the dementia or the emotions!

bummer!! so close but too far! hey, sorry about the red. cannot get out of it! you can pass it for sure after all your experience with it first time around. i know what you mean about the strange questions like cord compression. i think we had the same test! superior vena cava syndrome i have actually dealt with. the very best of luck next time. i think for me the test questions in the prep book helped the most.....pf

Your 4 years should provide you with a great knowledge base in order to pass. I can give you this advise: Use the sequel to the core cirruculum test questions book. There are about 400 question, mostly multiple choice. Take the time it takes to do the tests, place abcd on a peice of paper. Mark the questions you got wrong and study the rational. Note any inconsistency or weak areas. Focus on those areas. For me symptom management and pain management idt issues, eol issues were no brainers because I utilize these principles in work. Some of the ethics concepts (or the definitions) were new to me and disease process stuff i needed to review (not to pass so much as to feel confident going into the test). For some reason they focused alot on mouth care and the questions were twisted and ALS was the disease they also focused on. When I was taking it I felt like it was more of a vocabulary test then a test to measure hospice knowledge. I have not an idea on how many fail it, but I think after 4 years you will do great. The only other thing you can do is pay 30 dollars and do the practice test on line (the test center offers it) and I did this and was pleased I did since the format is similar. BRING EAR PLUGs if you are going to an office builing. My test was in the HR block office, and as it is TAX season it was actually quite noisy. THey did not let me bring in even water or my banana bread so i gobbled it up and went out 2 times during the test for the BR and water. The best advise is: stay calm and have a nice sleep prior to it. Hope you do great.

the Febreeze ritual, along with the lab jacket heist is hysterical! It reminds of the breast feeding years when i would drive down to a lonely river bank to "pump". Lord, what we have to do as hospice nurses! And the milk usually curdled. The only thing about the Febreeze is: the aerosol fumes may be equally toxic as the smoke! But then again, gagging on the toxic smoke (and other not such pleasant smells in such an environment) warrants strong measures. THANKS for the tip.

it seems like things maybe have changed from this interchange. But actually our mission is to help pts. It is just that in hospice we are helping symptoms and the dying process be gentle loving and meaningful in a good way as possible. By negative charting we are, ironically, helping our patients by justifying their continued "stay" in hospice. That being said, when our patients graduate from hospice because they are improved then we thrilled. But usually their "graduation" from hospice is temporary and we see them again within a year. I do not know what the statistics are on the amt of time they are back with us. Perhaps someone who reads this knows the average length of time from discharge to readmission (dx dependent) ANYWAY, to the nurse I am responding to: Our mission in nursing is to continue to help patients improve--but in hospice "improvement" is skewed. I have to make dinner our I can help define this more clearly!

Sounds like a linguistic issue. Patients are supposed to be declining; however minimal the decline might be in some cases.The "iffy" patients are the ones that careful attn be paid to negative charting if appropriate. If you focus on the positive then the chart auditors may see red flags and think the patient is not appropriate for hospice. So lets say the wounds you are healing because of your great teaching and great nsg care. and the lungs are clearing for some reason and on and on. On one hand you want to shout and extol the virtues of your great nursing interventions. you can and should report the positive effects. If the patients dx is one in which the course of disease process will take them down then have fun with some positives. when you have the non cancer dx folks failture the thrive or old age disabled folks use your common sense. if the pt is clearly terminal you sort of have to reflect it. But if they are really boarderline and do not meet the markers then they really should be discharged anyway. We need to be accurate, but in life there is plenty of gray areas....welcome to the joys of charting.

RN golfer, your letter is really, really funny! Hospice nurses are such a kick! I just started viewing and interacting on allnurses.com yesterday. it is informative and fun and educational! I totally know what you mean about sucking in and absorbing the smoking fumes (not to mention the lung issue). I get so grossed out. When ever possible I plan for the smoker families as my last visit. I usually leave the coat or sweater in the car (no matter what the freezing temp is) and then open the window and stick my head out as I am driving off. At one time I just figured I would join them are start smoking again! Stock investments sound ample but GO GREEN.

hi, the ratio of po to iv morphine is 3 to 1. Subq should not alter the ratio since it is going directly into the blood stream via tissue and not thru the gut (thus the first pass issue is naught) i have worked with many a cadd pump using subqu since inserting a picc line is costly (in the old days we could place them ourselves but now the an xray is required to confirm placement) subq is a great option As for how much the tissue can absorb: No more then 3cc an hour on someone not totally cachectic. 2 cc is more managable and maybe more comfortable we have the iv pharmacist mix in very high concentrates: even up to 100mg per cc for really high dosing. go for it.......that being said we prefer no ivs......our opiod of choice is methadone for a base and roxanol for breakthru. keep it simple and sweet. happy hospice. but since this response is from eons ago i hope this helps others

i just took the exam yesterday. it was definitely not easy. Your experience is key to passing. the study guide questions is the most helpful way to study because then you can see what you may be weakest in and focus studying those weaker areas. there was only one calculation for med out of all the questions the study time will vary. i casually reviewed over the last week. maybe 12 hours worth good luck

Morphine is the answer. But you tried to express that there may have been some other factors which were not evidence based which precluded your feeling morphine was what your pt needed. That happens to EVERYONE once in a while. But for this circumstance Roxanol with re-assessment was appropriate. When the rate decreased with, say 10-20mg SL, you may have chosen to direct the family to use q 2 hours (or whatever worked). Another stratagy I have is to think, "if this was me what would I need?" Live and Learn kuddos for caring and asking. Your next pt will be happy.

I hear what you are saying about funerals. After developing some intense and short term meaningful relationships with pts/caregivers, I used to feel I was obligated to go. Its true it feels "right" following thru with the initial grief support by honoring your/my dead patients' funeral. I now only go for the following reasons: my reasons are personal. Sometimes I go because I really like the patient and family and if I live in the same town and am available I go. Sometimes I go because I know the funeral will be sort of a cultural experience. Sometimes I go because I just need a really good cry and church organs and funerals provoke a strong cry reflex for me! I am not such a good crier and so this is incredible therapy for me. I do not go anymore for "obligation" alone because funerals can sometimes really bring me "down" or they are, quite frankly, boring as an outsider. Fortunately we have a terrific bereavement support team and I utilize this. 12 years in hospice is only afforded by maintaining the integrity of my personal space, my values, and emotional connectivity with those I care for, and the ability to "let go" without guilt and the permission to go when it feels right. When they ask I politely and gracefully tell them I am unable. I find sending a card is helpful and meaningful.

I just took the exam offered through the american hospice and palliative board (RN) It was a challenge! I was surprised that the results came through the minute I walked out of the examination room. I am writing to ask if anyone else took it on March 27, and what you thought! I was the only one in Roanoke VA taking it. I was also wondering what percentage of nurses pass this test. Any clues! Oh, yes....I passed! There were some interesting questions on culture. They wanted to know about traditions in the Muslim Faith at death and Native American Indian customs. There was only one question on medication conversion, no questions on Methadone (surprised me since we use so much for neuropathic pains) and lots on disease process. There was a strong emphasis on sudden acute "lifethreatening" events which I found rather odd since in 12 years of hospice nursing I have only seen these events a few times. Lots and Lots of questions which made me think for 3 hours! (the length of the test). There were not that many black and white question/answers. One had to use severel concepts to come up with the correct answer. I would love to talk more about it in this forum since I have no one to share this experience with! thanks

Our hospice will not hire a new grad with less than 1 year. I have been a hospice nurse for 12 years. My experience is that without a good year or 2 of full time nursing your skill level may still be a little shaky. A good hospice nurse needs not fear her own assessment skills since your role is independent. But if you are a fast learner and feel confident and want to do hospice go for it. It is a wonderful job