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I like working with new nurses, generally, because we learn alot from each othee and I get a chance to help them mature into competent, confident professionals. But. What do you do with a young colleague who went from school to team leader of a whole floor (LTC) and is sloppy, at times unprofessional in conduct, lacks finesse in dealing with resident and family behaviors, and worst of all - overly confident and resistant to criticism? I like this one, but it's come to a point where I feel he needs a heart to heart/'Come to Jesus' talk with myself or another colleague, or a disciplinary meeting with the nursing manager. Concerns have been raised kindly before, but it goes in one ear and out the other. I want this person to succeed - perhaps the gentle approach isn't the right one in this circumstance. So - pass on concerns to manager and wait for them to deal with it, or pull the person aside for a serious chat?

This is a difficult one, apparently. Bariatric res, never leaves the bed, doesn't tolerate bed laid flat or feet elevated very high, doesn't like slider sheets because they slide down too much (probably would be less if feet/legs were elevated more, but . . . ). Wants a draw sheet under buttocks only. Tells care aides to help her boost up by leaving side rails down so she can push up on them while they pull up behind her (reaching over rails) on the draw sheet. I reinforce good body mechanics (side rails down, bed elevated, HOB as low as tolerated), with little appreciation. Our OT put a turning sling under the mattress overlay, which the res refuses because of SOB. I'm not sure what else to suggest/do in this situation. I'm responsible for the safety of my team - even if they get frustrated with being told not to comply with unsafe requests.

What sort of certifications are you looking for? I have Advanced Foot Care, Palliative Care (LEAP Core through Pallium), and am going for Advanced Wound Care.

I mean a carry-kit or tray that has basic wound care supplies ready to go, to be brought to the resident room for treatment. It's help to have certain things ready due to time constraints, but all sorts of things are thrown in (including sterile dressings opened at bedside, cut to size and the excess "saved for later") - not terribly aseptic. Ideally I'd like a balance between having the basics pre-prepared and not carrying around a basket of this and that between residents ><.> We do have policies in place that have gone a bit by the wayside. Recent company handover means we will probably be re-evaluating what products we will use and negotiating a new contract (not sure who we use now, lots of Molnlycke products on hand). Betadine mostly for necrosis/eschar. Our community ET support also recommends it for stage 1/X PS on bony prominences (e.g. heels), but I've not found literature supporting that.

Hi all, myself and another LPN will be working on overhauling our wound care strategies. Managers would like us to start asap to get better continuity, although we will further certified in Advanced Wound Care this fall. One thing I'd like to change immediately is the wound care kits used on each floor. We have cabinets to stock dressing supplies, but the portable kit stocked with basics is essentially a generic carry caddy filled with assorted supplies. Any suggestions for a more organized kit system that is cost effective (considering we will need several), as well as suggestions as to what should be stocked at minimum? (Sterile saline, sterile dressing kit x 1, clean gauze, cotton tipped applicators, scissors, betadine, etc). What works best for you/your facility? The wounds we deal with most are: pressure ulcers, venous/arterial ulcers, and skin tears.

I understand you are not bashing, you are educating and advising and I appreciate it. I've been in the field for several years and have never (to my knowledge) made an error like this where a patient/resident was jeopardized. I have a meeting with my immediate super this week and will discuss it again, this time in person instead of over the phone.

We don't have a set protocol for nitro (due to the side effects) and it is rarely administered, so the rx is specific to the patient and usually a one time only order. Yes, I made an error in clarifying the order and should have specified the frequency. Fortunately there have been no long-term effects on the resident and they returned home with no significant findings. Part of what is troubling me is that I'm fairly sure if this had occured earlier in the shift and not at the end of a 12hr night, I would have been sharp enough to pick up at the time of order that the dose was not within usual parameters. Should have been less reactive and taken more time to review and process the order. I posted in part to find out 1) Is there any situation in which this dosage would have been indicated and 2) assuming it was a med error due to poor communication on both our ends and the GP did actually mean to have it spaced out, is there more I should do at this point to report the probable error (given it was reported to both managers and it did not result in injury to the resident) or file it as a learning experience and move on?

Three together. I explained that point to the NMs as well and they both agreed that it may have been an appropriate order and I followed it correctly as stated. The typical protocol is one, wait five min, if not resolved give up to two more q5min.

Situation - resident with cardiac hx presents with severe chest pain, altered heart rhythm (which may or may not have been chronic) and mild hypertension. Dr gives telephone order - "give him three sprays nitro and if it doesn't help, send him in." Clarification question, "Ok, give him three now and if he doesn't recover send him to hospital?" "Yes." Administered, resident presents with dizziness and tremors, then syncope and dropped O2 sats and mild hypotension, regains consciousness but ++ anxiety and increased pain, EMS engaged. Felt I should've questioned the order as the dose was excessive, especially for this age group and may have contributed to the need for EMS. Nurse managers stated all was done correctly and that the physician may have more knowledge on the patient that directed the treatment plan. I still think the order was inappropriate and could've been even more disastrous, but the moment was time sensitive and I didn't critically think the order (the drug is rarely given in this setting) until well after administration. What would you have done?

I can only say that it is the term that best fits the symptom. We are short on geri-psychs and neurologists (well, all MDs, really) in this area and the one in charge of this case isn't particularly invested. I did come across the article you linked. PBA doesn't quite fit - the screaming doesn't occur with crying/teariness/sadness, but it does occur with agitation/anxiety (which is ongoing). The compulsion can be inhibited for short periods, sometimes with self-harm (hand biting), but suppression can heighten agitation. Emotional dysregulation, impulsiveness, poor attention span, and lack of inhibition are also present.

That is painful. More than one? Excrutiating. I've had some "what, really?" moments with some nurses, but nothing like that.

Wasn't sure whether this topic should be in neuro, geri, or psych, so apologies if this sounds misplaced. Does anyone have information on compulsive screaming in adults with either neuro or psych dx in combination with dementia and/or movement disorders? Not "calling out" as we think of it - compulsive, ear-shattering screaming not associated with pain or fear and not associated with epilepsy due to no loss/alteration of consciousness. Able to suppress temporarily with great difficulty, primarily occurs when alone or not directly engaged. Refractory to medical management. Very unusual and perplexing case with what seems to be a rare and difficult to manage symptom.

If she has an iPad, look through some apps designed for young children and/or developmentally disabled, especially those that provide direct cause-effect interaction (e.g. press a button, make a sound or light). One young gentleman really enjoyed a musical app that he could make sounds on (with guided assistance). A favourite was putting on a song and making drum sounds to the beat. Other than that - going for walks/out and about if w/c enabled (full sensory experience) - there are programs for taking these kids on boating and hiking trips, massage (hand/arm and foot/leg) and aromatherapy, ROM, nail painting, reading books aloud, tactile stim like kinetic sand and silly putty.

At our facility, transfer to acute care is dependent on approval of a physician (with some judgment-based exceptions, e.g. traumatic amputation or code on someone who is not a DNR), and the decision to send or not depends on their level of intervention as well as family wishes. I would not be surprised to only receive orders to monitor and give PRN analgesia for certain residents. No STAT xray does not necessarily mean no treatment plan. It sounds like the physician and family decided they did not want to put the confused patient through a stressful ER trip involving hours of hallway time if it could be done by appointment in the company of a familiar face. Any significant change in status between now and the appointment may change the plan.

Monitored for not quite two hours with no change in symptoms, then saw some improvement, and further repositioning resolved it almost completely. Still very painful on lying->sitting->standing. Pain more or less disappeared over the next few days. Mysterious and frustrating.

For residents in w/c's, you would position yourself behind the chair (sitting, standing, kneeling, whatever works), wrap your arms around the rib cage and administer abdominal or chest thrusts, making sure to check the mouth frequently for the dislodged item. If the resident passes out, slide them to the floor and begin chest compressions (no, not a safe transfer, but an injury is less of a concern than a patent airway) as you would for any unconscious adult. The above is what *I* was trained in. If you have not covered this in your First Aid/CPR classes, then you need to find one that does. Maybe your facility could bring an instructor in to do an inservice for all the staff?

Positive reinforcement, frequent check ins, asking how I can help if I have time, finding time to listen to venting/concerns, rewards like ordering food in or bringing coffee, etc. If people feel like they're being heard and that their effort is noticed, that goes a long way. And if someone is struggling, making sure they get access to resources like STD, mental health days, and counselling.

You did nothing wrong. You sound like a conscientous CNA and unfortunately got paired with a patient who has difficult family members. They probably picked up on your newness - it's like chumming the waters for persnickety people. Part fear, part taking advantage of your reasonable sense of self doubt (which is not at all a weakness - I'd rather staff be unsure and ask questions them half-ass it and leave problems unaddressed). You'll meet many more like them. It gets easier as you gain experience and feel more comfortable calmly diffusing complaints. For now, continue judiciously referring to your colleagues for support. Validate any concerns, but reinforce that you're doing your best for the patient, e.g. "Bedpans aren't very comfortable, are they? I'm sorry. If you're in pain I can let the nurse know, but for now let's get you freshened up and in a more comfortable position."

In these cases, it's not typically a late nurse, it's that I receive a sick call in the middle of the night and can't fill it by 0700 (shift change). It's happened more lately because of people on vacation, or STD, and casuals not answering phones. We do have policies about how many shifts are allowed to be declined by casuals per period, but I don't think it's enforced. I love our management team but a little more pressure in this area would go along way.

Medical treatment is fairly well covered, but many families still struggle with expenses indirectly tied to it - time off work, temporary housing near facilities, childcare, travel, everyday expenses going unpaid because of loss of income, etc. And unless you are at the lowest income bracket, you still have to pay *some* - most working people have extended health coverage to help with that, but if your medication costs 10k or more a month, paying even a small part of that can be difficult for low-middle income families. There's always a way. The government handles most of the load - insurance, charities, and community support help with the rest.

Thank you for the reply! She's on transdermal fentanyl and morphine PO which has been a longstanding PRN. The GP ordered generic comfort orders for when NPO but declined to d/c scheduled meds at this time. Swallowing is ok, easy to rouse but increasingly fatigued, confused, with marked generalized weakness. Still asks for favorite snacks on occasion but can only tolerate a tsp or two. Only parenteral admin we can provide is subcut or IM. Most people tend to do well on butterflies IME with regular, frequent admin. I know it limits our rx options but it is sufficient - most res have a predictable palliative course and do not require invasive interventions to control symptoms.

For me, it's the opposite. I'm usually reasonably alert in the evening/night even with poor sleep, but by the time morning rolls around I'm getting 'spacey' and having more trouble concentrating (unless an adrenaline-boosting event rolls around at 0600).

I'm in Canada. Work 12 hr nights, four in a row. It is generally expected that if days is short then the night nurse has to stay and finish a morning med pass. There is no such expectation for days to stay late. I have in the past simply refused and referred them to call our DOC, because I was so fatigued and did not feel safe to stay and then drive the 40 minutes home later. I did ask our licensing body about this, but they werent very helpful. Can I be disciplined or fired for refusing an unsafe practice like this? Not that I would expect it - our management is definitely above average in caring for employees. But is this position defensible and ethical?

MRP = Most Responsible Physician This was on nights, at 2300. We had trialled giving Tylenol at hs the night before and the same pain recurred then, but resolved with repositioning. This time it didn't resolve, hence the phone call. My thinking - in addition to getting some quick relief - was that if I gave her the tylenol and it was not effective, it would be less bothersome to the physician to be contacted at 2300 at the onset rather than later at night. I've had perturbed replies from not doing this (e.g. "The patient was showing symptoms in the evening and you call me at *this* hour??"). Res is doing well now as reported to me. Very perplexing.

This is an elderly lady with a complex history autoimmune disorders (SLE headlining), history of acute on chronic abdominal pain without significant findings, one physician queried mesenteric ischemia, and the symptoms fit quite well. The least controlled symptom right now is nausea/vomiting and we're moving toward parenteral routes for all medications. We are at comfort care stage and have the tools available here in LTC to provide it well for 99% of our residents. With this lady, I'm wondering if dexamethasone may be helpful. I know it's used for refractory nausea especially in the case of malignant obstruction - would intestinal ischemia be an indication as well? Or is there a contraindication? I would expect it to help with the abdominal pain as well, no? We have zofran and gravol on board at the moment, and I'm hoping to get something better in place by tomorrow (N/V isn't persistent, mostly occurs after PO intake).