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nutella

nutella

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  1. nutella

    Hospice case management but less income

    I did hospice case management and now work in a hospital setting again. The stress level was not lower to be honest. The case load was always higher than what they told me when I interviewed for the job, they always expected me to see more pat per 8 h shift, I was driving a lot and out miles on my care and the documentation part was horrific. Also, my whole car trunk was full of hospice and home nursing supplies since you have to be on call for hospice and need to have all kind of stuff available from foley insertion kits to bedpans to pleurx drain kits and phlebotomy ... don't forget an extra folder for death certificates - nothing more annoying than arriving at a house at night to pronounce and not have a form in the car.... The per hour pay was less compared to hospital, the number of vacation days was much more and I liked community nursing. I did not like the constant expectation of taking on more pat or overtime - it did not add to my quality of life.
  2. I have been here since 2003 but I do not post excessively...
  3. As a nurse, I have never refused an assignment based on somebody else's convictions. However, if somebody makes racist comments I will tell them that this is inappropriate, I do not wish to engage in such conversation and that we do not discriminate. I think it is acceptable for people to switch assignments though. The other day, I felt that the family was not comfortable with me because I do not sound "American" enough - they did not say it outright but there were plenty of comments and behavior towards me was very confrontational. So I called my colleague and asked her to see that family since 1. I did not feel that my nerves at the end of the day were good enough to tolerate that shenanigans and 2. I did not want to put up with that. I felt that I would not be able to serve the pat in an effective manner. Luckily my colleague had not problems with that and I told the family that somebody else would come by. If she had not been available I would have done my best but I really did not think that I would be effective and that they would listen to what I have to say. And no - racist do not have the privilege to disseminate their crazy stuff and we all have to allow that because of freedom of speech etc..I am not a moral relativist.
  4. I am not sure why a highly sensitive person would consider nursing????
  5. nutella

    Accused of not giving dilaudid

    First - make sure that you have an MD order that allows you to give only 1 mg because if 1.5 is ordered and you give only 1 mg that sets you up for trouble. They can order prn mild pain and moderate pain or so. The point is to make sure you do not violate any MD orders. Secondly - I would probably try not to take her anymore and talk to your charge nurse or manager about it. Thirdly - if you have to take her - have a witness when you draw it up and administer. It is some hassle but if she cont to say that you did not give her narcotics that will be a problem for you regardless of how crazy or not crazy she is. When pat make a complaint like that, managers or risk may look into your medication administration practice without you knowing - if you have computer assisted technology etc they can see if you are administering and wasting regularly , the times and so on. This is why it is important to have the correct orders for what you do. Unfortunately, there are nurses who suffer from addiction and who will administer normal saline or such and divert medication, which is why complaints are often taken seriously even if this is not the case or the pat is known for crazy stuff. Talk to your manager, try not to take her anymore and if you have to administer a narcotic to her have a witness for your own protection - this is what I would do.
  6. nutella

    Normal Saline as a flush for PEG

    flushes through the feeding tube (g tube or j tube or GJ tube are usually tap water flushes because it goes into the stomach or jejunum and mimics the "normal way of eating and drinking" - using the guts. Sometimes tap water is not consider a safe choice because the pat is highly prone to infections but in those cases they usually prescribe bottled water. If a pat can get all their hydration and nutrition via g tube etc this is preferred over IV because 1. high risk for infections with iv and 2. it is better to use the gut. There are two possible options of what happened I think: 1. the provider who ordered the "saline flushes in the feeding tube order" made a mistake for whatever reason and in fact the order should be water flushes per g tube or N Gtube or whatever tube you have. This requires the pat to tolerate the amount of liquid so residuals need to be checked I guess. 2. the provider wanted only feeding through the tube for whatever reason and the IV per PICC line IV. In both cases, the order needs to be clarified with the provider.
  7. nutella

    RN's are you happy with your career, why or why not?

    Nursing has been a great career for me - I worked in different fields and areas, was always able to get a job and a secure income. I love what I do as well. But - health care in the US is totally crazy right now and nursing itself is a tough job because of everything that is happening with how we finance and regulate healthcare. Plus there is not much trust.
  8. I think it is only partly about money - it is perhaps more about how satisfied you are with your job now and in the future. As an RN you have added responsibilities but also more knowledge and have more job possibilities outside of longterm care. But if this is what you like and you think this will be your future as well perhaps it is not worth for you to go through the trouble of nursing school. Other things to consider is your personal situation, finances (school costs money), you need to have time for school. you could also consider other studies if you just want to get some added knowledge.
  9. nutella

    Difficulty Level: ABSN vs NP school

    Your biggest problem will be that you work 8 hour days. Every nurse I know who went back to NP school worked 3 x 12 h shifts while going to school and many had to take some vacation days for clinicals.
  10. nutella

    DaVita Benefits

    I worked for DaVita years ago - I found their benefits ok - they had some special perks. What bothered me was the frequent on call and the poor baseline pay for that job...
  11. nutella

    Scared.....No Nursing?

    Hi Name, I read some of your other replies as well. I wonder if you are distracted easily and that is what is getting in the way at times. But I need to say that nobody is perfect and perhaps you just have to work on getting a structured routine in place. Example: When you call a provider follow the SBAR - which is a communication tool. Follow the steps on the SBAR forms and have it in front of you when you call the provider. It helps you to go through all the critical steps (situation, background, assessment, recommendation). A lot is about keeping a structure in place in the middle of multitasking and chaos... Good Luck! SBARTechniqueforCommunication.pdf
  12. nutella

    Do Not Resuscitate Order for suicidal patient

    Have you considered that patient usually have to be a "full code" for surgery and usually for ~ 24 h after - after which time the physician should discuss with the surrogate decision-maker what the plan is going forward. So - for you in the OR it is irrelevant if the patient's code status has to be reversed for surgery. Regardless of the document signed 2 days before. As somebody else pointed out DNR means do not resuscitate - patients are still being treated unless they receive comfort measures only. DNR itself is a medical order and if on a POLST you have a portable medical order. But in that case it seems straight foward. He shot himself into the head. The surrogate decision maker asked for surgery. After surgery the physician discusses further code status. The surrogate decision-maker should also discuss with the physician what the longterm results could be - disability etc.. to make an educated decision about how far to go in his care.
  13. nutella

    new staffing laws in mass? CA nurses

    Safe care and high quality care in any hospital - and even more so in community hospitals - depends on the bedside nurse being able to "put everything together" - as we all know, the task oriented workflow creates problems when nurses do not have the time to critically evaluate the information that they are supposed to "hold." A bedside nurse having the time to look at the whole picture instead of running through endless list of tasks can make the difference between high quality care and just about safe care. And things get missed more easily when nurses have more patients they can safely care for. Safe patient care has become a public health problem as care has become more complex. Patient do not just come in for one thing - they usually have a gazillion things wrong with them plus a lot of them also have psychosocial problems, lack of suport, and financial problems but no Medicaid. The argument that nurses should consider acuity is just a tool by the Hospital Association to try to sway nurses from mobilizing the public to vote "yes". And so is the fear mongering - if a hospital closes because of the staffing ratios it was already on shaky grounds financially. Perhaps they should consider to cut back on CEO salaries - just saying... Hospitals will always safe on nurses because they know that nurses do not speak up as a collective (unless they are unionized) and as soon as they make an appeal about "patients waiting and not getting care" nurses will re-consider. But - here is the thing: Public health related issues need to be pushed from above - with policy and regulations. Otherwise nothing happens. Right now there is no incentive for hospitals to fix dysfunctional systems. What does it say about us as nurses ? They ask nurses to go to school for a 4-year degree but then they are unable to actually use their knowledge and critical thinking skills because they literally have no time to employ critical thinking - it is all about tasks. And the over charting to satisfy payors like Medicare takes away time without doing anything for real communication. Anyhow - we need mandated ratios in Massachusetts. Vote Yes - I am supporting Yes although I am not a bedside nurse anymore.
  14. First of all, the cited study Shimuzu et al from 2014 took place in Japan. Secondly, the article has a lot of more information about perception of "death rattle" - as always, perceptions need to be seen and interpreted within cultural context. I think everybody would agree that Japanese culture is very different from USA culture - perhaps USA family perception is similar but one cannot just assume... I am a certified hospice and palliative nurse (CHPN) with experience in acute care and community care - I have taken care and consulted on many patients who are in the stage of actively dying. In addition, I am a member of a professional nursing organization dedicated to palliative and hospice care (HPNA). Anybody who takes the time to review some literature on this topic "death rattle" and professional recommendations will find that naso-pharyngeal sunctioning or "deep suctioning" is NOT recommended because it does not remove the pooled secretions that result in the rattling noise. It does lead to discomfort and can result in injury and even bleeding in patients while absolutely not doing anything for the rattling. It seems that nurses in ICUs have the hardest time to resist the urge to stick a suction catheter in - nurses on medical surgical floors who are more familiar with this natural phenomenon in the dying patient usually do not attempt. Since the rattling noise that one hears close to the throat comes from seecretions that pool (patients cannot swallow close to death) in that area there is actually a simple nursing action that removes the secretions, can be integrated while providing care, and is effective: You simply turn the patient fully onto the side until the head is the lowest point - take the pillow out - place a washcloth under and simply wait few minutes with patient in this position. Secretions run out because of gravity. After that, reposition in 30 degree side and place pillow under the head again. I often see that the head is overextended, which results in the mouth being wide open and it looks uncomfortable. Make sure you have enough pillows... Secondly nurses need to educate the family and each other that "rattling" is a normal phenomenon, which does not disturb the patient. Thirdly, there are randomized controled studies about the effectiveness of medication to dry out secretions and other studies - some studies concluded that medication is not more effective compared to placebos. Current practice is that patients receive scopolamin patches or / and levsin to help with drying out secretions, sometimes patients get a dose of lasix if they are fluid overloaded and the rattling is further down / pulmonary edema. I also usually recommend to make sure patients do not receive iv fluids while they are dying because the body can't handle it and it seems to result in more "rattling". Please fellow nurses - do not stick a suction catheter deep down the throat or through the nose - Yankauer is fine for in the mouth cavity. Instead, position onto the side as described and wait for secretion to run out. If patients build a lot of secretions you might have to do that more regularly but you should repositioning anyways and can integrate it. I have done this numerous times and still do when I see a rattling patient who is dying in acute care. Gravity is your friend....And the best thing is that does not harm the patient. If the patient appears to be close to death (mottling etc.) make sure the family understands that death is imminent. Families are usually relieved when I educate them about the rattling and repositioning. Yes - the rattling noise causes distress in families and staff that is not educated. But suctioning does not help and is usually more for the nurse's own comfort. Repositioning takes more time and 2 people - so I can see why suctioning seems more appealing - but it usually does not help and can make it worse. I have seen patient bleed significantly after somebody sunctioning through the nose or "deep suctioning" while patient is dying - that is even worse than rattling. There are many articles but I am only citing one here: Jancin, Bruce. "Simple measures for dying patients can limit secretions, death rattle." Internal Medicine News, 1 Aug. 2007, p. 16. Academic OneFile, Off-Campus Login. Accessed 19 Sept. 2018.
  15. nutella

    MSN options

    My MSN had a concentration in quality and patient safety. Is there a reason why you are not considering a nurse practitioner program? Management is a crazy job in healthcare, not many jobs in education, forensic???? there are probably no jobs either. Also consider MPH, MBA healthcare administration (if you feel like business).
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