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nutella MSN, RN

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  1. nutella

    Are Nurses Oppressed?

    For years, I rejected the idea that nurses are oppressed. It was based on my own experience (did not feel oppressed) and my understanding. I thought that oppression is something that only applies to the well known marginalized groups that have been experiencing oppression. It was not until I started to work in a community setting and now in a community acute care place that I changed my opinion. I was used to academic centers and never felt powerless. I was mentored by strong clinical nurses who felt as equal partners in care when dealing with providers. A lot has changed in nursing. And what I am seeing now prompted me to re-think. I do think that nurses as a group are oppressed, behave like oppressed groups do, and often oppress fellow oppressed nurses. Ever witnessed report where nurses are afraid of giving report because the next nurse is highly critical and tries to exert passive-aggressive power? This is not an oppression competition where the most oppressed group in the country or world is the only one that can be oppressed or legit oppressed. It is good to understand those dynamics that lead to oppression so we can understand how we are being treated and also how we treat other nurses or people.
  2. nutella

    Case Management Nursing (CM)

    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.
  3. 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.
  4. 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.
  5. 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.
  6. nutella

    A Feminist Approach to the Opioid Epidemic

    OP - there seems to be a misunderstanding about - the feminist point of view/ feminist philosophy and - critical theory and marginalization You somehow manage not only to take things out of context - you mix up stuff to the degree that it does not make sense. It is my understanding that a feminist theory point of view would look at a situation/phenomenon from the view of gender inequality. But feminist theory does not equal a "caring approach" nor does that solve the narcotic crisis ....
  7. To be honest - I think you are going to be fine. I worked in neuro ICU many years ago but I doubt that too many things have changed in that area. The folks who had significant trauma in their head - no matter what -where often intubated and sedated for some while with daily wake ups etc.. Once they have to wake up for real , they would go through agitation/confusion etc..There were many hours I had to spend literally sitting next to the bed because the physician did not want to sedate them in any way and the patient was constantly needing redirecting and such. But it was not the same acuity and craziness that I experienced in CCU. You need a lot of patience in neuro ....
  8. It is absolutely unacceptable to make fun of students. That applies to nursing school as well as CPR courses and so on. I never made fun of other people when I taught first aid. It is inappropriate and cruel in my opinion.
  9. nutella

    "Do you want to live?"

    I agree that there are many barriers to addressing advanced directives in a way that is accepted by patients, their families, the governing entities and clinicians alike. What I want to point out is that when we talk about "attempt to resuscitate" that it has to be made clear that it is an attempt and there is no guarantee that we would be able to restore circulation and/or that the outcome could result in a less functional state, hooked up to machines etc depending on the baseline problems. In my opinion, it is important to establish informed consent - meaning the person understands what they are deciding for or against. There can be a lot of provider bias in the way that it is discussed as well.
  10. nutella

    "Do you want to live?"

    Nurses are the biggest patient advocates.... There is so much confusion and mistrust about advanced directives - good that you clarified.
  11. nutella

    "Do you want to live?"

    I agree that it would be most beneficial to have those conversations upstream with the physician who knows the patient best or most and who the patient trusts. And when something happens and the patients ends in the ER, it is more clear what the wishes are. I have called PCP offices in the past for collaboration purposes and one NP told me "I know I should be doing this - but I see patients every 10 minutes and there is no time for it." Medicare has billing codes now to reimburse for those discussions. This was the most common argument I heard in the past "I do not get paid for those long discussions", which is not true anymore. However, it does not seem that much has changed in general.
  12. nutella

    "Do you want to live?"

    My work is in palliative care and takes place in a hospital. I get that nobody has time so to speak. All healthcare workers including physicians, nurses, aids and others have the same dilemma: More patients with more complex tasks with the same amount of staff or (more often) less staff = more tasks to complete with less time or more tasks than time available. I understand that discussing code status and "options" is time intense and has gotten more complex and confusing. Furthermore, it seems to cause a lot of ambivalence and endless questions about possible scenarios that may or may not happen - which is why providers are not especially enthusiastic when they hear that the patient or family wish to discuss. The fact that everybody - regardless of age and health status - by default is a "Full Code" with the potential for maximum treatments leads to a lot of misunderstandings for patients and their families when they are not aware of this. People need to know "what they are signed up for by default" when there is a chance that they are being subjected to resuscitation because of illness and/or age. There is so much confusion around advanced care directives ! And it gets worse every year I feel because we are adding more biomedical "options", medications, and interventions. The least meaningful "conversations" that I have overheard over time include sentences like "Do you want to live?" "Do you want us to do everything?" "Do you want us to bring you back from the death?" "Do you want us to break your ribs when we jump on your chest?" "Do you want us to do everything or nothing?" "Are you ready to give up the fight?" You get the idea.... I mean, what kind of language is that???? When I asked about the reason for using "do you want to live?" outside of the patient's room the explanation was "I have to be time-efficient and this is what it comes down to. The patient said clearly she/he wants to live - that means full code because we will try everything to make it happen." To be honest - I was speechless. I totally get the time argument and with effort I can follow the "logic" but the patient for sure did not understand based on this conversation what resuscitation means. Or the implications. Or if this is actually congruent with the patient's values /preferences/ wishes - because the physician does not know that without asking other questions. Today, I also listened to this podcast that is about this kind of problem - I can highly recommend it : Geripal Podcast Live with Laura Petrillo by GeriPal PodCasts | Free Listening on SoundCloud Do your physicians/NPs/ PA use any specific format to discuss code status and advanced care planning?
  13. nutella

    Books for a New Hospice RN

    Hi - I think it is normal to be nervous - home hospice or hospice in the community is so different from most other nursing!! I really liked that we had standing orders for all our patients, which gives the hospice nurse some discretion on what to order and recommend and also for the family who is being taught to take care of their loved once. Generally speaking, I think that it is much easier to keep a patient comfortable at home with hospice as opposed to acute care with comfort measures only because even though the goals are the same, acute care is the worst setting for that to happen. Nurses and physicians and everything else is set up and geared towards extending life and the lack of experience with CMO /hospice care makes it much harder to get good symptom control... I used so many skills in home hospice including accessing VADs, inserting foleys, wound care, teaching to patients and families about primary care and medications, and I also have done a fair amount of nursing care hands on when this was needed. Hopefully, the organization has a good orientation program and you will feel supported and like home hospice!! One word about the documentation: There is a huge amount of documentation nowadays for hospice - all on the computer. Admissions can easily take up to 4 hours with everything including the initial paperwork, assessment, teaching, documentation. The documentation to satisfy Medicare is interesting because it consists of a lot of checkboxes but I found that to actually help other team members understand what is going on and what my plan is, I needed to write a narrative in addition. The downfall of home care and home hospice is when nurses do not document right away or right after the visit at point of care and hope that they will have time later. This hardly ever happens I found because there is always the call you get from the family or the office to do an extra visit or to pronounce a patient etc.. First I was not too eager to use the laptop in the home or facility, but that changed once I figured out that documenting at point of care was really to my advantage. To make my life easier and my documenting faster, I got myself a computer mouse that I liked and a small mouse pad and would use the computer in the homes as much as possible to enter data right away. Between visits, I typically finished the documentation and narrative in the car before driving to the next visit. Once I stuck with this routine, I was able to finish all my documentation and visits within the normal work time - the problem is that many hospices hire you salaried knowing that most nurses struggle with the documentation piece and always end up working from home for several hours. Admissions I found difficult to complete in the home and on the road because of the sheer amount of work to do but lets say I would admit somebody to hospice and have to do acute symptom control as well and teaching - I would usually stay there for a while until patient is comfortable. In those cases, I found out that setting up shop next to the patient with my laptop was really helpful in getting the documentation process started.
  14. nutella

    What Has Happened to Hospice?

    yes, sadly that seems to be the trend right now. Quantity of patients over quality. The same with productivity. I was hired for ~ 18 - 24 patient CM because some of them were palliative with one visit per week. But when you have all hospice it is impossible to do a good job especially when you have several who are actively dying and require daily visits or extended visits for symptom control.
  15. nutella

    Hospice car

    If you have enough space in your sports care for all the supplies.. if you live in a winter area it might become a problem in winter if your car is not that good with snow. I am not sure that I would have wanted to park a sports car in the trailer parks.
  16. nutella

    Books for a New Hospice RN

    Congratulations! Are you going to work in the community? Consider a membership in the : http://hpna.advancingexpertcare.org/ Essential books - which I have used and continue to use: HPNA 978