nutella

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.

I have been here since 2003 but I do not post excessively...

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.

I am not sure why a highly sensitive person would consider nursing????

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.

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.

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.

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.

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.

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

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.

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.

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.

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).

IMO step down is the worst - even worse compared to telemetry floor because patients are high maintenance with often dysfunctional situations/ families etc but lack of resources .... ICU is great - I haven't worked in critical care for some while but did in the past - loved it.

How you move on depends on your preference and the support that is available to you. First of all, it is very normal that the first death experienced keeps you somewhat busy - but it should not result in an all-consuming feeling or keep you busy to the degree you cannot focus on anything else. It is part of most nurses work to deal with death and dying as well as after death care in many areas. Personally, I view death as a normal occurrence, something that happens. I have spiritual beliefs that I find helpful. Working as a palliative and hospice nurse means that I am exposed quite often - sometimes it is good to share an experience that bothers me with my colleagues. Sometimes I feel that a spiritual ritual helps me to move on when there was something unusual about somebody's end of life. A lot of people (me included) find it helpful to journal and write about things that need to be processed in some way. It is a good way of expressing the underlying feeling or realizing what is unsettling about an event. If you need to see a counselor I am sure that your nursing school has some mental health services...

The Joint Commission gives examples on their webpage: https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=1518&StandardsFAQChapterId=27&ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword= read especially those points: "7. The medical record must accurately reflect that the lesser potent medication was administered based on patient preference (RC.02.01.01 EP 2). It is NEVER acceptable to administer a medication of stronger potency based on patient preference. 8. Each organization is responsible for determining how such orders are to be entered into the medical record. However, the following is an example for consideration: Acetaminophen 325 mg 2 tablets po every 4 hours prn mild pain. Hydromorphone 2 mg 1 tablet po every 4 hours prn moderate pain. May administer less potent prescribed medication based on patient request per the organization's medication management policy (MM.04.01.01). The policy must be explicit in that such an order is ONLY for administration of a different (lesser) agent, not changing the dosage ordered of the same medication. If the policy allows a lower dose of the same medication than ordered, it would not be accepted as compliant." It pretty clear outlines what the expectations are, what needs to be considered when ordering and administering and what needs to be reflected in the documentation. If your providers do not order medication in that format or do not order medication in a manner that supports the safe administration as well as considering patient choices it would be helpful to bring that up to whoever deals in your workplace with pain medication orders and providers/standards. I also find it helpful to have index cards with commonly used orders etc. to have the language at hand when I have to talk to a provider. Many have a hard time with keeping up to date on what is acceptable as this changes periodically - they might appreciate suggestions on how to write orders - make sure to discuss this with your educator / manager as well. I found that standard order sets can help for populations that have similar needs - in those cases, the work place might consider to add or modify existing order sets to include frequently used restrictions or conditions. It is essential that your documentation reflects what is going on. Example: A nurse complained that the patient is experiencing severe pain not relieved by medication ordered BUT the pain documented was consistently "0" or low numbers. There was no description of pain or pain quality and the medication was only given two times in that shift but ordered prn q 4 hours. In those cases I just wonder....

Seriously? There is so much information that is missing ..... 1. There are clear recommendations and clinical guidelines with the DSM-5 . 2. You can not just look at an isolated "symptom" or "diagnosis" - the question is: How much do any "symptoms" actually interfere with life or keep people from doing what they want to do? You can have "OC - behavior" without it being considered a "disorder" - for a lot of folks it fluctuates as OC behavior / thoughts can wax and wane. 3. OCD can come in a "package deal" - meaning it can be a co-morbidity to another illness. 4. It is important to learn about people's days and how they function because it can give you more information about how anything interferes or if there is something else going on. 5. It is not uncommon to ask family members more information as self-reporting can be insufficient - however, usually the patient who is of legal age would give permission. And it is normal to ask about family history as some diseases seem to "run in families" etc.. 6. It is important to address living situation/ family dynamics. Sometimes people are better off going to a residential treatment facility with more structure and to get a better idea of what is going on. Sometimes not. But it is important to look at the overall situation, which is where social work comes in as well. 7. Medications..... well. The DSM has recommendations for treatment. Medications are not always the answers and something like CBT may be more effective. However, not everybody is able to see a CBT specialist, has access to mental health, or can afford to pay for it. Medications can be "cheaper" and seem "easier" but there are side effects and they might not work the same way CBT does. Most psychiatrists have gotten careful about prescribing medications and will recommend other options first. The main point is that the physician and patient need to have a dialogue and actually talk. Patients should ask for the rational for specific recommendations. Unfortunately, people sometimes expect the healthcare system to cure not only some illness with unrealistic expectations, but also to fix their whole dysfunctional situation around them from family dysfunction to personal dysfunction and to "take care of everything."

Death is a normal part of life and in my job (palliative care) death is a frequent occurrence. I view death as the dying process as something "normal" - granted, in the US we have institutionalized death and society is somewhat removed from experiencing death as a "normal" part of life but it is not optional and it is normal. What is "not normal" is the way people approach the topic "dying" and "death" and the way people often approach this last part of life. Family members and medical professionals can put a person through much discomfort and "suffering" through too many interventions, too aggressive treatments, and transitions in hope to "give him/her a chance" (regardless of the fact that mom /dad is 90 + years old...), don't want to let go, or just want to avoid any "dealing with this" (and hope that the person "just drops dead"). Some people going through the dying process with more discomfort than others. When I am in the room while somebody passes, I silently say a "prayer" that is congruent with my spiritual believes - if there is no family in the room (just me and the patient) I say it out loud. Our team is small but we also talk to each if there is something that keeps us "busy" or if we need to get closure. There are floors who had small ceremonies on their floors when a patient had an extended stay and died under difficult circumstances.

My goals for 2018: - get into shape again. I had shoulder surgery in summer and cleared for exercise. Would like to go back to fitness kickboxing or such but have to start off more gentle... - continue my studies in a PhD program. - gaining clarity over my now part time job - I am unsure how this will work out given that at some point I will have to focus on study related things... - some traveling if I can fit it in...

Is it affordable and their NCLEX rate is reasonable ? That is more important compared to a single professor. Nursing school is demanding and stressful - no matter where you go. Microbiology, pharmacology, statistics etc are all difficult classes for many nurse students. The reason seems to be that students who gravitate towards the science do not necessarily study nursing .... IMO there is a lot wrong with nursing education to begin with and it is probably safe to assume that you will have to do a lot of learning by yourself.

This is a really good reminder that all of us are constantly being "on camera" - I think we tend to forget that there are recording devices everywhere from the hallways to the elevator. Perhaps the OP took some candy and put it in her scrub pockets and that appeared to be "a violation" of some sorts to the person getting a glimpse on the recordings. Or they are just looking for a reason to fire people. Or we do not know the whole truth and more than just gummi bears went into the scrub pockets. Whatever it is - it is a good reminder that everything we do is "public". I would also stay away from passing candy randomly to children who are visiting on the floor - that is something you typically do not do.

My MSN has a concentration in quality and patient safety, which I had chosen because I wanted a graduate education in nursing but not education, management, or nurse practitioner. Here are my thoughts on MBA/MHA : In my opinion, the MHA degree is more or less useless. During my MSN I had two classes with folks from the MHA program (project management and something else I do not remember). I do not think that the MHA prepares people sufficiently for leadership roles that are significant. I know a few nurses who got their MBA and some with a concentration in healthcare, which makes sense to me. All of them are happy with their choice and work in leadership or/and have their own business. It really depends on what you want to do in the future. There is also the Clinical Nurse Leader - which is a graduate degree. And I met somebody who went to law school because she was not so happy anymore with being a nurse - she is very happy now...

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 ....

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 ....