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anashenwrath ASN, RN

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anashenwrath has 7 years experience as a ASN, RN and specializes in Hospice.

I am a Registered Nurse, ADN, CHPN, living in Cape Cod and working in Hospice. Beginning to look into moving into an NP with a concentration on gerontology.

anashenwrath's Latest Activity

  1. anashenwrath

    Asymptomatic in SNFs/ALFs?

    Hi all, Hospice RN seeing COVID+ patients exclusively. So far, all my patients have been at SNFs or ALFs, all are geriatric with lots of comborbidities and usually dementia. One thing I'm noticing is how mild symptoms seem to be: mild cough, a few days of low-grade fever, poor PO intake and increased lethargy. I've only had one patient that needed supplemental O2 and one who developed really significant pain (she had a hx of chronic pain and I think the virus just amplified it). Don't get me wrong, these patients are still dying super fast. Usually within days of coming on service. I've had to move my "actively dying" goalposts, bcs the s/sx I usually look for for active dying aren't there. People are still rousable, maybe even eating a little bit and then the next day they are gone. I read an article about that SNF in Washington that had that terrible outbreak, and it said most of their patients were asymptomatic. Is this something others in LTC are seeing? It's hard bcs I have so many families who are reading about these distressing symptoms, and then when their loved one isn't experiencing them, they start getting hopeful that it means they might recover. It's heartbreaking. I feel like having more experiences to speak to will help me support them.
  2. Hi all, hope everyone is taking care out there. I am a hospice nurse, so normally have a mix of home patients, SNFs, ALFs. My county has a little under 1,000 positive cases; we are in our surge, not yet peaked. We hadn't had any confirmed positive cases at my hospice, but there was recently an outbreak at a nursing home and my company asked if I would see patients in this building and any subsequent positive cases. Essentially, I'm the "covid" nurse for the time being (no, I'm not seeing my routine patients at this time!) Any other visiting or hospice nurses in my situation? I am having kind of a hard time bcs I can't really do anything bedside. I use the facilities equipment for vitals (but can't always find it), and I bought a very crappy stethoscope that I can disinfect after use. I carry a small pile of recommendation forms in a clear plastic bag that I leave at the nurse's station so I can write out recs after my visit. Most of what I do is deal with family members who are freaking out bcs they can't be bedside. Normally I would help them facetime, etc, but I don't want to bring my tablet or phone into patient's rooms, even with plastic bags. I don't know. It just feels very surreal, and I want to make sure I'm doing everything right for myself and for my patients. I'm just wondering if there are any visiting/hospice nurses who have been caring for COVID patients in LTC settings for longer and maybe have developed a good routine? Thanks all and please take care!
  3. anashenwrath

    Opoid crisis and providing hospice care

    I'm on Cape Cod (ie, that place where HBO did a documentary about the opioid crisis) and find overall it's not too bad. Like anywhere, different prescribers prescribe differently, but it's not necessarily about the opioid crisis... it can just be ignorance about dying or symptom management in general. Same old same old. I think it's actually become easier with families because I can be very upfront about checking meds. "Sorry I have to count your pills every visit; it's just the way things are done these days." People who may have taken it personally back in the day totally understand it's just the climate of our times. I have had to manage comfort kits when there were active users in the house, which has challenges. We usually deal with it via lockboxes and trusted family members. I had one lockbox broken into. That really upset me. I'm pretty sure I know which family member did it, but couldn't prove it. We ended up double-locking the next kit and only the hospice crew had the combination. THAT was annoying. I thought we would have to do continuous care, but the patient actually passed very quickly and peacefully. Oh, but what really cheeses me is, at least in this state, nurses aren't allowed to destroy meds in the home (or take them, obviously). Usually, families are more than willing to destroy them right there in front of me, but sometimes I will get a family that will be like, "Ehh, thanks. We're just going to hold onto these." THAT concerns me. Even if they do dispose of them later, if they just chuck them in the garbage, someone might notice and pick them out! I feel like dumb protocol like that contributes to the ongoing crisis.
  4. anashenwrath

    I made a medication error. What will happen to me?

    As others said: not sure what your working environment is, but I think you'll be fine. I remember when I made a narcotic error. And I didn't catch it, my supervisor did the next day! I was horrified, mortified, and thoroughly convinced I was going to be drawn and quartered. I can't even describe the SHAME I felt as I sat in her plush office, mumbling about how the error had occurred when I picked up an unfamiliar shift to cover short staffing. (Like that was an excuse) I didn't get any sort of reprimand except some education and a reminder not to rush. You went above and beyond. You sound like an excellent nurse. Be at peace!
  5. anashenwrath

    ER to Hospice

    Congrats OP! Based on your username, I'm going to assume you're in Oregon, which is a very good state for EOL care! Reading through your pros and cons, I noticed a lot of "logistical" factors, so I wanted to chime in as you get started as a hospice nurse. Yes, we get mileage, amazing bedside experiences, and awesome self-management. Yes, I have ended my day at 3 pm sitting on the beach in my scrubs, documenting on my tablet. BUT: that's not a reason to be a hospice nurse. I have sat at a patient's home for 6 hours (until 1030 pm), putting all my other visits on hold, while that patient breathed their last breath and their 12yo daughter screamed at me (most of my other families were ok with rescheduling, some made me feel like crap). I have had my phone ring at 8 pm with the on-call nurse trying to figure out how to get symptoms under control. I have had to drive an hour out of my way to change a dressing or have a family meeting because "dad seems depressed." I have had family members--HCPs--who were so in denial that they accused me of lacking compassion bcs I advised against CPR. I'm not trying to be dramatic or anything. I just really want to make it clear, hospice isn't all about the mellow hours and "kumbaya" philosophy. We work ourselves to the point of exhaustion caring for people and families at the darkest hour, and our reward is frequently tears, occasionally anger. Please prepare yourself for a type of burnout you may have never experienced before. Yes, there are hospice nurses who kind of "coast" through their caseload without ever really investing in the work. The other RNCMs are not fans of these individuals, and usually the families ask for another nurse after a while
  6. anashenwrath

    Triage and on call

    Ugh my heart breaks for our on-call nurses (especially bcs the RNCMs have been covering for one of them for the last three months!). On-call gets called for anything (ignoring actual out-of-control symptoms, admissions, and deaths). Boo boo? Fall with no injury? Anxiety? Out you go! Not only that, but triage is not the most dependable... patient called triage with c/o low bsfs in the morning...triage didn't let me know until almost 4pm! The plus side is, you can tell triage (at least in my company) to HOLD on putting a visit on your tablet until you speak with the patient. For example, I called the low-bs patient's nurse and she confirmed patient always runs low. Then I called patient and confirmed BP before lunch was 129. Called triage and said everything was cool, then wrote a note and left report covering everything. I always try to triage on my own: call the patient or family and talk it through. ALWAYS make it crystal clear you are more than happy to visit, but let them know you wanted to call first and talk out what was going on. When I was covering, I didn't have to go out too much. Maybe three nights a week? I honestly don't think on-call is a bad gig. But if people call and say "Gram gram is on hospice for COPD but she has a canker sore that's really bothering her! WE NEED A NURSE" Yeah, you'll be going out to look at it.
  7. anashenwrath

    Cape Cod Nursing

    Cape Cod RN here! The healthcare system on the Cape is kind of a horror show. Cape Cod Health basically runs the show, Outer Cape Health is "reorganizing," and we only have two major hospitals (both owned by CCH I believe). Emerald physicians is the biggest primary care group, and they recently became members of (surprise!) CCH. That being said, I love working here, because my specialty is hospice, and we have a pretty big senior population. (Like 85% of some of our towns are over 65 years old). There is, IMHO, an enormouuuusss need for better home and community care. There have been a lot of attempts to get "house call" programs off the ground, but they never make enough of a profit. NPs can do well here, I think (I'm actually looking into pursuing my own NP license), because there are so many SNFs and ALFs that rely on NPs. Oh, and obviously, summer the population booms and thus the need for nurses! Since my focus is visiting nurse/hospice, I can't speak too much about the hospital (even though I am in there a lot), but feel free to PM me if you have more specific questions. I'll do my best!
  8. anashenwrath

    Aspiration drama!

    Great responses from you both. Thank you! I've incorporated this advice into my last few visits, and I think we'll get on the same page (hospice/patient, spouse, and facility). much love to my hospice homies!
  9. anashenwrath

    Scheduling Hospice Visits

    I see about 4 patients a day. Prefer 3 so everyone can get plenty of TLC, occasionally have 5 and then I'm antsy and grumpy. I know nurses who do up to 7 (but they're in there for about 15 minutes a pop). I assume an hour a patient and factor in drive time. I divide my patients by area and visit one town a day. If I have multiple patients in a SNF or ALF, I try to see them all the same day. (Not sure what your census is. I have 14-18 visits a week.) Home care patients get priority for picking their day/time. After a couple visits, I get a sense of whether this is a patient/family that needs lotsa love (so let's always assume they'll get an hour at least) or if they're kind of get in-get out (so I can probably get it done within 30 minutes). OH, and I always top-load my week. Best case scenario, I will have an easy Friday. Worst case scenario, I won't be drowning when the inevitable Friday afternoon admission comes in. XP
  10. anashenwrath

    Aspiration drama!

    Hello all! I am dealing with some drama with a patient on hospice for end-stage Alzheimer's at an ALF (darn ALFs!) and was wondering if the community could give me some feedback. Pt is total assist for all ADLs and has significant dysphagia, yet her husband comes in faithfully three times a day to feed her (and with that I'm sure a lot of you know exactly where this is going!) Diet is pureed. Recently, pt has had incr coughing, gurgling while feeding. She pockets and takes minutes to swallow. Otherwise afebrile, lungs sounds clear. Facility can NOT thicken, but I ordered thick-it and did nectar-thick teaching with spouse. Unfortunately, while he always smiles and nods and gives me return demonstration, every time I come to the facility, the staff complain that he is not thickening enough, feeds her way too fast and will sit with her for over an hour trying to get her to eat. I sit with him, reinforce teaching, and the cycle begins again. Earlier this week, pt began coughing and vomiting up liquid at breakfast. Facility freaked out and spouse became angry bcs they refused to feed patient until I assessed. I found her asymptomatic, but ordered a swallow eval to make everyone happy. Swallow eval concluded what we all know. Patient is at significant risk for aspiration. They recommended pleasure feeding w precautions. Now the facility is basically asking me to police this spouse and are saying that if they see him attempting to feed her too fast or not thicken appropriately, they are going to call Elder Services. It's important to note that ALFs in my state are SOCIAL MODEL, which means they are considered a "home" environment, NOT a medical environment. I'm thinking of maybe writing up some sort of "aspiration contract" that the spouse could sign indicating that he understands the risks of aspiration should he continue to be noncompliant. Anyone ever done something like that? Samples? But beyond that, I don't think there is much I can do... I don't feel comfortable "policing" this guy. If the facility wants to call ES or tell him he can't come in at meal times, I guess that is their prerogative. But I feel like the spouse has verbalized an understanding of the risks and there isn't a way to "force" him to comply, unless I recommend his wife be moved into a skilled setting (as she has no symptoms, it's not like I can GIP or inpatient her). If this was a home patient, I think I would do my best with teaching and reinforcement, but at the end of the day, I would drive home and leave it to the powers that be. If it was in a SNF, the staff would be able to thicken food appropriately and follow through on interventions in a way the ALF can't. Is there anything I can/should be doing here that I'm not???
  11. anashenwrath

    Is this common?

    I work nights and that's about my ratio. One CNA, me, and 40 patients. During the day it's 2 nurses and 2 CNAs. It's super tough. The 6am med pass has me in cold sweats, especially when I realize the 7am shift is filing in and I haven't finished, or even recorded report! Our Unit Manager is pretty good, but last night she sent a rehab pt with chest pains to ER and everyone had to go help. I was in tears bcs it took so much out of my shift. Same thing if we have a fall. Everyone has to go assist, so you feel like you're losing time and of course you're terrified of what's happening on your own floor. It feels like if everything goes perfectly, I have time to provide competent care to my patients. But when does everything go perfectly in nursing? And yes the paperwork is brutal, the docs specifically ask that you don't call them, and breaks are automatically deducted, even though I've never taken one. I just factor the half hour into some of the time I take to finish up. Even though I'm usually there another half hour after that. But at the end of the day (or beginning... whatever) I know that I am on my way to becoming a skilled geriatric nurse, and hopefully someday I'll actually feel like a nurse and not a med passing, note writing, perpetually panicking disaster. As long as everyone is safe and free from infection, I feel ok when I click out.
  12. anashenwrath

    how are med passes possible on time?!?!?

    Thank you tyvin. It feels a little better knowing...at the very least...I'm not alone in being shocked and overwhelmed. I just hope it gets better--or at least that I learn my patients--soon. Our total census is 100. 40 on the LTC floor, 40 on the dementia unit, and 20 in rehab/post-acute. During nights it's one RN and one or two CNAs per unit. Edit: I should clarify that not every single resident gets meds during nights. I would say maybe 30 or so. But I do have 10 finger sticks at 6:30 on the LTC unit as well.
  13. I'm on week 3 at an LTC/rehab center and I just want to know... where do I purchase the time machine that all the experienced nurses must have to get their work done on time??? I'll be working the 11pm-7am shift, with my big med pass between 5 and 7. I have about 40 patients, and I'm always still passing meds when the next shift comes on. so i feel like a total tool when they're asking for report and i'm not even done passing meds. I try tricks like flagging pages in the chart (yes, we still use paper charts) and writing the meds on my census sheet. but i still have to double check everything bcs I'm SO scared of making an error. and then of course i need to do my treatments, check orders/charts, do skin checks, etc. I feel like I let my patients down bcs I never spend any time with them. and THEN of course, there are call lights, PRNs, pts who don't want to take their pills, insulin coverages (6:30 am), and god forbid if a fall/code is called on any floor, I have to assist. Oh, and then it's time to chart. I promise, I'm not complaining about the work. I actually love LTC, and the patients/staff so far is great. I really really really want to excel. People say that once I learn the patients better, it'll be easier. everyone is being so nice. But in the meantime, I feel like I look so bad to my peers and my patients, and I'm so afraid that I'm letting everyone down. I'm literally having nightmares every night... er... day. I just don't get how this is possible outside tampering with the space-time continuum!!!
  14. anashenwrath

    First job! How can I be a great LTC RN?

    thank you! luckily a lot of my downtime during school was spent toileting, etc, so I'm definitely willing to help out on any of that! in fact, i'm worried that i'm going to be more comfortable with those tasks than nursing tasks. and the advice on documenting is very welcomed. like they say: if you don't document it, it didn't happen.
  15. anashenwrath

    can't you just call me if you say you will?!

    Thank you!!!!!!!!
  16. anashenwrath

    First job! How can I be a great LTC RN?

    Thank you so much everybody. this is really some great advice and is calming me down immensely. And I'm definitely noticing themes in the advice, so I will definitely be sure to review charts, ask questions, and be a team player! I'm so excited to be going into LTC and I really want to do a great job! Gah, I could start getting weepy over this! Special thanks to CapeCodMermaid, bcs she's actually been giving me advice from day one. Cape Cod is where I'm heading! So long New York City!

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