ErinS

When we compare oxycodone and roxanol we generally see the same symptom relief from one to another. I do not think having morphine instead of oxycodone would have made her more comfortable, but she may have needed a different dose. The hospice nurse was not being negligent in not ordering morphine, she likely just knew that the oxycodone was doing the same thing for her that morphine would.

I think there is a big difference between being a daughter and being a nurse. I think that most of what you were doing is what we often see family members doing- helping to bathe their loved ones, providing support and encouragement, asking for things that may improve comfort. I think where the line may have been was doing a nursing assessment. And I agree with the social worker on this one to some point. There is a time to be a grieving family member, and a time to be the nurse in charge of a loved ones care. That being said, I always invite family to help with personal cares, including post mortem care. Often those physical acts are the last way to show loving care to someone who is comatose, or demented. I am sorry you have regrets, but you must remember (as we always tell our families) you did the best you could with what you had, and I suspect your excellent care kept your mother healthier and happier for longer than she would have been otherwise.

Our company uses several nurses with minimal hospice/homecare experience to do our intake. These nurses get orders, build the charts in the computer and coordiante care with md offices and insurance companies. This may be an option for you.

We have a conflict of interest policy that does not allow employees to work in the same function for a different company.

I believe your hospice experience can be variable depending on the acuity of clients a hospice takes, the diagnoses, and the nurse. Hospice is generally not a field heavy in 'nursing tasks' such as placing IVs, but very, very heavy in nursing process (also called care planning), assessment, and psychosocial support. That being said, I work in a hospice that has a very high acuity and lots of clients in the hospital. I do admissions, so I interact with nearly all our patients at their first visits. In a normal week, it is not uncommon for me to do the following: Start a subQ infusion Access a port Place a foley Drain an indwelling ascites drain Draw labs Give a bed bath Do wound care So I would say that I feel fairly competent in my ability to perform 'nursing tasks', but working with students I recognize it is often difficult for students to recognize everything I am really doing in a visit. For example, I go into a visit and sit down and chat with my client. During this time I am assessing for mood, affect, skin color, dyspnea, signs of pain, and signs of weight loss. I then do VS, listen to heart, lungs, and BS, and check feet and legs. While I do these things I continue to chat with client about bowel movements, appetite, fatigue, pain. One thing to remember about hospice is we are focused on symptom management. For example, I may hear crackles or wheezing in a client's lungs, but if they are not having symptoms (coughing, dyspnea, fevers, LE edema), I just keep watching. As a student, I encourage you to tell your preceptor you would like to do the assessment and care planning for a client by yourself and run by her the things you think should be priorities and why. You may also, unfortunately, just be with a nurse who does not much love her job anymore. It happens. Good luck!

Apply for all those jobs that say 1-2 years, and apply at assisted livings and nursing homes. You really need that solid 1-2 years of acute care or SNF experience when working hospice because of the autonomy. Some new nurses have been hired by hospices on this site, but I believe that has primarily been for inpatient hospice centers. Right now, focus on getting any job, any where, but preferably a med/surg/ICU in the hospital, or a SNF. My hospice really likes nurses from SNFs because they are great at working with SNF staff, but also because we know they are used to HARD work. You may want to put out feelers for areas needing more nurses. One place to start would even be a travel agency. They will not hire you without some experience, but you may find a recruiter willing to let you know where the highest nursing demands are in the country if they think you might be interested in traveling down the road. I believe where I live (northern Utah) there are a lot of SNF jobs even for new grads, but it is tough to get into hospitals.

Well, my thought is that they are not hiring obese nurses and they are not hiring nurses who smoke. Where do we the draw the line on high risk behavior? Should we still hire nurses who drink alcohol, or drive motorcycles? And, a previous poster commented that a patient can not trust a nurse who is obese to give nutrition and diet information. As an obese person, I just LOVE it when someone who has never had to work at maintaining their weight tries to talk to me about weight loss and healthy eating. I KNOW what it is like to work out 5 hours a week and track everything I eat, and still struggle to see weight loss. I understand the struggle for these patients, both in the difficulty in losing weight and the difficulty in being heavy. The number of times I hear a nurse say 'Well maybe if they would just lost weight...'. If it was that easy, we would all be thin. Anyways, all of that being said, I understand the reasoning behind this rule. This is one of my big motivators for working my ass off (literally!). Although I understand the reasoning, I think they will come to regret this rule. It is difficult to find quality nurses. Give me 1 fat nurse with a great work ethic over 5 skinny lazy nurses any day!

i am paid per visit, about $43 per visit credit (this is expected to cover about 75 minutes of time). I make very good money compared to the nurses that work in local hospitals, where the hourly rate is $25/hr.

I would take a month and feel out your coworkers. Find someone who you feel you can talk to, and bring it up. I work in a state with what I would describe as a 'stifling' religious culture, of which I do not partake in the primary religion. In addition, it is a very conservative environment. Our team is comprised of team members of various religions, races, and sexual orientation. We also have a prayer at our meetings, but it is not always Christian prayer. Our chaplain leads our 'spiritual thought', and it is often from various religious backgrounds- like last months was a Jewish prayer. Perhaps you could even discuss this with your chaplain as an option. I think it makes me a better hospice nurse to recognize a broad range of spiritual beliefs, even in my community with a very predominant religion.

Been there, done that. Shame on the hospice companies for continuing to allow this abuse of the system. It is actually fairly common in the hospice I work for to d/c pts. The primary reason is all those debility pt's that are losing weight until hospice comes and provides that little bit of support and suddenly weight loss stops. They tend to go on and off service before they really start the decline that keeps them service. Reading just the first paragraph of this blog makes me think of several pt's that came onto hospice for legitimate reasons, and where d/c'd within the first cert period. These people are master manipulators, and it is often difficult to tell in the admit interview that they are providing misleading information.

I am surprised they are requiring prior hospice experience. We actually prefer someone that has really solid base nursing experience, but no or little hospice experience so we can teach them our way. That being said, I think you need to highlight that you have had end of life experience. So when you are applying for jobs, instead of describing your work as "cared for elderly pt's in a skilled nurse setting", I would put something more specific like "Cared holistically for clients throughout their lifespan, with a focus on ensuring their end of life was comfortable and dignified". But you better be prepared to describe exactly how you did this. Good luck!

Okay, so I hope I can give you some reasons as to WHY we see a lot of what we do. Dyspnea: you will find very quickly that people with dyspnea handle morphine and ativan together very well. In fact, i have never seen these two meds cause severe respiratory depression in my practice when given together for dyspnea (I would define this as the respiratory rate dropping to Fever: 3 things cause fever in hospice pts. The first, obviously, is infection. The second is dehydration. We regulate our body temperatures through being well-hydrated. As the dying stop drinking, their fluid balance shifts, and they can no longer maintain a steady body temperature. This results in both fevers and hypothermia. The last is a nervous system response, similar to when someone has a heart attack and becomes hot and flushed. Sometimes this is from the heart in the dying, but sometimes it is related to changes in the brain. With this temperature I encourage families to leave a light sheet on their loved one and use cool cloths if they would like, but I also explain it is normal and tylenol likely won't decrease the temperature. And finally, just my 2 cents here. I came to hospice from acute care, where it was drilled into me that pain and anxiety medicines killed people and caused respiratory distress and we need to monitor, monitor, monitor. Needless to say, it was a strange thing to come to hospice. It was a scary thing to come to hospice. But like I said above, I have seen pt's on 200mg of dilaudid and hour and 10mg of versed still be alert and oriented. Although those meds can cause respiratory depression, I think a lot of the fear about those meds has been blown way out of proportion. The only respiratory distress that was r/t meds that I have ever seen was on a post-op pt, and it seemed to be r/t the anesthesia (narcan didn't work). Good luck out there.

I think that this would depend on a few issues. One of them being is there one certifying agency that all insurances in your area recognize (I honestly do not know if this matters, but just a thought). I think Joint Commission comes with a certain prestige, but the audits are tough and it brings a lot of regulations with it. The hospice I work for is Joint Commission certified, but we are part of large hospital network that had the resources for that. Maybe it would be worth doing an informal survey of hospices in your area, and also ask referral sources if it makes a difference to them.

What is your productivity? I went to the conference in San Diego and I was very surprised at how low productivity was for many hospices, compared to what I am often doing. I do not necessarily feel overworked, but I have to be firm about working 40 hour weeks. Our productivity is 25 visit credits a week. This works out to 5 routine visits or about 4 inpatient visits or 2 admits per day. We are paid per visit- being productive is not a big deal to me because I make more the more productive I am, but it seems pay per visit is getting less common. It is unusual that I do less than 30 visit credits per week, and I am probably closer to 35 most weeks.

Although this pt appears to be entering his dying process, the ostomy over the wound seems to have promoted some healing- I think it has just kept the wound the right moisture without being packed pull of really wet stuff.

So my gentleman with the liver failure with the giant hip wound has some new things going on. The wound is getting worse daily. In addition to getting bigger, the drainage continues to increase, despite starting antibiotics. The wound bed actually looks fairly clean (no slough), and the drainage appears to be ascites. This gentleman has also gone from needing a tap 2 times a week to not having one for over a week and his belly is soft. Our doc thinks the ascites is leaking through the tissues into the hip wound. The nurses have been changing the dressing 4-6 times a day. We decided in IDT to drape the wound with tegaderm and apply an ostomy bag to the wound to manage drainage. Hopefully this will work!

It depends on if someone is using narcotics. If someone is on narcotics we usually start with Senna-S, 1-4 tabs daily. If that does not work we will usually use lactulose. If someone is not on narcotics, we start with prune or sometimes just fruit juice, then use colace. If colace doesn't work we move onto the Senna-S and lactulose. If someone is unable to have a BM, but their stool is soft, we will start a bowel care regimen using suppositories or enemeeze. I hope this helps.

The best in a long time: Had a pt hit the call light. When the nurse (I work hospice and was just standing in the hall) went in to ask what she wanted the pt responded: "You better keep your voice down out there. President Obama is in the hospital, and he just called, and he is coming up here to visit me." We all had a good laugh over that!

Wounds related to terminal diagnosis: 1. Any wound related to cancer 2. Pressure sores in a debility pt 3. Surgical wounds related to primary diagnosis (so a wound from paracentesis in a liver failure pt) Hope this helps!

I am feeling like the best bet may be to just turn over the wound care to the facility, and help with dressing changes to relieve their burden and so I can do my wound assessment. In my experience, this kind of wound does not respond well to wound vacs because it is nearly impossible to debride the slough that is likely in the many tunnels of the wound, and the vacs do not work well for wounds with slough. I will let you guys know how this week goes. Thanks for your suggestion.

Hello everyone! I love wound care, but am in the midst of a puzzle. I admitted a 50-something year old man with liver failure. Hx of etoh and Hep C. So he has a dehiscence post I&D of his right hip. On the surface the wound looks good, maybe 3cmx2cm. But upon cleaning with sterile q-tip I find the wound tunnels and is more like 13cmx 8 cm. It is having copious amounts of yellow drainage, starting to smell infected. We are restarting an ABX that was stopped before he came to us. He is in a facility, and in the past I have treated non-healing wound with lots of drainage with Dakin's solution, but the facility says that is against their policy. The problem is that this wound is having to be change 2-6 times a day to manage the drainage, and it is cost prohibitive with dressing changes that frequent to use any of our more standard wound care products (facility recommended aquacel AG or Maxorb AG). I am hoping someone out there will have some cost-effective recommendations on how to manage this wound. Thanks!

We use aspira drains. They can be placed anywhere fluid needs to be drained, so we occasionally see chest tubes, but usually we see them for ascites drainage. They have this nifty port that you connect a bag system to, and then there is a squeeze pump that will get fluid going, and then a bag for it to drain into. The best part is it is so easy to use that we often teach caregivers how to use it.

Go and work on a medical or step-down floor. You will get to take care of lots of people who are dying, while improving your skills. This job would be terribly intimidating if I had not had a solid base of medical skills. You want to be the best hospice nurse you can be, and I am not sure that will happen without that solid medical basis.

A few hints on informational visits. I talk slower and in a lower voice than normal- this seems to be less intimidating. I also allow 30 minutes of my visit for them to tell me what is going on. This allows me to discuss a specific plan of care for their loved one. We know that hospice is great because of the support, but it can be hard for family to understand how that applies to their loved one. I also emphasize that once someone does not want to return to the ER, hospice is the best option. It is rare that I do not admit after an eval, so this must work okay. That being said, I work for an ethical company that does not offer the moon and stars (for example, we do not discuss continuous care as being an option, because we rarely ever have a pt in a crisis that qualifies for continuous care). I know that sometimes the pts I eval are interviewing several hospices, and those hospice are offering things that I can't, like CC at end of life.

I am not sure what kind of wound you are looking at, but I do hospice and we have a wound care nurse we consult with and then we do the dressings, even though I don't have detailed wound care training. If someone has a wound vac KCI will provide this service. My honest thought is that if your pt needs home health and wound care, then he needs an agency that can provide that. I am not sure how you would get Medicare to pay for a visiting nurse to wound care, unless your agency contracted with that nurse and did the payment. Also, in my area there is non-emergent medical transport that is very inexpensive. It is provided by our ambulance agency, you just have to ask for a van transport. Also, I am not sure about home health, but with hospice the agency is required to contract with a dietitian or have one on staff. It sounds like your administration needs to find the staff to contract for dietary and wound care.