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Not much. I think I need to raise the question in an organization-wide way. Just sent out an email about this - thanks.

I've been a nurse since before you were born, and a hospice nurse for 7 years. My concern/peeve is this: Ativan is sometimes ordered and given for agitation, with no Haldol or other antipsychotic available. This drives me to. . . psychosis. In my book, benzos are for insomnia and/or anxiety, in pts who still have their marbles. In pts who have delirium and delusions, especially paranoid delusions, I think benzos frequently make them worse. AND make them fall - the confusion and restlessness are no better, and they're more unsteady. I often use the two in concert, but I NEVER choose to use a benzodiazepine as first line in someone who is striking out, confused, and especially paranoid. When I rule the world, I'll be sure that every admission has a kit containing a little Haldol, Ativan, OMS, and atropine drops. Oh, and a stunning array of bowel meds. Thoughts?

I tried to remove a PICC line today that had been in for 6 months, site looks good, no issues with it. (I'm an infusion nurse but not recently). It pulled about halfway out with gentle intermittent traction, then stopped. I massaged the arm above, pulled again (gently) and something "gave", the pt felt something in his axilla, and it pulled maybe another inch, but then just stretched and retracted. Tried pausing for possible vasospasm, but no more give. I didn't want to pull any harder, obviously, and risk breaking it. Never had this experience before - anyone? I cleaned the area with CHG and coiled most of it under a transparent dressing; I'm sending him for an xray tomorrow. Any thoughts? I wonder if it migrated around a corner in the wrong direction. Could vasospasm cause complete lack of movement, or just resistance? I greatly appreciate the expertise and helpful spirit of this site - thanks!

I've been a nurse for umpteen years, and a hospice nurse for 6. My impression with bone pain from mets is that ibuprofen works better than decadron, along with a narcotic (the pts are always on narcs to begin with, so I don't have experience with Ibuprofen without narcs). Somehow, there's a belief that, after narcotics, Decadron is the first line for bone pain, because it's "more of an anti-inflammatory". True, but it's NOT an analgesic. I've had several cases where adding ibuprofen to the mix brought dramatic relief, but there's resistance to combining Decadron and IB because of GI distress and bleeding risk. (I find this risk/benefit ratio pretty acceptable, personally, as do my patients.) I'd much rather toss the Decadron and use IB, if forced to choose. My questions: Is it common practice to combine Decadron AND an NSAID with an opiate? From comments on this forum, it looks to be. Any thoughts about which opioids are most effective for bone pain? Any experience with lidocaine patches? And is there a maximum dose concern with putting one on each hip? Thanks - LOVE this site.

Thanks for this post. I just started working in a clinic where we deal with lots of diabetics and do teaching; I thought "Oh, I'll become a Certified Diabetes Educator" and was floored by the number of hours required. I don't get it - it seems insurmountable for most people. One thing I'm hoping to start is shared medical appointments (there's a PDF you can find put out by the VA on this); that would get me some hours, but a THOUSAND?? Jeez. . . Good luck to you, and keep us posted.

Thanks SO much. I'll pass this on to his MD. It's wonderful to have this level of support available! DM

I've found this referred to in old texts, but can't find anything current. We have a patient whose catheter plugs with purulent matter every 1-2 weeks, despite biweekly irrigations. The sides of the connector become narrowed by hard, white deposits, and irrigations produce large amounts of purulent and stringy matter. He's had many rounds of various antibiotics/antifungals, is otherwise asymptomatic. At one point he was diagnosed with a chronic fungal UTI. I would think 1/4 strength, or even more dilute, would manage the purulence and spare him the discomfort of frequently occluded catheters, but I wonder about absorption via the bladder or damage to the walls (though I'd think they couldn't be much more damaged. . .) Any thoughts or experience with this? Other irrigants, such as something alkaline (baking soda is a great antifungal)? Thanks for your thoughts, and for this forum!

I've found this referred to in old texts, but can't find anything current. I'm not a student, but saw great responses here, and don't know where else to ask this. We have a patient whose catheter plugs with purulent matter every 1-2 weeks, despite biweekly irrigations. The sides of the connector become narrowed by hard, white deposits, and irrigations produce large amounts of purulent and stringy matter. He's had many rounds of various antibiotics/antifungals, is otherwise asymptomatic. At one point he was diagnosed with a chronic fungal UTI. I would think 1/4 strength, or even more dilute, would manage the purulence and spare him the discomfort of frequently occluded catheters, but I wonder about absorption via the bladder or damage to the walls (though I'd think they couldn't be much more damaged. . .) Any thoughts or experience with this? Other irrigants, such as something alkaline (baking soda is a great antifungal)? Thanks for your thoughts, and for this forum!

Thanks! LOVE this site - so many good brains to pick. I'll stop rolling my eyes when I use filter needles. . .

Thanks, Blondy. Good points!

Thanks for your input, Ashley. I do plan to call the BON. As I mentioned, we'd be a "knowledgeable go-between" for pts and MD's - I'd never adjust medications without an order. It's certainly within our scope of practice to assess and triage - just don't know under what umbrella. It obviously requires more research - just wondering if there are people who have done this, as it seems to be a "thing".

http://ask.metafilter.com/6351/Fired-Now-What interesting link about how to deal with having been fired.

Oh, the "fired" thing. . . I'd call your (former) HR department and ask what they'll say to prospective employers. Maybe call places where you're NOT going to apply and ask how best to discuss this? Just a thought. Hang in there, m'dear. You might also see if there's a way you can file a grievance, and change it to a resignation. Do you have a union or professional organization? Or maybe your nursing board? You have options, and you're good.

It's really hard to make a blanket statement about this. I make visits if it would be helpful, to anyone, to do so. Usually SNF's don't want a visit - they've tidied up the patient and, unless family is there and need emotional support (often the SNF staff know them better than we do), there's not much reason to go. I DO notify the doctor and mortuary, and family if that's the staff's preference (again, they may have a relationship and prefer to call themselves). In my county we don't have to pronounce or involve the coroner. My question to the caller now is "Would it be a comfort if I came out?" I don't want to shade the question to elicit a "no", but I also don't want to intrude; sometimes it feels that way, if the family is very matter of fact. Often it feels like the visit makes a huge difference, but sometimes it feels like they have to entertain me. I suspect this is a dicey issue for many hospice nurses.

A friend and I are thinking of starting a service called "A Nurse in the Family", perhaps, where, for a monthly retainer of probably $100, we offer 24/7 phone support, a monthly visit to help with problem-solving, medication questions/issues, caregiver support ideas, etc. We'd also accompany the patient to ER or for a hospital admission as an advocate, up to once a month if required. Additional visits would cost $50. Questions: Is there a precedent for such a business? I see a few sites about Nurse Concierge services, but they don't tell me much. What legal hoops would we need to jump through? We'd essentially be a knowledgeable go-between for the pt, family, and physician. Not exactly practicing as nurses, but that's a bit gray. I'd appreciate any thoughts on this - I'm old and tired of working for people who are younger and crankier than me. But I still have lots of energy, knowledge, and compassion.