Pondmud

In so many ways, we do best when we meet people where they're at. If your patient had trouble with "furosemide" but is comfortable with "water pill", I don't think it's wrong to call it a water pill. So let's say you've got a Dementia pt who believes she's in an airplane and you're a stewardess. She freaks out and gets anxious whenever you reorient her - what's the harm in being a stewardess, and what's the benefit of giving her the truth?

I graduated 12/2011 from San Mateo, and can tell you I got my acceptance phonecall on Halloween for a January 3 start date. If that timeline is their baseline, then I guess you'll hear at the beginning of March for a May start date. Stressful, but banks like to give student loans to nursing students, and SMU's financial aid office is very responsive, so with any luck you'll be OK. As for the emphasis on math/english sections of the TEAS: this makes sense to me. Your success in passing the NCLEX hinges on that much more than your knowledge of science, because the content isn't what will kill you, it's your ability to read the question and catch those nuances. Also, the whole nursing thing demands that you write well and succinctly, and that you can do the arithmetic to give your patient the right doses. :) Good luck, you guys. I hope your experience in nursing school will be as good as mine!!

While there is validity to sedating an agitated person as a means to provide comfort, I think medicating someone with the primary goal of sedating (as opposed to relief of something else that brings a sedative side effect) them requires deliberation. Is this really what the patient wants? I've known plenty who have traded pain relief for consciousness because they would rather have 6/10 pain and see their children as much as they can, versus being at 2/10 and miss out on everything, forever. That said, there are also a small proportion of people who just can't tolerate the distress of EOL, and ask, as one daughter put it, to "go to sleep". Yes, it is their stated wish - but as clinicians, we have to be absolutely sure that's what they really want.

Actually no wait - my brain just farted. You've now been on the job for 2 weeks - congrats!! There is all that. There are standard-ish orders for pain, nausea, agitation, congestion, constipation and etc., and I can tell you what ours are, but each facility is going to be a little different. All the mechanical skills like PCA and inserting tubes you will develop over time, and that's reasonable to be patient about. Your eyes and hands-on assessment skills are going to be key. What do you see when you look at your patient, and what do you see 30 minutes after you give a PRN, to evaluate its effectiveness? This will help you discern over time which prn to give, since there will be lots of instances where you can give 2-5 different things for the same problem. I would put assessment skills as number two. Number one should probably be narcotic safety. This will keep you out of hot water. Know your facility's p/p for that stuff. Waste properly, document correctly, have witnesses as needed. You're working with formularies that can terrify an ICU nurse. This is especially true of those PCA pumps. Take your time. Check your pockets. Keep your practice clean.

Oh my gosh, I'm so sorry to hear that this happened to you. I get what you're saying about whether you will be able to care for him the way you'd want to, should he be re-admitted to your facility. The worst that happened to me was that I was punched in the face by a former bouncer - shook me up for the rest of the day mostly because I didn't expect it, but this doesn't compare at all to what your experience was. Dementia is so difficult because as you said, he was physically strong. I don't know what's the proper and safe way to provide care for such patients. Certainly, even with a calm affect and no signs of agitation, it doesn't seem responsible to leave staff alone in such situations in case s/he needs backup. We had one patient some months back who was a big guy, physically strong, but with a lot of altered mental status issues. He was at risk of elopement related to poor insight - in these cases, we normally assign them 1-to-1. However, we felt that doing so would cause a safety risk for the nurse assigned to watch him, especially considering that he was perfectly ambulatory and could go off-unit to who knows where. In the end, he was transferred to a locked facility. This worked for him, but I don't think is the right choice for your guy.... I hope you'll update on the situation, both yours and how your facility ends up working this out?

We've used versed and ketamine NCA for terminal stages, but only rarely. I don't know if it's written up as such in the P&P's, or if this is how our medical team views these meds, but we treat it as palliative sedation and there are a *lot* of paperwork consent/ethics things involved when these are ordered. I don't know what the differences are in absorption for sq vs IV, except to say that I bet there's some wide variance in absorption rates given factors like cachexia and third-spacing. I suspect that at my facility as well, it's to allow LVN's to administer meds that we might favor SQ even when there is IV access.

Agreed - the test was quite heavy on the oncology knowledge (I still don't know how to predict metastases from the venous flow), even though there are just as many cardiac and pulmonary patients out there as onc patients who end up in hospice. Firefly - you will get it next time, and you know that :)

Same here - lorazepam or diazepam are choice #1 and #2. We may use the IV route if it's a picc line, but in the absence of that, and if the patient cannot take PO even as a slurry, we will go with the subcutaneous injection. Maintaining IV access pretty much doesn't happen at all on my unit.

Well, it's certainly a plus that you would like to get to know your patients and their families better. I am afraid that there are certain nurses attracted to the "slower" pace of hospice so that they can pass their meds, give some sleepy-time PRN's, and relax.... It's not that there is less to do, what you're doing is simply different. I love getting to know the families and really getting together a plan that works for them. I like doing the patient teaching, to let them take control over parts of their lives that they thought they've lost, even if it's just for a little more time. In hospice, you get comfortable with treating symptoms based on what your eyes, ears and hands tell you - lots of lab tests and vitals aren't part of comfort care. I think it's an older-fashioned style of medicine, and it's beautiful. The advice I'd give is this: Find a way to always keep your heart open, but make sure you've got good boundaries, too. Expect for hospice to challenge your beliefs about life, death, and how we spend our time on earth. Expect to get really comfortable discussing a topic that most of society finds terrible uncomfortable. good luck! :)

Oh gosh. This post was from a year ago. I bet you can answer all your questions now :) If not, I might be able to fill in some blanks?

I just sat for and passed the CHPN exam yesterday :) Here's what I can tell you: I think it's highly possible your previous experience may cover for the 2 years hospice-specific experience that the exam recommends you have You know how to assess a patient's symptoms, you know how to deal with the psychosocial issues of patients and their families. You probably know medications for nausea, constipation, pain, agitation and congestion; the signs of imminent death; what cancers are likely to metastasize where. A coworker told me that I could probably study and pass the exam after having less than a year's experience. The main difference, she thought, was that the content covered by the exam would be more meaningful to me after working a few years. As it turned out, I took the exam after working 2 years in an in-patient hospice unit. That being said, the exam makes you feel like you failed, even if you did well! You need 75% in order to pass, and I got 91%. I still felt terrible about my performance. The reason why is that the questions are written like NCLEX questions. So for example, you'll have multiple choice 4 answers. One is clearly wrong. Another is kind of right, but doesn't address the question exactly, so you eliminate that. And then you have two equally good answers to choose from. Evil! I would say - get the study guides and see for yourself. You can schedule your test any time. Good luck :)

There may be a consent to treat, implied agreement as evidenced by the patient consenting to be admitted to the hospital; but upon admission don't we all have our patients sign a Patient's Bill of Rights, reminding them that they have the right to refuse treatment as well? It's so much cleaner when someone is 5150'ed, and to a lesser end-stage dementia, and a much, much lesser degree delirium... OP, is this your struggle? Or is it a more basic human pain of observing someone else in pain?

I think the context surrounding why she was straight-cathed is important. What if she were retaining urine, and they didn't want to go with a continuous catheterization because 1. they hope to resolve the problem and return her to continence, or 2. they suspect she is at risk of pulling the tube and thus cause herself serious injury? Now - Hopefully whoever ordered the cath considered all other alternative. Also hopefully, they did everything they could to manage the pain (pre-medication, lidocaine jelly, etc.). The other element to this is your reaction to the patient's experience of the procedure and the pain it caused. While you don't want to harden yourself, it's also one of those things that you'll have to do, like being a parent and taking your kid to get a vaccination. They will cry, and maybe tell you they hate you, and maybe be a little scared of nurses and doctors - but ultimately, aren't you preventing a bigger harm? I won't say it becomes less uncomfortable for you. Maybe the discomfort becomes familiar, and you draw your own lines between what is ok for the greater good, and what is ethically distressing?

Hi everyone - I'm very new to home health nursing, and I've got a question for some of you more experienced nurses since I'm just learning the ropes: In my initial meeting with the client, I was told of some of their experiences with nurses from other agencies. Some of them performed interventions incorrectly, there doesn't seem to be much communication between one nurse visit and the other, etc. My feeling about HH vs. hospital nursing is that HH is a little more "wild west". You perform much more independently, you don't necessarily get contact with other nurses to learn how they do things. But bigger than that, how do you stay current on evidence-based practice, how to use new equipment, etc.? I realize that some of the things we do in acute care/hospital settings don't translate to the home environment, I am concerned that I might develop some bad habits, or miss out on some learning, that might put the patient at risk. So I was wondering - does your agency offer continuing ed so everyone can assume a reasonably uniform skill level, or have you found certain CE organizations that cater to the education/training needs of a home health nurse?

As one student at San Mateo, I'd say that YES OMG the program is intense. However, it is possible to complete. While there are some professors whose teaching styles haven't been a perfect match to my learning style, every single person has been helpful and supportive. I adore my classmates. That said, I do have some advice. 1. Expect to feel completely overwhelmed, lost and freaked out. Rest assured that everyone else in your group feels the same way. However, 2. Trust your faculty when they tell you "you still get through this". They take their roles very seriously in making sure you learn what you need to learn. 3. Expect not to feel like the smartest kid in class. You're in a classroom full of smartest kids, and you may feel uncomfortable average. However 4. you are not competing with them. SMU fosters such a collaborative culture, one that (ideally) matches with the best work environment, where people share knowledge and develop best-practices for mutual success. It's completely different from the rest of my college experiences. You may feel completely off-balance when you start, but that's alright. It's a good program, and they do give you the tools to be a successful and amazing nurse.