mrsamjones

This will be a bit long so forgive me now. I am a new home health RN. I was hired by a company to do client assessments and create a care plan. That turned into administering meds. No big deal, right? I've done medication administration countless times. I went out and assessed the client. I had them sign the service plan set up by admin. They need medication administration to ensure compliance. This is a company getting their level 2 RSA license. So I check that there is doctors orders. Was thorough in documentation. Rechecked all charts. Fully expected to do well at survey by OHQC. That is where it all went south. The surveyor stated that I was not following doctor's orders and they were incomplete due to the following: Order stated med 25mg 1tab daily of a med. Hour of sleep for another and BID for another. It didn't have the doctor's office stamp but it did have their signature and dose, route, frequency, person. She said it was incomplete due to lack of designated time to administer, daily is nonspecific. Lack of office stamp. List different from what patient stated they took. So she said, also, that I was not following orders because I administered the medication at time, daily, requested by the client. Also because I was not giving medication BID. The client is able to independently take their medication. Just not compliant. That was the purpose of the two to three visits weekly. Another issue was, although I had doctor's orders to give meds, I didn't have an order for why we were giving meds. No what each medication was taken for but that he was noncompliant. My issue with this is that, no where in the regulations does it list that specific of details for home health medication orders. Second, the client contacted us not the physician. Also, another thing she said was why does the clients med list have 13 meds but I only gave 3. I explained that this was all that was ordered by pcm. I also advised that I had advised the client to get un uptodate list from pcm and I would then request another medication order. The problem was he had 3 doctors and none communicated. Also, the client ran out of medication and I advised him yo refill. She said I should have called the pharmacy used by client to get refills. I am so frustrated because I am a diligent RN and take great pride in the care and quality of work I do. I can rationalize now why those things should be included but find it hard because of such vague regulations Anyone else experience this problem? Any advice? Am I wrong that I feel like an inadequate nurse and fearful that she'll report me for deficiencies that I truly did not disregard or ignore?

Educating patient on ambulation with her walker. It's a hospital rolling walker with springs in the front. She looks at me and says, " I got hydraulics now!"

Third day of three straight 12s and your director only gave you two days off from the last week to the start of this week: "We only have 18 patients Census is low, you're right sized."

Patient on medsurg floor recovering from an I & D of a perirecral abscess. I am the overnight shift and doing my chart reviews. Reading the doctor's note for previous. Come across "Patient's a** normal" in his note. Fall out of my chair laughing. I realize that the doctor was abbreviating assessment but it was too appropriate to the diagnosis.

I work on a MSP unit and we typical have at least 6 if not seven patient. I very much rely on my CNAs for VSS normally during the 12 shift. Maybe doing 8 hours, I will have the opportunity to do them myself and assess the patients. Thanks for the response.

I guess I should have clarified, we typical do a bedside report on our patients in which I am able to do a quick once over. You can typical tell if the patient is stable at this point. That is why I felt comfortable writing that in a note; however, you are right in that it would be extra time to write that.

Hi all! I will be changing my shift work from 7p-7a to 11p-7a. My question is, anyone that works this shift, when do you do your assessment? My thoughts were, if I am given a timely report (perfect world nursing) I would attempt to do my initial assessment with 0000 vital signs. If I do not get a timely report, I was going to write a brief note for each patient detailing that I assumed care of the patient, the patient is stable but sleeping (if stable) and that I would chart my assessment with whatever med pass was due next. Of course if the patient I received report on appeared to be at risk of complications or appeared unstable, I would wake them and do an immediate assessment i.e. post ops, respiratory problems etc. What is everyone's practice for the 8 hour overnight shift? Thanks!

Bahaha! Love this!

Looking for words of encouragement or advice about returning to work after having my beautiful baby girl. I am very anxious about going back to work after having been on light duty (secretary work and discharge phone calls. No patient care) for several months and having been out on maternity leave for 6 weeks. Anyone else experience anxiety about returning back to work? I worry that I have gotten out of the flow of things. I work on a med surg floor. Plus I am going to overnights from days.

I know it is a really long post but I appreciate the time you are taking out to critique it! Thanks!

You have to let the little things go. So what your house isn't clean, your laundry is piled up, and the kids ate McDonald's three times this week. Study hard party harder AFTER the test. Take a deep breath and remember other's have struggled through the same and look where they are. Most of all love what you do and do what you love. If your heart isn't in this then it is hard to find the motivation to continue!

For a while I was placing a science board on the table and this would be my family's cue that I was unavailable. That did not work for more than a few weeks I have since started planning my sleep schedule so that I go to bed early so that I can wake up early. The morning hours at my house are some of the best times for me to study. You can also try to study during your breaks in classes rather than going on your phone and checking your Facebook Also try going to the local library. If you have kiddos, a fast food place with a playground is a good alternative to being at home. It gives the kids something to occupy their time rather than bugging you!

One of the mantraes of nursing school is: "Follow your hospital's policy!". This is certainly true of laboratory values and diagnostic tests. Most of the time your nursing program will give you the normal ranges for the laboratory values and diagnostic tests. Personally I suggest that you save yourself the money and go to this website: Lab Tests Online: Welcome! I use this site all the time for my clinical and nursing classes. The other suggestion I have is to write down the values that your program deems as normal on a couple of notecards. Create one for clinical, lab, and lecture and keep it with you at all times. This helped me to learn the values and keep them fresh in my mind. Hope this helps!

Hey guys, its that time again....nursing care plan for clinical are due I have put together two care plans and would appreciate a critique or suggestions of what I could do better. The two I have put together are for a 91 yo Male recently diagnosed with CHF who was admitted to my floor with Dyspnea and CHF. [TABLE] [TR] [TD]#1 Priority Nursing Diagnosis: Decreased Cardiac Output[/TD] [/TR] [TR] [TD]Related to: alterations in preload, afterload, and myocardial contractility associated with the cardiac condition causing the heart to fail. [/TD] [/TR] [TR] [TD]As evidenced by: Subjective data: The nursing home staff reported the patient was SOB and confused. The patient stated upon admission that he had CHF. He also informed the admissions nurse that he was on oxygen at home. Objective data: Elevated BUN 34; Elevated Creatinine 2.1; Increased BNP indicative of CHF 17,772; Stage II pressure ulcer on the left heel and a stage III pressure ulcer on the coccyx; Decreased H&H 10 and 32; Decreased Albumin 1.6; The patient did not move from the bed during my time with him; He had to be changed 2x because he was unable to get up and go to the restroom. The patient received 4LO2 via NC; [/TD] [/TR] [/TABLE] [TABLE] [TR] [TD]Nursing Outcome (2 outcomes that are pt objective, measurable and time defined)[/TD] [TD]Nursing Intervention (NIC) (At least three interventions/outcome)[/TD] [TD]Scientific Rationales for Interventions [/TD] [TD]Evaluation of Outcome [/TD] [/TR] [TR] [TD] The client will demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate, and rhythm within normal limits for the client; maintain strong peripheral pulses throughout the shift on 03.11.2013. [/TD] [TD] Monitor I & O 3x a day 0700-1400, 1400-2100, 2100-0700. Assess the client for signs of decreased cardiac output; listen to heart sounds, lung sounds, JVD, BP, HR. Monitor the BUN, Creatinine, BNP, and potassium. [/TD] [TD] Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output. These things are criteria for diagnosing and monitoring HF. Monitoring potassium and kidney function are essential to minimize the potential for life-threatening hyperkalemia that can occur from renal insufficiency, advanced age, and advanced heart failure. BNP monitors for how far HF has advanced. [/TD] [TD] The client's BP was within his normal at 124/67. Pulse remained within normal for the client at 92. Peripheral pedal pulses were +2 and radial pulses were +2. No JVD noted. BUN and Creatinine remained elevated and the potassium level was low. The outcome was met. [/TD] [/TR] [TR] [TD] The client will have improved cardiac output as evidenced by unlabored respirations 15-20/min; no change in mental status during the shift on 03.11.2013. [/TD] [TD] Assess the client's respiratory status q2hr. Administer IV fluids as ordered and observe for s/s of fluid overload. Place the patient in Fowler's or semi-Fowler's position. [/TD] [TD] A change in respiratory status may indicate further complications of the client's HF. In the client with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volume. This position may decrease the WOB and may also decrease venous return and preload. [/TD] [TD] The client continued to have respirations of 17/min with 4L O2 via NC. His mental status did not deteriorate during my time with him. The outcome was met. [/TD] [/TR] [/TABLE] NURSING CARE PLAN #2Nursing Diagnosis [TABLE] [TR] [TD]#2 Priority Nursing Diagnosis: Impaired Gas Exchange[/TD] [/TR] [TR] [TD]Related to: Cardiopulmonary dysfunction secondary to a cardiac condition causing the heart to fail[/TD] [/TR] [TR] [TD]As evidenced by: Subjective data:The nursing home staff stated that the client was confused and SOB. They also stated that he may have aspirated something while eating. The client stated that he was SOB. Objective data: The client is on O2 in the nursing home. Hx of chronic intermittent hypoxia, asthma, CHF, and pneumonia. The client has bibasilar rales and bilaterial rhonchi. X-ray of the chest shows pulmonary venous congestion that indicates there is pulmonary edema. HR 92. Respiratory rate 18/min. O2 95.[/TD] [/TR] [/TABLE] [TABLE] [TR] [TD]Nursing Outcome (2 outcomes that are pt objective, measurable and time defined)[/TD] [TD]Nursing Intervention (NIC) (At least three interventions/outcome)[/TD] [TD]Scientific Rationales for Interventions [/TD] [TD]Evaluation of Outcome [/TD] [/TR] [TR] [TD] 1. The client will maintain adequate oxygenation as evidenced by a pulse oximetry reading greater than 90% on 03.11.2013[/TD] [TD] Monitor the client's oxygen saturation q2hr by pulse oximetry. Position the client in semi-Fowler's. Maintain low-flow oxygen therapy; 4L via NC. [/TD] [TD] An oxygen saturation of less than 90% indicates significant oxygenation problems. Being in a semi-Fowlers position increases oxygenation and ventilation. Low-flow oxygenation helps to prevent hypoxemia [/TD] [TD] [/TD] [/TR] [TR] [TD] The client will maintain a normal respiratory rate and rhythm; lung sounds will be clear during the shift on 03.11.2013. [/TD] [TD] Monitor respiratory rate, depth, and effort. Monitor client's behavior and mental status. Administer the client's Levalbuterol (Xopenex) 1.25mg q4hr as ordered. [/TD] [TD] Normal respirations in an adult are 15-20 breathes/min. Less than 15 breathes/min indicates respiratory distress. Changes in behavior and mental status can be early signs of further impaired gas exchange. Levalbuterol is a bronchodilator. It helps to decrease resistance in the bronchi and bronchioles in order to increase airflow to the lungs. [/TD] [TD] [/TD] [/TR] [/TABLE]

They didn't do one strangely enough. I suppose the patient's admission of being immobile for nine days was enough for them to do a doppler of the leg. Honestly the site of the DVT is hard to dismiss as being anything but a DVT