BackInTheGame

We d/c unused pain meds too and our DON is the only person who has the authority to destroy d/c'd meds with the facility supervisor as witness. What gets me fired up is a doc who d/c's pain meds that ARE being used on a regular basis. Had a pt once who's pain assessment was always in the 8-10 range with Lortab taking it down to maybe a 3 and Ultram only taking it to a 5-6. The doc decided that the pt couldn't possibly be in that much pain and d/c'd the Lortab and Ultram and left us with nothing but Tylenol q6h. This is also the same doc who told me that the liver problems I have (non-alcohol steratohepatitis) can't possibly cause pain either. Hmmmmm guess who is no longer my doc.. lol. The pt has asked repeatedly to see the doc face to face but all the doc does is come in, review the chart... which btw has qshift pain assessments and documentation of pain meds and effectiveness... and then quick as a flash is gone from the unit. The doc even admitted once to our DON that she didn't like her job... ok that's fine, but why take it out on patients who are dependent on her for care?? I just don't get it.

I personally would wonder why the aide is so adamant about you not asking the RN about it. I agree with so much that has been said here and one can never overemphasize the need to DOCUMENT DOCUMENT DOCUMENT!! Maybe you could say something to the RN quietly. You're leaving anyway so maybe say hey is there any advice you could give about my performance or in areas where I could improve... I dunno.. something along those lines.

You said it happened to two others. Any times where she said that and it turned out not to be true? The way I see it, if she's 100% accurate, then cross your fingers and get ready for a lot of congratulations. Yes, I think that sometimes people, and not just the elderly, have a kind of "instinct" when it comes to things like that. Best of luck to you!!

The woman to whom I was referring demanded to get up out of bed. She wasn't forced, nor is any patient in the facility forced to get up or sit up all day. According to her, she wasn't raised to lay around in bed all day and as long as she had her say, she'd get up every morning. She also had severe kyphosis and was unable to sit up straight. Laying in bed was uncomfortable for her and sitting up and leaning was how she preferred to be.

We have floor mats for fall prone residents when they're in bed. They're like larger versions of kindergarten mats so they fold up in thirds to make getting to the bed a lot easier... some times.

Ok this is going to sound horrible but there are times where I miss restraints. Not for my convenience but sometimes, they are needed for patient safety. We have a ZERO restraint policy and we get yelled at just for putting both siderails up on a bed. We've been able to reword some things, like lap buddy's being an assistive device (they're listed as restraints at our facility). One doc thought it was used to restrain someone until he saw the resident without it and realized that she constantly leaned forward in her chair and it really was necessary not only for her safety, but also for her comfort. Without it she leaned across her overbed table all day. I miss the days of being able to use a soft vest for someone in a chair. Instead we've become experts at the one second sprint across the unit to catch someone who thinks they can still stand unassisted. Had to send a pt to the ER the other night because her mind refuses to wrap around the fact that she needs help transferring. I agree that restraints, as a whole, should be avoided at all costs but sometimes they truly are necessary.

Yeah, it's the same here. Multiple med passes even though we try to standardize times, there's always those who need meds at "odd times". On my unit a full house is 35 patients. On my 3-11 shift, I'm the only licensed staff so med orders aren't an issue but they do have a similar problem on day shift. Usually there is a charge nurse plus one other LPN. Usually she's really good about putting orders in the MAR when the med nurse is in a pt's room. But for me, I don't mind someone interrupting me to add med orders or change existing ones. I'd rather be interrupted than have a med error. I also agree that there are times, especially when the floor is extremely busy and the orders directly impact that particular med pass, it's ok to delegate. Seems to me that if you hand the task off, it's no longer your error although I can see why your DON is saying it is. I guess the rationale is that YOU are the charge nurse, therefore you should have some kind of psychic power or ability to enter someones mind and MAKE them do the orders, and obviously your DON must think your transmitter's broken. Sorry, poor attempt at humor. What I want to know is, how do you deal with the fact that most of the time, when you step up to the med cart, families and patients come out of the woodwork with all kinds of questions, comments, and requests. I've tried everything I can to tactfully convey that when I'm at the med cart, I really need to give the meds my full attention but to no avail. Any suggestions?

I agree. When a person is admitted for "comfort measures", then give them COMFORT, whether it be narcs or not. We have families not wanting us to put family members on oxygen because they consider it "life support", but when we explain that it's a comfort measure, to help them breath easier and allieve anxiety, they usually agree with us that it's ok. Why should people be so against narcs when it's so obvious that they're needed? If only they could see through the eyes of the patient.

NOT counting narcs??? Never heard that one before. We have a doc that refuses to believe that her patients have pain. We fight tooth and nail and toe to toe with her over this issue. She won't even let us give Ultram without a fight and actually went through the unit one day d/c'ing every pain med on her pts. Unfortunately she is in my doc's practice and occasionally I end up having to see her. She tries to tell me that the NASH I have doesn't cause pain. Yeah right.. let me give it to her for a while and see how SHE feels. Sighhhhh.. I agree though, if a person is nearing end of life.. give them whatever is necessary to ease any discomfort they may have. What's it going to hurt? One kind of funny thing though (not ha ha funny but still... ). Had a pt.. end stage cancer.. refused pain meds because as she put it "I don't want to be one of those junkie people". God love 'em.

Last time State showed up on our doorstep, it was because of a family complaint... later proved to be totally unfounded. One of the RN's was getting a census sheet for shift change and someone came up and asked if we had daily census and staffing sheets and asked how many residents we had and all kinds of pointed questions. Well, the RN looked this person over from head to toe and said "And you are????" Yep, that's right... busted a State surveyor for NOT wearing identification!!! Yay score one for our side.. lol. Well that set the tone for the rest of the survey. Showed them that we paid attention (ok so it was only that one time but still.... LOL) and that we were pretty good at not being intimidated... well... at not SHOWING it at least.

Oh and one more VERY important thing.... DOCUMENT, DOCUMENT, DOCUMENT!!! If the person is verbally abusive to staff or others, quote every word... even the four letter ones.

Oh God love the sundowner's because sometimes it's hard for the rest of us to. As far as #1 "problem child" goes, I agree with a lot of these suggestions. Had one like this, major league blow ups around 8pm. Luckily his doctor happened to be on the floor at the time and actually got in there with the rest of us to wrestle him back in his chair (it eventually took six of us!). She ordered a STAT one time Haldol order and then sat down with all of us to get our suggestions. He ended up being put on several meds but none of them worked well or worked for more than 2 or 3 doses. Now though, he's declined to the point of being bedridden and just doesn't have it in him anymore to get agitated. I told the others though, watch out when he does go off again because that's not going to be a good sign. As for #2... if all medical roads lead to nothing majorly wrong, then it could be anxiety related. Had one similar and after the doc put her on 0.5 of Ativan every evening, things drastically improved. She's happier and we all get a bit of a break. The dose wasn't enough to sedate thank goodness, but it was enough to calm her. Best of luck.

I agree with you on "report books". Ours simply contains the census sheets with our notations that are passed along in report. We use the census sheets rather than a kardex. As a matter of fact, we don't even use a kardex. On our Rehab and Recovery unit, the census sheets are used to give report and then shredded. A lot of the nurses keep their own "report books" and make sure they're locked up at all times. Most of them do this to avoid having to say "HUH??" if our DON comes to them and asks about something that happened months before. Good idea actually. They also use their books for charting purposes and make sure that the factual information is in the nurse's notes. Other than that, they keep notes on feelings, attitudes at the time, the floor census, and staffing for that particular time. Some facilities strongly discourage this practice but I, for one, think it makes sense in the long run.

oh yeah i definitely agree. give me a floor with good aides and i am one happy camper. luckily i'm on a unit like that now. the two "regulars" are top notch and when they're there i know that it will be a good evening. that's why i know tonight will be good because i know that one of them will be there and our "fill in" is a-ok too. never be afraid to say i don't know and never hesitate to ask for help. i started out as an aide and nothing made me feel more unappreciated then when an lpn or rn felt "too good" to ask an aide for help. i'm not saying that that is what anyone here is doing... i'm just saying that sometimes, that's how it's percieved.

i just realized that it sounded as if i was unconcerned with the death.. i wasn't. the supervisor was handling the details and making the calls and the room was filled with family and staff who were close to the woman. i'd leave the room occasionally, give out a few meds to keep from getting too far behind (i have a 35 resident unit to care for), and then i'd go back to see if the family or supervisor needed anything. it's just that after re-reading my post, it sounded a bit calloused to me. mental note... preview first... then post.

just had to add my two cents worth here. the nursing school i attended was run in cooperation with our local hospital which is a small rural facility with a 111 bed ltc facility attached. as you can imagine, our course work was geared towards geriatrics. we got maybe a week of peds, a week of or, ob, etc. and the main emphasis was ltc. as an 18 year old brand new lpn, this was definitely not where i wanted to be. now i'm 35 and can't imagine working in any other area. there are times i've daydreamed about working somewhere with more decent hours, weekends off, etc., but still i stay. in a lot of cases, we're severely understaffed, overworked, and of course, underappreciated but then, just when you're ready to throw in the towel, a moment happens that makes it all worthwhile. today was a good example. i've always worked 3-11 (i hate alarm clocks lol) and i knew that today would be hectic. we had a feisty little lady who was on her way out but she'd been stubbornly hanging on when most would have given up and gone on. last night she spiked a temp of 106.1r and we knew then that it wouldn't be long. at 1530, with her son holding her hand, she took her last breath and slipped quietly away. her daughter arrived not long afterwards and i met her in the main hallway. even though i had meds to pass, calls to make, and a million other things to do, i walked up to her and she hugged me as if she'd never let go. "all i can say is thank you." needless to say, we both shed more than a few tears and i spent the rest of my shift knowing that to one person at least, i had made a difference. someone tell me to shut up now.. lol

i think that laws encouraging leaving newborns at firehouses, police stations and hospitals should be in place in more states. it sure beats the alternatives. several years ago a baby was found lying on a curb under a row of hedges. she probably wouldn't have been seen at all if it had been summer. as it was, the leaves had thinned out considerably and she was visible to a passer-by. how this little girl survived as long as she did is a miracle in itself. when she was brought to the hospital she was severely hypothermic but she obviously had a strong will to survive and she completely recovered without any permanent damage. this little girl is now 12 or so and doing fine. every once in a while the local news brings this back up, especially when legislation involving abandonment is in the works. i'd much rather hear about a baby being left at a hospital than being found in a mall trash can or dumpster. i say it's a good idea and more states should adopt legislation to help women who feel they have no alternative.

yeah thanks. just found a reference to iv administration in an article about meds and vent patients. guess you really can learn something new every day.. lol. yeah i know that's true, especially in this profession but just had to actually say it anyway

im and po here. i've never seen an iv haldol solution and when i just looked it up, im and po are the only routes mentioned.

we have one smoking area designated for employees, and like i said earlier, it's way out in bfe near the helicopter pad. we aren't allowed to wear name badges there... like no one knows we work in the hospital because we're not wearing a badge lol. the patients and visitors have a separate area and this is what i think is rediculous... it's right next to the employee entrance.. lol. cars can be smoked in... as long as you're not on the property. so far, no one has complained about having to clock out but it's the fact that the company is dictating how we spend our precious allottment of down time during the shift. i know for a fact that before this policy was in place, 90% of all of the smokers would have one cigarette during meal breaks. that constitutes approximately 10 minutes. the rest of the time of course, is spent trying to sit for a moment in between answering call lights. i guess we can't really complain though. in another facility, employees who smoke have to walk about a block away from any entrance and stand under a bridge in a not so great area of the city. it just bothers me that facilities think that a person can be forced to give up an addiction.. or habit.. whatever name you choose to call it. i'm involved with someone who was addicted.. well he still is but now he's in the "recovering" category.. to cocaine, marijuana, alcohol plus numerous prescription meds.. vicodin and ms contin to name but two. now that he's recovering, he smokes. did before but now it's his only vice and i wouldn't dream of asking him to give that up before he's good and ready. lesser of two.. or more.. evils? perhaps, but the alternatives are scary.

in our facility we're not even allowed to use haldol. face it though, sometimes it's necessary and thank goodness we've got one doctor who says "if someone has a problem with my order, tell them to come to me." i agree though, if it says im only i don't give it any other way. we had one doctor order glucagon 50ml im.. i was like ummmmmmmmmm no! she argued with me and said to give it because she said so.... i once again said no way, not gonna happen. told her if she wanted a 50 ml dosage given im, that she could do it. of course, she wouldn't and if she had tried, i would have done all within my power to stop her. she finally listened to the pharmacist on duty and changed the order. meanwhile we had someone who couldn't take anything by mouth, had no access anywhere else, no iv, g-tube or anything... with a blood glucose of 36... sighhh needless to say, we were able to finally convince her to let us start an iv and get his sugar back up. scary time though when a doc won't listen.

well now, for me, nursing as a career started out as my grandfather's dream. well, he wanted my mother to become a nurse and when she didn't, it fell to me. i began nursing school while a senior in high school. i graduated high school at age 17, nursing school at 18 and was a charge nurse before my 19th birthday. boy was that a mistake that was. got totally burned out before i turned 21. couldn't make myself even drive by a hospital or nursing home for years. two years ago i started working in the kitchen of the local hospital, mainly to prove to myself that i could actually walk through the doors day after day. actually got a look of satisfaction from one of my nursing instructors who is now a hospital volunteer. back when i was in school she said i should quit and become a secretary or something. well basically, that did it. worked my hind quarters off and renewed my lpn and luckily enough people with whom i'd worked before still worked at the hospital but were now in positions of directors and supervisors. our don was willing to give me a shot. now even on the craziest, most hectic days when nothing is going right, i can't see myself doing anything else. i love my job and although this may sound boastful, i'm good at what i do. i guess it took those years away from it to realize just how much i'd missed it all. it also took that time to develop the confidence and assertiveness it takes to deal with doctors, other departments, and families. i've learned tact and diplomacy and now i actually have family members and patients seek me out on a daily basis. had two ladies tell me that i was no longer allowed to have days off lol. i've learned to tolerate other nurses who get upset because i have a good rapport with doctors and families. i simply am who i am and do not appologize for it. not every day is perfect, and not every patient's story has a happy ending but i like the fact that i've made a positive difference in so many lives and on so many levels. wouldn't trade that for anything in the world.

i have a co-worker exactly like this. she'll get urine specimins and then say that we need an order to send it to the lab. ok so what's stopping her from getting the order for a u/a when she's the one who obtained it? usually by the time i get on the floor at 3 the specimin is room temp at best and i for one, refuse to get an order on urine that's already been collected by someone other than me if i have no earthly idea how long it's been sitting around. i also hate the fact that she leaves it just lying on the desk without bagging it. yuck. several evening nurses don't say anything because she intimidates them but i refuse to go down for someone else's oversight. it's one thing to say "hey so and so is having some dark or cloudy looking urine, you might want to see if it happens again and maybe get an order for a u/a." fine, i have no problem with that but don't leave your work for me to do. i'll gladly stay over to make sure all my work is done. to me, it's only fair that i finish what i started so what makes her so daggone special, right?

thanks. wrote this after having "one of those days". tonight though i got pulled from my normal duties to patient care and let me tell you, it was fun. we have one fella who has end stage colon cancer with mets everywhere imaginable. usually he's our "problem child" but tonight he had us all laughing until our sides ached. it's amazing how those we try to heal end up healing us just when we need it most.

southwest.. or central, depends on where you draw the line. little nothing city of bedford, which is halfway between lynchburg and roanoke. our hospital is jointly owned by both carilion and centra health systems. carilion makes all our policies though.