abooker

I tell them that the Airway, Breathing, Circulation hierarchy we are taught to focus on seems completely irrelevant to a patient who lacks the capacity to enjoy it. The traditional disciplines help them medically, but we help them make it all worthwhile again, so they can meet their personal goals. I believe psych nursing may hold the key to our next leap forward in health care. "Normal" patients are making unfortunate and irrational compliance and lifestyle decisions which contribute to repeat hospitalizations, even with the new technologies. The psych population may hold the key to addressing irrational decisions.

They're "flicking" you. I think flicking might be appropriate or even necessary if someone needed their egos deflated just a bit to keep the team functioning well and keep things safe. But some people don't do it correctly, or do it to coerce excessive cooperation. Sometimes there is Munchowsens or some other pathological condition.

Hi. I'm an ADN -RN, and I'm only three months into my first job, so take my advice with a grain of salt. I wasn't going to post, but I don't want you to feel like your concern is being ignored. If you're receiving consistent feedback that you look stressed or frazzled, then you look stressed or frazzled. If you feel calm, then you are calm. The two are not mutually exclusive. I am helping a pt with "smiling depression". Maybe you are her opposite? I think this is like that age-old question my husband dreads; "Honey, does this dress make me look fat?" There's no way to answer it correctly. If he says I look heavy, then he feels like he has insulted me. If he says it looks wonderful, then he feels like he has been manipulated into complementing me. Either way, he feels bad. But really ... I want to know if I look ok, and that's frustrating. He won't elaborate if I ask what about the dress makes me heavy, so I can find something in a different style. Would I insult you if I asked what you thought about investing in some psychological testing? They have scales that might help you get a grip on how you and the world interact, and discover if there really is a disconnect. Please consider stepping on a scale. Personally, I think you're brilliant. You're on a med-surg unit on day shift, so you've got the MDs and visitors and meals and ADLs and all sorts of crazy things happening, and you haven't even been there a year. Management might already be leaning on you to join various committees and you know your co-workers well enough that there is the inevitable social interruption to look at pics of the new grandchild or listen to someone's bout with a kidney stone. Looking frazzled would be a great time management tool. Your excellent clinical skills, knowledge and interpersonal skills cannot be compromised for the sake of time, but looking "uncalm" is a great non-verbal cue to others that they need to let you scoot on to your next task. I think you have a *great* look, and if you figure out how you do it, please let me know. I need to copy you during the med pass, so folks will only interrupt me if it is urgent. :)

Took mine September 1, 8:00am and found out I passed at 8:00am central time this morning. I checked at 7:52 central time, and it wasn't up yet.

I feel your pain. Could there be such a thing as a "good enough" nurse? Winnicott from developmental psych class theorized the "good enough" mother. Good nurse, bad nurse is all-or-nothing thinking. Things appear in black and white categories, and if performance falls short of perfect, it feels like total failure. Passing meds on 40 residents absolutely cannot be done without rushing from start to finish. That is part of the job. Are you taking breaks? My friends started dragging me off the hall for 15-minutes every morning, even though I didn't have time. This actually resulted in my finishing my med pass earlier, because I could think more clearly. (And the caffeine was a help, also.) Assessment - Do you have everything you need before you begin? My NM was happy to buy my "neighborhood" a large blood pressure cuff when I let her know I was spending 15 minutes every morning playing hide and seek on our rehab unit looking for the one belonging to the facility. Do you know where your residents are? I had to learn that on Tuesdays some of my people go out into the community in a van for activities. On Wednesdays and Fridays, the beauty shop is open. On Sunday mornings there is a church service. Before, I was all over the building looking for them. The resident's rights of medication administration, can you honor those? Some facilities will avert their eyes if you pre-pop several med cups. At other places, this will get you fired. What are the "bad" nurses doing? Maybe something they are doing isn't completely naughty? If there is an Employee Assistance Program offered by the workplace, maybe this would be helpful. It could allow you a place to vent, and they're already familiar with the environment where you work. And it's free.

Just record it. The data does not flow anywhere, as far as I was able to determine. But the DON had about six inches of printouts so it goes somewhere. Maybe to the MDS? I think our entire eMAR was designed to feed the MDS. The clinical side seems set up for rehab or a more acute population.

I am a charge nurse in LTC, doing the medication pass, treatments, physician's orders, etc. We have an eMAR. So I'm in the middle of my med pass, and I discover that one of our nurse managers has suddenly edited a lot of medication orders. She set things up so if you're giving Mr. X atenalol you can't check it off as "prepared" or "administered" until you first document blood pressure and pulse. If you're giving Mrs. Y lisinopril and digoxin, you have to chart twice, one for each pill. This is not a person you question the decisions of. You keep your mouth shut and just deal with it. Or else. I'm not saying vital signs aren't important. Physicians have already given us monitoring instructions for many residents with cardiac issues. These are entered under "ancillary" orders and pop up on our screens once per week, to be done at some point during day shift. I stopped taking these daily vitals. I thought they were unnecessary and reduntant and a disruption to work flow. Peers on other shifts and on my days off also stopped. We independenly discovered a workaround that would let us get our work done without getting all these vitals. Rather than click on the little monitoring icon and go under "vital signs" we could go under "free text" and put something, aything there. I used a little dot "." The Acting Director of Nursing did not like the little dot. His paperwork says, "failure to properly document in a medical record and failure to follow physician's orders." He absolutely refuses to discuss it. I had always thought of a physician's order as something that comes from the lips or from the pen of a physician. I have not been able to locate a standard of practice for blood pressure medication in long term care residents (stable health, taking med for years ...). What should I have done differently to avoid failure in this type of situation? We can't do these vitals and administer these meds in a timely manner with our current level of resources. Current plan of action: 1). Delegate medication vital signs to CNAs at start of shift 2). Discipline all CNAs who fail to provide vital signs in a timely manner 3). Discipline all CNAs for failing to help residents prepare for breakfast in a timely manner 4). Discipline all CNAs who fake vitals 5). Wonder why nobody wants to work here.

In Missouri, our school gave us a letter stating we were GNs so HR departments would let us work while awaiting the licensure exam. I take mine September 1st! :)

You're correct - DNR means we will not intervene if this patient arrests / codes. That is one type of advance directive. There are others, that include non-treatment. Not putting a tube in this man is absolutely legal. He has a right to exercise his autonomy in receiving medical care, and his family has a right to exercise such autonomy on his behalf since he is incapacitated. Karen Ann Quinlan was a patient who prompted the discussion which resulted in the laws that govern such decisions today. He is at the end of his life. We are not prolonging his death. This is an entirely different situation from killing someone - like administering a lethal dose of morphine. We aren't killing someone, we are allowing him to die. Different thing entirely.

Maybe it is one of those culture change initiatives, where offering the client anything but the cleanest, purest substances indicates a lack of client-centered care?

Flu vaccine time, for the seasonal flu. My nursing home offered it to staff first, then the residents, and in a couple of weeks, we'll be offering it to the general public. I've been thinking about pandemic flu ... surfing the World Health Organization web site. http://www.who.int/csr/disease/avian_influenza/country/en/ If bird flu (H5N1) mutates so it can be transmitted person to person and starts killing millions, who should get the vaccine, and when? There will be two shots, 21 days apart, and there won't be nearly enough for everyone. I have Steve Taylor's "Lifeboat" playing in my head. Is there a disaster plan in place for a flu pandemic?

Here's a different point of view, blaming the hospital: http://www.sgvtribune.com/ci_10563882?source=rss_emailed About 50 out of 3,200 workers were caught. This post contains a comment by someone working for the hospital system. They wrote: I work here and was stunned to hear about this as I know several who I work with also terminated. I am so embarrassed by their behavior and ashamed that professions (not just registered nurses were fired. Not sure if news knows about this) were highlighted in all the news. All I can say is that the behavior of those fired DO NOT reflect at all on nurses as a whole and by far there are many more honest workers with solid work ethics than the 4 dozen mentioned. http://abclocal.go.com/kabc/story?section=news/local&id=6366941

I managed to find three free flashcards claiming to help prepare for the HESI http://www.flashcardsecrets.com/hesi/samples.htm I couldn't find any public domain questions. There might be something at academic libraries or nursing school media centers. HESI is a product of the publisher Elsevier, so I'd be shocked if you found anything out there for free.

There don't appear to be any acute problems. She's been evaluated for lots of things, as she has been to the ER three times since Mother's Day. Good to know there are LTC behavior units out there. I was thinking she'd be sent back out to a hospital where staff are trained to deal with acute problems, and they'd release her to a nursing home, who'd send her to a hospital, who'd send her to a nursing home, and she'd spend her final years as a human ping-pong ball, at least until the dementia gets her. My facility has a locked "memory unit" and all the staff here are trained to deal with Alzheimer's-type dementias. Her issues are different. "Therapeutic lying" does *not* work with her!!! :) Good to know there are folks out there who know what they're doing when trying to provide a home for people like her. Thank you.

I have new nursing home resident with a looooooong history of unstable interpersonal relationships. She has the usual physical problems you'd expect in LTC - mobility, ADL's, multiple meds, some dementia ... but the primary problem is IMHO her difficulty coping with being in a nursing home. I know it's a huge adjustment - Nobody says; "Hoooray! I get to say goodbye forever to most of my independence and most of my posessions!" Most of our newbies withdraw for awhile, then gradually adapt. My new resident is not like most. She's been deeply involved in all the activities since Day 1. She expresses extreme fondness for a staff member, then later describes that same staff member as completely worthless. She does the same thing with herself. She complements herself on her beauty and her talents, then later says she feels ugly and worthless. She binge eats, and she hides liquor that her family brings in her room. (She's limited to one drink per day since she's on lots of meds and is a brittle diabetic, and we're supposed to keep it locked up in the med room). Today, she told me that she knows how to commit suicide by using her insulin. I told her I'd *definitely* be keeping my med cart locked, and we both laughed, but there's truth in all humor. The root of this lady's problem, as far as I can determine, is that she isn't getting everything she wants all the time. She doesn't appear to see this as unrealistic, but as more of a communication issue. She seems furious at her family, friends, society, and me for not "getting" what it is that she wants and needs and deserves. Clearly, we're all morons, but she loves us anyway. My problem, as far as I can determine, is that I enjoy working with this lady and I don't want to lose her. Unfortunately, we've had to send her out to hospitals several times. Once, she ended up on a behavioral health unit. She's now asking me to set up several outpatient appointments for her to see various doctors, even though we have the same kinds of doctors that visit the facility. I believe she plans to elope - get out of the building and convince some ambulance crew or transport van driver to drop her off at her house. She's incontinent and almost total care, so home health can't take her back. Her family is physically and emotionally unable to provide the 24/7 care she needs. Our social worker has suggested that maybe LTC is not the appropriate environment for this lady, and maybe she needs to live out the remainder of her life on a psych unit. I didn't even know there were places like that - long term care psych? I'm meeting with the social worker and perhaps the family on Monday, doin' the "care plan" thing. Any suggestions for goal-setting here? Resident's goal is to go home; family's goal is to keep her from going home; my goal is to get her to accept the fact that she *is* home, and the social worker's goal is to send the resident somewhere else. I have no idea how to advocate for this lady, or if a psych unit could take better care of her than I can. I'm afraid for her, because some of the psych patients can be a danger to self or others, and this lady has an amazing capacity to find someone's emotional buttons and push them. Help?

What does a good nurse manager look like? I imagine low performer nurses on the hall leads to low patient satisfaction and low nurse morale, which leads to low manager morale and low performing managers. I certainly wouldn't go to them and say; "You're terrible" or try to go above their heads. I imagine there are powerful people believing all they need is new floor nurses. Would it be possible to grit your teeth and try being positive and encouraging to management? Sometimes they just may not know what you want from them. (If you want them to jump off the nearest cliff, maybe this is a good thing.) Is there anything you find tolerable about one of your managers? Is one of them doing something ... even some little thing ... right?

Thanks for the video. Always helpful to share different perspectives. People laugh at what makes them uncomfortable, and the whole topic of male modesty is uncomfortable. I'm not surprised that many of us have never heard a male patient complain, and certainly never heard a female nurse admit to it. But just because we don't know about it doesn't mean it hasn't happened and that it won't happen again. If most of us haven't heard of a male patient complaining about his treatment by female nurses, or about sexual improprieties, does that mean it does not happen? I don't think so. Victims of sexual assault rarely speak out, especially if they're male. If we don't leave ourselves open to the possibility that some men might feel modest, or anxious, or even violated by females, just as some women might feel that way about men, then that makes us less effective nurses.

Ghaaaa! I don't want to believe the hoarding might be a cost-cutting issue. I've heard there are facilities like that, but thankfully mine isn't one of them. From my standpoint, it looks like a supply chain issue. After my scavenging expedition, I'd be tempted to hoard critical supplies under my desk, too. A comfort measure, so they'd be there if I and mine needed them. I'm thankful to whichever coworker stashed a cannula in with the personal supplies so I could get the job done. Gotta remember to put another one back there. I have lots and lots of supplies today, just where they should be. My resident is in the hospital, but doing fine. Life is good (today). Thank you all for your words of support.

I'm having trouble communicating with management. One of the 27 residents on my hall had been having what all of us assumed was a psych issue all night. She was agitated and hallucinating and had a psych history, so nobody apparently had thought to do the head to toe assessment thing. I had two med passes and two other residents I needed to call doctors on, so I dragged the nurse manager out of her office so she could help me with this. I was most likely rude to her. She kept telling me what I could theoretically do for the resident, when what I wanted was practical, hands-on assistance dealing with the issue. Apparently, the NM didn't do the head to toe assessment thing, or check her vitals. I'd assumed it was done on night shift and by the NM, and I did it at the end of my shift just so I could chart it. This lady's oxygen saturation was 84% on room air. I rushed to get an oxygen tank. There were no nasal cannulas for oxygen in the clean utility room. I went back to our Med A unit. I was told to check a different supply room on the Alzheimer’s unit, and that I’d need to find a key. Many nurses on Med A don’t share resources with LTC. Various nurses, several times, have reminded me that we’re a drain on their resources because they make a profit and we don’t. I hunted down the nurse on our Alzheimer’s unit, who opened the supply room for me. There were no nasal cannulas in that room, either. The nurse explained that since our supply person was out, we didn’t have many supplies. I didn't know our supply person was out. When I've had similar problems before, our supply lady has told me we nurses take everything and hoard it, and then accuse her of not stocking it. I went back to other halls, and ransacked until I found a nasal cannula. There was one stashed in a pocket of a laundry cart, between the antifungal cream and the toothbrushes. I returned to the clean utility room for an oxygen tank, and discovered there was no valve I could put on the tank. I went to another resident’s room who used oxygen for meals, and took the valve from his tank, since he was using his concentrator while in his room. His tank was completely empty, or I would’ve used that. The green seal from the new tank did not fit the valve from the resident’s old tank, so I couldn’t put it on. (The night shift supervisor showed me quite recently that there are different sized seals; they’re not all interchangeable). I went to another resident’s room who was out in the dining room with a tank, so I borrowed her concentrator. I put the hallucinating resident on 2 liters of O2 via nasal cannula, and her sats went up to 96% on 2 liters. She calmed down and began making sense. I gave the nurse manager the vitals I’d collected. I’d started to chart them myself, but got flustered when I noted no vitals had been charted since I’d taken them, four days ago. About this time, the DON came by and asked if we needed any supplies. I assume the nurse from the Alzheimer’s unit had called her. The resident whose concentrator I’d borrowed needed it back, so I asked the ADON about a valve for a tank. She had a new one under her desk. It sounded like she had a whole box of them under there. I put the new valve on, but it didn’t come with the green “Christmas tree” cone to connect the cannula to. I went back to the ADON who said she’d seen a little bag of them somewhere in the clean utility room. I found the bag I hadn’t seen before – it was opaque -, applied the oxygen, returned the concentrator. At some point, I gave the resident whose valve I’d tried to borrow a new tank of oxygen and hooked it up with his old valve, after digging through the trash to find the old seal. This morning, I went to our administrator to tell her this story. I was hoping she'd be willing or able to address the scarcity issue that has been explained as a series of isolated incidents. I’ve done the “chain of command” thing before, and the nursing folks seem to view the problem as how I handle stress. I have an “external locus of control”, and maybe I should talk to an EAP counselor and do a little Cognitive Behavioral Therapy. The administrator said something similar. This was an isolated incident. She understood how I might feel stressed, and pointed out that I could’ve used some equipment on the crash cart. I know I screwed up. Nursing Fundamentals – first semester, second lab. Always, always do a head-to-toe assessment, first thing, with any change in behavior. I got caught up in the med passes. And I guess I could have used the equipment on the crash cart. I’d assumed it was for true medical emergencies - the 911 kind. And I shouldn’t have expressed frustration to the NM, the ADON, the DON and the Administrator. We only like HAPPY nurses. I’m hoping for some constructive feedback here. From my perspective, it seems as if “I need help" = “trouble coping emotionally” and that’s it … end of issue. The DON explains many of my concerns as “communication problems”. The fact that my co-workers and I often don’t have access to the physical resources to do our job (they’re locked up in the basement or under a manager’s desk somewhere) doesn’t seem to factor into the equation at all. So … communication problem. Is there an appropriate way for me, as a low level employee, to approach management the next time I have "trouble coping emotionally" with an issue that might have a negative impact on patient care? I don't have a desk to hoard things under.

Quality care seems to involve ignoring the information being compiled by the electronic chart. I don't know ... should I ask CNAs to avoid charting inputs and outputs, or should I continue to ignore the messages alerting me to dehydration, or ... ? The only knowledge I seem to be deriving from the info provided by our new system is that I should question the information received. I'm not yet finding it useful as a clinical tool. Does this come with time, or is there something more proactive I could be doing? I'm in long term care. Looks like the system was designed with a hospital in mind, and maybe that's why I'm having problems?

All of my residents are dehydrated. They're eating and drinking normally, their skin turgor feels good, and their urine looks straw-colored, but they're all dehydrated. I would never have known this if it weren't for our new electronic charting system. Although we've only been using it for two or three weeks, I'm already seeing tremendous improvements in my delivery of care. How otherwise would I know to push fluids and hold furosemide? If some of my residents start to cough and I hear crackles and wheezes in their lungs, I guess I'll be asking for chest x-rays? Maybe sending people out? I guess this will decrease medical errors by lowering the census and giving me more time per resident. I don't see how our new system will help lower health care costs. Anybody have any insight into this?

Mark Twain! Why does this garbage still happen? Maybe some small people just want to feel special. You know ... the ones who walked four miles in seven feet of snow every day just to get to clinicals. They can't deal with what you've got to deal with (I.e. nursing school + racism) and that you'll make it anyway, and that's threatening to them. Maybe they like to believe it is some rare ability or some deep, personal struggle it takes to be a successful RN. Implying a motivated and determined individual can do it seems to take away from their "specialness" or whatever. I can't imagine what the idea of a motivated and determined and Black individual must do to a racist's self-inflated image. Many people try to be "helpful" by pointing out the "reality" of being an RN. Lots of people drop out; many are unhappy ... But that's true for every profession. It is profoundly insulting for someone to assume that because they're not successful or satisfied, than you wouldn't be, either. Some nurses want to regulate the number and type of newcomers entering the profession. The BSN as a minimum standard for sitting for the NCLEX, the rejection of LPNs as new hires in hospitals, and making the NCLEX more difficult to pass all limit the number of new nurses entering the profession even as the nursing shortage becomes more severe. More nurses = more competition for jobs = less opportunity for racist jerks to flourish in the workplace. I'm guilty, I suppose, of racism myself. I recently handed a young African American woman from Agency a shower list, stressed the importance of charting our residents' BMs, and told her to ask the other CNAs if she had any questions. She just kept standing there, looking mildly amused. The regular CNAs, all Black, were stifling giggles. Finally, she asked; "Do you want to give me report first, or shall we count the narcs?" Turns out she was my relief. They tell me I must have assumed she was a CNA based on her age. That's my story and I'm stickin' to it. :omy:

Check out the NY LPN to RN articulation program here: http://www.lpntorn.info/programs.html These community colleges should know how to help you. There is a New York State Nursing Forum, and they might be able to help, too. Go to "Local" then to "United States" and then to New York to browse the posts. There is even a "sticky" about LPN schools here: https://allnurses.com/forums/f164/looking-lpn-schools-ny-119260.html

I feel frustrated with a LOL (yes, I fully acknowledge and respect her personhood) who believes everything is better if the nurse does it. "I want the nurse to put me on the bedpan" "I want the nurse to adjust my blinds" "Could you ask the nurse to get me some ice?" I had a looooong discussion with her about why I wouldn't transfer her from wheelchair to bed. She is a two-person transfer with severe right side weakness, and thought that because I was the nurse I could make up for two CNAs. She told my supervisor that I refused to help transfer her. The kicker is, this lady used to be a nurse.

Another good stethoscope thread is here: https://allnurses.com/forums/f8/best-affordable-stethoscope-41776.html