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vampiregirl BSN, RN

Hospice

Content by vampiregirl

  1. vampiregirl

    New Hospice nurse, all tips welcome!

    Different agencies have different case management expectations and different structures. In addition to your mentor's suggestions, I would recommend talking to other case manager's to find out their tips, tricks and systems. I just started at a new agency, but from previous experience my case management was a combination of ideas "borrowed" from other case managers, tips I've gained from other sources (allnurses) and my own spin on things. The most important thing is figure out a "system" that works for you!
  2. vampiregirl

    White Swan Sizing-Help!

    Ugh. Figuring out sizing for specific scrub brands is never fun:( I tend to veer to ensuring I choose scrubs that fit the largest of the measurements - so based on your scenario I would choose the XL pants. But it's also not helpful to look/ feel like the saggy baggy elephant. Have you checked out reviews for the specific item you are looking for on amazon or one of the heavier trafficked uniform sites? It takes some sifting through reviews but I've been able to find good insight that has helped me make a better decision when specific brands are required. Another thought is do the pants have to be embroidered? If not, they should be returnable. It sounds as though you are comfortable with the shirt size, so this would be the more "critical" item since typically items embroidered can't be returned. Good luck!
  3. Management of pain and dyspnea can be tricky at end of life. Having worked inpatient hospice I've cared for some patients that have required much larger than typically normal doses of opioids for symptom management. Patient assessment and monitoring is critical when administering any medication. "Larger" doses should be titrated up slowly to assess what dose a patient needs for effective symptom management. Monitoring of respiratory status should be frequent/ ongoing and other considerations (level of responsiveness, pupil response) also assessed frequently. With palliative and hospice patients, the goal should always be to control symptoms with the minimum amount of medication necessary to control symptoms. As I nurse, I'm always acutely aware that I am responsible for any medications I'm administering. If I have concerns, I collaborate with a provider prior to administering the medication. I was very familiar with the meds I was administering and have had fairly extensive education about symptom control at end of life. I don't know anything about the nurses who administered the meds in question - so I don't know about the education and experience of the nurses involved. This could definitely be a factor in this story. Another consideration is that patients approaching end of life can occasionally have rapid changes in condition (such as death) that are unrelated to meds having been administered. However, the number of patients involved in the article certainly concerns me. I guess what I'm trying to say is that we simply don't have enough information to draw any conclusions. My heart goes out to all those involved though - the staff and the family/ friends of those patients. I can't even imagine what it would be like to have a loved one die of what was originally thought of as a terminal process but then questions arise as to whether the timeline had been manipulated by someone providing orders and/or care.
  4. vampiregirl

    Repositioning end stage of life hospice pts

    This is one of those topics for which there are several different perspectives. Also, it comes down to what is best for an individual patient and their unique circumstances. In most cases I find the benefits of repositioning outweigh the burdens. It promotes skin integrity, allows for assessment of incontinence and in most cases promotes patient comfort. Certain positions also help with secretion management (in the realm of comfort). Patient assessment and symptom management are considerations prior to repositioning. Patient communication is also important - even if they are not responding to caregivers. Smooth/ well coordinated repositioning makes a huge difference in patient comfort. Draw sheets can be very helpful, as can having adequate pillows to support the patient in a new position. Ensuring a patient is positioned properly (good alignment) and reassessing comfort after repositioning is also important.
  5. vampiregirl

    IV Fluids Infiltrated w/o pain?

    A couple of thoughts... I agree with iluvivt's explanation and recommendations. Another consideration is blood clots. While this isn't a common senario, I have encountered this once. I cared for the patient after it was diagnosed and was being treated. Cancer patient with liver metastasis so increased risk for clots. No pain, significant edema arm distal to elbow. Radial/ ulnar pulses in the arm were present but weak. Temperature to touch comparative to other extremity was just a little cooler if I recall correctly (but not significantly so). A nurse had noticed this and something "just didn't seem right" from what I understand so a provider was consulted. Clot confirmed via ultrasound and anticoagulation started. Where I'm going is that as we get more nursing experience our assessment skills grow. We start out with the basics (assessing for pain/discomfort) and grow with experience and continued learning. Good for you for asking questions! If your unit has an educator, maybe also reach out to them. An educator can follow up as to what happened with this patient so they can provide more specific/ accurate responses for this patient.
  6. vampiregirl

    ACHPN exam?

    For the CHPN exam in 2015 (different exam/ certification, same credentialing agency), I used the candidate handbook and purchased the core curriculum. I also purchased practice tests from HPNA, which included 2 practice tests. I took the first one as I was beginning studying to identify areas that I needed to focus on and took the 2nd practice test about a week before my "real" test. I think I prepared for 4-6 weeks total. As for the areas represented, I seem to recall the candidate guide pretty much gave an accurate picture. I also know several other nurses who have taken the test and all of us had either different tests or different perceptions of what areas were more represented. Good luck! I encourage any of my hospice colleagues to pursue certification. I learned a lot from studying for the test and I think it has positively impacted my practice.
  7. vampiregirl

    Patient tracker app

    I'm not familiar with an app that does this. I've just used the data/ views available in the EMR to reference what I need. For me, entering this info in an app would be a redundancy. I do use "sticky" notes on my computer screen for quick reference of mantoux dates, cert period end dates and FOV since these dates aren't readily available in screens I routinely view. I used initials for privacy. I would also be concerned about security of such an app unless it had been reviewed/ recommended by my employer. Have you checked though to see if there is a secure mobile version of your EMR that is an app?
  8. vampiregirl

    Anybody wear Natural Uniforms?

    Has your place of employment given you any guidance other than the assigned color? I've worked for places that specify the brand(s) of scrubs and I've talked to people who have even been assigned approved style(s). Also, have you inquired if there is a uniform allowance, discounts available from specific vendors or a payment payroll option? When I worked for a facility that went from anything goes scrubs to specifics, there were things put in place as the facility recognized that not everyone had the disposable income to purchase a whole new wardrobe.
  9. vampiregirl

    As seen on TV

    My friends have officially banned me from watching medical tv shows in public places as I cannot refrain from "providing education" (i.e. talking to the tv) about incorrect procedures. It's always interesting with a patient or a helpful family member recommends/ requests something that they saw on tv. I try to maintain professionalism but wow, sometimes that's a challenge!
  10. vampiregirl

    Favorite school nurse resources?

    These are great! I'm a volunteer camp nurse for a week in the summer and I'm adding many of these links to my "toolbox":)
  11. vampiregirl

    Therapy dogs and Allergies

    Great educational, thought provoking thread! I'm not a school nurse but school isn't the only setting where animals are potentially a benefit to patient care (well, and the healthcare staff too!) but other factors unfortunately have to be considered also. Here's a link that contains info that might be helpful to some, who like me, were confused about some of the differences in laws etc. Differences between Service, Emotional Support, and Therapy Animals - SERVICE DOG AND EMOTIONAL SUPPORT ANIMAL LETTERS & REGISTRATION
  12. vampiregirl

    Dr Google scares me

    Exactly! Sometimes patient's are receptive to education about to find reliable sources on the web. And appropriate sites can be a great resource for further information about a diagnosis, especially a new one. And other times, it's a lost cause because "if it's on the internet it has to be true!":facepalm:
  13. vampiregirl

    Getting more wound care Experience.

    The typical goals of hospice wound management (drainage management, odor control, comfort) are different from those in other settings but the assessment of a wound is the same. I would recommend getting a wound resource book to learn more about wounds and practice every opportunity you can on assessment/ documentation. I work in hospice and have both a palliative care wound book I refer to as well as "regular" wound resources. Education about prevention of wounds is another area that you would need to be familiar with for wound care. Some of the risk factors can't be altered for hospice patients but I still do a lot of education to prevent unnecessary wounds. Turning/ repositioning, floating heels, incontinence care, ensuring other interventions aren't creating pressure points etc. Wounds can affect quality of life even for a hospice patient. And I've had to get really creative on dressings for some of the fungating cancer wounds I've encountered. As fragile as many of patient's skin is, I have to diligent about dressings not impairing skin integrity (tape!!!). Do you have a home health care division associated with your hospice? This might be a way to get some wound experience if you ever have the option to get overtime or float if low census and floating is an option. Skilled nursing facilities are another great place to learn/ practice with wounds. That's where I got my initial experience. Most have a designated wound nurse who is a wealth of knowledge.
  14. vampiregirl

    New nurse and I had a breakdown at work

    To the OP... You've gotten so much great insight and suggestions from others. The tough part will be figuring out what will work best for you. This would be one of those times that a crystal ball would be really, really helpful! I used to be able to do nightshift no problem. Much to my surprise, I tried a night shift position earlier this year and it just didn't work for me anymore. The affects were obvious in many different aspects of my life. I eventually took a position on another shift when it became available and slowly things improved/ returned to normal. Although some posters urged caution with your educator's and manager's recommendations/ support, I would consider the options they have presented. Obviously they see the potential in you. If YOU decide that a day shift would be better for you/ your family, then you have that option. Good luck with whatever you decide. And if what you chose doesn't work out exactly, that is OK. You are at the very beginning of your nursing career - for many of us the beginning wasn't without challenges and we survived:)
  15. vampiregirl

    I want to try camp nursing

    The Association of Camp Nursing website (campnurse.org) might be a good place to start for information about camp nursing. Also, maybe consider contacting your local YMCA or YWCA to see if they offer a camp or are connected to one. I volunteer one week each summer for a camp, it's a great experience.
  16. vampiregirl

    Are We Letting Our Patients Suffer?

    I agree that at times the pendulum has swung too far the other way. As a hospice nurse, I've cared for patients who have not had pain adequately addressed until hospice admission. And then they've had a significant improvement in quality of life once the pain (and other symptoms) are managed. At times it seems like assessment of symptoms and appropriate interventions are taking a back seat. Different types of pain require different interventions - for example if a patient reports leg pain, bone metastasis and pain caused by tumor pressing on a nerve are effectively addressed by different approaches. A pulled muscle or cellulitis are two other causes of leg pain and treatments are different. Another consideration of pain control is monitoring opioid use. If a patient is requesting refills too soon, is it because the patient is taking more meds than prescribed? Even then, is it because the prescribed dose is ineffective or is the patient forgetting they took a dose and taking another too soon? Or are the meds unaccounted for due to another reason, such as diversion? If meds and pain control are being closely monitored from the start then any concerns can be addressed early. Sometimes this means changing the med route or quantity dispensed. Or it may mean involving other resources. But the bottom line is, that patients are receiving appropriate assessment and pain control interventions instead of just "blaming" the opioid issues for a provider being "unable" to effectively address the pain.
  17. vampiregirl

    "Green House" model

    That's a different concept, I think that is more popular somewhere in Europe. But that one sounds fun too!
  18. vampiregirl

    "Green House" model

    Good questions! I already asked about behaviors - they have a psych provider contacted but it doesn't sound like they have many behaviors. I didn't see any when I toured. This model has better staffing and is more individualized to the patients - I suspect that contributes to few behaviors. The houses are designed for safety for dementia patients and they are not in the same "home" as the rehab patients where I will be. Hmmm. I will have to inquire about total care though.
  19. vampiregirl

    "Green House" model

    Glad to know I'm not the only one not familiar with this concept! The facility is a state licensed SNF with the beds certified either Medicare/Medicaid or Medicare (for the rehab homes). They also accept private insurance and have a few private pay patients (long term care). Welcome Home - The Green House Project
  20. vampiregirl

    Is it camp season yet??

    Glad I'm not the only one feeling a little melancholy today and "camp sick" today. Camp is such an amazing experience and one of the highlights of my summer. I'm already looking forward to my week of volunteering next summer.
  21. vampiregirl

    Oh, my aching feet!!!!

    Another idea for a foot roller is a tennis ball. Works great for me. A purchased a Dollar Store 3 pack - which I share with my cats:)
  22. vampiregirl

    How to pick yourself up after bad day

    Looking back, I think I had more "bad days" when I was newer nurse. Until I figured out a good routine, how to prioritize, and time management. Having said that though... every once in a while I still get run over by a tough shift now and again. Unfortunately, I don't know a single nurse working in a clinical position that doesn't encounter that now and again. It's a part of the nursing world. First of all, see how the next shift goes. Then look back a week or so later. It that was just a "bad" shift, then you can be thankful that it was just that:) If you start to see a "pattern" of frequent bad shifts then may ask for assistance from a trusted co-worker or manager for suggestions. I also at one point realized I was "expecting" shift to be bad before I got to work... and you know what - those shifts often lived up to my negative expectations. I had to change my thinking, and suddenly I had less "bad" shifts. Where I work now, it's a given Fridays will be a hot mess. We just roll with it and joke about it being Friday. Knowing this ahead of time makes it much easier to deal with. We help each other out as much as we can and know we will likely be sitting in a empty conference room having a "charting party" (not really a party, just nurses frantically charting so we can go home) after we give report. Often we will order a pizza to be delivered or someone will bring something that can be eaten quickly when people have a minute during the shift. I make sure I start every shift with a full water bottle and there are always a few quick snacks in my work pouch - it's a zip top bag where I keep extra pens, highlighters, sharpie, ibuprofen, change for the vending machine, a flashlight, a mirror for assessing heels and my headlamp for catheter insertions:) Snacks that are non-perishable and have good energy value (individual packs of nuts, protein bar etc). Sometimes, taking 3 minutes for self care can end up saving me a time later if I have a minute to refuel and figure out a game plan (instead of just putting out little fires). I have a 50 minute commute, I take that time to process a little and then listen to great music and enjoy the drive home. It took me a long time, but I've learned to (almost always) leave the day behind by the time I get home. I've got some co-workers who stop by the gym. Or Starbucks. Talk to your co-workers for suggestions on how they decompress after a crazy shift.
  23. vampiregirl

    Forced meds?

    Sounds like a tough situation. What suggestions/ input does your supervisor/ manager offer? Is there an ethics committee that you could collaborate with?
  24. vampiregirl

    Forced meds?

    Right of refusal can get complicated with intellectual disabilities. Even in situations when another individual (legal guardian or in the appropriate circumstances, a provider) has directed that the medication/ intervention etc. be administered/ implemented if the individual refuses. Approaching things from a different angle sometimes works. Identifying why the individual is refusing can be helpful. Providing education in a manner that the patient understands is also important - I wouldn't use the same verbiage for an adult with "normal" intellectual abilities as I would for an adult with the cognitive ability of a 3rd grader. Also, finding out if the individual has a specific routine for taking meds can be helpful. Engaging the individual in the process sometimes works too (site selection etc). Or diversionary techniques (take a deep breath... and blow out while the insulin is being administered etc). Where I'm going with all of this is that even though it can be time consuming, if an intervention is medically necessary sometimes (not always!) refusals (and power struggles) can be side stepped by implementing different approaches.
  25. vampiregirl

    Issues getting Epi?

    Ran into this while ordering supplies for an EMS service earlier this year. Pharmacist explained to me it was a change in laws that prohibited retail pharmacies from selling scrips unless issued to a specific individual; something to do with the licensing of the pharmacy. They referred me to a wholesale pharmacy who could legally sell the item issued to a agency for administration under protocol or by physician order. I ended up going with a medical supplier - the medical director had to complete a form authorizing meds to be ordered.
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