dian57

Our facility is trying to develop a system for adequate MDS documentation. We have tried posting diagnosis driven cheat sheets (document on at least 2 of these items/shift) posted on the chart and a check-off flowsheet with lines on the back for narrative notes. We have revised our CNA documentation flowsheets to reflect MDS language. Our 2 year trial of EMR CareTracker was a disaster and we have returned to paper. It seems no matter how much inservicing, reminding, checking, reinforcing we do, our documentation is not there or inaccurate many times. Each time I do an MDS I get one set of information from the CNA sheets, another from the nurses notes and yet a different picture from staff/family interviews. Has anyone successfully managed a way to obtain consistant and accurate documentation in the record?

Risk for falls with injury will be reduced. Then list all the interventions you have in place to reduce the risk.

A 20-something woman and her mother came in looking very, very concerned. Problem? Daughter swallowed her gum. Therapeutic wait? You betcha.

First, I am NOT saying the facility was not at fault in this case. But a word of caution must be spoken. We (the public, not just nurses) really need to keep in mind that this story was printed in the media. The media, in my experience, is not always extremely concerned with getting their facts 100% before printing. The reporter most likely interviewed the family, who are understandably upset and angry over the incident. The facility cannot, without violating HIPPA laws, comment on their investigation of the facts. Anyone who has ever read a story like this should keep in mind that we are hearing ONE side, reported by the media. During the trial, the facts will emerge and the story may end up being a little different. We may never see THAT article, however. If the staff and facility did, indeed, attempt to cover up this incident they should be punished appropriately. But before final judgement can be passed, there has to be more investigation and all the facts need to be considered.

Since we initiated the supervised activity program the only falls we've had are rolls out of bed (onto bedside mattresses) and late night wandering out into the bathroom (although staff was alerted by bed alarm, couldn't get there in time to prevent fall). However, NO injuries, which is great. After 3 pm we really don't have other departments available for inclusion in the program. SW goes home early, dietary is busy cleaning up, rehab is still doing programs/therapy of their own. After 5, when LTA goes home, it's all nursing. I'd like to include them in the daytime supervised activities eventually. Years ago we had an All Hands On Deck kinda program--everyone (including Administration) came out of their offices and departments, handed out the meal trays and stayed to help feed. We were MUCH smaller then and unfortunately this has since gone the way of the dinosaurs. Sometimes the nurses take a wanderer with them on the med pass or rounds to keep them busy and supervised.

We have the same issue (doesn't everyone in LTC?). We instituted 1/2 hour activity "bursts," as we've determined our population doesn't have much more than 30 minutes worth of attention span to devote to any given thing. We started with the evening shift as the fall numbers were greater, we've since expanded to the dayshift, too. I've changed the program names to minimize identification of our facility. But feel free to use any ideas that might work for you. No matter how short, however, we always have a staff member with the group--in 1/2 hour assignments. 3-3:30 pm--TOASTing. Give everyone a 120 cc cup of juice/water. The person running the program makes up toasts. "Here's to the President of the United States!" and everyone takes a drink. "Here's to your grandchildren!" This is good for increasing hydration. Ask the residents who should get the next toast. 3:30-4 pm--Sing-a-Longs. These are videos that have a Sing along with Mitch kinda feel. The patriotic ones are big sellers here. 4-4:30 pm--reading aloud the newspaper or the National Enquirer (not exactly fine literature, but it keeps everyone's attention) 4:30-5 pm--Book reading program. We advertise a book and each day read a chapter or two till it's finished. If it doesn't take the full 1/2 hour, we ask questions about what was just read. Takes us about 2 weeks to finish each book. Start with Charlotte's Web. 5-6:30 pm--dinner music with a featured artist each week--Glenn Miller or Count Basie weeks are most popular. I like the Andrew Sisters. 6:30-7 pm--Getting settled. This is mostly getting people out of the dining room and situated in the room with the big TV in preparation for the movie of the night. The drink and snack cart also comes in with them. 7-8:30 pm--Featured movie (previously advertised and discussed during dinner to increase attendance). The old black and whites are popular, so are the Judy Garland/Mickey Rooney ones with musical numbers. The aides come and remove people for PM care-they can return in their pajamas or go right to bed. 8:30-9 pm--sensual therapy. Hand massages, nail care and manicures. Soothing music. 9:30-10 pm--most are in bed by now. The die-hard fall risks are still up or back in their pajamas. We put in another movie and continue with the sensual therapy or hand out the PM nourishments and snacks and put on music. Want to know a neat trick I learned at a fall seminar? Fold up a white sweater and put it on a female resident's lap. They don't want to risk dropping it on the floor and will sit holding it for a long time. A baby doll or Bible also works sometimes (depending on the level of dementia). If you have some that no matter what you do, can't focus on the activity--try seating them near a pile of towels and pillowcases and ask them to fold them for you. That keeps some people busy a long time.

First, let me apologize if I repeat something already posted. I have not read all the previous posts. Palliative Care is a relatively new concept in our country; a country that is accustomed to fixing everything. We tend to white-wash illness and death, banishing our sick family members to the sterility of a hospital. Many are not comfortable with the ultimate defeat--death, albeit a perfectly natural ending awaiting us all. The first things to consider in a terminal illness situation are the wishes and expectations of the patient. Open communication is needed so they can make their own informed decision on how and where they want to die. The family needs to hear these things. The team (patient/family/healthcare workers) needs to work together toward the same goal--a comfortable and dignified death. Do they want to continue diagnostic testing, including bloodwork and vitals? Do they want aggressive treatment or just enough analgesia to remain comfortable? Do they want artificial hydration or nutrition? Do they want 02, even though hypoxic narcosis is a much more humane condition for the dying? Do they want to stay home or die in the hospital? Someone must explain these things in plain language so the patient and family can make informed decisions. In Palliative Care, there is something called The Doctrine of Double Effect that says, in essence, a patient can be given pain meds to control their pain, even though the dose may hasten death. I would venture a guess that many experienced nurses have been in the position of administering that last dose of morphine to a terminally ill patient with respirations at or below 8. I believe communication is the key in these situations. In a perfect world, people would all spell out their wishes in a Living Will and appoint a Health Care Proxy and NOT leave a fractured family to anguish over doing the right thing or not. The patient in the original post had no business in the ER, that was an unnecessary indignity that should have been handled by Hospice at home. Just MY 2 cents.

As far as visitors and excessive use of callbells and visits to the nurses station with questions: I've often considered posting a sign that says: If you have run out of conversation with your loved one, GO HOME. Do not entertain yourself by requesting the staff toilet, shave, reposition or medicate your loved one because you have become bored. Again, GO HOME. Really.

I remember another student nurse experience and hope this doesn't offend anyone here. I was all of 19, a student LPN. My instructor, a student friend and I stood at the bedside of a 30ish man as I prepared to do my first male catheterization. I had to talk my way through it, giving rationales and possible problems as I went along. Introduce myself, check the ID band, open the kit, expose the site, place the barrier, decide clean hand, dirty hand. Grip member at 90 degrees, swab meatus with Betadine. Now she asks me something and I have to answer. I swab again and notice something's happening down there. Oh, no, I start thinking. From the corner of my eye, I see he's kind of smirking. I swab again. Yep, full glory erection. Like a deer in the headlights I look up at my instructor and give her the Now, what? look. I don't dare make eye contact with my friend. Instructor says something about returning in a few minutes and turns her back (probably to hide the smile). There I am with a stranger's erection in my hand, my face beet red and I just let go. It hits his belly with a loud SLAP and my girlfriend bursts out laughing. I throw the sheet over the guy, gather all the supplies and flee. What does the patient say as I pull back the privacy curtain? "Oh, baby, don't go."

Recent policy change here: PICCs are placed by surgeons in the OR of our community hospital. Can be removed only by IV certified RN at bedside.

There was a little boy down the street and his parents wanted to name him Harley with Davidson as his middle name. They settled on Dallas. The little brother was Austin. Were they from Texas? Nope, just thought it would be "a hoot." Yep, that's just where I want to get my chuckles from, people's reactions to my children's names. Oh, boy . . .

Always do the right thing. This means different things to different people. I always take it as Let your conscience be your moral compass.

I had the hardest time with Maternal/Child nursing. And, like HarleyGirl, I can tell you why--I had absolutely NO INTEREST in Maternal/Child nursing. As one of the oldest students in the class, I got along well with the infamously difficult instructor. I explained my disinterest in the course matter and told her I would always be a geriatric nurse. She said one day one of my patients would have a visit from their family and a grandchild/great-grandchild would choke or be covered in a funny rash. Wouldn't Maternal/Child health come in handy that day? Okay, I saw her point but still struggled mightily through the semester. My favorite course was Nursing IV/Endocrine.

I was an LPN for 17 years. I had this one nutty RN supervisor for awhile who relieved an even nuttier day supervisor on my unit (LTC). One evening the other LPN on the unit looked at me and said, "What are we doing? Let's go back to school. Look, if XXXX and XXXX can be RNs, so can we." She made the assessment appointments, we met for breakfast and drove together to the college and 5 years later, I was an RN. After our first semester, 4 more LPNs and 2 CNAs at the facility started the program. All but one made it through. I encourage all my staff to continue their education. Don't let anyone spoil your dream with their own spoiled-grapes attitude. Be proud and keep on going. The time goes by whether you go to school or not, so do something constructive and get the degree. Come here for encouragement if you don't have the support you need in your job or circle of friends.

JBudd reminded me of a silly thing *I* did on the job recently. The DOH was in for the annual survey. I was 6 weeks into my new position as DON and feeling more than a little stressed with their barage of questions, requests for records, "quizzes," etc. At one point I was rummaging through my desk drawer for some file they wanted and my phone rang. I grabbed it and said in my professional phone-voice, "This is XXXXX, can you help me?" Talk about Freudian slips.