mtjoanna

[ATTACH=CONFIG]23551[/ATTACH]

I started my nursing career in a psych hospital, so became pretty adept at documenting "exciting" events very factually. Unless two patients/residents had an encounter/altercation, mentioning another resident, and his/her situation in the charting is not generally appropriate--though for your private records, it's perfectly fine. It is technically not within our scope to attribute a specific emotion to another person--you can say that "daughter appeared to be angry" but not "daughter was angry," then follow that up with observable facts: stepping very close to this writer while speaking in a raised voice, taking a photo of this writer without this writer's consent." Something like that, anyway. You want to keep your charting as free of your emotions and frustrations as possible--this tends to demonstrate your level of professionalism. It can be hard to divorce yourself of your frustration/angst sometimes, but it's an excellent skill to develop.

At my previous facility, I was the only nurse in the building from 1800-0600 and had up to 54 residents at one time. The 1800-2100 med pass was brutal as most of the residents had multiple meds and there were a lot of diabetics with BGs and sliding scales, and all that goes on with a typical LTC med pass. I was kinda the primary noc nurse for awhile, so I did some rescheduling of meds. Down one hall, they were all ordered for 1900 (this was the special care unit; when I passed meds in that unit, I was giving the CNA there her 30 minute break, so would do that hall first); down another hall all meds were 2000, and down the 3rd hall, 2000-2100; most of the meds were ordered as "HS," not at a specific hour of day, so I had that freedom. It permitted me to stay on time most days. I could even, usually, deal with a fall or two and still have most of the meds done on time.

My facility actually has 2 transitional care units, each with 16 beds. During the day, two nurses staff each unit with a max of 8 patients while at noc, there's one nurse to the 16 residents. Now, the evening med pass is a breeze--the first SNF I worked at, I was the only nurse for 48-53 residents, so I got pretty efficient at the med passing business--16 is easy peasy. But, at night, there's little to no back-up for emergent situations, which do occur. We are getting people sooner from the hospitals, so they are sicker and more delicate. Most get stronger and go home, but there are some who experience respiratory or cardiac issues, infections, complications r/t the emergency surgeries that they went to the hospital for originally, so you have to be pretty on top of your assessments and dressing change knowledge, and be willing to actively advocate for your patient if you see something amiss. During the day, there's another nurse, the unit manager, and others around in case something occurs, while at night, you really don't have a lot of backup. Our facility requires that all the nurse managers, and all of the nursing administrators (from DON down) to take call, so you can always call them, but it's not quite the same as having another nurse in the building with you. As far as less acuity at noc because all the patients/residents are asleep--that's kind of a running gag with noc shifters. It can be quite busy, especially since you generally have fewer people to answer lights, help people to the bathroom, deal with outbreaks of Noro-virus and other such things. I actually prefer nocs partially because there are fewer managers around, getting in the way of me doing my job, but probably at first, I'd recommend a new nurse stick with days--you'll get more exposure to the different jobs that the PT, OT, ST folks do, deal with more of the dressing changes, so you'll see more wound care (which I find fascinating), and not be alone in crises. If your facility has an in-house hospice facility, that's worth checking out too. I'd love to do hospice, but right now with my Dad dealing with stage IV lung cancer, his chemo not working well anymore and me looking at going through hospice stuff with him, I don't think that's the place for me yet. It's a special privilege to be part of someone's last days, to help make that terrifying event less terrifying to the patient and the family, to be part of easing fears, finding solutions to difficulties as they come and finding ways to truly be a patient advocate. Sometimes that means wading into icky family dynamics, going toe-to-toe with providers, and encouraging the proper use of pain medications--which many people don't want for fear of becoming addicted. Even as they lay dying. It may not be med/surg, but it really encompasses the full range of nursing skills and is an honorable use of your days/nocs.

I'm currently working transitional care. I started my career in psych, moved to long term care--which I very much enjoy--but because of the need for full time hours, moved to the transitional care unit. I'm working nights, which I wouldn't necessarily recommend for a new grad. The unit I work on, during the day, has 2 nurses, each with up to 8 patients, dealing with a wide variety of medical issues. Lots of hips and knees of course, but also CABGs, back surgeries, wound care, respiratory issues, dealing with PICCs, catheters, IVs, feeding tubes, new colostomies, etc. I very much enjoy it. You get to build more of a relationship/rapport with the patients than you can in med/surg but unlike LTC, the goal is for them to get better and go home. On a side note, I've not yet found the transitional care "specialty" section here on allnurses--or is it lumped in with LTC?

I have had a few instances of people asking me about stuff--the greenish chunky discharge from her ear, what this color of poo might mean. My advice generally consists of "that sounds like an excellent question for your provider."

Not cheesy at all! One thing that means a lot to us "pee-ons" is having sincere recognition from the bosses.

I'll freely admit that I used my first paycheck as a nurse to fulfill a life-long dream and bought myself a horse. I've never regretted her!

So, a year has passed since this incident. Six months ago, my husband and I moved to another town and I am working in a different facility. This facility is non-profit, owned by a church denomination and has been wonderful. There were several more issues between th DON and myself and I finally got to the point where I couldn't take it anymore. I came close to giving up nursing. This new job has allowed me to rediscover my love of nursing and has cemented my enjoyment of long term care. The staff to patient ratios is smaller, there are providers who are much more responsive/responsible, and my supervisor and DON have a LOT more common sense and common courtesy. My overall stress level has reduced so much I've been able to stop some medications and I no longer face going to work with a feeling of dread with my stomach in a tight knot all shift. There are hectic days, but none of my worst days have been as bad as a normal day at the previous facility. I NEVER want to work in a for-profit organization again. Ever.

I did that with mixed results. It was good with all the nurses and most of the CNAs but I did have some issues with a few of the aids. One of them specifically told me "I'd be just fine if you showed me some favoritism. Seriously." We worked it out eventually but there were some bruised feelings on both sides when I didn't show favoritism and occasionally had to call her out on poor performance.

It's a long-term care facility, not in a hospital, though they have PAs and NPs that round daily from both local hospitals. There are actually 2 transitional care units, both set up very similarly to each other and I'll be working in both units. During the day there are 2 nurses and 2-3 transitional-care aids (CNAs with extra training) for 16 residents. My shift will be 1800-0600, will have all of the 16 residents, and from 1800-2300 will have two transitional-care aids and one aid after 2300. I came from a facility where I worked the same hours and was the only nurse in the building for 45-53 residents, so the 1:16 sounds pretty good.

I am currently in orientation in transitional care. I've worked at this facility for 6 months in one of their long-term care units and have loved it but they didn't have full time hours for me there and the transitional care unit did, so I've moved departments. I had some transitional care residents at my previous facility but they generally were recovering from falls or pneumonia, things like that. So far, I've oriented 2 of my 6 nocs of orientation and one was very, very quiet, the other showed me that I have a LOT to learn about dressings and post-op care. I'm seeing fresh CABGs, hips, total knees, a fresh abdominal surgery with wet-to-dry dressings, am told that there are often PICCs. I'll be working nights, so won't have much in the way of back up available and am feeling excited about how much I'll be learning but also a bit overwhelmed and not wanting to screw up. Those who have made this transition, what words of wisdom do you have? What resources would you suggest?

I know! I've had that same "work harder not smarter" line of doo-doo from someone who had never touched a patient...

I couldn't find whether or not video links are allowed (via youtube). I suppose I'll find out if it's not allowed I saw this on my facebook today(my facebook info is NOT in the link) and ended up laughing so hard I almost experienced bladder incontinence!

So I've just completed my first week of solo nursing at my new position. This week, I had a fall, a death and our wing went under quarantine, as 4 elders ended up with diarrhea within an hour of each other. The CNAs employed at this facility are pretty top-notch and handled the situations smoothly and professionally, so they were not the major catastrophes that I've gone through at my previous facility. At my previous position, I had a minimum of 8 hours of paperwork each night, so after the initial frantic med pass, most of my 12-hour shift was spent sitting down working with the blankety-blank computer. Here, I work an 8 hour shift and spend 7 of those hours on my feet working with the residents and 1 hour on the computer. I now have time to look at the (fantastically adorable) quilt that one of my elders is piecing together, to clean the droopy eyes of another elder (who is so sweet that the residents argue over who gets to take care of her), laugh with the elder who laughs at me and asks to dance. I'm still busy passing those pills, but it is part of my job now and not the main focus. My feet, legs and lower back are sure feeling the difference after 4 days of this! The shoes that worked for me at the other place aren't quite up to this job. I've ordered some others to try and otherwise try to not hobble too noticeably at work. I also have to get some better compression socks. But even with the feeling that someone slapped my feet with a 2x4 for awhile, I'm happier at this job than I have been with nursing for some time. These are just details that need to get ironed out, and losing some weight would go a long ways towards helping that. I've noticed that I eat far less than I did at the previous job--I am hungry and enjoy my lunch but am not snacking my way through the shift.

I too love the longevity of relationships within LTC. I never thought I'd want to do LTC d/t the frequent short-staffing and high stress of the job, and my first experience with working at a for-profit LTC nearly burnt me out of nursing altogether. However, I have just started at a new facility (new to me, the not-for-profit facility has been here for a very long time) and am able to love my job again. This is a beautiful profession that we are in and I am blessed to be able to share the lives of those I care for.

LOL nurse Leigh. Apparently, she has shown up at people's doors before. If you are a no-call, no-show, not-answering-your-phone, you may end up with this DON politely knocking on your door to see if you are ok. I find that I am ok with that type of house-call. :)

I think higher wages in general would be better than a bonus program. I agree with others that a great CNA can have all kinds of bad things happen on her shift while a lazy, irresponsible one can have a great couple of weeks. However, if a CNA can make as much money assembling burgers or slinging fries at people as they do doing the hard, emotional, more physically draining job of caring for our sick and elderly, we can't expect to be fully staffed on a regular basis. More money for less work will pull more of them away from this field. Pay them what they are worth and I'm willing to bet that you will find that staff retention increases, and with increased numbers of CNAs would come far better working and living conditions!

True; I attended a seminar run by a man who works with vets returning from war with PTSD. One thing he has them do is to journal--with paper and pen/pencil as physically writing activates a portion of the brain that typing on a keyboard doesn't.

I have just finished my second of 5 days of orienting on the shift that I will be working in a new facility. The first day I was surprised (in a good way) to find that one of my coworkers was one of my classmates in nursing school! My previous facility was problematic--I won't rehash all the problems here, but will say that after 2 days, I'm very impressed! The residents are far more relaxed here--their rooms are clean (and so much bigger!!), even the bathrooms are neat and tidy. The meals I can't evaluate yet--they had a classically trained chef preparing the meals (with his staff), but he retired the day after I started so a new company has taken over that department. The food was good today, but different enough for the residents to comment on. The CNA staffing is better too--I worked with some excellent CNAs at the previous place but they were unhappy, over-worked and stressed out and it showed. Here, I can see evidence of the nation-wide staffing shortage as I am working a couple of pool aides each shift. Apparently, this company immediately accesses agency/pool CNAs if they can't fill it in house, so the CNAs are typically not terribly short, and are accustomed to working together. There is a pharmacy in house, so that helps keep the meds coming routinely, and there are several PAs and NPs that have offices in the building--they round almost daily! There's even a gerontologist working at the facility! No more "benign neglect" from the doctors I work with--I can actually respect their decisions! I could continue for awhile, but I'll keep it brief (kinda). I know that as I work here longer, I will find things that I don't like, that could use improvement, but in general, it is simply a good quality place with a high quality of care and the expectation that staff provide good care to the residents. There is a lot more support available to the staff too, so if I end up having a really bad day and don't feel like I can manage alone, I do have resources available--and that is amazing! At the end of my second day, I am looking forward to going back, to establishing my routine, building long-lasting relationships with staff and residents, and am so relieved that I made this change. It's worth it to enjoy being a nurse again! (lots of exclamation points in this post-yay!)

I have personally found that having 2 dogs works better for me than having one. Yes, it is twice the food and vaccinations, but if you are careful to get dogs that are able to be good friends, they keep each other company while you are gone and help provide an activity outlet as they play and roughhouse together. I'm big into rescue--I've never purchased a dog from a breeder and never expect to. There are a lot of dog breeds that I enjoy--such as off-the-track Greyhounds. They are happy to relax most of the day but do well with a good daily dose of exercise--though you have to be very careful about where you let them off-leash! Whatever dog you settle on, do your homework! If you buy from a breeder, call around and ask the vets for a reputable breeder of the kind of dog you are looking for. Ask to see the parents, get references from those who have dogs from this breeder. Check into the common health conditions of your chosen breed (labs and golden retrievers often end up with bone cancer and have major issues with hip dysplasia; German Shepherds have major issues with joints, allergies, bleeding disorders, etc; bulldogs have lots of skin issues--think folds and yeast!!). If you go for a rescue, also check into them. Check their reputation--some will send sick animals home without notice; others are known for evaluating their animals well and sending them to appropriate homes while others are just looking for a quick turn-over. Many people (myself included) prefer a mixed-breed dog and they are often healthier than the pure-breds. However, it is not always so--sometimes, the mix picks up all the genetic flaws from both parents and can be disasters! Having dogs is very rewarding--I love mine! But be prepared for all that comes with it. Have fun!

Is relocation a possibility? If it is, start applying across the country. I don't know what the restrictions on your employment are, but I do know of one nursing home in rural Montana that is DESPERATE for nurses and would not turn down a new grad. It is not a great place but it is a job.

I had one pt think that I was Hitler, so she tried to strangle me. Surprisingly strong for an 88-year-old, though somewhat lacking in visual acuity. I'm a short, chubby, blonde woman in so the resemblance to Hitler seems a bit of a stretch. Ah well. It was psych! Boxer pull-ups would be an interesting challenge to develop...

You may need to start developing a more authoritative role within the home. You have the training and knowledge that has earned some respect and your willingness to help is greatly appreciated. Now you need to step into the role as manager. Make your requests politely worded instructions and if the staff doesn't respond, start with disciplinary measures such as writing them up. There will probably be some push-back, back-talk and such, but you are not asking the aids to do something outside their scope of practice, but to simply do their jobs. That's what they were hired for and what they should be doing without you goading them. It's not always fun to be the "mean" nurse, but your first job is the care of your clients-not catering to staff who are unable to exert self control. Once they learn that you are in charge and will maintain certain standards, you will probably be able to settle into a comfortable working role with them. I learned, the hard way, during my first job as a nurse that there are some drawbacks to becoming friends with the aids--c/o favoritism and other such issues occurred. Any place you work, unless perhaps home health (home health nurses can correct me if I'm wrong), you will be expected to "manage" the aids in your area.

In my area, a lot of the folks have grown up on ranches, so it's not uncommon for older gents (and ladies) to feel the need to get up and check the livestock. It's also very common for people, especially in the evening, to feel the need to "go home" for this or that reason. Enter their world: "I just checked the heifers. I didn't see any new calves; you can do the next check after breakfast." Or "it's awfully dark and cold out there tonight. Why not stay in this bedroom for tonight and you can get a fresh start in the morning." I've had a number of people try to pay me for their "hotel" stay. I assure them that the bill has already been covered and the room is theirs for another night. Don't try to convince them that "this is your home now;" as they will fight you because what you are saying makes no sense to them. It is not uncommon for there to be some combativeness with pericare. I know some staff get impatient and upset with this but the residents are often not able to remember where they are and sometimes get to where they don't know who they are anymore, but they darn sure know that you aren't supposed to be messing with their pants! Imagine how you'd feel to have someone you don't know try to remove your clothing and mess about with your "private affairs." Also remember that a LOT of sexual abuse was never discussed or dealt with with our older population, so some of their panicked responses could be from memories of old trauma. Alzheimer's (AD) literally eats away the memories, starting with the most recent memories first and working backwards. This is why so many of those with AD are unable to recognize family--in Mrs. Smith's mind, she's only 24 years old, there's no way that she could have a grown up daughter--so that woman who looks so familiar must be a sister or a cousin. There's a lot more information out there. Actively educate yourself--this is a great site with lots of info: Healthy Brain Versus Alzheimer's Brain | Alzheimer's Association. It's a worthwhile and important job that you are getting ready to do--it's an honor to be of immediate help to those who are under your care. Remember that, and some of that attitude will show and will help when things are difficult.