Kittypower

Would they be allowed to take a Roho cushion to sit on during dialysis? It would also help outside of dialysis, but I know that the ability to move around is limited during dialysis.

He didn't want a turkey sandwich, he wanted a burger.

You did it exactly right. Never leave the old packing in unless the order specifically states to. Leaving it in creates a nice place for bacteria to grow and cause an infection. Also, you cannot adequately clean a wound with the old packing still in. You did great!

It's really a case by case basis. Hospice patients can be admitted with a prognosis of 6 months or less. Many are not actively dying and not re-positioning a patient who still has months to live would make them more likely to develop a wound. When a patient is actively dying, yes, wounds will not heal. However, I have had plenty of patients with wounds that did heal. The type of mattress, how close the patient is to death, whether or not they already have wounds, there are a lot of things to consider when determining when and how to re-position patients.

Where exactly in TX are you looking?

I have found plenty in home hospice that is challenging. Patients in their home experience respiratory distress, severe terminal agitation, severe pain, etc. Getting those taken care of can be challenging, particularly when the medication you'd really like to use isn't available because you just got the order and had to order it STAT from the pharmacy. It can take 2 hours to get the medication STAT. Sometimes, in the middle of trying to deal with a crisis, I get a phone call that another patient is having an issue that also needs to be dealt with. It's plenty challenging. But every day isn't always like that. Some days go smoothly, others are a bit rougher. Don't get me wrong, I love what I do and find it very rewarding. But I wouldn't say there's not much challenging about it.

When I first started in hospice I had similar feelings. It took a concentrated effort to pause and breathe after each visit and to leave work at work when I went home. You can't be all things to all people, and that's okay. Give yourself permission to not know everything. Turn your phone off when you get home unless you are on-call. Leave the after hours stuff to those working after hours, they can handle it. When I find myself thinking about work on my off hours, I say to myself "On call can handle it, let it go." Establish and maintain boundaries. Do your best, but don't harp on yourself when you're not perfect. Don't put pressure on yourself to do more than you can. Instead, do your best at what you can do. Ask for help when you need it. It takes time and effort to manage the stress of working in hospice. Honestly, I'm still working at it myself, but when I look back I can see how far I've come. And remember, breathe! It's amazing what a difference just breathing right can make.

I think my mother passed, her blood pressure is only 64/32.

So, you've got a lot that you're concerned about. I'll do what I can to help clarify things. I do admissions for the hospice company I work for. That often includes info and consents. First, Medicare guidelines are just that, guidelines. Each and every situation is unique. If a patient is being considered for Alzheimer's Disease, for example. I look at both PPS and FAST scores. There is no specific PPS given in the guidelines for PPS, but for FAST, the guideline is 7A. This means that the individual is incontinent of bowel and bladder (does not have to be 100% of the time) and cannot speak more than 5 words in a day. The words do not have to be appropriate to the question or attempted conversation, they just have to be words. For example, you may ask the patient what day it is. They may answer "Window." It is a completely inappropriate answer, but it is a word and it counts. Sometimes, I have a patient who can easily say a dozen or more words that make sense. On the surface, it looks as though this patient would not qualify. That is when I need to dig deeper. What else is going on with this patient? One thing I will look at is their appetite and weight. Is the patient eating well? Is the patient loosing weight. I may look back at serial weights over the last 6 months and find they have last 20 or 30 pounds. Their caregiver may tell me they hardly eat anything and it takes a lot of coaxing. I will also consider functional decline. Maybe a few months ago they didn't require much help with ADL's but now can do very little for themselves. Looking a their History and Physical and labs, I may find that they have Class 3 heart disease and require oxygen. They also have renal insufficiency with an elevated Creatinine level. If their serum albumin level was tested I will look at that. In general, Medicare looks for a level less than 2.5. I will gather all the information I can that provides a clear picture of everything going on with the patient before I call and talk to the physician. That way, the physician can make an informed decision about whether or not to admit the patient. Just because a patient does not meet the qualifications for one diagnosis, that does not mean they are not appropriate for hospice. Medicare understands that comorbidities play a factor in overall health and prognosis. It's up to us to paint the full picture. You do not have to ignore other diagnoses. They do play a factor in the decline of the patient's health. Diseases do not act on the body in isolation. Likewise, the decision to choose one diagnosis over another is based on the severity of each diagnosis and what will most likely be the deciding factor in the patient's death. If the doctor feels the patient is appropriate for hospice, he or she will take all the information you provide, including all diagnoses, to determine which one to use. It requires a good working relationship with the doctor to do what is best for the patient. As far as time is concerned. Yes, there is a lot of pressure to complete everything in as little time as possible. What I have found personally, is that as I have done more info, consents, and admissions that faster I get. I've found that I can identify what issues are most problematic for a patient and family and address those in detail. I find that often, they have a basic knowledge of hospice and I just need to fill in the gaps and correct any wrong ideas. I am clear about what we can and cannot do. As I go through the consents, I go over each section and remind them of what we talked about already. That helps connect the discussion with the paperwork. Time varies considerably with some taking 30 to 40 minutes and others taking an hour or more. Once consents are done, I complete the admission. Much of the information I need, I already have by this point. I complete the assessment, go over medications and make any changes needed (after discussing with the physician of course). If I am doing the whole thing from info to admission, I will usually take 3 1/2 hours or so. If info and consents are done and I am only doing the admission, it usually takes about 2 1/2 hours. Of course this varies from one situation to the next. I have found that my supervisors are pleased with my admissions because they are thorough and done correctly. That goes a long way in having some leeway with time. I do what I can to keep things as quick as possible, but will not sacrifice quality. It has taken time to build up the reputation I have at work, but it was worth it. They know that patients I admit are appropriate for hospice and the documentation will represent that. When the pressure is on, I am careful to truthfully tell them what I can and cannot do. I work hard and they know that. When I say I can't do something, they believe it. I hope this helps. Please don't let someone with unrealistic expectations make you feel inept. It is their problem, not yours.

I'd visit the Santyl FAQ page at Collagenase SANTYL® Ointment | The Continuous, Active Micro-debrider. "How long should I use Santyl?" is a question and the answer is when medically indicated or the necrotic tissue is gone. Maybe print out the page and pass it along. It's not needed once the non-viable tissue is completely gone. There is no reason to continue using it.