volsfan

I wanted to add that you must also consider that the families and patient's can choose whether or not to treat an infection.

All I can tell you is that is our company's policy; whether it is right or wrong I don't know. I can see both sides of the argument. We open the kit to explain all the meds to the pt, but they are already labeled with their name on it. We then close and seal it and it is to remain sealed until we receive a future MD order and instruct the family regarding this. This brings up a good point though about the legalities and ethics. Anyone know the legal laws regarding this topic? Where could I look? Do you think it is by state?

Although our MD has to sign for us to have the comfort pak in the home (from HP) we are suppose to get another order to use any of the medications in the kit. If we start using a med from the kit we get them then add it to their routine meds; and order it PRN. Example: A pt is having moderate to severe aggitation in the middle of the night and the on call staff starts him on Ativan from the comfort pak, per MD orders she obtains. The RN Case Manager arrives the next day and he has had two doses which are working well. The medication would be added to his routine med list and a prescription bottle of it ordered. Two months later the pt revokes. The nurse would destroy the Comfort pak; but the pt still has his Ativan b/c it was ordered as a routine med AND in collaborating with the physician who will take care of the pt after revocation; usually due to going to hospital they would be supplied with a medication list which has the Ativan on it. So, the pt is not without. It is in the patient's name. The comfort pak includes: Ativan, Morphine, Haldol, Atropine, Compazine, Tylenol supp. On the kit it states DO NOT OPEN UNLESS A MD OR NURSE TELLS YOU TO. Therefore, once they are off service they will not have a nurse/md telling them to do anything with it.

All our staff is salary; including on call staff. The starting salary is $24.00/hr. Our case loads are b/t 12-15, but can get as high as 17-18. When the RN Case Manager is on call (backup/primary) they get paid a minimal daily rate, it's under $10.00, nothing to get excited about. If we have to go out to make a visit then we get anywhere from $25.00-$150 depending on the time; usually the visit is $25,00 to $50.00, rarely more. However, the time does not include travel; which can be a problem. It is really not worth it to be on call IMO, but like I said we only do it for 6 weeks out of the year; which is much better than the place I came from and doable. Every hospice RN Case Manager in our area has to work call; no matter who they work for. Nobody likes being on call, but it is a fact of life. Leda1st, since you guys are salary and don't have on call staff it's really not fair. When I worked so much on call at my last place we were hourly so at least we were compensated well.

Our company has 2 FT and 1 PT on call staff who work primary call. The RN Case Managers rotate backup call; and will take primary call if the on call staff are sick or on vacation. Mon-Fri: 1 primary (depends on day of who it is) with a backup RN Case Mgr Sat/Sun: 1 primary on call works (8 am - 8 pm); the other works the (8 pm - 8 am); the part time on call staff member works 12 noon-8 pm and then the RN Case Manager is backup. About 6 months ago we moved to having the RN Case Mgr doing 1 whole week call at a time, giving us call every 8 weeks. As a case manager I didn't like this at first, but now enjoy knowing I am on call only 6 weeks out of the year. However, there will be times that the Case Manager will be out many nights during a given week; so if this happens I would make sure they get enough sleep and check to see if they need help with their case load. This is usually rare, but it does happen. I know not all hospices can have the staff we do. I came from a smaller one and we were on call every other weekend working 24 hour shifts. Our average LOS was low, like 25 days and every weekend we averaged 2-3 inpatients who would die. So, basically we busted our tails. It just didn't work; case mgrs got sick and burnt out. Our staff turnover rate was extremely high there. And I guarantee pt care suffered due to the staff being tired all the time. If you don't have designated on call staff I recommend sitting down with your case managers and collaborating on a schedule. If they are part of the process they will accept the decisions better and may make your job easier by coming up with something all on their own.

I would find out why the management thinks this way; where are they coming from. Is it b/c they are misinterpreting some law, policy, etc. I am in total agreement with Katillac. Many times the pt will have already been on narcotics when they came on hospice it is crazy to think you would destroy those meds when they revoke. The only thing our hospice destroys is the Comfort Pak and if we have been using medications from that pak we would have gotten them a regular prescription for it anyway.

There is also a difference in how Medicare pays. They will pay significantly more for someone to be on Inpatient care.

Per the COPs: The initial assessment must be done within 48 hours, by an RN. The comprehensive assessment must be done within 5 days; this includes the psychosocial (social worker) and spiritual (chaplin) assessment. The family can defer the social work and chaplain, so this would be documented as part of the comprehensive assessment; and as an RN we do assess for spiritual and psychosocial needs. However, a hospice company can have a policy that is more strict than the COP guidelines. Hope this helps.

Many hospices use ekits b/c they are cheaper to have than getting each of the medications individually.

To pjtk, As a home hospice nurse I review all comfort pak contents with my families b/c the families are usually the first to give the medications in the middle of the night or on weekends while they await for the weekend nurse to arrive. I have found it to be a good practice since there are multiple medications and when there is an "emergency" for the families they should be educated and feel comfortable about the contents of the kit. If they are left uneducated they are more likely to make a mistake if the hospice nurse is trying to instruct them over the phone. This generally takes an additional 20-30 minutes to review during a visit, but it sure does help. I would call the hospice you are with and speak with the manager. If how your nurse treated you is the company policy regarding the kits I would interview other hospices. If not, I would request a different nurse. Education is the major part of our job and at the very least she/he should have spoke to you in greater detail regarding the kit. Gail

An average day: 7:15-7:30 See first pt of the day (I like to get started early, you will find if you start prior to 8 AM it works better) Work until 1030-1100 seeing pts. Take a break for lunch, b/t 15 minutes to 1 hour. Depending on if eating with coworkers or took my lunch 1200-1500 Finish up seeing pts and/or go to scheduled meetings. 1500-? Go home and finish up any documentation needed. I see most of my home pts twice weekly; carrying a caseload of 15 pts on average and average 5 visits per day. My home pts know I will be there on what days and around a certain time of day; such as early morning, mid morning, midday, etc. I always call if I am going to be "late" and let them know I have been delayed. So, if I have to bump a pt from early morning to midday I certainly call. When I get a new pt on service I fill them into a open spot. You have to be flexible in this job. You will get to know which pts you could even bump to a different day and which ones you just need to keep on schedule. If I have a cont. care case going I make a call first thing to see how they did overnight. If they are "comfortable" then I fit their daily visit in based on location; if not then I will see them first thing. If your company doesn't do CC cases, but you have a pt not doing well I would do the same thing. I agree: carry extra supplies, restock as soon as you run low; extra forms organized in a binder; program all numbers in phone including pts. I put pt and then pt name so when I scroll for the name it is easier b/c it goes straight to all the pts. Example: Pt Smith Recerts: We are lucky that we are on computer, we have a screen that tells us when the next one is due. My old employer did not, but during all Monday morning meetings we were given our census printed and it told us any upcoming recerts that would be due. I always turn them in 1-2 weeks prior so they can get them signed. If you don't have those luxuries I would get a calendar and on admission of a new pt put in their recert dates, going out 6 months or so. Even better would be using MS Outlook and doing a recurring event. That way when they die/revoke/discharged you can just delete the recurring event and not worry about missing something. And you wouldn't have to count. Well, I have much more, but got to get my day going!

If the pt is in the hospital on INPATIENT STATUS and not outside the plan of care, the COPs (Alabama) require a member of the IDT to visit 6 days per week. You would need to check your particular state to see if it is different. Most hospices here require a 7 day per week nurse to visit b/c other members of the IDT cannot write physicians orders and if they are on inpatient status they most likely will need changes to their plan of care. If the pt is in the hospital outside the plan of care then the COPs do not require the daily visits, just your routine weekly visit. I am assuming this is your case since they use to not require it and now they do. If this is so I would find out why they changed it. My guess; the loss of a pt to another hospice once they returned home or a family member upset b/c a hospice did not visit at all while they were there. If the pt is going to the hospital outside your coverage area they should be discharged from service if it is more than a couple of days. The reason being is that you cannot manage their care if they are not in your service area. Once they are discharged from the hospital you could pick them back up.

She shouldn't have to pay out of pocket since it is related to her diagnosis and would not really be considered aggressive tx, at least that's how my hospice would view it. I know all of them view aggressiveness a little different. But, ours would say you are treating a symptom rather than the disease and if it helps it would improve her quality of life for a brief period of time. I would have to do some research, but I don't know that TPN really would prolong life at this stage.

TNP is appropriate in the hospice and home setting. But always remember it's about quality of life. If the TPN will bring improved quality to her life to her, even for a short period of time, then it sounds like it's worth it to her. When speaking with her about it I would explain that you will do a trial period of TPN, have a goal date to re-evaluate whether or not it is helping. I would also be very specific about the pros and CONS of TPN and review them when you start it. Good luck.

A good hospice company will not have the high turnover rate that other hospice companies do. I know this from personal experience. Our longest Case Manager has been with our branch for more than 6 years (basically since our branch opened); I have been there the shortest amount of time and that is right at one year. I came from another company that replaced at least one position every 6 weeks due to high staff turnover. For the most part the case managers hung in there for an average of 6 months (I almost made it a year). I think a lot of it has to do with the expectations of management, training and the overall structure. Many hospices I hear about (and the one I use to work for) require their case managers to do admissions, continuous care, and primary call every other week, with a case load of 18-20 patients. This is just too much in my opinion based on the emotional and mental work you do. If you are providing continuous care for a patient then who is watching over all your other patients.? I could go on, but that would just be ranting. Gail Y, RN CHPN

There are several courses in prenatal/postnatal fitness education. You only need a nursing degree. Don't worry about not having worked with OB patients. It really won't give you the knowledge you need to provide classes to pregnant women - unless one goes into labor and delivers during class! Here's some places to look: http://www.childbirtheducation.org/fitness.html http://www.maternalfitness.com/fitness/fitness.html The copper institue also has something, but I couldn't find it right now. They have moved some stuff around. But, there web link is: http://www.cooperinstitute.org/index.cfm Hope this helps!

I have a BS in Exercise Science and am an RN. I would imagine if you are treating someone with a current disease process, to legally cover yourself you should get their physician to release them with a medical release form. Otherwise it would be just like you were a personal trainer. I would recommend steering clear of "prescribing" any types of supplements or a nutritional plan. My schooling for exercise science was very specific about not prescribing a diet plan due to legalities since we were not considered qualified - those nutritionist take a national/state exam just like nurses do. As far as supplements there are several people who have been sued due to prescribing supplements which when taken resulted in death/injury. Hope this helps.

I had been working as an OB nurse @ a local hospital for over a year. Then I obtained my RN in May and they offered me a full time position. I took it as I love my work. However, our census has been low since then and I am not even working 4 shifts in a two week period. I started applying to other jobs elsewhere b/c I have to work. It has been two months now and I am having no luck in finding something or even getting an interview. I think it is because it looks like I am job hopping or b/c I am a new graduate with little RN experience, but this is a situation I can't help. I can't even change departments in our hospital and I am gettig the feeling we are about to go under. I am about to the point where I feel like I am going to have to settle for any job I can get instead of applying to jobs within the areas I am interested in, but I don't want to end up unhappy somewhere and then have to suck it up for several years b/c it really will look like I am job hopping. Any suggestions.

I am no longer on this case, but was wondering what your thoughts are and if anyone else has run across this same situation. A parent of a pediatric patient in the HH system has prolonged getting their child decannulated b/c they say they don't know what they are going to do when the nursing care stops. They prolonged it for over a year and I just found out tonight it is going to be another year b/c they don't want their child to enter a brand new school next year w/o a nurse to help with the transition. The transition has nothing to do with medical issues. I just keep thinking of all the resources that are being used on this case while there are other cases that really need the resources.

Since we haven't had any responses I was wondering this. If we want to promote wellness by giving seminars to corporations, helping people learn the proper methods of working out, etc. Can we promote ourselves as a nurse? If so, what areas would we need to be careful legally? I have also thought of contacting doctor's offices to provide fitness consultation services to their clients, with a doctor's prescription. I don't think any insurance companies pay of things like this right now. Does anyone know? Has anyone done something of this nature?

Just wondering your thoughts. I am having a hard time coming up with a good polite response to the questions from friends and neighbors about my work. For instance, this weekend someone asked about my patient's diagnosis/condition and who it was that I worked with. They already knew I took a patient to school b/c I live in a very small town and a neighbor had told them I was a nurse that took a girl to school. They don't know who the patient is, but were very pushy in asking about diagnosis'. I didn't give any information, but it was an uncomfortable situation for me. Any ideas on how you have responded to people's questions? Would it have been okay to tell her my patient's first name since all she would have to do is come to the school to see who I am with, or no? I am sure this situation will happen again in the future and I want to make sure I am cautious and polite, while maintaining my patient's confidentiality.

I don't totally agree with HarryHK as there are many pre-employment screening clinics out there. LabCore and Quest are the big ones, but as with all businesses each one is unique. You must find out how your business will be unique, different, and possibly better. Deliver something those big guys can't - faster service, or friendlier service, more services, etc. I would definitely target your midsized and smaller towns and use your contacts. If you get a couple good contracts and do good business for them then other business will follow.

Thanks Sweet Home Alabama! I actually moved to Illinois from Daphne, AL almost a year ago. My husband got transferred up here. I have to say we just got back from visiting and we miss it so much. We are planning on returning, hopefully sooner than later! Where in AL are you? Gail

I too have an Exercise Science degree, and am an LPN working towards RN. I have been considering opening a business that provides Occupational Health Services and Corporate Wellness services to local businesses. My services would include pre-employment screening, creating company safety documents, creating company wellness programs, and the like. Many manufacturing companies also do regular hearing testing, fitness testing (treadmill), etc. I am just contemplating the idea, but I would start small with one or two services and then as my company grows and I gain more income I would add more services and hire employees to do the added services so that I would not have to get the certifications myself. I feel the Exercise Science background with nursing really goes well with corporate wellness. Many companies might hire you to do one day wellness seminars, but you could also do cholesterol screening, BG testing, etc to bring the nursing aspect into it. Let me know what you are thinking. I would love to bounce ideas around with each other! PM me! Where are you located?

It doesn't matter where you do your clinicals. For example, I did my LPN program in Alabama and sat for the NCLEX for an IL license. All you do is fill out what state you want your license for and then the state has to approve all your stuff. So, if you want to STUDY in IL and then get an AZ license all you need to do is make sure AZ accepts the college creditials- ISU in your case. My husabnd and I move around a lot as well so I made sure of all this prior to entering the program. My problem is I never know where we might move! I recently saw somewhere that IL will accept ISU, but I haven't checked on this one b/c I am not planning on doing the ISU program. They do not accept Excel. and it states this very plainly in the application for licensure.