CHAPTER 4 WHEN? STARTING, SCHEDULING, STOPPING
“On
your mark, get set, go!” It’s easier to win the race if you have a head start, so
get started early on: where, who, how care will be given later.
The hospital will
likely give you a specialist to aid in the transition to home, but you will
quickly be on your own unless you hire a nursing agency, which would
simplify your tasks but at higher costs and give you less control than you
would have if you were managing the care yourself. We started with an agency,
learned from them, saw how to do better, and started hiring our own nurses.
Without an agency, you’d quickly have to advertise for, interview, and orient
your new nurses, and you might not have your systems in place to demonstrate
the requirements of the job.
Advertise in local publications
and on the Internet.
Ask people who might have
employed nurses before.
Interview in the home: name,
address, training, experience, availability, references, extra capabilities.
Would they fear or be allergic to your pet? Rule out smoking on the job. In
case of emergency, can they help evacuate the patient? Do they have any
physical disabilities that would keep them from moving the patient in bed and
transferring the patient to and from the bed? Keep your questions task-related. Do not ask questions that might
suggest you would discriminate unfairly or illegally. As you converse, try
to determine whether they are sufficiently intelligent and articulate and
pleasant to make you comfortable having them in your home. After they leave,
write your comments on your home-made form, so you don’t forget, and give them
a tentative grade (A down to F). Don’t write down something that might
embarrass you later, if it came to light.
Call references, unless you have ruled
the candidate out. If a majority of the references for a candidate don’t
respond or are lukewarm, rule that nurse out. You are looking for “wonderful,”
”great,” ”outstanding,” etc. from people she/he worked for. Ask how long
they were employed, doing what, and would the employer hire the person again.
Again, do not ask questions that might suggest you would discriminate unfairly
or illegally. Friends of the candidate can be expected to be enthusiastic. Consider
using a detective agency to do a background check.
Ask what nursing
credential the candidate has, RN or LPN. Registered Nurses (RNs) have more training
than Licensed Practical Nurses (LPNs), and they typically get about 50% more
per hour. An LPN with many years of experience is probably equivalent to a new
RN, although the latter will have more “book learning.” We had a mix but
paid all the same (to forestall rivalry or jealousy), attracting LPNs from much
farther away than RNs.
In
the rest of this chapter, and in the Exhibits, which are in the back of the
book, we will show the different forms, the “charts,” we created for scheduling
shifts, treatments, medications, assessments, etc.
SHIFT SCHEDULE, Exhibit #1
First is an example, Exhibit #1, of the
schedule we posted for our nurses, usually at least a month in advance. The shifts varied in
starting and ending times to accommodate certain nurses. The initials
identified the nurses, whose names are not given in the sample.
This schedule’s title indicates the schedule was posted over
a month in advance and was considered tentative, but probable. The August schedule
was posted May 31. The first column is the work date. Next is the first shift,
usually 8 a.m. to 4 p.m., followed by an afternoon-evening shift (e.g., 4 p.m.
to 10 p.m.) and an overnight shift (usually 10 p.m. to 8 a.m.). We did not give
the overnight nurses an overnight pay-rate differential, but the longer hours
and the relative lack of activity on the overnight shift made it adequately
attractive to keep it staffed.
If a nurse worked
a shift routinely for a prolonged period, she essentially “owned” it, so she could plan her
life outside the job easily. If she could not work a shift, she had to get a
substitute from the staff of about ten nurses. They could exchange hours or
money or both, and they did so freely and reliably. Once in agreement, they
would cross out the initials originally on the schedule and replace them with
their own. We paid the nurses before
they actually worked for the coming week, so they had to work out their
settlement with each other if they made it after we made the payroll. In one or
two instances, we lost money due to a nurse’s failure to work the pre-paid
shifts. One such loss was about $1400, however, from a nurse we had fired after
pre-paying her but allowed to finish her week; she failed to show up.
Soon after
arriving, the oncoming nurse would discuss with the nurse being relieved what
significant activities had occurred. She would also read the communications book
and then look at the comprehensive charting book.
COMMUNICATIONS BOOK
Bound composition
notebooks were used and eventually stored when full. Notifications of the nurses, requests for
supplies or substitutes, comments on nursing practice were entered by
management and staff at will. This did not replace the more formal nursing
assessment forms, however.
CHART BOOK
As much as physicists like equations, nurses dislike documentation. It is often a thorn in their side and
frequently perceived as time taken away from the actual job of “nursing,”
giving care to the patient. But it is
also recognized as required by law and necessary for optimal care. Nursing combines giving care with making
assessments and recording both.
We have, over many years, developed our
home-care documentation to be user-friendly and require minimal charting time,
thus decreasing time taken away from caring for the patient. Some documents have taken the form of
checklists requiring only initialing the completed actions for medication administration
and treatments. Our assessment sheet,
which is organized by systems and is a one-page, two-sided document, provides
for merely checking-off or circling most assessment criteria. Minimal writing is necessary – but space is
also available when needed.
Our
forms have worked well in our practice. Whether used for nursing professionals or
family in-home caregivers, these are merely “to-do” lists and “observation”
forms. They provide a list of what
needs to be done and when it must be done.
Additionally, by noting what, when, or how something looked today, for
example, it provides a means for comparison to see if there is improvement or a
decline from one day to another. Once
written and/or checked off, it no longer has to be remembered. It can be factually referenced later, if
needed. It eliminates “I think….” And if the area, box, or section of the form
isn’t completed, it’s a reminder that something wasn’t done and needs to
be. In the nursing profession there is
an adage: “if it wasn’t charted, it wasn’t done. “
In this part of the book, we give a brief
description of the
documents we use, leaving more detailed descriptions to the appended
material near the end of the book. Please refer to the Exhibits section for
document samples. Some information
has been changed for patient privacy or redacted for space limitations. Field descriptions and medical information
pertaining to the forms appear also.
PHYSICIAN’S ORDERS: DAILY AND PRN MEDICATIONS, EXHIBIT #2A, EQUIPMENT
& TREATMENTS, EXHIBIT #2B
We obtain renewed medication and treatment
orders from the patient’s primary care physician every 90 days. This is done for insurance purposes as well
as to provide the nurses with ongoing orders for their practice. Generally, it is nothing more than a list of
all that is necessary for the patient’s continuing care. Once submitted to the physician, he evaluates
and signs off on the orders, and they are returned to us. See the Exhibits section of this book for
details.
EMERGENCY PLAN,
EXHIBIT #3
This
needs to be near the front of the patient’s “chart,” or book, although unlikely
to be needed.
Responses
for potential emergencies are described for the following:
· Loss of electrical
power
· Loss of ventilator
· Fire
· Choking
Not
all possible emergencies can or should be covered, just those whose severity
and probability are greatest. Please
refer to the Exhibits section for this document sample.
REFERENCE INFORMATION AND CONTACTS, EXHIBIT #4
This merely provides a
complete and detailed listing of patient specifics, physician contacts, and
other pertinent information pertaining to the household and the patient.
· Patient information
· Miscellaneous contact
information
· Physician and pharmacy
information
· Emergency transport
information
· Vent settings
Please refer to the Exhibits section for this
document sample.
MONTHLY NURSING TREATMENT FORMS: EXHIBIT #5A
(page 1) & EXHIBIT #5B (page 3)
Simply stated, this
document is a “to-do” list of requirements for the patient’s care. Like any “to-do” list, the purpose is to
ensure what needs to be done is not forgotten. It eliminates forgetting to perform tasks and
prevents essential information from being omitted during the nurses’
reporting-off period. In addition, it
provides a method to track and reorder inventory, since it provides what
equipment is used and how often it must be replaced. Lastly, besides assuring that essential
activities are completed, it holds nurses or caregivers responsible for
ensuring the item was done, as well as done correctly.
These tasks are done
periodically, such as on each shift or on a daily, weekly or monthly
basis. They include patient treatments,
such as dressing changes, as well as changing equipment to ensure continued and
optimal operation…for example, changing the in-line suction apparatus. In our practice, we also use the Treatment
Sheets as reminders to the nursing staff to, for example, check the
Communication Book, and we try to ensure their practice is safe for them by
reminding them to use Universal Precautions.
Toward the back of this
book, two exhibits of this patient’s
six-page document are provided to illustrate
various time frames and how to depict when a certain task may require attention
when not completed on a daily basis. Please refer to the Exhibits section for this document sample.
DAILY MEDICATION ADMINISTRATION RECORD – PAGE 1:
EXHIBIT #6A
PRN MEDICATION
ADMINISTRATION RECORD – PAGE 6:
EXHIBIT #6B
Often referred to as
the “MAR”, this follows the same
pattern as the treatment form. However,
instead of the activities which need to be performed, the administration of
medications and feedings are noted.
This is another “to-do”
list but is solely dedicated to the administration and application of
medications, ointments, creams, suppositories and any other substances that may
“go into or onto” a patient for treatment of a condition prescribed by a
physician. Again, only a sample of the MAR is provided: the first and sixth pages of
eight, in this patient’s case, are shown.
NURSING REVIEW/ASSESSMENT FORM: PAGE 1: EXHIBIT #7A &
PAGE 2: EXHIBIT #7B
Assessments are crucial
for evaluating and appraising a patient. The
patient is observed in a step-by-step pattern, system-by-system. Use of touch, smell, sight, and hearing are
all vital in the assessments’ completion.
The Assessment Form is how the assessment is documented. It provides a history of the patient’s
medical condition, which then allows for comparisons as well as to understand
what is normal for that person.
At the beginning of each nursing shift, the oncoming nurse
begins completion of the Nursing Review / Assessment Form. This one-page, two-sided document is used to
evaluate the patient’s current physical and emotional condition; log medication
administrations; track treatments; ensure proper equipment settings and
changes; and generally provides a permanent record to ensure vital information
isn’t lost or misreported. While a
general physical assessment will be completed early in the shift, the form is
used throughout the entire period to document any changes in the patient’s
condition and record completed actions.
The form used for the
patient is broken down into thirteen sections. Most categories pertain to the major body
systems. However, there are also sections for general information, equipment
checks, nursing and shift identification, as well as allowing space for
notes. A large amount of information is
recorded simply by selecting or circling items.
Not only does this serve to remind nurses what to assess and aid in its
full completion, it also minimizes handwriting legibility problems.
VENT SETTINGS
Used for
ventilator-required patients with pulmonary problems, vent settings are
dictated by a pulmonologist. For
this patient, each shift, these setting are checked to ensure they are accurate
and have not been mistakenly changed, which potentially could be
life-threatening.
INTAKE
Whether the patient is
able to eat by mouth or uses a gastric tube for all fluids and nutrition, the amount the
patient ingests is vital to know. Too much fluid could cause edema, hypertension
(high blood pressure), and could create pulmonary problems if the fluid backs
up into the lungs. Too little fluid can
result is hypotension (low blood pressure) and decreased perfusion (oxygen
supply) to vital organs. Recording
nutrition is imperative to ensure that enough quantities of protein, water
and nutrients are available to promote healing, maintain skin, and provide fuel
for continued functioning of the body at the cellular level.
NEUROLOGIC
The neurologic system
is comprised of the brain, brain stem, spinal cord, which completes the central
nervous system, and included are various nerves located throughout the entire
body, the peripheral nervous system. It is a
complex system, using neurochemicals and transmitters and cellular structures
to take external input from the environment via our senses and internal input
from bodily functioning to transform them into usable, functional, and creative
data which we perceive as life.
This section is used to
assess and detail neurologic function and changes throughout the shift. In general, only two main points are assessed
for this patient and are highlighted in an appendix.
RESPIRATORY
The respiratory system
ensures the body is provided with oxygenated blood via the smallest
functioning unit in the lungs, the alveolus.
It is at this cellular level that carbon dioxide is exchanged for
oxygen. In addition to the lungs,
other essential members of the system include the pharynx, epiglottis, larynx,
trachea, bronchus and its tapering limbs, and the associated respiratory
muscles and diaphragm.
This section is used to
assess and detail respiratory function and changes, throughout the shift. In addition to assessing pulmonary function
and treatments, a portion reflects equipment changes that are often required daily.
CARDIOVASCULAR
The cardiovascular
system is comprised of the heart and all the blood vessels; that is, the veins
and arteries. The system functions to distribute oxygenated
blood received from the lungs and deliver it throughout the body via the
arteries. Venous return to the heart via
veins takes deoxygenated carbon-dioxide-rich blood back to the heart to return
it to the lungs for oxygenation and CO2 removal. Assessment of this system includes blood
pressure readings and heart rate, which are detailed under Vital Signs (V/S),
as well as pulses, tissue perfusion and fluid backup called “edema”. This section is used to assess and detail
cardiac and venous function and changes throughout the shift.
GASTROINTESTINAL
The gastrointestinal
system, often abbreviated as “GI” system, begins at the mouth and extends
throughout the body to the end of the large colon at the anus. It processes food using many complex
sequences and functions to transform bulk into minute substances for use at the
cellular level. While processing food,
the system also conserves water and returns it to the body and prepares what is
unusable for elimination via stool. The
GI system is comprised of the oral cavity, esophagus, stomach, small intestine,
and large intestine. However, various
other organs also contribute and play key roles in the proper functioning of
this system. These accessory organs are
the salivary glands, gallbladder, pancreas, and liver.
Patients that do not
obtain nutrition by mouth require all substances for survival be directly
received into the stomach or the jejunum section of the small intestine via a
tube placed surgically. This patient had
a percutaneous endoscopic gastrostomy (PEG)
to place a tube into the stomach, out from stomach wall through the skin to
outside the body with which to deliver nutrition. Daily care and assessment are essential for
the continued functioning of the tube, and this section is used to assess and
detail gastrointestinal changes throughout the shift.
GENITOURINARY
The urinary system
captures liquid waste from the body and voids it by way of urine production and
elimination. Through a process initiating from the
kidneys, which are located on each flank or side of the body, all fluid is
filtered. What is necessary for the body
at that time is restored: non-essential substances as well as extra fluid are
eliminated. Other organs involved in the
voiding process include the ureters which bring urine to the bladder where it
is stored and eventually eliminated by way of the urethra.
The reproductive system
is close to the urinary system, although these are two separate systems. Both systems are assessed at the same time, and although no
separate fields are dedicated to the genital-reproductive system, and since
menses has stopped, it is documented as one system for this patient.
For this patient,
urinary catheterization is not performed.
The patient has routine Undergarment (disposable diaper) changes at
regular three-to-four-hour intervals with implementation of absorbent inserts
to help keep skin dry. Another option is
urinary catheterization, which allows for urine to flow freely: a tube is inserted
into the urethra until reaching the bladder. Urine then flows into and is
collected in a bag for accurate measurement and assessment. Catheterization can be done intermittently
throughout the day without leaving a tube in place. Sterile procedure must be followed to keep
from causing an infection in the urinary tract.
MUSCULOSKELETAL / SKIN
Also essential to the
body are the muscles and skin. Muscles
provide metabolism, strength, and functionality for motor actions or even tasks
related to the most basic functions such as breathing and pumping of the heart. Skin is the largest system of the
body. It acts as a protective layer,
promotes temperature regulation by perspiration, and is an indicator of
other bodily system functionality, such as cardiovascular, respiratory, and
gastrointestinal intake and elimination.
Skin breakdown can
cause severe and devastating effects. Skin
breakdown starts as a non-blanchable area (one that doesn’t turn pink from
white when pressure is removed from the site), a reddened patch often on a bony
prominence. Tissue breakdown occurs
quickly, and in the most severe cases, can extend to the bone. Depending on the patient’s underlying condition,
breakdown can occur in as little as two hours.
Once breakdown starts, it is difficult to stop and recover from the
process.
This section is used to
assess and care for the muscles, bones, and skin as well as document care to
eliminate skin breakdown throughout the shift.
PSYCHO/SOCIAL
Psycho-social aspects
of a patient pertain to the emotional, psychological, and social
characteristics. They are assessed and documented to provide
insight on how well the patient is adapting to the illness and the care and how
they outwardly present concerns or emotional well-being.
This section is used to
assess and detail psycho-social well-being and changes throughout the shift.
BOWEL ELIMINATION / CHANGE RECORD: EXHIBIT #8
Another form we developed was to solely track fecal output. One of the most challenging aspects in
nursing is bowel regulation, especially in a bed-ridden patient on liquid
nutrition. Optimal bowel function requires bulk, as in
fresh vegetables, fruit, and whole grains.
Hydration is vital so that the body doesn’t take all the fluid from the
stool, resulting in an impaction.
However, too much hydration may result in fluid overload, affecting
electrolyte imbalances, edema, and backup in the cardiac and pulmonary
systems. Bowel function also requires
movement, both by the body and by peristaltic activity of the gastric and colon
muscles. Medications can also impair
normal function, producing either too much output or not enough. For example, opioid pain medications can
induce constipation.
To track, record, and
provide ease in reporting, we developed the Bowel Elimination / Undergarment
Change Record.
At one glance, any
nurse or caregiver can look to see a past and present status of bowel
elimination, including quantity and quality of the stool – both very important.
It also provides a time when disposable undergarments (often referred to as
“adult diapers”) changes are to be made.
So, it performs a dual task: when
to do a change (for us, usually q3h=every 3 hours) – and what occurred during
each change.
To ensure elimination,
we have in place measures to promote bowel activity because we were able to
provide the physician with documentation.
Physician-ordered bowel protocols include daily administration of
Miralax, alternate days of other bowel-movement promoting medications, and PRN medications to help evacuation if necessary
after 48 hours without such movements.
As such, bowel elimination is no longer the problem it once was, and it
hasn’t been a significant problem for quite some time.
There is another
purpose of the Bowel Elimination / Undergarment Change Record besides keeping
track of bowel function. It provides a
means to decrease the risks of bedsores. Once a bedsore begins, usually as a benign,
small reddened area that doesn’t turn white when the skin is depressed
(non-blanchable), it can quickly turn into an open wound that can damage skin,
fat tissue, and muscles, continuing to the bone. By changing these disposable undergarments
often, we get to assess any breakdown at a very early stage. Since the patient
is being moved, this activity allows for improving general skin care with
treatments such as applying lotions to the back, and for auscultating lung
sounds with a stethoscope, or performing pulmonary treatments.
Wetness and pressure
are two contributors to bedsores that are also decreased by using frequent undergarment
changes. Urine and feces are caustic to skin during
prolonged exposure. Changing diapers at
regular intervals reduces the time the patient’s skin is in contact with these. After cleaning and drying the skin, we apply
a water-proof ointment, such as A+D, to the skin as further protection,
providing a barrier from these corrosive, acidic substances.
Constant pressure on
the skin at bony prominences, such as the coccyx bone at the base of the spine,
is also reduced during the disposable diaper changes, as the patient must be
rolled to do the change. Even limited
changing of positions throughout the course of the day greatly enhances the
viability of the skin. It relieves pressure
from lying on the bones, decreases shearing forces that occur as the body moves
downward in bed by gravity, and provides enhancement to blood flow. This does not replace turning and positioning
at regular intervals; it just adds a beneficial factor.
This two-sided form is
merely a table. Completion requires only
the nurse’s initials and use of a code to quantify and qualify the stool.
RX MEDICATION TRANSLATION: EXHIBIT #9
The generic and the band names of the medications ae listed here, both
in brand name order and in generic name order.
STOPPING…PULLING THE PLUG
Both of our patients at home expressed
the desire to continue to live, even with restrictions, and neither had “Living
Wills” or Do Not Resuscitate (DNR)
orders, which indicate the situations under which they would not want heroic
efforts undertaken to save their lives. This made our decisions easy in
case something life-threatening should occur. The younger patient has had over
a decade of life that she has generally enjoyed after her life-threatening
episode in the hospital. The elderly patient, after nearly dying in the
hospital, returned home, had a few “good” months, then lapsed into a period of
long sleeps and only occasional lucidity, sometimes seeming to enjoy the
company of her nurses and relatives, but usually seeming to be unaware.
Based
on my experience with my wife, I [DWC] wrote the following several years
ago:
Some
people argue that it is a waste to spend our resources on the disabled,
especially as they get older. I disagree.
We
value things on the basis of their usefulness and their scarcity. Water is
useful, but widely available, thus generally inexpensive. Silver has practical
and monetary uses and is relatively scarce, so it is much more expensive than
water.
We
do not know how long we will live. As we get older, we know there is less time
left; it is scarcer. If we can make good use of it, enjoy it, be helpful,
whatever, then the scarcity enhances its value. Even if what we do is not as
good as it was years before, the years we have left can be quite precious.
Tina's life is precious, as is my own.
Some
social planners come from another perspective, viewing public funds for medical
care as investments. Babies who are unwanted or unlikely to survive do not
merit investment, in this view. Your productive value goes up as you grow up,
become educated, enter the work force. Toward retirement, your productivity may
decline. At the very least, you have only a few more years in which to
produce. These planners are reluctant to
"invest" much more in you. Time to "pull the plug" on
Grandpa or Grandma. Get that Do Not Resuscitate (DNR)
order signed and let them expire with the next heart attack. This approach is
"rational" from a public-expenditure viewpoint, though it takes no
account of the value of the ill person to himself and those who care about him.
It is part of a slippery slope that goes from not treating to euthanizing.
Tina's
care has been expensive. We've spent money and IBM
has spent more and Medicare has had a share. We certainly expected to help pay
our medical costs. IBM recruited
me partly though the attractiveness of its medical benefits program, which I
knew we might someday need. When IBM
wanted to cut its work-force, I volunteered, again considering future medical
coverage needs. That leaves Medicare: decades of withdrawals from my pay checks
have gone to this program, with the notional "locked-box account" for
coverage of my family and me. As with other insurance, some people end up
needing more and others less, a lottery of sorts. Fair enough, we thought. Now, some suggest we
are "selfish" to be getting "more than our share" of
medical coverage. We are not exactly winners of a lottery, but no one argues
that winners of lotteries are "selfish" for collecting "more
than their share."
Although I am glad we have done what we
could for my [DWC’s] mother, it is less clear that she benefited from the
heroic efforts made in her final year.
MOVING
ON
Sometimes,
stopping will be less dire: the patient is cured, or the patient is not cured
but needs a different environment to heal.
