Thursday, April 11, 2013

The Life of a Dementia Care Nurse.

I was recently asked why I wasn't out on the floor more. I did my best to explain the massive amounts of paperwork that is required and my behind the scene contributions, but it seemed lame, even to me. I think every nurse would rather be “out on the floor” with the patients they are in charge of.  So after a particularly busy day, I decided to write how my day went and the responsibilities I am in charge of.


Today started off with five residents experiencing severe behavior problems. They each needed their care notes, behavior charting, regular and "as needed" meds reviewed, as well as interviews with caregivers to know what to report to the doctor of each resident. As I am faxing off the third evaluation, an answer comes in to the first one. I must then make sure that the order is transcribed correctly and see that the med that has been discontinued has been pulled from the medication cart so it will not be given accidentally. I also write a note in the Medication Aide communication book about the changes and I start to head back to my office to evaluate more residents, but as I pass by the desk, a resident wants to know why they haven't received their medication. I explain that their medication is not due for 2 hours. Another resident is screaming for coffee with 2 sugars. And a third resident wants to know what they can do. After I get the coffee and I show the resident who wants something to do to activities, I get stopped by a family member who is upset and I talk with them till they feel better about the situation. They happen to be a family member of one of the residents I am working on, so I also update them on the situation. I stop on my way back to my office to check a resident’s feet that we have been doing soaks on, and note that her feet look great and I will chart on them when I get a chance. I instruct the treatment aide to continue the treatment till all calluses are gone. As I continue on, I find a resident walking down the hall without their walker. I hold onto them and call for someone to get their walker. A few more feet and I hear an alarm sounding. I enter that resident’s room to find they are up walking and their personal alarm is sounding because they are not steady. I sit them back down in a chair before the staff arrives to take care of them. I finally reach my office door to find a group of 3 residents with questions ranging from "When is the ship going to dock?" to "why am I here? And “Where can I find a car to take me to my brother’s house?" I reassure the residents and make sure they are smiling and satisfied before I enter my office. I sit down to write more evaluations and I hear a familiar tune being played at the piano. It’s only a few bars and it’s the same tune over and over, every day the same thing. First the tune gets played, then the resident stands outside my door and stomps his feet till I look up and smile and he says "thank you honey" then I go back to my work. It is similar to the "Groundhog Day" movie. Every day, over and over, it’s the same routine. I hear another familiar sound coming down the hallway. This happens several times a day as well. First there is the sound of shuffling feet then a stop at the doll house and the sound of the pieces been hit together, but today the dollhouse is gone because the resident’s hands were bruising and it is thought it could be from the doll house and banging the pieces together. I hear banging anyway. He is banging his hands on the shelf because that is his routine, so I make a note to write in his service plan that he is now banging his hands on the shelf, and I think it might be better to bring the doll house back. He then comes and tries to shut my door. But he has difficulty because of the door stop, so I get up and take the door stop out so he can close the door. This door has been closed in years past before it was my office, so this resident wants it to be the same as it used to be. I glance at the time. It is time for the shift to change, so I wait till the resident is down to his room and I open the door so I can talk to the staff on their rounds. I tell them what I would like them to concentrate on this evening. I tell them which residents I am working on and the doctor responses. They are encouraged because they get beat up every shift. They get kicked, hit, pinched, grabbed, strangled, bit, head butted, yelled at, and cursed at, I give them encouragement for doing such a great and selfless job. The day is winding down and I have 2 evaluations left to go. The Manager hands me a response to another of my evaluations and the medicine ordered is one that the resident cannot tolerate. I call the doctor and he decides to make changes to the existing medications. I finish my remaining 2 evaluations, make 6 notes for things to start on tomorrow and I go home. However I am on call 24/7 so I keep my phone by me at all times. I do have some days where I might not be called, but the average is 2 to 12 calls or texts per weekday evening/night. Weekends average 6 to 36 calls and texts. I have had times where I was mowing the lawn and had to stop every few feet to answer a text or call. Tomorrow will be another day with other responsibilities.


Some of the other things I do are listen to lungs to check for pneumonia, stomachs to check for constipation, skin breakdown to develop a treatment plan, ears for excessive wax and evaluate residents after a fall if they have an injury. I evaluate pain, swelling in the legs and if a resident is confused more than usual. I do a neurological assessment if it appears the resident has had a stroke. I do TB tests, Flu vaccines and pneumonia vaccines. I evaluate dip sticks on resident’s urine and report to the doctor if there is an increase in confusion or falls in a resident. If a resident is having surgery I make a plan so that the pre-surgical showers and special soaps get completed. I practice “diffusing an angry person” when I get yelled at by doctors because some of the paper work didn’t end up at the resident’s appointment. I talk with family members who have nursing questions. I investigate complaints. I review the pharmacy recommendations every 3 months and audit to ensure the necessary changes were completed by staff. I coordinate care with hospice, speech therapy, physical therapy, occupational therapy, and home health when they are ordered. I evaluate weight loss and gain and make recommendations. For new residents I am required to evaluate them for appropriateness for this level of care. Sometimes they are not able to come to the facility, so the Administrator and I go to visit them where they are living.  I complete a five page pre-admit assessment, a care plan, and a psychoactive medication assessment if they are on any psychoactive meds for each new resident. This assessment has to be updated in 30 days and then with each service plan meeting. Every 3 months I audit the charts, service plan and psychoactive meds for the effectiveness and any side effects.  I attend Service Plan meetings. I review all incident reports daily and write any additional recommendations to keep the resident safe. Physician’s orders for the residents are sent out every 4 months for the doctor to review and sign. Before they go out, I review them and make corrections. I fill out the lab protocol for all of the in-house doctor's residents per his instructions depending on the medications the residents are receiving and I review the labs and contact the doctor for orders if needed once the results are back. For residents who are not with the in-house doctor, I contact the primary Care Physician to make sure the labs that are needed for certain medications are being completed at the office or if they want us to do them here at the facility. I review the Medication records to make sure each medication has the reason it is given and side effects to watch for. I review the Level of Care assessments that are completed every 3 months on each resident to look for any changes in the resident that may not have come to my attention another way. I hold monthly meetings with the medications aides and treatment aides to go over what we are doing right and what we can improve upon. I evaluate the Medication aides to make sure they are passing medications in a safe manner. I train staff to take care of catheters, oxygen, do blood glucose checks, eye drops and blood pressures. I make sure they know how to do the Heimlich and know standard infection control. And sadly, I attend funerals.

I am sure there are responsibilities I have forgotten, but this is a fairly good picture. I couldn’t possibly get everything done for each of the 50 residents that live here without the assistance of my RSC, Shift Managers, Med Aides, Treatment Aides, floor staff, Assistant Administrator for helping me with lists and forms and last, but definitely not least, my Administrator for handling staff issues, family concerns etc. In addition to nursing responsibilities, I help out by answering phones, answering a call light or personal alarm, grabbing a walker for the resident who has forgotten it, walking a resident down the hall and helping them get into bed, cleaning up cat hair, sweeping, taking out trash, feeding and watering the animals, watering plants, getting coffee and /or snacks for the residents who have forgotten they have already eaten or giving emotional support to a resident who realizes his wife has passed away for the 100th time. I also look for lost items, audit the facility for any dangerous items and have them locked up. I am in charge if the Administrator and Assistant Administrator are out of the building. In that case it is my responsibility to take care of any administrative issues. I work through almost all my breaks and lunches. I do my best to complete these responsibilities within my scheduled 30 hours a week.......I am a Dementia Nurse and I love my job.


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