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.
