The Wild Thing With Wrinkles

For a couple of years, I did MDSs (Minimum Data Set assessments in nursing homes/SNFs- mine were used to determine Medicare reimbursement rates and care plans for SNF-skilled nursing facility- patients who were generally there for rehab and then to return home; some did end up staying permanently) in a facility that was in a town with a couple of ‘sister’ facilities within the same corporation.  We were ‘separate but friendly’. They were still competition, but part of the same overall corporate bottom line.  One of those facilities had been going through a period where the DON (Director of Nurses) was the only RN in the building… ever. So she never had a day off, and was always on call. This went on for several months (I would have bailed, God bless her). One weekend, she had asked her administrator if one of us at the facility where I worked could take call for the weekend for her- meaning if there were problems requiring RN intervention- or at least notification- someone else would do it. She needed a break.  Because of health issues and medications, I didn’t take call at the facility where I worked  (and the need to do the MDSs 5 days/week; the deadlines didn’t allow for days off following having to work the floor if staff calling in sick needed someone to cover their shift), I agreed to take call. I felt bad for their DON, and could respect the need for some time off.  I didn’t know the staff or residents over there, but knew if I ran into something strange, I could notify my administrator who could contact their administrator.   I’d be on-call from 3 p.m. Friday through 7 a.m. Monday. I held my breath and went home.

At 5 p.m. on Friday, I got a call. Two hours in… this wasn’t good.  One of the nurses was upset that one of the male residents wanted to have a ‘conjugal visit’ with one of the female residents.  OK.  And the problem was???  She didn’t think they could do that. I asked if they were both cognitively intact, and had the physician statement saying they could act on their own rights. Yep. They both did.  In that case, they were aware of their actions, and were able to make those decisions. (Had one or both of them been cognitively impaired/demented, then that is a totally different situation… no diddling in the nursing home).  She double checked my answer- I told her that it was their home…they had the right to get busy as long as they both were capable of acting on their own rights.

The nurse was still uneasy about the whole thing. She asked about the roommate. I told her she needed to find a way to keep the roommate busy, and discretely ask her to allow her roommate some private time, or find a room where the two horny ones could have some privacy.  She needed to put a sign on the door that asked everybody to knock before entering (and wait for an answer !), and not act like anything was going on that required some sort of national security clearance. They were having sex, not discussing Pentagon secrets  (though in this day and time, those lines are blurry).  The nurse was still not comfortable with the whole thing.

She told me that the horny female resident was a double amputee (legs). I wasn’t sure how that mattered given what they were wanting to do. *scratching head*  I asked her what her concern was… the response: “She doesn’t have LEGS!”.  Last I knew, legs weren’t mandatory for doing the wild thing.  I told her to have the CNAs (certified nursing assistants) help the lady into bed, make sure she was safe, and leave.  Finally, I told her that if anybody had any problem with this come Monday, tell them I’d given the OK since both residents were able to make their own decisions, and that it was their home.  They had the right to intimate relationships… legs or not. I’d heard our social workers and consultants discuss various ‘rights’ many times. I was comfortable with my decision.  Let ’em have at it.

During this whole conversation I was thinking ‘it’s 5 p.m. on Friday, and I’ve got sixty-two more hours to go….’.   I was doomed. But, the rest of the weekend was eerily quiet. NO calls from the nursing home.  I hadn’t heard of any disasters on the news involving a Hill Country nursing home, and my administrator hadn’t called me  with any concerns from their administrator.  I had wondered during that phone call on Friday if they were yanking my chain to see how I’d respond, but sometime later, I think I remember hearing that the two residents involved in doing the wild thing were, in fact, a ‘couple’.

That next Monday, back at the nursing home where I worked, I was asked how being on call had gone, and told them about the wild sex questions. They all laughed.  It was funny, but more importantly, the residents weren’t stopped from being able to make decisions in an environment where nearly everything was decided for them.  The alert, cognitively intact residents of any facility can’t be ‘banned’ from living their lives as they so choose. If they are safe, it’s not up to me- and if they’re not safe, and can act on their own rights, I have to do what I can to make things safe for them.  I don’t have to agree with their decisions (no matter what they are- sex or otherwise), but I’m not permitted to impose my ‘rules’ if they are more restrictive (or permissive) than what the state guidelines permit. Nursing home residents have rights. The facility is their only home; it’s not like they can take off to the Holiday Inn for a few hours.  I found it rather sweet that those two had found each other in an institutionalized setting, and actually wanted some ‘privacy’.  And, their DON got some time off. 🙂

Being A New Grad/Young Nurse

I graduated from an ADN program in May of 1985.  Back then, we took boards in June or July (I don’t remember which now), and 1500 of us sat in one room for two days, taking each of four sections of the test when we were told, how we were told, and for how long we were told. Total of 1000 questions.   If we got up to use the bathroom, we had an escort. I was the first one done on each section, so got asked a lot of questions on the condition of my bladder.  I was just done!   I think each section was allowed 3 hours, and had 250 questions.  To pass boards, one had to get a minimum of 600 correct.  None of this 75 and done business 🙂

As soon as I graduated, I went from being an agency CNA to being the only RN-educated person in the building on nights, and after 5 p.m. when I worked double shifts.  Trial by fire. There was always an RN on call, so I had back-up, but when it came to on-site hierarchy, I’d gone from the bottom (agency is always at the bottom) to the one in charge.  I had to learn a lot quickly; school is all well and good for the procedural part of nursing, but for hands on, clinicals only offered how things were supposed to work.  Time for this 21 year old to figure out what needed doing, and just get after it.  On my ‘slow’ shift, I had 30 Medicare/full-care residents in a skilled nursing facility.  It was great experience for learning trachs, suctioning, catheters, g-tubes (we used a lot of Foleys back then for feeding tubes- much easier to change out), and had to do my own percussion respiratory treatments with these little padded vibrating thingies.

We didn’t have glucose monitors back then, so had to dip urine with sticks that reacted to the amount of glucose in the urine. That was an issue, since the urine could have been in the bladder for a while, even when using needle aspiration if they had a Foley … I had to base the insulin dose (from the sliding scale) on that stale urine.  It’s what we had.

“No Not Resuscitate” orders were more of a judgement call.  If they were in a nursing home, generally we didn’t jump on them, or initiate CPR while waiting for the 911 guys.  They were old, worn out, and dead.  It was fairly simple.  Sometimes, I think that’s better. What do we bring them back for if they’re already so compromised?  For the ones who were rehabbing to go home, there was more of a chance we’d do all we could to get them to the hospital before they totally crapped out, so IF there was a chance, they were closer to the machines that would/could keep them alive until it was figured out if they had any chance at all.  If they were in the hospital, it was a bit more formal, but the input from the family was just starting to be included in what orders ended up being written.  I didn’t have to agree- just follow the orders.

My first hospital job was about 8 months after I’d graduated, and moved to a different state. I was assigned to the neurology/neurosurgery floor- a far cry from the NICU job I’d wanted.  I learned a lot there- and was mortified at some of the things that the textbooks spent a few paragraphs on (or none at all), and the devastation that can happen in someone’s brain.  Near drowning (a 4 year old) is close to the top of the list. She’d never be mobile or  aware of much.  Progressive supranuclear palsy leaves someone’s mind intact, but paralyzes even their eye muscles, so they’d need special glasses to even watch TV- sort of like periscopes. Until they die.   Herpes encephalitis is horrendous.  Jacob-Creuzfelt (or Creuzfelt-Jacob, depending on where you are) is a cruel, progressive set of symptoms that eventually shuts down everything.  I was getting a full frontal about mortality.  Yet, I learned so much.  I’ve always enjoyed learning more about neuro after that first hospital job, and went on to work coma-stimulation in a head injury treatment center. That’s all they did- head injuries, and all ages.  Long term care and skilled nursing rehab were also extensions of the neuro experience I had.

I didn’t start out where I’d dreamed I’d work when I was going to nursing school.  I went to school to work pediatrics. Well, let me tell ya… peds isn’t all it’s cracked up to be.  I eventually got a full-time pediatric job, and floated to NICU and PICU now and then.  I’d taken care of kids on the floors I’d worked on in regular hospitals, and in head injury rehab.  But to get non-stop kids, with many, many horrible abuse stories, or knowing that whatever kid was on the news at 5 p.m. would be one of my patients at  7 p.m. got to be a major grind.  That and the reduction in hours based on census was tough; I’d tried to reach the nurse manager of an adult unit to make up hours, but never got a return call (Yankees !!).  Where I’d worked in the South, people were glad to have someone show up who wanted hours.  At any rate, between pediatrics being totally different (I hadn’t anticipated SO many abuse cases), the hours being chopped, and my health starting to be a major issue, I needed to leave.  I thought I’d found my dream job when I got that call that I’d been offered the job.  In the end, though I am thankful for the experience, I didn’t like it.  I really didn’t like NICU. I learned a lot about where the  chronic pediatric patients started, but those miniature babies were not fun to work with, unless I got stuck with the ‘feed-and-grows’. All they had to do was gain weight- otherwise they were pretty stable. They weren’t bad.  I saw some babies that were totally unbelievable.  No thanks.

For the newbies out there, don’t just focus on what you think you want.  Take what you can get and make the best of it. There is an overwhelming possibility that it will make you a better candidate for any job where experience of some sort is required.  Serve your time, pay the bills, and work for the goal you think you want. But also don’t be surprised when what you want ends up being very different when you are working with a full patient load on your own. Speculation and assumptions don’t end up being very realistic… ❤

Why Work At A Nursing Home…

If you work at a nice one, there’s no reason not to work at a nursing home. I’ve heard the slams by non-nursing home nurses over the years that somehow nursing home nurses are the bottom of the barrel, but I’ve found this to be quite untrue.  Different types of nursing require different skill sets, and nursing  homes often deal with many specialties under one roof.  There is always the physical maintenance of chronically ill and dependent (in some form) patients. The knowledge of medications is extensive.  Nursing home nurses must be able to deal with psychiatric issues, and know the most effective ways of handling them.  There are always the emergency issues that require adequate assessment to get the resident the proper level of care. Wound care is critical- from surgical wounds to superficial skin tears that are so common in fragile elderly skin.  The nursing home nurse has to be very familiar with various hoses and tubes, and how to keep them functioning.  And then, there are the family dynamic issues that can change on a dime with any one of the nursing home nurses’ typical 15-30 patients and their families.  Time management is crucial.

Then there is the fun part of nursing homes.  I’ve been fortunate to work at some great facilities over the years. My first job out of nursing school was at a facility where I’d done staff relief work as a CNA.  When I started my nursing career there, I was the only RN educated person in the building most shifts I worked.  The ADON (Assistant Director of Nurses) was there until 4-5 p.m. when I worked 3-11 p.m., but otherwise I was in charge- without a license.  I was a GN (Graduate Nurse), and since I had access to an RN 24/7 it was kosher back in 1985 in Illinois. Now, I think that’s nuts.  Fortunately, I’m not so stupid that I didn’t realize what I didn’t know, so was very good at asking questions.  I was typically responsible for 30 heavy care and/or Medicare patients on 3-11 p.m. AND another 30 dementia patients when I worked 11 p.m.-7 a.m. – my actual shift.  I did a lot of double shifts.  That’s how things were done back then. I was 21 years old.

I mentioned ‘fun’.  I had some very entertaining residents.  Most were out to lunch in a very sweet way.  Those were the days of ‘reality orientation’ which is actually quite cruel. It attempted to ‘make’ the demented person come back to the right year and place, and it might have lasted about 3 seconds, and then they were still confused and unhappy again.  Things moved to ‘validation’ some years later (I started using it as the result of frustration… when in Rome…) which didn’t lie to the resident, but acknowledged where they were in their heads.   They weren’t going to be ‘fixed’. Dementia is progressive.  Let them be in 1954.

One of my little ladies wanted to call her mother every night before bed.  This lady was about 89 years old, which in a generous ‘young’ estimation made her mother at least 107. Uh huh. I was still in reality orientation mode, and asked this lady how old her mother was.  She gave me some age that was younger than she was.  This wasn’t going well.  I asked her how old she was. She gave me some number younger than what she said her mother was (well, at least she was keeping up with the story she was sticking to).  This went on for about 2-3 minutes. Finally, I unplugged the phone, put it on the counter, and she called her mother, said “Thank you”, and went to bed.   After that night, we bypassed the inquisition.  She was happy.

Then there was this skinny little man who tooled around in his wheelchair wearing a hat with his name on it.  Going by the nurses station counter, all I’d see is the hat scooting along on the other side .  “Max” was toothless, clueless, and so sweet. He also had an irresistable dopey, toothless grin.   He  was about 5 foot 5 inches, and probably weighed 85 pounds dripping wet.  And he was quite a character.  One day, he came up to the station in his chair, and stopped.  I saw the “Max” hat, parked in front of me. I heard his gravely, soft voice saying “Hey! I want a cigarette.”  Max didn’t smoke. Hadn’t for decades.  I told him “Hey, Max, you stopped smoking 30 years ago.”  He replied “Oh yeah”, and left.  We went through that routine often.  Another night, all hell was breaking loose with numerous patients having to go to the hospital for various reasons. I had ambulance crews coming from all directions at various intervals. While I was waiting for another crew, I was on my way down the hall to see the sick resident when I saw Max walking towards me, naked as a newborn, with his catheter disconnected from the bag, swinging like a pendulum as he took each step.  Max was about as stable on his feet as  a greased pig on glass. The naked part was just not pretty, and with an ambulance crew now in the building and heading towards me, I had to get Max covered up (and keep him from falling on his tail). Too late. One of the ambulance guys looked at me in horror and said “Tell me we’re not here for him” (or something close).  I told them which resident to get, and went to wrap Max in a sheet as I guided his skinny butt back to bed.

Another night, Max’s catheter was clogged, and no amount of irrigating it worked. I had standing orders to change out catheters as needed (we used a lot of catheters back then), but I couldn’t get the balloon deflated. This was a problem.  The catheter was stuck.  I could feel poor Max’s distended bladder against his skinny skin, and knew he had to be miserable.  SO, I called the doctor and explained the situation. He told me I could send him to the ER to get it removed, or do the same thing at the nursing home that the ER would do. I was young and game for a new task, so asked what that involved. He told me that I needed to keep injecting air into the balloon port until the thing blew up.  Uh huh.  Alrighty then.  Well, if that’s what the ER would do, it sure would save  Max a trip to the ER, and me a lot of paperwork to just get it over with.  I got a 60cc syringe with the proper tip, and went to work.  The first  60 ccs went in with no change. Max wasn’t reacting, so I figured it wasn’t bothering him. The second 60ccs also went in with no change. I was getting nervous. The balloon was 30cc and already full of sterile water before I started in with the air.  About halfway through the third syringeful of air, I heard a pop, Max went “Ooh”, and the catheter shot out of him like the bullet from a military assault rifle, shooting pee on the wall about 6 feet from where it was coming from… OK, well, that worked!  I replaced the catheter, and Max went to sleep, much more comfortable.  Now we have bladder scanners that would have told me how much ‘room’ I had before blowing up the bladder was a major concern.

Another resident in that facility was a former missionary. She was now way out to lunch, and had some big issues with her feet that made them look ‘clubbed’. Normally, she rode around in a wheelchair, but with her bedtime routine, she could walk to the bathroom with guidance, and get some exercise while she got set for bed.  She’d go to the bathroom, wash her hands and face, and uncerimoniously hand her dentures to whoever was helping her. Then she’d toddle back to bed, climb in, sit bolt upright, and recite the 23rd Psalm. When she was done, she’d look towards the door (her vision wasn’t so great), salute, and say “Goodnight Everybody”, and lie down.  Every night!

These are just a few examples from one place I worked.  Yes, it was hard work. I had a lot of medications to pass, treatments to do, and paperwork (with a real pen and paper!) to get done on each shift. But the residents were great.  Well, most of them. But if being there and taking care of them meant that even one or two felt better, that was worth something.  I got a lot of great skills for a new grad.  By the time I went to work in a hospital some 8 months later, I could deal with stuck tubes, time management, and  brand-generic medication names with the best of them.  I loved the nursing homes I worked in, because I worked in great facilities. Had I worked in a pit (and I’d seen some as an agency CNA), I’d feel differently- but I never made the choice to settle for those. 🙂