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The wandering engineer, an unusual dinner, a blizzard and a Hospice consult.

Posted Jan 27 2009 7:13pm
When I returned to work this week I had been off for a few days. I like having 3 or 4 days off a week, even if that means the shifts I do work are all crammed together.

I delayed my usual preparations for the frenetic grind of working the Floor to sit down with our DoN. I brought up the whole behavior plan thing, only to find out that our parent company is preparing the framework to do more or less exactly what I had proposed.

She then told me that the Captain had left us. His behavior had escalated (much as you would imagine the behaviors of a 90+ retired naval captain escalating while being henpecked by burnt-out CNAs) and he was sent out to a specialized behavior setting. Although I was glad he didn't end up in the mental hospital; I was quietly, invisibly seething with rage at the two CNAs who saw fit to gang up on him when there were no RNs about. I later calmed myself by checking the permanent schedule to verify that certain changes had taken place.

The DoN said that they were holding his room, and that he wouldn't be able to return until the behavior plan was in place, the CNAs were properly trained and understood the implications of the behavior plan, and one of our RNs had visited him in his new milieu to verify that his aggression had decreased.

His repetitive, non-functional calls for help and borderline personality grated on all of us, but I was disappointed to find him gone. I felt as though we had failed him as caregivers and supervisors. The captain didn't require specialized care, just caregivers that reacted to his behaviors consistently. Basic dementia care. I'm told things will be different when we open the locked unit early next year.

The DoN asked me casually if I wanted to trade my evening shift on the floor the next day for a day shift as supervisor. The facility needs an RN in the building every shift, and on days it's usually the DoN. She hadn't been able to get a day off in a while, so she proposed that I leave early that night (at 9 instead of 11) and pick up the day shift the next day.

I readily agreed, since this would mean I'd be working side-by-side with the LPN who acts as charge on Day shift, a person who practically runs the facility single-handed. I'm definately going to learn as much from her as I can!

*****

The next day I walked back on the unit bleary-eyed from 4 hours of sleep and surprised the third-shifters, since they had received a taped report from me the night before. Some of the support staff thought I had stayed all through the night!

I had a re-admission to work on, one of our rehab patients came back after being sent out for a Volvulus of the Splenic Flexure.

I figured I could make short work of the admission, so I helped out one of the LPNs with dressing changes between steps.

Before too long, it started snowing. It started snowing a LOT. Traffic accidents. One resident's relatives who flew in on a private jet got stuck in traffic and had to stay at a motel instead. The dietary staff all left early, leaving us with no one to wash dishes or prepare food. To their credit, they set us up with a cold-cut buffet and disposable tableware (it's bad enough I have to do clerical work, I am NOT doing dishes).

Worst of all, we were missing some CNAs. The lead CNA (the Scottish woman I write about so fondly) stayed far beyond the end of her shift to keep the CNA headcount nice and legal (we need at least 3, 4-6 is preferable). Two CNAs couldn't make it at all, despite the fact that the DoN had left a message up for a week saying that CNAs could clock in early to beat the snowstorm and that missing their shift due to the snow would count as an unexcused absence. One aide called asking if the DoN's husband could come pick them up, so I transfered them to the scheduler's line. Unfortunately, the phone numbers they gave us to get back to them didn't work, so they were SOL there.

The second aide called (the one who mouthed off to one of the LPNs behind the nurse's station) asking more or less the same thing, I told her the same thing I told the first one and asked if she'd like me to transfer her to the scheduler's office.

"It don't matter.." she said.

"Oh. Well, in that case, I have other things to do." *click*

Back to work.

With the dietary staff gone, we decided to move most of the residents who usually eat in the dining room (mostly the long-termers) into the lounge/library area and set up the cold cuts there.

With only three aides on the floor instead of the usual 5 we would have for the census we had, I abandoned my rapidly mounting paperwork to help out. I ended up being of limited usefulness, not having much practice with the long-termer's individual quirks and anxieties about transfers. I managed to transport two by wheelchair to the lounge in the same time the other three had transferred 10 or so. The Lead CNA occupied some of the dementia and psych disorder residents by making up songs to sing to them, one or two would make up verses and sing them back to her. It was heartwarming.

The scheduler and the HUC helped feed the long-termers (many of them need to be supervised while eating or fed by hand) while I transcribed orders and put out fires on the rehab side.

Throughout all of this, the wandering engineer was wandering. He used to be a professor, and his wife lives on the independent living side of the campus. For a while he was on a tab alarm (which sets off a horrendous siren if the person attached to it gets out of their chair), because he was considered a fall risk. After it was apparent that he was pretty steady on his feet, we got rid of the tab alarm. The problem then became that he would wander around everywhere. Urinary retention, supra-pubic cystostomy and pretty heavy dementia, by the way.

Our unit isn't a locked unit, but some residents have "wander-guards" strapped to their wrists. If they get too close to one of the exits, the door will lock and an alarm will sound. The wandering engineer tripped the alarm many times that evening, mostly because someone had set up a table with cookies and cider right next to the front entrance.

He was always restless, but now he could wander about as he pleased. This was an overwhelmingly positive development, but not without it's drawbacks. His agitation increases somewhat when his wife leaves to go back to their apartment, a regrettable but unavoidable fact of his care. Most troublesomely, he never remembers which room is his (or even that he has a room here) and he tends to randomly walk into the rooms of other residents.

His speech is disorganized and full of indefinite articles. He's always talking about "it" and "then" and "there" in a way that makes it clear he's trying to articulate something very important to him, but when asked what he's talking about he just gets confused. He's always trying to disassemble some things and testing the structural integrity of other things (I heard civil engineering was his specialty).

We aren't supposed to have favorites, but I can't help having a certain fondness for the wandering engineer. Part of this may be because I used to be an engineer myself, another part may be that I tend to get the most attached to the residents that require the most attention to ensure their safety.

After dinner was finished and the room was cleared out, I peaked in to find that the door out on to the snow-covered patio was wide open. I went immediately into elopement mode, figuring the wandering engineer had wandered out into the snow.

He was on the other side of the room, trying to figure out how to take the electric wheelchair apart, shivering from the snowy wind.

*****

This week I also found that our chemo patient had returned. She was still refusing all of her medications. She was in immense pain, having quit her voluminous medication list cold-turkey. Hospice had rejected her once, when I heard this in the administrative report (kind of like the nurses morning report but with the heads of all the departments, including the charge nurse and top admins) my jaw practically dropped.

"How...how could she not get on hospice?" I was struck stupid by the information.

"They have criteria." was the nonchalant reply.

On my time hospice was called again, and this time she was accepted as a hospice patient. The Lead CNA (the same Scottish woman who had stayed past her shift) asked me to come help make her more comfortable.

I ended up just running errands for her after helping her reposition the patient. I fetched some ultra-absorbent pads for the bed so she could get rid of the incontinence briefs. She was refusing oral care in addition to the meds, and wouldn't let anyone do anything but change her. Watching the CNA care for her reminded me (as I'm reminded every shift) how much I still have to learn about this job. She had me bring some ginger-ale, she whetted the oral-care swabs with them and moistened the patient's mouth, talking to her soothingly, confidently.

We stood out in the blizzard afterwards smoking cigarettes, and she told me she cared for her mother as she died from multiple sclerosis. She only brought it up when I mentioned a friend of mine with MS who wanted to come in to volunteer.

"Not many people understand MS." She said thoughtfully. "Me mum sounded like she was drunk all the time, she ne'er touched a drink in her life."

"She was diagnosed when she was young and died in her 70s." She continued in her thick Edinburgh accent. "She ne'er even had a pressure ulcer when she died. Ne'er spent a day in the hospital. I took good care of 'er."

In stark contrast to her usual sing-song cheeriness, she sounded almost mournful.

The cherry of her cigarette glinted in her eyes. She looked fierce and proud.

*****

Halfway through the shift one of the other RN supervisors called me up and asked me to switch shifts with her. This means I don't have to work on the day of the Christmas party (at the swanky resort casino nearby), but I WILL have to work 7AM on the day AFTER the Christmas party. Oh well, I never get much sleep before a 7-7 anyway.

Plus, this means I get to supervise again instead of taking the floor.

I drove home through the blizzard, just as I've driven through every other blizzard that's hit this part of the country since I could drive. I'm at home in the snow.

One of the residents is leaving soon. She's sad because the home she raised her children in is being sold, and she's moving to a different facility soon. She had been sitting in her room all day, so while we were getting everyone up for dinner I brought her to the bay windows in the lobby, where we watched the snow together in silence.
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