First RN job = part time, nights, stable pt

  1. I finally got an RN position after graduating from a BSN program in December! Not my first choice, but it'll give me experience (and hopefully confidence as an RN).

    I'm working in home health just part time right now (until my other temporary job ends in 3 weeks). I'm on weekend nights, which means I won't be able to get into a different sleep routine, and prob. won't be able to sleep during the day. I'll just spend Monday (which I have off) trying to catch up.

    I have two concerns. First, the pt is pretty stable - no scheduled meds/feedings overnight. Mainly just listening for a need to suction the trach, keeping an ear out for the O2 sats monitor alarm, and being there if he wakes up and tending to any needs then. My concern is staying awake! The weeknight nurse apparently has been napping...

    My next concern is my training/orientation. I shadowed a nurse during the day shift to see how the days go, but I wasn't able to do any care or get any practice (the day nurses are from a different agency). Since the pt is sleeping during the whole night shift, I don't know how I will get any practice with suctioning, or be prepared for (have practice with) emergency trach care. I guess we will just have to wake him up and do it, right? I can't imagine my supervisor will leave me on my own without having demonstrated the necessary skills... I hope! I hope that we still will practice it even though I won't routinely need to do trach care or emergency care.

    I'm sure I'm just worrying too much and it will be just fine... right?
  2. Visit itri4vt profile page

    About itri4vt

    Joined: May '10; Posts: 65; Likes: 20


  3. by   systoly
    napping... My BON considers this pt. abandonment.
    You need a laptop and a thermos. You can use the downtime to find out everything about your pt and the equipment. If there aren't any manuals available, download them from the equipment manufacturer. You can take inventory of supplies and Rx and make reorder lists. You can ensure the chart is organized and up to date. You could make lists of all the sx and Dr.s apt.'s the patient has had, when the pt. was on antibiotic, what for and for how long. Is there an updated contact list?
    As far as trach care/suctioning is concerned, ask the agency if you can spend a couple of hours on another shift and get hands on.
  4. by   ventmommy
    You really need some hands-on! Is this a child? If so, hopefully the parents will be supportive of you. You can't plan on an emergency trach change so you need to be 100% confident in your skills. An emergency is NOT the time to find out that you didn't know that trach was cuffed or you don't know where lube is or that you are a panicker!

    We let our nurses use their laptops to study or quietly watch movies (no earphones!) or they can use the TV/DVD/Cable in the bedroom as long as it is quiet. We have a small lamp that is always on so they can read and see our son. One of our nurses likes to knit and has made three afghans for our son and countless blankets for other people!

    We have manuals for every piece of equipment in his room. Our night nurses are the ones that change vent/oxygen filters, change suction canisters/tubing, wipe down equipment.

    Sleeping is absolutely forbidden. If a nurse can't make it through her shift, she needs to wake one of us up and go home. I am pretty certain that after the second time a nurse is caught sleeping that the agency terminates employment.
  5. by   itri4vt
    Great tips! The only shift my nursing agency does with this pt is MY shift, and unfortunately there was no overlap with the previous nurse. So, if I had hands-on experience other than this shift, it'd have to be with another pt (since another agency is covering all the other shifts).

    I know the DVD player/TV is okay, and I'm sure they wouldn't mind if I brought my laptop (although probably no internet). I like to read books too. The family's area for all the supplies, equipment, literature, and documentation is quite unorganized. It's all mixed in with toys and papers, so if I wanted to find a manual, I might not be able to... I wonder if they'd mind if I sorted it out and organized it better? I don't know how I'd go about asking about that though without sounding critical.
  6. by   systoly
    Just ask straight up, " Is it ok if I rearrange the supplies and literature?", and see what kind of reaction you get. In my experience, the response is usually positive.
    The few times I've gotten a, "You don't like my housekeeping?", I say something like, " It would help me provide better care and hopefully take a small load off your plate".
  7. by   ventmommy
    Maybe the parents are just overwhelmed with stuff, maybe they would be disorganized even if they didn't have a MF child. You can just say something like "it would really help me out to be able to read all the manual's for the equipment that ___ uses, would you mind if I organized them and left them in his room?" Then once you start organizing, just keep at it. The parents will probably be relieved!

    If they don't have a care notebook, maybe you can offer to help the mom make one. Just explain how easy it is to look things up and that ALL caregivers would then have access to the same info and if G-d forbid, he has to go to the hospital, all you have to grab is ONE notebook and the go-bag.

    Does your agency have trach sims that you can practice on? Make sure that all the supplies for an emergency trach change are at the bedside and in the go-bag. Mentally go over emergency situations (mucus plug, decannulation, decannulation and can't get trach in, CPR, etc.) every day so that you are prepared.

    Does Mom or the day nurse usually do the trach change? Find out from them how they do it. Do they use a towel roll? Does he hold his own head up? We use a towel roll under the shoulders and there is one at the foot of his bed. When we are out and there is an emergency (which has happened) either the nurse or I will hyperextend his head/neck and just hold it.

    Make sure you know where all the emergency supplies are (oxygen, ambu-bag, mask for ambu-bag, occlusive dressing, phone).

    If they don't have internet or won't let you use it, you can get an aircard from AT&T or other wireless carrier. We let our nurses use our internet.

    Most parents are open to suggestions from nurses. I know I was when my son first came home. Now I know that my nurses suggest my systems to other parents!
  8. by   systoly
    Ref. web access: for about $60/month you can get service via a high speed USB modem.
  9. by   caliotter3
    Everything previously said. You are showing good initiative in being proactive about your training. The best thing you can do is to continue reminding the agency that you would like to accomplish this with another patient. However, don't be surprised if it takes some time for them to find a patient for this venture. Not many patients would be open to practice runs for a nurse who will not be working with them. Look online for local opportunities for a vent class if the patient is on a vent. You can sometimes find one that is open to the public in the education departments of hospitals. As for the organizing and cleaning of the patient area, I have on occasion, simply done it, without making a mention. Never had anyone tell me they didn't want a straightened out area. Don't make noise taking stuff to the dumpster and you should be ok. Find something to do to keep yourself awake. You will not be doing yourself any good by getting caught sleeping by the family. This is a night shift hazard that must be dealt with successfully or else you need to change shifts. You should be doing routine trach care either at the beginning or the end of your shift. I do mine at the end of the shift to leave everything in order for the oncoming caregiver, but if my patient would prefer it at the beginning of the shift, I would do it then. Or if completely messy, I would do it at the beginning, out of necessity. Also, if you don't get the opportunity to practice skills, never underestimate the usefulness of doing mental dry runs, even with a textbook or manual open. That is a valid part of your day to day training that you can do on your own without disturbing anybody.
  10. by   nursel56
    Cali's suggestion of doing mental dry runs is excellent. We should do this all the time just because of the fact that many of the patients are so stable after a period of time the routine can take the edge off your alertness, in the same way that first responders are constantly doing training exercises and simulations of real emergencies. Yes, the information is in your head, but you want it right there right now when the unexpected happens, especially on night shift it seems.

    When I first started taking care of the home vent/trach pts I was pretty nervous, too. Most of the time they have an established way to suction that can vary from pt to pt trach to trach. Some want you to suction going in and out. Some want you to only suction to 1.5 inches. Some want you to rotate the suction catheter slowly, some want .. etc and very often they've arrived at that through trial and error, and both the patient and the parents can become quite anxious about that, understandably.

    So I asked to go for a second orientation (unpaid but totallly worth it in peace of mind) focussed only on the trach and vent routines and made notes and diagrams that I filled in as soon as I got home while it was fresh in my mind. For every bad thing that could happen I wanted a ready answer. They might have thought I was an OCD P in the A - that's OK.

    A few months ago there was a post from someone on a night shift who had a child left with no air for a few minutes due to vent tubing becoming disconnected but the nurse froze I guess and didn't troubleshoot correctly. We've had people who didn't know where the ambu bag was kept or where to attach it on the ventilator dependent patients.

    When I started I worked in a home with multiple people on skilled nursing--- which was a godsend for me but they were sort of like the ladies down by the river doing their wash telling me these stories about the day things went really horribly wrong - my eyes were like saucers I'm sure. I always made a little mental note of what never to do.
  11. by   itri4vt
    Thanks for all the advice. I had my orientation last night with my supervisor, and we spent a lot of time updating the chart (no one had really been to review the case in a long time, so the plan of care was kinda outdated, and the chart was full of extra papers we had to pull). Learning to document correctly with outdated forms is a pain, since there are things listed to check off that are no longer done with this pt. However, the more I have to do, the easier it will be to stay awake.

    We practiced emergency trach changes, routine trach changes, trach care, and bagging all on a baby doll. So I know what to do, but I haven't done it on an actual person yet. I expressed that concern multiple times, and she said that after the family get comfortable with me, I could ask if I could come in during the day on their monthly trach change to do it. I just don't see that happening though, because no one wants their kid to be someone's training - even though it would benefit them in that I'd be more experienced with their particular child.

    So I am going it alone tonight... and if an emergency happens - the trach gets pulled out, there's an obstruction - I know WHAT to do, I know WHERE the equipment is, and there are trained parents in the home that I can call for help. I have been fairly level-headed in emergencies in the past, so that helps me feel better too. However, I do feel a little silly being the trained, paid professional there and my instructions were that if a problem arises, wake up the parents and have them take care of it. And if it's an obvious problem that needs emergent attention, call for help and start doing it yourself.

    Is this normal? Is it normal to have only 1 day of orientation and only practice on a baby doll, plus 2x suctioning on the real child before going it alone? I feel way too dependent on the parents.
  12. by   caliotter3
    Don't worry about feeling dependent on the parents. This will go away with time. And as for normal orientation, that is way more than most people get most of the time. I never got to practice anything on a doll. You will do fine.
  13. by   nursel56
    It sounds like you've got at least the basics! You'd be surprised how many people are able to breeze in and hope for the best . . I never had to actually manually ventilate my patient either, but you know to pull the trach out of it's obstructed, and you have the parents near by -- plus 911 if you run out of options - I'm sure they would rather you ask until you're sure -- at this stage I don't think it will come across as not confident. I always tell people that I am a stickler about details and I don't want to "think I know" I want to "know I know" and I say it in a confident tone of voice. How can you argue with that really?

    One night at the house with multiple vent cases the power went out - normally not a huge deal as it comes back on pretty fast. We have 8 hrs plus or minus on the external battery and 2 hrs on the internal - finally the dad had to fire up an old gasoline generator and we had those thick orange extension cords snaking all over the house and flashlights! I felt like Pioneer Nurse.

    When people scoff "it's so easy" in private duty well until you're on your own and things go wrong!
  14. by   Sehille4774
    Ha! What a fun thread.

    You sound alot like me 1.5 years ago when as a new grad, BSN I managed to get my first job doing pediatric home care with trachs and vents. Some of even basic nursing jobs in LTC or acute care had 80-140 applicants for 1 spot back in 09.

    Ironic huh...spending 4 or more years in school tediously going over the simplest task many many times in order to become competent in those General skills, only to get hired in one of the few areas of nursing where students get little or no in-school experience and end up getting only a few days training by your job in the skills that you do on a daily basis. That tells you how desperate they are in this setting or 'speciality'. This should also tell you something about your is not a good sign if you constantly being put in situations that are unsafe for you and the patient. Some agencies are pretty bad--they will do whatever it takes to placate the parents and keep a case..some seem at least concerned for their nurses and will draw the line when necessary. Weird too how you are the nurse yet the parents have more experience then you! Parents can be your best resource though...most know 'how it is" with home care training and are glad to help any new nurses for the safety of their child. Most times the parents are diligent and can be trusted for info more then the multitude of other staff members involved in a case as they have been with that child from the beginning, have seen what works, what doesn't---and ITS THEIR CHILD. I have found many charts to be lacking..especially history. Inaccurate at times.---and the supposed office manager type staff spend about 30 minutes per month with the client so dont have a full picture like the parent would. sorry.

    You seem to be asking all the right questions though..which is important because In case you haven't noticed you are self taught in many ways.

    It is July now, so I am sure you a through the worst part of this. I know it took me awhile before I started to feel relaxed---both for the pt and my license. Not an ideal way to enter nursing...but what you gonna do? Lucky for you, you should have the educational background to figure it out for yourself....some really don't but the agencys are so desperate for people they would just about take anyone I think sometimes! (see the part about doing whatever it takes to keep a case) After four years of school though and a professional license, you deserve employment, and you deserved it in the setting you trained for which was the hospital.

    Your experience is the norm with home care...their is little formal pediatric/respiratory training available to nurses (i had a total of 3 peds patients in my 5 years of school) Nursing Schools dont teach these in depth becasue peds has been de-emphasized on the NCLEX..and as for respiratory therapies like CPT, suctioning, coughalators..RT handles that usually in Acute care. So many nurses young and old entering home care are coming in with little experience just like you did and learn on the job.

    Hope all is going well. Try to get oriented to as many cases as you can so at least you can learn as much as possible. Peds and trach and vent exp. is valuable in many other, er, nicu, picu, general practice nurse practitioner.

    I am going to pay the 300$ to take the ANCC CPN test (certified pediatric nurse) and I am going to try employment at a local ped hospital who does hire without acute care exp for many of the reasons i described above.