Typical day for a Home Health nurse... - page 2
Not a bad day today... started back per diem today. 6 cases, all in the same township. Not my usual zip codes though, so I did waste some time and scheduled visits akimbo, instead of in a line like... Read More
Mar 14, '03Awww sunny, you are a nice doggie nurse!! See, in homecare we really do holistic care of the whole family!! Furbabies too!
Mar 14, '03Originally posted by hoolahan
Awww sunny, you are a nice doggie nurse!! See, in homecare we really do holistic care of the whole family!! Furbabies too!
Mar 14, '03Today I had a really "easy" day....makes me nervous because the FULL MOON is next Tuesday so Monday and Tuesday ought to be doozies!
#1 89 y/o LOL with HTN and mild orthostatic changes (I'm talking 10 points systolic with no dizziness). I'm only to call the MD if BP greater than 200/95. She's also been having a "faintly feeling" with slight epigastric pressure when she has been up and around for more than a 1/2 hour or so. Says it lasts only a minute or so. MD is aware and no change in orders. So, today, when I am ready to d/c her because her ortho BPs have been unchanged, her meds are unchanged she has the "fainty feeling" with epigastric pressure while I am there, lasts maybe 2 minutes. No seating, no SOB, no pain in arms or jaws. BP was 200/90. Five minutes later she back to her "normal" 170/70. Call her MD....only change in orders is "continue to monitor her 2x/week and fax me the BPs, oh, and decrease her Megace to QD. " GRRRR. The patient saw the MD yesterday and was told to find an assisted living asap. I'm thinking she needs a new MD to change her meds and consider that anxiety may be an issue. Nothing concrete...just a feeling I have...and you know those "feelings." I feel like I am spinning my wheels in there....I fax my notes to the MD every visit.....I think she thinks of me as a phlebotomist who takes BPs.
#2 "Covering" another RN to administer a monthly B-12 injection. The new primary RN has asked me to address this lady's homebound status. Turns out the lady has been on caseload for 2 years for these injections....all the while driving herself all over. Address homebound status and tell the lady we will be arranging for her MD office to administer the injections in the future. Her primary said she'd d/c her.
#3 New Admit. 89 y/o lady who had showed up in the ER several times this year with c/o SOB. Got admitted for two days when she added "chest pain" to the complaint. Known to have CHF, I'm to teach her about her disease and meds, monitor her cardiac status and eval for a HHA. During the interview, she starts talking about how nervous she gets, living alone, and fears her heart will fail. Says her MD won't give her meds fdor anxiety "because they are addictive." (SHEESH!!! This is the same MD who, in the past, has told me to "jolly the patient along" whenever I try to address depression.......) I admit her so I can see her a few times to teach her about her CHF, her meds and her diet. She's fine today....no edema, clear lungs, stable VS.
#4 90 y/o man with G-tube feeds and a neuro-muscular type disease that no one has put a diagnosis to. I'd been his nurse a while back and just loved him. He's lost a lot of weight and is pretty weak. Oriented the HHA and talk to the PT about her plans for him. His wife is a doll and so devoted! The tube feeds are gravity at this point, but she's trying to talk the doctor into letting him switch to a pump...so maybe they can do more than feedings and exercises during the day? He has a new decub which I gave some samples of calmoseptine for...I love that stuff...clears up superficial decubs like magic! The plan is to get this man strong enough for him to have surgery so he can take po again. Please God he gets there.
#5 80 y/o lady I see once a month to administer a B-12 injection. This one truly is homebound, O2 dependent and insists on doing as much for herself as she can. Refuses a HHA because, though it takes her quite a while to shower, she wants to do for herself as long as she can. I refuse to let the per diems do this visit, she's such an love, I think I deserve this visit!
Back to the office to fill out all my forms. We are in the process of switching to computer, I'm still doing paper. All our forms look like the ones on the computer...to help us get used to the form, I guess.
I have a TON of recerts in my box. All are for next week and the week after...whew! I should have most of these people d/c'd before their recert dates, lets hope!
Finish filling in my schedule for next week. I've been a discharging fool lately....so I know I'll be doing a lot of admits next week.
Can't believe I had a day with no labs, no disasters, no messages from "quality assurance"! Shut my beeper off and RUN!
Mar 15, '03Hi everybody....I like this thread. It has helped prepare me for what I will be seeing/doing. I have just started HH this Monday, after working a med-surg floor. I used to work Hospice and had done a touch of HH, so I sorta knew what I was in for. I wanted a position that would let me work a little slower pace physically, since I have a bad ankle and need to have surgery on it soon.
I spent Monday doing office junk....you know: read the updated Policy & Procedure book, update paperwork for my file, get my beeper, cell phone, get my nurses' bag and stuff it full of supplies. I was not nervous at all about my day...I have known nearly all the nurses for over 3 years. We do have a new Manager tho, but EVERYONE says what a sweetheart she is. My impression so far is the same.
Tues thro Fri I went on call with one of two different nurses who are precepting me. Yesterday & Thurs I did some of the visit care while the other RN helped, just to get my feet wet. I did a triple line lab draw on a 21 year ol female who has lung CA and a newborn baby (4 weeks old!) She is also getting ATB Vanco IV that we have to stary until it is run thro. So on one of these daily visits, I held the baby and fed him!
I started a peripheral IV line for a different female who will self-admin IV steroids x 4 days for an exacerbation of MS. We will see her once a month for 6 months to restart the IV...then she will self-admin x 4 days and then d/c her IV. Nice young lady 26 yrs old, married w 2 kiddos.
I have been w the nurse three occasions to see a man who is so very sweet, had a baby toe amputation d/t DM, to change dressing and eval wound. He is also "legally blind" and scheduled for retinal surg in 2 wks, hopeful to regain some eyesight. He is in his 60's...when he found out my Hubby & I ride Harleys, made me promise to drive over someday when the weather clears up just so he can "see" the bike and hear it! Says there is NOTHING like the sound of a Harley engine! RUMBLE RUMBLE.....I agree w him! The other RN & I agree this man is starved for male attention & conversation, since all he has around him is women. I need to see if Hubby might just drive by his home someday....
Saw a LOL in a senior housing complex who has HTN, CHF. There to assess BP, ck meds. She has a little Pomeranian named Walker who has NO TEETH and tried to gum me before an aide picked him up & held him during the visit! hahaha He growled like a little tiger everytime we touched his lady!
On three days saw a 64 yo lady who had bowel resection w an abdom wound dressing, not healing well d/t DM. She is perhaps mildly retarded (very very...but you still get the impression she may be IQ in 80's?) Has a mildly retarded daughter who lives with her and does the dressing changes and cares for the colostomy, cooks, cleans, etc. Theses two are the cutest pair...they tease and pick on each other, and the RN is just sweet w them...you can see the love here...That dtr is doing a WONDERFUL job, writes down the BS, writes down BP, the wound is healing great...used to be (per the RN) "big enough to put your two fists in it", and is now maybe 8cm by 3 cm! Dtr is a great cook and promises me a pineapple-upside-down cake!
Yesterday saw a 17 yr old male, autistic w retardation, who lives w 24 hr caregivers thro a group home type of organization. He attends our local MRDD school which will move him to their workshop for employment after HS grad at age 18. We just give allergy shot q month and stary to assess for any rxn. Obviously NOT a homebound case, but the county MRDD pays for our visits. He is a sweetie. Active, but not real verbal...beautiful eyes. And he is a bit of a flirt!
That is just a few of my visits for the week. I have been in a home on the "wrong side of the tracks" that was maybe a $8,000 home all the way up to a home maybe $250,000. But w/o exception, I have been met warmly, the ppl are interesting, and I am excited about this job!
Yesterday morning, I got my laptop and had computer class. We are going to all be "live" by the end of the year. Right now, two RN's are total computer, the rest of us do limited stuff...OASIS and time logs, mainly. It was not bad...will be glad to go "live" if they want me to. It is a Toshiba w 17 gig HD...not bad! Had to sign my life away for this baby...
Well, next week I am going to do revisits and opens w my preceptor Mon & Tues, and I will do the cases while the RN is my back-up. Then the plan is Wed I will be out on my own for some revisits! YAY! My job is full-time Case Mgr. so some of my work will be office stuff, paperwork. That will come later, altho one of the RN's who is primarily a Case Mgr and does PI work for HH, has a new case she is ready to hand over to me already! hahaha I am so happy to be here.....they have all made me feel so welcome and are glad to have me.... It is quite a change from working the floor! I had to go to my floor to pick-up my paycheck and some mail....it sure didn't break my heart to leave that day after seeing everyone racing around like always! I have had 4 or 5 MD's tell me they will miss me on the floor b/c (as one said to me) "I always knew if you had my patients they were being taken care of". Another MD, (who is my fave!) grabbed his chest and told me I had broken his heart, because he valued my nursing skills and always liked seeing my "smiling face" . That was really sweet.
I have not said this, but the HH I work for (obviously) is with the same hospital I worked floor on. I work mainly this county and will be assigned to one particular part of the county/city. All the RNs have an area they are primarilly given. Cuts down the driving. We do get paid mileage (32.8 cents) and get paid by the hour. I will make the same hourly pay I made on the floor. Our cell phone, pager, laptop is supplied as well as nurse bag and supplies for it (blood sugar monitor, BP cuff w scope if you need one, etc.) I will see between 4 to 6 patients a day and also case manage. On-call rotates...we have an evening RN who works 6 days a week so on-call starts at 8 PM til 8 AM. THen weekend call is Sat 8 AM til Mon 8 AM. Right now, I will be on-call one week night every 8 or 9 days, and weekend every 8 weeks or so. That is of course after I am full thro training. We also just hired a contingent RN and she will take some on-call too. So what do you guys think??? Not too bad, huh? I feel blessed to have gotten the job. They interviewed me 4 weeks ago and w/in the same day, told me I had the job if I wanted it. At the interview, 4 people were there: the manager, a case mgr, and two of the RNs I will be working with. The Mgr told me they wee all unanimous that they wanted me to come there! It is so nice to be wanted!!!
Thanks for "listening"....I know I am in the "honeymoon" period, but I truly feel it will be a great place to work.
Mar 15, '03Oh, forgot to tell ya....the big thing at this hospital right now is we are scheduled for JCAHO in April. So, of course, all the managers are trying to get us prepared. I asked about what I could wxpect...I think I will get off easy b/c I am a new employees to the HH...bt I might get picked out to answer questions regarding orientation stuff. We have been given a booklet of info to know in prep for inspection. The nurses told me that the HH Mgr made a game out of it w few weeks ago....had a meeting where they played "Family Feud" and asked questions...one person was the "Richard Dawson" character, dressed in s uit and tie etc...she said she did the role except for NO KISSES, lol....the winning team got prizes of little plastic bird feeders filled with jellybeans for their desks. How cute!
Mar 15, '03reg... I can read the excitement in your posts. So glad you are liking what you do. And never fear, you will form bonds w the docs, esp the docs in the clinics, and get to know who to ask for in the md office who can get things done for you.
There is a cardiologist in this area I have spoken w so many times, yet I have never met him, and when I call, he knows it is important enough for him to come to the phone, tho I must say his office nurses are fabulous, and I rarely need to speak to him personally. He told one of my pt's he was "lucky to have me as his nurse" and this from a doc hwo has never worked side by side w me, so you will form new bonds, and if you are a good nurse, that will show thru whether you are on the floor, of on the phone w the docs.
Keep posting, it is nice to see how others' assigments are. My day was kind of draining, so I don't want to re-lice it by writing about it tonight, maybe tomorrow??
Mar 15, '03Reg, it is wonderful to "hear" the ffresh excitement in your posts!!! Keep it up, you'll keep the rest of us feeling fresh!!!
this is my w/e off...but i did do one visit earlier....client with a VAC...only 2 of us are oriented to it...the other nurse is his case manager, but she's getting burned out on him...he's a grouchy soul....can be a likeable grouch at times, but he is frustrated with it taking so lon gto heal his wound...but it is doing well with the VAC....but he is inssiting it is not working, cuz as it is healing and as the infection has cleared, the amount of drainage had drastically dropped....he refuses to comprehend this, insists that the VAC unit is faulty...the rep finally gave in and got him a new one, just to shut him up...no such luck....she won't even return his calls now. (in one way i can't blame her, but i really don't think highly of this girl, for various adn sundry reasons... )
Apr 13, '03Thanks for the bump.
Hey, it has been five weeks and I am still in love with this job! We just finished JCAHOand did really well...94. They got us on those darn abbreviations we aren't supposed to use anymore. The rule is an "all or nothing" rule. If anywhere in any chart they pull there is an unauthorized abbrev. (lol) you get dinged for it.
And, just to make the soup even spicier, ODH came in at the same time. But- WE GOT A 100%!!! WOOT!!!
I haven't been here that long, but I feel like I helped a little.
I have been "Case Managing" two of the patients I see and am starting to get the hang of what this means. One is a 65 y/o lady w end-stage COPD. She is reall Hospice material, but she says she just isn't "ther" yet , mentally. She is a retired RN ans we bonded immediately. She takes methyltrexate and gold injections for her arthritis and couldn't get out of the house for her shots d/t feeling so dyspneic. I really hated to see her give up the shots when they are just starting to help her. So I made numerous phone calls to obtain the serum and an order to give the shots. She was really happy about this and I felt great that I was able to help her out. Isn't this what is cool about HH?
The other one is a total knee, female, 77. Lives w 79 y/o husband. She is doing great and her sister goes to her home every day to help her. This pt. has the beginnings of Alzheimers too. Well, I told the sister last Friday I felt the pt could be released from HH next week. So of course over the weekend, she thought her knee was swollen and hot. I think they are just nervous about being released from our care. So we have her for another week or so, and then will have to let her go.
I have seen some really neat machines in patient's homes, too. A CAD cassette for IV infusion, and a cool pill machine that you fill little cups with pills, snap on a lid and drop it into the machine. It dispenses the cups at the right time of day and "talks", telling him "It is 8 AM and time to take your medicine." It even changed time automatically w Daylight Savings time.
I just drive around from patient to patient, (enjoying my new car, BTW) and saying to my self, "I *love* this job!"
I am taking a medical LOA for about 9 or 10 weeks. I sure hope I don't get stupid in that period of time. My manager knew I needed this time off when she hired me, so there is no problem there. She is even going to allow me to come in and do some chart reviews while I am unable to see patients. Nice! (I am having my ankle operated on tomorrow and will be in a cast for 9 weeks, unable to drive.)
So how is everyone else doing??????
Apr 13, '03Oy! I have had the crud for over 3 weeks now. Working in the cold wet snow last week did nothing to help me!!
Yesterday, I woke up, saw the cold rain, and called out. Thank goodness it was mild and sunny today, so I worked. I think I was punished for calling in sick...
I had 2 news admits and three re-visits. 14 mile total mileage.
Called one of the revisits b/c I was to teach the sister to draw up the insulin. She waas not able to make the appt, and since he had enough syringes drawn up and FBS was 120, I told him we'd be there wed at the latest. (Did not tell the supervisor of the opening...sssshhhh, I only do this when I feel like doo doo!)
Next re-visit, a wound, no biggie, simple visit.
Next re-visit, in a roach motel (aka high-rise bldg) was a daily wound. She attempted to refuse visit yesterday, why I don't know and why nurse pushed for visit I don't know, but when I got there today (no phone of course, so I had to make the trip) she "wasn't home, but the person ansering the door would only crack it open, like she didn;t want me to see inside. I'm thinking Hey lady, you don't have to tell me twice...LATER!!!!
First new admit. OMG, obese lady with gigunda breasts, s/p cabg. No mentions of open wounds/wound care on referral. (see where I am going w this?) I get there she can barely stand, has diff ambulating, is crying in pain, and person in home was snapping at her, and got hostile w her b/c she asked him to clear a space for me to sit (major clutter and junk on the floor, this place hasn't seen a vacuum in a dozen years)
She says she is having CP, aka incision, plus arthritic pain in shoulders. She needs more celebrex, but no Rx given, only thing that helped her pre-op.
She has to beg to get a glass of water, which finally I just went inot the kitchen and got for her, avoiding the hostile one. was a little afraid to have too open of a conversation w her d/t this semi-scary dude over-hearing and possibly over-reacting.
She can't even put pain pill into her own mouth, I have to put it in, along w her other am meds, and hold the water to her lips.
At this point, it is clear that the 4 wounds I discovered will not be able to be taught to this CG, pt can't reac/see areas, and this lady is not appropro for HH. I tell her as much, and she cries, saying her son won't lift a finbger to help her. I explain that due to her pain (figured we could play the CP card, even tho I know it was incisional pain) and call 911, and I could speak to the docs and try to get her re-admitted so she could 1 get the assistance she needs, 2 get her meds, 3 get her drsg's changed, and 4 get her meals and adl's met.
She absolutely refused this. This baffles me. I mean I know it is depressing to go back to the hospital, but isn't risking sitting in your own poo kind of depressing too?? I do not pass judgement on the pt, but I do think to myself, well, you made this choice, so now you have to live w it.
Her breats were so HUGE, there was no way she could hold them up to even look at her would in a mirror d/t her arthritis. This teensy area btw the breasts that was not healing, gushed a cup of serosang fuid when I did lift them to do the drsg change. I was grossed out w this cold and all. But no odor, and clear fluid. It won't be long before she gets and infection in this environment and unable to control sugars, and she will be septic. She never told anyone what home situation waas like, if she had, they probably would not have d/c her to home.
So urgent MSW referral made, per our policy, they do NOT want US to call APS, they want all communication to go thru MSW. I am OK w this b/c all APS would have done on Sunday is offer her the same options I had, and she had already refused that.
Also PT and HHA. RD may be needed at a later date, but her RBS was 149, so not too bad.
I documented that she was probably not appropriate for HH< but that "ethically, SN felt that assistance offered by VNA was better than no assistance." I did of course call the sup, but d/t lurking mean guy, I was afraid to discuss this IN the home w sup, so I had no choice but to commit. I'll probably catch some heat for this one!
Next admit, a sweet LOL, clean neat house s/p CHF. She has complete faith in her docs. Takes meds as directed on bottles, and has no idea what any of these meds are for, despite the fact that she has been taking them for 2 years or more. Teaching started. But you know how you can't always tell if someone is wifty on the first visit? I have a gut feeling we may have a little wiftiness going on here, that will come out eventually. She has a caring involved dtr, but she couldn't be there today. We'll see how this develops.
Just wated to share this one b/c of the ethical dilemma. What would you guys have done in my place?
PS Sun, thanks for the bump, you think I should stick this one too?
Reg, glad you are enjoying it!
Apr 13, '03Just wated to share this one b/c of the ethical dilemma. What would you guys have done in my place?
PS Sun, thanks for the bump, you think I should stick this one too?
2) couldn't she have been admitted for rehab? shoulda been soon enough after hospital d/c to still get in , right?
Apr 13, '03She came from 3 weeks of rehab. They are usually pretty good there about finding placement or being certain someone is d/c to a safe environment, but in this case, the lady didn't speak up. I asked her about it and she said, I didn't say anything, they just came in and told me I was being d/c'd. I KNOW they give people like 4 days warning in that place, but I also understand that not everyone thinks they have a choice, so they don't speak up.
OK, I'll stick it.
May 7, '03oooooooh.. I'm so jealous !
I just started reading all these posts (gee, didn't even know this thread was here 'til I decided to take a closer look at the HH Forum..) :imbar
This is definately my type of nursing ! No FAIR !!! Please keep this thread fluid, because I really do want to check it dailey.. it is a marvelous way to learn SO MUCH about HH nursing.. will definately give me a heads up for when I decide to go through with this in the future. I LOVE this thread !!! WONDERFUL !
Thanx, Guys !