First case - infant with g-tube

  1. So I have my first case lined up for next weekend. Brief background- I'm a recent grad LPN, been looking for work for about 9 months and so far this is the only place to give me a chance. Been reading a lot about home health and see many differing opinions on doing it as a new nurse. I tend to agree with the ones who aren't "for" it but don't know where else to apply because NO ONE will look in my direction. This agency allows me to go watch a nurse work but that's the extent of the training, orientation, etc. in short, I'm nervous...!

    First case - 3 month old infant recovering from bacterial meningitis. Dehydration, hyponatremia, seizure activity. she has a g-tube and is getting continuous feeds @ 25mL/hr neocate formula.

    Baby's meds are Ativan, Prevacid, clonidine, kappra, and myclicon.

    Aside from reviewing care of g-tubes, tube feed and med admin procedures, & seizure protocols in babies, do you have any other suggestions as to how best to prepare for a 12 hour shift with this child? I've used the kangaroo pump she has before but again that was in clinicals and this is all very new.

    HH nurses, what do you do to prepare before your cases? Do you bring equipment with you (stethescope, baby pressure cuff)?

    I guess everybody starts somewhere- I was just hoping my somewhere would be under someone's wing, not flying solo! But I'm going to give it my best

    Thanks y'all.
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  2. 15 Comments

  3. by   tktjRN
    I'm getting nervous for you and I've been doing home health for 10 years, but not peds. This company sounds like they're only interested in warm bodies and filling the assignments. I would make sure to review your clinical policy and procedures for this company. Make sure you get some malpractice insurance. Bring a bp cuff, stethoscope, pulse ox, and thermometer. I'm sure you'll do just fine... See if there is a nurse, that you can call-for a resource, if needed. It Always makes me feel at ease when there's someone to trouble shoot with..
    Good luck!
  4. by   notyetnurse
    Thanks, I am excited to be working but really feel concerned by the lack of training. You know that nagging little voice in the back of your head that says "something isn't right"? That's what has been playing in mine for days. I'm having bad dreams about birth defects with babies and not being able to identify disease names, etc... Don't know if it is normal anxiety or really something is wrong. I would feel a helluva lot better if I was shadowing a nurse for a shift instead of leaping into this thing solo.
  5. by   JustBeachyNurse
    Generally infants in PDN/HH do not get blood pressures. Any child requiring a pulse ox will have an oximetry in the home you should be using the thermometer in the home. All you should need is a stethoscope. Getting a BP or pulse ox on a client when it is not in the plan of care is not a good idea. Plus the pulse ox is supplied by a DME company who maintains safety and calibration. You cannot guarantee calibration on a personal pulse ox.


    And you should not be there without a preceptor to give you an orientation to the case and ensure that you know how to use required equipment especially as a new grad first job. It's not the standard in private duty pediatrics to be sent solo on a first case with an agency.
  6. by   iluvivt
    Do not share your anxiety or nervousness with the client. Remember you want to instill confidence.If there is something you do not know you need to find out before you take action if is is not an emergency,of course. Make sure you follow your agencies protocol for hand hygiene and care of any equipment you use there or bring into the home.

    You will be fine if you use good judgment and ask questions when needed. Review assessment parameters so you know what normal is . See if you can review any previous nurse notes if they are available and read the H and P and all current orders.
  7. by   Jory
    First of all, I want to applaud you for making the right considerations. You really need to go to RN school . That's a compliment.

    Other considerations are going to be:

    1. Make sure the baby has bowel sounds.
    2. The gauze around the tube...it needs to be changed q12h or when wet.
    3. You need to check the water level in the tube at least every 72 hours. Sometimes this is what makes it come out.
    4. You need to know where the extra one is and how to replace it if it pops out.

    However, I agree...you don't have enough training. That's scary.
  8. by   JustBeachyNurse
    Also, confirm that you are permitted to check the G-button balloon and reinsert G-buttons. In some states LPN's are not permitted per nurse practice act to inflate/check balloons on G-Buttons and may only reinsert but not reinflate the balloon should the button become dislodged. Seems silly but the parent/caregiver or an RN would have to check the button balloon and reinflate the balloon in the case of dislodgement as per the nurse practice act in my state. I would check the MD orders regarding checking balloon volume as most manufacturers recommend only checking balloon volume once per week not every few days.

    See if you can review the 485/plan of care and take notes. Look up any medications that you may not be familiar with and any diagnoses, procedures, and ask the RN to clarify any physician orders. I would make certain that your office trains you on how to use the kangaroo pump but also some basic troubleshooting.
  9. by   notyetnurse
    First off, thanks so much for all the replies and the advice - it's exactly reasons like this why I came here originally while in LPN school. Jory, I certainly do appreciate your belief in me and kind words - I am going back to RN school as soon as possible (hopefully August)

    regarding this situation, I'm strongly leaning toward telling the case manager today that I'm just not comfortable going it alone. The more I think about it the more I realize that I'm not prepared for these things without backup.

    Do you think the best way to phrase this would be "I really appreciate the opportunity but I have been thinking it over and don't feel prepared to care for these children without training yet. My main concern is their safety and although I've been trained, I do not feel prepared in the odd chance that something goes wrong, machine malfunctions, etc. I'd be more than enthusiastic to work here with more training, or if I could shadow a nurse for a full shift."

    What do you think? Anything you would add?

    Thanks everyone...

    Heather
  10. by   JustBeachyNurse
    Give me about 10 minutes and ill PM you some jnfo.
  11. by   notyetnurse
    Ok justbeachy, thanks so much.


    --Heather
  12. by   KATRN78
    If you don't feel comfortable then trust your gut. However, do not let yourself to talk you out of every new situation. Does your agency provide case by case orientation? Go to the orientation on the client and see what you think.

    G-tubes are very simple. She is on very common medications. She sounds like a very basic general peds case.
  13. by   ventmommy
    Have you met the parents? Some parents are extremely knowledgeable about their child's care, equipment and procedures. New nurses were accepted in my home but then again, I almost never left. I would take a new nurse willing to learn over a new nurse with fake confidence any day. Now if the parents aren't confident and knowledgeable that might be a different situation.

    As far as equipment goes, we did not allow nurses to use ANY of their own equipment because I didn't know what their cleaning procedures were and where else they were used (other homes, hospitals, LTC, SNF, etc.). We had a protocol for cleaning things in our house including my son's stethoscope.

    Those medications are fairly common to SN children. G-tubes are easy-peasy. I will never understand states that restrict LPNs from reinserting, reinflating g-tubes when I could train my 13-year-old to do it with no problem.
  14. by   nursel56
    Hi Heather, I know I'm late to this discussion but thought I'd throw my thoughts in anyway as I know that agencies can sometimes place the value of a staffing flow sheet with no holes in it over the appropriate match between the nurse and the client (sometimes to a shocking degree). Here are a few things I've found helpful:

    When you can, get a copy of the plan of care (form 485) to study as it is the blueprint for your nursing care, as mentioned above and look up anything unfamiliar on it. Note what brand and model of equipment (vents, pumps, etc) are used and locate the online owner's manuals for those to study and keep as a reference. They should be in the home, but that is not guaranteed.

    I always insist on at least two hours of orientation with a nurse (or competent family member as ventmommy said) who is experienced with that patient. You will find in PDN that many nurses will breeze through "orientation" as quickly as possible, so you need to take control and make sure you learn what you need to learn to take care of that child safely.

    When I orient new nurses I've found that using a blank copy of the agency assessment form as a guideline to make sure everything gets covered works well. It might help you organize your thoughts to have that on hand as well.

    In children, even taking vital signs might have some individual quirk to it, so have them demonstrate how to do each procedure listed in the plan of care. Children especially don't have a one-size-fits-all set of steps applied directly from textbook to patient. If you have doubts, stop them and ask about it. I've even gone so far as to take notes and draw little diagrams.

    Imagine "what will I do if" for all potential emergency situations that could occur with your patient and what you will do for each of those. They do happen in home care and it always seems to be when you least expect it. Have the emergency contact numbers at hand as well as pharmacy, respiratory therapy (if applicable), and MD.

    Remember your Case Manager is supposed to be your resource person. That RN, or one who is covering call is there because even though you are in the home alone, it's still supposed to be a team. If you are new, you need to use that person as a resource, as well as legally cover your butt if something bad happens. In time you'll gain confidence but never lose sight of the fact that your CM is supposed to be actively involved even though not physically watching you. It's better to be thought of as a PITA than be hung out to dry.

    It's normal to look closely at our fears and sort out what is a natural warning sign (as you felt with this child). Having said that as someone else pointed out do your best to display a calm demeanor on the outside - this gets easier with practice! Anyway, those are my and best wishes to you!

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