First case - infant with g-tube

[notyetnurse]

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.

[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!

[notyetnurse]

Hi all, Well I would like to take a second to reply to each of you. Kat, I definitely don't want to talk myself out of new cases even though i am afraid; this agency does not provide any type of orientation - What I've gotten is because I've pushed to go see the patient (unpaid) in advance and watch another NEW nurse working with this child. Small things like that concern me a bit. Vent mommy I have met the mommy twice and she is very knowledgable but also has a history of bipolar disorder, isn't on meds, can't be alone with the child (DCF neglect case bc baby got meningitis and it wasn't treated for a bit) so there's a lot going on there. Seems nice tho...

And nursel56, no worries about coming in late - I'm grateful for everyone's advice. This agency doesn't seem to have nurses who are familiar with the cases; apparently the turnover is great - another reason I wonder. Went to shadow a nurse last night and she basically pulled me aside in confidence and told me how nervous she is being a new grad with no orientation and no experience with babies but this was her first case.

All in all, I've agreed to go this weekend. I can't back out now. I am going to get up tomorrow and drive there and do my absolute best and if I can't hack it, and insufficient help is available, I will not return Sunday. Hopefully I still get paid for the day of work. Nothing's worth hurting someone or losing a license over however.

Heather

[KATRN78]

excellent. i would do the same.

[Flatlander]

I recently started working in home care with a 14 month old with trach, g-tube, neuro deficits, etc. The family is very knowledgeable and willing to answer questions, demonstrate, train and so on. The agency has a case manager in charge of the case and a manager who will answer questions in the case manager's absence. I had no prior experience with peds and was very nervous about trying it out. It turns out that the care is not so different from adult care, and it's gratifying to be learning and developing confidence in this new arena.

When in doubt call your supervisor/manager, the parent/caregiver, the doctor (pediatric nurses are very helpful). You may find this new experience very rewarding. Good luck!

PS -- Thanks to OP and the rest. I've learned alot and tested my assumptions by reading your comments.

[LilyRN99]

High turn over for a case is a red flag. As a new grad you should get to shadow a nurse to learn about that particular child. Like others have said some parents are more than willing to teach you how they do things. Sounds like you can't rely on this particular mom. Make sure you have the supervisors phone number. And you do have the right to refuse to return to the Case or not accept a case at all. Sometimes it takes a while to get on a case that is a good fit for both you and the family. You would do better with a case that has been with the agency for awhile so you can get a detailed report from the regular nurses on the case and from the supervisor. A supervisor should always go over the plan of care with you before you go to a Case. And usually when a nurse is new on a case (even after shadowing a nurse) the supervisor will visit to make sure everything is going ok. GT care is pretty straight forward. Time and document all seizures. We have a seizure log. Keep in communication with nurse supervisor.