Longest visit you ever made?

[hoolahan, ASN, RN]

Today I made the longest visit in my VNA history, and I hope to never have to do it again!

Bedbound man with new trach new peg w/ feeding pump, texas cath, and as an added bonus, NOT on the referral, EIGHT decubs!! I did not have enough wound care supplies to dress all eight. The two big duoderms on his back I left alone, they were dates with today's date. The six on his legs, including a stage 4 on the ankle, I did the best I could with the limited supplies sent from the hospital and in my bag (now empty of all spares!)

Trach, O2 supplier did haldf set-up. Family had no idea where to put things, etc. That is how overwhlemed they were. They needed to be directed in everything from how to place his hand on the bed to how to arrange the room, equpiment in the room, where to plug things in! I felt for them (I had to right, I stayed almost 4 hours!)

Walk in and first problem is pt head is at the foot end of the electric bed, so we had to gather the forces, and it was a process to switch him around in this room that was barely big enough to fit the bed, let alone four people trying the manuer a tall man completely around in the bed!

Next, they sent a nebulizer with face mask attcahment...hello, this is a trach. No t-connector or any such device. I had to call the O2 company 3 times, suctionwas weak, they told me how to correct that and it worked, then they never set-up the compressor humidity unit. so I figured that one out, then I called when it was time to review the neb again, and demanded they come and double check the set-up. I siad "I just spent two hours here, most of that time setting up your suction, and equipment which you should have done, you need to do a neb teach in person, b/c I still need to teach the feedings and do his dressings and meds, and I will no accept no for an answer. I have no mroe time to spend fixing your eqipment! They agreed to come back. Man, why do they have to fight?? These poor people need support!!

Then we couldn't get the feeding to go vis pump. The supplies included Ross feeding bags for a flexiflo pump. I think the problem, no flow alarm, was due to the bag is such a "crinkly" and cheap plastic, it kept kinking up where the tubing connected to the bag, and no matter how I tried to rig it, it kept folding over and I think the pump was in effect sucking air, and wouldn't run. Called that company, they were close and volunteered to come out, even tho I said I would teach bolus feeds for the night. So then we had to do bolus feeds, crushing meds and giving meds via peg, etc.....

Then I got to the dressing on his feet. 6 decubs!! Family was SHOCKED!!! They were never told he had decubs! So they said, I have to wonder why they didn't ask about the dressings on his feet. He was hospitalized for 4 months!!! In that time thought, SOMEONE should have discussed this, and we definitely should have had wound care orders. Got the doc, got an air mattress ordered for the bed, not even an eggcrate was sent!! And I wanted a second opinion on the stg 4 decub, so we will follow up with improved wound care orders tomorrow. I asked our wound expert to see him.

Then of course there was trach care and suction teach and general care of bedbound client!!

Lovely people, but HYPER!! The poort wife was trembling. The son kept turning and talking really loud and repeating every single thing I said, "Ya hear that Ma? Ya gotta flush the ube before AND after the feedings? Are you writing this down?" I sent him to the pharmacy around the corner for the meds, just to give his mom and me a little break!! LOL!

3 hours and 45 minutes later I came home. Hubby was PO'd I missed dinner. Worked on charts til 10pm. Got majorly dumped on today. 5 revisist (one a D/C), a new admit, and this new admit since I was late call.) I am just waiting for them to c/o about my OT. I don't believe in working for free. I think they are using me to open every trach case! Each one is a disaster. The kicker is, I do not understand why this particular company was used. The pt has Medicare, and there is a GREAT O2 company in the area that is soo reliable and responds to pt needs without hesitation, b/c they know if they invest the time in correct teaching, eventually, they will be independent, and the pt does well. This company just wanted to do everything by phone, and that is not always cool when epople are freaking out.

I'm off tomorrow, and I fear what they have instore for me since Thursdays and Fridays usually are BAD days!!

Anyway this vist was 3 hrs 45 minutes. What was your longest visit and tell about it.

[nur20]

Sounds like an extended case that i worked on for several months, of course i had eight hours to put out all the fires. Quite a bit of time was spent haggling with the suppliers.But the longest 1 hour visit of my career was not so technical but funny. A 91 y.o. 300 pound total paralysis female with frequent uti's. The only procedure on the referral was an in-out cath and am care, which turned out to be a total bed bath. Needed the hoyer lift just to get her in a comfortable position in bed or should i say one that satisfied her family member.I wrestled wth a b/p cuff that was on the verge of being too small. The cath was so short that by the time i reached the bladder it almost disappeared. She had what seems like a hundred stuffed animals which had to wear the same ribbons and barrets that i use on her hair when i combed it(orders from family member as they stood there watching my every move). Then the animals had to be strategically placed on the bed so mom would be surrounded, anyway one hour turned into three. I do applaud her regular nurse, this 91 y.o. 300lb,bedbound pt had beautiful skin with no decubs

[hoolahan, ASN, RN]

nur20, that is a riot. I think I myself would have drawn the line at the ribbons in the teddy's! I don't think Mediscare is willing to pay for hairdressing of teddy bears! :roll You are very kind and patient!!

I have one very nice family I see. The man is 40 and has MS, and is bedbound. I go out for weekly avonex inject. His dad is so cute. He sat me down at the kitchen table and insisted I watch how he prepares the inj. Inject the diluent slowly by tipping the bottle to the side, creates less bubbles. Then with syringe still in, turn syringe upside down, bottle under it, and swirl slowly ten times to the left, then ten times to the right then draw it up and change the needle. I watched, and it was a very good technique he had!. But it didn't stop there! I prepped the site with an alc pad and set it beside me, and he picked it up and said, "Can I show you another trick?" Sure, so he takes it and uses one corner to "point to the target" by placing it on his leg to with the corner pointing to the inj site. (As if I would forget!) Then he pinched up the muscle for me (!) and I gave the inj. He just is afraid to make the actual stick! It may sound annoying, but he was so sweet and then when I gave it, the pt said "That was a good one!" I had the seal of approval from then on!! It's one of my favorite visits!! Love those people!

[nur20]

Hi Hoolahan, you are absolutely right,but the agency pays up to 2 hours. I took the 3rd hour probono

[hoolahan, ASN, RN]

You really are a nice person!! I am still chuckling over the idea of you spending that last hour with the ribbons and bows and teedy bears!!! :chuckle

That is a great story!

[NRSKarenRN, BSN, RN]

Hoolahan, sympathize with you---had 3 or four visits like that. Draining, exhausing re communication time spent all because NOT set up properly at hospital discharge or DME company dropped the ball. I' ve been on both sides and as intake RN am constantly amazed at piece meal info given to us. Barbara and I in my office pride ourselves over orienting via phone all the NEW case managers on the Rehab and SNF units at our local facilities, ESPECIALLY Social Workers, LOL. Keeping up with the insurance changes each year and which ones will pay for which supplies can be daunting for a new CM with no homecare experience.

Ross cheap plastic bags WILL NOT RUN on a flexiflo pump, I've tried it too.

A PATIENT can almost ALWAYS request a change of DME company if non-responsive to your pt's needs.

---------------------------

My longest case tops you by an hour. Had a 92yo bedbound confused, man (foley, COPD/Pneumonia and small stage 2 sacral decub) with 68 yo wife...both were on home care (wife developed pneumonia too). Living in one bedroom apt was 19 yo granddaughter who had just had baby taken away by Children and Youth two weeks prior to this visit and had mental health problems (suspected drugs too). NEVER saw any of 6 children in area despite late afternoon visits.

Arrived at 11:45 AM with HHA. Saw wife asleep on sofa with back to us in LR--no lights on. Husband in Dining room hospital bed complaining of being hungry...course had BM too so aide proceded to wash him while got hot lunch cooking. Could hear 19yo in back bedroom. I'm walking in and out of apt carrying in bag, chux and diapers, Ensure ( DME would supply to patient thru insurance but NOT deliver to patients area, no car for wife, so of course I hoofed it for past two months).

Been in the home 20 minutes when 19yo comes in LR, turns on light talks to grandmom and shakes her, starts screaming "She's dead, she's dead" and is hysterical. Quick check of VS---DEAD and cool, slightly stiff at least two hours. Call PCP, agency and then coroners office as not suspected. 19yo freakin out, calls her friends. I call Office of Aging (COSA)-Cl MGr (who I already conferenced with re lack of food) and Protective services. Located daughter 10 min away who now has SECOND child of this 19yo daughter in her posession and says she can't take in her DAD nor can any other family member.

Minister to husband, gently break news of wife's death while police arrive and await coroner. Went in cabinet to get clients nebulizer meds, and see wife's iron pills and FULL bottle of antibiotics, 7 days old. 19yo says Pt. was afraid to take "death pills". Aide pulls me aside and quietly admits that she stumbled over COLT 45 QT bottle next to sofa upon entering home and she placed in trash can.

Give report to police and coroner while attempting to quiet granddaughter who is now accusing me of her grandmoms death due to those pills doctor prescribed (thank God same PCP....another call to him). COSA Cl Mgr arrives and situation reviewed---daughter agrees to meeting in one hour to discuss case, I'm asked to participate as I have all clinical info in case SNF placement needed. Police recalled to home to have funeral home remove body as 19yo refusing. AIDE extends visit time stay with client---ok'ed by agency.

Quick visit client in area (20 min) then go to Daughters home for meeting---cannot convince her/find another member to take client in. Confirmed 19 yo was treated on PSYCH unit for Drug withdrawal and unsafe to care for grandfather. Lucky, call by Protective can get client moved to SNF in 1 hr as I have all clinical info including recent labs I drew in field chart.

Go back to apartment with COSA CL Mgr. to pack up patients possessions --warned by family that POLICE called a THIRD time that afternoon as 19yo picked fight with neighbor and stranger in car that drove up. CL Mgr. wants my big bodily support, I agree as I need her to pull strings for my other patients. Aide (not afraid of 19yo) relieved from case at 3:45. Emptied foley and gave another nebulizer treatment. Police called +stay in apt with us and subdue 19YO screaming she will care for grandfather, we cannot remove him, as ambulance crew picks up patient. Left at 4:30PM

Irony was wife would repeatedly say to me, her husband would only be placed in a nursing home over her dead body.

NEVER went on that block again.

[kids]

o-m-g!!!

i wil stick with my nice quiet little private duty peds cases...did spend 4 hours doing an admit that the family had been ordered and authorized for 12 hours a day for 1.5 years but couldn't get nursing...they relocated >300 miles across the state because we could staff them.

-nancy

[ucavalpn]

Wow I haven't had anything this bad ....Yet . My first month, on my own in, home health I did find a dead pt. He knew I was comming to visit , but did not answer his phone when I called to confirm. He was so reliable I went out anyway to check on him. no answer at his apt.,so I had the manager let me in. He was in bed looked as if he had just layed down , covers barely rumpled . Been dead at least 2 days . Couldn't locate his son to let him know of this . the phone # he had given us was not correct. This man looked so peaceful , I just could not feel bad about his passing . I do feel badly that I was unable to share this with his son . I'm sure the local police found and notifyed him . But I think he might have wanted to know his father passed rather peacefully.He was very sick and knew he would not be able to live alone for much longer.

[Kiscellus,R.N.]

I did home health forever as well as home infusion. I have been a supervisor and a field nurse. I have so many crazy stories about patients I have seen. Someone should write a book about some of our more colorful patients. I personally got burned out from all the driving. So I now have one of the best jobs EVER....working for (of all places) a national Lab designed primarily for home health/infusion agencies. Hopefully, I won't have to go back to the field. Although I think am a pretty darn good infusion nurse. :)

[live4today, RN]

When I did Home Health visits, one visit took three hours. Good thing I was paid per hour instead of per day. Had the agency done their homework a little better on that patient, I would not have had to spend all that time doing what they should have done in the first place. Geez! Just can't get good help these days, can we?

[hoolahan, ASN, RN]

OMG Karen, that was the visit from hell!

uc... have never found anyone dead...yet. I have so may 90+ year olds now, I am sure one day it will happen.

Admitted a 99 year old today! Damn good shape too! I said let me watch you walk with your walker, she stood up and only came up to my upper arm. Too cute! She practically marched with her walker. Quite the contrast from the other new pt I resumed today. Another one who lives alone and cannot take care of herself. I called her at 8:45, she said I fell and I can't get up. She laid on the floor with the phone alll night!! I called her emergency contact who went over asap. She was very upset while her neice was cleaning up the room. She liked her clutter!! I laid it on the line. I said you have so much clutter here, you barely have rrom to walk if you could, and I do not think you are safe here alone. You need to seriously consider hiring a live in, or a helper who can stay longer hours and more often than our aide, or you will end up in a nursing home. She said "Someone in my home would get on my nerves." I said what would be worse, staying here or a nursing home? No answer. Her neice stopped me on my way out and said thank you, we've been teliing her that for years! I hate to seem like a meanie, but I have 3 pt's like this now. The powers that be just decieed that the one who just got re-admitted will not be accepted back onto service unless she has 24/7 caregiver, paid or otherwise. Thank God, b/c last time I saw her I believe she aspirated and she refused to go tot he hospital!!

Welcome kiscellus, don't think I've seen you post here before!

Renee, didn't realize you did HH! Welcome to you too.

[live4today, RN]

hoolahan, what's with the grinching of your teeth emoticon? Do I disgust you that much? :)