Input needed from the more experienced agency nurses please

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Specializes in Home Health,ID/DD, Pediatrics.

Alrighty, I'm newer to agency nursing and a "baby RN" as far as time in goes (2.5 yrs). I am working for a Pediatric agency doing PDN.

Now I know states have different regulations etc...but in general it seems to me based off my observations that:

In the home, things are so much more "lax"(having a copy of all the med orders in the chart for reference, MAR and Plan of Care and RX labels matching, not enough history/background on resident from other providers in the chart etc...)

I want to make sure my expectations are realistic. It just seems to me that when you are in a situation where you, as the RN are in the home providing care you should have copies of all the written orders for EVERY medication -- even ones resident was on prior to being picked up by the agency you are with and, there should be at least some copies of notes and sufficient medical information IN the chart from other healthcare providers. I say this because when the agency relies on only parents for information how do I know I'm getting accurate info? What I'm told as far as background, past events etc...does make a difference in my ability to provide care for a small person who can't communicate with me.

My concern is reliability of information, perception and lack of understanding colors what I'm told from parents and I feel that I need more information from the other providers as I'm on the "front line" more than the majority of others providing care. I have asked my manager about this, I was told "you have the same info we have". Maybe my lack of experience in home health is to blame, or unrealistic expectations? My assessment skills are I think pretty good, my gut feeling is that in some cases un-informed family may be driving the patients healthcare in unnecessary directions for their own comfort/convenience and things may not be presented in the most accurate light...hence unnecessary treatments etc...

Any thoughts? Suggestions? Observations?

I don't like feeling like I'm missing what I need, I know often times you are when providing patient care. Something is just bothering me, my gut says investigation is needed.

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Specializes in Peds(PICU, NICU float), PDN, ICU.

You may get more answers in the PDN area. But I've seen this with lots of agencies. More reputable agencies aren't as bad. It shouldn't be more lax, but it is.

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Specializes in Psych ICU, addictions.

Moving to the private duty nursing forum to help you get more targeted answers.

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I have been in private duty for a while, with quite a few different patients. We keep a large binder that contains the bare bones information related to the diagnosis, meds, etc. According to my company's policy, the nurse receiving a new order (the day shift nurse who goes to the MD appts or the nurse who calls into the MD office) must drop off a copy of the order to the office. The case manager supposedly verifies every order - for meds, at least. The case manager then prints out our MARS - so that, in my opinion, makes them liable for discrepancies. Of course, I still check the labels and all that stuff, too.

Many of my patients are on vents, have cough assist, etc. and I have been unable to find any documentation related to vent settings and the like. Few of the parents I have worked with have kept up with the documentation either. We all just go with the flow. Makes me a little nervous at times.

PT/OT/Speech comes to the homes and writes their own orders that we follow if needed.

If I feel something is wrong, but not emergent, I inform the parents and DOCUMENT LIKE CRAZY. Parents have the ultimate say-so on 99.9% of things. They can give any medication they want without an order. Scary!

Realistically, I have found that documentation is the key. If an order seems fishy, tell the parent and have them administer the med (or whatever the case may be), then contact your agency for clarification. I also keep a personal notebook with little details I may need in case anything ever comes up. No agency or parent is going to back you up if something goes wrong.

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Regarding medications. A prescription label IS an order and parents can't just give what we want. I can't just give 50mL of Keppra if I wake up and feel like doing that! I can give OTC and PRN meds as I see fit but it's also my responsibility as a parent to be certain that they don't interfere with the multitude of other drugs.

Why isn't the RT or pulm making sure that vent settings are posted somewhere? LTV (not sure about Trilogy) has downloadable forms for RTs/MDs to fill out with all the settings. I kept a copy in our emergency book, a copy on the wall and a copy in the vent backpack. How are nurses supposed to verify that the vent settings are correct if there is no order for them?

Actually, settings for EVERYTHING were available at all times (cough assist, VEST, T/pump, oxygen compressor, bed) to the nurses and in the emergency binder.

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My company doesn't regard the label as an order. I was specifically told in orientation that parents can do whatever they want. Scary! VentMommy - you need to be a case manager - I've read a lot of your posts. You have a good head on your shoulders!

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I probably wouldn't last long!! I have no patience for stupidity and nonsense from families or nurses.

You won't provide toilet paper, a lamp or a toilet for the nurse? Here's your opportunity for me to help you. You still won't? Bye-bye family. I can't staff your case if you don't realize that your home is a work place.

I think I would EXCEL at helping new families organize rooms/go-bags/charts and lists as well as giving tips for getting out of the house in under 30 minutes.

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The lack of pertinent info in the chart drives me nuts.

I had no idea what exactly was wrong with the baby I was caring for (as in exact diagnosis and reason for extensive hospitalization) until the family filled me in. There is zero history in the chart...nothing but a few vague diagnoses in the POC.

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How can you competently provide care for that baby? What if you had to call 911 and go to the ER while no parent was available? How do you provide a history to the doctors?

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How can you competently provide care for that baby? What if you had to call 911 and go to the ER while no parent was available? How do you provide a history to the doctors?

That is exactly right. I will know in the future to always demand that info up front.

This is my first PDN case, so I am still learning. I have worked mostly intensive care in hospitals prior to this, so it has definitely been an adjustment.

And I always thought I "flew by the seat of my pants" in intensive care! PDN takes the cake in that regard...!

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Don't always rely on the info you get from the schedulers. They will say anything to fill the shift.

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Where I came from, we relied on a plan of treatment (POT) which was updated by the office and signed by the physician every 30 or 60 days. This POT was our bible. If a medication was not on the POT, it could not be given without a visible order in the binder. Labels on bottles from the pharmacy did not always reflect the up-to-date dose and even pharmacies make errors. Even Tylenol could not be given without an order. Treatments were ordered as well as enteral or special feedings.

We did initially ask families for a medical background, preferences, etc., but we documented this in the binder and it stayed in there for any nurse to see. We wrote helpful hints, the child's preferences, routines, and even where to find supplies to make life less complicated. Families could read and add to information but could not change the POT without a doctor's order.

Ventmommy--you rock!

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