new grad with unknown HH agency, complicated pt case

carwin · Jul 15, 2010

i am so sorry for what i'm about to say, but i must. you have no business as a new grad being in home care. a 2 hour orientation is nothing. you need to work in a hospital and get experience that will reinforce skills touched upon in nursing school. you need to develop confidence, which you lack by the tone of your letter. you didn't ask the family about the diagnosis. that should have been the next question out of your mouth. you need stellar assessment skills. the interview is part of the assessment. remember, there's no colleague at the nurses' station to come listen to lung sounds for you. you will be expected to function as an rn. you will be held to the rn standard in a courtroom.

your sister had no business seeing that patient with you, unless she's also an employee assigned to be your preceptor with that patient. that is a hipaa violation already. a violation of hipaa can result in civil fines and/or criminal penalties! you will lose your license before you get it.

you are serving as a warm body. your are putting yourself and that patient in danger.

i don't know where you live, but got to a nursing home and get experience if there is no good teaching hospital around.

ladies and gentlemen, home care is not the easy specialty. these free standing agencies will hire a tree if it were a licensed rn. also they will get you sign off on things that you shouldn't-why!?!?, because you don't know any better.

jerzie, please don't take this case for your own good. i can't stress this enough.

Kim, HHRN · Jul 15, 2010

I don't think you are giving yourself much credit. Will you be nervous? Sure, everybody is when they are new and there has to be a first time for everything, no matter if it is the hospital or in HH. I have been a HH nurse for 2 months now, had 3 months hospital experience, and a year as an intern in a hospital. I was a COMPLETE basket case working in the hospital. I hated every minute of it and felt rushed the whole time and felt I wasn't doing a very good job. My point is this.... I have learned SO much more in the home health environment than I EVER had in the hospital.

The thing that you have going for you in home health is you have more time to spend with the pt and can do a much more thorough job. You have time to research things out before going to their home. Plus your coworkers are just a phone call away. In the hospital, they show up on your floor while you are trying to take care of 5 other patients at the same time. Lovely situation, isn't it? No thank you!!! Not for me!!!!!!

Have I been nervous at times? Heck, yes. Did my first foley catheter on Friday and another one today. I was terrified the first time. Now it's a breeze. Did my first trach teaching and care about a week ago. I was shaking in my boots but I did my research prior to get me prepared.

Have you done any OASIS assessments or been trained on it? It basically spells it out for you in black and white on what to assess the pt for all from the pt to the pt's environment (barriers to the home like steps). Use that as your guide. Do your homework on trach care, cath care, and feeding tubes. Find another RN you trust and ask your concerns.

You can do it!!!! You're gonna have to start somewhere, might as well in HH.

iluvivt, BSN, RN · Jul 15, 2010

I think that you may be able to do home care BUT a 2 hr orientation seems very inadequate. You really need about at least a 2 week orientation where you shadow another nurse and get the hang of all aspects of the job...you do not even know what to ask for so you can perform a proper visit and nursing care. Even after that you will have questions and may need some help from seasoned nurses...so have all your contact numbers with you so you can call an agency resource.....NEVER guess and try to do something you feel that you may be inadequate call for help..and be discreet as needed..make the call outside of the pts earshot....I say "I need to get something in my car and I will be right back"

1 You need to see a H and P whatever one you have on file......review it and note all the patient's medical problems so you know what to assess and can look for any potential problems. What care has the home care nurse recently provided. Do the nurses leave a copy of the last visit record in the home with the most recent vital signs? Do you have a way to view the most recent med profile?

2 What care are you expected to provide..trach care...catheter care ( is this a urinary catheter or a vascular access device....if its a VAD how long has it been in place and do you have a confirmed tip placement...if it is a PICC you need even more baseline info...if is is a urinary catheter how long has it been in place? How long as the J tube been in place? Are the seizures new or an old dx..what is th pt taking to control the seizures? What supplies will you need and are they in the home...anticipate that some may be missing..always keep a small stock in your car of frequently used items..k.now the procedure for proper medical waste disposal in the county in which the pt lives

3 Is the pt trached and for how long..has the pt had any recent resp infections? Is eO2 being used in the home?

4 Is there a primary caregiver..will they be present...what language do they speak..will you have any communication problems?? You will need to brush up on your teaching skills and documentation skills..make sure you clearly document all your teaching and the pts and caregivers understating of the teaching and if they need any reinforcement...YES you will sound like a broken record and assume nothing repeat the teaching as needed and more than you think b/c when pts are not feeling well they do not retain it as well

5 This all seems like it may take awhile but once you get the hang of it...you can whip through it an hone in on what you need to accomplish and can catch any problems early b/c you are anticipating them

6 What specific care are you providing do you have current MD orders?? How much leeway do you have do you have with the MDS do they want to be called for minor problems? I can give you a little outline if you can tell me what nursing care you will provide are these long shifts or just assessment and then a a procedure or two during the visit? I think you can do this with a little preparation..the more you know about your pt and what you nned to do exactly your anxiety will drop dramatically be prepared do not wing it!!!!!

caliotter3 · Jul 15, 2010

You should have been oriented by the other nurse(s) on the case or the nursing supervisor. Your sister had no business getting involved, but let's face it, she is going to be your lifeline. You need a job, you might be able to plow through this. Go to the agency and demand a copy of the 485. If they just opened the case, they still should have done a a preliminary one to send forward to the doctor for signatures. Look up what you can about G/J tube care, trach care, and catheter care. Take your med book and your illustrated skills book (if you have one) with you in your backpack. Have a cell phone to be able to call the nursing supervisor, if you need to. Did the family express willingness to tell you about care of the patient, including his med regime? If not, who is going to orient you to his care? I'm sorry, but it sounds as if this agency, instead of offering support, is throwing you out there to fend for yourself and they know you are a new grad. You are going to have to plow through this. Take your laptop with you and you can communicate to me through AN if need be. I'm here during the morning hours. I work the PM shift and am not available after about one pm. I'll try to be helpful, but I don't know what I could do over the internet, good luck. Off today, but work Friday.

ArwenEvenstar · Jul 15, 2010

I think some of the responses think you are doing traditional intermittent visit home health (where you visit multiple clients each day). But you are talking about private duty or shift work, which is a bit different of a situation.

Will you be alone with the patient? Is this a new thing for the family, or is this a long-term case where the family has been dealing with this for years? Most families (good ones at least) won't leave you alone with the patient until they feel you are competent. One agency I worked for, another nurse on the case oriented you. Orientation might have been just a few hours or 2 or 3 days, depending on the complexity of the case and your experience level. The other agency pretty much had the family do the orienting. A nurse in the office did carefully review the careplan and answer your questions, but the family did the hands on orienting in the home.

With the seizures and unstable BP, besides the other things, it seems this case is too much for a new grad though. If the family is with it and responsible, and will orient you well, it could work out okay. But it also makes me leery that this agency isn't offering you more orientation or isn't adequately answering your questions! It seems like they just want a warm body in there and don't care about your experience level, confidence, or adequate training! Beware!

In these private duty/shift work cases, you do need a degree of confidence. You need to know what you know, and know what you don't know. You need to watch out for yourself! Because not all agencies or families are ethical or responsible.

And you mention that the family called you?! The family should NOT be calling you and they should NOT know your phone number either! All communication should go through the agency! You are setting yourself up for trouble of all kinds if you get too personal with the family in these private duty/shift work situations. A professional boundary is imperative!

After typing this out...I don't advise you to take this position. Look for a case that is more stable. There are easier, long term cases where the patient is very stable...and only need a nurse because they have a g-tube or trach or whatever.

Blackheartednurse · Jul 15, 2010

I think that you may be able to do home care BUT a 2 hr orientation seems very inadequate. You really need about at least a 2 week orientation where you shadow another nurse and get the hang of all aspects of the job...you do not even know what to ask for so you can perform a proper visit and nursing care. Even after that you will have questions and may need some help from seasoned nurses...so have all your contact numbers with you so you can call an agency resource.....NEVER guess and try to do something you feel that you may be inadequate call for help..and be discreet as needed..make the call outside of the pts earshot....I say "I need to get something in my car and I will be right back"
1 You need to see a H and P whatever one you have on file......review it and note all the patient's medical problems so you know what to assess and can look for any potential problems. What care has the home care nurse recently provided. Do the nurses leave a copy of the last visit record in the home with the most recent vital signs? Do you have a way to view the most recent med profile?
2 What care are you expected to provide..trach care...catheter care ( is this a urinary catheter or a vascular access device....if its a VAD how long has it been in place and do you have a confirmed tip placement...if it is a PICC you need even more baseline info...if is is a urinary catheter how long has it been in place? How long as the J tube been in place? Are the seizures new or an old dx..what is th pt taking to control the seizures? What supplies will you need and are they in the home...anticipate that some may be missing..always keep a small stock in your car of frequently used items..k.now the procedure for proper medical waste disposal in the county in which the pt lives
3 Is the pt trached and for how long..has the pt had any recent resp infections? Is eO2 being used in the home?
4 Is there a primary caregiver..will they be present...what language do they speak..will you have any communication problems?? You will need to brush up on your teaching skills and documentation skills..make sure you clearly document all your teaching and the pts and caregivers understating of the teaching and if they need any reinforcement...YES you will sound like a broken record and assume nothing repeat the teaching as needed and more than you think b/c when pts are not feeling well they do not retain it as well
5 This all seems like it may take awhile but once you get the hang of it...you can whip through it an hone in on what you need to accomplish and can catch any problems early b/c you are anticipating them
6 What specific care are you providing do you have current MD orders?? How much leeway do you have do you have with the MDS do they want to be called for minor problems? I can give you a little outline if you can tell me what nursing care you will provide are these long shifts or just assessment and then a a procedure or two during the visit? I think you can do this with a little preparation..the more you know about your pt and what you nned to do exactly your anxiety will drop dramatically be prepared do not wing it!!!!!

Hi can you sent PM your outline.I'm a new grad doing intermittent visits,mostly I assess,take vitals,check BS,take weight,teach about meds,very rarely I do catheter or trach.Thanks

caliotter3 · Jul 16, 2010

Wondering how your first shift went. Hope things were ok for you and the patient.

jerzie0820 · Jul 16, 2010

Thank you all so much for the input. They are exactly what I needed to hear.

Littlemissfirecracker, I feel a little relieved that I'm not the first one to start on HH with very little hands-on knowledge. I've only done a few during clinicals but even though I'm a new grad I'm confident that I know at least some of the basics.. trach care, suctioning, g/j feedings, meds, CPT, etc. I knew this would be something that I'll be doing a lot whatever clinical setting, so I studied them carefully and even watched tons of videos on them. I'm an old grad, [that's how tough the job market is] so I made sure everything was still fresh in my mind. I'm really nervous but I'm glad that I'll be able to do these procedures without so much pressure or having to worry about getting other things done.

iluveivt, i do have all the contact numbers i need and i now know what the diagnosis was. the nurse who oriented me was very supportive and told me all the possibilities. There are many other nurses who do different shifts all throughout the rest of the week and we do have a chart with all the nursing notes. I was also told about the old meds the patient is taking, as well as the new ones used to control the seizures. All the nurses are also given instructions on black and white regarding which specific care to provide, and I like that even the time is provided for us.

arwenevestar, thank you so much for the input! the nurse who oriented me showed me the patients careplan which i do believe will help me a lot throughout the process!

caliotter3, thank you so much for the support. Unfortunately, i was told that it's best not to bring anything that will distract us from giving proper care, but I was really hoping I could bring a laptop for reference whenever i need it. also, i understand my sister doesn't have a business being there, but she was correct on giving her opinions. She just needed to use the bathroom and it was within the patients room and of course I had their persmission. I will start tomorrow morning instead of tonight. I'm still very nervous but at the same time excited :) Wish me luck :)