New to Home Health and Confused

[deefizzle]

I am brand new to HH and just finished week 3 of orientation with my preceptor. I started seeing patients last week with her shadowing, so on Monday I am going to see 2 patients completely on my own, with the plan to case manage them going forward. I'm nervous. My preceptor, while very nice and great with her patients, was not the best educator and I feel like there is a lot I still don't understand, in terms of how HH works. Whenever something unusual would come up, she would pretty much take over and handle it without really explaining much to me. I've been a nurse for 6 years (acute in-patient rehab and urgent care background) so I'm comfortable with the actual nursing aspect, but just feel very unsure about the HH aspect. My manager told me to expect 6 months to a year before I feel completely comfortable, and that the office is always there to support me and answer any questions I have. I just don't want to look like an idiot in front of my patients.

Some examples in particular. On Monday I'm drawing labs on a patient (which BTW is NOT my strong suit) so I'm already feeling stressed about that. The results get sent to the PCP. I'm used to seeing those results and reporting them to the doctor. In this case I won't actually see them. Then the doc is going to adjust the patient's coumadin based off the INR results. I'm assuming they communicate that directly with the patient? Then I find out from the patient what the adjustment is?

We also saw a patient who was new CHF. We are monitoring cardiac status. His BP was 200/110. No chest pain or SOB, lungs clear, trace edema. My preceptor said we will see you next week to recheck BP. In my opinion that is something that should be reported to MD. I'm used to: if BP is that high, we at least do an EKG. Obviously I'm not doing that in home health. But at least we should call the doctor right? See if they want him to come in? EKG in office? Labs? Or get an order to monitor?

Just looking for some thoughts, tips, words of wisdom...thanks

[artsmom, BSN, LPN]

That's a lousy preceptor! Bp that high you definitely call the MD, and if I couldn't reach them I would send the pt to the ED. In the home you're the eyes, you are the only one doing the assessment and need to cover your behind.

As for the INR- draw the labs in the am, call the MD office in the afternoon to f/u on the results and new orders. In my job anyways, and especially with coumadin, you need to verify orders with the MD office, not just the pt.

This job is A LOT of phone calls. Never assume someone else made the call to the pt either, things get missed all the time and you're there to close those gaps.

Your manager is correct, HH takes awhile, I'd say I was truly proficient around the 2 year mark.

[Nurse on the Go]

I'm so sorry you're not receiving a more thorough orientation!

Yes, you would definitely want to call the MD right away for that blood pressure. I found that when I would use the words "I'm in the home with the patient and I need to speak with someone urgently" my call would often get higher priority and I would get to actually speak with someone in the MD's office vs. being sent to voicemail. Your agency should have standard parameters for vital signs and when to contact the MD- this becomes part of the patients plan of care/485.

That is good advice from artsmom above about verifying INR and dosing orders with the MD, not the patient. Some MD offices and anticoag clinics will work directly with you and some will take care of contacting the patient for you (be sure you ask!) but always make sure you receive the results first-hand and make sure you document who followed up with the patient.

Regarding labs in general, the MD will likely see the results before you do. I always liked to ask the lab to send a copy of the results to the MD and a copy to my office so I knew what was going on. That way I could clarify if anything was abnormal or I had questions.

If you're not feeling comfortable with lab draws, can you ask to spend a day just doing labs with another nurse who is very comfortable with that skill? Or, if you work for a hospital-affiliated agency, can you spend some time with the staff from the hospital lab? Just a few suggestions.

Hope that helps. Good luck on your new adventure!

[KelRN215, BSN, RN]

Lab draws (off central lines/port-a-caths for heme/onc patients) were one of my more common visits when I was a home health nurse. I always wrote on the lab req to "fax results to MD at XXX-XXX-XXXX and nursing agency at XXX-XXX-XXXX." Some labs were really good and we always got the results. Some were hit or miss and some we never got them.

[DallasRN]

You are not alone in your frustration with the so-called orientation. I'm a nurse with 36 years experience behind me. I absolutely know what I'm doing in terms of assessment, etc. However, I did not/do not know home health. My orientation consisted of following a nurse around, doing all the vital signs, taking off shoes to assess edema, listening to breath sounds...all this done on patients (about 95%) that I honestly did not understand why they were being seen. One patient had a "wound" on the coccyx that I would have called a boo-boo but I carefully applied a band-aid once a week, week after week, while she documented wound care. From someone with about as much home health experience as you, I would say first and foremost, follow your own "gut" about things, i.e., the elevated b/p. If you walked out of that home without notifying a doctor and that patient stroked or had a MI, the law really wouldn't care you were "in training" with your acute care background. Your name tag says RN. It does not say GN. A couple of times, I had to really push issues to get things done. You will, too. Read everything you can find to read on HHN. Online and books. Does your agency have a library type of thing? Look at youtube videos. There are some good ones. You will start coming across other HHN as you're making visits or sitting in McDonalds documenting between patients. You'll find they might be willing to share helpful tips. There are some nurses on here that provide invaluable info. They've been in the trenches for a long time. Pay attention to what they say.

We made it through nursing school. We made it through all sorts of acute care nursing. Think of the multitudes of things we've learned along the way. This is just something else we can and will learn. (To bad you aren't near me. We could form our own "training" group of two and nail this job!)

[sam65462]

I completely understand about being confused! I am also new to HH. I have been a nurse in acute care and clinics for 7 years and decided that I wanted to try something different. I am enjoying it so far, but I'm only a month in. The paper work part is confusing. I am spending several hours charting every night but I feel like it will get better as I learn more. I am constantly contacting the office and other nurses to ask questions. I feel like I am being a pest but I want to do things correctly. Have any of you used online resources to help with charting and if so which ones?

[msutkowski]

Yes, call the physician will vital changes. A lot to happen to patient in a week - like stroking or dying. It may take up to a year to feel fully prepared in HH. You may experience situations that are unfamiliar. Agencies have their own process for labs - ours is the field nurse draws the specimen, the lab faxes results to the office, internal care manager faxes or phones results to physician. Sometimes the physician will adjust dose through nurse and sometimes will contact patient directly. Be patient and you will learn physician preferences. Do you have a email or in-basket system for communicating? I would recommend putting concerns and questions in writing and ask for response in writing. HH is very rewarding, you will love the individualized patient care.