Privately hired for trach+vent.

[darkbeauty]

I've been offered a position asa private duty nurse via private pay for a trach + vent patient at home. I have always wanted the experience to work with vent dependant pt and they are willing to train me as a family. From a legal perspective for mine and patient protection, how do we go about documentation and taking orders without an I-485 or Plan of Care signed off by Physician? Other agencies do fill in shifts and have their own prepared in a binder, but as a privately hired nurse in the state of Pennsylvania, is there anything I should be weary or careful of??

Anyother advice would be highly appreciated as well.

Thankyou

[ventmommy]

I would be EXTREMELY nervous to have a trach/vent patient with no experience and not having an agency to back you up. Who are you going to call if you have an urgent question and the parent isn't available?

Why don't you want to work for an agency that takes these kinds of cases?

Sidenote: Ventmommy is NOT a nurse but trained all of our PDNs and still takes foster trach/vent babies and is a respiratory therapist.

[darkbeauty]

It's not that I don't wanna sign up with an agency.

The client is via VA, and gets x amount of hours approved, the remaining they pay outta pocket to cover 24/7 skilled nursing so paying the nurse cash eliminates the middle man (the agency). The guardian spouse will be in the house for the first few shifts so in no way will I be alone with pt for the first 6 shifts plus shadowing other nurses for 4 shifts. It's totally up to me if I'm comfortable with this arrangement or not. I came on this forum to be enlightened as to what could potentially be harmful or not about an arrangement like this.

Thankyou for your input Ventmommy, I see you are an RT and your opinion will be valued.

[ventmommy]

There is a lot that can harmful. Can you handle an accidental decannulation with a hard-to-replace trach that turns into a code? Are you comfortable with trach care and trach changes independently? Can you replace a Mic-key or know how to keep a stoma open if a GJ? Do you know trach CPR? Do you what all the settings and outputs mean on the vent?

I'm definitely not trying to be negative here but want you to be aware of the implications of what can happen.

[darkbeauty]

I've never had a decannulation experience but am pretty comfortable with standard trach care and inner canulla changes from 10 years of LPN experience in a skilled nursing facility and trach home care patients.

Am familiar with Mic-key and GJ care as well as a handful of pegtube detachment accidents.

Never had trach CPR, only use of ambu-bag. I have done a vent class to understand settings but for this patient, all settings remain the same I do not touch anything except when beeping then I would have to access patient first.

I am very green to vents and this is why I am coming here for advice to see if its something worth persuing or too risky and I appreciate your input in letting me see that this may be too risky for a person like me.

To be honest I have concerns as well I just wanna make sure am not declining the case out of fear or agreeing to take it from lack of info.

[ventmommy]

I think a lot depends on the parents and how comfortable they are having an inexperienced nurse. Vent assessments are more than just checking the settings. If you see that the tidal volume is now 10mL instead of 240 mL (or whatever the expected value is), you need to know what to assess and how to fix it. If the high pressure alarm is sounding, you need to know what that can mean, what to assess, and how to fix it.

We took new nurses and nurses with no trach/vent experience but I was home about 99% of the time. But if you search my name, you should see some stories of near misses that would have killed my child if I had not been home because the nurse wasn't able to handle the situation appropriately.

[caliotter3]

I would contact your state Board regarding practice and documentation issues. When I have worked private duty in my state, there has been no requirements other than those ironed out between the patient's family and the caregivers. As for the care plan, the nurses had access to the agency 485 placed in the house for reference. The primary nurse worked for both the agency and private duty for the family, she handled almost all communication with the PCP. Emergency situations would be handled as usual with follow up depending on interaction with the agency, family, doctor, other nurses. The private duty nurses kept a notebook with a narrative for each private duty shift for the family and other nurses to refer to. That was it. To get more comfortable, I would consider working for an agency first so that you have access to a dedicated on-call nurse, clinical nursing supervisor, and the agency vent training program. Also look for vent training programs in your community.