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Except that I still had to document her last bit of IV intake, my communication with the attending, and write a note regarding transfer/report which included reviewing her CIWA scores to ensure an accurate note. Thanks for intentionally missing the point though.

I work on a med-surg/tele floor that gets a fair number of ETOH withdrawal patients. Today I took care of a woman that had been sober 9 months before starting a 2 week bender prior to admission. She was up to a liter of vodka a day prior to going to the ED and even stopped for shots on the way in. Her CIWA score was all over the place for night shift (probably because she was seen on camera taking her own PO ativan). I received her at 0645 (~18 hours since her last drink). I initially scored her at 17 and gave 4 mg IV ativan (per protocol). An hour later I scored her at 18 and gave her 30 mg of scheduled tranxene. The tranxene helped tremendously. She then scored an 8, received 2 mg of IV ativan, and scored a 9 post-medication. Next score was a 10 with another 2 mg of ativan given. Before the hour was up for a recheck she called the CNA and complained of hallucinations. At this point she was just past the 24 mark since her last drink. I go in and she is crawling up the walls with anxiety (which she described as panic level), restless, nauseated, moderate headache, having trouble talking due to her tremors, hearing whispering voices, seeing spider webs, sweaty palms, tingling in her hands and feet, and saying she isn't going to make it through withdrawal. She remained oriented, but I scored at a 27. Her vials were stable the entire time (pressures in the low 100s, respers in the mid teens, heart rate in the 70s, afebrile). I page her attending and he comes to see her. He agrees that she needs to be transferred to the ICU. By the time everything is taken care of for the transfer and I get her down to the ICU ~45 minutes have elapsed. She had calmed down and was no longer climbing up the walls as I was giving bedside report to her nurse, but the ICU charge commented "Apparently she is scoring in the 20s *eyes-rolling*". I'm thinking to myself ***, hospital protocol is to transfer to ICU at 19, even with generous scoring she is high enough for the transfer. Why does it matter that she isn't disoriented or jumping out of bed? I kept her on my pt list and checked their initial CIWA score after I got back up to my floor. They scored her a 4. I was expecting a lower score since she had calmed down, but 4? How is that even possible? If I'm ever in doubt about how I'm scoring someone I get another nurse to independently score and compare. I'm always within a few points of the other nurse. I'm at a loss and wondering why there was such a discrepancy. Anyone have thoughts on the matter?

I'm curious which bedside skills you are worried about losing? I didn't do any trach care (no vents at my agency) or any NG placement/removal in home health, but I got to use pretty much everything else I learned in school. There were regular foley changes, wound care (pressure ulcers, venous stasis ulcers, surgical incisions, dehisced incisions needing negative pressure therapy), IV antibiotics (through either a PICC or peripheral line, occasionaly with a pump but more often an infusion ball or simply counting drops), lab draws, IM/Sub-q med administration, ostomy care, and central line dressing changes. Anybody can be taught those skills (which for most you are hopefully doing for competent family/caregivers). All of that said, the most important bedside skill (that you will use every day) is the head to toe assessment. Don't get lazy and think because people are at home it isn't necessary. You are in a position to catch any number of possible complications and hopefully prevent readmission or ER visits. I'm starting on a telemetry unit here in a few weeks and the process for me leaving home health was to be offered a new position, give notice, stop taking admits, and move people over to other nurses. I was able to answer almost all of the interview questions with examples from my past 18 months of home health experience.

I can also vouch for google voice. I was given a monthly stipend for my cell phone and just set up google voice on my android. My google voice number was for everything work related which kept my personal number safe. The ability to set up multiple voice mail messages based on the caller was nice as well. Co-workers, the office, docs, family, and on-call each had their own message. Even though calls went to my personal phone I didn't answer after hours unless I was on call or expecting a return call. It worked out well and was never abused.

I just started as the nurse for a small DD agency (for both residential and day program). We have 60ish people coming to day program M-F and 35 in residential with a good deal of overlap between the two. My current concern is the storage and tracking of medications. Right now we are only storing meds for 7-8 clients at a time (epi-pens/benadryl for a couple people with severe allergies, PRN inhalers, and a handful of controlled meds. I've put procedures into place to ensure that controlled meds are accounted for per state regs (2 signatures at the end of the shift), but I am looking for a storage solution to comply with the double locking needed for controlled meds (valium, ativan, and phenobarbital) and for general med storage. Does anyone have suggestions for a cabinet/procedures to keep everything in order? Edit: Also, suggestions for storage and tracking of expired and D/C meds (including the same controlled meds) would be appreciated.

1. Denver Metro 2. $23.50/hr for meetings, $47 for regular visits, $57 for evals/recerts/resumptions/agency discharge, $85 for opens, $2/hr on call, $0.48/mile minus to/from first/last visit 3. No benefits 4. I've got an ipad rather than the portable file box I used to lug everywhere.

I agree, and that is what am doing now. I was told specifically by my case manager that I needed to add visits for med management and that is what I had an issue with. I'm still learning how everything works in home health and talked through the issue with my director of clinical services. I'm used to making visits for observation/assessment of chronic conditions, but I guess I've never looked at risk for skin breakdown the same way. It makes sense to me now, and if they had presented it that way instead I doubt I would have felt the same way. I've learned something that will allow me take better care of my patients which is always good in my book.

I recently switched agencies, and I am going on two months at the new one. Initially everything about the new agency was better, but cracks are starting to appear. I was added on to take care of 3 little stage 2 decubs in a pt's gluteal cleft. The pt is in an assisted living, chairbound, and non-compliant with any kind of offloading/position changes. My orders were for dressing changes 3 times per week, so I put her down for 2wk1, 3wk4 unsure how long it would take for her to heal. Three weeks later everything looks great, and I'm thinking to myself "Awesome! We got you healed up faster than I thought, so time to D/C." I'm at case conference the day before I'm going to D/C when we are told that there are too many people with discharges coming up, so we need to try and extend some for a few more weeks. This included the patient I was going to D/C. My CM told me that I needed to get an additional order of 1wk4 for med management, but I cannot find any justification for this. I have no problem with adding on some extra weekly visits for med management to ensure that it wasn't a fluke when a pt/caregiver set up meds correctly/was compliant for a week, but this pt is medically stable, PT/OT have her at max ability, her wounds are healed, the staff at the assisted living administers medications, she cannot retain any teaching that I could do, and she receives weekly NP visits from her doc's office. I was 4 visits short of my initial frequency, and my CM has since added on the additional 4 without either of us receiving orders. "Assessment completed. Pt stable without complaints. Wounds healed" isn't going to cut it for 8 more visits. I'm being told that too many early discharges raises flags when the company is audited, but this seems ridiculous. Not only that, my CM is telling that I don't have enough initial visits for other people. I've found that some people progress much faster than anticipated while others take longer, and that my initial frequency is something flexible that changes based on the needs and abilities of my patients rather than a hard line that must be adhered to.

If you don't mind me jumping into the conversation I would be happy to answer some questions. I'm new ADN grad working in home health. Home health isn't my preferred specialty, but the agency I work for is the only place to offer me a job so far. I applied at 3 other agencies that all wanted hospital or home health experience before applying at for my current position. This was in addition to dozens of hospital positions that never responded. The consensus on allnurses seems to be that home health is no place for new grads, but that really depends on the person and your employer. I worked as a paramedic before and during nursing school, so I am used to walking into situations that are far more dire than any of my clients *knock on wood* have been in so far. Also, my employer recognizes that I am a new grad and don't have the experience that other nurses at the agency have. They don't push more clients on me than I am comfortable taking, and they ensure I am able to provide any care that has been ordered before giving me opens or new clients to carry. I also have team leaders that are more than happy to provide me with guidance regarding case management since that was not covered in my program at all. I'm trying to build up my load of clients, so scheduling isn't bad for me yet. I try and respect the times people would like to be seen, but that is rapidly becoming impossible when it seems like everyone only wants to be seen between 1300 and 1500. I can't really give you an answer on time management since I am still working on that myself. So far I am liking home health. I'm a bit of a talker, so I enjoy building rapport and using that to guide how I teach my clients. I still find myself reviewing pathophys before seeing clients which serves to increase and reinforce the knowledge I already have. I've already seen patients in their home with conditions that nurses with 20+ years of experience haven't seen which only makes me enjoy the job more since I get to expand my knowledge base while subsequently sharing it with my patients and peers.

Thanks for the advice. It would be near impossible to schedule both jobs at the same time. The VA jobs are supposed to be a mix of 8's and 12's, and the home health is however I schedule visits along with required grand rounds (bi-monthly), case conferences (PRN), and on-call days (one weekend a month). I went ahead and scheduled both interviews for the same day. I was informed that by both managers that they were in a time crunch, so hopefully I hear back from them sooner rather than later on their decision.

I graduated in May of this year, but was unable to take boards for a few months since I was relocating across the country. I took (and passed) boards in August and have been licensed for about 2 months now. I have been applying to for anything and everything that I remotely qualify for often without even getting a response. I went in to fill out an application at a home health agency last Monday and left after three interviews and a job offer. During the interviewing it was mentioned that they would like me to work there for a year since they didn't want to pay to train me and then have me jump ship. I agreed to that, but never actually signed an agreement. Even though home health isn't where I see myself working in the long run I was ecstatic to have been offered a job especially since they wanted me to start immediately and the market for new grads is saturated. During my second day of orientation I received a handful of voice messages while out seeing patients with another nurse. I was called to set up interviews for two separate positions. The interviews are for positions that I applied to in mid-August at our local VA hospital. The first is hiring four nurses, and the second is hiring three. As a veteran myself I would really like the opportunity to work at a VA hospital. With only two days of interviews to fill the positions I feel like I have a really good shot at either of the units since I interview well and it is my understanding that the VA likes to hire vets. I feel terrible every time I talk to the nursing team leader since she seems to mention me working there a year during every conversation. She seems genuinely excited about me managing cases as soon as possible. I had no intention of applying to other jobs since starting at the company, but this seems like an opportunity that I cannot pass up. The hospital jobs would be the best thing for both my career and my family, but I feel like I'm lying every time I talk with my manager. Anyone have advice on how to handle this situation?

Is anyone else running into this question when applying for jobs? Every hospital in my area seems to have a different definition of what a constitutes a new grad. I've run into anything from 6-18 months, and how much your experience counts depends on where you worked. One hospital in particular considered LTC and home health at half time, so even if I had 2-3 years in either of those specialties I would still be considered a new grad. I'm ready to start answering no in an attempt to my application past HR and into the hands of the person actually doing the hiring. It is very frustrating that someone with 6 months of experience and a BLS card would be considered for an recent ED position I applied for, but 5 years as a paramedic with ACLS, PALS, TNCC, and ENPC doesn't even make it past HR.

I am an EMT-B for a private company in the Western burbs. Our basics start out around $9/hr. We put up ambulances for 10, 12, 13, and 24 hour shifts. On a BLS rig you can expect to do lots of discharges, dialysis transports, and the occasional emergency, mostly nursing home falls. Our ALS rigs are medic/basic, and we do the occasional vent/IV pump specialty transport. We don't run with the extra people on calls like the fd does, so you can get experience outside of your scope beyond simply driving the medics around. As far as ER tech jobs in the area go, most hospitals out here in the Aurora/Naperville area want you to be a CNA or a paramedic, or sometimes even both. I'm starting ns at College of Dupage this fall and feel like the past couple years have done great things for my assessment skills and ability to communicate with pts. One bonus of EMS work is the that the scheduling often makes it possible to work full time in just a few days a week, leaving days open for going to school.