What to expect in a nursing home

[Sasha]

Skilled Nursing Facilities (SNF) don't want to call 9-1-1. They want to call private response. So, as both a dispatcher and a field employee you will learn what reported chief complaints most often really mean. Here are some of the most common ones I have seen:
1.) A report of "Weakness" = ALOC / (sometimes) CVA
2.) A report of "Congestion" = SOB
3.) A report of "Fever" = Septic Shock
4.) A report of "Low BP" = Decompensated Shock

I know it's been said, but I'll say it again, NEVER TRUST THE VITAL SIGNS REPORTED BY THE SNF!!!!! Even if it's dialysis, you should never leave the scene without checking your patient's vital signs first.

Now, as far as disease processes, look into diabetes and the relation to PVD, ESRD, and peripheral neuropathy. The fact is, many of your patients will be dialysis patients. Do you know what a Fistula is? Bruits & Trills? How about a permacath? And what's the difference between a PICC line, a Hep Lock, and a Permacath? I would suggest looking all these up. Take a look into Blood Labs results and normal ranges: WBC & Hematology, and Ions & Trace Metals. Learn what those labs mean. Many of your patients will have a baseline ALOC, and much of treatment will be based on assessment, not their complaint (as they may or may not even have a verbal response in certain cases). For this reason, if you haven't already, memorize your GCS scores and neurological tests.

5) Report of "Abnormal Labs"= Anything under the sun, you will potentially walk into someone who'se trying to die on you.

 

[adamjh3]

Report of "Pneumonia" = dizziness secondary to hypotension tertiary to bright red bloody stools. Yup. Not sure where pneumonia came from there... didn't even know pneumonia was a chief complaint?

These patients are a GREAT opportunity to learn. If you have time on a reasonably long transport look at the patient's history in detail along with their med-list, eventually you'll start making connections between medications and disease processes. And TALK to your patients, even if it's just small chat, you will be amazed at some of the stories these people have to tell. A lot of times a nice conversation is the best treatment we can give to some folks. A lot of folks in these facilities don't have family near by and may only rarely, if at all, receive visits from friends or family.

 

[IAems]

Dealing with real patients, the vital signs may fall well outside of what the book says is "normal". Failure to understand this can lead to you deeming conditions that are normal to be emergencies.

This patient population is the least likely to have "normal" vital signs. Keep that in mind...

Right on the money. I had a patient who's heart rate was always in the mid 40's. In fact, I only worried about this patient when his heart rate was within normal limits. Doctors routinely withhold hypertension medications prior to dialysis, meaning blood pressures will sky rocket (especially after an entire weekend without dialysis). You will have to rely on your general impression and your patient's vital sign trending to determine baseline status and stability of vital signs. Remember, "stable" and "within normal limits" are two different things.

 

[mintygood]

This thread is helping tremendously, keep 'em coming!

 

[18G]

Took a patient to a SNF the other day who had a trach. We were in the process of getting the patient situated to move over to the bed while the RN was changing over the patients O2 and getting the humidification going.

All along, the RN was complaining about accepting this trach patient and tried to tell us we would probably have to take him back because his O2 sat wasn't high enough and she never got report from the sending.

So I put the pulse ox on and it reads 91%, then 89, 84... and mind you the patient was checked by respiratory right before we departed with the patient and all was good.... the patient was clearly desaturating so I started trouble shooting with checking the O2 source first and foremost and wouldn't you know... the RN never turned the O2 concentrator on... hmmm... why is this patient desaturating???

Scary.

 

[the_negro_puppy]

Often the sickest patient you will find (medically) are in nursing homes.

 

[Akulahawk]

Skilled Nursing Facilities (SNF) don't want to call 9-1-1. They want to call private response. So, as both a dispatcher and a field employee you will learn what reported chief complaints most often really mean. Here are some of the most common ones I have seen:
1.) A report of "Weakness" = ALOC / (sometimes) CVA
2.) A report of "Congestion" = SOB
3.) A report of "Fever" = Septic Shock
4.) A report of "Low BP" = Decompensated Shock

I know it's been said, but I'll say it again, NEVER TRUST THE VITAL SIGNS REPORTED BY THE SNF!!!!! Even if it's dialysis, you should never leave the scene without checking your patient's vital signs first.

Now, as far as disease processes, look into diabetes and the relation to PVD, ESRD, and peripheral neuropathy. The fact is, many of your patients will be dialysis patients. Do you know what a Fistula is? Bruits & Trills? How about a permacath? And what's the difference between a PICC line, a Hep Lock, and a Permacath? I would suggest looking all these up. Take a look into Blood Labs results and normal ranges: WBC & Hematology, and Ions & Trace Metals. Learn what those labs mean. Many of your patients will have a baseline ALOC, and much of treatment will be based on assessment, not their complaint (as they may or may not even have a verbal response in certain cases). For this reason, if you haven't already, memorize your GCS scores and neurological tests.

5) Report of "Abnormal Labs"= Anything under the sun, you will potentially walk into someone who'se trying to die on you.

"Weakness and Lethargy" is also a catch-all for patients that are experiencing any and/or all of the above in any combination... and for those patients that are attempting to escape via the Heavenly Door...

Whatever you're told the chief complaint is... take it with about 5 POUNDS of salt. The salt is probably worth more. They're trying to get the patient out of there without "alarming" the ambulance crew that this patient needed to go by 911... yesterday.

Do your own evaluation. Find and read the charts for yourself. If you're doing all IFT stuff, you might find that you keep transporting the same patients over and over (literally). Use your own mind... what's abnormal for the rest of us very well could be normal for your patient. This patient population often is much sicker, on more meds, experiences significant polypharm problems, and generally tries to confound us every which way but the real one.

As much as I didn't like transporting the same patients over and over again, I loved it too... because I got to see what happens when all the above starts to come into play. Patient assessment skills can be very well sharpened by doing this, especially if you run into a nurse or two that is very competent, not burnt, and loves to teach you what to look for.

And CNA staff are trained for different things... but they do know what is normal behavior for their patients. Be nice to them too. CNA's can be good sources of information too. They may not know much, but when they say "Mrs Johnson is usually really chatty and active. She was fine just 2 hours ago..." you really should listen...

 

[addictedforever]

A nursing home calls 911 for Pt having SOB. We respond:
(Pt is found in Fowlers with head tilted forward, obstructing airway)

EMT: How long has she been like this?
CNA: I don't know but she sounds like she can't breathe
EMT: (Checks the O2) She's on 5 lpm (Turns up to 20 lpm)
CNA: Oh I didn't know what number it was supposed to be on
EMT: Um, ok.... (tilts Pts head back and checks airway) What is this? (Pulls out a pair of dentures in the back of the throat. Pt begins to breathe normally) Did you guys check her airway?
CNA: No, I didn't know what to do so I called 911
EMT: I hope I die before you twits are the ones taking care of me when I'm too incompetent to know the difference

Just a quick note. In the state where I work as a CNA, we are not allowed to adjust the O2 without the nurse's okay to do so. And most CNA's are not trained in basic first aid procedures. Some are not even trained in CPR. I had to take the initiative to learn that myself, because I did not want to be totally incompetent if something should happen. And by the way, all the NH's I worked in 911 was the "crash cart". If something happened, you called 911.

Good advice...but I also have to advise some caution. Dealing with real patients, the vital signs may fall well outside of what the book says is "normal". Failure to understand this can lead to you deeming conditions that are normal to be emergencies.

For instance, in Middle of Nowhere, we have NH patients who's B/P hasn't been above 85 in decades, a few who's heart rate stays south of 60 all the time, a few who's resting respiratory rate is close to 8 and others who it's closer to 30, and some with a "normal" SpO2 in the high 80s. That's in a town of 10,000. Dialysis patients may get picked up with a stystolic pressure in the 150 range and dropped of with it post-dialysis in the mid-90s.

This patient population is the least likely to have "normal" vital signs. Keep that in mind...

Amen! If you find a competent CNA, ask them about vitals. If they've been paying attention they can usually tell you what the vitals are normally.

And CNA staff are trained for different things... but they do know what is normal behavior for their patients. Be nice to them too. CNA's can be good sources of information too. They may not know much, but when they say "Mrs Johnson is usually really chatty and active. She was fine just 2 hours ago..." you really should listen...

Please listen to the CNA's. They usually know the norms for their patients.

I had one paramedic come to transfer a pt for a suspected DVT. I tried to tell this EMT-P that this pt did not stand up to transfer, usually the pt. was max assist with three people. He wouldn't listen. Since he was so insistent on standing this pt up to transfer, I went to put some non-skid socks on so he would be less likely to slip. The paramedic yelled at me for doing that, because then he wouldn't be able to feel the pedal pulses. So I left them off. He stood the pt up and instead of being right there helping him, the paramedic just basically let the guy try to transfer himself. The pt. ended up slipping. I had to catch him in my arms and try to get him on the gurney before he landed on the floor. I was mad!

Just tho't I'd throw that in there so that you know it isn't always the NH staff who is incompetent, but most of the time, I will admit, it is, unfortunately.

 

[the_negro_puppy]

I jsut finished night shift.

A few hours ago went to a nursing home job description "Short of breath, 02 stats 75%)

On arrival cardiac arrest CPR in progress.


By CPR I mean poor compressions with pt on a bed, 5 people standing around watching.

When asked about the pt's medical hx, get blank stares. When asked about if a DNR exists, blank stares (including from RN). While attempting resus, staff told to please look through medical file and let us know if they find anything that says not for resuscitation. /rant

 

[sirengirl]

....Things like MRSA...

I just wanted to re-iterate how sick folks get in nursing homes. Seriously. Where I volunteer we are completely surrounded by nursing homes and rehab facilities. There's a particular facility well known for it's rehab patients coming down with pneumonia, because they lay the patients supine on their backs. There's another facility well known for the patients being on inproper O2 levels. There's another facility where no one wears gloves. There's another facility that allowed the same patient to be transfered back and forth to the ER (by us and by the county) 3 separate times within a 4-hour period, WITHOUT telling us the patient was in isolation for MRSA. A week later another patient from that same home (different room) also came down with MRSA.

Seriously. Scrub yourself after you get out of a home. You can't ever be too safe.

 

[medictruth]

Honestly determine LOC because our version of normal may not be theirs. Take your own vitals and never take anyone elses word for it.

 

[KrisB]

Man, this is a hard thread for me. I've been an LPN for 16yrs and have worked in pediatric brain injury rehab to pediatric office to plastic surgery (scrub/circulating), but primarily geriatrics. I would love to deny everything in this thread, but I can't. There are some damn good nurses I've worked with and some I wouldn't let change my bandaid. I still to this day point to where I want an injection given... sounds like such a simple thing but they just don't seem to have a clue, and that goes for some hospital staff, too.

I was training a new nurse on my floor and asked her to get me a tylenol sup. She had no clue where to find it. Sad. I tell her in the fridge and she stood there for a couple minutes looking bewildered. She finally looks at me and holds up the glycerin supp. Really? At this point I wanted to say go home. When I reached for them myself, she tried to read acetaminophen and couldn't, had no clue.

Nrsg home nurses are a mixed bag, as are the cna's. And, I agree, always take your own vitals! Geriatrics pt.s can be tricky and if you are dealing with lazy staff you are likely to get the standard 120/70, 70, 20. I've seen a nurse swear she just took my pt.s vitals a matter of minutes ago and they were the canned vitals...btw, I had just found this pt had died. It was the beg of my shift and found her on my rounds.

I took the last 4yrs to stay home with my autistic son and wanted to get back out there only to find LPN's don't really exist anymore. So, I am considering going through the emt course and prob continuing to paramedic. Thank you for all the great info I'm finding here!

Sent from my ADR6300 using Tapatalk