What to expect in a nursing home

[mintygood]

Hey guys. As some of you may have seen, I recently got a job with a convalescent ambulance company. I will begin my first orientation shift on monday and I wanted to pick the minds of the more experience so I can be super prepared for my new job. So my question is this: what are some common diseases/ailments that I will encounter in nursing homes.

 

[LucidResq]

I think one thing to be aware of and cautious of are the communicable diseases. Things like MRSA, norovirus, C.diff can spread like wildfire in nursing homes. You have so many people in close proximity, many with weakened immune systems and the like. Don't be afraid of your patients, but don't get yourself sick or pass bugs around to them.

 

[medicdan]

I also encourage you to do your own assessment and vitals on your patients-- not refer to that of the staff or facility. Even for routine transports, practice and complete a full exam on every patient.
Although not everywhere, my experience is that staff are not always as on top of patient's conditions or are operating on old information much of the time...

 

[mintygood]

Great tips guys, thanks a lot. What, specifically, are some common chronic illnesses?

 

[usalsfyre]

Great tips guys, thanks a lot. What, specifically, are some common chronic illnesses?

COPD, CHF, DM, dementia, Alzheimer's, hemiparesis from CVA, "locked in" syndrome, CAD, hypertension, hyperlipedemia, chronic UTI or bladder infection, chronic pneumonia, depression, certain schizo affective disorders, profound MR, seizure disorders....the list is exhaustive, what's above doesn't cover half of it.

 

[mintygood]

COPD, CHF, DM, dementia, Alzheimer's, hemiparesis from CVA, "locked in" syndrome, CAD, hypertension, hyperlipedemia, chronic UTI or bladder infection, chronic pneumonia, depression, certain schizo affective disorders, profound MR, seizure disorders....the list is exhaustive, what's above doesn't cover half of it.

Great starting point. Just wanted a list to start doing research on. Thanks!

 

[18G]

Nurse incompetency seems to be a disease prevalent in all nursing homes. So definitely be on the lookout for that one.

 

[mintygood]

Nurse incompetency seems to be a disease prevalent in all nursing homes. So definitely be on the lookout for that one.

During my clinicals, we responded to a code where the respiratory therapist intubated our pt's esophagus. When the medic I was riding with asked "why does it look like she has a beachball in her stomach", the respiratory therapist said "I have no idea but I definitely heard breath sounds in her lungs".

:facepalm:

 

[loves2(k)box84]

Don't forget those lovely decubitus ulcers

 

[ZombieEMT]

Nurse incompetency does seem to be a common disease in nursing homes. Like emtdan said, do your own assessments. Sometimes you will find there are major differences. I do not know how some of the nursing staff still work in medicine, its ridiculous. The worst is when you run into a whole staff that performs inadequate CPR. I have made it a practice to treat each patient as if I got them from the street, start from scratch.

 

[Akulahawk]

Nurse incompetency seems to be a disease prevalent in all nursing homes. So definitely be on the lookout for that one.

Nurse incompetency does seem to be a common disease in nursing homes. Like emtdan said, do your own assessments. Sometimes you will find there are major differences. I do not know how some of the nursing staff still work in medicine, its ridiculous. The worst is when you run into a whole staff that performs inadequate CPR. I have made it a practice to treat each patient as if I got them from the street, start from scratch.

What can appear to be incompetence can also be simply due to sheer overload. The In other words, the nurses might not be able to get to know each and every patient like they would if they worked in a unit where the nurse/patient ratio was say 1:5 or 1:3... SNF ratio might be 1:30 or more. SNFs might have tons of CNA staff and a few LVN or RN staff all due to the all-might budget. Get to know the CNAs. They might have 10 or 15 patients to deal with, but they can also give you a good idea about how the patients normally interact with others... Get to know where in the chart/paperwork you can find PHMx and the Meds. Find out where on the transfer paperwork that the last vitals are written. Learn where to find quickly if the patient is DNR.

Always Always ALWAYS approach each SNF patient (initially) as if they're about to code. They might actually be ready to... And keep an eye out for the "weakness and lethargy" chief complaint. I don't know how many patients I've transported over the years that were "weak and lethargic" only to find out that they were last assessed 2 hours ago and are currently contemplating circling the drain...:blink:

And usalsfyre's list only scratches the surface. To make things even more interesting, the patients will likely have not one or two... but several problems on that list alone... with a laundry list of meds to match. IFT transport can be (and often is) a very different animal than 911.

 

[smelleecat]

Nurse incompetency does seem to be a common disease in nursing homes. Like emtdan said, do your own assessments. Sometimes you will find there are major differences. I do not know how some of the nursing staff still work in medicine, its ridiculous. The worst is when you run into a whole staff that performs inadequate CPR. I have made it a practice to treat each patient as if I got them from the street, start from scratch.

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



I feel terrible for almost every person in a nursing home. It's too sad for me.

 

[the_negro_puppy]

[youtube]rMZ_3wfff3I[/youtube]

 

[Sasha]

Here is a tip, if someone says no, even if theyre confused. Dont touch them, they tend to swing.

 

[Sasha]

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



I feel terrible for almost every person in a nursing home. It's too sad for me.

This is an example of what not to do. Dont be an ***, its bad for our overall image and can.get you fired. CNAs are educated differently than an emt, they are mainly there to help with ADLs and stuff like wound care.

 

[TxParamedic]

Sigh....You will run into everything in a nursing home. Sometimes it is being handled with great care and compassion by some of the best nurses and nurse aids you could ever hope to meet and sometimes it is being made worse by people you can't imagine how in the hell made it through nursing school. My personal go to story when I train new people is the "turning blue" call I responded to and found the Pt slumped down in bed with four pillows behind her head. Once the pillows were removed she pinked right up! So yes stupidity runs rampant sometimes. I agree with the previous posts. Do your own assesments, the good nurses are your best source of information the rest are useless at best.

Did anyone mention scabies?

Oh an BTW, In twenty years the only Pt that has managed to land a solid punch to my mug was a little old lady I thought was contractured......she turned out to be coiled, ready to spring! the staff warned me "watch out she bites" they failed to mention she had a jab like a middle weight!

 

[IAems]

SNF Complaint Translator and other info

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.

 

[mintygood]

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.

great info, thanks so much!

 

[johnrsemt]

Always make sure that the patient you are taking is the RIGHT patient. I was bit by that one twice; patients switch beds for fun, because they are confused or the staff is confused. I have never had the staff tell me that I had the wrong patient. That makes us look like idiots when we come back from Dialysis after getting told by their staff "that isn't Mr Jones"

 

[usalsfyre]

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.

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...