Confused on lpn scope of practice

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    Who does the initial admit ?? the RN or LPN ? who initiates the care plan ?? oh and we now need a physicians order to use our nursing judgement. i.e. We can't hold a med based on nursing judgement if the order doesn't specify. we have to have an order that would say something like "Hold if sedated" i have seen bp meds without parameters. would i give a bp med to a res. who has a bp of 110/60 ??? i have to call the dr and get an order to hold the med. and our facility will not, WILL NOT, let the Dr write standing orders. The only thing i have seen that does have a hold (other than insulin) is Dig. but not all of them are written that way. I know you never give dig if heart rate is under 60. but i will have to call the dr to get that ordered. I have to call dr for tylenol, tums, ect. And we can't get a standing order for it. now they are talking about having the lpn's do the UDAs...I HAVE NO IDEA WHAT THAT IS !!! And we are suppose to triple chart now i guess, chart on the mar, in the nurses notes and now the UDAs whatever that is and update care plans. and its not a team effort with those care plans, you can make a suggestion for additional pillows to prop legs/feet ect and it gets questioned and if you update care plan to enforce that then you didnt do it right or its not relavent to the care plan AND IT'S YOUR LICENSE. i'm so tired of hearing that, i'm ready to give my license back.
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  3. 6 Comments so far...

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    Whoever gets the admit does it usually.
    All meds should have specified indicators- BP parameters, level of sedation, pulse, whether their bowels move (hold) or do not, etc. It saves a lot of time at the outset.
    You sound new to that scene, sorry to her your anguish. LTC is not for the meek. It's awful, at it's worst. Your place is mismanaged.
    As far as the care plan, it should be started before the patient even gets there, by the MDS person, a DON, etc- to be proactive, and to be prepared. There's no regulation requiring a care plan upon admisson, though.
    sallyrnrrt likes this.
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    In NY, RN's write the care plan do the initial assessment. LPN's can update a care plan. Whoever gets the admit is stuck with it, which is why change of shift admits get the RN supes so mad! Is it days or evenings responsibility? LPN's make observations and collect data, RN's can analyze that and write orders. You should have standing orders for common meds, like maalox, mom, apap, etc. That stinks that you don't. The doctors must be frustrated as well with all those phone calls! Something's weird here....As to parameters, you're right, it should be part of the order. If I were you, the next time the doc is on the floor ask for parameters so you don't have to keep calling her/him. Best of luck, this is one tough job despite the general view that LTC is not.
    fairyluv likes this.
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    If your admin thinks your license is on the line over a nursing home care plan, I have a taco stand on Mars I'd like to sell 'em.
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    In MS the RN must do the admit assessment and start and continue to chart the care plan. The LPN can assume care of the patient as soon as they arrive but those two things must be done by the RN.
    As for mess if there are no parameters we always call the DR if we feel that according to our nursing judgement the pt should not receive the med and get a ok from the doctor to do so.
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    Quote from fairyluv
    Who does the initial admit ?? the RN or LPN ? who initiates the care plan ?? oh and we now need a physicians order to use our nursing judgement. i.e. We can't hold a med based on nursing judgement if the order doesn't specify. we have to have an order that would say something like "Hold if sedated" i have seen bp meds without parameters. would i give a bp med to a res. who has a bp of 110/60 ??? i have to call the dr and get an order to hold the med. and our facility will not, WILL NOT, let the Dr write standing orders. The only thing i have seen that does have a hold (other than insulin) is Dig. but not all of them are written that way. I know you never give dig if heart rate is under 60. but i will have to call the dr to get that ordered. I have to call dr for tylenol, tums, ect. And we can't get a standing order for it. now they are talking about having the lpn's do the UDAs...I HAVE NO IDEA WHAT THAT IS !!! And we are suppose to triple chart now i guess, chart on the mar, in the nurses notes and now the UDAs whatever that is and update care plans. and its not a team effort with those care plans, you can make a suggestion for additional pillows to prop legs/feet ect and it gets questioned and if you update care plan to enforce that then you didnt do it right or its not relavent to the care plan AND IT'S YOUR LICENSE. i'm so tired of hearing that, i'm ready to give my license back.
    Go to your state's BON website-you should know your scope of pratice. Refer to your policy and procedure manual too,but your employer can not ask you to be responsible for something not within your scope.It's up to you to know what is appropriate and protect yourself.Im ny state an RN must do the intial assessment. I do the complete admission and my own assessments-the RN unit manager is responsible to doing her own assessment.Some will document a conplete assessment,others will document that they concur with the LPN's assessment. I'm waiting for the day the crap hits the fan on that,it has happened in other area LTC's already,they were cited by the DOH.I think those RN's are running a risk.
    I'm thinking if you have to hold a med they want you to always call the MD and get the orders for parameters.I've seen meds held in LTC for days and no doctor was ever made aware and the situation was not addressed.That's probably what your admin wants to avoid.That includes the B/P of 110/60-get parameters.You know that these residents didn't check their B/P's daily at home,we generally check parameters for a few months and if the med has not been held we ask the doc to reduce the B/P's to weekly and eventually monthly.Look up the action of each med,check a follow up B/P after admin.
    Not having standing orders can result in significant delay of treatment,most LTC's have them or have been cited by the DOH for that delay.Call the docs often enough for tylenol and you'll soon have those standing orders.Again-maybe your facility has been cited in the past for not following through with things like complaints of persistent pain and that's why you can't have those orders. Can you get a repeating routine order for a PRN when you call the doc?
    Look up your facility's DOH surveys-they also have to be available to the public (ours are in the lobby) I'm thinking there have been some significant citations in the not too distant past.
    I have no idea what a UDA is but you had better find out fast.Our RNAC (MDS staff) initiate the careplan upon admission.It's good pratice to get in the habit of updating them everytime you get a new order for a med ,tx or have a skin tear,fall,etc.If someone is telling you that you are doing it incorrectly use that person as a resource,ask for their help and get them to teach you.That helps to foster team work. We have some careplan templates we use for certain conditions (frequent faller,skin tear,pressure ulcers) and everything else is individualized.Take the time to read some when you can,this will help you learn the art.
    The whole " it's your license " crap gets on my nerves.Nurses loose their licenses for a variety of reasons -people that throw that one around are using the threat as a club to hit you in the head with because they don't want to take the time to use their words to teach you what you may be doing wrong.However if you give dig to someone with a heart rate in the 40's because the facility will not let you use your nursing judgement you could end up in some trouble.Hold the med,call the doc right away and get an order for parameters to go along with every order you get.
    sallyrnrrt likes this.
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    Digoxin does NOT have to be held simply because the heart rate is less than 60. That is old thinking. Not all BP meds need a parameter....people at home don't take their blood pressure 2 times a day before they take their meds.
    sallyrnrrt likes this.


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