Iffy practices at my new job...

Specialties Geriatric

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Specializes in Geriatrics, Hospice, Palliative Care.

Hi, I'm a new nurse at a LTC facility, and am orienting on a floor with 31 pts. I was told by several nurses to watch out for the nurse who is orienting me, that she can be tough. That's fine with me, nursing is a second career and I can work with most people. HOWEVER, she told me that she does one med pass for the 3-11 shift - everyone gets their meds sometime between 4-6, regardless of when they are scheduled, because otherwise she would never get everything done. She told me the order to do things, and send me off with the cart (I hadn't yet met any of these pts, and had no idea who was who). So, I did the first med pass "her way" with a lot of trepidation, in order to get it done. I made a new cheat sheet for myself so that I could see who got meds at what times, so that I didn't have to flip thru the hellish handwritten MAR every hour. Using my cheat sheet, I was able to get the med pass done in a fairly legal way, but probably would have had a hard time getting the documentation/notes/other stuff done if she hadn't done that for me while I was doing meds. I can work on speed, it will just take time.

Here's the problem: one gent said that he wasn't feeling well, was pale and diaphoretic, a bit nasueus; this was around 5 pm. I took his vitals, had normal BP, resps were irregular at 32, and HR was an astounding 185. I reported this to the nurse, and she said that he should be fine once his Coreg kicks in. I checked the MAR since I didn't recall giving it to him, and saw that it wasn't due until 9 pm. She said that he is a DNH/DNR, so I should just give him the Coreg since he's used to getting it at that time from her. I gave it, and his HR did go down to 110 about 30 mins later.

SO - while I obvoiusly want my pts to be well, I want to respect the unit's routines (two pts were angry when they got their meds at 9 pm, as they were already in bed), I also want to do the right thing. There are a zillion reasons for giving meds as scheduled, safety being the first, but there is not a unit manager who I can approach about getting meds rescheduled so that we are all on the same page. Any ideas? I'm new, and really don't want to alienate my coworkers or upset routine. Other than this, I really like the place where I am working; I think that most of the nurses give excellent care.

Thanks, e

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In LTC, she is right - she'd never get anything done if she had to give one pill at a time to every patient. You have to make sure that you aren't giving pills together that can counteract/interact with other pills. As a general rule, you give every thing at once unless it is something like an antibiotic or cardiac med that is ordered every 6 hours. Knowing your meds and the residents reactions to them is critical.

The times that are written, whether at the hospital or NH, are arbitrary times meant to make it easier for the pharmacy to fill everyone's meds at the same time.

If this patient gets Coreg 1-2 times a day, and those times are spread roughly equally throughout the day, and are given at roughly the same times every day, then this man isn't not likely to be harmed.

The nurse should be documenting the times that it is being given though - not simply writing "2100" because it is on the med sheet that way. It would also be better if they changed the times on the med sheets to reflect a more approximate time to give it. However I have come across DONs that will not do this because it makes the facility look bad that they have to give 2 cups full of meds at one time because they have such a high nurse/pt ration.

In the hospital we give some 7,8,9 am meds all at the same time for the same reason - we don't have time to run back and forth from the med room to the patient's room constantly. But it requires knowing which meds you are doing this with, whether you can do this safely, and documenting the time that you gave them correctly.

LTC is a bad place to have to learn the facts of life that are so different from school because you have way too many patients to try to care for. I would rather that this nurse do what she does than to not give meds and treatments because she never made it that far down the list of things that needed to be done. Make sure that the times the med is given is written down correctly, even if it seems "off" with the MAR. And be prepared to answer why things are done this way if you are asked.

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ugh...this happens alot since I only work weekends at some places. I'm not familiar with the routines and come 8 and 9 pm when you try to to the med pass as listed it is sometimes impossible to get the res to take the meds or they flat out refuse because it is too late. I totally see the need to combine med passes. It probably should be done and would make things much easier and let us work more efficiently. How do you go about this being new?

I would still try to go by the book as much as you can. Do they have meetings with the nurses or will they have a evaluation after your probationary period? Maybe you could bring this up as a suggestion? I'm sure most docs would agree with you and the pharmacist wouldn't have problems providing the meds are okay to be given this way.

How about if you are around when the doc rounds you could ask him about a few of their patients.

"you know doc..Mr x, y, z like to go to be early and it is hard to get the 9pm meds in...could we switch them to an earlier time?"

You could do this if you were to call the doc for other reasons too.

Get a few of these orders and maybe the rest will follow.

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Specializes in Geriatrics, Hospice, Palliative Care.

I totally understand that it will be impossible and probably annoying to the residents to give them pills every hour if they are scheduled that way; I have worked it out to do two big med passes on my 3-11 shift, one from 4-6 and one from 8-10. I think that is safer for the residents. And perhaps we can have some meds rescheduled (if medically safe) so that we only have to pass to a patient once time a shift. I want to be efficient and safe!

Thanks for the responses; I've learned so much from this board.

e

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This happened at the LTC where I work part time occasionally.

Their MARS are a mess. Since I work nights, the day shift wants the night nurse to give some of their 8 am meds. I reluctantly did it a few times, but I only gave like the ones who were getting something at 6 am anyway.

Then.........get this......the day shift nurses would give some of the meds for the evening nurse, like 8pms along with their 4 and 5 pms.

Some of the day shift nurses are not very conscientious about making sure it is initialed.

I don't understand why they think this helps. It creates such a mess, you don't know if something was given or not given.

I prefer to just give what is scheduled on my shift and nothing else.

And at 6 am, I have just 2 hours, from 5-7 to get it done, that includes finger sticks and insulins. Of course I know you're supposed to get it done in that window, but if I have interruptions, like if someone falls, I get behind, then I can't get out what I"m supposed to give let alone meds to help the day shift nurse.

It's ridiculous. And the DON knows they do this and she agrees with it.

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Specializes in Licensed Practical Nurse.

I also do one big med pass from 4-6p but of course i am careful about certain meds that have to be given every certain amount of hours! I have to combine my medpasses mainly because i also have fingersticks, dressings, GT feedings, and much paperwork, and if i have a trach pt i have to do trach care! if there is anything i wish would come true in nursing is mananagment enforcing realistic goals for staff members, passing meds isnt easy, wish they could understand that!

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I tried to edit and add this to my post, but it wouldn't let me.

But I wanted to say that as posters above me, I also understand the logic of combining meds for the resident's convenience, IF it's okay, but why not just change it on the MAR, instead of the nurses having to guess all the time, about whether something was given or not?

It makes for a dangerous situation.

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I had a nurse do that to me when I oriented. I did it her way that night and then asked never to be put with her again. Now that I've worked that floor a while I admit that I sometimes give pills out of the faciility's order if it's OK. Sometimes it's OK to five that 2000 colace at 1800 with the rest of their pills so you won't have to wake them later. Or with residents that won't take pills once they are in bed. But, all at once it lazy and ridiculous and yes everything can get done that way, if you get off your butt and do it!! Some people just won't!

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Specializes in Geriatrics and Quality Improvement,.
I totally understand that it will be impossible and probably annoying to the residents to give them pills every hour if they are scheduled that way; I have worked it out to do two big med passes on my 3-11 shift, one from 4-6 and one from 8-10. I think that is safer for the residents. And perhaps we can have some meds rescheduled (if medically safe) so that we only have to pass to a patient once time a shift. I want to be efficient and safe!

Thanks for the responses; I've learned so much from this board.

e

remember too, that this is their house...LTC is where they live, and if they were home, they would be taking the pill in the AM when they get up and in the PM before bed. Presenting it that way will often get you more cooperation from the docs. Also, if it is Q12 MUST...then try 6AM & 6 PM, if they are already getting a 6A, its not an issue...

good luck,

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Specializes in Geriatrics/Family Practice.

Because most LTC facility will ask you to do way to many things, with to many residents and not enough time, you learn to make due. Yes, I'm guilting of picking and choosing the appropriate meds that can be given earlier or later. One time a day meds, can usually be given whenever. My first priority are insulins, cardiac , pain meds and antibiotics and their may be more, but that is just a short list. Vitamins, liq. supplements, colace, miralax, and one a days are not a priority for me. If my residents are dirty, thirsty, or just need something more on the hollistic side of nursing that kind of trumps non life threatening medications. I don't like to walk into a residents room and smell urine and feces and have not one CNA around to clean them, so I do and the meds wait. How can a resident have any dignity when you stick non-necessary or one a day meds in their mouths and walk out knowing they are laying in their own waste. And last but not least paperwork is the last on my list of priorities. I think most of it is a waste of nursing time and energy and that time should be spent with the residents and not sitting at a desk. I know that the paperwork is important to cover your butt, the facilities butt and get the old mighty dollar of reimbursement, but I love my resident interaction above all and wouldn't do anything to jeopardize their care, but will make them my number one priority. If a resident needs a hug and my undivided attention, does it really matter if they get their MVI or colace late? Maybe according to the state, but not to me. Yes, I play the game along with everyone else when state comes in, but I know in my heart of heart that I'm a good nurse and very good to my residents and for that I can go home and look myself in the mirror. So as my nursing instructor said "When in Rome do what the Romans do, but if it doesn't feel right, do what makes you feel right and know that you did a good job, to the best of your ability." Sorry so long.

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Specializes in geriatric & childrens psych, rehab, woun.

I hate to be a kill joy, but unless you change the times on the orders and mar, if you get caught giving the meds to suite your schedule you are risking your license, you have a window in which to give meds and if you combine them in those time perimeters, you will have no problems but if you are combining lets say 4pm meds and 9 pm for your convience, then you are endangering your license. if lets say sara old lady wants all her meds before she goes to bed at 8 pm then talk to dr kildare and have him change the times if possible, most of our 9 pm are sleepers or poopers and that is usually not a problem, but lets say it is coreg which is usaully 12 hr apart that should stay at that type of interval but if given at lets say at 8 a and 8 p will fit in to acceptable parimiters, only you can protect your license. look i'm not perfect, i am anal, and i have been a lpn since 1980, and in ltc and psych all of my career, no one gave me my license i earned it and so did you, i have 31 resident on 7-330, i dont have a ward clerk and right now have no unit manager, i do the pharmacy corrections, labs, drg's, medicare charting, the doctors all come on my shift, all the meds and treatments and have the don screaming at me over the overtime 8 to 12 hours a week, but it is my license i look out for and if i can save yours i will. and i have patients i have to go back to to give them their meds,because they won't take them because they are delusional and think you are poisoning them, and in 45 minutes they will thake them willingly. remember it is your license

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Specializes in LTC, ER.

I do understand that some things scheduled for hs can be given earlier, but I agree with other posters that it would be best to just get an order to switch times. The problem with just arbitrarily switching times on meds is that if you are not a pharmacist do you really know that the hs meds are scheduled that way d/t a potential interaction with the 5pm meds?

My biggest problem though is the fact that you had an unstable pt with a hr of 185 and he was just given his dose of Coreg. If a patient had presented in triage of my ER with that hr he would have been taken directly to the resusitation room, and he would NOT be given a po med to get that hr under control.

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