Med Pass

  1. Hi all. Although I am working med/surge full time now, I still pick up a shift in a LTC facility 1/wk. PRN, so I working someone else's routine.
    Last night's 2-10 was a nightmare. Unfamiliar with residents on the station, family complaining of AM breathing Tx not being done, no charting, etc.
    This could go on, but my main concern/question of the day being.....

    Say a Resident has meds at:
    1600
    1800
    1900 (mostly Xanax here)
    Obviously,these meds are all being given @ 1700, with "supper".
    1600 and 1800 fall into the time frame, but 1900 does not.
    So I have alert residents refusing the 1900 med because "they don't get a pill now"( But I went by the mars timeframe)

    I understand not wanting to be on the med cart all night, but giving xanax 2hours early seems extreme (and illegal?)

    As a new nurse I am trying to practice good habits, as well as what I was taught in school. I double check residents by comparing the picture, asking their name and having it clarified by a staff member, etc. I am already being classified as "a little anal".

    Any input?
    -Lelu
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  2. 63 Comments

  3. by   marjoriemac
    I would be worried to. I think the drug times should be reviewed. In my home drugs on the mars can only be given inthe half hour up to when they are prescribed. Also the drugs given at one time may not be suitable as they may interact with each other, hence why they were prescribed at different times. I say speak to your manager and clarify their policy.
  4. by   CapeCodMermaid
    The few times I've had to pass meds, I've run into the same problem. I go by the book which means the med label on the card must match the MAR, no one gets meds 2 hours early, no one gets an ativan and a percocet and an ambien at the same time and no one gets meds left at bedside. I can't tell you how many times I get told, "but the other nurses....". I am NOT the other nurses. Do things the right way and if they call you anal so what. You HAVE to be anal about the med pass or mistakes will be made.
  5. by   rehab nurse
    part of the problem with med in a LTC is that is goes by facility policy.

    last place i worked, has like this

    9am daily meds
    9am and 5 pm bid
    q 6h 5, 11, 5, 11

    etc. what i mean is that most meds just go by policy. if patients wanted their ambien at "hs", for some thats 8pm, and others 11pm. we try to individualize.
    yes, giving meds two hours early is technically illegal, but if what you're giving is "mostly xanax", it's not going to kill them if they get it after supper at 1700. however, it needs to be rewritten to be at 1700 so the nurses who don't work the unit all the time give it at same time as the regular nurses (who do the same thing at my facility and have the terrible habit of giving meds once a shift...lazy!!!).

    i'm not condoning their behavior, as giving meds like that could be extremely dangerous. i'm just giving my opinion as to what could be done to fix it. this happened every day i worked since i was only part time. then residents are refusing meds they need to be calm, sleep, etc. the more alert residents will say "but the other nurse ALWAYS gives me them all at once!!! why can't you???"
    it makes ME look like the one doing things wrong, when i was doing it by the book!!!
    so, anyways, i hope i'm making myself clear here. i'm not condoning giving all meds at once, however, if the patient likes it that way, and the xanax lasts for them (or isn't being given just a few hours apart) then maybe the doc will let you change the times. on the other hand, it those nurses are giving something that's supposed to be given at 5p and 9pm (say something like an abt or a bp med or something important!!) all at once, then that needs to be reported cause it's a big med error. also, for others, an ambien or xanax at 7 pm is gonna wear off in middle of the night instead of lasting all night as intended, because some nurses were giving it early. a lot of the nurses at my place (former) were just plain lazy, and wanted not to move. they only had 9 or 10 pts on afternoons. no reason they couldn't do two med passes. and the poor nonverbal patients have no idea what the nurses are giving, and can't speak up.

    i hope i'm coming across like i mean to. it's hard on these boards sometimes to explain myself properly!

    also, don't worry about being "anal". you're being safe, and that's good. it's your license!! you worked hard for it, and you don't want to get into sloppy habits. don't worry about what the others say about you. pretty soon you'll learn more about the meds common to your residents, and you'll be a bit faster. just keep doing things the way you were taught...better safe than sorry. i've seen terrible med errors in NH, the worst being a pt's eyes bleeding out because the INR was never checked, and the nurses kept on giving the coumadin...pt turned out blind. i think some nurses don't think bad things can happen in nursing homes. but they can.
    Last edit by rehab nurse on Sep 23, '06
  6. by   BabyNurseLPN
    I'm a fairly new nurse. two months new actually.
    I have two patients that request their prns every night
    one gets 2 ultram and a sleeping pill
    the other wants an ativan and a percocet.

    How dangerous is it to give these together? I know it is always done for both patients. The other nurses who give it have been nurses for awhile.

    Also, I have a pt. that was getting around the clock vicodin and at 9pm the had a vicodin and 5mg of methadone.. I tried to question this timeing with the Hospice Dr. Mostly attitude was what I recieved and no real answer.
  7. by   rehab nurse
    i have never seen our pt's get two ultrams at once, but if they are just the 50mg plain tabs, i have seen younger patients get it. ultram is one of those funny meds...either it wacks someone out, or it works pretty good. what kind of sleeper are they getting? restoril, ambien? ambien is hands down the most popular at my NH.
    ativan and percocet is fine together as well.

    what you want to watch for is for people who have impaired liver or renal systems...sometimes these pts need a lower dose. and many older people do have impaired renal/liver systems. you'll see in any drug guide the excretion route of a med, if it's renal it will even have the normal doses.

    being a new nurse, i would get to know the "normal ranges/doses" of the meds you give. yes, it takes a good many months, but you will start to remember them over time. every specialty has meds that are commonly used.

    as long as those meds you are questioning are not written "not to be given with x" you should be fine. just monitor them for lethargy, etc, esp if it's a new med order for them. that's why it's so important to document your PRN meds, so if the person is excessively groggy the next day, day nurse can look at what the person got last night and see "oh, this person had a PRN ativan.." or any other med. very important.

    but, i have given all those meds above together, sometimes more! one lady had 2mg ativan (unusual dose), 10mg ambien, and she got two lortab 10/500's. hardly touched her. but some little old ladies may get 0.5mg of ativan and be asleep for 12 hours....everybody is so different, that's why its so important for the nurse to watch carefully for the effects of any meds!!

    good luck, and congrats on being a new nurse!!!
  8. by   rebesmillpn
    Hello,
    At our facility we have a 1 hour before and 1 hour after window for meds to be given. You are exactly right if you go by the MAR you will probably be out of your time frame. Check your facilities policy and see if they have a guideline to follow. If not the next simple thing to do would be to get a clarification order from the MD and change the time the med is to be given. If there is a specific reason why the med can't be given at a different time then write that as a order and document it in the nurses notes and then all the other nurses whether part time, prn or full time will have to follow the order or they will be subject to a write up or license being suspended for failure to follow MD orders. I think you acted appropriately and done the right thing, and if it takes you being an anal to make sure the resident's are taken care of accordingly then continue to be an anal.
    Keep up the good work and good luck.
  9. by   Suninmyheart
    In my LTC facility our am meds take so long that we are ALWAYS outside of the 1 hr before 1 hr after window.

    :smiley_aa In fact it is one giant medfest from 6 am to 2pm.

    In response to your post - I admire the nurses who are "anal". Keep it up!
    We need more nurses like you. I am very very new and it is nurses like you that I want to learn from.
  10. by   CometLPN
    At our facility it's 1 hour before or 1 hour after. That's your window. There's always going to be exceptions, someone dies, falls, etc. But if people are just doing it because they're lazy and don't want to be on the cart that long that's their problem and they need to learn how to manage their time better. I'm a fairly new nurse as well, and even though your day can be flipped. You should pretty much have somewhat of a routine. I would check the resident's chart. Some meds are made time specific by the MD. Otherwise I would definitely notify your ADON or DON. And don't worry about those saying you're anal. Just remember.."it's better for them to respect you, then like you." also, if you're doing it for the right reason, meaning in the resident's best interest, you're doing the right thing. I do have one lady in our facility that every night at 2230 or 2300 requests her PRN morphine and an ambien and unfortunately it's her right to request it and since she's in her "right" mind we are unable to do anything about it even after discussing her past dependency on morphine and the current risk of trauma it could do to her. And for the ultram thing we do have a few people in our facility where the doctor has prescribed routine ultram as two tabs instead of using plain tylenol or a narc.
  11. by   CoffeeRTC
    This happens to me alot at one facility I work with. Since I'm a floater...I see different pts evey time I work. Some times the med passes take so long that I'm giving 5 pms at 7pm then I have 8 or 9 pms to give out. Well..they are getting their 8 pms then if it is a q day dose or bid dose. Narcs and sleepers etc need to wait. I just hate it when I'm doing the 5pms and they say...I get all of my meds now. Um..no you don't.

    Now if the res want it that way...why can't we get an order to say give XYZ at Xpm per res request? Just watch what the policy is and if needed you can get a doc's order for a change.
  12. by   flashpoint
    I can relate to this one...our policy is we have between one hour before the scheduled time and one hour after the scheduled time, but two hours before and two hours after will not be considered an error. Their logic for this policy...this is the resident's home...it is not fair to wake someone up for meds or make someone stay up for meds. If we have a resident get up to the restroom at 0430, I give them their 0600 meds...it gives them some extra time to sleep, I'm not going to wake them up half an hour after they get back to bed, and it makes the med pass go faster. If someone has a rough night and gets up to the restroom several times or whatever, I can let them sleep at 0600 and the day shift nurse can give their 0600 meds at 0730 when they are at breakfast.

    The other night nurse and I try to follow the same routine...we start with the same residents, give HS meds at the same time, do treatments at the same time, etc...the only time there is a problem is when someone from another shift fills in and tries to do treatments or whatever at times the residents are not used to. We also have a list of what we do and when...that way someone filling in can read it (they never do) and know that we give Mabel one of her HS Tylenol at 2000 and the other at 2200 because she says it upsets her stomach less and helps her sleep better.
  13. by   CoffeeRTC
    I totally agree, Cotjockey.
    It kills me when I see the pm med pass for 10pm at my current facility. Most will start with that pass at 7pm and be done by 9:30. Most of the residents are asleep or in bed by 9pm at the latest. My big question is why not change the times?

    Thier reason. The other halls pms are at 8pm. They time it like that so when we are working short (1 nurse per 50 res instead of 2) they can start one hall and then do the next and be more in compliance. Hmmm good reasoning....we are always short there too. Hmmmm wonder why I only have 2 shifts left there? Nope.
  14. by   weirdRN
    I have meds to pass at 8A. I start at 7A. I never get done before 1030. I give over three hundred pills every day for 30 some residents. I suspect the nurses that get done earlier are somehow cutting corners they shouldn't.

    I follow the MAR as closely as I possibly can for time frames and combinations of medications. However, the number of meds and residents makes it IMPOSSIBLE to stay with in the one hour prior and one hour after rule.

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