New RN in LTC

joanna73, BSN, RN · Aug 11, 2012

I was a new grad in LTC 2 years ago. I've been working for over 20 years in supervisory roles, but only 2 years as a RN, so there is lots to learn. I think any new role takes 6 months to a year until you begin to feel comfortable. Always ask if you aren't sure, and try to develop a collegial relationship with the NA's. While you are supervising them, the NA's are a major asset, so you'll need to work with them. They are invaluable. I found the most challenging aspect of LTC is learning the residents and their behaviours. The med passes can be huge, but take your time. The speed comes much later, once you've learned to organize yourself.

serenidad2004 · Aug 11, 2012

When I was a brand new LPN in LTC I worked 2nd shift and was going to be responsible for 43pts myself with only 3 CNAs and no CMA. I was given 4wks with another nurse... the 1st week on days and the other 3 on 2nds... now granted after about a week with the other nurse helping and following I was ok on my own but it was nice to know that she was there just in case. I dont think 3 days is adequate esp being brand new as a nurse and basically brand new to medicine in general. I would request more time with a preceptor, that short of an orientation is almost setting you up for frustration and failure. Just my opinion tho if you feel youre comfortable then thats all that matters

alyiana · Aug 11, 2012

Thanks. Once I'm "own my own" I know I will still be able to ask the other nurses for help. We will have one nurse for each hall, and then a night supervisor/admit nurse who has been the one training me, so I know she'll still be able to help answer my stupid questions. They said that they expect me to "feel like a fool" for a while, and if I don't they will be concerned about me. I'm grateful for the fact that I have 2 experienced CNA's and a Med aid, so I don't have to pass meds, and I don't have to worry about little things like getting my patients to the meals. While I know I always have to keep an eye on it, and help them when necessary I have that one less worry.

I'm working 2nds and for the past 2 nights even with help I didn't get out of there til 2 hours after my shift was supposed to be over. (Though I'm sensing this is normal).

What about documentation? I'm worried about that.

AngelRN27 · Aug 11, 2012

I, too, am a new grad RN without prior Nursing/Medical experience and also just started working at a SNF (Skilled Nursing Facility/Nursing Home)... The responses to your post were very encouraging. This evening will be my 7th day on the job, but my first evening (second/3-11) shift. I agree with one of the responses that three days sounds like too short of an orientation, but I guess that depends on the nurse, the facility, and the patient population.

From my first week at work I have learned that joanna73 is right-- learning the residents' tendencies and behaviors is the meat and potatoes of this type of job and will take a while. It amazes me how the staff at my facility knows each and every resident so well! They know when they prefer to woken up, what type of assistance they need, etc.

I wish you luck!

al586 · Aug 11, 2012

May I add to the excellent advice you have already received? I'll probably forget a few things, but hopefully some of these will help you.

When coming on shift, here are a few things I do, many of which can be done in report. After a while, many of these steps won't be necessary, as you get to know the patients...

Check the lab books to see who is having labs done that day.

Check my B&B list, to see who may need MOM, enemas, etc. (I also write a reminder to check for results)

Note needed, outstanding & pending orders

Check the calendar for any resident appointments out of the facility.

Find out who the diabetics are, and how often they get accuchecks. (They are often the first people I go to on my med pass.)

Note how each patient takes their meds - crushed, whole, or whole in applesauce. (I prefer applesauce to pudding, as I have a few lactose intolerant patients.)

Note which patients leave the unit for meals, and time their meds & treatments accordingly. (They are also top of the list on my first med pass.)

Stock my med cart, if necessary. It never hurts to add some extra Thick-it, alcohol wipes, gloves, skin prep, and so on.

After my first med pass, I do some charting, new orders, & check the treatment book. I then start my second med pass & do my treatments.

Of course, space must be made for new orders, unexpected complications, and so on. But the basic prep at the start of the day seems to help my day go more smoothly. I hope this helps!

alyiana · Aug 13, 2012

Thanks. Yesterday, my last day of orientation, I worked with a nurse who had worked many doubles during the week, so she was tired and pretty much let me take over. What I did was take a piece of paper and wrote down which treatments needed to be done during the shift and which ones needed to be done at a certain time (particularly accuchecks), and which meds were due when, at the same time I flagged my MAR. I don't have a whole lots of meds to give as the Med Aid (best asset ever), gives the majority of them.

Any tips on assessments and documentations in LTC?

joanna73, BSN, RN · Aug 13, 2012

Re: documentation: usually charting is by exception in LTC, so anything out of the norm for that resident. Were they up frequently during your shift for some reason? I chart PRN narcotics or antipsychotics given. I won't bother to chart PRN colace or something like that. If the resident has a UTI, I will chart how many times they voided during my shift. Falls need to be charted as well as a near-miss. Check with your facility about fall protocol. Generally, make your charting concise, if you expect to leave on time.

alyiana · Aug 13, 2012

Joanna: I wonder if many of the nurses do extra charting then. I work a 2-10 shift and I stayed to 11:30 and 12:15 charting. One day one of the nurses I relieved didn't leave til after 5! While I do know that was on the Medicare hall which has extra charting, and every patient has to be charted on every day, so it's a lot more. I think that might be what's scaring me.

I think the other nurses try to chart on if anything is out of the norm, like if they are on ABT therapy for a UTI or if they have a wound on their leg or something of the sort.

I guess a lot of "out of norm" I'll realize once I get more comfortable with my residents. I haven't had the same hall more than once, but I think starting Tuesday I'll be on "my hall" so I'll be more comfortable with the patients as I get to know them.

joanna73, BSN, RN · Aug 13, 2012

Wounds also need to be charted as you find and assess them. You will learn to use your discretion regarding what is, and what is not important. This takes time. Some nurses are efficient with their charting, some are not. It depends. Mostly, this will depend on the acuity at your facility.

alyiana · Aug 22, 2012

Thanks everybody for your help. I managed to get an extra couple of days of orientation and I feel like it was just what I needed. I ended up with a different nurse who really could explain things better to me. I've now officially had 5 days on my own, and they went smoothly. Though I will say now sometime this week all the nurses will have an in-service on incident reports, and I feel like I had something to do with that because I had to fill out several. (Not that anybody else could help me more than I was stumbling through myself). I've been on the same hall each time, and I'm starting to get to know my residents and what they need each shift and how best to manage my time. I know several other nurses do things in room number order, however, I have started to organize by which residents go to bed first, because it ends up saving me time from having to wake up the residents. There is nothing like having a resident refuse an important medication because some strange new face woke her up from a deep sleep telling her she needed to take medications. (I would probably refuse there too).

Anyway, it's starting to go smoothly, and I can manage the day to day stuff pretty well. It's just when something out of the ordinary happens that I have to look around the nurses station to see who looks the least busy.