Please help! Questions I haven't read here yet....so curious!!!

RNBearColumbus, BSN · Mar 1, 2013

Hi, I've read lots of threads here and they are very helpful! I am considering a position in LTC and I'm skeeeeeered! I am SO used to having my own "little" group of patients, and I like to know EVERYTHING that's going on with them! Well, here are some questions I am just dying to know!!!
1) I read here about people passing meds to a gazillion patients----ON TIME---which I give you major kudos for! My question though------what about the crushing, the ones who need to take their pills sloooowwwly and one at a time, what about all the thickened liquids. Is it written on your MARS to remind you?
Yes, usually this is in the MAR. I'm assuming that you will get some sort of orientation period on the unit. The nurse you are orienting with should tell you which residents have special needs with medications.
2) What about full report on EVERY patient you're responsible for....I have to assume you don't get report on ALL your patients-- just significant changes/ issues? And if not, how do you know what's going on with them? What if the doctor(s) / family ask "how has Mom/ Dad been this week?" (I realize I can read the chart, but I am so used to the hospital where you get details of their day---I know, I need to get OVER that! LOL!)
If you are on a skilled unit, you should get a report on each patient. But if you are on a long term unit, most of the residents are stable. You really only need a report on people that have had significant changes, or are receiving specialized treatments like ATBs, IVs, or have some other medical condition that is out of the ordinary for them.
3) THis is a biggie for me----what about all the patient's ins and outs? As their nurse, I NEED to know how much they're voiding, when was their last BM? (I saw this getting missed A LOT where I used to work, (again, this wasn't LTC)....sometimes after having
to go back through the chart and looking at I & O, I'd discover it had been a week since their last BM and nothing had been done----. I don't want these sweet people being uncomfy/ getting impacted. It sounds as though there is just NO TIME to check all of these things when you have 20, 30, 40 patients!?!!
Your CNAs/STNAs should be recording BMs and voids someplace. In most facilities these days it's in a computer system from which reports can be generated and those residents not having a BM in 2+ days are identified, and appropriate intervention can be given. Rely on your nursing assistants. They are your eyes and ears on the unit.
4) When you have a brand new admission, do they arrive with info on how to transfer them safely and/or how MUCH assistance they need? This is also a biggie for me----we need to know that BEFORE they're admitted! Do they usually arrive with orders for everything, or do you find all of that out later when you call the doc?
Most hospitals sending you a patient will send information that includes the meds the patient is on, what assistance they need with ADLs, and any special instructions. The GOOD hospitals will call with a report just before the patient is discharged. That is your opportunity to ask questions, and get information that might not be on the discharge paperwork.
5) Speaking of admissions, (and discharges!).....how would you possibly have time for all of that when you have 15, 20, 30 other patients?
It's possible. Remember that in LTC/SNF, the majority of your patients will need nothing from you other than medication and maybe a dressing change. And that's OK. You will not be able (or expected) to do a full head to toe assessment on every patient. There will be a few that require more attention, but they will be a minority. It's absolutely possible to give great care even with what might seem to be an outrageous nurse patient ratio.
I LIKE being busy, and I don't mind working hard, but I just cannot fathom how anyone can do this!!! I am REALLY trying (and praying!) to have a positive attitude and stop worrying about every. little. detail. I truly love the elderly and WANT to give them the best care possible!!!! Thanks in advance!

My responses are in bold above.

Like I said, it's possible to give great care even with a 30:1 patient:nurse ratio. I do every day. As a new nurse or a new nurse to LTC, it may take you a while to get a routine down and learn the unit, but once you do, I'm willing to bet that you will love LTC/SNF nursing.

Good Luck!

CT Pixie, BSN, RN · Mar 1, 2013

1) I read here about people passing meds to a gazillion patients----ON TIME---which I give you major kudos for! My question though------what about the crushing, the ones who need to take their pills sloooowwwly and one at a time, what about all the thickened liquids. Is it written on your MARS to remind you?

No, its not written on the MAR. What I did as a new LTC nurse was ask the nurse giving me report to tell me how the pt took their meds (whole, crushed (and what food did the pt refer the meds in ie:apple sauce, pudding, shakes etc).

2) What about full report on EVERY patient you're responsible for....I have to assume you don't get report on ALL your patients-- just significant changes/ issues? And if not, how do you know what's going on with them? What if the doctor(s) / family ask "how has Mom/ Dad been this week?" (I realize I can read the chart, but I am so used to the hospital where you get details of their day---I know, I need to get OVER that! LOL!)

We go down the report sheet and it goes something like Mr Jones, he's fine today nothing new, Ms Smith nothing new, Mr Brown has had a wet congested cough the last 3 shifts, Ms White had a CXR done earlier and we are waiting on the results....etc.

3) THis is a biggie for me----what about all the patient's ins and outs? As their nurse, I NEED to know how much they're voiding, when was their last BM? (I saw this getting missed A LOT where I used to work, (again, this wasn't LTC)....sometimes after having

to go back through the chart and looking at I & O, I'd discover it had been a week since their last BM and nothing had been done----. I don't want these sweet people being uncomfy/ getting impacted. It sounds as though there is just NO TIME to check all of these things when you have 20, 30, 40 patients!?!!

I&O's are done by the CNA's and placed on the I&O sheets we have, if they are on I&O (remember not everyone is having every ounce counted) the nurses chart it in the proper placce (My facility is computerized charting so we have a special section for that, also, its listed in the TAR so that it cues you to chart on it), the BM issue is the same way, each shift the CNA will mark on the paper if there was 0, 1, 2, 3 etc BM's and the size (xsm, sm, med etc) We follow the BM trend and see who is in need of what, the nurse reports it to the nurse who will be doing the MOM, etc. That nurse then does the med and if no results reports to the next shift and they initiate the next med protocol.

4) When you have a brand new admission, do they arrive with info on how to transfer them safely and/or how MUCH assistance they need? This is also a biggie for me----we need to know that BEFORE they're admitted! Do they usually arrive with orders for everything, or do you find all of that out later when you call the doc?

We get the transfer info from the hospital if they come from there or if from another facility. If they are admitted from home, we have a PT eval done before we let them walk ad lib etc. They normally have orders that come with them from the hospital and we call the doc and give them the meds, they approve or disapprove the meds, we then enter the med orders.

5) Speaking of admissions, (and discharges!).....how would you possibly have time for all of that when you have 15, 20, 30 other patients?

Ohhh admissions or discharges are wonderful (hear the sarcasm!). They are normally admitted on MY shift 3p-11p. With my first admit I was in near tears, I thought I'd never get done, but you learn what needs to be done ASAP, what can wait etc. As long as my admission charting was done by 11pm it was all good. We never had any discharges on my time, (discharges home or to another facility etc) but we would send them to the hospital from time to time and it was easy enough since we are computerized, we could pull all the paperwork needed for the transfer and send it w/the patient so the nurse at the hospital had all the info needed, we would also call ahead to the ED to let them know what/what we were sending to them.

At first LTC can be very daunting, but after you settle in, it becomes routine.

You say you are more comfortable with your little group of patients that you know everything about...guess what, in LTC you have the same pts day in and day out, you truly know EVERYTHING about them and whats going on with them. Moreso than when you are with them in the hospital.

WittySarcasm, BSN · Mar 2, 2013

Hi! I had to add my input too with these questions! I started out in LTC and have been here for about 2 and half years- so while I'm still new-ish I have learned a lot of little tips that help!

1) I read here about people passing meds to a gazillion patients----ON TIME---which I give you major kudos for! My question though------what about the crushing, the ones who need to take their pills sloooowwwly and one at a time, what about all the thickened liquids. Is it written on your MARS to remind you?
With our MARS there are FYIs of pills may be crushed and so on, but these are not always up to date- a person may take her pills whole one day and a week later end up needing it crushed to make it easier. What I do instead (if it's not my normal unit or someone new) is ask the nurse I'm getting report from to just tell me how they take their pills. Some are annoyed when you ask, because they wanna go home as badly as you do at the end of your shift. But it makes it so much easier.

One good tip I give is if you know someone is going to be slow at their pills. Like if it's the 8pm pass and you know Mr. Smith takes 10 pills and must swallow each one at a time. I usually will save Mr. Smith for last. I know it may seem stupid but then at the end of my pass if he wants to take 20 minutes then he can. I'm not standing there hopping from foot to foot wishing he would go faster.
2) What about full report on EVERY patient you're responsible for....I have to assume you don't get report on ALL your patients-- just significant changes/ issues? And if not, how do you know what's going on with them? What if the doctor(s) / family ask "how has Mom/ Dad been this week?" (I realize I can read the chart, but I am so used to the hospital where you get details of their day---I know, I need to get OVER that! LOL!)
Ok this depends on the unit. If you are on a strict LTC, meaning grandma's new home is here and going to stay here. Then normally report is really fast and will only talk about any changes- medical or mental; or what to look out for if someone is suspecting something.
Now if you are on a more skilled unit or rehab, report will usually be the same. If there's no changes the report will be just that. But skilled and rehabs have more chances of new patients. So report will then be longer.

If you are new to the unit the report will be a little more in depth, if not just tell them you don't know their baselines and would love to know them.
3) THis is a biggie for me----what about all the patient's ins and outs? As their nurse, I NEED to know how much they're voiding, when was their last BM? (I saw this getting missed A LOT where I used to work, (again, this wasn't LTC)....sometimes after having to go back through the chart and looking at I & O, I'd discover it had been a week since their last BM and nothing had been done----. I don't want these sweet people being uncomfy/ getting impacted. It sounds as though there is just NO TIME to check all of these things when you have 20, 30, 40 patients!?!!
CNAs do the I/Os. They will chart it on a board that then the nurse will write on the chart. Usually on a strict LTC unit they may not have very many on I/Os. I'm thinking of ours and there are not very many. Mainly people with medical reasons or those on tube feedings.

For the BMs the CNAs will write on a board for every shift this board is always where you can see it. What I do is before I start my med pass I look over the board quickly, write the names of the patients that haven't had a BM for 3 days (which is our facility's policy) and ask the CNAs to report if they have one during the shift. If not, then towards the end- usually after dinner at least- I give them something to help them go.
4) When you have a brand new admission, do they arrive with info on how to transfer them safely and/or how MUCH assistance they need? This is also a biggie for me----we need to know that BEFORE they're admitted! Do they usually arrive with orders for everything, or do you find all of that out later when you call the doc?
For admits I always make sure the hospital calls me report. If they don't I will contact them as soon as the patient comes to my doorstep and ask for the nurse so they can give me report. During report I ask any extra questions they don't tell me. Like- can they transfer good? Fall risk? When was their last BM (this is really helpful I found out)? What is their normal- if it's normal for them to yell at a white wall then I won't worry. Last set of vitals? And the most important, did they have any PRNs and what time? Because if they can talk the first words out of their mouth is ALWAYS I want my (prn).
5) Speaking of admissions, (and discharges!).....how would you possibly have time for all of that when you have 15, 20, 30 other patients?
If you are strict LTC unit there usually isn't that many admissions/discharges. However what I have learned with admits is to do the most important parts. Admissions at our place is a 24 hour process, so I will save shots (who wants their PPD, flu and pneumonia at night?!) for the next shift or dayshift.

Actually instead of saying what you pass on it's easier to give the order how I do it. Once I get the Dr.s ok for the meds I write up the MARS first. Then we have copies of generic ADLs that I make a copy of and give. If there are any extra things I have to add I will write them in. Then when I introduce myself I will just then do an assessment, you can tell a lot from just talking to them. While the CNAs remove all of the ambulance/transport company's sheets and blankets and get their vitals I look at their skin. Save all the notes for when you do your charting. Don't try to write the notes as soon as you get the person, it kills your med time. You will have a little down time druing the med passes- and that is when I do the notes or that I'll do the assessment of the new admit.

Discharges, at least at our place, are never last second unless they go AMA. Otherwise we normally know about it a couple days in advance, therefore I usually end up working on it during my downtime. (I'm perm on one unit so it helps)

I'll be honest. At first you will be behind, you will see other nurses hurry along and get done before you. You will be scared. I'll be perfectly honest. When I first started I would shake while at my med cart. I would run myself ragged and still never seem to get done on time. I remember at one place the next shift got so mad that I was behind that they took my med carts from me and just passed their pills and mine.

But at the same time, as you get experience you find the little helps that get you through your shift. Tips that we give may hinder you but you may find your own that makes your shift fly perfectly. And before you know it, you'll have it down.

WittySarcasm, BSN · Mar 2, 2013

I also forgot to add, that I keep papers in my bag. Like the generic ADLs- there's no patient names or anything like that. So I keep a copy in my bag in a folder. If you find that there are any forms for admits, discharges, ect. that are useful to always have I suggest keeping a copy in your bag/locker wherever. It may sound weird but it will help.

I can't tell you HOW many times I went to grab a copy of the generic ADLs or something and find it file empty, along with the master. Just because it says MASTER in yellow highlighter doesn't mean someone won't just grab it and use it.

Hunting down the forms kills your med pass time. So instead I got to the point that I keep copies in my bag, they all are name-less so it doesn't violate HIPPA. If I find the file empty I just go to my bag and pull out what I need and make a copy for the new Admit/discharge. Or better still keep 2 copies in your bag so you can just grab the one copy and carry on.

RN 033 · Mar 2, 2013

I finally got a job after two years searching at a LTC / Sub-acute facility...I go home each morning (night shift) skeeeered! First nursing job, three weeks in and I'm responsible for 60 residents and two CNAs, and no....they don't all sleep all night! Honestly, I fear for my license most days. I'm so tired when I leave, but stay awake remembering little things and sometimes big things that I didn't do 100% correctly. As the night wears on, the mornings often turn into nightmares. The witching hours are usually between 4 am and 0630, just when I start to go brain dead from having only 4 hours of sleep each day that I work. I purchased malpractice insurance as a possible buffer if sh8t hits the fan someday. I don't really feel like I have another choice other than bankruptcy and hey, that won't cover my many thousands of dollars student loans that are due. I love the "job", the residents, their families and fellow employees. There hasn't been a DON at the facility for over 7 months and I feel like I'm walking on jello. This is NOTHING like what I trained for in an acute hospital clinical setting. My head is spinning! I'd love to run, but there's nothing to run TO. I would be back looking for the elusive New Grad position that I've searched for the past two years. I can only hope to provide the safest and best care possible while flying under the political firing radar until I gain enough experience to either feel comfortable where I am or move on to greener pastures.

gabulldogs · Mar 3, 2013

TEAM WORK. Hopefully you are able to get employeed with a LTC that actively portrays this ethic.

nervousnurse, ASN · Mar 4, 2013

THANK YOU, everyone!!! This has been SO helpful!

Oh, and "WittySarcasm"---about keeping copies of blank forms with you---what a GREAT tip!!! I have actually done that before---it is SO annoying that people will take the LAST one of any form without at least making a couple copies!

RNStrong---I hope it gets better for you!!!

There is one MAJOR thing that makes me VERY VERY happy to have this new job---the DON has been there many years and said she LOVES the patients and wants them to get the care they DESERVE.....

The DON also said she LOVES her employees, and I believe she was sincere about that! I have NEVER had a boss say she "LOVED" her employees! While we were interviewing, a couple very CUTE residents and one of the resident's wives came by just to chat with her....

The nurses were VERY busy, (of course!), but I saw LOTS of smiles on their faces, LOTS of kind interacting with the residents, and more importantly, I saw LOTS of residents smiling, too.

LOL, my very first job was in Pediatrics....my boss would LITERALLY walk by, I'd smile and say "hi", she'd look us straight in the eye, and NOT say hello--- that's just WEIRD. Back then, I took it personally and it hurt my "feelers"! LOL, ohhh, now I would just laugh!

Sorry, but---here is a professional nurse (the boss) who had a great staff, and I don't care HOW stressed out someone is, they can say "HELLO" to their employee, even if it's not in a friendly way.

"gabulldogs".....YES! Where I used to work, we had GREAT teamwork---I pray we'll have it at my new place, too. I am willing to help ANYone with ANYthing when I can....wouldn't it be the perfect world if EVERYONE was that way?

I am SOO happy! I had considered taking a job at another SNF/LTC, but I just had tooooo many doubts---at this other place, I felt at "home".....I cannot WAIT! :) I'm going to put my running shoes on, plus, I am determined that I can do this and have a positive attitude (NOT saying I won't have hard times, of course!) :)

At my last job, I didn't mind "running" for 12 hours with very little or NO breaks. But, I did NOT like the fact that I had NO time to chart, so my shifts were usually more like 14 hours! (thank goodness they did NOT mind if we stayed late to chart---they KNEW there was no time to chart, and YES, we got paid for every minute!! We also got paid an additional half hour if we didn't get a REAL break, which I give them a lot of credit for...I wonder how many other places offer that?)

That was another reason I sought LTC/SNF---EIGHT hour shifts---thank you, Lord! I feel like I can do ANYthing for 8 hours---but 12- (actually FOURTEEN!)---no way!!!

BrandonLPN, LPN · Mar 4, 2013

How a resident takes their pills should be written at the top of their MAR. Third shift writes that sort of info at the top during end of month changeover.

In most LTC facilities you don't need report on every resident. Do you really need to know Mrs Jones went to bingo and talked to her granddaughter on the phone? Anybody with anything going on should be written on some sort of 24 hour board.

There should be some sort of daily bowel care log. The third shift nurse should review the CNA flow sheets and initiate bowel care for the other shifts to follow up on. If ts made part of the daily routine it's easy peasey and never gets missed.

Good facilities will have the unit manager process admissions. Crappy facilities will make the floor nurse do it and interrupt the med pass.

CapeCodMermaid, RN · Mar 5, 2013

All nurses need to participate in the admission process.

withasmilelpn · Mar 5, 2013

Ok - I've been fortunate to bounce around a bit over the years and have seen how different facilities handle admissions. The best, hands down smoothest ones were facilities with an 'admission nurse' - the most chaotic were the ones that 'all nurses' take part in. I always felt when I was the admission nurse that it was the safest - I could go through the chart uninterrupted and would pick up those pesky details buried in the chart - an allergy listed on one page out of 25 that of course wasn't on the face sheet (more common than you think), the length of that PICC, ALL the dx - again not on the transfer sheet, review the labs - and medications - totally be on top of what I needed from the doc in advance.

Besides being safer, I knew I could give all my attention to my admit, making them welcome, orienting them and getting them settled and comfortable, do a thorough assessment and history, talk with their family, much more than when a rushed floor nurse with other patients.

First impressions are important, I think facilities that make admissions a priority are more likely to have a better reputation than those that don't.

The facilities with a lot of nurses with their hands in admissions typically miss info, drop the ball with certain parts of the admission because no one took the responsibility to get it done, or assumed it was done, etc etc

But that's just my experience,

gabulldogs · Mar 5, 2013

How a resident takes their pills should be written at the top of their MAR. Third shift writes that sort of info at the top during end of month changeover.
In most LTC facilities you don't need report on every resident. Do you really need to know Mrs Jones went to bingo and talked to her granddaughter on the phone? Anybody with anything going on should be written on some sort of 24 hour board.
There should be some sort of daily bowel care log. The third shift nurse should review the CNA flow sheets and initiate bowel care for the other shifts to follow up on. If ts made part of the daily routine it's easy peasey and never gets missed.
Good facilities will have the unit manager process admissions. Crappy facilities will make the floor nurse do it and interrupt the med pass.

Well said. We (floor nurse) trying to make management aware but no changes so far.