Speedy med pass

SleeepyRN · Mar 11, 2014

Second shift: Don't have to go to bed at night don't have to get up in the morning. You have all day to work out, take care of personal business. And? The managers leaves at 5PM, so the pace is relaxed? Heavenly, if single. Hellish, if you are not?[/quote']
There are benefits and downfalls to PMs. Im married, so I have an extra downfall. With up to 40 residents of SKILLED Medicare residents, I don't get out before 2:30am. Get home at 3am. Cant unwind from a difficult day of admissions and numerous physician orders (oh yeah, then there is patient care...eye roll). Can't fall asleep til 7am ish (just cant unwind) wake up at 2 pm to do it all over again. Zero time for a personal life, zero time for my husband.

SleeepyRN · Mar 11, 2014

I don't know any two nurses that do things exactly the same they all find what works the best for them. [/quote']
I can't stand it when residents say to me "Nurse so and so does it this way....gives me my meds at 8:15.....always brings my tylenol at bedtime (prn, sigh...of course I'm not going to know.) I could go on and on. The main nurse for one unit just moved out of the country so all the residents are feeling me out. One guy was furious day one because I didn't have his 6pm meds ready for him right after report. "Nurse so and so always gives me my meds at this exact time!" Sure, I'm learning their routine pretty well now, but I want to say "Do I look like nurse so and so? No? Then back off.

LockportRN · Apr 16, 2014

I initially found med pass to be slower with electronic MARs as well, especially on a busy rehab unit. Use a brains sheet, list out all of your BGM's and be aware of the time. Often the 'golden' hour before and hour after runs close to the next med pass time so you may be in the window to give out the next med if the times are within the parameters.

The best thing that happened was having the pharmacy look at med pass times and make them work better. Often, prior to this, I would have meds to give to a patient nearly hourly which was rediculous when you have 30 plus patients.

Best of luck, you'll get there!

spiderslap · Aug 21, 2014

I am in the exact same position, new nurse per diem. I feel doomed from the beginning of my shift. Its insane and difficult to not feel used by the facility who must notbcare about the results of such insane workloads.

garciadiego · Sep 1, 2014

Watch out for those short cuts, they usually lesd to errors.

musiQsoulbrother · Feb 1, 2016

interesting topic of discussion. i will leave my own tips and at the end list the once that i picked up from this forum (and other similar ones), and hopefully it will help someone.

i work at a LTC , with about 28 residents. my med pass starts at 9 am should end before 12 which is lunch time, but since breakfast ends at 9:30, i begin m pas at 9:30am, 30 minutes behind the time already.. Most times i complete minutes before 12 (on a regular day when i am being interrupted a lot)

with me its all about, finishing on time and going home, this includes med pass.

how to finish med pass quicker

Get to Work 30 minutes early
take a look at the schedule rooster and take note of who you will be working with , the cna's that are working with you and when at your unit make sure i get report and know who i am writing on, make a separate note so you can visit that, during my break time (yea work while you eat lol)

2. we get to work early so i can pre-check the residents that need vitals for meds, get a (working B/P machine) and check the resident b/p while i do my rounds, to get that out the way , or according to you facility policy, you must make sure your cna's have your vitals ready on time.

3. i count my narcs while while they are still in the bag, i hold it in their with one hand, pull it out, observe it and write on it. ( this makes it faster for me, might help you too, IDC)

(SIDE NOTE)

in the dinning room, make sure you collect the food tickets from all the residents, that you would be giving meds too, i learned that this helps me to give the meds to these residents faster, until you learn the residents by appearance, and the ticket also indicate who needs it chopped/mechanical soft, and this saves time

4. G tubes, can be a little tricky, some are backed up, some resident are uncooperative, so you must figure out a working system for you, you should be able to press the hold flow button give meds and be back before the machine starts beeping. message me if you need more info on this one (347) 560-0109

5. MOST IMPORTANT; the med pass

With The med pass, like previously mentioned, stock before you start, it cuts down on time wasted. so make sure you are well stocked with whatever you may be running out of.
on the first drawer of the cart, i clear up the center space in the front-center, enough space to fit a resident's batch of blister packs
this way when you need to look through it for a residents medication, it is all faced in front of you, you just flip through it, with one hand, and when you get to the right med, you turn it faced down sideways.
put your water to the far right or left and your cups the the opposite end.
place your MAR in the center or if you are lucky you are using a computer documentation (we not not so lucky yet!)

open the MAR
find a resident
read the medication needed
flip through blister packs , with one hand, and when you get to the med, you turn that blister pack faced down sideways.
or if it is a stock med, you should find it (it usually on the first drawer too)
after you have found and placed all the needed med on the table or turned sideways down, then you can start preparing the medications for that resident.
afterwards you then sign the blister pack, if its a new blister pack , you must include the date and your initial, if its not , just write the data
after giving the med to the resident, return and sign your MAR for giving them.

it seems little confusing , but that's my system of med pass in a nutshell, its effective. but with anything in life, their is variance, things that we cannot control. we try to avoid distractions unless it is emergency.

to avoid med errors

make sure you sign the Narc book as soon as you pop the narc. (very important), don't wait until after.
AFTER preparing a residents medications from the blister pack, as we return the batch of blister packs, into the cart, TURN IN BACK SIDE FACING us, so we can only see the white, this way , we can minimize the margin of error by a lot.

during your break

at the cafeteria, sit back with your 24 report, and start writing on it, for the residents that are on it, also write on the nursing report as soon as you can, leaving it flagged until you get your vitals to fill on it.

that's my little 2 cents,i hope someone got something from it. best of luck everyone.

other tips

make sure you catch the residents that comes around you, also if a resident is not around, prepare their med, pull out a tape, and write the resident name and room, and keep the med aside until you are finished, but most of the time, you will find them on the way to another resident, and you can give it to them then.
have your blister packs marked with a small red check mark in the right hand corner for easy identification for your shift's. It saves time flipping through all the meds. you just pull out those with the red checks and then double check that I'm giving the right med.
when doing med pass in the hallway, do it in z pattern, like do one patients room, do the next room, then a room across from it, then the next room, the a room across, doing this coupled with flipping the blister packs, will increase your med pass time by a lot, but the draw back is the use of a book MAR not a pc, so i guess the technique is best suited for pc documentation.
Pre-pour waters: set up like 4 or 6 cups of water at a time so you're not constantly pouring and you don't forget to pour water. Just don't forget to pitch the cups after they drink from them.
EAT BREAKFAST!! Seriously. When I first started on the floor, I never ate breakfast and by 8:30 I was sluggish and moving and thinking slower.
Do all your blood pressures/pulses/temps first so you know gets b/p meds and ABTs and you'll be able to assess who you may need to monitor closely for falls and possible calls to the physician that way you can prevent incidents from interrupting your pass.

sincerely

sam

NYC

MedChica · Feb 3, 2016

- Make sure the cart is stocked BEFORE you start. Rule #1.

- Make sure you've got mixed thicken liquid. It's a pain in the booty to have to stop and hunt down powder.

- Make sure you've got ensure and formula on the cart.

- Disoriented/Sundowning/Dementia pts? Go with the fantasy. Don't get frustrated with exit seekers. Be creative in your redirecting. "Let's wait for breakfast. Then you can go to work after you eat." ; "It's dark outside and everyone's asleep. Let's wait until sunup." ; "We've got a nice room for you over here with a tv in it. All paid for and everything. Let's come this way so I can show you where it is. They'll bring your breakfast to you."

- I like to manually flush but, in the world of auto-flush buttons, there's no excuse to not have well hydrated PEG pt's.

- During report, figure out your blood sugars and your crush/whole people. Also, make note of who needs BP/P and O2 Sat.

- Leapfrogging with the CNA helps create a buffer for the pt who likes to talk about everything under the sun.

- Get in the habit of using paper towels when you deal with PEGs.

- Give PRNs with the med pass if you know the pt will request it.

- When you pop a narc flip the card backwards & return it to its spot. When it's time to review the count, just go to the narcs that are flipped backwards. I never sign as I pop narcs. Slows me down. I pop and flip. When I've finished everything? I open the cart, search for flipped narc cards & refer to my notes to record the times of admin.

- Keep gloves in your 'clean' pocket.

- Skin tears happen. Keep some TAO & island/bandaids on the med cart or in your 'dirty' pocket.

- Temporal thermometers are quicker.

- Use pulse oximeter for pulse.

- Keep your wrist cuff and pulse oximeter within reach. Steth, too, but it can stay on the side of the cart if yours has a carrier. At one facility, we're told to record manually. No one does. I certainly won't get on here and lie as if I do.

Whatever. You're not going to be doing manuals for routine BID/TID vitals unless the numbers are out of range or change of status. Other than that, you'll have to take more scheduled BP/Ps than you will listen for bowel and lung sounds.

- Recognize a potential situation and head it off:

a. Skim through the blood sugars. 0630 b/s (recorded at 0400, most likely, and it's a lazy nurse so they don't think to give the pt anything to maintain glucose levels) of 70. It's 0700. Think you should go look over the pt or recheck the blood sugar? B/S of 210 recorded at 2445. 0200 B/S recorded @ 97. S/S begins at 200 so they didn't rec'v much insulin. Think they're dropping to quickly? Think you might want to keep an eye on them? Think a little glucatrol...or OJ or a shake or sandwhich and milk might help?

b. Alarm going off? Answer it. You can keep a lot of people off the floor that way.

c. Family member that you've never met comes in & everyone's talking about how they're such a huge pain in the booty. Don't duck and dodge them. Remain cheerful and available. You've gotta make a good first impression or they'll sit and nitpick and create problems for you the entire shift. I've seen it. With "problem" visitors, being proactive always works for me. That family member may not be what others say they are anyway. Could've had a bad day. Could've dealt with rude nurses/aides. You never know. I

d. Fall risk/wandering/elopement with combative tendencies on 1x1 presently seeking an exit to "go to work" dragging the CNA up all over the facility. Potentially combative pt looking especially volatile this morning with raised voice and pressured speech and all the distracting/redirecting in the world isn't working. As soon as you get on the cart pop those PRNS. Ativan, Geodon, xanax, apap, etc....

Anyway, behaviors escalate with time. Redirection doesn't always help.

Medicate "now" and you won't have a situation to contend with "later".

Medicate "now" and you don't have to scrape them off the floor "later".

It's about keeping them calm and safe...and uninjured (and out of handcuffs for assaulting staff)...and in their home. Too many incidences and they'll eventually be put out of the facility. If yours is one of the few geripsych places available, where will they end up? Jail, maybe.

No joke. This happened to a former pt of mine. The facility didn't 'put him out'. His stupid ass daughter took him away from us and put this 63 year old low-impulse control having occassionally psychotic man (who couldn't even watch the news at times because it gave him homicidal ideas. Seriously. He came to me contemplating murder/assault of another because of something happening on tv. Had to talk him down,buy him a soda and pop some ativan.) in an ALF. Well, he set it ablaze one night according to the local news. Now, he's in jail.

The aides and nurses where I worked were just like, "Well, what the hell was he doing in an ALF in the first place?"

Of course, he should be taken to task for breaking the law and endangering lives. He just doesn't belong in jail. He's (mentally) ill and, literally, "knows not" what he does, at times.

- Don't memorize unless you're writing every order.

This is what I call 'thin line' corner cutting that is typically done in real world:

- Start medpass earlier. Hit the PEGs and trachs early.

- Lots of bolus feeds/PEGs and you're running late? Push it. Same goes for combative (MR, disoriented) pt's on PEGs. Push it. Clamp the tube, draw up two syringes of water and push them through. They're fed, medicated, hydrated & the line is patent. Win-Win for the shift. I wouldn't let an Ax0x1 or disoriented and deluded pt lay in filth or refuse to bathe so I won't have them refusing anti-HTNs, ABTs, anti-anxiety and psych meds. If they have a psych dx, you already know that redirecting has it's limits & continuous refusals of important meds only hurts the pt in the longrun.

- Med noncompliance. They're AXOx2 or manic/schizo/disoriented and getting loopier by the day? Crush up important meds (throw in any ordered sedatives), add a bit of water. Put in microwave for 5-10 sec. Mix in coffee, juice or shake and serve.

- Always add crushed meds to HOT food and salads with creamy dressing.

- Throw the albuterol in the nebulizers. The pt will get to them. Just remind them.

- I'll check PEG placement once a shift. Good enough.

- A/Ox3 to 4 residents may be happy to have you place their meds at the bed side. Especially, if they don't like to be awakened or bothered. Just check to ensure that they've taken them. Warning: Don't leave meds unattended in the room.

- Do 0630 accuchecks at 0400. Just don't give the insulin unless longacting. You don't want them crashing out on morning shift.

- Pass creams/groin/abd fold powders to the aides. Just be aware that these are medications and technically a CNA can't administer. Do I use them to administer, anyway? Heck, yeah. They can throw on nystatin when they're changing them.

- Jevity 1.2 (for instance) out for continuous feed? Crack open some cans and pour it in the bag. No one has time to be doing bolus feeds on 6 residents.

- Heavy number of PEGs/Bolus w/hordes of meds BID/TID/QID? I will give every OTC (and once a day med) that I can on the first feeding/administration. You really can't bypass most OTCs. They need their iron and vit d. They need their protonix, lactulose & pro/uri stat. They need their eye-drops. They need their neb txts. Gotta give it.

- Sometimes, benadryl helps...

ktwlpn, LPN · Feb 3, 2016

A couple people have suggested pre-pouring....NEVER PREPOUR.It is against the regs and it's dangerous.Don't preload juices or water,either....That leads to a big mess when a resident or staff member bumps your cart.

Hoosier_RN, MSN · Feb 3, 2016

One nurse has given me a lot of ideas. He went through and labled the names and room numbers clearly with a sharpie and index tags that stick out a bit further than the traditional ones. he has found green friendly clip tags wtih bright colors. AM pass is green, Aft pink..and so on. Scheduled blood sugars for noon or am, Single scheduled narcotics or meds that need to be given alone or at 7:30 a different color. At first it seemed confusing and time consuming to set up so I had my doubts, but as he flipped through he just popped em in.
It's a real help when someone has to step in (like relieving for lunch or helping out while he does an admission or deals with a fall or sudden illness requiring an RN. The other thing he did was use a sharpie to clearly label seperate stock meds or individual pt meds. He uses a label maker for the caps that have the raised bumpy printing on them, or in a pinch silk tape. I know he has to spend a lot of down time doing this, but he says he just did one or two things at a time.
When stock meds run out the next nurse just peels the label and sticks it on the new bottle. Thanks to him, life is soooo much better. Oh yeah, he also writes the Pt's name in Sharpie pen on top of the med cards so it's easily spotted in a crowded drawer, and has clearly marked room numbers on the dividers, broken ones are retired. A wrist and manual BP cuff are in the bottom drawer with an extra stethoscope.

While these ideas sound good, unfortunately, if there is an order change, can set you up for a major med error. Never mark on med cards, as many pharmacies will not accept as returns if D/C'd. Just my experience anyway. In fact, it's a tag from state surveyors if they find this in my area

CapeCodMermaid, RN · Feb 6, 2016

1. NEVER prepour. It's dangerous.

2. Writing on the blister packs is against regulations

3. Ask your pharmacy consultant to look at med times to consolidate the pass....don't have 8,9, and 10 o'clock meds...give them all at 9 unless contraindicated

4. Speak to the docs about getting rid of parameters on long term residents with stable vital signs AND talk to them about unnecessary meds....NO ONE needs 4 vitamins and people over the age of 85 really don't need statins

Adele_Michal7, ASN, RN · Feb 6, 2016

1. NEVER prepour. It's dangerous.
2. Writing on the blister packs is against regulations
3. Ask your pharmacy consultant to look at med times to consolidate the pass....don't have 8,9, and 10 o'clock meds...give them all at 9 unless contraindicated
4. Speak to the docs about getting rid of parameters on long term residents with stable vital signs AND talk to them about unnecessary meds....NO ONE needs 4 vitamins and people over the age of 85 really don't need statins

I was going to say, I have never heard of anyone signing a blister pack. The only time I encountered that was when a former DON was trying to catch someone not give medications...

guest114 · Feb 7, 2016

This appears to be an old article but something I am dealing with as my first year in long term/acute care. I float and some days my medpass is very heavy and always brand new to me. Today I had nearly 30 residents with heavy meds and treatments... I'm used to floating so I managed to get it done but it was NOT easy. I had to use all my skills to get it done.. The patients acuity varies so greatly from dementia to gtubes and IVS... I was glad to hear I "did better" than the new RN they recently hired for this unit but I feel sorry for anyone who has to call that their full time position . Unfortunatley, I haven't had a lot of guidance from co workers.. A lot of mean nurses , I have learned to keep to myself but being left hung out to dry has made me learn quick also. I have made myself a clip board I bring to both of my jobs with cheat sheets of anything i need often : ICD-10 codes, how to enter orders in different systems , which numbers docs prefer to be called on.. Anything for an easier shift. I also jump on my treatments while pts are still in bed, because once they are dressed... Chances are your not getting to that sacral or inner thigh dressing. Same with eye drops. I go around between 7 -730 and do all this plus insulin/sugars. I am able to get familiar with my MAR/TAR this way and can do rounds before night shift leaves if I have questions...