There's a Mousetrap In My Med Cart
As some classmates in our RN nursing program gathered around in a small group this morning, I sided up and listened to a story that quickly carried me back in time when I was a newly licensed practical nurse (LPN) just learning how to manage my time as I passed the early morning medications.
As some classmates in our RN gathered around in a small group this morning, I sided up and listened to a story that quickly carried me back in time when I was a newly licensed practical nurse (LPN) just learning how to manage my time as I passed the early morning medications.
The law requires that all meds be given within one hour before or after the medicines are due, and this often creates a lot of stress for busy nurses. For instance, the 8 a.m. meds can be started at 7 a.m., and the med pass, for however many patients you are assigned to, must all be given by 9 a.m., or the facility you work for is out of compliance with state regulations and subject to censure.
Many of my classmates have recently gotten their LPN license and are now RN students. They have not had experience with passing medications or time to learn some tricks of the trade that come with years of 'working the med cart'.
The story this morning was told with tears streaming down my classmate's face that expressed more than words could ever tell of how disappointed she was, as a student nurse, to have not completed the assigned task of giving meds to her 17 patients in the two-hour window of time.
Ah yes. I had to turn away as I could not keep my eyes from swimming with empathy while my heart filled with understanding.
Her story will be repeated every day by many nurses, especially LPN's.
I call it, "A Mousetrap in My Med Cart".
My fingers are burning to tell this story in hopes that other nurses will feel better knowing that many of us have felt the pressure of that ticking mousetrap in our carts!
...Wishing the tired, sleepy, night nurse would hurry it along, I heard report on my patients just like I did at the start of every shift at the nursing home where I worked 7 a.m. to 7 p.m. three days a week.
There was a new admission in Room 5. The patient in Room 10 had fallen during the night and would need vital signs and neuro checks every two hours. Room 11 had ants crawling along the window that would need spraying today. There was a new patient in Room 13 who wanted pain pills more often than she had them ordered.
Time was ticking, and I knew the mousetrap of time would be set in my med cart on the dot at 8 a.m. I wanted to have my blood pressures taken before I started my med pass. I hoped I would have time for a quick check on each of my patients by then too.
As I prepared my cart and checked for supplies, a tiny little mouse scampered beside me when I ran to answer the phone from an impatient doctor who wanted to leave orders 'with the medicine nurse'. ...At least the patient in Room 13 could have her pain pills more often now.
I had 19 patients this morning, and the first patient had to be wakened from a sound sleep.
"Why do they wake you up to give you sleeping pills?' she grumbled.
"I need my pills crushed in applesauce," she said in a more agitated voice as she almost threw the pills back at me.
Back at the med cart, I was somewhat confused because two of the meds were enteric coated, meaning they should not be crushed. I wondered what the other nurses were doing about that. Maybe I could convince her to swallow them whole if I did some patient teaching about enteric-coated pills.
In the next room, my patient was sound asleep, but I did not have to disturb him because he had a gastric tube (G-tube) and was on constant tube feeding. My problem was that his powdered medication would not dissolve in water! I stirred and stirred. I added warm water. Maybe it would dissolve while I did a placement and residual check of the tube. But no, the powder continued to float on the top of the water. Finally, I just poured the mixture into the tube syringe - and it promptly clogged up!
Just then his wife stirred from her sleep in the chair and said, "You have to mix it with hot water first." Why hadn't someone just written that on the medication record? Now I had to spend several precious mousetrap-ticking minutes unclogging the G-tube!
"Please help me to the bathroom. I'm going to mess this bed if I don't get to the bathroom," my next patient begged.
By law, the medication nurse isn't supposed to be helping patients to the bathroom while passing meds. But tell that to someone who's holding the back of their gown and slipping off the edge of the bed. I turned on the call light and felt that mouse getting bigger as it ran down the call light string toward my fingers.
Due to a sleepy, slow-voiced, night nurse who took 45-minutes to give report, I hadn't had time to check any blood pressures, and my next patient had a medication that was certain to lower his blood pressure very effectively and quickly. I would not give this med without checking to see if his blood pressure was already low.
Shucks. It was 80/40. Too low for the medication. Too late, I realized I had put this pill in with his other meds, and now I had to figure out which one it was AND make a place to chart the low blood pressure because no one had done it before now. I also had to chart why I didn't give the medication. And, I had to do another patient teaching about this medication to the patient when he got upset because I held the med.
Already it was almost 9 a.m. and the mousetrap in my med cart was rattling around every time I opened a drawer. I could smell the sweet cheesy odor on the trap, and I could feel the mouse allusively nearby!
Patient seven had more pills than Carter has liver pills - as we like to say about patients who take more than 10 pills at one time. This one had 20 pills that had to be laboriously checked and rechecked against the medication record. I put a dot on each space on the med record to indicate each pill had been accounted for. I would put my initial in each space after I gave the meds. I hurried into the room almost tripping on the fast-moving mouse as it ran ahead of me and dashed under the bed.
"Now what are these for?" asked my patient as she dumped the pulls onto the sheet for a re-count and explanation. Several small white pills slipped silently to the floor and rolled out of sight under the bed.
Do I chance getting bit by the hungry mouse as I get on my hands and knees and peer into the darkness? All I see are two beady eyes reminding me that the trap is still set. If I don't find the pills and discard them, housekeeping will report the pills to the supervisor, and she will be sure to match them against who was suppose to have given them. I brave the mouse and return to the cart for new pills.
A half-hour later, in Room 14, my patient is asleep on his left side with a pillow stuffed against his back for support. There is a trocantor pillow strapped between his knees - a sure sign of a recent hip surgery. I cannot turn him by myself. We need to use the log-roll method of turning to prevent injury to his new metal hip.
Locking the med cart, closing all the med books, and covering any evidence of confidential patient information open to public view, I kick at the imaginary mouse under the cart.
"I know what time it is, but you won't get the best of me. I'll conquer you yet!" I hiss as I hurry down the hall to find help with my patient.
I'm quite aware that the medication is a simple stool softener than could be given at noon when the patient is up in his chair for therapy, but someone put it down as an 8 a.m. med because it's given once a day. I could skip it and no one would know - except I would know!
Twenty minutes later the patient is positioned up in bed, the pill is given, and I can move on to patient number 15 (of 19).
The clock says it's 10:00, and I have no more time to finish passing my meds, and still be in compliance. The second hand of the clock looks suspiciously like the long, brown tail of a mouse!
Biting my lower lip to stop the quiver and pushing back tears filling the corner of my eyes, I collect the meds for my next patient.
"I asked for a pain pill 45 minutes ago! Why can't anybody do anything around here? I called my doctor, and he said he gave you new orders for my pain pills. I want the number for your administrator!"
"I'm so sorry you had to wait. I know you must be in a lot of pain. I'll get your pain pills right now. In fact, the doctor said you could have two. Would you like me to bring both pills?" I reply in the most tender voice possible, although in a bit of a quandary because I can't remember my patient's name at the moment.
"No. I'll take one now and take the other one later if I need it," replies the patient who is unaware that the request will would require another clarifying order from the doctor, because he ordered two pain pills to be given every four hours.
I'm sure I hear a nest full of squeaking baby mice under her bed as I hurry back to my cart to sign out one narcotic pill.
My last room has two little ladies who are comparing notes on their care.
"I'm suppose to take my meds with food," one says to the other. "And I had breakfast hours ago."
"I take three different kind of eye drops five-minutes apart," adds the other patient as I walk through the door.
I turn back to find some crackers and milk at the nurses station.
After delivering the meds with food, I search frantically through the half dozen drawers in the med cart for the eye drops. I feel faint and nauseated. It's almost 11 a.m. and that mouse is still dodging my every step and getting bigger by the minute! I've been up since 4 a.m. with nothing to eat or drink so far this morning. The prescribed eye drops are nowhere to be found! I strongly suspect that the night nurse put them in her pocket and didn't check her uniform before she went to bed for the day.
I circle my initials in the space for the missing eye drops and wonder what I'm going to write as my reason for not giving the meds. And, I wonder how my patient will react when I tell her that I can't give them now.
It's almost time to start noon meds, and I've just finished morning meds - some of which are the same! Do I give them again?
It looks like the hall is becoming darker as it seems to fill with monster-sized marching rats, but it's only my supervisor who asks how it's going and offers an encouraging smile and a snack for my break.
I wait for her comments that I'm out of compliance or that I will have to do better if I'm going to work this hall. But instead, she carries a steaming cup of hot coffee hand in one hand and offers me one my most favorite dark chocolate candy bars with the other.
"May I borrow your keys to the med cart?" she asks with some mischief in her voice. "I have some mousetraps to remove."
I would remind my classmates and myself, as new RN's and possible supervisor of LPN's,... May we always remember to remove the mousetraps.Last edit by Joe V on Apr 12, '12
From 'Denver, Colorado'; Joined Mar '05; Posts: 23; Likes: 147.Mar 12, '09 by indigo girlBless your heart. I've been there.
It is really difficult to pass that many meds in LTC within the time frame, and still be a caring and considerate nurse as well. You were not a robot. You were giving great care.Mar 12, '09 by fathertod, BSN, RNQuote from prmenrsYou can use a cat for pet therapy with the patients too.. good nursing intervention!Maybe you can bring a cat to work??? Take care of those silly meeses.Mar 12, '09 by pagandeva2000What a phenomenal story! Now, the mouse is also called a COW, who is related to "Big Brother", so we are all afraid of mice, rats, raccoons, oppossums and even fictitious creatures like the Loch Ness Monster and Big Foot.Mar 12, '09 by EwwThat'sNastyIn my opinion it is simply a hard fact of life and I've seen often how it is done.
I took a contract shift at a home for the elderly, and had about 20 patients, most ambulatory with tons of meds and the same +1/-1 hour window.
It was quite the experience, who is who, where is Mary? (Mary had left with relatives to go for a drive), I raced about and succeeded on the first night. Then on the second night I still doing well and then, one of my patients fell. Uh oh, fall protocols with many recurrent vitals needed. And then my charge nurse developed symptoms of a heart attack, really. So between checking her and hearing her refuse to be 911'd, checking and rechecking the fallen patient, it was a difficult night and lo and behold, I failed to get all the meds passed within the window. I did get all the important/timely ones (insulin, antibiotics, cardiac drugs, etc.) but triaged to do this, leaving vitamins and items like colace on the last three patients to be hit later just outside the window. I didn't know what else to do.
Well, I was called out (by the head nurse who eventually decided her heart attack was a bad case of indigestion) and forced to sign a list of "med errors," which I did, but I think that it must have distressed them when I added:
"Signed under duress. Med passes done outside the open window causes included a patient who had fallen and who required fall protocol procedures as well as the requirement to care for the Charge Nurse who exhibited symptoms of cardiac distress. No assistance was given even to me even though I notified heard nurse of the impending problem."
I added verbally: "you know, most of the people before me never get med passes completed." She thought this preprosterous and I said: "Well, when the state investigates me I will explain that the med carts were difficult to work with as there were many missing med cards, such as vitamins. In the med stock room, looking at inventory records it will take only a cursory inventory review to see that this appears to have been the case for quite awhile." Indeed it was easy to see that many meds seem to have not been given for quite a while prior to me.
I never heard from that awful place again, and will never do that sort of facility med passes again.Mar 12, '09 by Ms.RNit reminds me of days when i had 40 patients in the afternoon shift, patients taking as many pills as in the morning. for the whole 8 hours, i did nothing but pass meds, patients falling left and right, patients about to code etc....Mar 12, '09 by twistedpupchaserI love the story and can relate, nothing is as heartbreaking as finishing a medication pass to discover that your next pass should have started 10/60 earlier. I have never worked LTC but have had to mix IVAB's for the majority of my Pt's, some with 2 or 3 to be hung, do you mix them all at once or run through and come back. There is never an easy option.Mar 12, '09 by Valerie SalvaI think that there are tens of thousands of LTC nurses who are giving their meds outside of the time parameters every day. Some meds passes are so huge, there is no way humanly possible to get the meds out "on time."
We pretend we give them on time, and mgmt pretends to not know how it really works- that is the reality of LTC.Mar 13, '09 by pagandeva2000Quote from Valerie SalvaOF COURSE we are ALL giving medications outside of the parameters sometimes in our lives! It is a horrible thing to have to decide whether to please a time clock or to SAFELY administer medications to people. Reasons like this make nurses leave the bedside by the droves, or why some medications are flushed down the toilet by desperate nurses. They need to be shot!I think that there are tens of thousands of LTC nurses who are giving their meds outside of the time parameters every day. Some meds passes are so huge, there is no way humanly possible to get the meds out "on time."
We pretend we give them on time, and mgmt pretends to not know how it really works- that is the reality of LTC.Mar 13, '09 by MerlinsmomWhere I used to work there was a unit we called the eternal med pass. 63 assisted living pt's-one nurse. You would end the evening med pass, and 15 minutes later start the HS med pass. It was darn near impossible until you were there all the time and got to know everyone's quirks, even then, it was rare to stay in that +/-1hr window.Mar 14, '09 by PfiestyWow! You missed a true calling. You are a terrific writer. Fantastic way to portray this issue!
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