Finallydidit 3,636 Views
Joined Nov 15, '09.
Posts: 137 (35% Liked)
As charge in a LTC I do 2 med passes,for 30 Residents, 12 of them are diabetics, so also do two accuchecks, 2 skin assessment, 2 monthly assessments, MC charting, as well as alert charting (usually about 15 of my res. need to be charted on per shift). If there are falls, skin tears, new pressure areas etc. I have to chart and fill out accident reports on them as well. Decide if someone needs to be sent to the ER, I take off orders, deal with the pharmacy, order meds etc. I also have to over see the CNAs on my unit, decide who does which hall, who does smokers, dining room etc. (They are responsible adults so I usually let them decide who does what, but it has to be documented). At my facility we have an RN and also a treatment nurse, so that helps alot, I have very few treatment that I have to do, and Unless the RN is busy she will usually offer to hang an IV antibiotic, grab a urine catch or insert a foley, or do an incident report, take off orders call the pharmacy, etc. ( anyway she can help out ) I also have to deal with alot of family members in the evening, either in person or just calling to check on grandma... But all in all it goes by very fast, I never look at the clock and think Geeeese I have another 3 hours to go.. Its more like WOW, I only have 3 hours to get this all done!!
3 months from now you will feel very different, I promise as far as your med pass and the HS meds, being given at 7p. HS is when the Res. goes to bed which could very well be at 7p. If that is the case then its okay to give it then. on my back hall BID and HS meds are sched. for 10p. I have a lady that goes to bed every night at 8p or before if the CNAs will take her sooner. She has a sched HS lortab. I give it to her right before I go to lunch at 7:30 everynight. The MAR may say 10p just to have a time, but the ORDER and the script say HS. So its okay to give at the Res. bedtime.
Just a few things I try to include..
If Resident complains of anything.. ie: headache.... chart what you did to fix it and when it was effective..
Res complain of headache pain 4/10, PRN pain medication given, eff. @ 1/hr
Also if a Resident is constantly non-compliant with care or meals, make sure that you document that the MD and family are aware of the situation. ie: Diabetic diet
Res. non complient with diet orders, comsumes candy bars and sodas several times a day, MD and family are aware of behavior
If documenting a new skin tear, along with a detail of what happened, I describe the wound, and then just add, cleaned and treated according to company protacals.
Think of it like this... They pretty much want to know the issues and why they need to be there. So make sure to tell them.. They also want to know what you are doing to fix the issues and if they are making progress or declining, so make sure you tell them that too. If they are not making progress, (non complient with orders, diet, therapy etc.) Tell them what has been reported (to Mds, family) so they know its out of your hands and being further evaluated
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