New job: "Don't worry about following the MAR" & other scary stuff - page 2

by kak85

11,082 Views | 49 Comments

Hello everyone! I am a newly licensed RN and just got my first ever nursing job! I was super excited to get started, but now I am so worried about harming a patient and/or losing my license! Many of the things I am told to do at... Read More


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    Also, I've found that doing nebulizer treatments simultaneously saves time. You'll quickly start to remember who gets them and who doesn't (though, of course, you should always double check for order changes). My residents all get the same nebulizer solution, so I can load my pocket with the number of bullets I need, work my way down the hall, and get them started at the same time. While those are running, I can administer meds to other residents. Also, I find it's helpful to either do my PEG tubes first or last.Finally, one nurse gave me this tip: For residents getting BP meds, place those drugs in a separate (labeled) med cup. Then, you can go in the room with all the meds (BP meds separated), take the BP, and give the antihypertensives if appropriate (or discard them if the BP is too low).I wouldn't want to be present during this facility's survey. There's going to be serious waling, and knashing of teeth, as it were in the Bible?
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    Oops, the quotations ought to have ended, where my reply began: "I wouldn't want to be...
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    Quote from Altra
    1. Double-checking insulin is a common (though not universal) practice in acute care, where you likely had the bulk of your clinical experiences as a student. It is not universally required.

    2. For patients in a long-term care setting, there are few meds that really need precise timing. Administering meds in that setting at 1800, 1900 and 2100 is neither necessary nor efficient practice, and likely is bothersome to the patient. I would suggest that a longer-term goal of nurses in your facility should be to get the patients' physicians to change their orders to reflect something more reasonable.

    3. Again, for LTC patients ... daily assessment shouldn't be required. Your documentation should not be designed to set up the expectation of daily system-by-system assessments. In an LTC setting I would expect a note at least daily, if not each shift, that indicated a more general assessment - skin color, respirations unlabored, no cough, ambulating/moving in a manner consistent with that patient's baseline, at baseline mental status, tolerating p.o. intake, no reports of new pain, etc. Listening to bowel sounds on each shift in LTC??


    4. If you want to wear gloves - wear gloves. Generally accepted standards on universal/standard precautions and OSHA regulations are on your side.

    The first year of nursing practice is often frightening. Learn all you can, and accept that there will be rocky spots. Lots of support here at AN. Good luck to you.

    ^^this is perfect advice.

    I would just add that you're spending too much energy worrying about what other nurses are doing. I don't wear gloves when giving an insulin injection either. Many nurses don't. If want to, do it. Is you're preceptor slapping you're hand and taking the gloves away?

    And the assessments you're describing would present an undue invasion of the time and privacy of you're residents. We assess by exception in LTC. I was a little unclear about the part where your preceptor said "just chart their normal", though. I would never chart on lung sounds or bowel sounds unless I actually listened to them.

    But the bigger point is you don't need to auscultate lung/bowel sounds every day. You do if they sound wheezy. Or they vomited. Or they have CHF and have increased edema. See what I mean? Focused assessments based on symptoms presented. Trying to chart an full assessment on every resident every shift will be impossible and, frankly, would just look silly.


    In any event, good luck. You're more worried than you need to be. all new nurses feel overwhelmed. It's normal. Don't listen to posters telling you to "run". They're being melodramatic and clearly have zero conception of what LTC is. Nothing you described about your facility sounds particularly worrisome. As far as I can tell it's a perfectly safe and nice place to work. It only seems horrible because you're applying hospital standards to an environment that is not a hospital. Common rookie mistake. Give this place a chance. You might be surprised.
    Last edit by BrandonLPN on Jul 20, '13
    canoehead, krisiepoo, nursel56, and 11 others like this.
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    New LTC nurse here too! Started 2 months ago. Got 3 nights of "orientation" before I was set loose with 30 residents of my own. I can tell you that no nursing home does things completely by the book. There is simply not enough time, staff, or resources. As for med passes, much of the time the nurse or administrator who puts them into the computer chooses an arbitrary time. As others have said, meds like ABX, insulin, BP meds, antacids, etc are ones that you should worry about the administration time. I am only required to do daily charting/vitals on 4/30 residents (to justify the facility getting paid more for their care), I do a quick head-to-toe assessment on them when I give their meds. Everyone else, I have gotten to know their baseline, if something off is reported to me or I see them and they don't look quite right, that warrants further assessment/charting. I only chart what I do and what I see. And I too wear gloves for everything when others don't. The only other nurse is on the other side of the building, so I triple check my own insulin. I have had to let go of the ideal "ivory tower" nursing that I learned in nursing school when I only had 2 patients. Now I have 30+. I try to be a safe yet efficient nurse. If, by the end of my shift, everyone is still in their bed safe and alive, I consider it a good shift and I don't sweat the small stuff.
    NurseNightOwl, silverbat, MAtoBSN, and 9 others like this.
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    "As for med passes, much of the time the nurse or administrator who puts them into the computer chooses an arbitrary time". Every SNF has a pharmacy manual (true story, but few have even seen it or know where it is). It details how to obtain meds, how to administer meds by route, what times meds are to be given, etc. For instance, a med ordered BID might be given at 9 and 5, per policy. Or, all antibiotics must be spaced around the clock (QID would be 12,6,12,6 rather than 9,1,5,9) Therefore, the med times should be automatically printed as 9 and 5, if a med is ordered "BID". The nonsense of arbitray med times is just that- nonsense. It's common for the day nurse, for example, to push more meds onto 3-11, and or vice versa. (Too bad the 3-11 can't do likewise with ADMITS, eh?) But every place does have policies about even minor med pass details.
    GrnTea likes this.
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    The glove issue isn't that surprising. I don't know anyone who wears gloves for those tasks.
    NurseNightOwl likes this.
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    It is the policy in my facility to wear gloves while checking blood sugars or administering an injection. Gloves while administering eye meds is also a must and gloves for gtube meds and feeds. We're in the process of changing our med times to morning, afternoon, and evening because that is more like what people do at home. It's not an ICU so specific med times really aren't necessary. You'll be fine.
    Teacup Pom, KelRN215, VickyRN, and 2 others like this.
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    Yep, we have a pharmacy manual and guidelines for med administration times. But there is still "wiggle room" within the guidelines to schedule meds so that residents aren't unnecessarily disturbed at all hours of the day and night. I know at least some of our administration times are ridiculous and could be changed +/- a few hours to make it easier on the resident AND the nurse, if only somebody had the time and was so inclined to go into the computer and change it. Our docs could care less if a BID med is given at 0700 and 1900 or 0900 and 2100. For some residents, QHS means 1800, for others it's 2300. That is what I meant by "arbitrary". I follow policy and protocol for time-sensitive meds. But I am not going to worry about giving something like a Colace or multivitamin a few hours early or late.
    canoehead, KelRN215, and VivaLasViejas like this.
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    wow...I could have written this post myself 3 months ago! New nurse, at LTC facility on Days with 30+ residents to myself. I had 6 days of orientation where I was told to give insulin in the hallways and do other questionable practices. I left my job everyday saying "this is not safe..I can't work somewhere like this."
    Well, 3 months later I am finding things getting much easier and I am being much easier on myself! Hang in there a little longer and see how it goes then. Ideally your facility should be having the physician orders changed so that the meds aren't being given outside the time window (if state were there that would be a cite). Can they be changed to AM, PM, HS, NOC? Then you'd have more time to give them w/o it being considered med error.
    My advice is to do things safely, but also know that working in the field is a totally different world than clinicals. Especially LTC. And as a new nurse we have been so engrained in school that "you can lose your license!" Things will be ok. Give the new job a couple months and see if you start feeling different. If not, start looking for a new job
    nursel56, GrnTea, MAtoBSN, and 3 others like this.
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    Start looking for a new job ASAP! I felt the same way at my first job. ( was LTC) I was always stressed out and started to wonder if I made the wrong decision by becoming a nurse. got a new job a hospital and am much happier!!


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