New job: "Don't worry about following the MAR" & other scary stuff - page 2
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... Read More
Jul 20, '13New 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 inwhen 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.
Jul 20, '13"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.
Jul 20, '13The glove issue isn't that surprising. I don't know anyone who wears gloves for those tasks.
Jul 20, '13It 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.
Jul 20, '13Yep, 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.
Jul 20, '13wow...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
Jul 21, '13Start 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!!
Jul 21, '13They can't stop you wearing gloves if you want to.
Also it's not acute care, it's long term dementia care- trust me you don't want to be breaking the routine and waking these residents up at 2200! But physicians should know better. Unless its an antibiotic of narc they should put meds all together where possible.
And like others said, double checking insulin injections is not the law, some facilities just have that as a policy. Once again it's more in acute care that you would see that type of thing.
Jul 21, '13Who times meds at your facility? As another poster said, medication times are often entered arbitrarily. For example, when I worked in the hospital (different than LTC, I know), the pharmacy automatically timed our meds based on how they were ordered. Anything BID was 8A-8P, anything qhs was 10P and anything entered "daily" was timed at the hour it was entered. Residents rarely paid attention to the time when they entered a daily med. So if I admitted a child on the day shift at 4p and he took BID anti-epileptics, nightly melatonin and a daily MVI once the orders were entered, the system would time the AED for 8P, the melatonin for 10P and the MVI for 5P. Fortunately in my facility, nurses had the ability to re-time medications and if, in reality, the child took all these meds together at 7P we just changed the times and administered them as they were administered at home.
LTC is supposed to be the patient's home. I highly doubt that these residents at home would take 1 med at 6P, another at 7P and still another at 9P. Most people aren't that strict with their medication times at home. I take my BID meds roughly at 9A-9P but if I sleep in on the weekends, I might not take the morning dose until 10 or 11 or I have to leave early and drive a long way, I might take it at 7.
If you want to wear gloves, wear gloves. If other nurses don't, that's up to them.
Jul 21, '13I agree with Altra overall. My biggest concern is the OP mentioning pre pouring all the meds and locking them in the med cart. If the surveyors decided to check a med pass or a med cart while in the facility that would be a big problem. Simply get the meds retimed to a more reasonable schedule so as to minimize number of med passes per day and taking into consideration the residents habits i.e. early or late riser same with bedtimes.
Also someone mentioned loading their pockets with neb vials. Again if a surveyor should see you taking an unlabled med out of your that could create problem. I still think The Commuter gave some of the best advice ever a few years back when she mentioned she always checked and organized her cart after report and made a list of all residents requiring accuchecks, nebs, eye gtts etc. so she increased her efficiency during med pass/treatments and didn't spend hours running up and down the halls trying to get everything done.
Jul 22, '13I work LTC which is a completely different focus than an acute care setting. The goals are to promote health and wellness for seniors as they live the remaining years, weeks, months of their lives. Certain medications must be given within a standard time frame: insulin, antibiotics, narcotics and digoxin, for example. The rest....they usually get it within a one hour to two hour time frame. It depends.
Some facilities double check insulins, some do not. My facility does not. This depends on the policy.
What you're describing sounds typical for many LTC units. Many of these clients were either at home or in a lodge for years on these medications. Guaranteed they were not receiving medications there in a 30 minute window.
As far as pre pouring medications....that's a huge NO. If you're organized (learning the residents helps), there is no need to pre-pour. Our MAR has each residents picture and preferences with their individual MAR. Prior to starting my med pass, my cart is stocked, orders are checked, and everyone who is up gets their pills first. Much simpler and safer this way.Last edit by joanna73 on Jul 22, '13 : Reason: finished thought
Jul 22, '13I completely agree with what Brandon & Altra both wrote and as far as what some of the posters said, they were way overboard on the dramatics.
To give you my personal thoughts on a few of your concerns:
1. Gloves, no I don't wear them for insulin injections, BUT, if they make you more comfortable, by all means, wear them. NOBODY is ever going to tell you to take them off.
2. Med times, think about it, if you have say 30 residents to pass meds to, how much of your med pass are you going to get done if you are breaking those admin times down, you would be continuously be passing meds the entire shift and getting absolutely nothing else done.
3. Daily assessments are just NOT done in LTC. This is the big difference from acute care. Your residents are living in LTC with long term illnesses and conditions, they are, for the norm, NOT acutely ill. The "exception " here is if someone is having respitory issues, by all means assess lung sounds, same with bowel sounds for constipation or abdominal region pain.
4. This last point is one of my big pet peeves. It bugs me when I hear a new nurse state, "I don't want to lose my license for, (insert so called infraction). I swear some older nurses like saying this to new nurses to strike fear into them. Believe me, you are NOT going to lose your license for any for the "infractions" you listed in your original post.
5. To sum up my very long winded post, go to work, pass your meds, do your treatments the way you were taught, BUT don't get all caught up in the "this isn't EXACTLY the way we learned this in school". You will be fine. We've all been there and can speak from experience. I hope you stick with this forum and give us an update in a few month. I'm willing to bet by then you will be much more comfortable in your new career.
Jul 22, '13I am a new grad starting my first job in LTC today... I had always heard that long term care was very different from acute care but never really heard anyone explain the difference. This thread has provided me with a preview of what to expect as a long term care nurse. I really appreciate the heads up on the insulin.. I haven't started orientation yet so I don't know what the facility policy is re insulin checks but at least now I won't be freaked out if they tell me not to worry about the second nurse confirm.