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

BrandonLPN, LPN · Jul 20, 2013

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.

mind_body_soul RN · Jul 20, 2013

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.

mlbluvr · Jul 21, 2013

"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.

loriangel14, RN · Jul 21, 2013

The glove issue isn't that surprising. I don't know anyone who wears gloves for those tasks.

CapeCodMermaid, RN · Jul 21, 2013

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.

mind_body_soul RN · Jul 21, 2013

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.

milkers · Jul 21, 2013

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 :)

Guest234 · Jul 21, 2013

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!!

Bringonthenight · Jul 21, 2013

They 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.

KelRN215, BSN, RN · Jul 21, 2013

Who 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.

txredheadnurse, BSN, RN · Jul 22, 2013

I 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 scrubs 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.

joanna73, BSN, RN · Jul 22, 2013

I 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.