Back with my update and need some tips...

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Specializes in hospice, ortho,clinical review.

I said I would come back and eat humble pie if it wasn't truly a wonderful place to work, and these are my thoughts.

Been there a month. Been on my own for a little over a week, so I basically got about 3 weeks orienting with some of the days the nurse would be at the front desk for me to find to get a feel if I could handle it. I was ready for this challenge I thought and honestly none of the patients were that demanding care wise.

I do still rotate between daylight and evening and learned that besides personal reasons, I much prefer daylight as I love the interaction and the residents being "up" and doing their activities like making dog bones! I don't much care for the "sundowning" that occurs especially the couple of residents that make evening charting really trying.

As I read on another thread, and didn't want to threadjack...I'm seeing what many are in terms of getting the med pass done on time. It seems no matter the 3 halls that I've worked, the daylight one goes smoother and the evening one goes downhill because of the short time between getting report and dashing down the hall in basically an hour to get it all done for dinner trays etc..

I also have issues with meds I'm sometimes giving, but that's my personal belief system...however when I watch someone with recurrent UTI's and the overuse of antibiotics....anyway I struggle with this. I guess too, because I was blessed that although both my parents are gone...they went fairly healthy...certainly not to the degree I see in my work.

My bigger issue is although I love the place, I don't like the politics, which is why I always figured no matter where I am, I probably won't stay beside longer than 10 years maybe even more like 5, but that's a different topic! I don't like the med pass from hell. I don't like the shortcuts I'm being told to take, I don't like the combining 4's and 8's meds b/c it's "easier" than dealing with a combative or seriously lethargic resident at 8p. I don't like that I don't feel like I have enough time to do proper care in dealing with dressing changes or just looking at a resident, I received no tips on assessing the patient by a quick look, we only do vitals on the certain few.

Even though I'm willing to work any hall...I'm being told that's shooting myself in the foot as I'd do better focusing on one and getting down a system. After last night I can agree! The floor I'm on has 3 halls and I do know pretty much all of them but none of them great or super efficient, mostly b/c nightly we are getting new residents in a more critical state.

This has caused more and more unhappiness with the staff as they're tired of the overtime (at least we don't get griped at for using it) and the don't feel we're appropriately staffed for the acuity of some. They are no longer taking much of the long term as they are focusing on the more critical as it's better money as I understand it.

I need some tips in organizing my day as much as I thought I was good at this from a previous job, nursing is a whole 'nother ballpark.

Right now, I have 24-26 patients. (as soon as one leaves one comes in) One needs a daily BS for 430p only and just coverge which she always needs. Another gets her BS only on Tue and Thur at that same time, usually coverage and the third is on a feeding and her BS's are qid. I have one patient on a continuous feeding as well as o2 and monitoring her compression glove and making sure she's mummy wrapped as she likes to pull her g-tube out:eek: A little over 1/2 are crushed meds, mostly with pudding but one needs serious time consuming cajoling at 8pm with ice cream.

So prior I was just getting the BS's as I went, I see that didn't work too well. Last night I tried to do the 2 blood sugars 1st, but since there's a long distance between the rooms that need them, I decided I'd be better off trying to pass some of the "faster" meds in between. Well this might have worked in theory except I had to handle the doctor's calling back on 2 patients that o2 sats tanked and take orders, (which I've never done) and then find out another spiked a temperature in the dining room so I was running back and forth!:uhoh3:

Would it be better to grab all the BS's first on any given day? I get told that it's better to grab them as you go otherwise I'm wasting steps. What about the vital signs? Only a few need them on any given day and some are full some are just TPR sometimes the aides will get them, often not (days the aides always get them) 2 of the suppositories that were left from daylight had to be done but I figured that could wait until the 8pm rounds as they aren't as intense.

I loved what I read on the other thread about doing it "right" all the time instead of just when state is there but how? Confused residents are milling about in the halls which is where some meds/eyedrops get adminsitered and it all feels very chaotic.

We have a print out of the residents name going down a 8x11 sheet with about 1/2 inch of space to write inbetween what's going on. So I take additional sheets from the daybook which are at least blocks of space to write in, but I find I get so busy I can't really find the time to chart in them! Some nurses tell me they don't chart anything in the MAR until they're done with the pass but they "look" at the MAR to make sure the meds are still correct. I tried that on just 2 patients and felt overwhelmed, but I do feel it's time consuming to intial the boxes so what to do?

Sorry this is ridiculously long...but I wanted to give an update and really, really need some help :bowingpur:

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Specializes in hospice, ortho,clinical review.

A couple other things....(feeling really overwhelmed today)

I have a few "fast" patients maybe 7 of them, take the meds with water or ensure and they're done. But they're scattered through the hall, sometimes wanderng the hall too, sometimes not. I was told to get the aides to line up the residents that go to the dining room in the hall to get them done first....other nurses disagree!

I saw a nurse was able to give 2 of her residents they're meds at the same time while they were standing there b/c she "knew" what they took, but I don't think you can prep more than one resident's meds at a time can you?

Is it better to go room by room, or zig zag down the hall and back up again? One hall I was on worked well with the zig zag system b/c of the percent that went to the dining room and those that didn't I started at the back and worked up, but this hall I can't seem to nail a system as most go to the dining room, it's scattered residents in different rooms and dining room resident's meds need to be before 5pm as that's when the trays come and the rest start getting trays at 530p, trays of course being delivered from the front of the hall to the back.

But one of the resident's I found was far easier and faster when timed with her tray in her room I didn't need to spend as much time waking her, orienting her, getting her to take them. But how to always time that? Ask the aide to get me no matter? Have the med prepped in advance? (that's probably against state rules)

I think I'll feel better when I have a system, I feel so lost not being able to get orgainized with this hall.

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Specializes in hospice, ortho,clinical review.

Can anyone point me in the direction of a thread that might have good tips?

I'm not sure what would be the best search word to find what I'm looking for.

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I have 30 Residents on my hall, 12 are diabetics and I always get my BS first. If your CNAs are allowed to get vitals, Then as Charge make them do them, and make it their first priority. If you pass a few quick and easy ones between your diabetic rooms them by all means pop their meds and give them. After my diabetics, my coumadin residents are my priority. I usually park my cart in the center of my hall and just walk from room to room. The time I have to spend dodging wheel chairs, laundry carts, and visitors, its really much faster just to pop and walk.. Not to mention great exercise..

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Specializes in Geriatrics.

I outlined what I do in the thread "How many residents do you care for " or something like that. I have been in this business a long time and I'm usually very by-the-book. I've only ever been written up a handful of times, all learning experiences, and pride myself on being very organized and efficient.

That being said, once I get used to a facility's routine, I am guilty of taking a few shortcuts, but I own them, most of my DON's knew I took them and was basically just told to not do it when state was there. If it wasn't for some shortcuts, things wouldn't get done in a timely within guidelines, manner.

Here is what I do on evenings...

I take report from the day shift nurse. I take my cheat sheet with me to report. On that cheat sheet is all my residents I will be charting on that shift. During report, I take notes on these people and any others I feel need an assessment or a watchful eye. After report, I immediately take the floor. This is usually at 1400. The very first thing I do (since I'm only there sporadically) is to check my MAR/TAR. On the back of my vitals sheet, I make myself another cheat sheet (I keep everything on one sheet) listing my neb. tx's, my blood sugars and insulins/times/that particular day, and my treatments. Then I get my 2p nebs out of the way, then give my CNA's and CMT's report. Our ADON and DON make the CNA/CMT assignments out every day, and we are not allowed to change them, so that is a big hassle out of the way. I never ever sign my meds MAR or treatments TAR until the end of my shift (except when state is there). I have 3 halls. I get a bedside table, my vital signs kit, my cheat sheet, and any narcs or neb tx's that need to be done, pick a hall and get to it. I do my own vital signs and assessments (my choice) takes about an hour sometimes, but I see everyone I'm in charge of, even just peeking into a room where I really don't need to do an assessment...that way, if a doc or a family member calls, I can say I've seen them, this is what they were doing when I saw them, etc.

If I have time I do stop and chit chat with my aides or those residents that like to chit chat and need extra attention...I always let every single resident on my station know that I will be there until 10p and they need to come to me with any problem, even the confused ones. I consider this very very important, even though we have a dry erase board with all this info on it at the nurses' station. Some residents don't always come to the nurses station...family members too.

So I'm down the hall doing my assessments and vitals. I go by my cheat sheet. The only meds I pass are narcotics and the G tube meds. I don't leave a hall until I am done with that hall. The only exception are prn's. I check my MAR's at the beginning for any med changes...I go by the MAR and set up my narcs right after my supper break as hs meds are my biggest pass. I use the clear plastic med cups designed for liquids and write the residents' names on each one with a Sharpie. I take my bedside table, my cheat sheet, my little med cups with the meds in them, my accu check/insulin kit, and my treatments supplies, load everything onto that bedside table, pick a hall, and go. I don't zig zag, except if someone wants a prn narc. I never leave my bedside table; if I have to go back to the med room, I take it with me.

All my charting I do after my med pass, my treatments, my nebs, my accu checks/insulins, G tube meds, etc. are done. That is when I chart my vitals and assessments, chart on my MAR and TAR. By then I've got about an hour left free....I do another set of patient rounds, checking on everyone and chit chatting. I go behind my aides and make sure everyone is in their jammies, clean, dry, teeth/oral cares done, rooms cleaned, trash cans emptied, dirty utility room clean, snacks passed and charted, etc.

If I am paged to the phone by a family or doctor, I take my bedside table with me, if I've got it. I write all new orders and/or family complaints/concerns/requests on my cheat sheet. I write on the report sheet during report. I wait to chart new orders until my charting time comes, unless we have an emergency discharge or a death. During charting time, is when I also notify families/docs of any new orders, incidents, changes of condition etc. The only exception being a hospice patient actively dying that shift. Or anyone else actively dying or with several changes of condition.

Sorry this is so lengthy....I hope this helps you in any small way. Any other questions, feel free to ask...

Blessings, Michelle

Edited to add: A few things clarified in my posts below! Sorry for any misunderstanding!

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Specializes in Gerontology, Med surg, Home Health.

Sorry but if you worked for me you'd have more than a few writeups. Pouring narcotics before you give them is wrong...giving a shift's worth of meds before you sign the MAR is wrong. I don't really care if you say you are too busy to do it the right way. One of these days something will happen and your shortcuts will cause you to make a serious error. Might sound harsh but again it's not about me or you...it's about the residents. And, yes, I've had the same conversation with nurses who work for me.

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mondk, when you say you chart on the MAR after you've given meds, are you pouring from memory? That's a bad practice and one I had to break. I was missing new orders even when I poured by the MAR because I wasn't reading it as I should have been. I started a HUGE thread on that here a couple of years ago. I figured out what I was doing wrong, but I don't understand why use use a nightstand instead of the med cart, either.

Whassup?

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Specializes in Geriatrics.

NOOOOOO, I always always check my MAR first. Our narcs are in a locked cabinet in the med room. The only way to pass them by state law would be to give them one at a time, after double checking your MAR. I double check the MAR, set them up by each individual med sheet, put them into an individual cup with their name on it, then pass them out. There is only right now, about 12 at hs. We nurses don't have a med cart. Only a locked narc cabinet. Sorry I didn't make that clear!

Blessings, Michelle

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Specializes in Geriatrics.

I don't do anything there "by memory" because I'm only there every other weekend. Too many things change!

Blessings, Michelle

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Specializes in Geriatrics.

Oh, to clarify too, I don't chart those meds until AFTER they've been given. I see many nurses that will check the MAR, pop the pills out, sign the MAR, then take them to the patient. I NEVER do that; because by state law, you aren't supposed to sign that MAR until the resident has swallowed those meds. I chart on my MAR after all have been passed....sorry again!

Blessings, Michelle

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Specializes in Geriatrics.

CapeCod: You are a good nurse; sorry I didn't make myself more clear!!!!

Blessings, Michelle

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No med cart? Geezum crow! I can't imagine. With an attached lock box for narcs.

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