Describe a shift in LTC? Please??

Wise Woman RN · Sep 6, 2012

You need more than 2 hours of orientation, really... I wish you the best, it's a difficult job... A handy hint - A nice new pair of pliers works great for crushing meds if you don't have a really nice pill crusher...

Good luck, fair winds and following seas...

Wise Woman RN

Dragonmom · Sep 6, 2012

WOW! 2 whole hours...

I would want to know:

who gets crushed

who gets blood glucose checks and when

who gets nebs and when

at least those three things, also knowing which aid is not new and will know the residents so that you can ask them for varification of identity, since LTC usually doesn't use wrist bands for ID.

Having an experienced aid in this situation (and many others) is PRICELESS!

Pat2012 · Sep 6, 2012

First of all, I'd ask for more than 2hrs of orientation.... I mean, if they did that at the place I work at, I'd be headed straight out the door...... My typical day: I have 25 realitively independent residents, and the hardest hall in the whole building. I come in, get a report sheet, worksheet for CNAs, look to see who needs MOM, count narcs in my cart, and then get report. After that, (assuming there isn't a crisis right at shift change), I prepare my cart: I get pudding, applesauce, ensure, juice, and ice water. I use my med Mar tabs and pull them out for the 5pm med pass and I pull out a red tab for diabetics. I also make sure my CNAs have needed vitals by dinner time. After that, I quickly get my treatments ready and check the tx book. Mostly for me, these are creams, powders, occasional dressing change, maybe an ear irrigation. You memorize them pretty quickly. Then I head down my hall way: I find all my diabetics first, because they need thier insulin before dinner and sometimes they are hard to find, I also find the people who need breathing treatments (we do this ourselves). I aim to be done by 6 but I usually don't get done until 6:15 or 6:30, because I have a lot of eye drops. Then I take a 30 min lunch break. After break, I will try to do some charting so that I don't have to stay after so long to get it done. Then I prepare evening med pass. I get fresh water, re-tab my med mar, and I will pull both the med cart and the treatment cart down the hall. I will also make sure that I have snacks for my diabetics. At night it varies how I do it. Sometimes I go for the people who go to be early because they are hard to wake up. I know certain people want their pills at a specific time and you learn the routines so you know who you need to go see first. Med pass on a rare good day, I'll get done by 10:15, however sometimes I don't finish until 11pm. Then I go back to nurses station, clear off cart, make sure med mar and tx book is signed, try to get everything the midnight shift nurse needs. When the midnight shift arrives, we count narcs together, I pass over the keys, and we do report. Then, I go through the list of who I need to chart on. I have yet to get out of there by midnight. There is a shift for you! I also have 3 CNAs for my hall.

Phoenix4 · Sep 7, 2012

Thank you!! These are definitely helpful to me! Please, anyone else feel free to chime in :)

WittySarcasm, BSN · Sep 8, 2012

Wow only 2 hours. Ok let me tell you how I do it when I'm on the med cart. First of all, most report will be fast because in LTC unless there is a change of condition the report goes 'Miss. K is fine." So when I'm on a new floor I ask how everyone takes their meds. It's more then crushed or whole, I've learned the easist way to get meds to the residents is to do it how they like it. If they only want vanilla pudding why not give it to them if they can have it. So at the beginning I ask for that info with report. They may roll their eyes but at least you'll be faster.

I tell people that almost all of the time you have a free hour from (for example lets take my shift) 3pm-4pm. I use this time to get myself set up. I make sure the cart is stocked with needles and syringes. That I have gloves, drinks and pudding and applesauce and ensure. Believe me I've taken carts that have been empty and it will kill your med pass time if you have to keep going to get stuff (you NEVER find all the missing stuff at once). Meds are going to be done for the 3pm (if you have a good nurse before you) because they know otherwise it'll be late.

As soon as I'm done with my count (and cart stocking) and report I find my diabetics and check their sugars and give insulin, at the same time if they have meds I hand them out. (we have a 4pm and 8pm pass, with a few stray meds). While they are eating dinner is a great time to not only finish handing out meds (the hour before and hour after is a lifesaver at these times). When done- and they still are eating- I use this time to eat myself, however if I don't feel the need to eat (or if I'm not hungry) then I move on. If they are done eating do a quick treatment. Some of our treatments are simple like 'wash G-tube site with soap and water,' those do while passing meds. Especially since you're probably using the G-tube to give the meds.

Some people flag when meds are due others write on the paper. I have always found it easier to just quickly scan the pages for each patient for meds. I do two flips, one for the first pass and then the second pass will help me make sure I got the pesky "encourage fluids" squares marked too. Really this part though just depends on what you find best for you. I've seen nurses unable to pass meds unless they write down the times for each med on their sheet. I tried that when I first started and it was just too time consuming. Others mark with straws, again it didn't work for me. You may try all of the ways we mention and find none that work, but you will find one that works just for you!

Ok during the second pass is when I tend to do the treatments for my patients. I try to do most through out the day, depending when I have a free moment, but second pass is when I will finish them. Except for PRNs I try to make the second pass the last time I head to the room.

As for how many it depends. If we are on the acute unit we can have from 15-20 patients, on the true LTC about 30. What is a true lifesaver is to find out what the CNA's can do, can they do fingersticks? Vitals? Whatever they can do try to delegate it. I know it sounds horrible but sometimes you don't have time to recheck that fingerstick a third time to see if the juice helped, or to see if that critical value went down. I'm not saying CNA's have it easier then us, because they don't they are just as busy as us. But at the same time sometimes delegating can help save you. They may have a free moment to check that bloodsugar while you're running around like a chicken without a head. In the same breath I also stress, if you have a free moment where you're done and you see a call light go off or someone say they want to use the bathroom, take them. Be helpful to your CNAs and they will always want to help you back.

Blackcat99 · Sep 9, 2012

When I worked in LTC, I use to have a few days when I would think "OMG. I think I may actually be able to leave on time today."

95% of the time when I was thinking like that, I would ALWAYs have a patient fall 15 minutes before the next shift. Or a CNA would say 15 minutes before the next shift "Oh I forgot to tell you earlier about the open area I observed this afternoon on so and so".

Lynx25, LPN · Sep 9, 2012

Oh God. Two hours? How rude. Here's what I'd do, but I've only ever worked at one facility so I don't know how much it would vary.

1) CHEAT SHEET Print out a census of every person you will be caring for. Have the orienter/ offgoing nurse mark every person who has..

-Crushed Meds

-Thickened Liquids

-Insulin and Accuchecks

-Peg tubes/ feeding tubes/ IV medication

-Disruptive behaviors, or little rituals that will throw grandma completely off her rocker if disturbed. (ie: I get my pills one at a time with fruit punch or I go socking staff in the kidneys for the rest of the shift)

-Fill your cart. Ask the offgoing nurse to help you make sure all of the supplies you'll need are there. Serious time saver.

-Don't stand around gossiping and giggling with everyone at the desk. I see co-workers doing this, they end up two hours behind, and then they gripe and complain when management cracks down on OT.

2) CHECK LABS We do our own labs here. Note any abnormals and call them in. I do this right off the bat because I usually get all of the PT/INRs on my shift

3) ACCUCHECKS AND INSULIN

Our check times are scheduled like 30 minutes before the medpass. I do them first, some nurses do it with the medpass. I'd recommend doing it before you start meds.

4) MED PASS #1

Start at the beginning, and work your way down. I can't stand a group of people pawing at my cart, and demanding to be next. Nope. I start at the beginning of the book and work my way through. Much reduced risk of med error IMO. IT'S GOING TO TAKE YOU WAY TOO LONG THE FIRST TIME. Don't panic. It takes everyone forever when they first start. You are throwing out meds to 30 people at an average of 10 pills a pop, and you only have a couple of hours to do it.

5) Chart/ Treatments

How did your first medpass go? Did you finish more than an hour before time for the next medpass? Great! Sit down and chart. The CNAs can help you out with how much Ms So-and-So ate, or anything strange that came up. If you have treatments, you can also do them here. Don't go alone, ask a CNA to give you a hand.

6) MED PASS #2

If your facility is like mine, you'll have two medpasses, and this one is not terrible. Still, I'd stay start it an hour before the scheduled times. It's still legal, and it will make sure you don't run over.

7) Finish it up

Finish charting, finish treatments, hit your cart with a bleach wipe and get out of there.

I've been LTC for about a year and a half, and very rarely stay late. I have thirty residents.

WittySarcasm, BSN · Sep 9, 2012

Still, I'd stay start it an hour before the scheduled times. It's still legal, and it will make sure you don't run over.

Yes I always do an hour before the med pass just because it gives you 3 hours (hour before and hour after) to pass meds to all of the residents.

Phoenix4 · Sep 9, 2012

This is SO incredibly helpful, I can't tell you all how much I appreciate that you've taken the time to share this with me. This will help me so much with making it through my first shifts! (And please, feel free to share any other thoughts!)

God bless you!

casi, ASN, RN · Sep 11, 2012

I'm not sure sure what shift you'll be working, so I'll go over a night shift. I work 10:30pm-7am with 43 residents (I think).

10:30-11pm Get report, count narcs. If you aren't familiar with the floor ask about how they take their pills, A&O, baseline behaviors

11pm-11:30pm: Go through my books, write down meds and treatments. On night shift meds can be at oddball times.

11:30pm-12am: Check my email, read 24hr report, give nursing assistants report

12a-1am(normally): 12am meds and tx, assessments on those who need it, fill portable o2tanks

1am-3am: Tackle the special pile of paperwork that is given to night shift.

3-3:30am: Lunch!! ZOMG LUNCH!

3:30am-5am: Go through books again to fill in blanks, chart, Make sure assessment forms are filled out, reassessments if needed

5-6:30am: 6am meds and treatments, as this is the time of the morning people start waking up there tends to be a lot of PRNs and new skin tears/bruises that need incident reports.

6:30-7am: Report and count narcs.

There is a lot of misc. stuff in there as well. As I said before medication times on night shift vary. There always seems to be incident report and fall f/u's that need to be done. On night shift you get to put out a lot of fires (sometimes literally) since the amount of staff is so low.

On nights there will be nights that you get to do a super good clean on the med carts and then crochet for an hour, and then there will be nights where you are excited when you get out by 8:30am.

lindseylpn · Sep 11, 2012

I haven't worked ltc in a couple of years but, I worked night shift and my schedule was pretty similar to the poster above.

I worked 10:45p-7:15a with 25-55 patients.

10:45- get report and count meds, skim over the 24hr report, see who I have to chart on for the night and make a list of vital signs I need to give to the cnas, make a quick note of who is on antibiotics or prn meds or who needs treatments, etc

11:30p- do the special 3rd shift tasks like test the glocometer, stock the crash cart, med cart etc. put my juice, applesauce etc on my cart that i need for med pass

12a- do my medpass, fingersticks and any assesments that need to be done.

check in with my cnas and see if they have vital signs done, see if anyone has a fever or need prn meds etc.

1or1:30ish- do any treatments, foley changes, lab draws, trach cleaning, urine specimens and do all of the things that get pushed to night shift.

2:30-4:30 chart

(I usually ate my lunch as I was charting, I rarely got to leave the unit)

4:30-5 get everything ready for the med pass, stock cart etc.

5a-7a do fingersticks and med pass

7a- give report and count meds

Any thing that happened later in the shift like a skin tear, fall etc, er trip, I had to do paperwork after my shift was over and sometimes on a super busy night I didn't even get to chart until end of the shift. I usually got off on time if I had 25pts but, stayed over if I had more. I usually left around 8am but, have stayed as late as 10a when I first started.

Stress that you need more orientation, you can't learn anything in just 2 hours.