Describe a shift in LTC? Please??

[Phoenix4]

Through various circumstances, I'll be going into a small LTC facility with basically 2 hrs of orientation.

I realize that different facilities will be different, but could anyone describe a shift for me? Does this start with report like acute care? What types of "treatments" might there usually be? Etc. No detail is too small to be interesting and helpful to me. Hints and tips appreciated!

What staff would be usual for say, 25 residents?

Needless to say I'm very nervous, and want to provide good care!

Thanks for any input!

[passredskins1]

2 hrs is just ridicuolous for orientation......they will put the blame on you if something happens....i dont care if you been a nurse for 25 yrs.....a 2hr orientation in a new facility is still not enough....

i work in a LTC facility too but hope to transition into a hosp soon....but for now...i usually work the evening shift... )3pm to 11:30Pm but i never leave @ 11:30pm...i always end up living @ 1AM....2AM b/ of all how busy it is...

i get report @ 3PM.....count narcs..... I stock up my carts before starting with syringes....fingerstick stuff...fresh ice

we rarely get a medicine aide on our skilled unit....i have 18 pts so before i go down the hall...

i prepull my meds....(i dont open them) but I put all my meds in a plastic cup by the patient name (trust me it makes teh 8pm med pass easier)

I watch out for the 4pm to 5pm meds...ususally only a few but i pass that out with my fingersticks...... and i call in my labs early (@ 3pm) soo that i wont bother the docs at night

the minute i take the fingersticks..i am giving the insulin (there is no time to come back)

after the first round....i then sit down....recall any docs for labs...issues if they didnt call back...sign my treatment books...and watch out for any needed treatments to be done...

i work in a skiiled unit...so you also have to prepare for admissions.....if there is transfer summary out....i tend to start writing the meds out...b/c the supervisor might not help out or is busy in the other units.....

I usually start my PM med pass at 7:30PM and can take me to ten at times...which is why i prepull (b/c meds might be misssing from the med cart...and it gives u advance notice to find whih meds are Not there)

LTC is a mess day to day.....i work part time b/c it can get tooo stressful on a persons body.....

[Phoenix4]

So a couple of follow up questions and a little bit of explanation.

I took a job with a temporary staffing/travel agency, so I won't be a regular employee of the LTC, hence the 2 hr orientation. I've been out of nursing a while (raising kids), live in a large, sporificely populated state, and this part of the state I was told point-blank does not have a nursing shortage and no one would need to hire me anywhere locally. Must have job=I took what I could get. (And yes, I'm terrified. I'm not going in just blindly assuming everything will be fine. This is also why I appreciate SO MUCH people helping me with routines and suggestions!)

My first shift is THURSDAY this week! (ACK!!)

So follow up questions...

It used to be in acute care, you had 1/2 hr before to 1/2 hr after the scheduled time to give the med to be considered "on time". I notice people are referring to an hr before and an hr after, is this an overall change in all areas, or is this usual for LTC but not acute care? (Starting med pass an hr before scheduled meds sounds like a great thing!)

I'm not finding a "scope of practice" for CNA's in my state (even though they have to be certified, and you can look them up on the BON website). Is it usual for CNA's to do fingersticks? (I'm planning to ask about that at the facility too, but I'd like to have an idea of what's usual.) I'm praying for good CNA's, they are priceless!

I was told once by a travel nurse that usually staff and facilities are pretty nice to travelers, because if they aren't, they won't come back :). Do you find that to be true? Or??

I'm open to any other thoughts, suggestions! And please know that I've appreciated EVERYTHING that people have taken their valuable time to contribute!

[VANurse2010]

The hour before/ hour after seems to be a more general change. This has been my experience both in LTC and acute care - 1 hour before, 1 hour after, although I've never been given a hard time in acute care about giving a med a little "too early" or "too late."

Unlike acute care, CNAs are not involved in anything "medical" such as accuchecks. Their role is to handle the ADLs and personal care so you can pass meds and do treatments on 20, 25, 30 people. I think the culture of the facility has more to do with attitude toward fellow staff than whether someone is a traveler. Just my two cents.

[jenngruver]

2 Hours of orientation isn't nearly enough....I oriented 4 shifts a week for a month before I took the floor alone. I work in a center that has 5 units with anywhere from 20-40 residents per unit. The units I work have 32 and 37 beds each. On both units I have 3 CNAs and a CMA (Certified Medication Aide), but on one unit (the larger one) the CMA leaves half way thru the shift. I work 2pm to 10pm. A typical shift on the smaller unit starts with report, and like others have said it's usually ms or mr so and so is fine unless there has been a fall, an abnormal blood sugar, a medication change or a treatment change or if we have a new admission or re-admission after hospitalization. This usually takes anywhere from 5 to 15 minutes. I then right up the vital signs sheet for my CNAs. The CMA comes and asks who's in the hospital or if any one has returned from the hospital. I then go do as many wound cares as possible before doing accuchecks and insulins (almost 1/2 my residents on this unit are diabetic) at 4:45-5:30 (and I have to catch them before they have coffee). I have dinner after all my residents have finished dinner (usually around 6-6:30). Then I finish up any wound care that wasn't done before dinner. By then it's 7:30 and time for accuchecks and insulins again. After that I have one resident on IV meds, so I start that (usually about 8:30). While the IV meds are infusing, I start charting (we chart by exception). At 9:15 my CMA is usually finished with the HS med pass and I count the narcs with her and get the keys to the med cart (night shift passes their own meds since it's usually just PRN pain meds). At 9:30, I disconnect the IV meds and finish charting. Now the other unit I work goes a little different after 6:30, I count narcs with the CMA then. I have my cheat sheet with a list of all those receiving HS med and which ones of those are to be crushed. I start my med pass at 7pm with those that have to be crushed as they are generally the first ones to go to bed, I cross them off my cheat sheet as I go. Then I start at the top of the list (my cheat sheet is by room) and give meds to all the ones that aren't crushed. I'm generally done by 8:30 with the HS med pass. Then my night continues about the same as the other unit minus the IV meds.

As for the CNA scope of practice, check with your state's Department of Health and Human Services, Department of Disability and Aging Services....that's who monitors and licenses CNA is my state.

Good luck with your first shift...hope all goes well.

[FloatDaddy]

I will also be starting in LTC as a noc Float between 3 units AND I'm a new grad! I am reading every bit of info that you fine nurses are writing. Thank you!!!!!!

[Phoenix4]

So, follow up...

I've had my first two shifts, my third is tomorrow. I had about 25 patients. The two aides handle clothing, toileting, feeding, but there is almost no interaction between the aides and the nurses. The RN (or LPN) on the wing handles meds, treatments, vital signs (they don't have aides do vitals). I had no idea that long term care moved so much faster than acute care! 25 patients, roughly 200 meds for the 4 pm scheduled meds. No ID bands, they move around all the time (so you can't just start at the first room and go down the hall like acute care, because they aren't there!). Most of the pics on the computer records aren't all that good, so I usually had to find an aide and ask where each patient was to give them meds.

The first shift I was there started with the med cart "changeover" with the new med cassettes refilled. That meant that I couldn't start anything at all until almost 4 pm. When I wasn't done with 4 pm meds by way late, the LPN (who was in charge, she's very good) had to call the nursing director to decide how to handle it, ie which meds to just skip, and had to help me pass meds to get those finished up.

The 2 hr "orientation" first (which they knew nothing about and were totally surprised, they said they usually just hand the keys to the traveler and that's it), then it was an 8 hr shift that became 12 hrs total. I was grateful for the orientation, at least I got some exposure to the computer records system. Some things though I wish they'd covered, like although they handed me the keys to the med room/narcotics stuff, no one said which key went to which thing! So I started with fumbling around trying to find the key to even get the med room open, trying every likely key before finally finding it. (There's a key to the med room, two keys for the medication cart {one for the whole cart, one for the narcotics drawer}, one key for the narcotic cupboard, one for the tackle box in the narcotic cupboard, another for the small tackle box that contains narcotics that need to be refrigerated. Naturally, I was fumbling with all those keys every time.)

They had a room for me to stay in for the two nights in the assisted living part, it was plain but quite nice, and it was really good to not have to drive home after that. I slept pretty well from 1 am to 4 am the first night, but then of course tossed and turned from 4 to 8 am, thinking of all the treatments I didn't do at all (I did no treatments, dressing changes, or skin checks whatsoever).

The second shift I could at least start at closer to the "real" time since there was no med cart change. I managed to get almost all the 4 pm meds done by 7 pm (and though 4 pm is the "big" med pass, they also have 5, 6, 7, 8 is another big one, 9, 10 and "bedtime" meds those vary more as to how many meds and how many patients get them). I did manage to get most of the meds done during the shift, still no treatments or dressing changes. I did still have to have help from the LPN on duty on the other wing to get the meds done.

All their records are on the computer, and the first night I kept having trouble with the computer screen on the med cart seizing up and having to restart it. That probably cost me an hour. But, the real problem was likely that the battery was low because I took so long to get the meds passed out, so it didn't want to do its job. Which meant that if you can't see the screen, you have no clue what meds to give.

I've never worked anywhere that CNA's didn't do vitals, is that typical? (No medication aides, etc.) The day nurses I took over for both commented that it was a huge workload for one person (as did another LPN who was working on the other wing). Yeah, that was encouraging... .NOT! Thankfully the LPN's from the other wing were helpful and tolerant. No breaks, no meals either day. Does this sound like a typical workload?

I already feel just sick that I have to go back tomorrow!

Maybe I should just give up nursing!

[Spring_Peeper]

I hope you don't give up nursing just based on this experience. That kind of heavy med pass would take a while to get the hang of; I imagine every day goes a little faster, doesn't it? Because you get to recognize the residents and where to find things, and which key goes to what. Don't despair! Sounds like the other nurses are chipping in to help you get it done, and that's great.

It does sound strange that the CNAs don't do vitals.