Gving all the meds all at once?

[ari3sdog]

I've been working as Nurse in LTC for 2 months now. Woot. I'm just concerned about the ways of other Nurses who gives all the meds for 5pm and 9pm all at once?

Is that bad?

I asked one of the Nurses if it is ok. She said.....

It's ok to give earlier if....

1. Vitamins

2. Eye drops

3. Docusate

4. Senakot

You have to give the other medicine on time if

1. B/P meds

2. Insulin

3. Heart Meds

4. Coumadin

5. Dilantin

6. Vicodin

7. Inhalers

8. Sleeping pills

I was thinking, if you guys do agree or disagree on these. It seems so hard to give all the 5pm meds and then later give all the 9pm meds on time. There are a lot of charting to do and Treatment, it so overwhelming.

They told me about the 1 hour before and 1 after rule on passing meds. They even laugh at me because I was doing the "Book Way" that pass all 5pm meds and then later 9pm meds, so I'm doing what they are doing. I felt I'm doing the wrong way, but everyone is doing it and nothing seems to go wrong. Also, I somehow agree about they told me about that certain drugs are ment to give on time, and some are ok to be late. Most of them are doing it for 17 years now and the patients are ok. Any comments to experience Nurses out there?

[gt4everpn, BSN, RN]

Well I;m an LPN new to the LTC and it is a lot to give our morning and afternoon meds to 40 patients + other tasks!! I try to do things as properly and efficiently as I can! I usually give everything within an hour before or after the ordered time, meds like BP, pain, etc.. are important!! I can understand giving 5pm and 9pm meds at once, but then again I'm cautious in saying that it is right!! For instance what if the order states Calcium 600 mg at 5pm and again at 9pm, I wouldnt want to give someone 1200mg at 9pm, if I can give them their second 600mg 9pm dose at 8pm before they go to sleep I will instead of double dosing them!! Remember double dosing isnt good!! Its bad enough the elderly have poor pharmcokinetics in general and they are more sensitive to drugs! This is unrelated to meds, but I remember once there was an order to call the M.D for a FS >200 before starting this patients GT feeding, I took it and it was 205 or 208(cant remember), I called the M.D and things were resolved but a nurse I was working with told me that I didnt have to call the M.D and to let a 205 FS slide! I didnt want to ! Maybe I'm too fresh outta school, I just feel more secure doing things the right way, Hey what ever happened to CYOA??

[The Hated Consultant]

First and foremost, you need to look at policy and procedure. One of the first things a surveyor usually asks for on the entrance interview is a med pass schedule. If you're giving medications scheduled for 1700 at 0900, those will be medication errors related to time. And too, your more alert residents will tell on you if you're being observed: "Where's my _____? I always get it now."

The nurse you spoke to is right...with some medications, like the Senokot, it usually doesn't matter what time you give them. But your nursing judgment has to come into play. You don't want to give something like Lasix too late in the evening, for example; when it kicks in, some older people may try to get out of bed without assistance and fall. I always cite a concern with Digoxin being given after 1800. Most old folks go to bed earlier than the average bear, and if there is an immediate problem with a decreased pulse rate, how will you know? Antacids can interfere with the absorption of some medications, so you need to space them. Synthroid should always be given on an empty stomach, 30 minutes before a meal or 2-3 hours after. You get the drift.

Always follow manufacturer's specifications for administration of medications. There is a difference between specifications and recommendations. But again, nursing judgment comes into play. If you're giving somebody on a whopping dose of Prilosec NSAIDs on an empty stomach, could the Prilosec dose be lowered or even eliminated with simple common sense tactics?

Taking ownership and initiative also is a step. If you see medications that can be moved to another time without interactions, or one that shouldn't be crushed to put down an enteral tube, for example, take the initiative and get the time of administration or the dosage form changed. (If the doc refuses to change the dosage form of a non-crushable medication, he has to address his reasons in his notes.)

This is an excellent topic; thank you for sharing.

[oncnursemsn]

This posting is where experience, what we're taught in school and reality have a major collision. As nursing instructor, and a still practicing nurse, I am always struck by how rigidly we teach our students the "5 Rights" and expect them to do so perfectly with their 1 patient. That same new grad may end up in LTC with 30+ patients- and the "rules" that were beaten into their head goes out the window. I know- I worked briefly in a LTC facility after having a hip replaced. I though it would be easier then working on the acute care floor. As all the readers of this post are laughing hysterically, I found out that my 42 patients and 2 ton med cart were not a good fit for my bum hip. I switched teams with the other nurse (90 patients and 2 licensed nurses...) and realized that the other nurse was doing all his meds for 3-11 in 1 med pass. So that's why he was sitting down and I was runny my a** off! My elderly residents asked at the 4pm pass "where are the rest of my meds?" Needless to say that stint didn't last long....

I agree with those who have posted on this forum about communicating with DON, MD, pharm and the resident themselves to get realistic times and then all will be good. Legal nurse, happy resident and meds given correctly.

[The Hated Consultant]

Excellent points about the collision of experience and reality.

[lvlissl2ebecca]

I just dont understand why its able to be this way in LTC? Obviously, this is a widespread problem and facilities everywhere are known to have this issue. It presents a real problem. I would never do it, but there are people who do. The problem is most deffinetly staffing. Why on earth is a 30 + patients and 1 nurse ratio even allowed!? Doesn't the BON realize how unsafe that is for the patients? Even on a good day, it's hard to remember everything ... what about the bad days (which happen more often than not) when there are doctors spewing orders at you and more than one person falling within minutes of eachother, and this or that resident is combative and disruptive etc.. Thats enough to make even the most seasoned nurse scramble. I, as a new nurse, just want to split into 10 people on a day like this. I understand that with the nursing shortage that it would be hard for facilities to keep a better n/p ratio.. but that would just mean they would have to improve pay in order to keep nurses and then perhaps, more people would like to work LTC. Grr.. I'm truely saddened when I think about how much better care the residents would get if only. Thats the bittersweet thing about nursing for me. I go home knowing that I did the best that I can do, however, my best is not nearly enough and never will be with the workload. That goes for any nurse who isn't a private nurse.

[leeae85]

Let's say the patient is a alzheimer patient and she will only take her meds disguised in food. Then you cant come in and give them at 9pm because she wont take them. Another example is when a patient goes to bed at 7pm and refuses to get up to take their meds at 9pm. These patients are missing vital doses of their meds due to time frames. The legal way to go about correcting these problems is to identify the issue then call the doctor and explain it to him. He will then change the times these meds are given so they will take them and your license wont be at risk. I dont know why some nurses dont just call the doctor for issues like this instead of taking it upon themselves to make their own plan. Giving meds early because of your own convienence is never ok. You need to do some charting throughout the shift instead of waiting until the end when it is all piled up. This is also helpful if something goes wrong towards the end of the shift to throw your time frame off then you already have half of your charting done.

well said!

[Jo Dirt]

I appreciate your post. I think I will give it a try as I thought about this thread last night and what I said about them thinking obscenities and then I thought... why do I care? Atleast I can give it a try. So, thank you for your insight. I don't mean to offend anyone when I tell the truth and say these things. I don't like the way that long term facilities work at all. a 31:1 nurse/patient ratio tops it all off. No, they aren't in critical condition, but all of them are demanding and time consuming in their own way. I do try my best to do everything the way it is supposed to be done, and with all of the things that go on in one 8 hour shift its hard to even get a moment to think about that (which sadly enough is low on the priority list with falls,neurochecks, meds, and treatments, doctors etc). I know I'm preachin to the choir.. my point is I may just go in on one of my days off and go speak to my DON about this.

You aren't peaching to the choir because there are evidently a lot of nurses who don't have a clue (btw, the ratio was 42:1 where I worked). A nurse can go in with the best of intentions, and most all of us do, but sooner or later you realize how defeated you are in the bigger scheme of things.

I saw all kinds come through the doors of that nursing home. There were the job hoppers who really didn't care one way or another and were just there to collect a paycheck, there were the ones who were naieve about what it was really like to work the floor of a nursing home and the responsibilities that went with it, there were the ones who were out to save the poor patients from all the other nurses who were "incompetent" and "lazy" because they were so upstanding (I always noticed, though these nurses held everyone else up to such high standards they always left plenty of allowance for themselves)...none of these types of nurses lasted more than a few months. The only ones who really stuck it out were the ones who realized you are not going to always do everything by what the MAR says, you aren't always going to be able to chart PRN meds as soon as you give them, the patients are lucky you have the time to give them their meds with all the paperwork you have to do to prove you have it to them...and uh, yes, no matter who you are you WILL do things differently in front of the state inspectors, I don't care who you are or how how much integrity you perceive yourself as having.

The average person thinks they are better than the average person.

You aren't going to save the nursing home, you aren't going to save the patients. The nursing home fuctioned before you and it will function without you. No nurse is going to last somewhere 17 yrs. if he/she is incompetent and doesn't care. It's one thing to report abusive and dangerous practices, it's another to sit and judge others from afar.

[Jo Dirt]

I just dont understand why its able to be this way in LTC? Obviously, this is a widespread problem and facilities everywhere are known to have this issue. It presents a real problem. I would never do it, but there are people who do. The problem is most deffinetly staffing. Why on earth is a 30 + patients and 1 nurse ratio even allowed!? Doesn't the BON realize how unsafe that is for the patients? ...... Grr.. I'm truely saddened when I think about how much better care the residents would get if only. Thats the bittersweet thing about nursing for me. I go home knowing that I did the best that I can do, however, my best is not nearly enough and never will be with the workload. That goes for any nurse who isn't a private nurse.

There is a reality to the nursing home business that gets swept under the rug and a lot of people don't want to acknowledge: nursing homes are often dumping grounds for old unwanted people who have families who either can't or won't take care of them at home. Most nursing homes are for profit, and they are "for profit"in every sense of the term. "Safe" staffing ratios are determined by the nursing home owners who pad the pockets of the state BON to pass these rules.

"Quality of life" in a nursing home is a joke, really. What does quality of life in a nursing home mean for most people? Sure, you have the lively old lady who can share wisdom and history from 90 yrs. of living, but for every one like her you have ten more who are miserable, depressed, incontinent and have no future. And Sunday visitors and making cheesy crafts aren't going to give them much more meaning to their lives. They come to the nursing home to die and the nurses and aides are blamed because they have to just kind of run the place like a farm and swipe up and down the halls like they are feeding pigs in stalls. I think of that giant medicine cart overflowing with meds and can still see the doctor's orders coming in. 42 patients in an 8 hr. shift. Not counting charting and treatments and taking down MD orders, how much time does that allow for each patient? 2 aides, i nurse, 42 patients. Even 30 patients.

[softstorms]

Not sure how it is at your facility.....but QID=4times daily. Our Pharmancy says that is 9-1-5-9. Q 6 hours is 12-6-12-6. As we change over to acute care from long term care some of our Dr's are writing for Qid for a lot of things (like antibiotics) , when I was taught they had to be Q6 or 12 hours. If you are looking a a drug you want to be consistant in the system, then it will have to be around the clock. To be honest, in long term care, most of your Pts should be awake, as they are being turned and positioned by your CNA's every 2 hours. So you should not feel bad about giving them med's at that time. Check with them and line up your meds to the time they are tolieting or making bed checks with them. I hope this helps.

[flashpoint]

Not sure how it is at your facility.....but QID=4times daily. Our Pharmancy says that is 9-1-5-9. Q 6 hours is 12-6-12-6. As we change over to acute care from long term care some of our Dr's are writing for Qid for a lot of things (like antibiotics) , when I was taught they had to be Q6 or 12 hours. If you are looking a a drug you want to be consistant in the system, then it will have to be around the clock. To be honest, in long term care, most of your Pts should be awake, as they are being turned and positioned by your CNA's every 2 hours. So you should not feel bad about giving them med's at that time. Check with them and line up your meds to the time they are tolieting or making bed checks with them. I hope this helps.

Well...in my LTC, we have residents...not patients. Since they are considered residents and since the LTC is where they live, not simply where they are recuperating from an illness, we try to keep it a very homelike environment. We try to make adjustments similar to those that someone would make if they were still living independently in their home...things like giving QID antibiotics when they wake up, just before bed, and twice in between. Also...only the ones who are at risk for skin problems are turned every two hours...the rest either reposition on their own or are on an individualized turning program...many of them can tolerate being turned every three hours or every four if they need to be. The same goes for toileting...a few toilet themselves or call for assist...those who don't are on an individualized program based on their habits. For the residents who we do reposition or toilet at night, we try to keep their stimulation to a minimum...getting them up to the restroom or turning them and doing pericare is enough...helping them to sit up, giving them food (as needed), having them swallow a pill, drinking water with the pill, then repositioning, etc, is just a bit much unless it is 100% necessary.

Sure…a strict Q 6 is more ideal than QID, but QID is better than not at all.

[softstorms]

Agreed!! Cotjockey LOL. In 25 years I have seen my pt's go from pt's to residents to clients and back again. In my LTC experience, both as an aide and then later as nurse, most of my pt's have been total care. I have read many articles about letting them rest and be undisturbed at night, and I agree with that. With all the products we have at hand now (special mattresses, new incontenice products, barrier creams) I agree that they should be left undisturbed. I guess it would be the nature of the infection and the need for the ABT that would make me question if it should be q6 or qid?

[Daytonite, BSN, RN]

The only ones who really stuck it out were the ones who realized you are not going to always do everything by what the MAR says, you aren't always going to be able to chart PRN meds as soon as you give them, the patients are lucky you have the time to give them their meds with all the paperwork you have to do to prove you have it to them...and uh, yes, no matter who you are you WILL do things differently in front of the state inspectors, I don't care who you are or how how much integrity you perceive yourself as having.

EXCUSE ME! I was one of the "ones" who really stuck it out and I did everything by what the MAR said or I changed it in order to fit circumstances. And, I charted PRN meds as soon as I gave them. My patients got all their meds as they were ordered. No luck was involved. And, the paperwork got done because I made sure I got it done. What I did in front of the state inspectors was exactly what I did when they weren't there. I was taught that if you develop and practice correctly then you don't have to worry about what you do when the state inspectors are around. I also drive my car at the posted speed limits and never have to worry about getting a ticket for speeding!

Either you never worked with nurses like me, made fun of us, or you were hanging out and doing the same things with the other group of nurses you are trashing on about.

"Quality of life" in a nursing home is a joke, really. What does quality of life in a nursing home mean for most people? Sure, you have the lively old lady who can share wisdom and history from 90 yrs. of living, but for every one like her you have ten more who are miserable, depressed, incontinent and have no future. And Sunday visitors and making cheesy crafts aren't going to give them much more meaning to their lives. They come to the nursing home to die and the nurses and aides are blamed because they have to just kind of run the place like a farm and swipe up and down the halls like they are feeding pigs in stalls.

Whether a elderly person is living in a nursing home or a private home they can be miserable, depressed, incontinent, have no future, stare at a TV set all day and wait to die. There are many circumstances that bring people to nursing homes and being dumped there by families who either can't or won't take care of them is not accurate and only your opinion. Many of the residents I interacted with wanted to be there. My own mother constantly told us that if she got to be so badly in need of constant nursing care that she wanted us to put her in a nursing home rather than be a burden to us. And, she was a nurse herself! I heard this sentiment so many times from residents and their families alike that you can't imagine. And, there are also a pretty good number of residents who had no children or other family to care for them. What kind of classification do they belong in? Whose house do we send them to when they need help and can no longer do for themselves?

Your overall view of what nursing homes are is very inaccurate.