LTC/rehab facility: ?'s --LPN Scope of Practice

[SlightlyMental_RN]

Okay...as a new RN, I'm hazy on this, so please help me out:

Can a LPN:

1.) Assess lung sounds? I thought they couldn't, but my facility has them doing this job, and other assessments, such as wounds, behavioral, GI, etc.....

2.) Can a LPN take MD phone orders? I thought they couldn't, but again, my facility has them doing so....

3.) Can a LPN develop a Short-term plan of care? I thought that that was another no-no....

They also don't have anyone do a double check on insulin to be administered, and they don't do counts on their narcotics half the time.

I'm really worried, as I don't want to jeopardize my license in any way. Thanks for any and all help!

[SunnyAndrsn]

At my facility, LPNs do take telephone orders. We do not have a HUC, so we always enter our orders ourselves.

It is impractical in most cases to double insulins, however, it IS supposed to be done.

Narc counts were a huge issue at my facility when I first started (first as an LPN, now an RN), however this has improved dramatically. It's now not an option to NOT count before leaving the floor, and it's in part by nurses insisting that this be done.

Care plans must be signed and ultimately developed by an RN, however we have pre-made immediate plans of care that address things such as pain, falls risk, etc. These are used when residents are first admitted.

Now my huge beef with (it seems) most LTC's is that LPNS are doing extensive assessments. I have to say that as a nurse, I do depend on other personal to alert me to skin changes, etc...however, the extent of this is that I depend on my CNAs to come to me when they see something to have me assess and document.

The way it's SUPPOSED to work in my facility is that the LPNs document (for example) "redness noted under breasts with (or without) odor". Then document the size (L x W) and pain status, interventions taken...ie, used PRN nystatin powder, notifed MD, washed/dried, barrier cream applied, etc. It's then our wound care nurse's job (RN) to follow up and decided if the area is a pressure sore, etc.

As for other types of assessments, this has always seemed to be a gray area. If a resident presents with a change of condition, the nurse (typically LPN) will do the assessment. I don't know...I was taught how to do a head to toe assessment as an LPN...

[zuzi]

LPNs versus RNs scope of practice NOW in California is a very grey area.....Is a powerfull lobby now special in California where many of duties from scope of practice from RNs could be transfered to LPNs, or rewritening in terms not so well defined , making able everyone to use speculations about interpretation of scope of practice of LPNs.

Let me to give you an exemple...

If in scope of practice of LPNs is is not any note about assesments of patients, then the RN scope of practice is well defined.

But if in he scope of practice for LPN, BON use "The LPN contributes to the assessment, planning and implementation and evaluation of patient care."... well my dear...IS A TRICKY AREA!

"CONTRIBUTION" could give FREEDOM of interpretation... and based on that... a good corporation lawyer... ALWAYS could proves that working with LPNs on assesments is LEGAL. An RN is just a FORMAL necesity there.

Is a money problem, is a trust problem, and is the Network... is a nursing shortage problem.

I will tell you a story from a former ZUZI life... long time ago Zuzi worked in a factory... hard work night shift.... all workers from there, very poor gurls.... Zuzi like you know her, always laughed and joked with them... at one moment I asked one of them.... "you work hard, and I don't see any supervisor here at night time...where are supreviors...without suprevisors you could lay down or don't work... why did you don't do it?"

Very proude about herself "important" mission there she told me... "because this factory deserve it all"... "they give me a goal, they give me a life, they pay me, they will send me at school, and one day I will be the supervisor here...I am proud that I am part of it...and you need to adress to myself with MISS.....

I look at her and I smiled....is not about the school, is not about position, is not about nothing is about how people are insiede. How they was grow up, how they real think that they are and deserve....

My father told me.... give the power to anyone and you will see his/her real face.

LPNs or RNs we need to have CLEAR rules made by BON. Is not about money...is about how could we can screw up a good healthcare system just because of money. Zuzi come from where YOU want to go NOW.... and is BAD!

When a poet will deal with healthcare problems and a banker will asses the patients behaviors, looool...is a screw up world. We need to be very carefull not for us... we are old... for our childrean... because they will not have anymore good guidances like we did!

I am so so sorry... I have woanderfull LPNs with who I worked but I am also around with totally screw up minds, are beuatifull RNs also... but also ones that are not much more good than an LPN, give a chance to RN to be an RN and to a LPN to be a LPN, that is all! Don't screw up all for money!

[SuesquatchRN, BSN, RN]

When I was an LPN I was taught a full cephalocaudal assessment. We called it data-gathering. In LTC I took charge and took off orders, called MDs, and documented, even for Medicare.

I was not a trained chimpanzee.

[SunnyAndrsn]

Insulin double checks? I have NEVER had ANYONE double check my insulin and quite frankly if someone tried to I would be offended. I went to school too and am quite capable of checking a blood sugar and administering an insulin injection as per sliding scale coverage. I always count my narcotics with the oncoming shift. Your additional education gives you the initials RN but there are many LPNs who may be just as educated as you are in LTC. Most of them have worked there 10+ years and know exactly what there doing and know those patients better than you do regardless of the initials behind your name. You should start looking for qualities in your coworkers that make you unified not segregated.

Just an FYI...many schools teach that two nurses must verify insulin before it is administered. As an LPN in my final clinical before I graduated with RN, the staff RN's always verified insulin with another nurse. It wasn't an RN vs. LPN thing.

[SunnyAndrsn]

I'm just coming back to this now and wanted to comment. I got really good at lung sounds when I was finishing my RN because we were doing full assessments on all 6 of our pts. at least once if not 2x per shift. In addition, in my final rotation I had several pts. with unusual lung issues, so we were auscultating a lot of lungs. I learned a lot for the respiratory therapists that came in too.

Anyway, as a result, I've become the "go to" person at my LTC/TCU job...not because I'm an RN, but because my co-workers would say "I'm not sure what I'm hearing" and I'd jump in and ask if they wanted someone else to listen. It was just good teamwork. If I heard crackles/wheezing/diminished sounds, I'd show them where and what I was hearing.

I think it's fabulous that you are encouraging infection control. I will keep a closed water or soda bottle on the cart, as I just can't be running downstairs to the break room for a drink when I need it, but eating at the cart, YUCK! I have been known to eat at the desk, which has gotten my hand slapped more than the nurses who eat at the carts because management says it looks bad. Yeah, I'm sure it does, but I also get my hand slapped if I'm there too late after my shift...breaks are very difficult to take.

What exactly are you doing at your job? Are you on the floor?

I wasn't too worried about the phone orders, but in nursing school, even the LPN's weren't allowed to take MD orders, so I was a bit thrown by the whole thing.

As for the assessing.....I guess that it just bothered me, as I know that the RN's in the facility aren't going around and assessing these people. They go by whatever the LPN says he/she heard/saw. It just seems so wrong--I went and listened to one person that the LPN said that the lung sounds were clear bilaterally. Ummm...no. There were Insp./Exp. wheezes--and we're supposed to monitoring this resident's respiratory status, as they had a recent URI?

The ST-POC thing also really floored me, as I don't feel it's right that they are developing these. I mean, that's why we have the additional training to be RN's. Right?

I wish that they did checks on the insulin or did their narcotics checks. You wouldn't believe the other stuff I witnessed today: One LPN was eating her whole shift (candy and snacks on her med cart)--not washing hands (ever!)--even after taking blood sugars and administering insulin (w/out gloves). Other LPN's had snacks in the pockets of their scrubs and were munching their entire shift. All I could think was "Wow." I know they thought I was weird because I contacted supply and made them bring up 4 bottles of hand sanitizer, and I kept asking where the gloves were, so I could keep myself and my patients safe.

[Sparrowhawk]

In Missouri we do all those things...the DON usually does the care plan at least at my facility, I'm sure it's different facility by facility too..protocol and all that. Eating while working and not washing hands is just disgusting. It's just best to check with your own BON....I'm finding the scope of practice is much broader in LTC then in general.

We don't double check our insulin...but I triple check it just myself...it's to risky not to.

[CoffeeRTC, BSN, RN]

Just an FYI...many schools teach that two nurses must verify insulin before it is administered. As an LPN in my final clinical before I graduated with RN, the staff RN's always verified insulin with another nurse. It wasn't an RN vs. LPN thing.

Yes...this is true. I just looked again at the OP's screen name..RN2009. We were all new nurses at one point in time. Heck...when I graduated from my BSN program, it was a total cultural shock to go to LTC and see the way things were really done. At first, I asked everyone to verify my insulin and I thought being the RN in charge I had to micromanage everything because in school...it was drilled in our head that we were in charge and that our license was always on the line. Didn't take me long to realize the difference of the real world. Do I cut corneres...maybe, but I'm still called the "by the book nurse" LOL.

I just chalk all of this up to gaining experience and putting what we learned in school to use in the real world.

[kcochrane]

As everyone else mentioned...first check with your state BON. Then you need to check the protocols at your facility. For example, in NYS LPNs can take MD phone orders, but at my facility, they can't.

Our facility does not require us to double check insulin, but the local hospitals do.