**HELP!! ICU RN Working PRN in LTC??

CapeCodMermaid, RN · Aug 28, 2016

Perhaps it's because of heard during my entire career that nurses who work in nursing homes aren't real nurses. Or perhaps it's because last week I worked 60+ hours getting ready for state survey and covering for nurses who called out. I've been at this facility for 2 months.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Aug 28, 2016

Thanks for your feedback. What suggestions do you have for organizing shift to accomplish med passes and other duties in 8 hours for 15 or more patients? Also, what questions should I ask on my first shift regarding the patients since I am a new agency nurse?

Be sure to find out what residents need to have their meds crushed and require thickened liquids, which residents require more time during a med pass because of whatever issues (or are simply chatterboxes) as you would want to see them last, which residents are insulin-dependent (if you have been lied to, which in my experience, you have [the only way to have a 1:10 ratio is if there are 20 residents in the place and 2 nurses], that morning med pass with all of those accuchecks and morning insulins is going to be a doozy!).

AND!!!!!!!!! Find out which are your DNR residents!!! You'd be surprised at the number of full code residents that are inside an LTC. DNR residents are the minority. And for Heaven's sake, eyeball all of your residents before accepting the keys. I worked with a nurse during my LTC days who finally stopped insulting my delay in counting narcotics/accepting keys after she was left with a corpse to dispose of 10-15 minutes after the off-going nurse had clocked out.

djh123 · Aug 28, 2016

Ha ha ha! 1:10?!? The lowest ratio at my facility - and that's only even if a few beds are temporarily empty - would be 15-17, with 20 or more being more the norm.

PMFB-RN, RN · Aug 28, 2016

Perhaps it's because of heard during my entire career that nurses who work in nursing homes aren't real nurses. Or perhaps it's because last week I worked 60+ hours getting ready for state survey and covering for nurses who called out. I've been at this facility for 2 months.

Interesting. In my long nursing career I have never heard anyone say that nurses in nursing homes are not real nurses. I was under the impression that, since they often have to deal with things without the vast resources available to those of us who work in large medical centers, they were kind of a cut above.

Spoiled1, MSN, RN · Aug 29, 2016

Ha ha ha! 1:10?!? The lowest ratio at my facility - and that's only even if a few beds are temporarily empty - would be 15-17, with 20 or more being more the norm.

Oh yeah, it's hilarious. I've never done LTC, but even I KNOW that's a lie!

Spoiled1, MSN, RN · Aug 29, 2016

The OP in no way hinted or indicated that she didn't think working in a nursing home was a real job. Not even a suggestion of that and I am totally mystified as to how you could have misunderstood her comments so drastically.

Thank you!!!!!!

CoffeeRTC, BSN, RN · Aug 29, 2016

Yikes, I couldn't imagine doing agency in LTC and not having LTC experience.

Will your agency send you to the same facility? Is this a long term assignment?

I have to agree...the 1:10 is a lie unless they are including nurses in with the CNAs? Even then it doesn't add up.

I would go thru and read some of the "new nurses in LTC" threads in the Geriatric/ LTC section.

Will you be house supervisor and/ or work the cart?

Organization is key. I work part time, so I try to come in a few more minutes early and read up on the 24 hour report for the last week or so. Get a census sheet and take brief notes. That way during report you have an idea what is going on with the residents. I like to know who is A&O, crushed meds, thickened fluids, fluid restrictions, IVs and any on going issues. For the most part, most of the residents are stable and do sleep at night. Its helpful to know the last prn pain med. (most get them on the 9pm round, so I will then know who is due early in the shift)

Start with the 12 a med pass and get the few treatments that need to be done then. Some IVs need hung then too.

After that i do the restocking/ checking the supplies and getting a list together for ordering.

Charting

Checking the lab book (labs from the PIC lines, specemins etc)

More charting

6 am med pass is a bit heavier with am accu checks and meds.

11-7 does the line changes too.

Spoiled1, MSN, RN · Aug 29, 2016

Yikes, I couldn't imagine doing agency in LTC and not having LTC experience.
Will your agency send you to the same facility? Is this a long term assignment?
I have to agree...the 1:10 is a lie unless they are including nurses in with the CNAs? Even then it doesn't add up.
I would go thru and read some of the "new nurses in LTC" threads in the Geriatric/ LTC section.
Will you be house supervisor and/ or work the cart?
Organization is key. I work part time, so I try to come in a few more minutes early and read up on the 24 hour report for the last week or so. Get a census sheet and take brief notes. That way during report you have an idea what is going on with the residents. I like to know who is A&O, crushed meds, thickened fluids, fluid restrictions, IVs and any on going issues. For the most part, most of the residents are stable and do sleep at night. Its helpful to know the last prn pain med. (most get them on the 9pm round, so I will then know who is due early in the shift)
Start with the 12 a med pass and get the few treatments that need to be done then. Some IVs need hung then too.
After that i do the restocking/ checking the supplies and getting a list together for ordering.
Charting
Checking the lab book (labs from the PIC lines, specemins etc)
More charting
6 am med pass is a bit heavier with am accu checks and meds.
11-7 does the line changes too.

I know, it's scary! But yes I will be going to the same facility and it's ongoing, long term. Thanks for sharing your wisdom and breakdown of your routine.

CoffeeRTC, BSN, RN · Aug 29, 2016

Once you get into a routine, it will be okay. Moving around from place to place with out LTC background could be tough. Your ICU skills will be useful when assessing residents. Things get missed without a careful eye! Other skills will be used too...we start our own IVs and do a good bit of off hour blood draws!

Good luck!

BuckyBadgerRN, ASN, RN · Sep 2, 2016

My "pearl of wisdom" is to stop thinking of this position as not a "real" job and for sure don't utter those words to others in real life

Hi all! I've been a nurse for 8 years with my background being ICU/Critical care nursing. I just finished grad school and need to work to pay some bills until I can pass boards and start my "real" job in October. Anyway, long story short I signed up with an agency to work PRN shifts. My first shift will be in a few days at a LTC/Assisted living facility. I was told the nurse patient ratio is 1:10 (I suspect this to be a lie). I've never worked in LTC and wanted your best pearls of wisdom. I will be working overnight 11p-7a. What usually happens on the overnight shift? What can I expect? Any information will be greatly appreciated. Thanks.

GreenOne · Sep 3, 2016

Coming from the hospital and working a stint in LTC, I was overwhelmed with the number of patients & knowing their important diagnosis & the amount of meds they are taking. It is helpful to remember that you are coming into their home & the goal of treatment isn't curing ailments but relief of symptoms. Know what the parameters are to notify providers, the threshold is high & often the treatment is wait& see. Blood sugar isn't tightly controlled. UTI's might not be treated until very symptomatic. It was odd not doing full assessment. I would ask another nurse what residents to hit up first for HS meds or AM meds. Get use to dementia or any resident refusing important medications, the provider may have adjusted the dose/frequency to compensate for that & as always its their right eg BS 400 refusing insulin, sz meds. Know code status of course. The providers and staff have probably been treating these residents for years, the CNA's are so valuable- they will pick up much earlier than you changes in residents. time am med passes with CNA rounds. Lots of vasovagal syncope. careful transferring by yourself. Residents might not be transferred to hospital when you think its warranted, the anticipated eventual outcome is death after all. We are trying to keep them comfortable and in their own home/LTC. Also bowel interventions. Some of the best nurses and CNA's I've met have been in LTC

amoLucia · Sep 5, 2016

A little late with this - whenever I had a new employee for orientation, and esp a new-to-my-facility agency nurse, my first priority was that they know how to use the facility's phone/intercom system.

I always made it a point to show her the IMPORTANT keys Like the med room and its refrig, the utility room, the employee BR, the supply room, etc.

I also made sure they knew where the phone lists are - for the DON/on-call supervisor, the administrator and other dept heads (like maint, if you get a flood from a broken pipe!!!), MD contact numbers, and other facility numbers like routine ambulance, DIALYSIS, the lab & xray, etc. POLICE, FIRE, emergency ambulance/EMT & 911, and security.

There most likely will be someone familiar with the place who does know where all this stuff is, but I just alert newbies anyway. I know that info was always well-received.

Depending on your State and the facility, as an RN, you most likely may be responsible for signing off the Death Certificate to release a body to the FH. Just ask about the steps - that's also another reason why to have Dept Head phone numbers!!!

I used to have an informal TO-DO (and HOW to do it) list just for situations like yours. Just my own type of 'cheat sheet' that I gave out or used for my own needs.

I don't remember if I noted this in the previous posts, but the off-going nurses used to give me a census- type list with info HOW PTS TOOK THEIR MEDS!!!! That's the piece that gets you thru med pass!

Good luck!