Vent/Advice Needed

vintagemother, BSN, CNA, LVN, RN · Jun 16, 2016

Responding to myself is a little strange, but I honestly want to figure out solutions!

1) don't let myself get interrupted during the big med pass! Ignore PRN narcotic requests. Give them with their morning meds. Don't answer the phone, because others can walk to the unit if necessary. (Half the phone calls are for people who aren't even residents)

2) don't stop med pass at all. No line jumping. The ones who can ambulate surround my cart to ask for narcotics which interrupts me. I think that I can simply give them a PRN when I give them their morning meds.

Feedback is appreciated!

rpsychnurse · Jun 16, 2016

You'll become more efficient with time- don't worry!

Co-workers faking vitals and blood sugars is very serious. I would report it to your superiors and don't fall into it! It will take a hell of a lot more time to deal with a patient in DKA because you faked a blood sugar than to just check it in the first place. If there are vitals/blood sugars that you feel are unnecessary, ask the physician to decrease them. Otherwise- they're there for a reason.

My thoughts- ask pharmacy/physicians to change some med times to make your pass easier. Having so many times sounds really tough- and I can't imagine it's necessary for all the meds to be staggered that way.

Trying to decrease interruptions- especially as you're still learning- is a great idea. You'll get better at prioritizing as you go! If it is a no-urgent PRN request- make a quick note of it on a scrap paper or brain sheet and say you will pass it with their regular medications when you get to them.

Try to avoid other distractions- delegate as much as possible to care aides/other staff. Patient is requesting an attend change? Delegate. You don't have time for that during your med pass. Patient asks you to go get a warm towel for them? Tell them you can't right now but if they can ask their care aide they will help them.

Definitely ignore the phone calls if they're not your explicit responsibility. They will call back if it gets missed- trust me. If that isn't possibl- ask your manager if you can get a portable phone to carry with you.

Honestly, it sounds like you're managing really well to me. In time, as you get a routine down and are more comfortable in your job things will go more quickly.

Something I try to remember is to give important meds (insulin, time-sensitive meds, etc) first and then worry about the rest.

vintagemother, BSN, CNA, LVN, RN · Jun 16, 2016

Thank you, RPsychnurse!!!!!!!!

Pheebz777, BSN, RN · Jun 17, 2016

well, you do have a "1hr before and 1hr after" window to give your meds. You can bunch up your 7-8-9 meds together by giving them at 8, and you can bunch up your 10-11-12 meds by giving them at 11? The pharmacy usually does have standard time scheds to avoid having meds on different time schedules, you can request them to change the times on some meds.

TheCommuter, BSN, RN · Jun 17, 2016

Medication times at nursing homes and SNFs are often arbitrary and not based on any concrete need. You can get the times changed on many of these medications.

jbudrick, MSN · Jun 17, 2016

In Connecticut, not providing pain medication in an immediate manner is considered a deficiency. Requests for pain relief cannot be ignored. Just saying .... You can anticipate that some patients will request pain medication at the first available time. In any event, you will get quicker over time. Also keep in mind that even though you have the one hour before and after, some meds must be given promptly such as seizure medications and insulin. Best wishes on your new job.

Remy Ox · Jun 17, 2016

You have been there for 3 weeks only, so it is okay to not be perfect. A routine doesn't happen right away and your coworkers are unsafe. Hmm. Fake blood glucose and fake VS! You are doing good to take time and be safe.

NotAllWhoWandeRN, ASN, RN · Jun 17, 2016

well, you do have a "1hr before and 1hr after" window to give your meds. You can bunch up your 7-8-9 meds together by giving them at 8, and you can bunch up your 10-11-12 meds by giving them at 11? The pharmacy usually does have standard time scheds to avoid having meds on different time schedules, you can request them to change the times on some meds.

The trouble is that you cannot simultaneously give 23 (or however many) residents their medications at 0800. And one little old lady with advanced dementia alone may take 10 minutes with pudding, applesauce, and creative wrangling.

I was criticized for "time management" and the DON acted surprised when I told her there were meds scheduled 6 out of the 8 hours of my shift.

I'm jaded by my own negative experience, but the bottom line is to maintain your integrity in how you work. Cluster meds when you can, prioritize the most time-sensitive things, and fit the other things (like PRNs) in when you can. Keep doing what is right, and if that is not good enough for them, be ready to move on to something better - because I promise you, there are better places.

allnurses Guide · Jun 17, 2016

I know your frustration so I am going to tell you how I did it. The electronic MAR that we used was PCC. It has a way to prioritize your med pass. so when I started at 3 pm and my first pass was 5 - I would start at 4 pm using the 1 hour rule and set priorities from 4 to 6 pm. I would start by taking all my blood sugars since dinner was served at 5:30. Then set out on my pass - hitting the diabetics first. Vitals related to meds were taken at the bedside when I came to that resident. While in the room I always ask about pain and give PRN pain meds along with scheduled meds if they were indicated. If people came up to the cart I would say - I am taking care of (insert name here) I will meet you in your room. Sometimes you have to interrupt your med pass for a physician or phone call but then you go immediately back to where you were. When meds were scheduled every hour as you describe I would call the doctor and see if they could be changed to standardized BID, QID, TID Etc. Often the doctors will say go ahead.

LTC is a very challenging environment so hang in there and stick to your guns. You will get this.

Hppy

beekee · Jun 17, 2016

I work days. I start with the diabetics. I take their vitals and blood glucose levels. Then, I go to the ones who always want PRN pain medication and take their vital signs. I then dole out the PRN pain medication with the scheduled medications. Then, I get the rest of the vital signs and swing back around and dole out the medications.

If I had a dressing change that's hard to get to (hip, knee) or a pain patch in these areas, I try to get to them ASAP (with the medications) before they are dressed. It'll save you time later.

If a patient asks to use the bathroom or anything else I can delegate, I tell them that the aide will be right in to help. I hate that I have to leave them, but I just don't have the time. Obviously, if I have a self-transferring, fall risk patient with dementia, I will stop and do it (because it'll probably save me time because I won't have to fill out all those forms for a fall).

We have med pass windows, e.g., 7 am to 11 am; see if you can get meds changed to a window instead of a specific time. We have the overnight nurse administer levothyoxine; if you are doing it, see if you can switch that so you don't have to worry about the timing.

Make sure to fill your pockets with straws, alcohol wipes, and anything else you might need during your shift. Stow a box of gloves in your cart, for those times they are missing in the room.

At the beginning of the shift, I write down everything on the TAR on my brain sheet, so when I'm in a room, I can take a look and quickly do it when I'm there. Most of the time, I'll try do the treatments with the noon med pass because it's less hectic. For instance, I can wrap legs with Ace wraps while the patient is doing an inhaler (assuming they can self-administer).

Even little things, like starting the BP and then putting on gloves for the blood glucose while you are waiting will save you a little time. Put a box of gloves near the test equipment, so you are walking back and forth for gloves.

Organize your cart so you know where everything is. Limit the number of drawers you need to open and close during a med pass, if you can. I try to keep the meds in two drawers, but I've seen carts where meds are in three; I'm always opening and closing drawers for stuff! Check the stock meds before you start to make sure you aren't out or close to it; get those stocked before you start.

And frankly, the expectations are sometimes just ridiculous. I'm still pretty new too. I'm getting better every week, but I can be so hard on myself when I see the other nurse already charting at 9:30 and I have four more patients to get to. I'm sure at some point they were in my shoes and some day, another nurse will be looking at going "how does she do it?"

kbrn2002, ADN, RN · Jun 17, 2016

First time saver is to cluster those meds together unless there is a very good reason they can't be given together. Even better, get those med times changed where you can so you are not giving meds every darn hour. If a bunch of VS are slowing you down ask the rounding MD if a lot of them can be discontinued. After all, they are LTC residents and they are in their home. How many people on BP meds do you think take their BP at home every time they take a pill? As long as they are and have been stable, try to get rid of those. Same with any accuchecks that are not insulin dependent diabetics. If you can show a stable history they can be decreased. I got all of mine reduced to 3x/week or less.

As for worrying about being slow, don't. It takes a while to get a routine down. After some time you will figure out who wants meds right on time and who doesn't care what time they get them. You will also quickly learn who the more time consuming residents are and you will be able to plan to take a little extra time there. I try to save my more chronically difficult residents for last so I don't feel like I need to rush away to get to the rest of my residents.

It's an overwhelming workload in LTC at times, so just hang in there and do your best. Speed will improve with practice. Good luck and try to have fun!