Hi, I'm a new nurse at a LTC facility, and am orienting on a floor with 31 pts. I was told by several nurses to watch out for the nurse who is orienting me, that she can be tough. That's fine with me, nursing is a second career and I can work with most people. HOWEVER, she told me that she does one med pass for the 3-11 shift - everyone gets their meds sometime between 4-6, regardless of when they are scheduled, because otherwise she would never get everything done. She told me the order to do things, and send me off with the cart (I hadn't yet met any of these pts, and had no idea who was who). So, I did the first med pass "her way" with a lot of trepidation, in order to get it done. I made a new cheat sheet for myself so that I could see who got meds at what times, so that I didn't have to flip thru the hellish handwritten MAR every hour. Using my cheat sheet, I was able to get the med pass done in a fairly legal way, but probably would have had a hard time getting the documentation/notes/other stuff done if she hadn't done that for me while I was doing meds. I can work on speed, it will just take time.
Here's the problem: one gent said that he wasn't feeling well, was pale and diaphoretic, a bit nasueus; this was around 5 pm. I took his vitals, had normal BP, resps were irregular at 32, and HR was an astounding 185. I reported this to the nurse, and she said that he should be fine once his Coreg kicks in. I checked the MAR since I didn't recall giving it to him, and saw that it wasn't due until 9 pm. She said that he is a DNH/DNR, so I should just give him the Coreg since he's used to getting it at that time from her. I gave it, and his HR did go down to 110 about 30 mins later.
SO - while I obvoiusly want my pts to be well, I want to respect the unit's routines (two pts were angry when they got their meds at 9 pm, as they were already in bed), I also want to do the right thing. There are a zillion reasons for giving meds as scheduled, safety being the first, but there is not a unit manager who I can approach about getting meds rescheduled so that we are all on the same page. Any ideas? I'm new, and really don't want to alienate my coworkers or upset routine. Other than this, I really like the place where I am working; I think that most of the nurses give excellent care.
Specializes in Geriatrics, Hospice, Palliative Care.
i work at a nursing center in oklahoma, and there is one resident who is hiv positive. which does make me a little un easy. is it wrong for me to want to refuse to do certian things for him? i mean i am newly married and i have a 3 yr old son. it's a scary thought! help! please
what certain things do you want to refuse to do for him? unless it is something totally out of the scope of your practice (having sex with him, smearing his body fluids on you, etc.), just practice universal precautions, and you should be fine. i hate to sound abrupt or smug, but really...you should consider that every patient has something that you don't want, and that you have something that they do not want. use appropriate care with each and every encounter! we have a 95 y/o lady with genital herpes...so you never know.
good luck with your new marriage! it is a joyous time.
I was just about to start a similar thread when I found this one. I recently started my first job as a nurse in LTC and saw quite a few things that make a bit nervous. Nurses routinely give a med hours late because of their own judgment. Or when I document I was told that since I don't know the residents yet and it would be impossible to assess at least 40 people each shift, to pretty much just copy what the last person wrote (and that last person copies from the nurse before etc.). I feel like everyone is making up a lot of things and signing off interventions they didn't do.
Today, I saw a CNA straight cath a resident! I don't even want to think how she learnt it, since obviously someone must have taught her.
I wonder if such things are common practice in LTC and inofficially accepted, or if it is just a bad example. I do realize that there are a lot of people to take care of for each nurse and it seems almost impossible to actually do every little thing.
Also, I wonder what could possibly be done about this situation? I haven't said much so far and I'm hesitating to report such issues, since I'm new and don't want to have the rest of my co-workers against me. I'm just trying to do my best at keeping up my own standards.
Specializes in Gerontology, Med surg, Home Health.
Universal Precautions are called that because they ARE universal. Probably many of your patients have diseases or viruses you don't know about. That is why we use universal precautions on everyone. You have no cause or right to refuse to care for this unfortunate person.
Am I missing something??????? My understanding is that we are obligated to the 5 rights of medication,one of which is right time. Where I practice I can't take it upon myself to arbitrarily change the med times for my convenience. I would first need to go through my DON and then if it is first safe and then approved by the pharmacy it just might be OK .. The the first thing my DON would want to do is counsel me as to why I can't get my meds done on time. It may be my problem and not the schedule and not the patient load. To just change the schedule for me without clearance is a justifiable reason to jeopardise my license. Like I said Did I miss something?:loveya: LTC RN 20+years
OMG- first of all, the nurse needs to be reported to the state for so many reasons. "Quit taking care of the patient"????? :omy: I would have called the elder abuse hotline right then and there. By going along with what she is doing, you are enabling her ongoing abuse.
2nd: the five 'Rs' of med passes are not just for nursing students or just for hospitals. You do have some latitude-1hour before and 1hour after the scheduled time. Everyplace I've ever worked in 32 years as an RN has had a recommended schedule for meds with the specific purpose of getting as many of them as possible at one time. But you have to actually have that WRITTEN down on the MAR, you can't just make it up as you go along. Anything less is risking your license and your livelihood. You sound like you really want to be a good nurse. Don't let this bad example of nursing ruin your good instincts! There are LTC facilities where they do things right! :oornt:
Specializes in Geriatrics, Hospice, Palliative Care.
Thanks for all of the replies; I don't have to work on that wing very often, but have made my own cheat sheet so that I have a pretty good idea who gets their meds at what time. If I work like a fiend, I can get it all done on time and by the book. The last two times I worked there, she appeared pretty angry about it, but I just ignored it and was pleasant to her. I'm not at work to make friends, but rather to take care of people.
Here's a question. I am also new to this field, as I have been working in pharmacy pretty much ever since I graduated 18years ago. I started working perdiem at an LTC facility about 4 months ago. I have 20 pt's to pass meds to, do treatments, IV's etc..what is the legal amount of time you have to give meds? I usually start my 9pm med pass at 630pm and am lucky to be done at 10pm. Between taking vitals, checking temps, skin checks, and checking sats I do not see how anyone could space it out perfectly the way the MAR reads. I love the elderly, I enjoy this job, but I wonder is there a job that allows more time?? I feel I need more time with each resident in order to do a really good job. :heartbeat
Specializes in Gerontology, Med surg, Home Health.
The regulation is meds are to be given one hour before to one hour after the written time...so a 6 pm med can be given anywhere between 5pm and 7pm. Unfortunately unless you want to work in home care, there isn't much of a chance to spend any time with the residents. The best thing to do is to work with the team and get rid of as many unnecessary medications and treatments. We had orders to do an O2 sat and respiratory assessment on 3/4 of the residents on the dementia unit. OKAY if they have symptoms do an assessment, but to keep assessing people who's lungs have been clear for months and who NEVER use their PRN nebulizers or supplemental O2 is ridiculous.
Holy cow! I mayy have said this before, but, Some of these posts frighten the heck out of me, lol. An entire shift of meds all at once? The nurse that was orienting you is uncaring and foolish.
I couldn't imagine a nurse doing that ever. I have no doubt that you have learned from that experience. Always stay in compliance with your med pass. If if it impossible to do so, let your supervisor or unit manager know that the times or meds have to change.
In LTC, she is right - she'd never get anything done if she had to give one pill at a time to every patient. You have to make sure that you aren't giving pills together that can counteract/interact with other pills. As a general rule, you give every thing at once unless it is something like an antibiotic or cardiac med that is ordered every 6 hours. Knowing your meds and the residents reactions to them is critical.
The times that are written, whether at the hospital or NH, are arbitrary times meant to make it easier for the pharmacy to fill everyone's meds at the same time.
If this patient gets Coreg 1-2 times a day, and those times are spread roughly equally throughout the day, and are given at roughly the same times every day, then this man isn't not likely to be harmed.
The nurse should be documenting the times that it is being given though - not simply writing "2100" because it is on the med sheet that way. It would also be better if they changed the times on the med sheets to reflect a more approximate time to give it. However I have come across DONs that will not do this because it makes the facility look bad that they have to give 2 cups full of meds at one time because they have such a high nurse/pt ration.
In the hospital we give some 7,8,9 am meds all at the same time for the same reason - we don't have time to run back and forth from the med room to the patient's room constantly. But it requires knowing which meds you are doing this with, whether you can do this safely, and documenting the time that you gave them correctly.
LTC is a bad place to have to learn the facts of life that are so different from school because you have way too many patients to try to care for. I would rather that this nurse do what she does than to not give meds and treatments because she never made it that far down the list of things that needed to be done. Make sure that the times the med is given is written down correctly, even if it seems "off" with the MAR. And be prepared to answer why things are done this way if you are asked.
And hope that you are not answering to a jury. Sorry, your response is wrong and the practice of the trainer is wrong. Meds must be given as ordered, not at the convenience of the nurse. The newby needs to do it the right way and if the trainer wants to get mad, so be it. The newby can tell it to the DON. All she needs to tell trainer is, "I don't feel comfortable giving an HS med at 4 p.m., so I will give it at HS." No holier than thou attitude, no asking for approval, just a professional nurse, however new, doing what is right, in the face of this tyrant who wants to jeopardize her license. And not calling a doc for the HR of 185? Excuse me? Unless there is an order not to notify the doc, doc is getting notified. ATAIHTSAT Forrest Gump
holy cow! i mayy have said this before, but, some of these posts frighten the heck out of me, lol. an entire shift of meds all at once? the nurse that was orienting you is uncaring and foolish.
i couldn't imagine a nurse doing that ever. i have no doubt that you have learned from that experience. always stay in compliance with your med pass. if if it impossible to do so, let your supervisor or unit manager know that the times or meds have to change.
why the sup or um? the doctorneeds to order meds at appropriate times. i know nurses have some leeway, such as with once daily meds, but if the doc orders antibiotics, cardiac meds, bp meds, whatever at set intervals, the nurse does not have the discretion to alter these orders. get with the doctor and get proper, realistic times written.
Because most LTC facility will ask you to do way to many things, with to many residents and not enough time, you learn to make due. Yes, I'm guilting of picking and choosing the appropriate meds that can be given earlier or later. One time a day meds, can usually be given whenever. My first priority are insulins, cardiac , pain meds and antibiotics and their may be more, but that is just a short list. Vitamins, liq. supplements, colace, miralax, and one a days are not a priority for me. If my residents are dirty, thirsty, or just need something more on the hollistic side of nursing that kind of trumps non life threatening medications. I don't like to walk into a residents room and smell urine and feces and have not one CNA around to clean them, so I do and the meds wait. How can a resident have any dignity when you stick non-necessary or one a day meds in their mouths and walk out knowing they are laying in their own waste. And last but not least paperwork is the last on my list of priorities. I think most of it is a waste of nursing time and energy and that time should be spent with the residents and not sitting at a desk. I know that the paperwork is important to cover your butt, the facilities butt and get the old mighty dollar of reimbursement, but I love my resident interaction above all and wouldn't do anything to jeopardize their care, but will make them my number one priority. If a resident needs a hug and my undivided attention, does it really matter if they get their MVI or colace late? Maybe according to the state, but not to me. Yes, I play the game along with everyone else when state comes in, but I know in my heart of heart that I'm a good nurse and very good to my residents and for that I can go home and look myself in the mirror. So as my nursing instructor said "When in Rome do what the Romans do, but if it doesn't feel right, do what makes you feel right and know that you did a good job, to the best of your ability." Sorry so long.
And this is what the public needs to know. And our lawmakers, too. This is the anguish good nurses must live with, all day, every day.
Don't let this bad example of nursing ruin your good instincts! There are LTC facilities where they do things right! :oornt:
Holy cow! I mayy have said this before, but, Some of these posts frighten the heck out of me, lol. An entire shift of meds all at once? The nurse that was orienting you is uncaring and foolish.
catlvr
239 Posts
what certain things do you want to refuse to do for him? unless it is something totally out of the scope of your practice (having sex with him, smearing his body fluids on you, etc.), just practice universal precautions, and you should be fine. i hate to sound abrupt or smug, but really...you should consider that every patient has something that you don't want, and that you have something that they do not want. use appropriate care with each and every encounter! we have a 95 y/o lady with genital herpes...so you never know.
good luck with your new marriage! it is a joyous time.
e