I'm embarrassed, but can use some advice on time management

[nlk96, BSN]

I recently returned to work in a LTC facility after a 10 year hiatus taken to have a family and return to school. I seem to be having more of a difficult time with time management now, than I ever did before. I could really use some tips/advice. Here's the lowdown:

I'm responsible for approximately 24 residents, on 2 separate wings

There are 2 separate med carts, along with 2 sets of keys

There's 1 laptop, that the battery always seems to be dying on. I am constantly going to the nurses' station to plug it in to re-charge it. This is so time consuming!

As you know, there are lots of p.o. meds, IV therapy, G-tube, many nebulizer treatments, nitro patches, lidoderm patches, and at this facility, all syringes are kept locked up and must be signed for when used.

There are 7-8 residents with blood glucose monitoring. Some get insulin at 7:30 AM, one gets it at 11:00 AM, and then there are the 11:30 finger sticks with coverage. Insulin is kept in refrigerator, which is in locked med room. There are about 12 residents on health shakes at 2 separate times during my shift. These need to be kept in the refrigerator until given. Again, these are locked in the med room.

I just feel like I'm often running around like a chicken without my head. I feel I'm doing an awful lot of unnecessary back-and-forth running, from the floor to the med room, getting the insulin, getting the shakes, getting whatever. Then, I have the residents that want their meds sooner or later because they're going out with family, going to an activity, etc....so I am running back and forth between the 2 med carts. Then, of course, there is the privacy issue, so I often have to wheel residents to their room or a shower room for finger sticks, insulin, application of patches, etc....By the time I sit down to chart (which is also done on the laptop), it's already the time I should be leaving!

I'm sure many of you are probably laughing right now, and believe me, I feel very silly typing this, but I really do feel that I could benefit from any tips you may have to offer. What can I do better?

Thank you for anything you can offer!!!

[itsmejuli]

Why is the insulin in the med room? That's just dumb, it can be kept on the medcart as long as its dated.

When I worked LTC, we'd keep the nutritional drinks on ice on the medcart. I was in FL at the time and this was ok with state.

[G MA RN]

Do the PO meds first, other meds, g-tubes, then nebulizer txs. Can the laptop be pluged in at the patients room?

If finger lances are called for they are usally morning orders. Those are very important. Remember ADL can some times be left for later. If you need to document, you can carry a scratch pad to make notes for later use. I hope this helped.

[Allison RN]

First of all, I don't think anyone who has ever worked in LTC would laugh at you. Most likely, they're nodding their heads thinking, Oh my gosh...I totally feel her pain!

LTC today is vastly different than LTC 10 years ago (at least from my experience). I had no trouble doing everything expected of me and more when I started 13 years ago. When I quit three years ago, I felt like I was an awful nurse who did nothing but satisfy MCR and MCD documentation requirements while I did drive-by med passes on people I should have known much better than I did. That being said, here are some things I would do or check in to:

1. Laptop battery...have you notified mgmt of the issues? Maybe it needs a new battery or an additional one so you can change them out instead of recharging. That may save you a little bit of time. And a few new batteries are cheaper than OT.

2. Does the insulin have to be kept in the fridge? The hospital I work at allows us to store it in the rooms. It does last longer in the fridge, but if you just have it out during your med passes and keep it locked in the cart, I wouldn't think it would cause a problem.

3. Is there any way you can combine some of the things for one trip down the hallway? For instance, doing health shakes and glucose checks during one of your trips down the hall?

4. Health shakes: a. can your aides help distribute? b. Can you get a small bucket of ice and keep the shakes in it on the cart? We were able to do that at the facility I worked in and it really helped us out.

5. The 1100 insulin..is that one of your 1130 checks with coverage? If so, can you combine those? We are able to give meds 30 min before or after time due and still be in compliance. I'm assuming that's the same for you because I think it's a federal CMS thing. You could start at 1130 with that pt.

6. The pts that you have to take into shower room for sticks, shots, etc: if this is happening prior to mealtimes (as it did for me) can you speak to them or your aides and have the pts stay in their rooms until you get to them? I know it may not work for all of them, but most of my pts were completely fine with doing that.

Lastly, don't be afraid to speak to your mgmt team. There are always exceptions, of course, but most will really try to help you. Maybe other nurses are having the same problems and they need to look at a different way to do things. And it's always in their best interest to keep their employees happy and productive. High turnover rates cost facilities a lot of money in advertisement, orientation periods, etc so it's always helpful to retain the employees you have. Not to mention the continuity of care for their residents. And if they can streamline the job in some way it cuts down on any OT someone may be getting staying over to complete their work.

I hope some of this helped. If you can take nothing else from it, again, please know that you're situation is not unique and don't get discouraged. LTC is an incredibly hard job to do and it takes very special people. Good Luck!

[RNChristy]

Why is the insulin in the med room? That's just dumb, it can be kept on the medcart as long as its dated.

Insulin should always be kept in the refrigerator (dated) in a locked med room. This is also a safety issue that JCAHO may look at.

OP, I agree with keeping a note pad with you if unable to chart notes on the laptop as you go. This helps to avoid forgetting any important that should be documented. That is something that I always did when working on a busy Tele floor. I have never worked LTC but it did help when with fewer patients also. Maybe, make a list before going to any patient's room and try to carry everything you need to decrease the running back and forth, if able.

Hope this helps. Good luck!!!

Christy, RN

[obenfermera1]

Insulin should always be kept in the refrigerator (dated) in a locked med room. This is also a safety issue that JCAHO may look at.

This is no longer true....I'm not sure, but I think it was 2009 when this changed. Joint Commission requires it to be stored "according to manufacturer guidelines" and if you check the websites, the manufacturers state that open vials of insulin can now be stored at room temperature for up to 28 days. Unopened vials are still to be kept in the refrigerator to ensure their quality until the expir. date on each vial. My hospital hasn't had opened vials in the fridge for over a year. :heartbeat

[RNChristy]

This is no longer true....I'm not sure, but I think it was 2009 when this changed. Joint Commission requires it to be stored "according to manufacturer guidelines" and if you check the websites, the manufacturers state that open vials of insulin can now be stored at room temperature for up to 28 days. Unopened vials are still to be kept in the refrigerator to ensure their quality until the expir. date on each vial. My hospital hasn't had opened vials in the fridge for over a year. :heartbeat

Thanks for the info obenfermera1. The facility that I work at still has the insulin in the refrigerator. That is their policy so I guess this can be by facility too.

Christy, RN:)

[CapeCodMermaid, RN]

One good source of information is your pharmacy consultant. He or she should be able to give you the up to date regs in your state. We don't keep the insulin in the fridge once it's opened. Some old habits die hard. We have many residents with finger sticks even though it's not the best way to regulate blood sugars. Lots of them don't want to have to go to their rooms for each finger stick or injection. We ask them and if they want we get an MD order and put it in their care plans that they prefer not to have their activity interrupted for a finger stick and we do it where they sit. Even the DPH can't argue with resident wishes.

And, please don't be embarrassed about any question you ask here. That's why this forum is here and we all need to ask advice at one time or other.

[CoffeeRTC, BSN, RN]

Ask the other nurses what their routines are for that shift/ hall.

Stock your cart at the start of the shift. We have the insulin on our cart (refrig unopened vials) shakes are in a bucket of ice too. Sign out a few insulin syringes before you start (if you can). Get a list of people that will be going on LOA or therapy for that day and get them done first. Make sure you are talking with the CNAs about this and they can let you know when so and so is ready for meds or will be leaving.

I get the diabetics first then the people that need to be somewhere next. Those with g tubes or don't leave the rooms until late go last.

Can they get a second computer or maybe they need to change the battery? Can you do the computer charting last or do you need it for the meds?

[Forever Sunshine, ASN, RN]

The computer would be a problem where I work. What is it specifically used for? Charting or MAR or both? Can you do your charting while its charging?

How come all 24 residents aren't in one med cart? Ours hold 25 even if I have to squish things in and make it all fit.

Definitely set up your cart before taking off, spoons, puddings, health shakes, insulins, needles, water, cups, straws, napkins, hand sanitizer, pens etc

Maybe the health shakes such as ensure can be given by dietary during a meal.

[teeniebert, LPN]

Maybe the health shakes such as ensure can be given by dietary during a meal.

This was the policy at my last employer. Where I work now, the Ensure/HiCal/Boost shakes are in the med room and are to be given by nursing. I'd much rather ask a resident's aide if Mrs. Soandso drank the shake on her breakfast tray than deal with the in/out/oh geeze I grabbed a HiCal and she needs a Butter Pecan Ensure/save time with an ice bucket/oh for f's sake I spilled the ice bucket on the MAR again...

[Forever Sunshine, ASN, RN]

This was the policy at my last employer. Where I work now, the Ensure/HiCal/Boost shakes are in the med room and are to be given by nursing. I'd much rather ask a resident's aide if Mrs. Soandso drank the shake on her breakfast tray than deal with the in/out/oh geeze I grabbed a HiCal and she needs a Butter Pecan Ensure/save time with an ice bucket/oh for f's sake I spilled the ice bucket on the MAR again...

Ensure is given but dietary but glucerna/Hical is given during the medpass. I know of 3 residents who I can get to drink it. Maybe 4. The rest just don't want it at that time.

Residents are more likely to drink it at their meal also or at least at a snack time(afternoon or HS snacks) They don't want HiCal at 4pm because it will spoil their appetite for dinner. They don't want it at 7pm because they just ate dinner and aren't hungry.

I'm always spilling the damn HiCal on the MAR. lol