Impossible to work correctly

Specialties Geriatric

Published

I just started my first job out of nursing school at a SNF, and it looks impossible to complete all of your work correctly in the time you have. My three weeks orientations just ended, and even with two of us working the cart it took 5 hours to complete our 9am medpass on 22 patients. We didn't get around to any of our treatments or charting because all we did was pass meds all shift.

Next week I start on my own and idunno what I'm going to do. Some nurses said they just skip all medicare charting, all of them said they chart that treatments were done even though they didn't have time to do them, and some said skip all over-the-counter medications but still chart that you gave them.

What are the best corners to cut to finish your work in time without risking your license?

I understand! I would never cut corners as a nurse. I would prioritize and delegate. I make sure that my fs and insulin is done first. I know which meds are critical for 30 min windows. I know who will refuse or be LoA and offer before I draw up.

Oh! I also think that we need to remember that this is 24 hour nursing care. There is always work to do....support your peers. Give and receive work that is hanging in the transition and enpower yourself and your culture.

Did you say 5hrs for one med pass with 22 residents??! Sheesh. It usually takes me about 2.5 hrs with 29 residents. Once you find your routine, and know what residents to tackle first, it usually cuts down your time. The hardest part is learning and figuring out your residents. Once you get that mastered, you'll do great!

As soon as you get your time management down, that med pass will be under 2 hours. Never chart something you do not do. I had 23 PEG tubes and over 30 blood sugar checks. It took me 8 hours to do my first med pass, after that I got a routine down. Good luck

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
What are the best corners to cut to finish your work in time without risking your license?

First of all, the 'risking my license' mantra is overused and inaccurate. Most nurses who have had action taken against their nursing licensure were working at hospitals, not LTC facilities or SNFs. In addition, the vast majority of offenses that led to revocation of nursing licensure revolve around addiction: impaired practice, drug diversion, theft, and failure to complete state-ordered impaired nurse programs.

Before we proceed further, look at the big picture. It's a SNF. In other words, it is the home of the residents who live there while they are there. This is why they are called residents.

Low-acuity residents do not require full head-to-toe assessments more than once per week. Manage your time by spending no more than 10 minutes with each resident. If you are working a Medicare wing, the residents will need a full set of vitals once every 24 hours. Also, low-acuity residents do not need to have their vital signs taken multiple times per day.

Look at the big picture and be mindful that you are not dealing with an acutely ill patient population. If they were truly acute, they'd be in an acute care hospital. Also, this might sound brusque, but the residents are not your personal friends. Be friendly and professional, but limit the conversation. You do not have all day to spend in each person's room.

Most adults in our communities have chronic illnesses such as hypertension. Would your neighbor with HTN who takes Amlodipine daily and Metoprolol Q12 hours check her blood pressure and pulse around the clock? No! She's just swallowing her pills, and nothing bad happens because she's not acutely sick. It is the same concept with SNF residents who have chronic stable disease processes that are managed in their homes (a.k.a. the LTC facility).

Therefore, unless parameters are attached (e.g. "hold if SBP is less than 110), there's no need to do constant vital sign checks before medication administration. The main exception is digoxin: a 60 second apical pulse is needed. Constantly performing vital sign checks before giving medications is unnecessary and will suck up your precious time. And believe me when I say you need this time for other tasks in the SNF setting.

Other than obtaining a full minute apical pulse prior to administration of Digoxin, or checking BPs for medications that have physician-ordered parameters for systolic and diastolic BPs, it is a poor use of time to constantly vitalize stable SNF residents. You are not working in acute care, and you do not have the time or tools to practice textbook-style nursing. You have entered the real world of nursing that has time constraints and operates on efficiency. Remember that.

A textbook world of nursing exists alongside a real world of nursing. If you try to apply textbook principles to SNF, a healthcare setting that is famous for scandalously high nurse/patient ratios, you will burn out to a crisp. I'll repeat myself: these residents are living at home. They are not acutely sick. They do not need full head-to-toe assessments several times a day. Hence, approach this healthcare setting as if you are in their home. Good luck to you!

I worked in SNFs for six years. With 20+ residents, there's no time for head-to-toe assessments. Again, good luck!

Specializes in Long-term/Geriatrics, Home Health.

I agree with TheCommuter 100%. Trying to do too much too soon will completely burn you out. When I first entered in SNF, I would come in to work 15 minutes early and I would write in my notebook which assignment I had, which vitals I had to do, write down how many g-tubes, trachs etc were on my assignment, see who had appointments and what time they were leaving and broadly look over what treatments I was responsible for that day. Just having somewhat of a game plan for the day helped me with my time management so I wasn't caught off guard. The name of the game in SNF and longterm care is multi-tasking and time management!

Specializes in nurseline,med surg, PD.

Just like being an athlete, you will speed up with time. Eventually you will have the MARS memorized and med pass will go quickly.

Specializes in LTC,Hospice/palliative care,acute care.
Just like being an athlete, you will speed up with time. Eventually you will have the MARS memorized and med pass will go quickly.

BUT (not stating YOU do,M.A.N.) don't rely on that. I've seen too many nurses get burned.You will get into a zone...it just takes time

Specializes in OR/PACU/med surg/LTC.

Yes don't try to memorize your MAR as it changes too often. I tend to know who gets blood sugars, puffers, eye drops. Pretty much anything that isn't in their blister packages. I still double to check to make sure they are still in MAR, but knowing who gets what is helpful. We don't have daily vitals on most people. We have daily BPs (not very often), or weekly BPs but I usually do them after the breakfast medication pass as they are only daily/weekly. You will get quicker.

You'll definitely get faster as you get to know the residents. When I first started working the LTC unit at my facility, I was horribly slow and med passes felt like they took forever. The beauty of LTC is that the residents are stable and they aren't getting new orders every week. As you get more familiar with the residents and where meds are located in your cart, you shave off a lot of time. Instead of reading through the MAR and learning all of their meds for the first time, you can start reading through the MAR and looking for changes. Even though I have the same residents each shift, I still take time at the beginning of each shift to flip through each individual MAR and look for new orders. Don't get complacent or assume that things never change just because it is long term care. It just doesn't change on a daily basis.

With time, you'll also learn which residents you need to get to right off the bat so that you don't waste time during your shift chasing them down for meds and treatments. I also try to get the treatments that require the patients to be undressed or in bed (ie, wound care on bottoms, creams, suprapubic catheter dressing changes, etc.) before patients get dressed and out of bed for the morning. Taking the time to organize your med cart at the beginning of the shift and making sure that you have all of your supplies will also cut down on the number of trips you make to the supply room in the middle of med pass. I also try to keep my med cards in alphabetical order in the drawers so that they are in the same order as the meds appear on the MAR. If meds are kept somewhere other than a card, we jot a little note on the MAR (ie, "bottled med" or "in fridge") to make it easier to find things.

We only do vitals on the people who have parameters for holding meds or a specific order for more frequent vitals. Even that isn't a full set. If it's a BP med, we get BP and HR. If a resident is on O2, we get O2 sats q shift. If they are on abx, we take their temp q shift while they are on them. Assessments are only done if ordered or if there is a change in condition. Otherwise, I spend the bulk of my shift passing pills. I can usually finish my morning med pass and the majority of my treatments for 20 residents in about 2 - 2.5 hours. And that's with me only working this unit once every couple of weeks. I'd be a lot faster if I worked it every day.

I also found that my time management got a lot better when I organized myself by task. While I still try to cluster cares for residents when possible, some tasks such as getting blood sugars, passing out supplements, and taking vital signs are easier when you get into that groove and knock everyone out one after the other. If I try to gather all of those things and take them with me to a room with meds, I usually don't have a free hand left to knock on the door.

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