Is this an acceptable practice???

[yoshana_x]

I am recently employed in a LTC facility and have a couple questions

1) how can I speed up my Med pass I take all of three hours to do 20 patients I think that it is a very long time so any suggestions will be good

2) someone suggested that i prepare my meds in individually marked cups during the early hours I was wondering if that is legal as in can i do somehting like that when the state is there.

3)someone else suggested that i put stock meds that i constantly open adn close a small quantity in a cup of each (ie FeSO4, chew ASA , Vit C, Oscal etc) is that legal and can i do that hwen the state is there observing.

Hopign to hear what everyone has to say I want to see what I can do tomorrow to speed myself up.

[agldragonRN]

i remember in clinicals giving an 8am med at 11 or sometimes noon....

i would never give a 8pm med at 5 tho....yikes

but giving an 8am med at 11am or 12 noon is okay fo ya? okay you win... :gtch:

yikes,

angel

[rigidchop]

first you need to know speed comes with practice. if you are trying to rush, you will make mistakes. worry more about doing it right. i never did understand all the rules about the times to pass certain pills. i mean, who in your facility schedules those times? not the doc, they just say bid,tid whatever. in my facility it could be me, or an RN deciding what time these meds are due. i'm not saying giving them 3 hours early is o.k. but its something to think about.

[agldragonRN]

first you need to know speed comes with practice. if you are trying to rush, you will make mistakes. worry more about doing it right. i never did understand all the rules about the times to pass certain pills. i mean, who in your facility schedules those times? not the doc, they just say bid,tid whatever. in my facility it could be me, or an rn deciding what time these meds are due. i'm not saying giving them 3 hours early is o.k. but its something to think about.

yes you are right. when i take an order that says bid. i usually put 9am and 5pm. but when i take treatment

order that says bid, i put 10 am and 7 pm. so i decide what time to put on the mar or tar.

regarding me giving lipitor at 5 pm for 8 pm. well, i have another patient who has the same md that has

lipitor for 5pm because pharmacy puts 5pm on the mar. so why another pt is on 5pm and the other is on 8pm, i do not know.

angel

[pagandeva2000, LPN]

The bottom line is that most people that make these rules are not out in the trenches; if they were, they would see that most of these demands are things that are not humanly possible. Working in LTC and giving meds to 20 patients is better than the many stories I hear about one LPN having more than 40 to administer. If that is the case, there would be no surprize that people are skipping all over the place, trying to survive the shift.

If no one is complaining about your med-pass, and you are new, then, continue as you are...you will get faster with experience, and you may eventually learn what safe short cuts you are comfortable with...because the truth is that the majority of nurses discover them.

And, for sure, I would give an 8pm Lipitor at 5 if there was nothing else due for the patient.

[Fiona59]

Stop doing dressings during your med run.

The thing to remember is nursing is a 24/7 job. Which means that the shift after you can do a dressing if need be.

Now for the BP question. Some LTCs only do BPs on their residents daily for the first month to establish a baseline. Then they go onto monthly BPs. So you don't have to do it. The same goes for pulses.

Remember, that more and more LTCs are adopting the "this is their home" attitude. Who knows when and how these residents took their meds at home and they sure didn't take their pulses and BPs before every dose.

I remember one resident who had 18 pills at breakfast and used to take a spoon of cereal, one pill, spoon of cereal, repeat process. And yes, I stood their and had to observe. After doing it twice, I requested that the times for some be changed and they were. The docs just didn't realize that when they said once a day, they all got lumped at breakfast by the pharmacy. Also if some meds just seem "wrong" leave a message and find out if they are necessary. Some patients stay on meds for years because nobody questions them. Premarin for a 99 yo?

[~MIA~, ASN, RN]

Premarin for a 99 yo?

This cracked me up...but it's so true!

[Thornbird]

The methods you and others mention, though common practice, are not acceptable practice. You will get faster as you know the patients and tehri meds, where things are on the cart, etc so that you are not lookinh for things all the time and flipping through all those pages reading and re-reading. Once you know them you just have to be careful to notice any changes.

It is a requirement that all facilities have standard med amdinistration times for BID, TID etc and that they be followed unless the MD orders otherwise. Some pharmacists and/or nurses go too far in following "recommended times" for med administrations, even when it makes no sense. For example Lipitor and other statins supposedly work best if given at bedtime, though this is not the way the orders are written and hardly anyone does it this way at home. So there it is on the MAR at 8, 9 or 10 pmm all by itself when the patient goes to sleep at 7. Some meds aboslutely must be given at specific times like ac or pc or they don't work at all, I have no problem with that. I request an order for a time change for a med that is ordered all by itself at a different time than other meds.

In my many years as a nurse, I have seen LTC's move far away from the "home" concept. When I began, LTC patients usually had their "maintenance meds" and comfort meds. They didn't take all the dozens of the latest and greatest, not to mention, most expensive meds on the market. I get so frustrated pushing the pills and giving amiodarone and coumadin to 100 year old bed bound patients who wish every day for their maker to take them. What's the point to crushing up Aricept and giving it to the patient who forgot their own name years ago? Why do you have to give them a mulitivit, an iron and a calcium when any sane person would take a multivit/iron/calcium combo pill? Why does everyone that ever had heartburn have to be on Prilosec or other PPI forever? The fact is they give these poor old folks way too many meds these days. I especially hate the trend to have 2-3 hour med passes at the end of 11-7 shift. It seems cruel to wake them up out of sound sleep to take meds they don't want. Back in the day, nothing was given on 11-7 but insulins and q6 hour meds, nothing was given after supper but sleeping pills and pain meds. That seemed a whole lot more humane and "homey".

If LTC's must continue to have these huge med passes, then they need adequate staff to do it. Taking illegal shortcuts only allows the outrageous workload to continue. Meds must be given with one hour either side of the time ordered. If none of the nurses could get it done something would have to be changed by admin. But as long as it gets done, they use the ostrich approach and pretend everyone is doing everything all legal and it's not an unreasonable workload. Then those who do it "by the book" just look slow.

I used to enjoy LTC. You had time to spend with your patients, you got to know them. There was time to get everything done and keep care plans up to date. I could take time to chat with them while doing meds. I felt proud of the excellent care they were getting and the respect that they got in their final home. Now I feel like a pill-pushing automaton that never gets everything done. Care plans are spit out by a computer and are pretty much worthless. My patients live longer but not healthier or happier.

[suanna]

well i am not even sure why i take so long yes i do stop and at times do wound care but for some reason I start out seeming like I am progressing well but then its as if i take a downward turn. I do try to go in early to do the BP's that are required for many meds and that is another thing I have seen the 'PRO's" skip things liek that taking apical for dig not doing BP for HTN meds and I guess stuff like that slows me down not to mention if somehting out of the loop happens. I don't know sometimes I wonder if I am cut out for this.

To answer the previous question this is the 7-3 med pass lots of crush with some difficult I dont' want to take it and I do stand there and watch until they take it all and that takes time when some pt have 10 and they taking it 1 at a time.

If you have any suggestions keep them coming.

Thanks for the feed back

?BPs required? These patients didn't take thier BP every day before they took thier meds before coming into LTC. What is your facillities policy on passing meds on a stable patient with a hx of HTN. As for heart rate with dig- have they been on the same dose for a while?, Is there any reason to suspect a change in the patients condion? You don't have to check a pulse for 30sec to determine a patients HR is ok for thier usual digoxin dose you can tell in two or three beats if it is unusualy slow. If a BP is required before a med is given, could the NA or other provider do the BP and report it to you before you start your med rounds on that patient? I suspect you are treating your LTC patients like acute care in-patients in a primary care hospital. Passing the patients usual meds in a timely and accurate way dosen't necessarily require that much assessment.

[Thornbird]

?BPs required? These patients didn't take thier BP every day before they took thier meds before coming into LTC. What is your facillities policy on passing meds on a stable patient with a hx of HTN. As for heart rate with dig- have they been on the same dose for a while?, Is there any reason to suspect a change in the patients condion? You don't have to check a pulse for 30sec to determine a patients HR is ok for thier usual digoxin dose you can tell in two or three beats if it is unusualy slow. If a BP is required before a med is given, could the NA or other provider do the BP and report it to you before you start your med rounds on that patient? I suspect you are treating your LTC patients like acute care in-patients in a primary care hospital. Passing the patients usual meds in a timely and accurate way dosen't necessarily require that much assessment.

While your points are entirely valid as far as what people do at home, this is NOT what is expected in long term care as far as regulations go. BP's that are parameters for meds must be done by the med nurse at the time the med is given. Routine vitals may be done by others but not those that go with anti-hypertensives. MD's used to be fine with D/C ing thes parameters once baseline was established, not so anymore. Regulations for nursing practice in LTC are that 60 sec Apical Pulses are to be done on patients with each dig dose. A patient on dig may develop toxicity at any time even after years of use. I also find it very "un-homey" to do daily weights on Lasix patients, but many MD's order this FOREVER not caring that the patient will be hoisted out of bed in the wee hours to get this done before breakfast with all the other thngs that 11-7 has to do in the A.M. One I deal with insists on making the Lasix dose dependent on the weight! Diabetics are poorly managed so they are subjected to an unnecessary amt of fingersticks and sliding scale insulins. Maybe all this is why they don't call them "nursing homes" anymore. The "hominess' is long gone and both nurses and patients pay the price.

Also, wound care is NOT to be done during med pass. No ther tasks, especially "unclean" ones are to be done during med passes. Often no choice, but don't let the surveyors catch you.

It is always good to at least know what the rules are so that you will be careful when others are around. Med passes have become impossible in some places. MD's don't seem to get that if they order all 30 of their patients to get Prilosec at 6:30 AM and there's only one nurse they are not all getting anywhere close to that time. While the MD's are more than happy to treat these patients as a "nuisance" when you have to call for orders after hours, all the rest of the time they are more than happy to write orders as though these poor folks are in the hospital where there are a lot more nurses and a lot fewer "crushes".

[TheCommuter, BSN, RN]

I get so frustrated pushing the pills and giving amiodarone and coumadin to 100 year old bed bound patients who wish every day for their maker to take them.

I also become frustrated at the unrealistic family member who is doing everything in their power to keep their 99 year-old mother alive who has a feeding tube, end-stage dementia, bilateral above-the-knee amputations, multiple stage 4 pressure ulcers, chronic pain, uncontrollable diabetes, dialysis 3 times per week, a tracheostomy, a cervical halo, a recent hip replacement, and a whole slew of other issues.

One family member was angry that the physical therapist refused to treat this patient after evaluating. "My mother needs to regain some of her strength, get some exercise, be fitted for some prosthesis legs, and maybe relearn to walk," was the delusional response.

[chevyv, BSN, RN]

It takes me forever too. I just had my first shift off of orientation this past Friday. I was on a wing I had never stepped foot on in my life. It was horrible! It took me forever and ever and ever. I totally missed a resident and gave them their digoxin like 2hrs late. I had to look to see what else they were on and how often they get dig and thankfully, it was only 1x per day and nothing else, so I gave it. It didn't sit right with me though. I just was drowning. I emailed my sceduler and told her it was the pits and I would need to follow someone around a shift or two before they put me on that wing again. I never even want to go back after that, but I've never been a quitter and everyone tells me it will get better. I can only hope and pray you are all right!

[Thornbird]

It does get better. But, it's just not easy, especially when you are new. I always try to help the newer nurses so they don't get so far behind, get frustrated and give up. Teamwork counts for so much when trying to get the impossible done. I know there are many shifts that I couldn't have gotten through adequately without a little help from my co-workers. I hate when I end a shift feeling as though I must have missed something important or as you said, discovering that I have to give a med at a less than appropriate time. Or worse, yet, I ran so late that it can't be given and now it's a med error.

It's really hard sometimes, even for the experienced nurse, to get it all done. Some shifts I just keep going at it, one thing at a time, til it all gets done. If I'm not fortunate enough to have a co-worker or sup. play angel, sometimes I'm really late. I just do the very best I can. That's all you can do. If the place you are working is so bad all the time, you may have to try another job. Although that's easier said than done these days. Try to be organized and don't be too hard on yourself.