LTC in Charge of 35. Helpful advice?

SuesquatchRN, BSN, RN · Jan 9, 2010

Need more info.

How many aides? Other nurses? Unit manager? How acute?

pedsrnjc · Jan 9, 2010

Wow, you've picked a very hard, but very rewarding job. I'm currently a charge RN at a LTC facility. Are you working a med cart or "charge" or both?

I don't normally work the med carts, I have a huge respect for our LPN's that do it every day without mistakes. 35 people and most of them probably have at least 5 meds at the 8 am med pass, it's overwhelming but it can be done. I've stumbled through it when we're short handed. If your "charge" it's a whole other ball game, but just as crazy.

My general advice: It WILL be hard at first, don't give up. When you feel overly stressed, stop, take a deep breath, shut your eyes and remember that no matter how bad it gets, at some point, you get to go home, your residents don't, so give them your best every minute of every day, and then go home and forget it until the next shift. Hit the floor running, keep a big smile on, but limit the chit-chat with co-worker to necessary stuff to get the job done until you have a good system. Just tell'em you're working on a system. Let your daycare/family know you will probably be late getting home until you get a system down, but in time, you will get a system, don't worry.

My practical advice: The sweet LPNs have helped me with some of this advice for working the med cart; When you hit the floor running, look at your charting first, then as you go through your day notice the things you need to chart and chart everytime you get a free minute. Smile at your residents. Try to get your blood sugars checked before you are scheduled to start your first med pass. Do your meds one resident at a time. Keep your vitals cart close by so when you give metoprolol you can check a quick blood pressure, every time you see a resident, ask them about pain, and believe them, and treat the pain, they'll love you.

If you're the charge nurse; carry a pocket notebook or a clip board and write down every issue brought to your attention, then spend your day trying to clear your clip board. Be careful when processing orders, your residents are safe when you are careful. Delegate gratefully; say please and thankyou. When you have a spare minute, offer to help the LPNs or Nursing Assistants. Always give people the benefit of the doubt, never angrily approach someone who's made a mistake. Theraputic Communication. Try hard to please families who are upset, try to see their side of the story and remember this is their grandma you're talking about. Pray with families of dying residents if your sense that's what they need. Always make sure the families know what is going on. Don't get upset by crabby doctors. Sometimes you have to be very specific with them. Don't ask, "may we have something scheduled for pain?" nine times out of ten you will get the note back with a "yes" and a signature and then you have to send a new note asking "which one, how often, ect?" Be specific "so and so is in pain constantly, tylenol isn't helping, may we have an order for vicodin 1 tid? and prn up to 8 doses total in 24 hours?"

This is a long post, but I feel passionate about my work and I hope you will too. You'll do great if you love your residents and treat the staff with respect. Good luck.

hcrabby · Jan 10, 2010

Yes, I will be in charge of all medications.

I am trying to get to know all the residents first, to remember who is diabetic and needs meds before meals, who is on coumadin, metroprolol, who needs wound care,

who requires their medicine crushed, and things like that.

They give us a roster of the clients, and from that I make notes of special treatments, and other things I must do such as assessments, calling docs, faxing orders, etc.

I just hope that residents and staff are patient with me and that they understand that I will not be able to do it as fast as them.

I want to get a good system going, so that I'm not feeling so overwhelmed that I can't breathe right.

Breathe, right? I am just so grateful to be able to do the best I can with the residents. They deserve so much dignity and respect. I tell the CNA's that they are blessings to the residents, and please let me know about any changes in status.

Nascar nurse, ASN, RN · Jan 10, 2010

Pick your battles with residents and their families carefully. I see to many new people want to "fight" about the stupidest things. Had a resident just this week want to take a glass of cranberry juice to his room. The aide was telling him "no" because it usually gets spilled or he lines several cups up at a time and forgets them. She was making this mellow, although slightly demented man so mad he was trying to hit her when I came upon the situation. Why, why, why make this poor guy THAT mad over a cup of cranberry juice (thats probably good for him to drink to begin with). If he is a spiller - get him a cup with a lid and if you see he has several lined up - throw the old ones out. For crying out loud, it's hard enough to get these folks to drink to begin with. I gave him his drink and she shot daggers at me for doing so. Oh well!

Fight the important things and let the rest go.

SuesquatchRN, BSN, RN · Jan 10, 2010

DO not pour meds the right when only when State is in. You won't remember how.

My first job had people show me a lot of things that were not kosher and when I went to the next one I had to unlearn a LOT of bad habits. And now I simply can't pour "sloppy," and it takes me more time to take shortcuts!

buster4 · Jan 10, 2010

what do you mean "pour your meds right only when state is in?".. I have not worked LTC.. but have often considored it...

CapeCodMermaid, RN · Jan 10, 2010

There are some nurses who take shortcuts and only go by the book when the DPH is in the building. The right way is the right way no matter who is there. Go by the book ALL the time and you can't go wrong.

SuesquatchRN, BSN, RN · Jan 10, 2010

what do you mean "pour your meds right only when state is in?".. I have not worked LTC.. but have often considored it...

It's easy to get into the habit of pouring meds from memory, not looking at the MAR closely enough, not popping into a cup and then combining that med with the rest for your final check - little things that can add up to trouble. And missed orders.

Midwest4me · Jan 10, 2010

pick your battles with residents and their families carefully. i see to many new people want to "fight" about the stupidest things. had a resident just this week want to take a glass of cranberry juice to his room. the aide was telling him "no" because it usually gets spilled or he lines several cups up at a time and forgets them. she was making this mellow, although slightly demented man so mad he was trying to hit her when i came upon the situation. why, why, why make this poor guy that mad over a cup of cranberry juice (thats probably good for him to drink to begin with). if he is a spiller - get him a cup with a lid and if you see he has several lined up - throw the old ones out. for crying out loud, it's hard enough to get these folks to drink to begin with. i gave him his drink and she shot daggers at me for doing so. oh well!
fight the important things and let the rest go.

i agree: pick your battles. most times it's just not worth the trouble. however, if other residents see that you overrode that aide's decision, then you may have problems. some pts already know how to "staff-split"; a phenomenon much like a child going to dad when mom says "no". in our psych unit, we have a rule of no food nor fluids allowed in rooms due to choking hazards.

hcrabby · Jan 11, 2010

Thanks for all of your advice. I came home tonight after shadowing and learning meds along with a the charge nurse and I am FREAKING out. I have the highest intentions of doing the best job possible, but when you have 35 to take care of, It is a HUGE responsibility. I just wiah that there was another nurse on my unit so that we could divide the patients, and therefore, give them more time and attention. I LOVE and Care for people, and I don't want to lose that ever in my heart. I don't want or plan to take a bunch of shorcuts either because I am there for only 8 hours per shift, 5 days a week. I want to learn organization and a plan.

I am so afraid, so unconfident right now, and I feel like a loser for not being able to do a better job.

My gut feeling says to resign, and seek to work somewhere with better nurse to patient ratios. But, the ecomony, and I am a new grad seem to be a problem.

Have you ever felt this way? I will not quit just yet. But my gut says to run.

My goal is to continue to get better at passing meds, and organize according to locations and acuteness of patients.

I have no system.

FYI- I found out a couple of other nurses have quit because they can not take the pressure of all the responsibilities. Also, the whole MGT team is new, and filling in, because the organization has just let go of higher-ups.

HELP.

SuesquatchRN, BSN, RN · Jan 11, 2010

Honestly, 35 is not undoable. Hard, but possible.

How many med passes for the 35 do you have? Get half sheduled for x and the rest for y - that gives you 3 hours. 5 minutes and change per resident, if all 35 get something. And some will get a calcium tab, others will be a bazillion meds plus blood glucose, BP, pulse, blah blah blah.

ORGANIZE. Before you start, make sure your cart is stocked. Check the fridge for meds you may not think of - liquid abx, etc. Have extra BG strips, etc. Cups and water. Thickener for the nectars and honeys. OJ for the princess who won't take her meds with water, ice cream or pudding for the demented who need to be coaxed. Your pressure cuff, steth, pulse ox. Combine.

Before you start, grab a piece of paper and tape it to the top of the cart. Jot things down on it so you can chart when you sit down.

Take it ONE RESIDENT AT A TIME. Deep breaths. In a few weeks it will come as naturally as breathing.

:)