My first ranting

[tokebi]

This is the first time I let out a pure personal venting on this site.

My facility is undergoing a stressful stage of preparing for re-survey, so consultants are often hanging around with hawk-eyes. I was followed by one today. One of the many mistakes I made: I drew several syringes of insulin, labeled by their room numbers as trays were being passed. I was caught with handful of them. The consultant said, "What are you doing? What's that in your hand? Go show them to your DON." I meekly opened my hand and showed those syringes to my DON who was sitting nearby. She looked at me and asked "Who oriented you? Is this how you were taught?"

To feel like a child caught doing something naughty, at my age...

Now, I love working there. I still can proudly say I don't regret a thing after working there for several years. However, the nursing practice as I envision it as opposed to what I'm expected to do from the corporate, there's so much disconnect that I sometimes want to say "The hell with it all!"

Is any of you working in LTC capable of doing everything by the book when you're responsible for the number of residents under your care? It's an open secret that we all take shortcuts. Do you actually take BP before every single BP meds every single day? Do you check placements of GT every time? Do you give meds to GT patients by gravity every single time?

For the 30-something number of residents I'm responsible for, it would be a miraculous day if I finish passing meds in two-hour period, doing all those above. And of course there's always something happening with residents that require me to engage in yelling contest with pharmacy people, lab people, doctors' offices, etc, on top of the frustrating amount of redundant paperwork. Then there are your superiors constantly on your back regarding overtime.

They talk of time management, so we learn to manage our time. We somehow learn how to do all the impossible things in the given amount of time. What I did -- drawing up all the insulin at once for the seven or eight people who needed coverage -- was one of them.

I worked telemetry floor prior to this job where any insulin had to be double-checked with another nurse. Believe me, I take insulin very seriously. Also, I take any med error seriously. And I'm always on guard, watching myself, second-guessing myself because I would not forgive myself if I made a med-error. So I devise my own way to do things correctly in the least amount of time.

Now, by taking shortcuts, do I make time to have my lunch? For idle-chat? To sit around? Ugh... I'm running around answering call lights, talking to the family, more importantly, talking to the residents. I have several residents who suffer from uncontrollable outbursts, panic attacks, to name a few. Every day I'm amazed how their symptoms disappear when some one-on-one time is provided, like this elderly lady who constantly calls out "Help Help!" with no apparent reason, but immediately calmed when I take her out to the patio or just wheel her around, talking.

Does the corporate want automatons of nurses who shove the impeccably prepared cups of medicine down the throats of the residents and no rapport? The perfect care plans and the correctly charted entries full of pretty words when none of it took place?

I'm not saying we should be allowed to take shortcuts. I'm saying we should be given the realistic amount of assignment for ideal nusing care, survey or not. Why must I be cornered into having to take shortcuts and then be punished for it without any real solution to do otherwise?

[Forever Sunshine, ASN, RN]

We write all our GTube meds for 6am and 6pm if we can. Surveyors are out of the building. Doctor says crush them all together or use liquid. One less thing for them to cite us on.

Can you come work at my facility? I don't even work 7-3(and I am not answering the phone in the AM if they call me in anytime soon) and I am honestly worried and feel terrible for the nurses who have to be watched during the survey.

It is just not practical. We even told our ADON that during an inservice last week and her response, "Its the way they want it done"

I tried it tonight with one patient on about 5 different meds. I did it with the first two(crushed seperately and administered with 20ccs of water) but her tube was getting backed up so i just mixed everything in a cup and flushed them all in. But it did take a long time. I did have another g-tube patient thats on 20 different meds.. I was strapped for time so I couldn't do it with her.

[tokebi]

Thank you carolmaccas. I wish you the best with your endeavors also.

It is just not practical. We even told our ADON that during an inservice last week and her response, "Its the way they want it done"

I tried it tonight with one patient on about 5 different meds. I did it with the first two(crushed seperately and administered with 20ccs of water) but her tube was getting backed up so i just mixed everything in a cup and flushed them all in. But it did take a long time. I did have another g-tube patient thats on 20 different meds.. I was strapped for time so I couldn't do it with her.

During pharmacy inservice, we were told that the reason for preparing and giving g-tube meds individually is that when we happen to spill something, we know which med is lost. Is that true? If that is the only reason, it seems like way too much precaution. Of course, if it were some liquid meds that could chemically react with each other, then I'd never mix without a question.

[Forever Sunshine, ASN, RN]

Thank you carolmaccas. I wish you the best with your endeavors also.

During pharmacy inservice, we were told that the reason for preparing and giving g-tube meds individually is that when we happen to spill something, we know which med is lost. Is that true? If that is the only reason, it seems like way too much precaution. Of course, if it were some liquid meds that could chemically react with each other, then I'd never mix without a question.

I heard it was the chemical reaction. But they mix together in the stomach anyway?

[tokebi]

I heard it was the chemical reaction. But they mix together in the stomach anyway?

Long time ago, I once mixed some liquid meds which included Reglan. There I was, humming to myself, nonchalantly pouring all the liquids into one cup. When I turned back around, ready to pour it into the syringe, the liquid mixture had turned into a slush of white precipitate!

Since then, I got paranoid over mixing liquids. I wish I could remember what other meds I mixed back then. Would've been an interesting chemistry inquiry.

I still don't really buy that we must prepare each crushed meds separately. Like you said, they all mix in the stomach.

[catlvr]

Tokebi, took me a bit of time to finish this thread, but may I say how inspired I am by the graceful way that you handled yourself? We all take shortcuts (the insulin thing I would never consider, because I'm not 100% certain that I could get it right). I do my very best not to take shortcuts, but sometime a simvastatin might make it into the dinner time meds if that is the only bedtime med for that resident. I only do this when I am on my regular floor, since I know those patients so well - if I float, everything is by the book. I know that you'll do great in your MSN program, and hopefully you can be a force for improvements in long term care.

Like Suesquatch and Capecodmermaid, our DON is really great about telling the nurses' to try to find our own LEGAL solutions: if a BP has been stable, get the parameters d/c since you can always take a BP if your sense is that something is up. If blood sugars have been stable, we try to move them from QID checks to BID, and once that is stable, we move them to BID every other day, since again, your nursing judgement always allows you to check if you have an inkling that something is amiss. If the parameters are there, though, I check them until I can get them d/c if appropriate. I view this as a quality of life issue - who wants their blood pressure checked four times a day? So many of our residents come here to die, and I want to make it as comfortable for them as possible.

I agree that LTC almost sets one up for failure, but even if you are lucky enough to have decent administration, they still cannot perform miracles. Once I accepted that staffing will never get better, I had less frustration - it is what it is, and I'll do my best with what I have to deal with.

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[tokebi]

My goodness, catlvr, "graceful?" You're being way too kind. I think I can be a little detached from the whole situation because my immediate livelihood does not depend on that job, as I'm single with decent savings. However, if I were... for example, my co-worker who works two shifts and home health on top of that in order to support her little kids and sick husband, it wouldn't matter if it was my fault; I'd be bitter and livid at losing my job in this manner. But then, my co-workers are wiser. I tend to be a little... oblivious (to those watchful eyes) as you can see... :doh:

and hopefully you can be a force for improvements in long term care.

When I become an RN and after trying out different kinds of nursing for experience, I know I will be returning to geriatrics/hospice. That's how much impact that nursing home job had on me. It's just too sad to think of all these nurses, including many of you right here in this forum who are so dedicated and yet so tired and disgruntled. Our elderly and those at the end of their lives deserve better. I don't even know if this status quo can be changed, but oh well, dreaming doesn't hurt...

Yikes, it sounds so cheesy!

On another note, I wish I were still working so that I could try implementing many of the tips given in this thread, like getting a specific MD order saying ok to crush g-tube meds together. Never occurred to me before.