New Grad drowning in LTC

OnlinePersona, LPN · Jul 4, 2015

You LTC nurses rock! I've never seen a thread by an overwhelmed new grad that was full of so many seriously helpful posts.

Seriously :-) the majority of the threads on here is filled with negativity

wanderlustnurse88, RN · Jul 4, 2015

I've been working in LTC for a while and know what you mean. There are some pills that I will give at different times. However, I NEVER recommend a new grad do this, especially at a facility i'm not familiar with. Reasons being:
1. chances are they don't know all the meds they're giving. It's unfortunate, but it's true. Plus, I can almost guarantee they don't know potential interactions that could occur by giving pills at the wrong time. If all someone gets at HS is a daily lisinopril or something, I'd ask someone more knowledgable (DON/MD or whoever's approval you need for your facility's policy) about moving it to be with another med pass to simplify things for everyone, including the resident. If you approach the DON about this from the angle that the residents go to sleep early and don't like to be woken for meds that don't need to be given at that time, they tend to be more interested in changing it (in my experience, anyway)
2. Some DONs are more strict about that stuff than others. As a new nurse to the facility, people are going to be watching her. I've known people in some facilities who were fired to giving meds at the wrong times instead of requesting the orders to be changed.
3. If state comes in and she never learned how to do her med pass per the orders, she's going to be even more flustered and more likely to make a mistake which could really hurt her and the facility.
Give yourself time, OP. You will get faster and more efficient as you learn your residents and your meds!

For the most part at my facility, daily meds are given at 0800 and the BID meds are 0800 and 1700. Hopefully you can work with the pharmacy to keep most meds during this time. The majority of my 1200 meds are pain meds, meds that need to be given away from certain meds. The same with the hs med pass. Should hopefully be just pain meds, sleep meds, and QID meds.

My facility use to have two staff for days and one for nights. So it ended up for the hs med pass, there was only one nurse giving meds for 62 residents. Our pharmacy was great at moving as much as possible from the hs med pass to the supper med pass. We have since gone to 8 hour shifts so we don't have to do that anymore, but I've noticed that more and more meds are being added to the hs med pass

Been there,done that, ASN, RN · Jul 4, 2015

Verbal orders are not allowed. For all all the reasons you described. Do you REALLY want to hang yourself out to dry?

As a seasoned nurse of many years... it is not up to me to discern phone orders.. with a thick accent.. to boot.

Write it down doc.. then I can carry out your order.

wanderlustnurse88, RN · Jul 4, 2015

As nurses we are allowed to take verbal orders. Our MD is only there once a week so we often take verbal orders during the rest of the week.

Adele_Michal7, ASN, RN · Jul 5, 2015

Verbal orders are not allowed. For all all the reasons you described. Do you REALLY want to hang yourself out to dry?
As a seasoned nurse of many years... it is not up to me to discern phone orders.. with a thick accent.. to boot.
Write it down doc.. then I can carry out your order.

My facility (a SNF) takes verbal orders through the telephone... This is the first I have heard of them not being allowed?

SWM2009 · Jul 5, 2015

My facility (a SNF) takes verbal orders through the telephone... This is the first I have heard of them not being allowed?

I have heard of verbal orders not being allowed in some acute care situations. In my LTC facility where most of the contact with MDs is via telephone, that is not at all realistic.

DanaH. · Jul 6, 2015

as a new grad the best training would be the new grad programs that the hospitals offer. Long term care rarely offer an organized and 6month program.

vintagemother, BSN, CNA, LVN, RN · Jul 6, 2015

It sounds like you work in an ltc snf. My experiences as a new grad were ltc "non medical", meaning our pts did not require complex care and were pretty much independent in ADLs. (Though our ratios were higher- eg 1:45 or 1:54)

I think the OPs have given some great suggestions.

Here's another few I'd add:

When shadowing, write down the times that the nurse starts each task. This will help you to pace yourself and prioritize your tasks. Eg start pulling meds or passing meds at 1530,finish by 1645. Treatments at 1730 , charting starts at 1900-1930, etc. I did this to learn which areas I needed to be "faster" in.

I also watched to see which corners the nurses who'd worked there longer typically cut. Some of these I wasn't willing to do, some I only did when time pressed and others, well I learned to incorporate when i finally realized work is not the same as the text book.

A good brain sheet became my Best Friend after I'd been working about 6 mos. thank you to the nurse who showed me hers and how she sets it up and uses it!! The brain had 2 sides, 1 side listed each pt and the routine items I had to assess for. The other side listed other tasks I needed to get done.

alt_one · Jul 6, 2015

A lot of good advice here. Focus on the med pass and always read back the order to the physician. One thing I tell myself as I make my med pass is one resident at a time. I have staff and residents calling my name or asking for help as I walk down the hall. Unless it is an emergency I don't stop what I am doing. I made mistakes when I tried to help everyone immediately. Meds and treatments left in other residents rooms or missing scheduled BG checks and insulin. I just tell residents that I'll have someone assist you shortly. As other nurses stated "It will get better over time". You'll learn everyone's routine and when is the best time to get treatments done. Good luck

jdub6 · Jul 13, 2015

Not a whole lot to add to the other great ideas. Just that my best way to organize my brain sheet: a census sheet that I kept at work. The permanent copy had residents listed either by room in a map or alphabetical. Color code DNRs. MP for med pass, FS finger stick, BP blood pressure etc placed in columns next to the relevant residents: the columns were based on my med pass and meal times. Under names was diet, a note if pills needed to be crushed or with pudding, thickened liquids. Etc. I took a new copy each day, looked over report and new added orders to make sure there were no changes (at my facility it was easy to tell cause any resident on a new med was on report for 3 days due to mandatory monitoring for side effects-i think that was state mandated). Then, during med pass, I could just start at one end of the facility and get whoever was there, check off the appropriate letters/symbols in the appropriate column and know easily who was left. I also had space to write in blood sugars, vitals etc to save time writing it In the mar during med pass.

One more thing: this may be frowned upon in some facilities and certainly by the state/joint commission etc, but if you use paper MARS, and you have your brain sheet (or even just a current census sheet) you can pour the meds in real time while looking at the mar, as long as the resident takes them all just check off that med pass on your sheet and sign off all those boxes later-only document narcotics and refusals in the moment-this helps you get people's meds out within the allotted time and I found I was less likely to accidentally not sign off ia need I knew I had given but missed the box or a while page because I was rushed and distracted during med pass. if you also quickly jot blood sugars and vitals on your sheet, it makes them easier to read in the real chart since you aren't as rushed. But, like I said, it may be frowned on by your boss.