New LVN working in SNF any tips?

SquishyRN, BSN, RN · Aug 28, 2015

I copied and pasted a compilation of some of my former answers to past similar questions I was an LVN for 3 years working mostly in SNFs before becoming an RN, so this is stuff I posted during that time. Hope it helps!

During orientation...

Some of the most basic and fundamental things relevant to your work day are frequently overlooked during orientation. Particularly paperwork. And oh boy is there a lot of paperwork in LTC. The seasoned nurses take for granted that they can do these things with their eyes closed, so it doesn't come to mind that you don't know how to do these things. I've noticed that new grads pay all their attention to the nuances of med pass bc that's all the exposure they received in school. I don't think they are scared to ask, they just don't know enough to ask about anything else.
Here's a list of things off the top of my head that I think are fundamental to know and ask about during orientation as a new grad that are often overlooked:
* How to take a doctor's order and carry it out.
* How to order labs / diagnostic imaging.
* How to chart. There are specific things that should be included in your charting depending on what you're charting about.
* The steps you take after a change in condition.
* The steps you take after a fall. Including filling out an incident report.
* The steps you take after a death.
* How to do an admission, if relevant to your facility. In some places only the RN admits.
And this is never overlooked, but I think it is the most important thing to get out of orientation so I'll just say it again, learn the nuances and preferences of your residents! The biggest time saver in LTC is when you know your residents and can anticipate and plan accordingly.
Good luck!
Edit: Oh, I just remembered another thing to ask about: how to do a discharge / transfer.

When you're finally on your own...

Do not get so caught up in finishing your med pass on time. You are new, you WILL be late. I've seen so many new grads get frustrated and flustered that they're an hour behind that they start cutting corners and make errors. Focus more on giving the right med to the right patient. You'll get faster as you get accustomed to the patients, meds, paperwork and routines, but you don't want to do something that may cost you your job (or even license) in the meantime. Tip: Since you already know that as a new grad that you're going to be late, prioritize giving the alert and oriented patients their meds on time even if that means not going room by room in the most efficient fashion. It only adds to your stress level when those patients are complaining in droves why they haven't gotten their 5pm meds and it's already 7. The confused and non-alert patients won't be giving you such grief =P Also, don't expect people to baby you just because they know you're new. You're on your own, so they expect you to be able to perform your job. Assume that people assume you know what you're supposed to be doing, so it's your responsibility to ask for things to be clarified for you if you don't know how to do something. So like the above poster said, don't be afraid to ask questions.

My step by step typical day in a SNF...

This is going to be lengthy, but since you asked for a step by step, I'll be more than happy to provide if it helps you in any way. I generally work 2nd shift (3-11), so it's tailored to that, but 7-3 isn't really that much different.
>Clock in
>If it's my first day back in a few days, I hunt down a copy of the census/roster. This is actually more difficult to accomplish than it sounds, but the business office (or whoever handles billing) is your best bet. I try to find the most recent one I can, since I can't always get that day's or even yesterday's. Sometimes it makes me feel annoying that I do this to the business office people every week, but they've gotten used to me doing it (since I'm the only one who does this anywhere it seems like). It helps me tremendously because I work in skilled nursing, not LTC, so the patients change frequently enough. If it's my second, third, etc day back, I just use the one I got on my first day and update when I make rounds. And even if you work in LTC, where the patients generally stay the same, as a new person to a facility (new grad or experienced) having a census helps in times when other people only refer to a person by either name or room number, but not both. For example, you see a patient in the activity room and read their armband as Mrs Smith, but you don't know their room by heart, so how do you know off the bat what page in the med book to turn to to get their meds ready? Or you pick up the phone and someone asks to speak to their mother Mrs. Smith, so you'd need to transfer the call to their room, but you're not familiar with that room. Having one just helps when you're new, period.
>I make my own rounds and compare the census to the patients in the rooms. I make note of who is new to me so I know to ask about that patient in report.
>I go to the change of condition books, both 24 and 72 hour, and make notes of what looks like needs to be done on my shift. All of this before receiving report, so I have an idea of what I'm going to be asking the day nurse during report.
>I get report.
>I check if any labs have been received and do any MD follow ups immediately. Keep in mind I work 3-11, so it's best to call the MDs while they are still in office hours. I don't want to wait until after med pass to call about, for example, a PT/INR result b/c 1) that's a pretty annoying thing to be calling a doc about at 8pm when they're at home when you could have done it earlier (you'll get yourself a real bad reputation with the docs real fast if you make a habit of doing that) and 2) Coumadin is usually passed during the 5pm med pass, so it's good to have the new order before you're supposed to be giving it.
>I stock my cart. Water, juice, apple sauce, cups, spoons, straws, alcohol wipes, lancets, syringes, and house supply meds.
>I check all my blood sugars, but don't give coverage yet. It's important to get blood sugars done BEFORE they start eating.
>I start my med pass and give insulin coverage to those that need it when I give them their meds.
>After med pass, I look at the treatment book and do any treatments that need to be done. Or report critical lab values that have come in during med pass.
>Make quick rounds to make sure everyone's ok.
>Lunch break =)
>Finish treatments if not done. Chart.
>2nd med pass.
>Chart. Make sure everything that needed to be done during my shift from report is completed.
>Write in the 24 hr communication/change of condition book (You want this done BEFORE the next shift comes in).
>Rounds, report.
>Go home.
Of course you're always going to be interrupted throughout your day with all kinds of things (I couldn't tell you the last day an actual shift worked out like this), but this is the schedule I generally follow. Everything up to "I get report" is the same for morning shift. I stock my cart after report in the AM. The MD follow ups get moved until after 1st med pass. I don't check blood sugars either. I just start med pass because the AM blood sugars are done by NOC shift. I don't do treatments doing AM shift either, there's a treatment nurse for that. But some places do not have a designated treatment nurse in the AM and they still do their own treatments. You just need to adjust your schedule to your facility and your own preferences.
To answer some of your questions (hopefully), charting usually involves your change of condition charting (which includes ABTs as another poster mentioned), medicare charting, and weekly charting. You as the charge nurse are usually responsible for doing all such charting. Different facilities vary. For example, at one facility I work, the RN supervisor does the medicare charting, but at the other facilities, the LVN is responsible to complete it. You are most likely definitely responsible for the change in condition charting. Change of condition charting is added as they occur. For example, if you received an order to start antibiotic treatment, you would carry out the order, which also includes writing it in the the change of condition book. This old topic has a good step by step from TheCommuter about carrying out an order: https://allnurses.com/geriatric-nurse...tc-617067.html. Even if a new order wasn't received, but something happened to the patient that was out of the ordinary, you would still put that on the change of condition so that patient can receive monitoring. For example, a patient has an episode of SOB that is resolved with PRN oxygen that he already has a standing order for. You notify the MD and receive no new orders. You would still put that patient on the change of condition for monitoring for episodes of SOB because having SOB is not his normal condition. Generally speaking, COCs (changes of conditions) stay on that list for 3 days (72 hours), but there are some exceptions, the most common being antibiotics. Antibiotics (ABTs as the other poster referred to them) are kept in the change of condition charting for the duration of the treatment. This is to ensure the monitoring of adverse reactions to the antibiotic. Some facilities continue to have the patient on COC charting for 72 hours AFTER ABT treatment, others don't. Follow your facility's policy.

As for charting...

As for charting, chart specifically to the issue you are addressing. Include a brief general description of the resident, but otherwise focus on the reason you are charting. For example, if you are charting because they have a UTI, you generally don't need "pupils equal and responsive to light, respirations even and unlabored, skin warm and dry to touch with fair turgor, extremity strength equal..." Etc, etc. Some people say only chart the abnormals, but that's wrong. Chart whatever is relevant to what you're charting about. For example, having clear, yellow urine is normal, but that information is relevant for a UTI. Having clear, yellow urine, however, is not generally relevant for PNA, so for PNA you should include respiration quality and O2s sat, which would be unnecessary for a UTI.
Here is an example:
Resident alert, verbally responsive, oriented X4, and able to communicate needs. No signs of acute distress. Denies pain or discomfort. V/S: ____________. Continues on PO antibiotic treatment for UTI. No adverse side effects noted. No diarrhea, N/V, rashes, or fever noted. Urine clear and yellow with no foul odor or hematuria. No complaints of dysuria. Oral fluids encouraged and accepted. Proper pericare instructions reinforced with resident. Resident verbalizes understanding. Needs anticipated and met. Will continue to monitor.
Notice I started with a brief, general description of the patient and vital signs. Always include pain as it is considered a vital sign. Next I included the reason I am charting (ATB for UTI) and the reaction to the ATB. Then I addressed observations relating to the UTI. Then I addressed specific interventions and ended with generalized interventions. Another example:
Resident bedridden, nonverbal, and unable to communicate needs. Opens eyes spontaneously and is responsive to verbal and tactile stimuli. No signs of acute distress. No signs of pain or discomfort. No restlessness, moaning, or facial grimace noted. V/S: ____________. Continues on IV antibiotic treatment for PNA. No adverse side effects noted. No diarrhea, N/V, wheezing, or rashes noted. IV site to L forearm clear with no redness, swelling, warmth, or discharge. Resident noted to have occasional productive cough with clear sputum. Respirations even and unlabored. Temperature of 100.2F and O2 sat of 95% on 2L via NC noted. Cooling measures implemented. Breathing Tx administered as ordered and tolerated well. Fluids flushed via GT as ordered and tolerated well. Needs anticipated and met. Will continue to monitor.
Again, same general format but tailored to PNA instead of UTI. Even though you are an LVN and are not the one administering the IV med, you are still the one monitoring and charting about the patient's condition and response to treatment.

That should be enough to get you started

bradycardic · Aug 30, 2015

Hey thanks I'm gonna read this

quiltynurse56, LPN, LVN · Sep 1, 2015

I work the evening shift. I clock in and receive report. We then do the narc count and pass the keys. At this time, I take a minute to prioritize.

My evening usually goes like this:

Take vitals on the skilled nursing residents

Do follow ups on those that needed following up on issues, we have list for those

Do my alarm audit at this time too

At this point I have pretty much seen each resident

Do any charting I need to do at this point

Prepare for the 4 pm med pass and pass said meds, takes about an hour (but longer at first)

Supper break

Supper med pass

Double check that the med pass was completed

Prepare treatments if any are needed

HS med pass, usually done in an hour

Accept new meds from pharmacy delivery, sign them off and put them where they belong (med cart, narc drawer, etc)

Chart

I have about 4 meds to give at 9

Finish charting, check my med drawers and narc count, prepare for oncoming shift

Give report and count

Go home

Now, on any given day, this can steer way off path as there are always questions from family and residents, new things to asses on residents, call physicians, take orders, fax information, order medications. Sometimes I have personnel issues as on evenings, I am the only nurse on site. I also have to make sure my CNA's have completed all their work, reported outputs as well as anything else I need to know. Mine generally do a good job of letting me know things as they come up.

The items mentioned in the previous post are gone over during your orientation/training period and comes at you so fast. I have copies of the lists in my file and know where to obtain them in the office should I need them.

I started my position the end of April and it was a couple of months before I felt really comfortable and I still fell like such a newbie. I tell myself we are all learning.

ASPIRING2BGREAT · Sep 1, 2015

Thanks for the sight! I hope to secure a position soon and these tips are very helpful. A couple of months and you sure seem to have it all down.

Thanks!

Nursing_journey, LPN · Sep 1, 2015

This is soooo helpful. I am grateful for nurses like you. Thank You!!!!

Genesislinx · Sep 1, 2015

Tips? Sure. Work there long enough to get at least a year's experience, then run like hell. Unless you like dangerously-high patient ratios, CNAs who try to run the floor and being a glorified pill-pusher for old people.

LVNlivin · Apr 2, 2016

Wow, GREAT POST! just got hired as lvn for snf!

Firefly1009 · Jul 5, 2018

very detailed thank you