New nurse in LTC... advice?!

kbrn2002, ADN, RN · Apr 12, 2020

The med passes will be your greatest time challenge. Expect it to be massive. If you work an 8 hour shift there should be two big med passes plus a few random meds scheduled at off times. The exception to this rule is the night shift. There will still be probably 2 scheduled med passes but they will be a lot smaller than on days or afternoons. The trade off is there is a lot less staff at night so you will be responsible for more residents than on other shifts.

There is a two hour window starting an hour before and ending an hour after scheduled med pass when meds are considered on time. Even for an experienced LTC nurse having it done in this time frame is difficult and often impossible. I never in 25 years of working LTC heard of a facility being cited by state surveyor's for late med administration though so don't worry about that too much. Especially in the beginning when you will be expected to be slow, the pace will pick up as you get a routine that works for you.

Pay special attention to your diabetics and daily weights as theses are more time sensitive. You'll want all your blood sugar checks done before they eat and insulin given close to the meal. There's been a shift lately for meal coverage towards carb counts instead of or in addition to sliding scale based on the blood glucose level so knowing exactly what those residents eat is another challenge. The daily weights are usually performed by the CNA's but you will still be responsible for recording them and following up as ordered.

There will probably be several supplemental O2 dependent residents and many with respiratory treatments. There's no RT so you will be administering those as well. Many facilities have policies that require constant supervision during a neb treatment unless there is a self administration order in place. I have to say this is a policy I have never seen followed unless state is in the building. There's simply not the time to sit with several residents for 10-15 minutes individually while they have their neb tx. Eye drops and inhalers are also rarely given with the required time between doses though it's not that difficult to do this correctly with proper time and task management.

Treatments, wound care, tube feed flushes, foley cath flushes, skin integrity checks, any other needed assessments including vital signs that are often required before administration of certain meds and whatever other random orders there are besides medications also have to be fit into the day.

The next biggest time hog is the required charting. There's going to be a ton of it. In addition to just signing of MARS/TARS there will be daily medicare/insurance charting, weekly charting, follow up assessment charting, change of condition charting, med monitoring charting with any order changes etc. and most of this is still done in narrative form for LTC. Unless you are fortunate enough to have a HUC you will also be making outside MD appointments, entering orders and following up on all provider visits both from facility rounds and from outside facility appointments. Falls and minor injuries are sadly common in a LTC setting and they require another whole level of charting including time sensitive VS and neuro checks. If it sounds like a lot that's because it is.

Expect to be interrupted, a lot! Between residents, family members and other visitors and even other staff you'll start to feel like somebody always needs your attention.

Then there is the staff you work with. They will become your work family and boy is there usually a lot of family drama! Listen a little to the gossip as you can actually get a lot of helpful information as long as you don't always believe what you hear. Especially when just starting you really need to follow the adage of better to be seen than heard. Be friendly and approachable but don't participate in the gossip you'll hear or it can and probably will come back to bite you in the butt!

You'll learn quickly who is great at their job, who is decent and who plain speaking here, just sucks. You will rely a lot on the CNA's as your eyes and ears. Pay attention to them. Delegate appropriately but keep in mind how hard their job is as well. Use your fellow nurses as resources, most will be more than willing to help when asked. Some might not be but again, you'll figure out quickly who the good one's are. Management can be a great resource, or they can be the absolute opposite. Hopefully you are working in a facility with supportive management that actually has somewhat realistic expectations for their staff.

As overwhelming as I make things sound with this super long post LTC can be the most rewarding career there is. It's not easy but then no job is. If you like getting to really know the people you care for you will love LTC.

Vonbunny08 · Aug 1, 2020

Great advice, LPN at LTC 10 years?