Nursing home as a new grad

TheCommuter, BSN, RN · Nov 21, 2014

vital signs are only done once a week assessments are only done once or twice a week

It's a nursing home. In other words, it is the home of the residents who live there.

Low-acuity residents do not need full head-to-toe assessments more than once per week. Low-acuity residents do not need to have their vital signs taken multiple times per day. Look at the big picture and realize you are not dealing with an acutely ill patient population.

Many people in our communities live with chronic illnesses such as hypertension. Would your next-door neighbor with HTN who takes Lisinopril daily and Metoprolol twice daily check his blood pressure and pulse around the clock? Nope. He's simply going to swallow his pills. And he doesn't pass out because he's not acutely ill. It's the same concept with nursing home residents who have chronic stable disease processes that are managed in their homes.

I worked in nursing homes for six years. With 20+ residents, ain't nobody got time for head-to-toe assessments. Good luck to you!

TeflonNurse · Nov 21, 2014

As someone who has worked in a nursing home (NEVER AGAIN!!!), I agree with the above poster. During my years as an aide there I worked nights and we only got BPs or temps when they were acutely ill, were taking a BP med, or when they were on comfort care and about to die. I don't recall what dayshift did but they were always more concerned with who's shower day it was when they came in so it was probably a weekly vital sign set up like the previous poster mentioned.

Also at night they couldn't have been doing assessments because on two of our floors there was only 1 Certified Med Tech supervising two aides. They wouldn't be allowed to do assessments.

In general I'd say if the place was anything like a normal nursing home of course the aides were complaining. What were the nurses saying? I would definitely shadow if you can .

NICUmiiki, DNP, NP · Nov 21, 2014

I would try to shadow without any managers around and see what it's really like.

RunBabyRN · Nov 21, 2014

Find out about patient ratios, what your duties are, the rules about overtime, etc.

I was on PMs, and I had 36 patients that needed meds, assessments (a few each shift), BPs or other vitals prior to administering medications, wound care provided, not to mention all of the random "fires" that come up. It was extremely overwhelming, and I felt like I couldn't practice safely, so I left. Do your research.

Also, the CNAs where I was were, for the most part, very friendly, and very helpful (really, everyone was). Get to the root of why the CNAs aren't very friendly where you're looking.

mathia2171 · Nov 21, 2014

*"we only got BPs or temps when they were acutely ill, were taking a BP med.." the residents are getting BP meds with out heart rate/BPs.... I am sorry but I am just not comfortable with this. The nurse told me she personally takes BP meds an only checks her own BP when she isn't feeling well..... okay but many of the residents simply can not communicate that kind of information. I have done clinical in several nursing homes as a student and they all had vital signs taken before medications were given per nursing home policy. In addition skin assessments only done once a week with showers! Is that normal for a nursing home setting also?

TeflonNurse · Nov 21, 2014

*"we only got BPs or temps when they were acutely ill, were taking a BP med.." the residents are getting BP meds with out heart rate/BPs.... I am sorry but I am just not comfortable with this. The nurse told me she personally takes BP meds an only checks her own BP when she isn't feeling well..... okay but many of the residents simply can not communicate that kind of information. I have done clinical in several nursing homes as a student and they all had vital signs taken before medications were given per nursing home policy.

I'm sorry but I don't understand what you mean about not being comfortable with giving BP/heart meds without vitals.It appears to be my post that you are quoting and I said that that was one of the few situations where we DID get BP. So we are in agreement :) Also this was years ago when I was still a CNA and this was NIGHTS.

I technically shouldn't have been getting those particular BPs anyway . We got them manually and according to our policy the NURSES were supposed to get the VS right before giving those kind of meds but there were always some slick agency nurses or lazy nurses from other floors who would write those in on the VS board and give the med based on what I got hours earlier in the shift. Not good! Even after I and several other CNAs told our House Sup. nothing was done. Going through school they gave me great examples of what NOT to be as a nurse.

Forgot to add : the residents didn't often need to tell us when they weren't feeling well. Work with people long enough and you get to know them like family and it's usually the aides (who work with them most intimately each day) who notice the change first.

TheCommuter, BSN, RN · Nov 21, 2014

I am sorry but I am just not comfortable with this. The nurse told me she personally takes BP meds an only checks her own BP when she isn't feeling well..... okay but many of the residents simply can not communicate that kind of information.

Constantly checking vitals before all medications are administered is unnecessary and will suck up all your time. And believe me when I say you're going to need your time for other tasks in the nursing home setting.

Other than obtaining an apical pulse prior to administration of Digoxin, or checking BPs for medications that have physician-ordered parameters for systolic and diastolic BPs, it is a poor use of time to constantly vitalize stable nursing home residents. You are not working in acute care. Remember that.

I have done clinical in several nursing homes as a student and they all had vital signs taken before medications were given per nursing home policy.

Perhaps that was the policy of that particular nursing home, which might not apply to the facility that employs you. Policies vary from facility to facility.

In addition skin assessments only done once a week with showers! Is that normal for a nursing home setting also?

It is very normal! Try doing full head-to-toe skin assessments on 20+ elderly residents. It is time-consuming and unnecessary. Again, you are not working in acute care.

There's a textbook world of nursing and a real world of nursing. If you attempt to apply textbook principles to a healthcare setting known for notoriously high nurse/patient ratios, your idealism will cause you to burn out to a crisp.

I'll repeat this: these residents are living at home. They are not acutely sick. They do not need full head-to-toe assessments several times a day. They do not need daily skin assessments. Approach this healthcare setting as if it is their home. Stop medicalizing it so much. Good luck to you!

amoLucia · Nov 21, 2014

To OP - take my word for this but all other posters have been 110% correct with their answers. As a newbie, it will be different working in real situations that practicing as a student. And nursing homes ARE NOT intense care facilities.

My take on the CNAs may be that they may just have been having a 'bad day'. Maybe they were working short-handed???

You can go on-line and look up the reputation/survey status of NHs to see how this place stands.

But my biggest indicator would be HOW DID THE PTS LOOK when you were visiting???? Did they look clean, were they doing some Activity Dept activities, did a meal look appetizing, etc??? Did the place NASTY smell, did equip seem in good state of functioning, did other staff seem to be acting reasonably courteous, not loud and seemed busy (not loafing around)?on

As a nurse with a gazillion years of LTC experience, that place didn't sound too off-the-wall to me (and I've been in some real doozies).

amoLucia · Nov 21, 2014

To TeflonNurse - I know what they did on the day shift. They were always checking the Bowel & Bladder Book.

Who pooped and who didn't- time for the laxatives!!!l :roflmao:

Tenebrae, BSN, RN · Nov 22, 2014

*"we only got BPs or temps when they were acutely ill, were taking a BP med.." the residents are getting BP meds with out heart rate/BPs.... I am sorry but I am just not comfortable with this. The nurse told me she personally takes BP meds an only checks her own BP when she isn't feeling well

You simply do not have the time or resources to do a full set of vitals on every single patient every shift. I do daily obs on diabetic patients and patients on digoxin to ensure their heart rates is ok. I'll check vitals if someone seems sleepy or not well. Or following a fall.

..... okay but many of the residents simply can not communicate that kind of information.

True which is why you are looking as you do your med round you are also talking to your HCAs, because often many of them know the patients better than you . I had someone who was very sleepy today I checked their BSL to ensure their insulin hadnt put them low. I also asked the CNA who was assigned to this person if this was a normal presentation, they said that often this person would be very sleepy on a weekend morning

You ask your CNAs to look at the risk areas of the patients skin they are seeing them more often than you do, ask them to report any breaks or reddened areas. One of my CNAs came to me Y day to report a break in the skin which I dressed.

I had I have done clinical in several nursing homes as a student and they all had vital signs taken before medications were given per nursing home policy. In addition skin assessments only done once a week with showers! Is that normal for a nursing home setting also?

To be blunt, you dont have time to do a full set of obs on 30 patients. In my facility we have an hour to do the mane drug round. A full set of obs for 20 patients would double possibly triple that time.

Reality is, the systems in place are very entrenched and you wont be able to simply change things.

Tenebrae, BSN, RN · Nov 22, 2014

I'll give you a run down of my morning shift. Your ideas would be great in an ideal world however they are not practical in a nursing home environment

7am: morning report

0715: Antibiotics for unwell resident

0720: Insulin injections for three residents: BGL has been taken on the night shift as we were doing report

0740: mane drug round. Obs

0900: controlled drug round (with 2 nurses)

0930: Cares for unwell resident

1000-1015: Morning tea (mine)

1015: Change of fentanyl patches on three patients

1045: Wound care, complex wound that requires daily dressing change

1100: AC meds for one resident, PRN analgesia for palliative patient

1120: Resident with large haemetoma requiring care liasing with the charge nurse re same patient

1145: Getting residents down to the dining room for lunch

1200: Organising a bureau replacement for tomorrow so we only have to work 1 down not 2 down

1220: Gravity feed via PEG for patient, including med administration

1245: My lunch

1330: Phone call to the acute hospital to find out what was happening for a patient of ours who had been admitted.

1340: updated care plan for palliative client who has become a major falls risk

1350: Liasing with specialist palliative care service re same patient who is showing signs of ascites

1400: Apply cream on a patients lesion

1415: Write notes for my patients I'd had direct dealings with (4), the CNAs write for all the residents.

1445: (supposed to be in report) getting opiate pain reliever for palliative client. Liasing with family re this persons care

1455: The patient with the complex wound has had a low grade fever all day. Just spiked up to 37.7degrees C. Get the patient paracetamol to hopefully try and get the temp down.

1500: Collating and giving handover for the next shift.

1515: supposed to be finished now. Had two more notes to write and got out of the place around 1530

Dont get me wrong I love my job. Working as an RN in a nursing home has been wonderful in reducing my stress levels the reality is, there are never enough hours in the day