tinkertoys

Our protocol is V/S Q shift x 72 hours for new admissions. After that, everyone gets a full set of V/S weekly. If a patient is ill or on alert for some reason, V/S q shift for at least 72H. Temp q shift if on antibiotics, AP and BP if appropriate for meds. We would never dream of calling a MD without first getting V/S If possible, we try not to disrupt their sleep, activities, etc., but sometimes it's necessary in order to give the care our patients deserve. Our patients are mostly skilled care. Maybe regs for patients who are physically stable and on very few meds are different...I don't know...

At our Center, we try to have in place for our pts PRN orders for MOM 30cc qd prn, and fleets enemas qd prn. Our 3-11 nurse makes her BM list at start of shift, listing all who have been 2+days without BM. CNT's are aware, and mark off those who go during shift. Then on last med-pass, gives MOM. If no BM next day, MOM is repeated. If still no BM, pt gets fleets enema next day. Most of our pts get colace daily, and many also get sorbitol 2-6 Tbl/day according to BM's. A few have QOD dulcolax orders. When all our nurses follow our protocol, we have pretty good results. There are always a couple of pts with chronic problems who need regular disempactions, but that has decreased with our protocol.

No, this is NOT the way this patient should have been treated!! She should have been examined immediately by her nurse to check for injury, especially for the possibility of a fracture, and the MD notified right away, with emphasis given to the patient's c/o pain -regardless of whether or not she could be specific about the site of her pain. At her advance age, it would be a wonder if she HADN'T sustained a fracture! I can't think of a single one of my doctors who would not have ordered x-rays immediately, and been very upset that it took 24 hours to get the results. I am not surprised that there will be no surgery. At her age, chances are that she would not survive surgery, and at her advanced age, the fracture may not heal regardless of whether surgery were performed. I am surprised, though, that she wasn't even placed on fracture precautions, with staff being taught ways to care for her without causing further injury or increased pain. She most definitely does not need to lie on the affected side, or to put weight on that leg. And the hip needs to be kept as immobile as possible. It IS possible that tylenol could relieve her pain. We all have different pain thresholds. But she should be monitored closely for signs that her pain is NOT being relieved. Thank you for your concern about your patient. I'm glad that you didn't just report her problem and forget it. Many would have. Her recovery may depend on what you observe and report about changes in her condition, so please continue to watch her closely, and handle very gently.

Our protocol is to give meds, THEN initial the MARs. I, personally, have a problem with that, in that it's easy to get side-tracked and forget to initial after leaving the pt. My personal preference is to gather my meds, make sure it's all right, then initial and give meds. If something is refused, etc, then I circle on the MAR and document details on the back. I find that there are fewer blanks that way, and I have the med in front of me when I initial so I can verify... not try to remember later. Saves time, too.

It is against regs to pre-set meds. I MIGHT be able to go along with gathering up the unit dose meds together for a few pts who get lots of meds that you have to search for (leaving them in their med drawer) ahead of time, but even that is iffy when it comes to Survey time. Also, if you recheck the gathered meds against MAR's right before giving, you are essentially doing a task twice- once when setting up, and again before giving - and I rarely have that extra time to spare. And if you skip that second check, you run a very real risk of a med error- At our Center, our med passes are organized to disturb the pts as little as possible when it comes to the med pass, so if they have meds to be taken before breakfast, they get all their AM meds at that time unless contraindicated. Makes sense for the patient - reduces the number of times we interrupt their therapy, etc. for meds, but can turn the 6am medpass into a nightmare. Especially if there are lots of pts with fingersticks and swallowing problems. There are some who request their meds at a later time, but for the most part, works very well. The real key to surviving that last medpass is organization. Make use of the "one hour before and after" window. The more things you can get done before you start that last pass, the better off you will be. Make sure that your medcart is well stocked before you start. Try to organize your medpass so that you are in the same part of the hall as your CNA's, so you don't get stuck answering lights, etc. If you answer the phone, too, lobby for a portable phone you can take with you on your medpass - that alone will save MILES of running and valuable minutes. :)

We do a computerized summary monthly on each patient, including addressing each issue of their care plan. 11-7 does this, and the MDS coordinator handles the quarterly, change-of-status, etc. We also do focus charting daily on our skilled-care patients, addressing their general condition and priority diagnoses. Each shift is responsible for a different set of patients, to spread the load. this is all in addition to any alert charting we may be doing. Not much fun, but I guess it's necessary.

Standing orders can be WONDERFUL in LTC, but should be utilized with caution. During a recent viral outbreak in our facility, we had standing prn orders for phenergan and lomotil for the pts of some of our Doctors. The orders had a time limit covering the weekend, which saved us a lot of time, and the on-call MD from a sleepless weekend. We have also had standing orders at times, OKing prn tylenol, MOM, fleets enemas, etc. We have to be mindful, however of the conditions of the patients involved. Sometimes the standing order is not appropriate given the medical problems involved, or the extent that illness has affected the patient...That's where your nuring judgement comes in. And even if the standing order is utilized, it is still very important the the MD be notified of the pt's problem at the first opportunity.

11-7 should do more??? Come On !!! Contrary to popular belief, LTC pts don't sleep at night. They are lonely and scared, and needing attention, sore from PT and asking repeatedly for pain pills +/or hot packs, they need to pee (constantly), they're confused, disoriented, often combative. Strangely enough, the patients who are alert, oriented, and ambulatory during the day, can not seem to breathe without assistance, much less turn over in the bed. We have more patients per staff member, more treatments(since we have so much time!), and the same amount of documentation per pt as the day nurses. If we have an emergency, injury, or a patient codes, we have no one to call for backup help...what we see is what we've got! and we must always deal with the on-call Dr's (if they answer their pages). Yes, I imagine it does seem much quieter at nite, because all the "brass" and family members have gone home, but the night shift works every bit as hard as the others- and often has to do it on less sleep, because of the demands the 'daytime world' places on us as well.

I work 7P to 7A in a 102 bed center, where the majority of our beds are skilled care. 1st and 2nd shifts have 4 nurses and one Team Coordinator, and an average ratio of 1 CNT to 9 patients. 11-7 has 3 nurses (no TC), and 5 CNT's. Because of the divisions within our center, it works rather well. I am very proud of our center, and the care we are able to give to our patients. I am becoming more and more frustrated, though, because it is so hard to find staff who are truly dedicated to the welfare of our patients. Most of our newer "team members" see this only as a job. They don't have any qualms about calling in at the last minute (forget asking them to get someone to work for them!), and refuse to stay over and help out if problems arise.They can't be bothered with call lights, teamwork, or making sure the job is done right. Those of us who have been there a while care very deeply for "our people", and take up the slack for THEIR sake. Like I said, we see to it that our patients receive excellent care...It would just be so much easier on us all if everyone did their part!!!!!