WittySarcasm

Not only are the above good advice but if they’re on a rehab for PT/OT you can also chart how they transfer and self care. ‘Pt transfers to bathroom with one person assist to stand pivot to wheelchair to toilet and back to bed. Pt needs lifting assist to stand. Is steady on feet. Mod I with all cares and hygiene.’ This has helped show the progress of patients in rehab and how they get better.

I began my nursing career in LTC, I was usually on the skilled floors except through agency which would put me anywhere. Anyways I finally decided to make the acute jump about 5 years ago. I went into acute inpatient rehab and yes it was a scary jump but at the same time I had so many skills (except for IV starts I will never get that skill I swear) already from being on the skilled side of LTC that I just had to learn the hospital rules for patient care. I’ve been floated to ortho and wound and med/surf and there’s been stuff I’ve encountered but I asked and learned. Yes it has been hard at times but also the time management usually has me finishing my stuff so early. Even if I go slow and take my time. Haha.

I’m not sure if this is in the right area and sorry if I’m posting in the wrong area. But I’ve worked LTC and inpatient rehab for my entire nursing career. I’ve wanted to always work pediatrics but I’ve wondered about how is it best to try to get into the unit. I know just apply silly, but is there any certain path that would be best? I want to look good when I do apply even though I don’t have such experience. I’ve been on ortho and wound when I’ve had to float and I feel ok and safe and comfortable with it. But I know this is specialized and I was just wondering what others thought. Can I just jump towards there, or should I do another unit before moving on? Thanks.

I agree with others saying this place is setting you up for failure. If moving to another place is possible I’d suggest it. However if it isn’t or you want to try to tough it out here’s some suggestions. I’ve worked LTC and in the hospital and this is just what I have picked up. 1) Call the doctor for anything that makes you feel uneasy- change of condition, abnormal vitals, falls. Even if everything seems normal you can still call and be like ‘he just seems off.’ Many times elderly won’t show any symptoms for UTI except for just being ‘off’. An example- yesterday they ate everything and was active. Today they are just sleepy and barely eating. Or they were sharp as can be yesterday but now it takes repeating tasks 2-3 times before they get it. And don’t be scared to ask if you can get a UA if you suspect an UTI. If your facility has a communication board for the doctor this is extremely useful for non-emergent issues- the resident wants to talk to the doctor about their medications, can they get a supplement since they just aren’t eating enough. Also always listen to your CNAs if they say that the person seems different. They are the first to know and the first to see everything. 2) Verbal and telephone orders can be taken at any time, per your facility rules. Just remember to repeat the order and the spellings of medications you don’t know or may easily be confused. Always spell out the doctor's names. For example ‘That order is 250 mg of Cipro PO twice a day for an UTI.’ This way you have verification you heard it correctly. 3) For charting I always went basic unless something was off. And even now I still do, it helps me keep organized in my thoughts and making my notes look good. For example if you’re just charting they’re still alive and fine you can do a basic head to toe charting. ‘Resident lying in bed, watching tv (or whatever their activity currently is). Vitals WNL. Assessment done and WNL. Up to BR to void, ate meals well. (Or whatever you want to add to show their current active level). And then build on from there. If they have dressings include that into your note. ‘All dressings CDI, no signs/symptoms of infection noted. (If drainage seen chart about how much- half dollar sized drainage seen on dressing, dark brown in color- I was taught to not use words like moderate or scant because this could mean anything but to use about what size it is- dime, half a nickel, etc). If they have IVs chart that they’re in good condition, (IV site and dressing CDI. No s/s of infection. All ports flush well). If they’re on antibiotics chart that they’re tolerating that well. (Continues on Keflex for UTI. No adverse reactions noted. No s/s or complaints of urgency, burning or unable to void). Document all calls to the doctor. Even if they don’t lead to orders just so you can show you called if something happens later. If they have A/V fistulas chart that there’s a thrill/bruit. Also almost forgot- are they there for Medicare charting? If so that is just to include they are still getting treatments there (for example if they’re there for PT, OT then chart ‘Resident continues to receive PT and OT.’) it is it just antibiotics they’re getting chart they are still receiving them. New admit charting- be sure to chart any skin issues seen on new admits so your facility doesn’t get the ding for it. But at the same time chart any new skin issue you see and what you did for it. For example, ‘Resident’s coccyx and buttocks red. Blanchable, educated pt on turning when in bed and chair. Took resident’s brief off to allow skin to breath when in bed. Placed zinc cream (or whatever cream your facility uses for skin) on site. Note left to doctor about skin issue.’ 4) If a procedure is being done you don’t know and another nurse is doing it go watch. When I first started my career I didn’t know how to change Peg tubes. I watched a couple get changed and could do it without problems. Is there a wound nurse? Follow her when she does the rounds. Is it possible for you to come in on a day off and just shadow for a shift? I know this was insanely long, but charting is something I semi get.

Hi. So I just have a quick question because I love to learn. I have a patient who is post crani- after a subdural. Anyways she's NPO and on a tube feed continuously. Which is all normal but her flushes is normal saline every 4 hours for hydration. I was just wondering why this is. Her labs are pretty much normal, sodium is slightly low but not anything bad. (She does have a PICC so It surprised me that if it was because of land that she did not just get IV fluids.) Anyways I just wanted to use this as a learning chance since I'm night shift and docetos are never around. Thank you to anyone who can help me understand this because google really wasn't working.

If you're able to always help your CNA/tech, never state 'that's the tech's job'. If you have time in your med pass/assessment then help them to the bathroom or to bed. You'll make so many friends. Plus you'll get hands on with your patients (plus noting material and assessment material). I find assessments can be done while talking to your patients. I deal with a lot of stroke patients- so talk with them. Ask about their family or their job or how their day was. Even non-strokes can be helpful here, is the patient alert? Are they answering correctly. Is their speech good? Is the eye contact good as you move around the room? Always check dressings, even if they're not due on your shift and document what you see- dime sized drainage on dressing and so on. If someone has a patient or a treatment or a care you've never seen before ask to watch. That was how I learned the most, because then I knew what it looked like. Also never be afraid to ask questions. And never be afraid to call the doctor or rapid response. I've called doctors just because the patient didn't seem right. There was no signs, and most times they say to watch them, but ALERT the doctor that something is up.

I started in a LTC setting, mine had a respiratory unit (where vented patients were there long term) and worked there and the rehab floor. After management changed I moved to the hospital scene, by entering their in patient rehab unit. At the LTC you can learn so much, from drawing blood from IVs to starting IVs to changing G-tubes and Foley's and suprapubics, and all the meds you will give. I also changed PICC dressings, flushed IVs and even D/C'd a couple PICCs, one thing about a LTC- if you're the only nurse you get to do all the stuff. I even learned how to do wound vac dressings and was able to fix or change them if the wound nurse wasn't present. What I did was dwell on those facts when I moved to the hospital scene. Now on the rehab floor I have gotten to see and do more. Though our patients are supposed to be 'stable' I've hung blood, pushed bolus IVs, start IVs, and other stuff. Some skills do lower if you don't use them all the time. But there's no guarantee in the hospital you'll hit every skill. I'd say keep an eye open for SNFs if nothing else comes.

Biggest things among everything else- It's not 'tech' work and 'nurse' work. It's patient care. If you don't want to wipe butts, bathe, help them dress then maybe rethink if you want bedside nursing. And dont proceed to act like you know everything. What you read in the textbook is the perfect world. Don't stand and recite the perfect world. We try to do as 'perfect' world but patients will screw it up. Listen and learn from your nurse. They might even give you cool tips that will help you when you're on your own.

I understand this example is not the strongest but it was more the latest moment I've had with her (mainly because I race for the lights). I had her once answer my call light, while I was in another room. The patient in question was a set up transfer (and truthfully she could have asked him or me) and he needed the bathroom. She proceedes to come to me and tell me the patient is demanding pain medications. Something that surprised me since his last 3 weeks here he never needed pain meds so I 'sped walked' to his room, only to see him half out bed. He tells me that 'I told the nurse that I needed to use the bathroom. She said ok and turned the light off and left.' I'd went back- after helping the patient and apologizing- and had her repeat what the patient needed (again she swore he wanted pain meds) which I had to explain the real reason. This is just another in a huge list of stuff she's done. Then there was the fiasco of when she was charge RN and refused to call a rapid response for me, refused to have the other nurse call it for me. And proceeded to LIE to me for over 20 minutes saying "they're on the way" when she NEVER called them. While I was with my patient who was on 6 liters of O2 and barely keeping 80%. While I tried to not cry she sat and lied to me multiple times. Which I didn't find out about the lie until I got another nurse to stay with my patient so I could call them.

Thank you so much for your reply. I'm gonna try to do that and hope for the best. I know everyone is tired of this and I hope through these ideas maybe something will help calm it down some.

Ususally I don't have them immediately talk to the manager, I've never actually suggested it to a patient but have had others do that. But if it becomes too big of a problem then I tend to pass it up the line- charge (though most of our charges don't want to be charge and tend to ignore that) and continue up the line. I did try to explain and I'm hoping that as the day progresses she'll kind of see it and maybe tonight will be better (especially since said nurse won't be back again).

I would try to get any meds switched to IV so she can have relief without the medication being sucked out through the PEG.

Maybe rant-y but I need to get this out there. Sorry if it annoys you. So, this has happened several times by the same nurse and I need ideas now. Going to the manager doesn't work- several have tried to no avail. Anyways this one nurse tends to say/do stuff to purposefully make patients mad or annoyed or complain. I, along with others, tend to keep her out of our patient rooms- even rushing to lights to get there before she does. Normally it works, but sometimes something happens and you're unable to. Today was that day, I was busy labeling blood that I had drawn and marking the IV blood pressure med I had given when a patient's call light went off. She jumped up to get the light. I had casually said that if it was pain meds she still had longer. I guess this nurse proceeded to tell the patient that I had told her she couldn't have pain meds and that she needed to wait- instead of asking the patient what she needed. The patient proceeded to cry when I later got her light, explaining she needed the meds- that she isn't drug seeking, and so on. She's upset to know that we are talking about her like that. And now refuses the pain meds she needs. Normally I would suggest she talks to the manager. But I know my name will come up. It'll be me that did wrong. And it frustrates me that I work so hard to keep them safe and happy and healthy just for 5 minutes to ruin it. The problem is there's no confrontating the nurse. Again others have tried- multiple times and result is always the same; she will lie, turn it around to where she is the innocent victim. I bend over backwards to make my patients happy for the 12 hours I have them. And it annoys me that I have to deal with this constantly. Any ideas on what can be done about this, besides shaking her and screaming endlessly. Or if nothing else thanks for the rant.

I agree too. I always do what is right for the patient. Sometimes they get mad that I don't treat the hospital like the Hilton, which I'm sorry that's actually a block east if you got lost. Haha

For me beside nursing is a love/hate relationship. I love caring for the patients. I know a desk job in management is not for me- paperwork for hours kills me inside. So I love caring for the patients, seeing them get better and go home. While dressing changes aren't fun I can do them easily enough and I have no problems. I happily will walk with a patient- when I have the time. And I can talk with them about stupid stuff. I love watching them get better and teach them about their health and help them learn and grow from whatever illness they suffered. However, at the same time! You are expected to do unsafe ratios, and don't you dare tell that one patient that the reason her meds are 20 mins later than what she wanted was because you had 6 other patients that needed their meds, a dressing that fell off, an IV that died and needs to be replaced, a code brown. On my unit each patient, and with night shift you get 7-9 patients, you easily have about 15 pages of charting. Along with quality checks or audits that are expected while trying to take care of everyone. I love bedside nursing, I don't like doing administrations job. I don't like having patients yell at me because I can't be there within 30 seconds of their light going off. I don't like having administration breathing down my neck because I can't get to the call light within 30 seconds but instead in 45 seconds. But I do love caring for the patients and doing the actual bedside work.

I understand the importance for customer service and satisfaction but sometimes I feel it goes to far to the extreme. Often it has left patients able to 'tattle'/berate/accuse staff and when management gets involved we hear 'you have to think of the satisfaction survey we give patients'. I work on the inpatient rehab floor so I see this often. Patients come to us expecting everything to be done for them and are normally shocked when we tell them they need to learn to walk to the bathroom, that they need to learn to dress themselves or other ADLs. We assure them we are here to help you, but also we are going to have you do what you can on your own (seriously with a unit named rehabilitation what were you expecting the unit to do?) I understand what sickness, pain, frustration can do to patients and that is why I always give extra understanding and caring patience but at the same time we try to teach them to become independent again. Recently I had a back patient that I was trying to teach her the correct way to stand with a walker (don't use the walker to pull yourself because it will tip and you will fall instead push off the bed). Due to this she complained that I was rude and had not wanted to help her. Meaning I was reminded about patient satisfaction and survey scores. While I didn't ask, part of me wants to ask administration which is more important- for a patient to learn how to move without falling or letting them fall and probably breaking something- but hey they are happy with me as a nurse. Sometimes I just feel that we put too much into patient satisfaction and not enough into making sure they are safe. -Leaving the bed alarm off of a fall risk patient that is impulsive just because they are mad when the alarm goes off. -Having an order that says to not awaken a patient until 0600 when they are a high breakdown risk and are awakened every 4-5 hours to turn and reposition them. because they are tired of being awakened every 4 hours to be turned. These are just a couple examples of the 'patient satisfaction' trumping over what is best for the patient. Am I alone in feeling like this? Do I just not see the bigger picture while caring for the patients? I just want to do what is best for the patient and their safety and health.

Believe me I had the same feelings as you when I started my career. But I'm so happy I got to work at a nursing home. I was on the rehab unit and I got to see so much. I learned how to put Foleys in, how to trouble shoot them. How to place IVs. How to do dressing changes. How to change a picc dressing and d/c them. I learned about tube feeding and about tpn. Even how to change a wound vac and trouble shoot them. I really feel that it helped put me ahead of others. I work at a hospital now on their rehab unit and I can easily jump in for anything that needs to be done.

Don't fret. I can tell you right now from experience no matter how old the patient is once they have a tube they are going to pull it out at least once in their stay. I've had grown men who are alert and oriented and sharp as a whip and they pull their Foley out with the balloon inflated just because. Tubes can be easily placed again. It just depends on your facility's rules. Where I was we could replace it when we saw it was out. Other places you have to call the doctor that placed it for orders. I promise you'll feel like crap when it gets pulled. It's not your fault. You were a great nurse and there's nothing that would have prevented it. Stuff happens. At the same time if she doesn't have one I'd ask about an abdominal binder. It keeps questing hands busy so that it takes a little longer before they can get to the tube. It won't stop it getting yanked out but it will make it harder to get to. I've had Foleys, GT, trachs, and piccs get pulled out by the patient during my career so far.

I left LTC a year ago but I was in it for 3 years and I have heard that not much has changed. So here's what I noticed. 1. What size is your LTC facility? All together we could hold about 150 patients. 2. What is the nursing to patient ratio? Depended on the unit. Because we had a respiratory unit that had nothing but vents, if you were on that unit you'd get 15-30 patients. Otherwise about 30 patients. That was for the first two shifts. The third shift you'd get 30 for the respiratory unit and up to 45 for the other units. 3. What is the CNA to patient ratio? The CNA would have from 6 patients for the first two shifts and 10 for the third shift. 4. Do you feel you are able to provide quality nursing care to your residents? It was hectic and many times I worried if I saw the patient enough but yeah I did. I had a wonderful staff with me that also cared for the patient and because we had tv in the dayroom many times I would try to just say hi to them as I walked by. I learned to have a groove that helped a lot when working, it would give me the chance to check people at least 3-4 times a shift. 5. Is your facility doing computer charting? We had just moved to computer charting. 6. Are you subject to mandated overtime? Nope. 7. How long have you been nursing in the LTC setting? I was in it for 4 years before moving on. 8. Do you feel that you are able to keep your various residents safe? Yes. I mean residents will get bumps and falls because the LTC is almost like a home setting but I felt we kept them safe through the day. 9. Does your LTC home have a mixture of residents? We were a state nursing home before we went private. So we got the homeless and those that were "to behavioral for any other place." On top of that we had the respiratory unit, rehab unit for those to go home soon, long term, and our locked unit for aggressive residents. 10. What is your hourly wage (ballpark) and do you feel you are underpaid for the work you are doing? I was paid about $22. I felt I was underpaid but I was under the new grad pay too, so maybe I would have been bigger if I had more experience. 11. What state are you practicing in? Arizona.

Does your facility have you changing it or does a special nurse? Because I can semi explain it since I used to do it all the time at my SNF.

Wound vacs usually are changed on certain days. The wound nurse or your facility or the doctor will have the days. They do beep for a couple of reasons and it is a musical tune that you will hear. It can be because it is clogged (if the tubing is kinked or locked) or if there is a leak. The vac will tell you what it is on the screen. If it is a leak you can usually fix it easy and fast. First feel around and if you can't put your ear near it and you can hear a hiss. When you think you found it put your hand or a finger over it and see if the suction gets better. If so place opsite over it until the beep hides away. It may take several pieces depending on where the leak is and how many bendable parts there are.

Once I was tech on my unit because we had too many nurses and needed another tech. Well day shift comes in and one tech comes and gets report and the other one doesn't come in. This is normal for this tech and they call and tell him to come in. Fast forward 15 mins and call lights are going off and day shift is expecting me to get them. Really. Why aren't you demanding your staff to come in on time. I sat there and told them no, they need to explain to their staff that being over an hour late means you get in trouble.

Ok mine are of course being late. I come in 15 mins early and while in the break room I grab the pens I need so when I come to the floor I'm ready for my assignment. To have to wait that extra 15 mins for you to find your pens and color your report sheet with different colors is stupid. Do it on your own time after I've given you report. While talking about report come to me. I rather not hunt you down in the morning when you scatter to your special spots. You can see on the white board if I have your patients and you see me sitting there waiting. Don't just run away and make me pace that unit for you.

This sounds much like my rehabilitation unit. We have patients that are not correct for the therapy that we expect them to do. Many times we have to return them back for medical conditions that they should have never have been sent over to us. I can remember getting the cancer patient that should have gone to hospice then with us where we were constantly taking his vitals. Or the patient that's been wheelchair bound for 2 years and we were teaching him to walk. Yeah...I found as long as they have insurance saying yes, we'll get them.

If you have them and the patient is a high fall risk I'd say set a bed alarm. They don't prevent falls but it will help you get to the person and check them. That and maybe q2 hour toileting