itthybitthythpider

Ive noticed the trend with skilled, too. SNFs are the new sub-acute and sub-acute is the new med-surg. So all the long-term SNF patients are being sent to ALFs and ALF patients are staying home

Even a wet to dry shouldn't be soaked through. But yes, it would definitely need to be followed up on if you felt there was a mistake. If you look through the chart and everything and it does say "change q3 days and not a moment sooner" I would ask someone who is familiar with the resident why it shouldn't be changed sooner if it's soiled. Or again, call the doc and get clarification. Everything I've learned says if it's soaking through, the wound is too wet and will cause further damage to the wound. We are the eyes of the doctor, so it's up to us to tell them when a treatment isn't effective. And if they come back and tell you that's what they want, then document, document, document!

Even if the order states Change every 3 days, they should be changed as needed, also, especially if they are soiled or soaked through. Leaving dressings on that are soaked through is not the norm. I know where I work, we automatically put a change PRN for soiled or loose dressing order for every treatment. Even if it's not written, it should be understood. Unless you have an order that states "do not take this dressing off!" Then I would call the doc and ask if we can change it and what we should put on, and descibe that it is soaked through or coming off or something.

Oooh! I'd never heard that before. Just the clocks.... That's an interesting idea!

I've got my fingers crossed for you, too. Good luck!

How do you determine tissue tolerance?

You are lucky, coming from a psych background! We get a lot of psych patients in LTC. Some nurses forget they are supposed to be more than passing meds and charting! You'll get the hang of it, though. As far as patient load, it's usually 20-30, depending on your state and facility.

Vancomycin needs lab draws, too. and procrit and epogen

And the argument that ensues during change of shift takes longer than getting the actual work done and staying over! Plus the next shift never has time to get their work done, so then you have extra work that you pass on, then extra extra work is passed, and so on, and nothing gets done. Then we get in trouble for that! Higher acuity patients + Staffing and budget cuts = Catch 22 Get your work done, or leave on time, either way you get in trouble!

I've had a couple get upset at me for sending a res out (and especially for sending them out without telling), but I can always justify myself to them and my DON!

Keep your "brain" (the piece or paper or papers you write everything on) close and use it often! I like to color code mine with different pens and I write EVERYTHING down, even if "I won't forget /that/."

For a DNR, we call the doctor and the funeral home and family, and that's it. I have seen police involved, but I think that was for unexpected deaths. The doctor will pronounce when we call with our assessment. Quick and easy, really.

One thing that helped me when I was learning was to take a list of meds I didn't know home and look them up in the drug book. Same with new diagnoses. I'm still learning everyday, too! I love nursing just for that reason

Cheaper supplies, cutting out unnecessary supplies. They don't pay for over time. HUGE focus on therapy, so we have to bend over backwards for them to get minutes in. Skeleton crew for CNAs. No holiday pay for this fiscal year. Luckily, no pay cuts. And we aren't desparate for residents and admits

I shed many many many many tears my first year in LTC XD My coworkers and I had a "crying room" (the utility room on one of the stations) where we would go when we were upset or needing to vent or something. It's VERY stressful at first. I agree getting a full time position is better, but that's hard to do without having a job for 6 months or so.... I was there, feeling like I wasn't cut out to be a nurse, feeling like I should give up... It was hard, but so worth it! Ask lot's of questions, ask for help, offer to help out others so you can learn how to do things. Keep your chin up and don't stop putting in applications, even before 6 months is up. Good luck!

That happened to my dad once!

Working off the clock is an epidemic in LTC -.- I wish I knew what to do about it within the facility (and nursing in general) that doesn't call in the state and get me fired....

I've had both the family not telling the resident and the resident not telling the family members where they were going. And both times we got blamed Our admissions coordinator is really good about trying to talk to the families and residents long before they come in, so that when they do get to the facility they have a familiar face to turn to. She's awesome!

Patient came to the ER while I was precepting there, so I went to get a history. Me: What brings you to the ER this evening? Pt: Chest pain. Me: What happened? Pt: I was under a car, working on it, when the car fell on my chest.... Me: How long ago did this happen? (Stupid question, right?) Pt: A couple hours ago. Me: What took so long to get here? Pt: I thought the pain would go away so I just went to the couch and got a beer. Um... What?!

My peds rotation was on the pediatric burn unit. There are no words to describe it, but I left every day there feeling ill. I remember holding the 3 year old in the body cast while she screamed in pain and just rocking her for a couple hours. Or the kid with severe burns who shivered in the shower and cried and BEGGED for us to stop. I realized then that peds was not for me. My ultimate goal when I graduated was to work in the ER, but the only place I could get hired at was a SNF. Any of my classmates who decided to wait til they got hired at their dream jobs ended up still unemployed years later. Hopefully your nursing career is a long one, so even if you want to put in a few years at some place out of loyalty and work to pay off your "debt" to them, you still have a long life ahead of you when you decide to leave there. Any experience you get anywhere will only benefit your "dream" patients in the long run. I used to have rose colored glasses when I graduated, and sometimes still feel guilty for leaving a job, but I have to take care of myself and my family so that I can take care of my patients. And the only reason, I realized, that I felt guilty was because I was leaving a few good coworkers and the patients there to fend for themselves. I am hugely loyal, but like respect, it has to go both ways. My loyalty is for the people who have my back and who depend on me, not to someone just out for a buck.

My favorite is when I tell the family that I can't do something, and their response is to look at me like I just grew two heads and each head is speaking a different language at the same time! If my nurses are busy (when aren't they) and I know a crazy family is here, I usually try and get there first and talk to them, make sure everything is ok and whatnot, before they have a chance to corner the floor nurses. That way I can try and get their problems taken care of before they have them!

At one building I worked in, my facility got in the habit of not taking "problem patients" back once they were admitted to an acute (usually psych) hospital. Almost like punishment at times. We had one lady with a mental disorder who, during our state survey, kept trying to talk to them (she likes to talk and complain and the surveyors new it was harmless cause she'd been there forever and they talked to her every year). After this last year, there was regime change, and all of a sudden the resident was sent to the acute psych and we were told she would not be coming back. It got so bad there that the hospitals (esp the psych) wouldn't take patients from us for a "tune up" because they figured we were dumping. Made it very hard to get help with the violent patients! On the other hand, I've had facilities dump on me before. One facility, before we had accepted the patient, dumped 2 of them on us. These were the most aggressive, sexually assaultive patients I had ever come across! There is another thing that bugs me, though. We have sent some residents to the ER, and when the ER gets ready to send them back, they call us and say "You need to come pick your patient up. We aren't going to send them back. If you don't pick them up, we will report you for abandoning your resident." They sent one resident back via taxi! Without telling us first. The ER had told the resident to have the facility pay the taxi when she got back to the facility. At 10pm at night when the business office was closed and we had no access to facility money. When we questioned the ER staff, they say "an ambulance is too expensive and we aren't going to arrange transport. Are you going to make the resident pay?" One of our NOC shift nurses had to drive out to the ER one night in her car to pick up a resident! That, to me, is an extreme misuse of the dumping laws.

Love that! CNAs are the best. Ask them a lot of questions, cause they know the residents the best.

That's scary 0.0

Yea, that's a little more confusing.... I only pass meds if the nurses are off the floor or we are short a nurse. Otherwise I "supervise" the nurses working the cart. But if you are only shadowing the LVNs passing meds, it may be that they need an RN on the floor, working the cart, and in charge of hanging IVs and things that LVNs can't do. Michelle126 is right... you need to ask for a job description. I just know what I do!