Question for those who work the 11pm-7am shift

LTCangel, ADN, BSN, LPN · Jul 9, 2011

I work 7p-7a and I have 24 residents from 7-11 and then take over both halls at 11p and have about 46 residents. I start my 6am med pass at around 5 and usually do my FSs at 6( they are ordered at 630). Most of them do not have insulin ordered until day shift ot thay are on Lantus at hs. If they do have SSI I wait til as close to 7 as possible to give insulin, if it's borderline on the SS then I will pass it on to dayshift to give after breakfast which is usually around 730am. I have one VERY brittle diabetic that I check between 4-5 because if I wait til 630 she will almost def be 30-40 and still be awake talking and smiling at me. So I am always ready to give her OJ and maybe some food and needless to say I have so far never had to give her any coverage. I have been at this facility for 2 months. I do not prepour. But some meds such as Prilosec can be given early since it's a once a day med. I flag all of med 12a and 6a meds while I am doing my 9p med pass so I won't forget anyone. I have gotten faster as time goes on and you will too. But I will say 60 residents with 20 FS is too many for one person. Also as far as BPs, unless the med is ordered with parameters BPs don't usually get done because this is considered their home and i=unless they are having symptoms or other known problems, I don't check. All of our residents have a sceduled body audit with vital signs once a week, just as most of them only get blood work once a year unless they are a med that requires more frequent checks, such as seizure meds or coumadin. Good luck, and God bless, I know it is sooo frustrating at first. If you continue to feel unsafe and unsupported then look for another job. Just sayin'....Lisa

jesbetts · Jul 10, 2011

I work 6p to 6a and I work LTC and Skilled my pt load is any where from 15 to 60.I usually have 3-4 vent patients and a couple just trach pts too. At my facility I give all 6am meds, which usually isn't more than 14 residents, and the day shift gives all 6 p meds. Our pharmacy schedules our meds as 06/0630 07/08, 11/12 16/17 and 20/21. which means we have from 0600 to 0900 to pass morning meds. it makes it a lot easier, the place i worked before i had 3 locked units 20 residents each I was responsible for giving all the 6am meds on 1 of the units and it was a royal pain to do 15-20 pts meds and try to give report all by 0630 so i wouldn't get into trouble for clocking out late.

joanna73, BSN, RN · Jul 11, 2011

Wow. I have 30 residents and I think that's enough. My meds take 2 hrs, so I can't imagine 60. You'd have to double that time for sure. Waaay too many, and med errors waiting to happen.

yooperPN · Jul 27, 2011

I work 11p-7a LTC, with about 60 residents under my care and 4 CNA's to help. Luckily we have about 3 fingersticks that are daily, and few more that are on a weekly/monthly stick. (I guess state has been cracking down on unnecessary fingersticks?) Finger sticks are due by 6am, so I start those at 5am (I was trained by many NOC nurses to do it this way). I have a couple residents that need their legs wrapped before they're up and dressed for the day, so I do those before 6am also. When I'm done with that, I start the AM med pass (we have about 8 residents who receive some meds between 6-6:30am).

Thankfully, where I work the BIG med pass is at 8am, so I don't have to pass to all residents. Most of my NOC is spent giving PRN meds, checking O2's, changing out tubing/irrigation trays, etc.

Let's help out · Jul 30, 2011

Oh, and By the way, GET YOUR OWN malpractice insurance and keep it quiet. Your facility's insurance company only cares about the facility. Call NAPNES for referral numbers. It's the best $110.00 I spend ea year. I'll do "beans and rice" before I'll go w/o my own private ins.

kybreyes54 · Jul 31, 2011

Hi..I am a LPN and work in LTC on unit of 45. We have 2 nurses a shift most times or Nurse and KMA. Start off, Does your facility know the State Regulations on med pass?.No signing off meds prior giving, no set up prior. I don't see how they can get by with that. And 60 residents??..That is insane, and a high liability ready to happen. No matter of there policy, if something went wrong and you took the assignment, you would be totally responsiable and could lose your license. I would be very careful. Good Luck

pixie120 · Jul 31, 2011

Yup, this is how people manage 60 patients. The facility would rather look the other way than make a more reasonable assignment.
Most of the PO meds will be prilosec and synthroid.
I used to work in a facility that has a 60:1 ratio on 11-7. All the nurses prepoured and started their med pass at 4.

So..why not change the times to the actual times the meds are being given? If the resident always reallygets the thyroid med at 0445, change the time! If the tube feed is really changed over at 0200, change the time. Are there meds on all 60 residents? Most I have ever seen assigned in LTC, not medicare unit, 40. 60 isn't safe.

pixie120 · Jul 31, 2011

One suggestion for change at the facility would be to have the blood sugars done first thing by the day nurse for the ones that need sliding scale coverage with lispro. We did this at one place and it took a bit to get used to, but when the docs started ordering lispro so it was a nessasary change. I am working on getting that changed at the hospital I work at, the day nurses get their panties in a bunch when the blood sugar wasn't done by 7am. Well guess what even if it was I would (if I worked days) do it again if I am giving lispro at 8am on a blood sugar done at 6am.
but WOW 60 and all those blood sugars. and i am sure you get in trouble for the "overtime" I know too many nurses, usually the old schoolers who punch out stay 1/2 the morning to chart. Not sure what they have to chart on till ten am but I would never punch out to chart.

I always chart in the MIDDLE of my shift. I don't understand nurses who chart at END of shift. If I have charted in the middle, and there is something new to report, then of course I do an addendum, but why would I leave all of my routine charting for last most busiest part of 11-7 shift? Also, work on whittling down who is on alert. Some midnight charting is "Resident asleep, no apparent ASE to ABO. ". Done. What else is there to chart? Remember, chart by exception. We don't have noc shift nurses do Medicare charting, just alert charting. Of course, if there are vitals to be had, chart thouse but would be done at start of shift, I/O start sheets, even shift finishes them. NOc can chart in beginning of their shift for the previous dayI/O. One problem I see is nurses who chart on everything but don't do an incident report, don't call the MD, don't notify the DNS, but chart if a toenail fell off, seriously. Don't file, don't organize and gather all those loose stacks of orders, seem confused by leadership and yet, have 3 hours of overtime every time they work and say they can't get the job done (and they do NOT have a med pass at my faciliy, except for levothyroxine, prilosec and a few blood sugars). They also tell the resident all night long, go to your room, no, you cannot have pain meds. Seriously, that is why there are all new nurses now on noc shift.

Whenever a manager works noc, they are immediately wondering what the big deal is. The manager is able to return all the d/c meds stacked to the ceiling in the med room, organize and clean up the station, supervise the staff, do EXTRA charting, do the glucometer checks, let the pharmacy in (on noc nurse told them we are closed now, come back in the morning, seriously not kidding here), put the meds in the right cart, under the right patient slot, and get out EARLY. I really, really think it is a motivational issues, either you really want to be a competent nurse, or you don't or can't .

Please advise me if I am wrong, I DO cover the cart from time to time, passed a lot of pills when Iwas the DNS in a Assisted Living, covered a lot of noc shifts when I was a floor nurse. I cannot be the exception cuz I hear from my managers all the time they cannot understand why some nurses struggle to finish their med pass much less follow-up on labs get MD orders and do skin checks. The nurses in my building get no more than 25 residents, and less than that on the sub-acute unit, and that set of nurses ALWAYS want overtime. Progressive discipline isn't always that effective either, particularly in the younger nurses.

pixie120 · Jul 31, 2011

WOW!! thanks for all the responses. i survived my shift... but not without the help of my supervisor. she didn't have any admissions or discharges to prepare for the day, so she helped me and the other new grad with our assignments (the other new grad had about 60 patients as well). we were instructed to start signing off the MAR early and do our charting early. all the misc tasks were done first. any meds due at odd hours were given on time... but the majority of the patients had meds at 6:30am. and YES, we were told to start at 4am. it started off well... until i remembered that i had another med cart full of meds to give HAHAHA. my supervisor did about 17 of my accuchecks for me. by the end of the shift, i was sooooo behind that my supervisor helped me with my insulin injections and with the rest of my PO meds. i had patients up at all hours of the night asking for PRN meds as well as dressing changes that needed to be done before i could do my med pass. so needless to say, i had to save most of my charting for AFTER i clocked out. i clocked out at 7:30am, but didn't leave until about 9:30am.
i'm not really sure how to manage nursing care for 60 patients in one 8 hour shift. i understand that some of them don't really require much nursing care in the first place. but others are very demanding and have a million things going on with them.
Are you in LTC or the hospital? If the MD doesn't require the B/P, it doesn't need to be done in a stable, long-term resident who has been succesfully taking the med for years (and gets at least monthly routine vitals) as long as the MD concurs. Those orders are acute hospital orders. How many of the 60 are LTC? It sounds like you may have enough nurses, but the way it's assigned is screwy? Why doesn't that manager do some of the med pass, like on that other cart? Anyway, talk to your DNS. She/He is your ally.

pixie120 · Jul 31, 2011

i realize that everything you pointed out is all wrong. that's my problem. i'm a new grad and tend to try to go more by the book than anything. but the more i try to do things right, the more the bosses pull me aside to say that i'm in the real world now and i need to take shortcuts to finish my work faster. when i was just starting out, the other nurses would come and help me give some meds. but of course i didn't have an opportunity to sign off on anything they gave until after my med pass was finished.
i had difficulty coming to terms with the idea of giving 9pm meds with 5pm meds. i've been pretty resistant to that shortcut. but when its 11pm and i'm still giving meds, my coworkers and supervisors keep telling me that i need to finish more quickly.
when i first tried combining 5pm's and 9pm's, it was hard enough. then they all told me to just start giving meds as soon as i've started my shift.
i'll get in trouble if i don't finish all the work (charting, giving all the meds, treatments, incident reports (if any), etc). but i'll also get in trouble if i go into overtime. i'm required to get everything done by the time i clock out for the day. i've already gotten in trouble with my boss for staying late (off the clock) to finish up my charting.
and as for the BP meds, i'd say 99% of the BP meds i give DO have parameters. so because of the ordered parameters, i find it unsettling to see that the other nurses aren't checking the BP. especially when i see that these meds have previously been held... i'm afraid of just giving a med when the patient's BP might actually be lower than the ordered parameters. or are they just holding the meds so they have less meds to give? i always wonder that when i see all the held meds in the MAR....
i guess i'm struggling because i'm constantly being told to take as many shortcuts as i can to get the work done... but everyone always adds in "...unless the surveyors are here. in that case, do everything right." like i said, i'm a new grad... if i can't do things the way i know is right without constantly getting in trouble with my bosses, then i won't be able to do anything right in front of the surveyors!!

Ok, lets start at the basics. As a nurse, you assign the times of the meds. The MD prescribes "Prilosec one tab po QD" we give it a time. Some of my residents take all of their AM meds at 5 pm, MD knows, ordered and given it that way. None of the times in the MAR are set in stone.

When I worked evening, I adjusted all the times to the times the resident wanted to take them, and then put that on the typed Physician orders for the MD to sign off, making it an actual MD order.

Some things are difficult to rearrange: Blood sugars QID AC and HS, Prilosec 30 min prior to meal and all meds, Fosamax weekly, on empty stomach with 8 oz water..... Thyroid in am.....Digoxin with apical pulse..... HOWEVER the rest is fine to move around. Most patients don't take am meds at 0800. I have guys that take their lasix at 8 pm, no fooling. MD doesn't care, as long as it's given every day, at same time, for most effective dialy dosing and having the med at most consistent levels in blood stream. Coumadin, 5 pm LTC, don't give first day of admit (hospitals give at 2 pm, don't always tell you, don't want to double dose, ask for PT/INR for next day so by 5 pm next day, have results and call MD if too low, too high).

Many, many meds are simply unnecessary (and this is an actual F-tag) in certain LTC populations and duplicate therapies ie Hospice patient who is still struggling to take MVI, Calcium, Iron etc when they really just need pain meds, bowel meds and comfort (ask Hospice to guide you on this). Residents with advanced dementia, who spit out meds, get the unnecessary meds (ask families to be part of this important discussion in a care conference) and see what meds they feel are important (of course keep all pain meds, bowel meds and antibiotics). Ask the pharmacist consultant to look at formulary and reduce nursing time ie DOss 100 mg po TID, waste of nursing time, DOss 250mg poqd much more appropriate, better chance of getting in the diffiucult patients who don't want to take many meds. We have a form we can send over for a pharmacist review (I use it for fall reviews, after a fall, please check for drug interactions and fall drugs).

Dementia units typically have only 2 med passes, AM and PM. In Assisted living and adult family homes they actually designate all meds a AM and PM (Am being defined as 0600-1200) (PM defined as 1201-8 pm).

Heparin IM on an ambulatory resident hmmmmmmm. Fragmin AND Heparin hmmmmmmmmm. Oxycodone prn, vicodin prin, routine tylenol, prn tylenol, routine morphine hmmmmmmmm. LOOK at your mar and start whittling it down.

This not only saves nursing time but is better for the resident. Destroy all d/c meds asap per facility policy. Ask your DNS if you have to count Schedule 5's and 4's (another big time waster). ONe of the most common things we see in LTC is chronic pain, being dosed inappropriately with short acting narcotics , ask the doc to give you the long acting pain meds, saves the resident and saves the nursing med administration times.

I hope this helps?