SNF/LTC new nurse needs advice

NutmeggeRN, BSN · Dec 22, 2014

Whatever is scheduled should be given...that said, there should be a an e-kit from where you can pull a dose or two from. Borrowing is a no no, (not to say that it is does not happen on occasion). It is frustrating because i have been told we will be held accountable if there is a missed dose. So I as the perdiem, who has not been there in a week or so, becomes accountable for the dose that the full time people or regular part timers did not order on time......irritates me to no end.

Mn nurse 22 · Dec 23, 2014

We have an ekit and local pharmacy that we use for the first few doses of meds or we specifically have the md write "when available" if it is something that can wait for a few days.

If that doesn't happen we have to call our on call md for an order to hold the medication until delivered from pharmacy.

We also have a list of "criteria for immediate physician contact" that gives us a guideline for when to call the MD.

Systolic BP >200

Pulse >120 or

Temp >101.4

Chest pain

uncontrolled vomiting or diarrhea

spo2

and more

A lot is basic nursing but the parameters give us a good reference and keeps us all consistent.

I rely on families to help make decision for hospitalization. A lot of them want comfort care only so we would only send those patients out if we suspected a broken bone or critical incident. Other families want aggressive treatment so we send those patients out more frequently.

tnmarie · Dec 25, 2014

What medications absolutely must be given daily?

All medication MUST be given as ordered. Unless it is PRN, it must be given daily as scheduled. If it is not given, it is a med error. "Borrowing" from another resident is technically insurance/medicare fraud and hence a big no-no. Your facility should have e-kits (warfarin is almost certainly in the e-kit). If a med isn't in the e-kit, you can call pharmacy and get meds from emergency back up. If there is no way to get the med there to be given as scheduled, then you must call the MD and let them know. They will usually order to hold it and/or give a one time dose of something that is available in the e-kit. TL/DR: if a med isn't on the cart: 1. check the e-kit. 2. Call the pharmacy. 3. Call the doc if med unavailable through e-kit or pharmacy.

What should I be looking for before I send a patient to the ER?

Too many specific scenarios to list! Basically any change of condition from the patient's baseline should be reported to the MD and the MD will decide if they want an ER visit. So you will call the doctor, notify them of the change in condition and they will order the ER transfer (or they may opt for labs, xrays, meds ect.). If the patient is unresponsive, coding, or in a life threatening situation, our policy is to call 911, get them out, and then call the doc after the fact. On the other hand, if the change in condition is minor, we wait until morning to call the doctor. TL;DR: In most cases except the most emergent, the MD will be letting you know who and when to send to ER (though you pretty well know who will be going out based on s/s).

What would you include in a good progress note?

Depends on what is going on with that particular resident. I use my head to toe assessment cheat sheet as a guide:

https://allnurses.com/attachment.php?attachmentid=12287&d=1360684094

There is also a great tool floating around on all nurses that deals with charting on specific issues called "daily skilled documentation guidelines" that I also use but can't find a link to at the moment.

Basically if there is anything going on with a resident (UTI, URI, ABT, PEG, FOLEY, TRACH etc) you will want to chart about it.

Good luck!

Sparrowhawk · Dec 26, 2014

Find a new nursing home, that sounds like a very dangerous facility

cecilsgirl · Jan 10, 2015

Not sure what State you are from, but if we can't give a med and if the patient is not his own decision maker, we MUST call the Dr. for an omit order.

BoyNamedSue · Jan 10, 2015

Generally, there is a protocol in place for emergent vs. non-emergent issues. Generally at night, when you are more than likely going to get the on-call doc., you have to ask yourself: what is the doc. Going to do? Ask yourself, is the patient symptomatic or asymptomatic? Would monitoring be a better option rather than calling? Keep in mind, calling a doc. Is not wrong, but eventually you want to come to a point where you can weed out the 'should I call' vs. the 'I should call now' situations. Second, medication administration is important, especially considering the type of med, and the patient'a acuity level. Jantoven is prescribed to thin the blood, keeping in mind the concern is for clots, you can kind of put two-and-two together on its importance. The key that I will stress is that nursing is a learning experience. You will not be perfect, but, with time you will notice a general trend towards trusting your gut and knowing the right decision.

Gooselady, BSN, RN · Jan 11, 2015

What medications MUST be given daily? is actually a question outside your practice -- but of course as a nurse, we know these things because we're nurses.

The 'take away' for you is that you follow the MD orders, period, end of story. It lets you off the hook, and simplifies your life (and honey, you need it considering where you work!)

If it says daily, then it's daily.

If the med is not available yet? Put 'not available' in the MAR or proper area for comments.

That's it. Keep it simple.

You will send yourself off on a wild goose chase otherwise, and you don't have time. It is beyond your personal control that the Warfarin was unavailable, that's on the pharmacy and facility in terms of 'responsibility'. Keep it very, very simple. The DON says 'no no' to borrowing other meds? Then don't do it (or do it very, very carefully cuz you could mistake swapping a 25mg for a 50mg with the kind of pressure you are under).

We're instructed to THINK just like you are thinking, but on the ground, in your kind of facility, keeping it SUPER simple, by the book, to the letter and if a med's unavailable -- oh well. Next patient!