What do you consider a heavy patient assignment?

Lelene · Oct 2, 2016

I worked in different nursing homes and they are really not that different maybe some worst just because of nurse to patient ratio. I now work at a LTC , some floors have only one nurse for 40 residents for the 3-11 shifts and you are expected to do everything, treatment, meds, admission, answer to your CNA needs, you are everything. Your day may become even worst if you have residents or family members who are very demanding. The staffing situation is a real issue.

Heathermd · Oct 2, 2016

This is the exact reason I had no desire to work in LTC. You have described at least 3 patients that should not have been sent to rehab (particularly the 2nd day post op hip and the CHF patient on fluids!) And should have still been monitored more closely I'm the hospital. Now I'm no expert in LTC, but I feel that rehab patients are still acute enough you should not have 25 patients! They need a lot of therapy and still have some acute needs. My hat's off to you for not losing your cool. I would have been in tears.

djh123 · Oct 2, 2016

I don't think there's anything whatsoever wrong with your time management. I think you were given a ridiculous load, which many of us in LTC/rehab facilities are given - either all of the time, or all-too-often.

LPNtoRNin2016OH, LPN · Oct 2, 2016

I appreciate all of the advice! I plan to go over some time saving strategies with a senior nurse to see where I can improve, even if there was no room for improvement in that particular shift, I can at least explore strategies to prevent myself from feeling so underwater that I hit a mental wall. Sad to hear the situation is about the same in every LTC, wish there were ways to change it, I do feel our senior citizens deserve better care. I leave each shift feeling like crap because I know I did not get everything done that needs to be done (like skin prepping heels, actual preventative measures to keep them from developing any new problems) but that's the reason I left the first time so I need to suck it up for my remaining time there and learn from these experiences, giving the best care I can.

Linka · Oct 2, 2016

Sepsis is subtle until it's not; if this was a patient recovering from sepsis, it's appropriate for LTC.

- for the hip guy, check the intraop records for estimated blood loss. Sometimes after surgery, hemodilution occurs (fluids after surgery, hemoglobin can be one point less, it's ok generally), but if you have any questions, page the surgeon and talk to him. IMO and I'm not an ortho nurse, hematoma would have happened right away if something was seriously wrong. There is also the possibility (I think) for retroperitoneal bleed, so keep an eye out for hematoma on the flank/ back (late sign), instruct patient to notify you of back pain (earlier sign). Pain management will be an issue, but administer the norco per order, don't allow pain to get to 4 if possible, administer the short-acting ones for breaktrhough. Be aware of approach used to repair hip (anterior vs posterior) and follow those specific body mechanics when turning, getting up etc.

- you can get order for anxiolytic from the MD if patient is alert and oriented- it does not matter legally what the family wants. Especially if heart rate is high, or if the patient is used to taking them at home routinely. A good question is "what do you do when you are like this at home?" You kinda would have to do damage control with family and I personally found that extremely challenging.

- I don't think the CHF hypokalemic patient was appropriate for SNF. with fluids, you dump the potassium even more. and depending on how much the ejection fraction is, this can have a bad effect on somebody. Was the doctor trying to correct his creatinine or something? was the baseline high to begin with? the doc needs to figure it out on his own, in the hospital. because what are you going to do when he/ she is SOB? provided it's not too late. give lasix, and then your K is really in the toilet. if you're gonna give IV K you have to be on tele unit, if you give PO it's very tricky for non-tele. How are you going to recheck K in 4-6 hours?

-bleeding from the rectum might not be the worst thing- sometimes people have hx of hemorrhoids- check when the last BM was and their bowel sounds. do an occult stool, call MD and check HgB in the am. as long as there are no clots...well, it's hard to tell.

Listen, I think you are doing great. You sound smarter than I was as a newgrad- i kinda ended up being a little bit smart later on haha.

It's easier said than done, but try to take a break and eat, because not doing so might cloud your judgement, you might end up running around all shift ineffectively.

your supervisor should be approachable and ready to help, and generally constructive. Approach her in a nice manner and tell her about the difficulties you are facing. Let us know.

Linka · Oct 2, 2016

I appreciate all of the advice! I plan to go over some time saving strategies with a senior nurse to see where I can improve, even if there was no room for improvement in that particular shift, I can at least explore strategies to prevent myself from feeling so underwater that I hit a mental wall. Sad to hear the situation is about the same in every LTC, wish there were ways to change it, I do feel our senior citizens deserve better care. I leave each shift feeling like crap because I know I did not get everything done that needs to be done (like skin prepping heels, actual preventative measures to keep them from developing any new problems) but that's the reason I left the first time so I need to suck it up for my remaining time there and learn from these experiences, giving the best care I can.

You want to get a lot of things done. Relax, have some post-its with what you want to accomplish and delegate.Don't expect to pass meds for a lot of people, reassess, chart and implement preventative measures. Talk to the CNAs and tell them that you want the patients turned frequently, verbalize expectations, check later on....once the expectations are there, you guys can work like a well-oiled machine.

Linka · Oct 2, 2016

This is the exact reason I had no desire to work in LTC. You have described at least 3 patients that should not have been sent to rehab (particularly the 2nd day post op hip and the CHF patient on fluids!) And should have still been monitored more closely I'm the hospital. Now I'm no expert in LTC, but I feel that rehab patients are still acute enough you should not have 25 patients! They need a lot of therapy and still have some acute needs. My hat's off to you for not losing your cool. I would have been in tears.

if the post-op hip was really POD2, then yeah it's a really questionable patient for SNF.

ShelbyaStar · Oct 3, 2016

This does sound like a lot to me. At my facility we utilize TMAs quite a bit but it wasn't unusual for me to be the only person on one floor that could do meds or anything for 20 patients, and then I'd have to go to another floor to do insulins and other things that the TMA couldn't. When I first went to nights I had both floors so about 40 patients to myself, doable when I mostly was giving PRN pain meds and maybe doing a couple other things. The majority of patients are still stable and LTC- working nights, there's some I don't see hardly at all.

Our acuity has recently risen as well and thankfully there is now usually two nurses on at nights, so it's still overwhelming but doable. There is way too much monitoring to be done for your load to be safe IMO- it sounds a lot like med/surg, only with at least double the patients.

NotYourMamasRN · Oct 4, 2016

In my experience, which was much like yours, LTC only sees dollar signs. They see dollar signs in admitting all these patients and don't want to waste any money doing responsible things like adequately staffing, training, and providing resources for their facility. LTC administrators are vultures.

supakimchee · Oct 4, 2016

I dunno, anyone over 300lbs? *Rimshot*

Kooky Korky, BSN, RN · Oct 9, 2016

Last year I returned to LTC PRN after 5 years of working in clinics,, we are a billed as a low acuity LTC w/ 8 beds dedicated to rehab patients. When I first started working, the rehab patients were stable, mainly hip fractures needing PT/OT, and stroke patients that were needing a little extra time before they went home.
The types of rehab patients they have been taken in lately are more sick than they ever been. Because we are supposed to be low acuity, we don't really have the capability in terms of time to take on more critical patients since all 25 of my patients are separated into 3 different halls.
My last shift was a double, I had 17 LTC patients, 6 rehab patients, and two empty beds. My 6 rehab patients consisted of a PICC line w/ ATB for sepsis (he was pretty stable though), patient w/ multiple wounds(one on the coccyx so constantly needed changed because he had many BM in a shift) and patient had c-diff. 3rd patient was pretty much self reliable, 4th was hip fracture w/ low hemoglobin who I was constantly monitoring due to pain and possibility of hemorrhage (she was like 2 days post op and hemoglobin was trending down), 5th patient walkie/talkie but very agitated with no orders for any type of anti anxiety due to family request, and my 6th patient on IV fluids, with hypokalemia/CHF who I was also constantly monitoring to make sure she wasn't filling up with fluid plus I was very concerned about the fluids + already hypokalemic situation so I was in contact w/ on call often. Plus my 17 other LTC patients. I never took a break (which lets get real, who does in LTC) nor never sat down besides to chart for 16 hours.
My boss happened to come in for the other side because no one over was scheduled to work. I ended up calling her at 2100 because one of my aides called to inform me one of my LTC patients was bleeding from the rectum which is the first time this has happened for this patient. I couldn't leave my rehab patient because she was starting to fill up with fluid, I stopped infusion per MD, and was in the middle of getting all of the other orders for her together when this happened.
My boss acted like I was incompetent. Now, I am no LTC expert so I am wondering if from your all's perspective if I may need to change my time management habits or if this is an actual heavy assignment. I am due to graduate with my RN in April and I want to make sure if I am not being efficient enough with my LTC patients to complete all of my tasks that I start figuring out why that's happening before I work in a hospital and have more critical patients than what I have now....

This load is ridiculous. Unfortunately, it is probably not uncommon. Just the fact that you couldn't take even your unpaid meal break should tell you that too much is expected of you.

Why not just throw people into the dirt if this is the kind of care they get when old, infirm, paralyzed, neurologically damaged? It is so wrong to treat helpless patients with such disrespect.

Can you imagine the care given to queens, kings, presidents, wealthy people and how it differs from the average nursing home/LTC/SNF/Rehab gets?

Tired nurse · Mar 17, 2023

I wish nurses at LTC only had 17 pts I have had 60 and still got *** out by the RN supervisor who cannot even do a med pass because she has never worked a floor. I used to love the old folks but they are being pushed to the side and ignored by corporate so they can take younger post op pts that should not be there. Nursing homes do not have the resources or equitment to care for them. They complain constantly demanding one to one attention of a nurse usually an LPN who has no less than 30 other pts. Greed is what drives this disaster. And God bless the hard working LTC workers!