Why is the fact that we CAN'T DO IT not relevant?

[abooker]

I am a charge nurse in LTC, doing the medication pass, treatments, physician's orders, etc. We have an eMAR.

So I'm in the middle of my med pass, and I discover that one of our nurse managers has suddenly edited a lot of medication orders. She set things up so if you're giving Mr. X atenalol you can't check it off as "prepared" or "administered" until you first document blood pressure and pulse. If you're giving Mrs. Y lisinopril and digoxin, you have to chart twice, one for each pill. This is not a person you question the decisions of. You keep your mouth shut and just deal with it. Or else.

I'm not saying vital signs aren't important. Physicians have already given us monitoring instructions for many residents with cardiac issues. These are entered under "ancillary" orders and pop up on our screens once per week, to be done at some point during day shift.

I stopped taking these daily vitals. I thought they were unnecessary and reduntant and a disruption to work flow. Peers on other shifts and on my days off also stopped. We independenly discovered a workaround that would let us get our work done without getting all these vitals. Rather than click on the little monitoring icon and go under "vital signs" we could go under "free text" and put something, aything there. I used a little dot "."

The Acting Director of Nursing did not like the little dot. His paperwork says, "failure to properly document in a medical record and failure to follow physician's orders." He absolutely refuses to discuss it.

I had always thought of a physician's order as something that comes from the lips or from the pen of a physician.

I have not been able to locate a standard of practice for blood pressure medication in long term care residents (stable health, taking med for years ...).

What should I have done differently to avoid failure in this type of situation? We can't do these vitals and administer these meds in a timely manner with our current level of resources.

Current plan of action:

1). Delegate medication vital signs to CNAs at start of shift

2). Discipline all CNAs who fail to provide vital signs in a timely manner

3). Discipline all CNAs for failing to help residents prepare for breakfast in a timely manner

4). Discipline all CNAs who fake vitals

5). Wonder why nobody wants to work here.

[CapeCodMermaid, RN]

I'd vote for #5. We don't use EMAR yet but really....taking vital signs before giving meds in LTC is not clinically warranted. Fine..if the person is a new admit take the vitals before meds for a week. Most of the docs around here do NOT write with Digoxin "hold for AP

[catlvr]

I work a hall mixed ltc and short term rehab, and do pretty much what CapeCodMermaid said (wish that I worked for her - what a fantastic DON!): when they come in, I take bp before the med and record it...once they are stable, I get parameters discontinued. We've had hospice pts who where supposed to get their bp taken four times a day, despite the pressure being stable; what sort of silliness is that? Doc agreed when I called.

The same with accuchecks - once the ltc folks are pretty stable, we get the accuchecks cut back to every other day; why stick someone four times a day if they are not getting coverage? It is better for the patient and better for the nurse. You can always check if someone is symptomatic or if you sense that something is amiss.

As for a non-physician writing parameter orders, I didn't think that they could do that; does the order say to hold the med if parameters are not met, or to call the doc, or are they just asking you to record it?

And CCM, we check hr prior to digoxin; (well, I don't, since i work 3-11 and it is a morning med in our facility) and that is what I was taught three years ago. Can you please enlighten me? I appreciate the education!

e

[VeronicaWileyRN]

I haven't worked with an emar, but I have seen then in use. There are certain parameters for medications that the pharmacy company have developed. If you don't have the stipulations on the MAR and state survey comes in, they will ask if the BP is being done per pharmacy The interm DON is responsible for all the staff to follow federal and state regulations. To make the changes you will need an order from the physician to decrease or elminate the excessive vital signs.

[StNeotser, ASN, RN]

I don't have an eMar but do have to get all the vitals on patients before administering any B/P or Dig.

We moved our am med pass hour from 0730 to 0830 as it was impossible to get the vitals - we start at 0600.

I work on rehab so probably have far fewer patients than LTC though.

[noc4senuf]

Per our Medical Director... vitals are no longer needed before Dig.

[abooker]

As for a non-physician writing parameter orders, I didn't think that they could do that; does the order say to hold the med if parameters are not met, or to call the doc, or are they just asking you to record it?e

Just record it. The data does not flow anywhere, as far as I was able to determine. But the DON had about six inches of printouts so it goes somewhere. Maybe to the MDS? I think our entire eMAR was designed to feed the MDS. The clinical side seems set up for rehab or a more acute population.

[CapeCodMermaid, RN]

My favorite doctor said to me once, "Most old people are on digoxin to give their heart the extra 'squeeze' and they need it even if their heart rate is in the 50's". If someone is showing signs of dig toxicity, that's a different story and we do labs. Certainly if someone is new to the facility or has issues with blood pressure or heart rate, it's appropriate to check, but on the stable ones?? Do you think people who live at home check their pressures before they take their meds? Nope.

[Anne36, LPN]

Yeah, I love it when Im in the middle of med pass and have to stop because I need a blood pressure and heart rate that my CNA has not given me yet. Now what do I do? Have to put away all the med cards, lock the cart, take the meds I already got out with me and hunt down a bp cuff. By the time I get back and finish it will have taken me 15 minutes to do med pass on 1 Resident. And this resident needs a second med pass later and treatments. Yippie! I have a few residents like that. I ask the CNA to get the vitals but they never get them to me in time and nowhere near when Im passing meds.

[Anne36, LPN]

Cape Cod Mermaid, No they dont check their vitals before giving meds at home, but remember this is their "home" thats why noone wears an ID band.

[CapeCodMermaid, RN]

Cape Cod Mermaid, No they dont check their vitals before giving meds at home, but remember this is their "home" thats why noone wears an ID band.

What is your point?