Will I have to take "shortcuts" in order to be a good nurse?

summerrose_10 · Aug 30, 2009

All GREAT questions

Prepouring----

can be done, make sure it isn't a shake well before use and is going to set there for any length of time.

Leaving meds at the bedside-----

this is a big NO NO, I have done it, it depends upon the CNA at times, if the pt. refuses to take it with me standing there, i will stand out of his sight and watch to see if he will take it. never leave meds totally unwatched at the bed side. NEVER leave controlled (narcs) meds unattended. I say this, then have seen many cases where it takes 45+ minutes to get one morning dose in some of these patients.

Borrowing meds, even narcs----

i have "borrowed" meds from another pt. at times. our med carts are restocked on tues. and for whatever reason, a pt. maybe short the last dose on Mon. nites, or tues. morns., so will borrow from another drawer, IF, exact same med/strength. I would NEVER, repeat, NEVER "borrow" narcs.,from one pt. to another. If your short for a pt. there is an issue that needs to be addressed.

Signing the MAR before the med is given-----

technically, no, never sign before the med is given. in reality, the meds are pulled and signed off. this generally is not a problem, UNLESS, something happens to you and you do not carry out what you have documented that you have done.

Combining meds (i.e. giving 9pm meds at 5pm)---

it depends... if your pt gets annoyed with the 9pm dose, find out if the 9pm can be given earlier. If pt. goes to sleep at 7pm is it critical to give him a vitamin supplement at 9pm instead of 5 or 6? I never give 9pm scheduled meds with 5pm, I try to get essential meds rescheduled.

I have also read posts on this site (and stories from nurses) about some LTCFs that want nurses to:

Clock out and then finish charting------

if your DON or charge nurse asks you to do this, they should be reported, and you really don't want to work with leadership like that. :banghead: Never clock out and keep working. Now, saying that, I have actually done this, but ONLY because I spent an excessive amount of time "chatting" and socializing with my co-workers.

Clock out and do recaps/changeovers---

not sure what recaps/changeovers are. If this is gving report to oncoming shift, I would never clock out before giving report.

Not write "med not available" if a scheduled med isn't available (then what?)

------ you can't sign off on the med if it isn't available and you can't give it. we can write "med not available" but that doesn't release us from not trying to obtain the med.

Be able to pass meds to 30-40 residents (even sub-acute) within the 1-hour-before-1-hour-after rule

----not sure where you would ever have 30-40 subacute patients on your own. in our wing there are many times there is no way possible to pass meds within this time frame. Some pts. really don't wake up until 10am. so there goes the 8am protonix, synthroid, blood sugar, etc etc. That is why we really need to schedule meds in LTC as Breakfast, lunch, dinner. With the Eden care that most LTC's want to give, strict scheduled meds are not realistic. Any nurse that says this type of med pass is possible with 30-40 residents is not being honest.

Only have 3 days orientation for a new graduate

hmmm, NO. Although I have seen this. It was with CNA's that became LPN's. They had worked in this LTC facility for numerous years, they where extremely familiar with all their residents, and policy/procedure. They had also done most of their clinicals at this place. I would never agree to this, but I guess they agreed to it:(

Sorry this is so long. Just remember to always use your nursing judgement. When it is you up on the stand defending your license, be sure you have a legit rational for everything you did. What you learned in nursing school is IDEAL, what you do in practice generally differs. I have high nursing standards and there are some shortcuts that I would never take. Don't let what others do lead you to take shortcuts that may cause you to lose your license.

I have seen some of the shortcuts others take. I've seen meds signed off that where never given, I've seen treatments signed off as being done when they had'nt. I've seen physical assesments signed off as done and they weren't. I've seen insulin signed off when I knew for a fact it hadn't been given. We can't change how others work, we can only hold ourselves accountable and keep the standards we learned in school. :nurse:

good luck to you, LTC is great for some:saint: others can't handle it. it is a lot of hard work, but, very rewarding.

congrats on becoming a nurse:yeah:

missbutton · Aug 30, 2009

Never clock out and keep working. It's a violation of labor law, and it's for your safety. Especially in nursing. If you are working, but off the clock, and you get hurt, your facility will not cover your workman's comp. They will say that you were not working and use your timesheet as proof.

NotFlo · Aug 30, 2009

In my experience:

1. Prepouring

Generally not done in any of the nursing homes I have worked at on 7-3 or 3-11. However, I know some 11-7 nurses who have to pass meds to 60 patients at 6 am that do prepour that med pass because they feel they would otherwise never get the pass done. They also start passing meds at 4am and if they're lucky they're done by 7am when first shift gets in.

There have been ocassions when I've poured someone's meds and found them in the bathroom, in the middle of getting washed up, or otherwise engaged in something that prevents them from taking the pills right at that moment. I'll save those pills and bring them back...I'm not going to toss them out and repour them when the pt. is ready to take them.

Leaving meds at bedside:

Well, there are some patients/residents who take a half hour or more to get meds into. It's really frustrating sometimes. Sometimes on alert/oriented pts. I leave them at the bedside, go back out to the cart right in front of the door, and start pouring my next pt. while glancing in to make sure they have taken their pills. I don't move along until the pt. has taken them. I have been getting more and more people that want their pills at one specific time and ask me to bring them back, not during breakfast, not during such and such TV show, they want them fifteen minutes before/after therapy, etc. and it's really frustrating because it's so hard to honor all these requests and still get the med pass done on time.

Borrowing meds even narcs:

Standard operating procedure at every place I have ever worked. Happens less with a good e-box and computerized refill ordering.

Signing the MAR in advance:

I never do this. I know some nurses that do their whole med pass, then sit down and sign off the entire MAR. I wouldn't do it though.

Combining meds:

I also never do this. If I notice a problem (pt has 9pms scheduled and is always asleep at 7) I'll ge the times changed. Once I filled on on a dementia floor though where they gave all the 5s and 9s together every night and told me to do the same or else I'd never get the 9s done and everyone would be asleep by then anyway.

NEVER punch out and continue to work. It's one thing I will never do.

Plagueis · Aug 30, 2009

Clock out and do recaps/changeovers---
not sure what recaps/changeovers are. If this is gving report to oncoming shift, I would never clock out before giving report.
Not write "med not available" if a scheduled med isn't available (then what?)
------ you can't sign off on the med if it isn't available and you can't give it. we can write "med not available" but that doesn't release us from not trying to obtain the med.
Be able to pass meds to 30-40 residents (even sub-acute) within the 1-hour-before-1-hour-after rule
----not sure where you would ever have 30-40 subacute patients on your own. in our wing there are many times there is no way possible to pass meds within this time frame. Some pts. really don't wake up until 10am. so there goes the 8am protonix, synthroid, blood sugar, etc etc. That is why we really need to schedule meds in LTC as Breakfast, lunch, dinner. With the Eden care that most LTC's want to give, strict scheduled meds are not realistic. Any nurse that says this type of med pass is possible with 30-40 residents is not being honest.
Only have 3 days orientation for a new graduate
hmmm, NO. Although I have seen this. It was with CNA's that became LPN's. They had worked in this LTC facility for numerous years, they where extremely familiar with all their residents, and policy/procedure. They had also done most of their clinicals at this place. I would never agree to this, but I guess they agreed to it:(
Sorry
good luck to you, LTC is great for some:saint: others can't handle it. it is a lot of hard work, but, very rewarding.
congrats on becoming a nurse:yeah:

Thanks for replying. Changeovers/recaps happens around the end of the month where each resident's new month's POS is compared with the previous month's POS/MAR. I've also heard this process referred to as 'edits.'

I've been told by some nurses that they "have" to borrow narcs, such as pain pills, if a resident is a new admission and it's a straight order (and pharmacy won't deliver for hours or until the next day), or if the resident has an order for one PRN, and asks for one. They state that there's no e-kit that supplies them, so they borrow. What alternatives do nursing homes have in this scenario?

I've read plenty of posts on this site where 3 days is the "norm" for orientation for new grads in LTC. However, my friends who were new grad RNs got a minimum of 12 weeks. Nursing homes residents are not always "stable" or "easy," and I cannot see how anyone can understand the piles of paperwork that has to be filled out in only 3 days. I give props to any of you nurses who have done it. Share your secrets, please!