wow-ltc is crazy!!!!

[pn5437]

After 3 days of orientation, I started on my own as an LPN at a skilled nursing facility. My patient load consists of about 30 residents and these include lots of g-tubes, tube feedings, accu checks and of course lots of meds! I work a 7a to 7p shift and I cant believe how crazy it is from 7-3. Being my first day, of course i was beyond overwhelmed. I learned how to give meds via g-tubes in orientation, but tube feedings and iv meds i had to learn my first day on my own. I was lucky enough to have a very nice nurse on my floor to help me, but i knew she was busy herself so I was worried about asking her too many questions.

The most frustrating thing about the day was not being able to find alot of the patients meds. I wasted alot of time searching for medications that I just never found. I assume most of these meds are being borrowed from other residents, but because I'm not familiar with what each resident gets, I couldnt go through the entire med cart looking for each med that was missing. I ended up not giving at least 13 medications on my one shift because of this. Of course I had a patient who fell, 2 patients who couldnt breath, 2 patients who would not stop calling me in their room and a family member who was complaining about the CNA. I had a hospice patient that needed to be suctioned, and I've never done this before so I asked for help. Long story short, I had 4 other nurses trying to suction this patient and they couldnt figure out why the machine wasnt suctioning. We finally got another machine, and that one didnt suction either. After almost 30 minutes of this, I ended up leaving the other 4 nurses to suction this patient because it was 2pm and I still wasnt done with my 9am meds!!

In the end I ended up leaving at almost 9pm and I couldnt even do my charting bc I was worried about getting in trouble with overtime since I am new. Is this the norm? I mean, I know its hard in the beginning but how long did it take you to become adjusted and HOW did you do it?? How do you organize your feedings and accu checks so that you dont waste so much time? And how do I tell the CNA's to please not chit chat with me at my med cart so I can actually do my job?

[steelcityrn, RN]

LTC is hard. Its very demanding work, and you have alot of family contact. Its not for everyone.

[wishinguponastarLPN]

I will soon graduate, but from watching other nurses they seem to reallly "cluster" their care. They try to do as much as possible all at once. For example, do an accucheck and feeding, and assessment, and any other treatments (suction, wound change, vitals ect) all at the same time if possible. That way you aren't running up and down the hallway in circles.

LTC is a beast! However, I have a feeling that your facility would have wanted you to chart even if that meant overtime. Basically all the care you did from 7-7 looks like it wasn't done. From what I have seen other new nurses do is once the relieving nurse comes in, they give report and then chart if it isn't completed.

You are new and it will take time of course to get your system down. Good Luck!!

[golflinda2214]

Did you get a decent orientation? Were you followed on the floor (before expected to be alone) by a preceptor or someone who should have explained to you where the meds were kept? And, truly, have you never suctioned a patient or just hadn't suctioned that particular one? You and anyone coming to work the floor of a LTC facility needs to be trained WITH a colleague before being turned loose to go it alone. That said, yes its time-consuming, seems-like-I-can't-ever-get-done work but it gets so much easier and the rewards are endless.

[bubblymom373]

As WishinguponastarCNA said cluster your care. When doing a accucheck give meds do assessment if needed etc. Tube feeding do the same. See if you can make yourself a cheat sheet of who gets what treatments how they take their meds etc.

As far as finding meds, ask the other nurse if there are any meds on the cart that are stored somewhere else. Make a note on the mar by the med so you can find it when doing the pass.

With charting when it becomes 7p hand off to the incoming nurse and do your charting. Not charting will get you in trouble faster than overtime, IMHO.

If you are behind in med pass and the CNAs want to chitchat a simple "I am very busy can we talk later" should do. Otherwise if they have time to stand and talk there may be some things that they could be doing to help you out. VS, finding the residents so you can give them their meds etc.

[NamasteNurse, BSN, RN]

Your title says it all--LTC is crazy. period. It's life and you will get used to it if you want to. You may even turn out to like it! That said...

It takes a good four months to get into the swing of LTC. My preceptor told me that when I started and she was right, right around the 4 month mark I began feeling like "ok, I think I'm starting to get this down".

You need to speak with your unit manager or preceptor and ask what are the priorities on your floor. Although some meds can be given late, there are MORE that cannot! One example is neurontin, which the patient will start to feel the effects of not having it right around the time it is due. Coumadin should be given 24 hours apart. Blood sugars must be done before meals. And so on. You need to ask someone to list these for you.

Get a little notebook and write down things that you question during the shift. Medications should not be missing, maybe they aren't where you are looking, but sometimes they need to be ordered. Technically you aren't supposed to 'borrow', but it happens all the time. Again, find out who is responsible for ordering and give them a list. (It might be you!)

Try not to blame the ones who trained you, there's no way they can tell you everything that could go wrong and you would panic if they did :)

The hardest part for me was getting out of people's rooms fast. Like the family member who was complaining about a CNA. Sometimes you just have to stop and breathe and listen. But there is a way to get out of the room, you will find yours. I usually say something like, well, I have a lot of meds to pass, let me look into that and I'll get back to you. Write it down in your little notebook and make sure you do get back to them.

I wouldn't leave without charting! You may get in trouble for that! Again, ask the unit manager what is more important, getting out on time or charting. They will most likely cut you some slack for a few months on the leaving late thing. We are told not to stay late too, but it's impossible to get out on time. I've never been approached about it.

As to the suction machines and other equipment being less than perfect, it's like that in a lot of LTC facilities. Doesn't make it right. There is so much frustration surrounding things like you described. One possibility is to do a quick round before you get on the med cart. Peek into the rooms you know may need equipment during your shift. Remember the ABC's, so 1. Airway/Breathing--- suction residents, trach residents, O2, nebulizers, cannulas, masks, tanks, shileys, suction kits, etc. Throw a few on your cart in case. 2. Circulation---check anyone with IV's. Check their insertion site, check the bag. will they need more fluid soon? Can you change the bag? Check the order, do you need a supervisor or abx? Throw a bag of whatever they are using on your cart if it's less than half full.

Now get started on meds. Look over the cart, fill it with stock items and cups, syringes, alcohol, lancets, applesauce, neb tx, etc. Check orders for blood sugars. See if there's any new orders. Off you go. I always check in with my neb people to see if they are ok and make sure they have O2 either on their wheelchair or in the wall unit.

You will find your own way. Every day go in there and do your best. Try not to panic. Ask for help. Find out who is responsible for each task, such as ordering meds, ordering supplies etc. Ask if you can do it. Don't skip anything and if you find you are falling so far behind that you will be skipping meds or charting tell your supervisor! They should be able to help. Best of luck!

K

[pn5437]

thanks for all your quick responses. When I did my orientation i was lucky enough to have very helpful nurses every time ( i had a different floor every day during my 3 day orientation) I knew there was no way they can show me everything-thats impossible. I read that ltc's tend to 'throw you to the wolves' and man was that right! lol I made myself a cheat sheet already so that my next shift wont be as hectic. Although it was insane, I learned alot in that one day.

[pn5437]

oh and golflinda-the answer to your question about my patient. No I've never done suctioning before so I wanted to watch someone do it. And to tell you the truth-most of the things i did that day I've never done before. So I guess the combination of a new job, so many things to do, new unfamiliar patients and learning all these new things at once was just overwhelming. But I know that one i get my organizational skills down it will be much better.

[MntnGirl]

3 days of orientation is barely enough time for you to get familiar with the layout of the floor neverless learning how to manage your time so that you can care for 30 elderly patients. All I can say is "WOW" and Good Luck.

[joanna73, BSN, RN]

I've worked in LTC for 5 months, 30 residents. Don't worry, you will become more efficient with time. It takes about 3 months. I would leave time at the end for your charting, though. We don't chart everything at my LTC (charting by exception), but you need to chart. Otherwise, there will be issues.

[withasmilelpn]

Ask the regular nurses who they do first. Who gets crushed, takes it how, who gets accuchecks. that way you can prioritize your care. The good thing about LTC is the residents don't change all that much and each of them often have a routine that they follow fairly consistently. I know which of my residents I need to get right away before they leave for breakfast and who I can get afterwards. I enlist my CNAs to bring me Residents that I need too - if I go to give them their meds and they are still getting dressed - I'll ask the CNA to bring them to my cart when they are done.

I note who gets meds more than once - for example a person on Sinemet and has parkinsons - and make them a priority too because it's important that those meds are given timely and not spaced too close together.

AM med pass is so heavy - I really try not to do too much else. Treatments can wait. Family members get sincere apologies and promises to follow up. Conversations with CNAs happen but in passing because I am always running around.

Cheat sheets are your lifeline and your brain. Make one just for you that fits the way you think. My sheet has a place for vitals and those on bowel protocol.

[pn5437]

hello again thanks so much for your responses! i completed my 2nd day and it went alot smoother then the first. I was better organized and made sure to stop as soon as i finished my first med pass to complete my charting, as well as soon as finished my last med pass. It was still crazy, but somehow i felt alot less intimidated and anxious-maybe bc i knew what i was getting into this time! lol