Stop with "Best care possible". Think more along the lines "Do What Really Needs to Be Done, and Don't Worry About the Rest".

Just some suggestions for time management:

Learn your residents' pills (while you pass meds to a lot of residents, their meds don't change much, or very often, so you'll soon get them memorized).

Even though you've been taught not to do it, pre-pour your meds. Nearly every successful LTC nurse I know does this. I make med cups labeled with the residents room number to label their meds, so I don't get them confused.

Make a list of the routine narcotics your residents receive. Pour those from the narc box first.

Pour everything else next.

Learn who gets meds when (say at breakfast, lunch, dinner, or hs). Combine whenever possible.

Set up those meds that need to be given at the first meal of your shift, and pass those.

Set up the rest of your meds for the shift after this.

Once you get through med pass, you should be able to block off some time for charting, usually at the end of a shift. Sometimes, you will have to stay over for a few minutes to put the finishing touches on your charting.

I usually fit in treatments some time after meds are passed.

If an unusual event happens during your shift, anticipate that you will run late on your meds. It's one of the unavoidable things about working in an LTC facility.

I am an LTC nurse and I would never recommend setting up meds. too much room for error not to mention that in most states it is a violation. Though it may seem overwhelming right now you will learn the residents, the treatments and the meds and will form a routine. Give your self time and don't get discouraged. You may have to stay late at first to catch up on charting but after you get your own routine down you should have no problem. Good luck with school. I am doing the same thing.

That's just a difference of opinion. But pre-pouring meds is something I see ALL THE TIME in LTC. You won't make mistakes if you know your residents . . .

I have spent my career in LTC. In the beginning, it is stressful and difficult. But after you learn your patients, it gets alot easier.

In time, you will be able to pass meds without looking at the MAR.....and NO, Im not saying you do this...Im just saying you will learn them well enough to know what they will be getting and when.

It is a violation to set up meds beforehand, but it is actually done alot.

1st shift is the hardest shift to work LTC, bc the residents get alot of morning meds.

When I would get there in the mornings, I would make rounds first, get an update on how the nite went, then check the diabetic patients and see how thier accu-checks are and give thier insulins and/or PO meds. Then I concentrate on everyone else.

Once you get all the meds passed, then do treatments, then charting so that you can chart about the treatments or any PRN meds that gave while passing meds.

Always have a notepad or paper that you can make notes on, keep it in your pocket. Write down your PRN meds, times, patients, etc....or any other little info that you need to keep ahold of.

Another thing, the patients with feeding tubes, most of the time, I would leave thier meds til last....bc they are the most time consuming.

The key to LTC is getting to know your patients. After you do it a few weeks, it gets easier..

After working LTC, i never wanted to go back to the hospital.

Good luck!

LisaRN

Thanks for the advise- all of you! You have given me hope that this might work out for school. I appreciate it!

Prioritize!
Look at your load, recognize the absolutes and go from there.

Sometimes "maintainance nursing" is all we can do. Especially in an LTC environment. As you get familiar with your residents, routine and workload you will become more comfortable and organized.

Yet, even on the most hectic of day there is always time for a smile, a touch and a kind word.

Lont term Care Time Management
I think your concern shows what a conscientious Nurse you are and having said that I know you will make safety your number one priority. I am currently an RN and work in an acute care setting but prior to that I was an LPN and worked 5 years in LTC,2 of those were with a staffing agency and worked at a variety of facilities. I had to be flexible and adaptible but Patient safety was always my first concern and following the 5 rights of med administeration will keep you from making a minor error or a serious error that might even cost a patient's life. Never pre mix meds. You cannot do this safely. If you start to do this no matter how well you know these patients you substantially increase the probabilty that an error will occur. Once a med is given you cannot take it back. I only harp on this because the above posters have you thinking that this is acceptable.. it is not. Yes, I know people do it, but there are a lot of bad nurses out there. Time management will come as you develop your own routine.. it will be hard at first but it will happen. Find a competent Nurse where you work for sharing advice and frustations. Enjoy... Geriatrics can be very rewarding.

This issue of pre-pouring meds is an interesting topic. Once upon a time, nurses used med cards (hand-written by the nurse) and med trays, and set up their meds in a medication room. Imagine trying to successfully pass meds on 40-60 residents under this system (and 40-60 residents was typical for an LTC nurse in those days). The only way to pass meds this way was to pre-pour your meds. And while I'm of the generation of nurses who never had to pass meds this way, I do recall seeing it done by nurses I worked with while I was going to nursing school. My last DON remembers passing meds this way (he's just a few years older than me), and he feels strongly that it was a much better way to pass meds than med carts. You would hardly characterize the nurses who passed meds under the old system as "bad nurses". They knew exactly who got what when. They also passed meds using the 5 rights (although in some facilities, it's no longer 5 rights, it's 6). And, I believe they were held just as accountable for errors as we are today.

Sometime in the early 1980's, medication carts became the standard in healthcare facilities, which required an entirely different way of delivering meds to patients. Not necessarily a better method, but different. And I'm guessing that if I thought hard enough about this question, I could probably think of at least 10 reasons why med carts are bad and lead to a lot of unsafe, inefficient and costly practices by nurses. But med carts still remain the standard in a variety of settings, including LTCs.

I've been in a variety of LTC facilities in the past year that are undergoing "Culture Change". One of the central concepts in "Culture Change" is to do away with med carts and nurses' stations. One alternative is to go back to setting up meds in a medication room or area. For a unit with 30 or more residents, the only way to do this safely is to pre-pour your meds. And while I'm not a big fan of this idea, there is a distinct advantage to this system --- you can tuck yourself away from distractions while you are preparing meds, and that is one thing that has been proven over and over again to cause medication errors --- being interrupted while you are trying to set up your meds . . .

BTW, I've also used Pyxis machines --- they are great for acute care, but difficult to implement in a free-standing LTC.

I've done a variety of things in my nursing career, and one of them includes a stint as a Poison Center nurse. While we all need to avoid making errors, I can tell you that we rarely heard about life-threatening medication errors in an LTC, and that's primarily because the kinds of drugs that are given in an LTC (with the exception of insulin) are unlikely to cause a patient's death unless they are given in a massive overdose. In other words, you have to work very hard to make this sort of mistake. On the other hand, we got calls all the time from acute care facilities because nurses made errors when giving IV meds, and these are the types of errors that are life-threatening . . .

I'm convinced that it's not so much the way a nurse passes meds that leads to life-threatening errors, but the setting he/she practices in and the knowledge or expertise of the practitioner. By their nature, acute care facilities are risky places to practice nursing, and anyone who works there needs to be sharp, and know the potential danger of every single drug they give, especially IV drugs. It's IV drugs that kill people. My advice to any acute care nurse is to have another nurse double check any IV med you give. That is surely the safest way to practice.

LTC and Med safety
I'am not going to get into an argument here. My point is simply that every where a Nurse parctices they should heed to the 5 or as you pointed out 6 rights of med administeration. Btw, the last med error I was aware of where I work as an RN in a Hospital was a new nurse who gave a po morhine cr to the wrong patient. The Doctor was very concerned and the nurse very shaken up re; the incident. Oral meds or IV meds are equally dangerous depending on the Patient and the dose and let's not forget possible allergies. All I'm saying to this new nurse is please be safe. Last post from me re; this, I've made my point and I think most prudent nurses and patients would agree with me.

I have not read the replies and apologize for any repetition of advice. I had the exact same problem. I am an RN, with a bloodsport of a divorce with my husband and his mother blasting me. I have problematic teen kids, which my husband or mother in-law don't even know. I raised my kids alone, but didn't divorce.

For years, I was an acute care nurse. The stress is hard. I thought that long term care would allow me less stress, pay the bills, and get through this disaster. I walked into long term care ignorantly, knowing residents don't have the same issues as acute care patients. What I found out, it is just as stressful, but very different, as an RN who take the ultimate responsibility of the entire facility.

I had your problem, just working the floor and how to get it done, when I was only used to eight patients, max. I found myself working a floor, and being RN Nurse Supervisor, with more responsibility than any LPN had to put up with, like staffing, problem solving, you name it. I couldn't get anything done!

What you need to do is calm down, first. That was hard for me. I took on the weight of the entire facility and lack of staff, as my problem, while running more than one floor, with staff and patient issues, which are supposed to be reported to the Nurse Supervisor. I had far less time and far more problems to deal with than any LPN.

The first advice I would give you is to delegate anything you can and do it with confidence. If your NAs are allowed to get blood sugars, make them. Make them do anything they are allowed to do, which differs with facility. Collect the information, down to vitals, with a NA you trust, and get your assessment, without wasting time.

Anything your NAs are allowed to do, which you delegated them where you were blown off and nothing was done, write them up. Cover your ass with delegation and make the person responsible accountable, not you.

Stand strong because you have to be or get ready to be run over. There are way more NAs than nurses. They will figure out how far they can push you by trying. Never allow that. You are in charge and try for the next Academy Award, if that's what it takes. Being nice gets you screwed. Being fair gets you everywhere, meaning do not pick favorites, ever.

Expect for your NAs to play favorites, screw off, not do what you tell them. Sometimes you have to be 'the bitch' or they run you. You have a floor to run, not them. Make them accountable. Don't be a push over because every NA senses this and takes advantage of you.

That is my strongest advice. Get your NAs to respect you by making sure they do their job or write them up without feeling guilt or your job is screwed. That really is how it all works. Stand strong. Be 'The Bitch'. They will not give you any trouble. Being nice to them invites a bulldozer to run over you, so just be fair. The end.

Next, you have a med pass, physical assessment, skin assessment, treatments, and documentation. The first thing you have to do is delegate anything you are allowed to your NAs. Expect this to be done by a certain time, known to them or write them up. They get the hint when you write up one person. You are against many wanting an easy job that will take advantage of you. This stops and you can be nice, when they start respecting you. You have to earn this and it isn't fun.

Depending on the shift you work, you already know med pass time is not optional. Decide on where is the best gap of time to get skin and physical assessment, according to shift. For example, I wouldn't go there, with skin assessments, working second shift, without asking the NA if there is anything I should look for, so I don't walk in blind and miss something. I want them in bed, with access for treatments also.

You better do you charting or you did nothing at all during your shift, as far as law and state are concerned. Do it!! Set aside the best time. Chart everything down to someone refusing dinner. Cover your ass! I would rather circle my initial, telling the next shift that I was not able to get two treatments done, leaving it on report, than I would get the treatment done, but no documentation that you did anything at all. It really is a 24/7 operation and I couldn't care less if the next nurse doesn't like doing those two treatments. Make sure you have it in written report that she knew it needed to be done.

As far as med passes, look at the diet. Regular diet, with regular liquids, tells you that this patient can probably take meds whole. To be safe, throw the meds in pudding and give them juice to chaise the pills down. It works. You don't want two trips. Bank on crushed, otherwise. They will take it and give them something to drink, within their fluid consistency.

Diet is always on the MAR. To make it fast, I crush meds while still in the package, toss it into pudding. Crush anything, if in doubt. It saves time. Say open, make sure they swallow, give them a drink. Check them for pocketing and remove and circle the meds. Put that in report and documentation. Use sugar free pudding or what is available, so you can cover diabetics, without looking. I worked agency, so know how to get through patients you don't know, without wasting valuable time.

Treatments? Tell you nursing assistants, like they don't know something is up with skin anyway, what they are allowed to do and you expect them to do it. Again, be firm or a bitch, as they will call you. They can cover creams, like skin barriers and others with unbroken skin, so make sure you tell them. Just hit that Treatment Book and delegate what they can do. They can do moisture barriers, but know your dressing changes. Document what you did. If not time, circle and pass to the next shift.

I didn't mean to write a novel of nursing at LTC. It was a shock to me. I come from acute care and was shocked at how much of a bitch I really had to be or be run over by NAs.

Good luck! You are going to need it!!