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Agency Nursing 101 - Session Notes

A Review of Medication Administration and Safety
Written by Natalie Troup, RN
Provided as a guide only, this is not training material.
In ALL cases, seek the advice of the Facility Clinical Manager or RN In Charge.

1. Orientation

1.1 As you accept the shift, ask have I been here before? What systems do they use, have I used this before? How many residents am I caring for? Do I need an orientation?

1.2 If you need an orientation, ensure you arrive 15-20 minutes prior to your shift commencing. Be proactive and ask the previous nurse for some guidance, explaining that it is your first time working at this facility. Asking for an orientation once the nurse is finishing their shift can often lead to a rushed or rejected orientation.

1.3 On arrival, introduce yourself, your role, and the agency you are from (make sure your ID badge is visible & the correct uniform is displayed);

1.4  Ask which area you are allocated to. Do you need assistance in finding this area?

1.5 When getting orientated to the facility ensure you take note of the medication rooms, important phone numbers, take note of any codes, pan room locations, layout of the rooms etc.

1.6 Consider where you will document this information. Consider bringing your own note pad.

  • *Remember you can ask the staff on your shift if you forget.

2. Handover

2.1 A handover sheet will be provided to you outlining the residents in your care, providing full name, room number and important clinical information.

2.2 Handover is an important component of obtaining information on residents. It outlines and provides a reference of residents who have potentially experienced a fall, opened their bowels, or require aperients, require pain relief, or have resolved pain from analgesia given.

2.3 Utilise the handover provided from the previous shift to follow up on the tasks required.

2.4 A clinical handover can look something like this:

ND-AM
Rm 1: has a doctor's appointment at 10am. Patient transport booked for 9am.
Rm 2: no change
Rm 3: bowels not open for 4 days, requires aperients
Rm 4: had a fall overnight at 2am, ½ hourly neurological observations finished at 6am. Next due at 10am, 2pm and 6pm. So far NAD, family notified at 7am. Doctor has been faxed and placed in book.
Rm 5: no change
Rm 6: wound dressing due today. Analgesia required ½ hour prior

3. Medication Administration

3.1. When checking DD's out for routine rounds or PRNs it is BOTH the nurse's responsibility that the right medication, patient, route, dose, and time is correct. Your first check is complete this with another Registered Nurse, second choice is Endorsed Enrolled Nurse, third choice is with an Enrolled Nurse and last choice if you are the only Registered Nurse on the shift is to check with a PCA/AIN.

3.2. When checking with a PCA you are only checking the count is correct. It is not their responsibility to ensure that it is the right medication, patient, route, dose or time is correct.

3.3. Thing to remember when doing the 5 Rights of medication administration:

3.3.1. Right patient: hardest task of your shift is finding the right patient. Use the photos on the medication charts as a guide. Assume all patients have dementia. Never ask "are you Bill' instead greet them and ask them for their name "Hi, my name is Natalie, I'm doing the medications this morning, what's your name?"

3.3.2. Right medication: you will find medications:
In the trolley packed in a webster pack;
Unpacked in the bottom drawer (includes eye drops, puffers, bottles, sachets, lotions, patches, gels, insulin, injections, vitamins & warfarin);
Treatment room (PRN medications & extra stock);
Fridge;
Resident bedside (puffers and eye drops);
Resident's bathroom, (lotions, potions and creams used for skin or bottoms);

3.3.3. Right time: ensure medications are administered at the correct time or as close to the time it is ordered. Not every patient can get their medications at the same time.
It is important to know your Parkinson and diabetic residents as it allows the most time sensitive medications to be given first.
Avoid being disturbed by politely telling them you are in the middle of the medication round and will sort out their concern a bit later (life threatening situations or falls are acceptable reasons to stop and leave);
Avoid leaving the trolley by dispensing medications in the dining room first and then attend to patients in their rooms;
NEVER leave the trolley unlocked or with medications on it.

3.3.4. Right route: majority of medications are oral. Keep in mind there are tablets, liquids, sachets, and solutions for oral administration. Patches, lotions, gels, and ointments are topical. Insulin is subcutaneous. There are also medications to be administered per vaginally or rectally (needs 2 staff members when administering).

3.3.5. Right dose: majority of medications you will match the drug chart with the webster or dispensing system. Medications like warfarin, DDs, insulin must be checked by nurses prior to giving to the patient.

3.4. Ensure a check and count of DD medication is completed at the beginning and end of your shift.

3.5. Please do not feel rushed. When you first begin it can take up to 6 minutes to complete one person's medication. This is 10 patients per hour, 3 hours for a 30-person medication round.

3.6. Rushing medications leads to mistakes.

3.7. There are PRNs, short term orders and changes/updates to medications daily.

3.8. Hand hygiene between patients is a must.

3.9. Wear gloves for all lotions, ointments, patches and rectal or vaginal medications.

3.10. Prepare your trolley with water, pill crusher, yoghurt etc. prior to starting.

3.11. Clean the trolley at the end of the shift, remove the waste and put everything back where you found it.

3.12. Only sign medications have been administered once the patient has taken it. NEVER leave a medication at the bedside.

3.13. When administering patches write the date and time on the patch.

3.14. Document and handover any refusal of medications.

3.15. Document and handover administration of PRNs and the effectiveness.

3.16. Always check the BSL immediately prior to administering insulin. REMEMBER that patients may have both PRN and regular insulin orders. There will always be parameters for insulin

3.17. Computer systems:

  • When working with computer systems ask at the beginning of the shift for a quick review or ask the other nurse administering medications if they can show you;
  • Majority of medication systems are the same. They have a "medication round time" e.g. 0800 or 2000. You click on that and a list of residents come up. You then choose your patient, individually check the boxes once you have checked it's correct and click "sign". Once signed the resident will disappear from your list;
  • There is a separate option for PRN medications, refusal of medications and out of the ordinary regular medications;
  • Most computer systems will alert when things are late, missed or not given;
  • If unsure, please stop, ask the in charge or call the agency for guidance.

4. Incidents

4.1. What is an incident? Something that should not have happened that causes harm or potential harm to a patient, care staff or visitor.

4.2. Examples: Verbal or physical assault, security breach, falls, wounds/burns/skin tears/pressure areas, head injuries, medication errors, needle stick injuries, near misses, theft, and allergic reactions.

4.3. Incidents should be reported and documented. Hiding or trying to cover something up has the potential to get you into trouble.

4.4. Process of incident reporting:

4.4.1. Call for help. Speak to your RN in charge. If you are in charge someone would have called you;

4.4.2. Assess the situation, what type of incident is it?

4.4.3. Is first aid required? Consider; vitals, wound care, ensuring the situation is safe

4.4.4. Notify of the incident (GP, Locum doctor, Family, Facility Manager)
Consider the time of day/night.

4.4.5. Document the incident. Ensure you follow the procedure for the facility. Examples include incident report, residents note etc.

  • If you have any concerns you can contact Caring for You head office and ask for assistance.

5. AM Shift Routine

5.1. Arrive early, introduce yourself as an agency member and orientate yourself to the facility.

5.2. Receive handover from the AM nurse.

5.3. Check DD's with the nurse on the previous shift.

5.4. Time plan your shift. Consider: BGLs, insulins, Parkinson medications, palliative care patients/medications & wound care. Ensure all tasks have been completed from the shift prior.

5.5. Start medication rounds on time. Consider these medication rounds can take up to 1-3 hours.

5.6. Check what DD's are due for your shift. Are there any scheduled patches or medications due?

5.7. Doctor rounds. Ensure the residents who are needing to see the doctor are on the list. Which doctors are visiting during your shift? Ensure changes are actioned.

5.8. Clean up your workspace. Ask how I would like to find this space.

5.9. Do a shift check. Have I signed all my medications? Have I missed anything?

5.10. Ensure handover is up to date and ready. Make sure the important components of the shift are outlined (e.g. PRN's, wounds, incidents, what needs to be followed up by the next nurse etc.)

  • Ensure you take your breaks. Ensure you check what you are entitled too for the shift.
  • Breaks are important for reducing mistakes!

6. PM Shift Routine

6.1. Arrive early, introduce yourself as an agency member and orientate yourself to the facility.

6.2. Receive handover from the AM nurse.

6.3. Check DD's with the nurse on the previous shift.

6.4. Time plan your shift. Consider: BGLs, insulins, Parkinson medications, palliative care patients/medications & wound care. Ensure all tasks have been completed from the shift prior.

6.5. Start medication rounds on time. Consider these medication rounds can take up to 1-3 hours.

6.6. Check what DD's are due for your shift. Are there any scheduled patches or medications due?

6.7. Clean up your workspace. Ask how I would like to find this space.

6.8. Do a shift check. Have I signed all my medications? Have I missed anything?

6.9. Ensure handover is up to date and ready. Make sure the important components of the shift are outlined (e.g. PRN's, wounds, incidents, what needs to be followed up by the next nurse etc.)

  • Ensure you take your breaks. Ensure you check what you are entitled too for the shift.
  • Breaks are important for reducing mistakes!

 

Strictly confidential and solely for the use of the recipient. May not be disclosed, reproduced, or circulated without the prior written consent of C4U Nursing Agency Pty. Ltd.

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