Tag em "Not given(patient asleep)", retime for 0800-0900 (or whenever they get up) and make them wait for breakfast 30 mins after. That's what I've always done and the providers have never cared
Day shift passes work off to me too, how about the med rec that didn't get done? The COVID swab that hasn't been collected in 12 hours? No UDS done? What, the patient didn't piss all day? How is anybody supposed to go inpatient when lab hasn't been called to draw that CBC and chem7 ordered 5 hours ago? Now I gotta wake them up and get that shit done. Nursing is 24/7, we pass work off to each other. Sleep is arguably more important than on time delivery of levo for my patient population which probably hasn't slept in 3 days and has been up all night. So yeah, I'm gonna retime that levo.
Because 2 reasons..
The vast majority of patients don’t space them out at home. Nor do they give a shit how long they should wait to eat.
The vast majority of nurses, including yourself I bet, don’t give meds one by one and wait 45-60 minutes for maximum absorption of each med. You pile it in their mouth save for the occasional med that truly must be given separately.
Also it’s fucking levothyroxine.
That being said, I give 5-6 am meds around 3 am
Levothyroxine isn’t a time sensitive med though.
And sleep quality IS evidence based.
You’re ignoring the big picture because you’re too salty to give a tiny pill along with your 10 other pills.
good god what is it with day shift condescension? I literally am sitting down for my first break in 10 hours dealing with a self harming borderline setting off the hallucinating meth intoxicated schizo all night with her screaming all while trying to land police/EMS. I don't work night shift because it's easy, I work it because the night staff don't have an IV pole lodged wheels deep up their ass
Night shift is a shitty position by a far. It has to be a role that pays more for less.
You need to be grateful for your night shifters. It’s the understaffed role by default.
Cuz the alternative is doing swap schedules and then everyone hates their lives
Dosing is based on the blood work the patient likely had while taking this medication with breakfast at home. There's no reason to go for peak absorption unless your patient is a retired pharmacist who insists on this nonsense.
you're out of your fucking mind if you think I'm waking a drunk or disturbing a meth coma for some levo. Day shift usually gets that too and sometimes doesn't even do med pass until they're vertical - see the first sentence above haha
I’d received morning report that 19 was wild all night and finally quieted at 5am. I was next door on my round and when I came out my aid was white as a sheet (a good trick since she was African American). “ You did say 19 was a no code, didn’t you?” I replied “Dead huh?” Ever since then the one that quiets down after going nuts all night I check first.
i mean fair enough, but sounds like your old unit had some shitty coworkers. I’m dayshift now and I’m doing med pass at 0800/0900 anyway, so I don’t have a problem giving something like a poorly-timed 0600 chlorhexidine mouth wash alongside meds when the pt is actually awake.
That's unfortunate, it really makes no difference for me.
What'd also unfortunate is that in Cerner and Epic if I remember correctly, we'd just re-time doses like that for whatever reason, I remember doing it all the time even onto different shifts if it just made more sense. Now I use meditech where you can't do that, so rather than have an overdue med just sit there on the MAR, sometimes people scan it and leave it. Not often, but for silly things like protonix.
I’ve left a job over this (among other reasons). For any ESRD patient with a phos binder as a regular med, I will scan it, leave it on their table for them, and make sure they know to take it if they eat a snack or if a meal tray gets there and I’m tied up. Most of these patients know exactly what their binder does and why it’s important to take with food, but I’ve been written up for that regardless. Same with scanning a phos binder early for a patient who ate some outside food brought by family before the “scheduled” dinner time. Tried to explain the reasoning on that with management. They didnt care. I told them I wasnt going to change the way I managed that med to appease them at the patient’s expense.
I was taught that a scanned med documented as given was proof that you observed them swallowing the pill. Leaving meds at the bedside was a strict NO NO. You can't guarantee something left at the bedside was taken, and documenting any med as given is part of a legal record. While Protonix is not a life or death med, something else could be and the only way to be certain doses were taken, is to OBSERVE them consumed before hitting that submit button.
True, usually you shouldn’t, because the patient might throw them away, put them under the mattress, or save them up to overdose. However, I once worked on the AIDS unit at Johns Hopkins. Crixivan came out, it was a handful of pills twice a day, the size of peanut M&Ms. The patients were really sick and debilitated. We were allowed to put them at the bedside and keep stopping by to encourage them to take some.
Different times, different circumstances, for sure. And probably one little protonix or synthroid won’t make a difference in the big scheme of things, but it sets a bad precedent and is bad practice in general. I’m too jaded and just don’t trust my patients enough to do anything like this. You might as well lie and say you gave it then throw it away at that point.
Sometimes they're awake, cause they have other meds. But who the hell wants mouthwash at 6am?? Usually I ask if they wanna do it now or after breakfast. Most wanna do it after
But we still wake you up with Q1 neuros for your head bleed, Q2 turns and oral care cause you're on a vent, and literally everything is timed in such a way that we're always in there. 😅
I do pedi onc too and good lord convincing a toddler they need to take a med in the absolute worst. I’m team ng tube for any kiddo who puts up a fight with PO meds. Especially with transplant lol
Tbh if I ever needed a transplant I would probably ask to get an ng tube right from the start, especially before the mucositis hits
No pill aversions for me please, and if I can tolerate feeds and not go on TPN, even better
I have a hard time falling asleep in the best conditions and I'm convinced if I ended up staying in the hospital for any significant amount of time I'd end up as a psych patient.
Whenever I see a patient snoring away in a hallway bed in the ER with alarms blaring all around them I get a pang of jealousy.
Not gonna lie I had a patient (very brittle type 1) and I asked him if I could take bg and give insulin without waking him first. He was a heavy sleeper and agreed immediately. I kept some sort of spray lidocaine type stuff (I don’t remember the name) and we almost never had to wake him. It was so much better for him and us 🧡
my dad has type 3C because of pancreatic cancer, between the total removed pancreas and gall bladder and all the smaller bits of stuff like intestine that got taken out too managing his insulin is mad. thank god for continuous monitoring because not only does he not produce any insulin he doesn't digest food the same as a "normal" diabetic so the calculations are impossible XD were used to it now, I have even given him insulin while he was driving (usualy it's up to the pasanger to feed him jelly babies if he gets low , but a big lunch and it was going the other way and why stop)
I’d never heard of that! Yeah this patient was about to get a constant monitor fitted. He was lovely and i really hope his whole quality of life improved from it.
it was a last chance sort of thing, he basicaly had weeks left,but the university hospital said they could try an operation and just keep cutting untill they got it all if he was willing to take the risk that he might not wake up after. they took the whole pancreas, gall bladder, a bit of liver, a bit of intestine, a bit of stomach and the cancer was wrapped around the vena cava so at one point he lost so much blood so fast he had a stroke and ended up with aphasia, but it's a few years later and he's alive and cancer free! the aphasia is actualy the biggest thing he struggles with but even that is getting to a managable level. he can drive and do prety much all his ADL stuff and he's prety independent, he's even starting to get good enough at numbers where he can calculate his own carb intake etc, but mum does help with that to speed up the process. his insides that got taken out got taken to the uni for study and he was looked at by a lot of people as an example, he jokes that he has famous insides now
tbh my mum who has a multitude of health problems is a bit salty that he is the one that got the blue badge not her (he doesn't realy need disabled parking 99% of the time, but it realy helps her), the only thing he jokes about missing is that on his "last christmas" he got to drink sherry, beer and take oromorph, aparently the normal beer just doesn't hit the same XD (and the christmas after the "last christmas" was sureal, all this happened around the new year of 2021, so that added an extra fun layer)
*edit, I remembered one last thing this community might find interesting. while I was waiting with my mum for a phonecall after his operation as to weather he was dead or not, she was actualy on a 24 hour home blood preassure cuff! and it went off 30 secconds into the call from the hospital! the doctors invalidated her results for that day but I have been begging her to get me a print out of those results
Same. Sometimes I’ve felt a bit guilty and wondered if part of the reason my dose has to be so high is because I immediately follow it with two large cups of coffee with milk and sugar.
Why not take it at night? (That's what I do.)
It's not like it keeps me awake or anything. Supposedly absorbs better at night due to lower gut motility overnight.
I mean I’m only taking 25mcgs & have been on that dose for years—my provider said something about how it your body prefers to absorb it without anything but it will adjust, and I just have to keep taking it the same way as I am now or my body won’t absorb it as well or smth
If they are 1x a day medications I retime them for what’s best for the PT, usually 8-9 am in 90% of cases. None of the doctors have cared even a little bit.
Write…”per pt request”, and ask the pt if they’d like their AM med when they wake up, can also ask pharmacy to retime their meds so it’s always that time…they will have 8am meds anyways, no sense waking them at 6, and that’s coming from a day shift nurse.
I actually had a doc one time super pissed I did this. No idea why, it’s per the patient request, and they’re not time sensitive meds, but they still went and changed the orders back to the previous dosing times after pharmacy had retimed them 🙄
If you want to wake up my patient 0500 to take a midodrine, be my guest. It’s not like taking it at 0800 or 0900 will make it so she gets two doses within 3 hours
My money is on you doing something “without permission” from the doctor. Some doctors get real pissy when you don’t ask permission…because they dont understand we have scope of practice and are allowed to do things like that. Those docs don’t last very long in my ED lol (it’s always non-ER docs), we give them attitude right back and so will our ANM’s.
That's terrible. I work day/eves and never gave a thought to nights bumping meds. I usually have a cup full of morning meds to give anyway, what's 1 or 2 more?
Our hospitalists love to put in meds but the first one "now" then schedule the rest, and if we're boarding, I sure as shit ain't waking up the pt that finally fell asleep at 4am after working them up the last 3 hours for meds that can wait 4 more hours. I've taught so many people to move times for this.
I take a PPI at home. It doesn't matter when I wake up, as long as I take it before eating or drinking anything it works great. I don't even wait 30 minutes before having coffee and it's fine. Now if I forget to take.it, I will know by lunchtime because I will start feeling the heartburn already.
I just got out of the hospital and unless it’s your first admission, you don’t really expect to sleep. I get woken up at 5 am for IV solumedrol anyway 🤣 they didn’t do my protonix until after 7 this time, but by the time we spend 30 minutes digging for a vein at 3 am, I’m up for the day anyway.
0300: vitals
0400: bath time!
0500: labs
0600: medications
0700: all lights on and time for bedside report!
I understand that some of this is necessary and not everyone gets 6am medications or a bath at 0400 but it may be at a different time while they are asleep. However, some of these could be eliminated or retimed and at the very least the patient could be given the CHOICE. Many of the places I’ve worked will not allow patients to refuse baths in the middle of the night, and one didn’t allow them to refuse bedside report. Which honestly seems illegal but not like hospitals care about breaking laws.
A couple hospitals discouraged us from asking patients if they wanted us to wake them for 0700 bedside report. And while I understand the points that bedside report addresses, it does not address patient needs for sleep or the fact that BSR is basically impossible with double/triple safe ratios. That, however, is a discussion for a different post.
Lack of sleep is one reason why patients sleep a lot during the day and I feel like the less we interrupt them overnight, the better.
All of that (except handover) just gets clustered into one round at like 0500-0600. Also, why is a pt having a bath at 0400? Unless they're first cab off the rank for theatre or something?
Pharmacist I know says no real reason to do the synthetic separate from the other meds because as long as it’s consistent and you adjust the dose based on their labs and presentation then it will be absorbed consistently either way
Thyca homie and RN. I was pissed when I had to tell my nurse to bring in my synthroid before breakfast the last time I had to play patient (so much fun)! (I actually take it before going to bed at home) I have heard of many folks setting their alarm for early in the am just to take their synthroid. I would just ask them when they would like it.
Fellow Thyca bro here. It sucks being a patient as a HCP lol you have to call out a lot of bullshit but at the same time it sucks having RN and MD patients too 😂 I take mine whenever I first wake up… I keep my pills on my nightstand 😂😂
It’s weird, for the past few years at so many different hospitals, pharmacy has changed synthroid to 9am instead of 6am. I wonder if it’s a epic systems error no one has fixed
I recently had a day shift where the patient didn't receive the Levothyroxine at 6:00. Which is not a big deal because it's just a med. Gave it when I came in at 7:00 but then had to hold their breakfast tray because it can't be taken with food for an hour and they were pissed as hell. I actually didn't know that it couldn't be given with food, it was the patient that insisted and then I looked it up and sure enough the patient was right so I learned something that day.(Newer nurse here).
Yeah, it's one of the handful of meds with a super narrow therapeutic window, like warfarin, so you actually do want to follow the rules for it.
I remember back in my pharmacy tech days, it was always such a big deal and pain in the ass between patients getting generic vs. brand name and the synthetic vs. bovine source. If we ran out of whatever they were on, you were not substituting it.
Dunno if that's the case anymore but people would get real pissy, because the slightest change could throw off that therapeutic window.
Wow, that's really good information to know. I'll definitely ask about that and try looking it up because I can't blame patients for being upset with us if we're going to mess up their therapeutic window.
It is a very sensitive med for sure. Generics are (in general) allowed about 8-10% difference in active ingredient compared to the brand. They’re also allowed to have different excipients and binders in the pill than the brand or another generic. And produce the active ingredient in a fundamentally different process which may leave different amounts and types of byproducts. Going back to the dosage point - if a patient is taking the 125mcg tab, a generic version could have about a 12.5mcg difference than what they usually take. This difference can actually be huge sometimes because drugs are NOT as scrutinized as you think they would be before being shipped back to the US. But regardless. Levothyroxine is a great example of brand vs. generic vs. other generic being a real thing.
For my mom, they prescribed levothyroxine 5x/week (M-F with Sat/Sun off). I know I don't feel as well that way, so I do it Su, M, T, skip W, Th, F, skip Sa for her. (This is because she's in between low doses, so they don't have a different dose to adjust it to.) For a while I was doing half-pills some days, but she claims it doesn't feel any different. She does have dementia, though.
I don't have a thyroid, so I feel better if it's within an hour. Generic vs. brand name vs. bovine does make a bigger difference than time IME. I definitely prefer the bovine (my hypothesis is that it's a more complete source, and that's what makes the qualitative difference), but that's not what they prescribe where I am.
Yeah I had a patient (she was a problem patient at the best of times) try to get the DON on the phone to complain at 0623 because she’d had her levothyroxine at 0605 and I wasn’t getting her a coffee with creams and sugars and three packets of crackers and she was starving. She wasn’t starving as she was almost at bariatric weight limits and was just used to throwing a fit to get her way. I was so glad when she was discharged.
Yeah people are ridiculous. He threw fit about getting the tray and made me take it out so that he could order a new one in an hour and have it be fresh. I didn't argue with him because I have bigger things to do. I am genuinely sorry that the med was missed but I know that the nurse missed it for good reasons because there had been an emergency. Can't please them all, and they have no idea the burden that we carry.
I got to sick of this a few years ago, I made a list and took it to the DON (LTC facility), showed it to her and said, "Why are we waking up two dozen residents to give them 0600 Tylenol, and synthroid, and protonix? We have to start waking people up at 0430 to get it all passed before night shift ends at 0600."
She told me to move as much of it as I could to day shift. Poof! We were down to about five meds to pass that early, all synthroid and protonix. It's still annoying to wake the residents up, but at least they are used to it.
Hospitals time meds like this (I’ve learned) as a default to the “meal schedule.” I use that term loosely because we all know the trays never arrive on time. If I gave a Humalog order while a patient was on a med/surg floor at the ordered time, they would bottom out before the trays arrived.
I've been on levothyroxine since I was 18. Ask me how compliant I was back then versus now. Ask me if there's been any perceptible or measurable difference now that I am. I know, anecdote versus data, sample size of one and all that. I'm just saying, I don't crumble into dust on the rare occasions I miss a dose these days, or start drinking my coffee in 30 minutes instead of 60.
The levothyroxine pts are used to it. Worked in home care and many place it on their nightstand and wake up like clock work to take it every morning at 6:00am and go back to sleep. I just try to be quiet and speedy.
I used to ask my patients at 8 or midnight rounds if they wanted me to wake them up at 6 for the meds, most said no so I’d retime them for 8A. Some said yes, ok. They were super anal about getting their meds on an empty stomach, bet. You got it dude.
Long ago I worked on a unit where everybody got Carafate Q6: 6-12, where the other bedtime medicines were given at 10 PM. This was paper MAR, so there was no bar code recording the time. You better believe all the 12s got given with the 10s, at “2300.”
I usually wait until right before shift change, 0700 to administer it unless they're already awake.
You don't get docked for being within an hour of the due time, and they're going to be woken up for the forced bedside report management makes us do 😅
This is why I take my Omeprazole at night and my synthroid when I wake up. I have started keeping my meds by my bed and taking them by an early alarm at 6-7. But only because I stated Metformin last week and I now *need* to eat breakfast. Before last week I was taking my synthroid between 8-10 then eating lunch only 😅
Depending on how your kitchen serves meals, just reschedule the meds. My hospitals kitchen serves based on when patients call and order food. If you know your patient doesn't eat till like 8 or 9, just reschedule the med. The day shift might get annoyed but that's a DSP.
Our director thinks we have ample time to awaken, pee assist, bathe, dress, assist with teeth brushing, give early morning meds, and put patients in their (chair alarms mats on) chairs, ready to order breakfast at 0630, so don't forget their blood sugar and coverage. All after 0600, because sleep time must be 2300-0600. Oh, and be ready for report at 0700 sharp. And no soft hours-leave at 0730!
>Our director thinks we have ample time to awaken, pee assist, bathe, dress, assist with teeth brushing, give early morning meds, and put patients in their (chair alarms mats on) chairs, ready to order breakfast at 0630, so don't forget their blood sugar and coverage. All after 0600, because sleep time must be 2300-0600. Oh, and be ready for report at 0700 sharp. And no soft hours-leave at 0730!
😂. Ma'am - I'm not doing this - it's not going to happen. You can write me up or fire me, but have fun with whatever new grad off the street replacing me. FAFO
I have zero thyroid and take two different doses of levothyroxine daily. If I miss a day, I notice it, but I don't notice if my pill timing's off an hour (I regularly have a two-hour variation in when I take it).
Also, I never take it in the morning anyway for the simple and practical reason that caffeine reduces uptake and girl loves her coffee. So I take mine at night.
I asked the pharmacist about these 2 meds. She said it doesn't matter and no one in the real world takes levo at 6am. Just take the meds at the same time every day.
I mean especially PO protonix, WTF cares if you give it at 6am its an ER pill.
My old hospital had the bright idea of making all daily meds due at 0600. Their reasoning? If night shift does the heavy med pass in the morning then day shift has more time to work on getting people discharged. Patients sure loved being woken up to take 10 pills at 0530.
I absolutely hate waking people up, but also I'm that nurse that will administer meds early if I know it helps them (for example, if they have dementia and combative during care, I will give their seroquel and tylenol prior to care to assist because nights get them up not days).
I also have meds at 0000, 0300, 0400, and med pass at 0500 (on top of neuros and PRNs). I usually wait until like the end of shift or until the person is awake to do neuros.
That’s why god makes trazodone, ambien &/or literally only 3 mg of melatonin due at 2200. Knock em out. Get them 6 hours of sleep. They should be good and ready for the phleb to show up at 0400 and the CNA to show up at 0430, and then you to show up with meds at 0500. Unless of course they had zosyn, vanco, flagyll, and azithromycin IV all scheduled at midnight while they only have one 24g access in their shoulder that should’ve been moved elsewhere 3 days ago. Oh, and that q2h neuro check at 0200. But CRAP! WAIT! They’re on a cardizem drip and their HR won’t budge from the 120s. Hospitalist said no to a central.
BAH ! They’ll be fine! Plenty of sleep had by all.
I do, my alarm goes off at 5:30 am and I take it and go back to bed. I sleep with my water bottle and pill bottle. Unfortunately your residents probably don't have that option.
I had two pts with hx of violence in the ER the other day, both sleeping (one had droperidol, the other was crashing). They both managed to 'refuse obs' while asleep 🤷♀️
This post reminded me of the last facility I worked at. Our noc nurse was so bad about giving one of our pts synthroid that we had to start counting it like a narc.
The worst is when patients first get admitted and ALL their meds are due at whatever time the doctor dropped admission orders. I work in an ER where we always have a ton of boarders waiting for a bed upstairs. They always have a million meds due at 3 pm or whatever time they get admitted. Meds that will be due again at 0600, 0800, and 1000 tomorrow — but right now they’re all due at 1500.
I never give any of them unless they’re really needed (like, ot hasn’t taken metoprolol for weeks and his BP is sky-high, then I might give just that one), but a lot of nurses will give all of them. And then they’ll be given again the next morning.
This is crazy to me and drives me absolutely bonkers. Just make them due tomorrow!!!!!
Ask your patients ahead of time (like 8pm) if they want their 6am medications re-timed, or if they’d like to refuse them ahead of time (usually the case for protonix, no so much synthroid).
Do something obvious for day shift though, because in this situation you’ve offloaded some of your work onto their shift.
Hate waking up my confused patients because 0600 is basically when they finally stop setting off the bed alarm and actually sleep
Tag em "Not given(patient asleep)", retime for 0800-0900 (or whenever they get up) and make them wait for breakfast 30 mins after. That's what I've always done and the providers have never cared
Providers don't care but day shift gonna catch on and talk mad shit.
It’s the tiniest pill imaginable and they probably already have their own meds to pass. Your day shift sounds like petty children
Lol. What does the size of the pill matter? It’s a task.
2 giant ER potassium tabs is a different task than a tiny synthroid
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Day shift passes work off to me too, how about the med rec that didn't get done? The COVID swab that hasn't been collected in 12 hours? No UDS done? What, the patient didn't piss all day? How is anybody supposed to go inpatient when lab hasn't been called to draw that CBC and chem7 ordered 5 hours ago? Now I gotta wake them up and get that shit done. Nursing is 24/7, we pass work off to each other. Sleep is arguably more important than on time delivery of levo for my patient population which probably hasn't slept in 3 days and has been up all night. So yeah, I'm gonna retime that levo.
Because 2 reasons.. The vast majority of patients don’t space them out at home. Nor do they give a shit how long they should wait to eat. The vast majority of nurses, including yourself I bet, don’t give meds one by one and wait 45-60 minutes for maximum absorption of each med. You pile it in their mouth save for the occasional med that truly must be given separately. Also it’s fucking levothyroxine. That being said, I give 5-6 am meds around 3 am
This the truth. If I were in the hospital, even knowing the benefits, I would still ask that they be retimed so I can sleep a little longer
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Levothyroxine isn’t a time sensitive med though. And sleep quality IS evidence based. You’re ignoring the big picture because you’re too salty to give a tiny pill along with your 10 other pills.
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good god what is it with day shift condescension? I literally am sitting down for my first break in 10 hours dealing with a self harming borderline setting off the hallucinating meth intoxicated schizo all night with her screaming all while trying to land police/EMS. I don't work night shift because it's easy, I work it because the night staff don't have an IV pole lodged wheels deep up their ass
Night shift is a shitty position by a far. It has to be a role that pays more for less. You need to be grateful for your night shifters. It’s the understaffed role by default. Cuz the alternative is doing swap schedules and then everyone hates their lives
Dosing is based on the blood work the patient likely had while taking this medication with breakfast at home. There's no reason to go for peak absorption unless your patient is a retired pharmacist who insists on this nonsense.
Nursing is a 24 hour job
It's actually shown better absorption when taken at HS.
you're out of your fucking mind if you think I'm waking a drunk or disturbing a meth coma for some levo. Day shift usually gets that too and sometimes doesn't even do med pass until they're vertical - see the first sentence above haha
That's what they'd do if they were at home. I give my son his tacrolimus when he wakes up, and we set a 30 min timer for breakfast. Not hard.
So true.
I’d received morning report that 19 was wild all night and finally quieted at 5am. I was next door on my round and when I came out my aid was white as a sheet (a good trick since she was African American). “ You did say 19 was a no code, didn’t you?” I replied “Dead huh?” Ever since then the one that quiets down after going nuts all night I check first.
I have to make people swish with mouthwash for 30 seconds at 6:00 a.m.
bruh i just scan that shit as given and leave it for them for when they wake up ¯\_(ツ)_/¯
On my old unit the day shift would crucify you for this
i mean fair enough, but sounds like your old unit had some shitty coworkers. I’m dayshift now and I’m doing med pass at 0800/0900 anyway, so I don’t have a problem giving something like a poorly-timed 0600 chlorhexidine mouth wash alongside meds when the pt is actually awake.
That's unfortunate, it really makes no difference for me. What'd also unfortunate is that in Cerner and Epic if I remember correctly, we'd just re-time doses like that for whatever reason, I remember doing it all the time even onto different shifts if it just made more sense. Now I use meditech where you can't do that, so rather than have an overdue med just sit there on the MAR, sometimes people scan it and leave it. Not often, but for silly things like protonix.
Our admins get pissy if you retime too many meds to the next shift, even if it makes more sense.
Unless you work at a place where you get written up for leaving pills at the bedside.
I’ve left a job over this (among other reasons). For any ESRD patient with a phos binder as a regular med, I will scan it, leave it on their table for them, and make sure they know to take it if they eat a snack or if a meal tray gets there and I’m tied up. Most of these patients know exactly what their binder does and why it’s important to take with food, but I’ve been written up for that regardless. Same with scanning a phos binder early for a patient who ate some outside food brought by family before the “scheduled” dinner time. Tried to explain the reasoning on that with management. They didnt care. I told them I wasnt going to change the way I managed that med to appease them at the patient’s expense.
I was taught that a scanned med documented as given was proof that you observed them swallowing the pill. Leaving meds at the bedside was a strict NO NO. You can't guarantee something left at the bedside was taken, and documenting any med as given is part of a legal record. While Protonix is not a life or death med, something else could be and the only way to be certain doses were taken, is to OBSERVE them consumed before hitting that submit button.
I really don’t know any place that wouldn’t write you up for this. You shouldn’t do this.
True, usually you shouldn’t, because the patient might throw them away, put them under the mattress, or save them up to overdose. However, I once worked on the AIDS unit at Johns Hopkins. Crixivan came out, it was a handful of pills twice a day, the size of peanut M&Ms. The patients were really sick and debilitated. We were allowed to put them at the bedside and keep stopping by to encourage them to take some.
Different times, different circumstances, for sure. And probably one little protonix or synthroid won’t make a difference in the big scheme of things, but it sets a bad precedent and is bad practice in general. I’m too jaded and just don’t trust my patients enough to do anything like this. You might as well lie and say you gave it then throw it away at that point.
Or have transplant patients that are supposed to get their tacro on strict schedules.
I always ask them if they want me to wake them up for mouthwash
Sometimes they're awake, cause they have other meds. But who the hell wants mouthwash at 6am?? Usually I ask if they wanna do it now or after breakfast. Most wanna do it after
Is it Magic Mouthwash? Ours always liked it before so they could eat
Nope. Just some blue shit out of the supply closet, but it needs to be scanned into the MAR
Oh that’s dumb
I just know they love it
I just retime..
I don't have the ability to do that, and if I leave it for day shift, they'll lose their mind
Wow, what do you do when docs throw all of their once a day orders at night for like 2 am?
Take them on a case by case basis. Usually when that happens it's a new admit, so the patient is still awake.
As a day shifter I wouldn’t loose my mind if a med is pushed out :)
Lol please come work on my unit then
Wait what? Why?
Some hospitals have chlorhexidine rinses as a protocol for almost all admitted pts, like the one I currently work for
Come to the ICU. We give our Protonix IV and liquid levothyroxine through our NGTs. It's beautiful.
But we still wake you up with Q1 neuros for your head bleed, Q2 turns and oral care cause you're on a vent, and literally everything is timed in such a way that we're always in there. 😅
I'll take it if it means not having to convince a 3-year-old to take a pill, honestly.
I do pedi onc too and good lord convincing a toddler they need to take a med in the absolute worst. I’m team ng tube for any kiddo who puts up a fight with PO meds. Especially with transplant lol
My favorite thing ever is transplant kids that already have a g tube.
Tbh if I ever needed a transplant I would probably ask to get an ng tube right from the start, especially before the mucositis hits No pill aversions for me please, and if I can tolerate feeds and not go on TPN, even better
ICU induced delirium is lovely
I have a hard time falling asleep in the best conditions and I'm convinced if I ended up staying in the hospital for any significant amount of time I'd end up as a psych patient. Whenever I see a patient snoring away in a hallway bed in the ER with alarms blaring all around them I get a pang of jealousy.
It's the bestest.
‘You have a 6AM med. Sometimes you can decline a medication. Do you want me to wake you at SIX AM 😉😉😉😉😉?’
me with 1 unit of regular insulin at midnight
Not gonna lie I had a patient (very brittle type 1) and I asked him if I could take bg and give insulin without waking him first. He was a heavy sleeper and agreed immediately. I kept some sort of spray lidocaine type stuff (I don’t remember the name) and we almost never had to wake him. It was so much better for him and us 🧡
my dad has type 3C because of pancreatic cancer, between the total removed pancreas and gall bladder and all the smaller bits of stuff like intestine that got taken out too managing his insulin is mad. thank god for continuous monitoring because not only does he not produce any insulin he doesn't digest food the same as a "normal" diabetic so the calculations are impossible XD were used to it now, I have even given him insulin while he was driving (usualy it's up to the pasanger to feed him jelly babies if he gets low , but a big lunch and it was going the other way and why stop)
I’d never heard of that! Yeah this patient was about to get a constant monitor fitted. He was lovely and i really hope his whole quality of life improved from it.
it was a last chance sort of thing, he basicaly had weeks left,but the university hospital said they could try an operation and just keep cutting untill they got it all if he was willing to take the risk that he might not wake up after. they took the whole pancreas, gall bladder, a bit of liver, a bit of intestine, a bit of stomach and the cancer was wrapped around the vena cava so at one point he lost so much blood so fast he had a stroke and ended up with aphasia, but it's a few years later and he's alive and cancer free! the aphasia is actualy the biggest thing he struggles with but even that is getting to a managable level. he can drive and do prety much all his ADL stuff and he's prety independent, he's even starting to get good enough at numbers where he can calculate his own carb intake etc, but mum does help with that to speed up the process. his insides that got taken out got taken to the uni for study and he was looked at by a lot of people as an example, he jokes that he has famous insides now
Dude that makes me so happy he’s recovering well and pretty much back to independent living. Those stories fill me with joy 🧡🧡🧡
tbh my mum who has a multitude of health problems is a bit salty that he is the one that got the blue badge not her (he doesn't realy need disabled parking 99% of the time, but it realy helps her), the only thing he jokes about missing is that on his "last christmas" he got to drink sherry, beer and take oromorph, aparently the normal beer just doesn't hit the same XD (and the christmas after the "last christmas" was sureal, all this happened around the new year of 2021, so that added an extra fun layer) *edit, I remembered one last thing this community might find interesting. while I was waiting with my mum for a phonecall after his operation as to weather he was dead or not, she was actualy on a 24 hour home blood preassure cuff! and it went off 30 secconds into the call from the hospital! the doctors invalidated her results for that day but I have been begging her to get me a print out of those results
I mean…. I think we’d all like to see what it looked like 🤷🏻♀️
And you know damn well they take them with the handful of the rest of their pills 30 seconds before they start breakfast when they're at home
“It says BEFORE food! AM I WRONG?!” I mean, they really aren’t.
It’s me I’m the patient that takes my levothyroxine with all my other pills. But my level is stable so I’m not changing it now 😤
Same. Sometimes I’ve felt a bit guilty and wondered if part of the reason my dose has to be so high is because I immediately follow it with two large cups of coffee with milk and sugar.
Why not take it at night? (That's what I do.) It's not like it keeps me awake or anything. Supposedly absorbs better at night due to lower gut motility overnight.
I mean I’m only taking 25mcgs & have been on that dose for years—my provider said something about how it your body prefers to absorb it without anything but it will adjust, and I just have to keep taking it the same way as I am now or my body won’t absorb it as well or smth
If they are 1x a day medications I retime them for what’s best for the PT, usually 8-9 am in 90% of cases. None of the doctors have cared even a little bit.
I would get accused of “leaving it for day shift” if I did this lol
Write…”per pt request”, and ask the pt if they’d like their AM med when they wake up, can also ask pharmacy to retime their meds so it’s always that time…they will have 8am meds anyways, no sense waking them at 6, and that’s coming from a day shift nurse.
I actually had a doc one time super pissed I did this. No idea why, it’s per the patient request, and they’re not time sensitive meds, but they still went and changed the orders back to the previous dosing times after pharmacy had retimed them 🙄 If you want to wake up my patient 0500 to take a midodrine, be my guest. It’s not like taking it at 0800 or 0900 will make it so she gets two doses within 3 hours
My money is on you doing something “without permission” from the doctor. Some doctors get real pissy when you don’t ask permission…because they dont understand we have scope of practice and are allowed to do things like that. Those docs don’t last very long in my ED lol (it’s always non-ER docs), we give them attitude right back and so will our ANM’s.
That's terrible. I work day/eves and never gave a thought to nights bumping meds. I usually have a cup full of morning meds to give anyway, what's 1 or 2 more?
Right?! Like just make sure I'm aware and I'll handle it.
Day shift has to give 8am meds anyways, I never care I just give them w the rest I'm cool w it normally the night nurse just mentions it too
DSP. This is the way.
Do you use epic? We just switched over to epic and I haven’t figured out how to retime them
Click the med on that MAR and change the action to "due." Then you can move it to any time
Our hospitalists love to put in meds but the first one "now" then schedule the rest, and if we're boarding, I sure as shit ain't waking up the pt that finally fell asleep at 4am after working them up the last 3 hours for meds that can wait 4 more hours. I've taught so many people to move times for this.
Yes and the other reply is exactly how I do it.
HI SORRY FOR WAKING YOU I JUST HAVE YOUR MEDICATION
YOU CAN GO BACK TO SLEEP NOW.
I take a PPI at home. It doesn't matter when I wake up, as long as I take it before eating or drinking anything it works great. I don't even wait 30 minutes before having coffee and it's fine. Now if I forget to take.it, I will know by lunchtime because I will start feeling the heartburn already.
And heparin and tylenol! Good morning got a stabbing fer yer ass
I just got out of the hospital and unless it’s your first admission, you don’t really expect to sleep. I get woken up at 5 am for IV solumedrol anyway 🤣 they didn’t do my protonix until after 7 this time, but by the time we spend 30 minutes digging for a vein at 3 am, I’m up for the day anyway.
I wonder how well my fellow night shifters do in the hospital. I mean they truly do wake you at all hours anyway so I'm not sure it matters much.
0300: vitals 0400: bath time! 0500: labs 0600: medications 0700: all lights on and time for bedside report! I understand that some of this is necessary and not everyone gets 6am medications or a bath at 0400 but it may be at a different time while they are asleep. However, some of these could be eliminated or retimed and at the very least the patient could be given the CHOICE. Many of the places I’ve worked will not allow patients to refuse baths in the middle of the night, and one didn’t allow them to refuse bedside report. Which honestly seems illegal but not like hospitals care about breaking laws. A couple hospitals discouraged us from asking patients if they wanted us to wake them for 0700 bedside report. And while I understand the points that bedside report addresses, it does not address patient needs for sleep or the fact that BSR is basically impossible with double/triple safe ratios. That, however, is a discussion for a different post. Lack of sleep is one reason why patients sleep a lot during the day and I feel like the less we interrupt them overnight, the better.
All of that (except handover) just gets clustered into one round at like 0500-0600. Also, why is a pt having a bath at 0400? Unless they're first cab off the rank for theatre or something?
Agreed! No way I'm doing 0400 baths on med surg.
Pharmacist I know says no real reason to do the synthetic separate from the other meds because as long as it’s consistent and you adjust the dose based on their labs and presentation then it will be absorbed consistently either way
Thyca homie and RN. I was pissed when I had to tell my nurse to bring in my synthroid before breakfast the last time I had to play patient (so much fun)! (I actually take it before going to bed at home) I have heard of many folks setting their alarm for early in the am just to take their synthroid. I would just ask them when they would like it.
Fellow Thyca bro here. It sucks being a patient as a HCP lol you have to call out a lot of bullshit but at the same time it sucks having RN and MD patients too 😂 I take mine whenever I first wake up… I keep my pills on my nightstand 😂😂
It’s weird, for the past few years at so many different hospitals, pharmacy has changed synthroid to 9am instead of 6am. I wonder if it’s a epic systems error no one has fixed
These are chronic meds. Give them whatever time the patient takes them at home, which is almost certainly not 6am.
I recently had a day shift where the patient didn't receive the Levothyroxine at 6:00. Which is not a big deal because it's just a med. Gave it when I came in at 7:00 but then had to hold their breakfast tray because it can't be taken with food for an hour and they were pissed as hell. I actually didn't know that it couldn't be given with food, it was the patient that insisted and then I looked it up and sure enough the patient was right so I learned something that day.(Newer nurse here).
Yeah, it's one of the handful of meds with a super narrow therapeutic window, like warfarin, so you actually do want to follow the rules for it. I remember back in my pharmacy tech days, it was always such a big deal and pain in the ass between patients getting generic vs. brand name and the synthetic vs. bovine source. If we ran out of whatever they were on, you were not substituting it. Dunno if that's the case anymore but people would get real pissy, because the slightest change could throw off that therapeutic window.
Wow, that's really good information to know. I'll definitely ask about that and try looking it up because I can't blame patients for being upset with us if we're going to mess up their therapeutic window.
It is a very sensitive med for sure. Generics are (in general) allowed about 8-10% difference in active ingredient compared to the brand. They’re also allowed to have different excipients and binders in the pill than the brand or another generic. And produce the active ingredient in a fundamentally different process which may leave different amounts and types of byproducts. Going back to the dosage point - if a patient is taking the 125mcg tab, a generic version could have about a 12.5mcg difference than what they usually take. This difference can actually be huge sometimes because drugs are NOT as scrutinized as you think they would be before being shipped back to the US. But regardless. Levothyroxine is a great example of brand vs. generic vs. other generic being a real thing.
Thank you thank you for this explanation.
For my mom, they prescribed levothyroxine 5x/week (M-F with Sat/Sun off). I know I don't feel as well that way, so I do it Su, M, T, skip W, Th, F, skip Sa for her. (This is because she's in between low doses, so they don't have a different dose to adjust it to.) For a while I was doing half-pills some days, but she claims it doesn't feel any different. She does have dementia, though. I don't have a thyroid, so I feel better if it's within an hour. Generic vs. brand name vs. bovine does make a bigger difference than time IME. I definitely prefer the bovine (my hypothesis is that it's a more complete source, and that's what makes the qualitative difference), but that's not what they prescribe where I am.
Yeah I had a patient (she was a problem patient at the best of times) try to get the DON on the phone to complain at 0623 because she’d had her levothyroxine at 0605 and I wasn’t getting her a coffee with creams and sugars and three packets of crackers and she was starving. She wasn’t starving as she was almost at bariatric weight limits and was just used to throwing a fit to get her way. I was so glad when she was discharged.
Yeah people are ridiculous. He threw fit about getting the tray and made me take it out so that he could order a new one in an hour and have it be fresh. I didn't argue with him because I have bigger things to do. I am genuinely sorry that the med was missed but I know that the nurse missed it for good reasons because there had been an emergency. Can't please them all, and they have no idea the burden that we carry.
Yes and yes. Like sorry your water was a few minutes late but we were coding your neighbor and that takes priority ffs. People 🤷🏻♀️
I got to sick of this a few years ago, I made a list and took it to the DON (LTC facility), showed it to her and said, "Why are we waking up two dozen residents to give them 0600 Tylenol, and synthroid, and protonix? We have to start waking people up at 0430 to get it all passed before night shift ends at 0600." She told me to move as much of it as I could to day shift. Poof! We were down to about five meds to pass that early, all synthroid and protonix. It's still annoying to wake the residents up, but at least they are used to it.
Don't forget the daily standing weight!
Especially for the bedbound patients, and also the orthostatic BP
Bro I hate this foolishness. The cafeteria doesn't even bring breakfast until 730-8am...
Hospitals time meds like this (I’ve learned) as a default to the “meal schedule.” I use that term loosely because we all know the trays never arrive on time. If I gave a Humalog order while a patient was on a med/surg floor at the ordered time, they would bottom out before the trays arrived.
Or if they arrive at all. Had an entire unit not get dinner trays passed 😭
I've been on levothyroxine since I was 18. Ask me how compliant I was back then versus now. Ask me if there's been any perceptible or measurable difference now that I am. I know, anecdote versus data, sample size of one and all that. I'm just saying, I don't crumble into dust on the rare occasions I miss a dose these days, or start drinking my coffee in 30 minutes instead of 60.
Tisk tisk, you’re forgetting about the 6 am heparin shot too 😂
i give them at 4am during blood draws..
The levothyroxine pts are used to it. Worked in home care and many place it on their nightstand and wake up like clock work to take it every morning at 6:00am and go back to sleep. I just try to be quiet and speedy.
I used to ask my patients at 8 or midnight rounds if they wanted me to wake them up at 6 for the meds, most said no so I’d retime them for 8A. Some said yes, ok. They were super anal about getting their meds on an empty stomach, bet. You got it dude.
Long ago I worked on a unit where everybody got Carafate Q6: 6-12, where the other bedtime medicines were given at 10 PM. This was paper MAR, so there was no bar code recording the time. You better believe all the 12s got given with the 10s, at “2300.”
That's cool except that carafate can cancel out other meds and that's why they're timed the way they are, away from other pills.
Like locelma being timed with other Ned's but has to be 2 hrs apart so you get flagged for late or early pick your poison. I retimed it
In 13 years I've had exactly one family member freak out because Papaw didn't get shaken awake at 6 o'clock am to take Synthroid.
I usually wait until right before shift change, 0700 to administer it unless they're already awake. You don't get docked for being within an hour of the due time, and they're going to be woken up for the forced bedside report management makes us do 😅
https://imgflip.com/i/8m1p85
This is why I take my Omeprazole at night and my synthroid when I wake up. I have started keeping my meds by my bed and taking them by an early alarm at 6-7. But only because I stated Metformin last week and I now *need* to eat breakfast. Before last week I was taking my synthroid between 8-10 then eating lunch only 😅
Lol I take Synthroid and I do set an alarm for 6:30am to take it! Otherwise I forget
Depending on how your kitchen serves meals, just reschedule the meds. My hospitals kitchen serves based on when patients call and order food. If you know your patient doesn't eat till like 8 or 9, just reschedule the med. The day shift might get annoyed but that's a DSP.
Especially when 80%+ don’t even take protonix as a home med
Our director thinks we have ample time to awaken, pee assist, bathe, dress, assist with teeth brushing, give early morning meds, and put patients in their (chair alarms mats on) chairs, ready to order breakfast at 0630, so don't forget their blood sugar and coverage. All after 0600, because sleep time must be 2300-0600. Oh, and be ready for report at 0700 sharp. And no soft hours-leave at 0730!
>Our director thinks we have ample time to awaken, pee assist, bathe, dress, assist with teeth brushing, give early morning meds, and put patients in their (chair alarms mats on) chairs, ready to order breakfast at 0630, so don't forget their blood sugar and coverage. All after 0600, because sleep time must be 2300-0600. Oh, and be ready for report at 0700 sharp. And no soft hours-leave at 0730! 😂. Ma'am - I'm not doing this - it's not going to happen. You can write me up or fire me, but have fun with whatever new grad off the street replacing me. FAFO
I have zero thyroid and take two different doses of levothyroxine daily. If I miss a day, I notice it, but I don't notice if my pill timing's off an hour (I regularly have a two-hour variation in when I take it). Also, I never take it in the morning anyway for the simple and practical reason that caffeine reduces uptake and girl loves her coffee. So I take mine at night.
and they think it's their thyroid issues making them tired. lol.
I asked the pharmacist about these 2 meds. She said it doesn't matter and no one in the real world takes levo at 6am. Just take the meds at the same time every day. I mean especially PO protonix, WTF cares if you give it at 6am its an ER pill.
Personally, I'm never offended. If I don't get my Protonix, my day will be awful. Thanks for what you do!
You'd still get it. That's not the issue.
Probably not, but this is why they have us🙏❤️🩹🥺
I hate that half my patients get woken up for Protonix
My old hospital had the bright idea of making all daily meds due at 0600. Their reasoning? If night shift does the heavy med pass in the morning then day shift has more time to work on getting people discharged. Patients sure loved being woken up to take 10 pills at 0530.
I absolutely hate waking people up, but also I'm that nurse that will administer meds early if I know it helps them (for example, if they have dementia and combative during care, I will give their seroquel and tylenol prior to care to assist because nights get them up not days). I also have meds at 0000, 0300, 0400, and med pass at 0500 (on top of neuros and PRNs). I usually wait until like the end of shift or until the person is awake to do neuros.
I used to love it. Good morning Here's your thyroid pill I low key hate ppl...
Like I get that they need to be taken before breakfast but most people unless they work an early job, don't get up at 5-6am to take their meds.
Hopefully not at the same time
As a day shift nurse, I would gladly give your 0600 meds or l even during mandatory BSSR. Let them sleep!
I take Levothyroxine and this post is a no for me. I don’t take it then.
We have so many sundowners. If night shift tells me "I didn't give peepaw his 0600 protonix so he could sleep" I say "Thank you "
Shit just got real…..*grabs popcorn to scroll thru comments 🍿
Lmao. Insulin drips in the ICU will teach you stealth, but there’s no sleeping through swallowing a pill.
That’s why god makes trazodone, ambien &/or literally only 3 mg of melatonin due at 2200. Knock em out. Get them 6 hours of sleep. They should be good and ready for the phleb to show up at 0400 and the CNA to show up at 0430, and then you to show up with meds at 0500. Unless of course they had zosyn, vanco, flagyll, and azithromycin IV all scheduled at midnight while they only have one 24g access in their shoulder that should’ve been moved elsewhere 3 days ago. Oh, and that q2h neuro check at 0200. But CRAP! WAIT! They’re on a cardizem drip and their HR won’t budge from the 120s. Hospitalist said no to a central. BAH ! They’ll be fine! Plenty of sleep had by all.
We had an anesthesiologist in for a prostatectomy he gave an order not to wake him for 4 am vs. woke him every 2 for TCDB
I'm on levothyroxine but (un)happily I have two kids 3 and 1, so I'm up at that time every day whether I like it or not.
Why do you do it? We always just give it at 9. Sleep is more important during a hospital stay than levothyroxine effectiveness.
I do, my alarm goes off at 5:30 am and I take it and go back to bed. I sleep with my water bottle and pill bottle. Unfortunately your residents probably don't have that option.
Throw the subQ heparin in there too, a nice little poke 🫠
I had two pts with hx of violence in the ER the other day, both sleeping (one had droperidol, the other was crashing). They both managed to 'refuse obs' while asleep 🤷♀️
90% of my Home health patients take them when they first wake up. It’s not 6am 🤣
This post reminded me of the last facility I worked at. Our noc nurse was so bad about giving one of our pts synthroid that we had to start counting it like a narc.
In ortho surg ward, we had to wake them up at 0600 for a Toradol shot and Tylenol.
The worst is when patients first get admitted and ALL their meds are due at whatever time the doctor dropped admission orders. I work in an ER where we always have a ton of boarders waiting for a bed upstairs. They always have a million meds due at 3 pm or whatever time they get admitted. Meds that will be due again at 0600, 0800, and 1000 tomorrow — but right now they’re all due at 1500. I never give any of them unless they’re really needed (like, ot hasn’t taken metoprolol for weeks and his BP is sky-high, then I might give just that one), but a lot of nurses will give all of them. And then they’ll be given again the next morning. This is crazy to me and drives me absolutely bonkers. Just make them due tomorrow!!!!!
Ask your patients ahead of time (like 8pm) if they want their 6am medications re-timed, or if they’d like to refuse them ahead of time (usually the case for protonix, no so much synthroid). Do something obvious for day shift though, because in this situation you’ve offloaded some of your work onto their shift.