New to Rehab Nursing

[RNikkiF]

I will be starting a new position at an independent inpatient rehabilitation hospital soon. I currently work at an LTACH/Rehab Hospital. The pace that I am currently used to is very fast. We have anywhere from 4 to 8 patients (10 on a REALLY bad day!) that range anywhere from borderline unstable IMCU patients to straight rehabilitation patients to vent, tube feed, critical drips, PICCs, Hickmans, implanted ports, TBI/ABI, MVA, CVA, DM, anything respiratory, etc. We have lots of foleys, IVs, complex wounds, etc. It is a very fast paced environment.

I have never worked in a facility whose only focus is Rehab. I don't really know much about the pace of the day, or what a typical day may look like. This isn't subacute. Can anyone who currently works in an acute rehab facility give me a general idea of what to expect on a day to day basis? All of the patients must be able to do a minimum of 3 hrs therapy a day and the ratio is typically 4 to 6 from what I have been told.

I'm worried that I'll lose some of my technical skills (IVs, tube feed, wounds, etc.) and honestly, I AM looking for a slower pace than what I am in now but I'm worried that it is going to be a drastic change and that I may get bored. Don't get me wrong. I know that critical thinking is crucial in rehab and I will be providing lots of patient and family education (which I LOVE to do), so I know it isn't like I'm not going to be doing anything, it is just that I think that I'm not going to be using as many technical skills.

In addition, it sounds like there is a much greater focus on FIM assessments than my current facility has. Because we aren't straight rehab, the nurses only do part of the FIM assessment and our therapists do the rest. Do the nurses do the entire FIM assessment at rehab hospitals? Are nurses solely responsible for assisting all of the patients with ADLs? I am currently used to CNAs assisting with the majority of ADLs unless a patient needs to make accommodations, in which case therapy goes to the patient's room every morning to assist them.

If anyone can give me some insight into acute rehab, I would appreciate it! Thanks!

[TheCommuter, BSN, RN]

I currently work at a freestanding rehab hospital, but with much higher ratios. On days and nights it's one nurse for every 7 to 11 patients. I work the night shift. Each nurse is paired with a CNA/tech to care for patients as a team. Personally, I wouldn't want to do ADLs or total care on anybody.

You will not lose your technical skills. We start IVs, administer blood products, deal with complicated wounds, tube feedings, TPN, central lines, PICCs, Foley insertions, etc. I doubt you'll get bored because day shift tends to be fast and furious. I will remain on nights because I cannot handle the pace of days.

At my workplace nurses do FIMs every shift for the first 72 hours of the patient's stay, then they do a FIM within 24 hours of discharge.

[Boog'sCRRN246, RN]

Please don't expect inpatient rehab to be a floor with a SLOWER pace. You will not be bored and you will not lose your skills. Inpatient rehab is inpatient for a reason - ideally, the patients are medically stable, but honestly, there has to be a certain amount of medical instability for them to even qualify for admission. They have to have something going on that can't be managed at a lower level of care, like a SNF or home health. So, minus the vents, everything you're already dealing with at the LTACH is what you will be dealing with in inpatient rehab.

Four to six patients is an appropriate nurse/patient ratio for day shift. I'm sure you're familiar with not only having to manage physician's demands, but therapists as well. As far as ADLs, when those are not being performed with OT, it is the nursing staff's responsibility. When I was on the floor, the CNAs normally did morning ADLs while the RNs passed morning meds and assisted as needed. Hopefully you will not ever be expected to perform primary nursing on a rehab unit. It's just not possible, nor is it safe, especially with patients who are max-total A x2-3 for transfers.

And finally, FIM scores. FIM scores are the bread and butter of inpatient rehab. It is how the unit/facility gets paid. Patients have to demonstrate functional gains that are quantified by FIM scores. On my unit, if nursing staff showers a patient, then nursing staff are the ones to do that FIM for that shift. Nursing did FIMs every shift, although, like The Commuter mentioned, the only ones that count to show gains are the first 72 hours and the last 24 hours.

There is so much more to a day on rehab, but I'm sure you don't want to read a novel. Good luck!

[bridgetteRN]

BoogsCRRN, you did a fantastic job of explaining! When people who aren't familiar with rehab nursing ask what I do, I may have to repeat verbatim what you wrote, thank you!!!!

[WittySarcasm, BSN]

I agree with everything BoogsCRRN said. You won't loose skills. On my rehab unit we give blood, deal with complex wounds, have feeding tubes, PICCS, start IVs, turn q2 hours.

Though it sucks sometimes we get stuck with primary care nursing which makes it for a busy day. But almost everyone is either a max assist, if not then we have a rule that no one can walk without a staff member. This is because you're probably too weak to walk. Or too high of a fall risk, there's a reason you're at rehab.

Fims is important because that is how the unit gets paid by insurance. You have to show some how these patients are getting better. They are easy, our unit only does the pressure sores, bowel and bladder parts. The rest is for the different therapies.

[1KoolRN]

Thanks for starting this thread!! And thanks to everyone for all the great advice!! I recently started days in a free standing acute rehab facility and absolutely LOVE it so far! I graduated in May '13 and spent my first 8 months doing nights on a med/surg unit. That was so insanely stressful, but I gained tons of invaluable experience! This new job has been a breath of fresh air, regardless of how busy it can get! I wanted to post a comment I left on another thread, in case anyone had some ideas to share ~ All of the advice given so far has been wonderful and so much appreciated!! Thanks again and also, in advance, to future posters

I would also love to hear how y'all organize your day. I work days and have been trying to put a brain together myself. We have 2 different computer programs: 1 for meds, orders, labs, records, etc and 1 specifically for assessments. We also update kardexes throughout the day, make a copy of each and then write up our reports for shift change on the back. So, there's already alot to keep up with! I've been experimenting with a task sheet with room to write down changes, new orders, etc. Just feels like there's still so much to keep up with. Also, if anyone has any tips or pointers for CBE, I would love you forever!! I was told day shift always needs to do a full assessment and address everything, regardless if there weren't any changes. Time management has been a big focus for me, as I'm sure it is for most nurses (esp new ones). Thanks so much for all the advice!!