I am starting a new job soon where I will be working straight nights. Right now I work 3-11.
I've picked up a few night shifts, and one thing that I've found I dislike a lot is having to wake patients up for assessments. I have to turn on the lights, pull their warm covers off of them, ask them a bunch of questions, make them move around, make them use the incentive spirometer etc etc. Patients have gotten annoyed with me, or have fallen asleep while I was assessing them. Family members staying the night, I can imagine, are probably less than thrilled when the nurse comes in and turns on the lights and starts chatting etc. The few nights that I've worked, I found myself apologizing for waking them up, and hurrying through my assessment.
What I want to know is, how do you night nurses deal with this? I've heard some night nurses say they use a penlight instead of turning on the lights...but I think it would be harder to get a good assessment this way. Or even one nurse on my floor said that they give the patients a couple hours to wake up on their own and push the call light for something and then she'll go in and assess. I kind of like to get my assessments done asap.
I think nights will be hard because I like to get to know my patients, and not feel like I am constantly disrupting their sleep. But it's all that I could hired for right now....Some words of wisdom on how you make it work would help!
I work 12 hr shifts so I start assessing patients between 22-2300 and since I was already there at 1900 I know whose stable or not. If they are stable I let them sleep, but sometimes you get busy and then have to rush to finish the assessments before the shift is over because someone went bad or you got an admit. Only one time do I remember a patient having a problem before I had a chance to assess them, that person had a syncopal issue with blood pressure, heart rate issue at 4AM. We were able to stabilize them, but that could happen whether you had already assessed them or not. Some of my coworkers just go from room to room and wake them just to be on the safe side.
I still feel comfortable letting them sleep if I wasn't able to assess them right away due to experience re patient stability and also we have tele monitors so that gives you an added way to monitor your patients!
That said, every nurse develops there own routine of doing things. Sometimes you have to wake them anyway ie to give them antibiotics or draw blood so I try to minimize interruptions and let them get back to sleep as soon as possible!
I work 12 hr shifts so I start assessing patients between 22-2300 and since I was already there at 1900 I know whose stable or not. If they are stable I let them sleep, but sometimes you get busy and then have to rush to finish the assessments before the shift is over because someone went bad or you got an admit. Only one time do I remember a patient having a problem before I had a chance to assess them, that person had a syncopal issue with blood pressure, heart rate issue at 4AM. We were able to stabilize them, but that could happen whether you had already assessed them or not. Some of my coworkers just go from room to room and wake them just to be on the safe side.
Not trying to sound rude, but seeing as you work critical care (jeez, even if it was not critical care!), how do you manage to get to 0400 without doing an assessment?! Or even 2300 for that matter!!! What am I missing here?
And no offense, but the tele monitor is no substitute for an assessment. Sure it'll tell you that your patient's still alive, and some hemodynamics, but that's about it.
we do not define death as emd/pulselessness since u brought it up
the point is, an spo2 monitor and a heart monitor do add more reassurance, as in the case of sp02 we can set the alarm to 94% or what have u as the low alarm, and it only works if there is a pulse
and in the case of cardiac monitor, we can also narrow the alarm settings, and we usually can get an indication of distress before EMD shows itself
but in either case, it is more benefiicial than not having either device in the first place, which may have been the point made by the post-er.
one should, however, not become complacent because of these facts, and nothing replaces frequent room rounds
I get to work early- 2230 or so, I read some notes on my patients, I get report as soon as the evening nurse can give it to me- if my patient is awake I warn them that in the next hour or so I'll be in to do an assessment. If I have to wake someone I generally apologize for waking them up, but I want to have a quick listen and feel and then I'll let them be. If they have scheduled meds, like scheduled APAP or Heparin/Lovenox in the middle of the night I generally ask them if they want me to wake them up for it. If they're very inactive or not really walkers I'll just give the Hep or Lovenox because I'd be more worried about DVT on someone who is bedbound. If they have a scheduled antibiotic or other medication then I tell them I'll be waking them for that at such and such a time. Then I tell them I'll be peeking in on them every hour, I won't wake them up unless it's necessary (like if I tele lead comes off or they alarm).
Often, if I can swing it, I try to tail behind the PCA when they do their vitals- since we have an hour leeway and following for meds I take any midnight meds with me and just give them at 2330, 2345.
I'm still pretty new at it- I've had times where I get there and I've already got ER on the line calling for report on an admit who they want to get rid of :) or I'll get on shift and right away I have a patient on the call light wanting 20 things that I can't give them. I have a theory that if anything is going to go wrong, if a patient is going to crump, it's going to be right at shift change!
If they have scheduled meds, like scheduled APAP or Heparin/Lovenox in the middle of the night I generally ask them if they want me to wake them up for it. If they're very inactive or not really walkers I'll just give the Hep or Lovenox because I'd be more worried about DVT on someone who is bedbound.
I had a walking 4x/day, completely independent with ADL's, no mobility issues patient throw a PE on me before; turns out, he hated the shots and since he was so active, some nurses were letting doses slide. Well, sure learned the hard way. Since then, I never hold any Heparin/Lovenox, etc... just offering some advice after our mistake
i get to work early- 2230 or so, i read some notes on my patients, i get report as soon as the evening nurse can give it to me- if my patient is awake i warn them that in the next hour or so i'll be in to do an assessment. if i have to wake someone i generally apologize for waking them up, but i want to have a quick listen and feel and then i'll let them be. if they have scheduled meds, like scheduled apap or heparin/lovenox in the middle of the night i generally ask them if they want me to wake them up for it. if they're very inactive or not really walkers i'll just give the hep or lovenox because i'd be more worried about dvt on someone who is bedbound. if they have a scheduled antibiotic or other medication then i tell them i'll be waking them for that at such and such a time. then i tell them i'll be peeking in on them every hour, i won't wake them up unless it's necessary (like if i tele lead comes off or they alarm).
often, if i can swing it, i try to tail behind the pca when they do their vitals- since we have an hour leeway and following for meds i take any midnight meds with me and just give them at 2330, 2345.
i'm still pretty new at it- i've had times where i get there and i've already got er on the line calling for report on an admit who they want to get rid of :) or i'll get on shift and right away i have a patient on the call light wanting 20 things that i can't give them. i have a theory that if anything is going to go wrong, if a patient is going to crump, it's going to be right at shift change!
please rethink this. (see ashley's post also)
i was a walkie talkie at home, and threw multiple clots over an extended period of time in all tree lobes of my right lung pushing that lung into the apex of my heart causing ischemia d/t actual contact from the swelling. acute, subacute, and chronic. no history of dvts. nearly died. come to find out i had a hypercoagulopathy (non-specific- many panels drawn).
if someone isn't sick "enough" for round the clock care, they're called "discharges" :)
Tele doesn't even tell you the patient is alive - it only tells you that there is electrical activity in his or her heart...
OK....what am I missing? Some category of death with NSR????
I've seen the respiratory 'wave' still moving on someone (vent) with no pulse, but never seen someone "dead, with electrical activity" unless EMD, and that's sort of a technicality re: death from what I remember (just floated to a few ICUs- not one of my main areas of nursing).
But electrical activity in a dead person???? Help me understand :)
It's a little different for LTC though. If I need to wake them, I will. However, I try to let them sleep where I can, and do things when they are most awake. Dementia patients do much better with sleep. Otherwise, many of them are more agitated and disoriented during the day. Depends where you work.
This is very true. Aside from the SNF/Rehab areas, nursing homes are the resident's "home"...most assessments are ones of exclusion- if something seems off, that resident gets the appropriate resident; waking up a demented patient (aside from incontinent care and safety checks - bed alarms, bed heights/rails as appropriate, etc) is avoided- it's more of a walking through quietly, and listening or looking for chest rising and breathing.
The tube feed, trachs, etc are on their own schedule.
OK....what am I missing? Some category of death with NSR????
I've seen the respiratory 'wave' still moving on someone (vent) with no pulse, but never seen someone "dead, with electrical activity" unless EMD, and that's sort of a technicality re: death from what I remember (just floated to a few ICUs- not one of my main areas of nursing).
But electrical activity in a dead person???? Help me understand :)
It is as you described.
First, electrical mechanical disassociation is not a definition for legal death. It simply means that there is electrical activity without a pulse--of course, instead of feeling for a pulse, we should be auscaltating the heart sounds, as there will be no heart sounds without blood flow/pressures causing valvular events--this is true EMD
This is most common in a trauma patient wherein they are severely hypovolemic--and upon giving them lots of fluids, in addition to cpr, epi, atropine, transcutaneous/transvenous pacing, can frequently be reversed
There are other cases of EMD, frequently secondary to some other initial insult, and during the code the condition can present itself, amongst other scenarios (massive PE), but the beforementioned is more common
the post-er was possibly trying to say not to become complacent and put the patients life in just what a cardiac monitor is telling you, and then incorrectly associated EMD with not 'alive'
And with that I agree entirely.
There is no replacement for frequent assessments of your patients with your own eyeballs.
First, electrical mechanical disassociation is not a definition for legal death. It simply means that there is electrical activity without a pulse--of course, instead of feeling for a pulse, we should be auscaltating the heart sounds, as there will be no heart sounds without blood flow/pressures causing valvular events--this is true EMD
This is most common in a trauma patient wherein they are severely hypovolemic--and upon giving them lots of fluids, in addition to cpr, epi, atropine, transcutaneous/transvenous pacing, can frequently be reversed
There are other cases of EMD, frequently secondary to some other initial insult, and during the code the condition can present itself, amongst other scenarios (massive PE), but the beforementioned is more common
the post-er was possibly trying to say not to become complacent and put the patients life in just what a cardiac monitor is telling you, and then incorrectly associated EMD with not 'alive'
And with that I agree entirely.
There is no replacement for frequent assessments of your patients with your own eyeballs.
So, essentially those pesky patients with no BP, no resps, no palpable pulses, but that occasional auscultated 'lub.............^^^ dub...."so it SOUNDS like a "pulse" of about 4bpm....can't pronounce them, but they're not in Kansas anymore Those drove me nuts, mostly for the families --- took 'forever' to finalize that they were COMPLETELY gone ....
Except for the occasional float to neuro ICU, NICU, PICU, I didn't have the luxury of tele...if they were circling the drain, I was there either calling a code (we didn't have RRTs), or holding their hand/supporting the family. Nothing replaces actual assessment :)
I am coming off of a night shift so please excuse any poor thinking on my part. First of all, what is EMD? It sounds like what I know as PEA (pulseless electrical activity). And google says that it means emergency medical dispatcher...
Anyways I have always been under the impression that PEA very rarely looks like NSR, rather it usually looks like an advanced heart block or brady rhythm. Not saying that you should substitute tele for going in and looking at a patient, but I feel MUCH more comfortable if my patients are on tele, and if I have any question about their status I don't feel bad about putting them on tele until I can have a doctor come and look at them.
On my floor, getting my assessments done is rarely an issue because I work 12 hour shifts, and most of my patients are still awake at 1930 when I am done with report. When I pick up a patient at 2300 I will either wait for a medication that is due, or poke my head in to introduce myself and do a quick assessment. I put a lot of stock into rest for my patients, but if they put up a fuss then I calmly explain that they are in the hospital for a reason, and if something happened and I didn't have a good baseline for my shift then their care would be compromised. Except I would say it in a much less run-on-sentancy sort of way
brandy1017, ASN, RN
2,910 Posts
I work 12 hr shifts so I start assessing patients between 22-2300 and since I was already there at 1900 I know whose stable or not. If they are stable I let them sleep, but sometimes you get busy and then have to rush to finish the assessments before the shift is over because someone went bad or you got an admit. Only one time do I remember a patient having a problem before I had a chance to assess them, that person had a syncopal issue with blood pressure, heart rate issue at 4AM. We were able to stabilize them, but that could happen whether you had already assessed them or not. Some of my coworkers just go from room to room and wake them just to be on the safe side.
I still feel comfortable letting them sleep if I wasn't able to assess them right away due to experience re patient stability and also we have tele monitors so that gives you an added way to monitor your patients!
That said, every nurse develops there own routine of doing things. Sometimes you have to wake them anyway ie to give them antibiotics or draw blood so I try to minimize interruptions and let them get back to sleep as soon as possible!