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jab1432 BSN

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  1. jab1432

    3rd shift nursing assessments

    I ended up leaving the rehab unit because, in part, of too many conflicting unit policies/hospital policies/manager policies... I got tired of dealing with either reasonably grumpy patients or unreasonably grumpy oncoming nurses. I grew tired of being expected of not getting any solid/clear answers from management, did not want to wake my patients unnecessarily, but did not feel comfortable not knowing my patients (so I woke every new patient or every patient if my assignment changed). I did have CNA's who could alert me if the patients got up to pee, but typically they were stretched so thin they didn't have time to do anything other than go from room-to-room answering call lights and bed-alarms all night. If my memory serves me correctly only about 1/2 of my patients got up through the night on most nights. Everyone woke up between 0500 and 0600... but as previously stated this was too late to be doing/charting assessments...
  2. jab1432

    Which Nursing Jobs are the Least Stressful?

    I agree with your assessment neeka8. To add some detail as to why I found rehab to be a high-stress job: In-patient rehab is nowhere near the bottom of the ladder in terms of stress. You typically have more patients and less staff than other units. The patients are supposed to be "medically cleared for rehab" but whoever is clearing these patients for rehab must be on crack. I worked in-patient rehab for a year in a hospital and hated it. 8-12 patients sounds right, tending to lean more towards 10-12 but on occasion you can have 14-16 (as in about once a month in the hospital I was at). If you are unlucky enough to be on 3rd shift (11p-7a) then you will be dealing with many sun-downer patients with considerably less staff than the other shifts... and some nights you will spend your ENTIRE night running from one bed-alarm to the next... no exaggeration. We often had to get patients in wheelchairs and sit them in the nursing station and then deal with getting scolded by the someone from the other shift (sometimes the manager, sometimes the oncoming shift, sometimes PT/OT) since the patients didn't get their rest, to which you have to rebuke this person and tell them that either the patient doesn't get sleep and may not do well today in rehab, or they fall and break their head open and the hospital gets sued... funny thing is when you do this sometimes when you come out of another patient's room you find the patient in the wheelchair butt-naked (because they are confused and removed their clothing) and then you have to throw a blanket over them, wheel them back to their room, dress them, try in vain to persuade them to go to sleep, and wheel them back into the nursing station... rinse and repeat. I worked in the ICU before this and at least in that particular ICU I found the job to be low-stress (though it was a 36 bed ICU with residents who spent the entire night awake on the unit and a dedicated charge nurse who took no patients and just helped out and responded to codes)... and I worked cardiac-telemetry after this and found it to be equally stressful though in different ways. Day shift rehab consisted of trying to get assessments done, round with doctors, assist with med-pass and wound-care, bath before PT, daily patient review-board meetings, admissions, and discharges all while trying to work around PT/OT's schedule because if, God forbid, the patient is on the crapper when PT comes to get them they will say "patient not ready for PT due to nursing" and if the patient isn't able to be fitted back into their schedule to fullfill their full 3 hours of PT/OT between 0830 and 1600 then the hospital may not get paid for their ENTIRE STAY and of course you'll be hearing about it from your manager. Evening shift on rehab was about the same as day-shift minus working around PT's schedule, although now you are "cleaning up the mess" from day-shift since it is absolute chaos during the day since you pretty much are task-focused... which means calling doctors (none of which want to take accountability for the patient and you have to call 2-4 before choosing one to get snippy with and force them to give you orders), finishing discharges and admissions which are sometimes not even touched or done completely wrong... assisting with showers, getting the patients ready for bed which means you have to assist them out of the hospital gown and into normal clothes. Night shift on rehab is different in you usually (but not always) don't have any admissions or discharges. However, you are expected to WAKE the sleeping patient, de-clothe them for your assessment, then reclothe them. This in-of-itself is highly stressful as you can imagine how happy you'd be to get awoken between 11:30pm and (however long it takes you to assess 8-16 patients)... getting lights thrown on, asked stupid questions, rolled to your side, wounds assessed, etc... after having an exhausting day of rehab and knowing you will be awoken between 5am-6am for vitals and meds... not to mention how often they get awoken by their "neighbors" jumping out of bed and setting off alarms. Night shift is the ultimate "clean-up crew" because you are expected to go through the entire day's paperwork, find missing orders that weren't completed, find out of consulted physicians ever saw the patient (and try to read their chicken-scratch if you are in a hospital that still uses paper charting)... get the charts ready for the next day, ensure all ordered meds are on the MAR, ensure all D/C'd or held meds were properly D/C'd or held, obtain samples/specimens needed for testing, ensure orders were put in the computer properly and often do it yourself because you won't have a secretary... pass pain pills constantly throughout the night to patients who are usually only awake enough to ask for them (which at first you don't do but afterawhile you stop giving a crap and give them against your better judgement because you grow tired of the patients whining/b*tching about not getting their meds and then PT/OT gripes at you for having "snowed" your patients [one time a RN on night-shift called a rapid response and gave narcan to a patient she snowed because they wouldn't wake up enough to talk.... but I had that patient before and she would wake up, scream holler b*tich cry and moan, threaten suits, etc... if she did not get her pain meds... and or course after the narcan she did all of the above), not to mention you have 30 minutes or less (depending on how long report was) to check and pass sleeping medications since most institutions don't let you do so after midnight since it will make them drowsy for PT/OT because evening shift doesn't have to deal with the consequences of not passing sleeping meds so they don't think about it and don't always do it. Not to mention, at least on my rehab unit, you are working with a lot of burnt-out staff who have been on rehab too long and lost their normal nursing skills so when it is time to do anything even slightly invasive such as starting an IV, foley irrigation, changing a PICC dressing or pretty much anything that an experienced nurse should be able to do with their eyes closed... they are going to cry for you to help them... and if they ask you about a patient who "isn't doing too well" you had better go assess the patient yourself or you will be dealing with a code or a dead patient. Not to mention all the rehab-specific paperwork... I know all other floors have their caveats... but rehab is a different beast entirely and, at least in my opinion, you have too many patients that you are solely responsible for than is safe.
  3. jab1432

    3rd shift nursing assessments

    Thank you for your replies. Vital signs are only checked q-shift for the first 3 days the patient is on the unit, afterwards it is just once per day. The policy is where I am confused. I'm told that even though we are in the hospital, we are not part of the hospital. When a patient comes to the unit from the hospital they need all new admission paperwork... and to go to another unit they need a discharge order... not like in other units where they just need transfer orders. The few nurses who come in for the 7p-7a shift only have to assess the patient once at the beginning of their shift and don't have to reassess during the 11p-7a portion. I'm told I'm expected "to conduct complete assessments q-shift" as part of the "hospital guidelines"... yet I am told I need to not interrupt their sleep as much as possible. It typically takes me 3-5 hours to do all the chart-checks and MAR checks (depending on how many call lights go off and how many people request medication). So typically I try to have all my assessments and patient-specific paperwork completed and documented within the first 3-4 hours otherwise I will run out of time and not be able to complete everything before morning comes... We rarely have IV or PICC lines on the floor, but I do check those and flush them every shift (even though a morning shift nurse said it only has to be done daily). The problem I have about delaying assessment until they wake up is at least 1/3-1/2 sleep through the night most nights... which means at 0600 when I have to start my medication passes, everyone is waking up at once, requesting toileting, pain pills, etc... and I only have an hour to pass pills on nearly every patient as well as meet their requests... I simply don't have time to deal with assessments at the end of my shift... plus the morning shift will be coming in to do assessments shortly after anyway. Again, thank you for your replies, I suppose I will need to talk with my manager (who isn't a nurse) to find out specifically what sorts of assessments are required on night shift. For the sleeping patients who are stable and CVA (no dressings) I've just been doing sleeping assessments (resting with eyes shut, breathing even and unlabored, continue to monitor).
  4. jab1432

    3rd shift nursing assessments

    I am a new-grad and recently started 3rd shift (2300-0730) on a rehab floor. The patients are all very stable. I have a question about the assessments. I've asked many nurses and all have different opinions... so I thought I would best be served by getting a general consensus on an online forum. I arrive on the unit at 11pm, I usually don't get out of report until 11:30-midnight. I have 8-12 patients per night. Generally every patient except one or two is asleep when I come on. They've all had a hard day's work at rehab (we give at least 3 hours of rehab per day except one or two rest days per week). I sometimes get chewed out by some morning nurses for not looking at surgical wound-sites during my shift. These patients did their time on med-surg and observation units. Many morning nurses don't care because they know we don't have scheduled dressing changes at night. I wonder if it is really necessary to wake up every patient to look at their wounds (they wear their normal clothes at night, so this would mean wake up, sit up, remove articles of clothing, remove dressings if not OTA, and then put them back to bed). It seems like an unnecessary burden to both the patients and me for me to look at their wounds when their wounds have been fine since surgery. Even if their wounds are not fine, on night shift there aren't any interventions we do since they are already on antibiotics and scheduled (during 1st and 2nd shift) dressing changes. Is it necessary to wake fully clothed patients after being worn out by rehabbing for 3 hours just to look at a wound I can do nothing about?