Questions about Night shift

Davey Do · Oct 31, 2010

1. Certain problems can only be addressed by the attending during the day, as long as its not a major area of concern.

2. Limitations might be there be by calling the physician on call vs the attending: Full knowledge of the paticular pt/situation. It's up to the nurse to give any and all pertinent information.

3. The attendings do make comments about orders written by the on-call that is inappropriate for the patient. Let the attending deal with it.

4. Labs will you call on vs. leave for the attending (besides critical values) for the morning: Any of concern.

5. I know how the day shift works- Like when the patient can expect to see PT or other consults.

6. It is okay to administer antibiotics without waking a patient and informing them:They sign a consent for tx. Inform them prn.

7. Patients who ask for pain pills, a sleeping pill and something for their nerves: In a progressive order and to their hx. Try, e.g. pain pill, wait for an hour, sleeping pill, wait. Then antianxiety.

Dave

ReWritten · Oct 31, 2010

Did you just get a night shift position and are curious? I've been working for only 3 months on a med-surg floor in a country hospital, so I'll share how it works at our place...

1. Do you find that certain problems can only be addressed by the attending during the day? You learn to prioritize of what is important. My patient last night wanted Dulcolax at 1 in the morning. I'm not going to call and wake up a doctor for that. That can wait for the morning. If our patients need to be restrained, we go ahead and do it and make sure the doctor signs off in the morning. If it's not something critical, it can wait.

2. What limitations might there be by calling the physician on call vs the attending? The only one I know of, the doctor doesn't know the patient. But then again, not all the attending doctors can remember their own patients either... When you call, you just tell them about the patient to get an idea for an order, and sometimes you can make suggestions of what to be ordered. The attending can change it in the morning if he/she desires.

3. Has the attending made comments about orders written by the on-call that is inappropriate for the patient? Nothing I've seen. They'll come by and just change the order if they don't like it. I have seen "arguments" written in orders between doctors, so that's kind of funny...

4. What labs will you call on vs. leave for the attending (besides critical values) for the morning. We only call on critical values or if the doctor specifically states in orders to call him about results.

5. Do you know how the day shift works- Like when the patient can expect to see PT or other consults? Me personally, not really. I just know roughly when breakfast is served, when the doctors arrive on the floor, and typically the patient will know what time they'll have surgery.

6. Is it okay to administer antibiotics without waking a patient and informing them? Yes. They're scheduled... I'm in there at all all sorts of crazy times to give it to them. I try not to wake the patient, so I'll come in, hang it, and leave. Very rarely is a patient going to refuse an antibiotic, they know they need it.

7. Patients who ask for pain pills, a sleeping pill and something for their nerves- how do you approach that? If it's ordered for them, give it to them. If it's not ordered, call the doctor to get an order. Don't leave your patient there suffering just because it's not on their MAR. However, if it's not time to get another pain pill, we'll try to make the patient more comfortable, or give them a cool wet wash cloth to try and ease them. If they already had a sleeping pill, see if they can have a pain pill that might help.

divaRN* · Oct 31, 2010

]The MDs covering night shift are mainly there for emergencies. Usually they will not write a PRN or standing medication order. However they will write a one time order. They will not make changes to the POC for a patient as they are not the primary MDs for the patient. The common lab work we run during the night are PTTs for heparin gtts, cardiac enzymes to r/o MI and CBCs if someone is bleeding or receiving blood. We will call if those are abnormal. If there is an emergency and a lot of lab work is ordered the MD is usually looking for those results. However I always like to give them an fyi saying the results are up if they are busy and happened to miss it. I have a small idea of how the day shift works but I can never give exact times to patients. I feel even day shift RNs can not give exact times either. If a pt is due for IV abx in the middle of the night say 0300. I will notify them of this when I first meet them. If they have IVF fluid running I inform them that I will just hook up the ABX to the existing line so they will not have to be woken up. I have never had a patient who had a problem with this. However if they are not on IVF I do need to wake them up. I tell them I will wake them up so i can get access to their IV and then they can go back to sleep. Patients do not like getting woken up in the middle of the night for medications so I try to make it as quick as possible. If a patient wants something for sleep, pain or anxiety and nothing is ordered I first look at their home meds or ask them what they normally take. I then look at medications they have been administered while in the hospital to see if they received a one time dose the night before. Then I will call the MD with this information, make a recomendation and obtain a one time order. I will then let the patient know this is a one time order and if they want to keep receiving this medication in the hospital they need to discuss it with their primary team in the morning.

NewTexasRN · Oct 31, 2010

1. Do you find that certain problems can only be addressed by the attending during the day?

Yes, but it depends on what it is. For example if it's a problem with physical therapy it will have to wait because they work on day shift. It really depends on the situation. Night shift doesn't always have a secretary, aide and other things. Some staff only work on day shift.

2. What limitations might there be by calling the physician on call vs the attending?

Sometimes this can be an obstacle for me. The on-call physician might be conservative and it's frustrating because you know that the primary physician knows the pt better and they will give orders for what the pt needs. Some PA's and Nurse practitioner might say let's wait in the morning, but something needs to be done right away. Sometimes the on-call person is not really familiar with case. One time I had a pt in going in and out of v-tach. I called the on call physician and he said, "What do you want me do?" I was shocked. I knew the primary doctor would have never said that.

3. Has the attending made comments about orders written by the on-call that is inappropriate for the patient?

From my experience I would have to say no. Most of the time the on-call person tends to be conservative.

4. What labs will you call on vs. leave for the attending (besides critical values) for the morning.

If they request for you to leave all lab results for them some times I will put them in the front of the chart or the progress notes. If a pt has been in the hospital for a long time and they have critical labs they may want to keep an eye on them so you can leave it for the morning always run it over with the charge nurse. Sometimes it's a critical lab value, but it's slowly coming down from the previous day and the attending or the on call is already aware so you can also leave it for the morning. But it all depends on the situation. Just remember to protect your pt's and your license by doing what's appropriate even it will annoy them if you call.

5. Do you know how the day shift works- Like when the patient can expect to see PT or other consults?

Generally, it depends. I work on a ortho unit. So day shift routine to me is like a different world. I really don't know when PT comes to work with the pt or when some doctors go to see their pt's. But it varies in each unit. It really depends on where you work. To be able to educate the pt's some nurses will expand their knowledge by asking day shift.

6. Is it okay to administer antibiotics without waking a patient and informing them?

To be technical about it, you should never really touch a pt without their permission otherwise it can be battery. If you are providing ANY kind of treatment to the pt you are really supposed to explain what and why you are doing it.

7. Patients who ask for pain pills, a sleeping pill and something for their nerves- how do you approach that?

It really depends on the unit. For ortho, yes obviously the pt is going to need pain meds. For some scenarios the pt might be there for another medical reason and you might have to call for pain or sleeping pills. You have to assess the situation ALWAYS before you call the physician. Look at your pt. What are their vitals. If the pt respirations are 12 are you going to ask pain meds? Think. What about allergies and past medical history? Everything really depends the pt and situation at hand. There's a hundred different scenarios.

Hope this helps!

Jilissa · Oct 31, 2010

Hey I don’t have the most experience out there but hopefully this helps some.

1.I’m not quite sure what you mean by this question, but if there is a problem with a patient and you need the attending during nights I think (although they may not like it) they should be contacted because you both are responsible for the patient and the problem should be addressed when it occurs (things like an I&O cath can be ordered by the on call, but more serious issues should be addressed asap).

5. OTPT, at my work starts as early as 0830, this could be different for other hospitals. It also depends if a patient is doing ADL’s with them, because in that case they may come earlier.

6. I think you’re going to get different answers from people about this one. In my opinion you should let them know that you are starting their antibiotics because you want to assess for reactions (in case). You also might end up waking them up when you double check their armband to ensure that it’s the right patient anyway.

7.When you have patients who are asking for all of those medications you want to know why..why do they need it? I think breaking it down, ask them where the pain is and suggest other means of relief aside from medication (unless they’ve had surgery, chronic issues, etc) something like a warm blanket i.e. for a sore leg (this can also aide them in sleeping)..it all depends on where the pain is coming from and if it could be avoided prior to “bedtime” (should their feet be elevated while up during the day to avoid pain from swelling later?) Then address the sleeping, why? Is it too loud, do they need their curtain closed/door shut...what is their routine at home, maybe their sleep pattern has been thrown off, or they are worried about something...Some patients just need someone to talk to and explain what is going on with them and the hospital, etc. As for the anxiety, it’s common for people to be anxious when in the hospital, is it a previous issue or did it start when they came in...I know this seems like a lot to address on a night shift but I guess it’s better to go at the situation while it’s happening as opposed to another time? Just don’t go in with the mindset that they don’t need all of these pills and one, two or all shouldn’t be needed, because they very well may be needed.

Tepidorchid · Oct 31, 2010

Thanks for these answers- its helping me understand these questions which have boggled me for a while- they're rather subjective.

As far as the last question:

7. Patients who ask for pain pills, a sleeping pill and something for their nerves- how do you approach that?

I was looking to understand if I can give these medications together or if it's better to wait. They're all sedatives and our system allows us to give them at the same time technically. I assess the sedation level of the patient, and try to start with lower doses for the prn meds. Usually I would ask the pt to wait for the effectiveness of a pain pill before I give them anything for sleep that is more sedating. Is this right?

Tepidorchid · Oct 31, 2010

I also have a lot of confused patients. Haldol and Ativan are often PRN doses but I find it so morally difficult to give anything if the patient is agitated and unwilling. Some people I can't even tell if they're confused or just off because I'm not familiar with their baseline. How do you approach giving meds to confused/agitated pts?

Davey Do · Oct 31, 2010

As far as the last question:
7. Patients who ask for pain pills, a sleeping pill and something for their nerves- how do you approach that?
I was looking to understand if I can give these medications together or if it's better to wait. They're all sedatives and our system allows us to give them at the same time technically. I assess the sedation level of the patient, and try to start with lower doses for the prn meds. Usually I would ask the pt to wait for the effectiveness of a pain pill before I give them anything for sleep that is more sedating. Is this right?

Valid question with valid concerns. Your approach is fine. Of course, you're concerned with respiratory depression, falls, confusion, etc. Some patients have a high tolerance, have been on these meds for years, and have taken them concurrently without incident. However, I stick by my first answer: Prioritize. Relieve the pain- narcotic analgesic. Assess the affects after about an hour. Then, insomnia. Give the sleeping pill. Still awake an hour later, restless, c/o anxiety. Give the antianxiety.

Dave

Davey Do · Oct 31, 2010

I also have a lot of confused patients. Haldol and Ativan are often PRN doses but I find it so morally difficult to give anything if the patient is agitated and unwilling. Some people I can't even tell if they're confused or just off because I'm not familiar with their baseline. How do you approach giving meds to confused/agitated pts?

Once again, Tepidorchid, you've got some good questions with valid concerns. Time and experience will guide you, because you have to make the call.

A patient has the right to refuse treatment. We cannot force an individual to take meds. Unless by Court Order. Or, following the legal and institutional guidelines when an individual is a threat of harm.

Those who are willing to take meds seem to benefit more from the dopamine antagonist antipsychotic, Haldol. Zyprexa and Risperdal have less side effects. All the antipsychotics seem to be less sedating and work to decrease agitation.

Ativan has a calming affect, but, it too, has untoward effects. So, it goes back to being your call when you have appropriate orders.

Approching the Patients and having them understand that med compliancy is to their benefit is a work in itself. Maybe specific circumstances would be an easier answer to deal with.

Keep on keeping on, Tepidorchid.

Dave

Tait, MSN, RN · Oct 31, 2010

1. Do you find that certain problems can only be addressed by the attending during the day? We don't have attendings at our hospital so I am not sure I can answer this one. I try to get all of my issues ironed out by 10pm. I ask my patients if they need something for sleep early, and tell them I won't call the doctor after 11. Changes in patient condition, restraints (for first time orders), pain and critical labs are all within my zone for late night calls. I make the call quick and to the point, often having worked out exactly what I think I need (i.e. the patient doesn't get pain relief from Morphine, but has had a good track record with Demerol etc).

2. What limitations might there be by calling the physician on call vs the attending? No attendings so this one I am out of.

3. Has the attending made comments about orders written by the on-call that is inappropriate for the patient? No attendings.

4. What labs will you call on vs. leave for the attending (besides critical values) for the morning. I call critical labs (requirement) and anything that is giving me worry (low but not critical H/H with an odd large drop).

5. Do you know how the day shift works- Like when the patient can expect to see PT or other consults? This one is always asked of me, but honestly when it comes to docs, I tell them I have no idea, and neither does day shift. If it is say a post-thyroidectomy by a specific doc I will tell them he will be there by 0830, because I know he will be. I rarely get asked about PT, consults I tell them will be more than likely after 1100 because the doc generally has to be called in the morning. My biggest issue is procedures. We only get schedules for surgery, cath lab and sometimes EP lab. Other than that my patients guess is as good as mine for colonoscopies and other less invasive procedures. They come and get them when they can.

6. Is it okay to administer antibiotics without waking a patient and informing them? I tell my patients at the beginning of the shift that I have this, that and the other to do for them tonight and not to worry if I am stalking about their room at 3am hanging an antibiotic. As others have said however, they sign a consent for treatment, therefore you do not have to inform them if they are snug as a bug sleeping.

7. Patients who ask for pain pills, a sleeping pill and something for their nerves- how do you approach that? This one can be tough depending on the patient. Generally I do things in stages. I start with pain, and will sometimes give them either the sleeping pill or the anti-anxiety. I tell them they can have something later, in an hour or two if they still can't sleep. This generally goes over pretty well unless they are seekers. Then I play it by ear and the history of the patient.

In reference to confused patients and meds: I do my best to get patients to take their medications, however if someone is confused and fighting me I will cease and desist, and try again later. When it comes to Ativan and Haldol, if they are swinging at me, biting me or screaming I will do my best to get them medicated, because it is not only our safety, but theirs. Generally our psych group is pretty good about getting us milder sedatives to work with scheduled, and then heavier meds for emergencies. Detoxes I work carefully to keep them from DTing, but also I try not to keep them over-sedated. When in doubt I look to a strong nurse on the floor that I know I can trust.

It all comes with time, but I love night shift, will be sad to leave it beginning of next year, but experiences must grow on!

Tait

hopefulwhoop · Oct 31, 2010

If our patients need to be restrained, we go ahead and do it and make sure the doctor signs off in the morning. If it's not something critical, it can wait.

This is dangerous territory. I know of instances where the nurse has gone ahead and done something similar (ie do something expecting the Dr. to sign it off later) and the Dr. refuses to back her up. This really could end up in court in extreme cases.