3rd shift challenges in home care

[ButterflyBreath]

This is only my second 3rd shift case. First did not require much interaction throughout the night except repositioning, as client was on hospice. This case is different.

It's a 30 hour a week nursing position with an additional 10 hours for a CNA. However my agency has never been able to fill the CNA hours, so they allow me to work the CNA hours and then come on as a nurse after that. This has some challenges.

In my state (or maybe it's just the agency) I cannot administer meds or do other things only an LPN would do while I am checked in as a CNA...even though they are paying me the LPN rate! So I get my client ready for bed as a CNA, and then come on as an LPN after she is already asleep. I obviously can assess her while I am getting her ready for bed, but can't report them in my CNA notes. The idea is for her to sleep, so even when she wakes up throughout the night and I'm working as an LPN I don't want to roll her around and rial her up to do the assessment...she won't go back to sleep. I suppose I can note my observations and chart the assessment even though I did it earlier in the evening before my nursing shift began, but what if I weren't doing the CNA hours and wasn't able to do the assessment? Is it acceptable to chart an assessment you did technically before the shift began? I can trust that the family would report anything abnormal or concerning, but we're supposed to do a full assessment every shift.

Luckily this client is very stable and in general never has much serious going on. However lately (this week) she has changed meds and is not responding as well as we'd like and I have to do more assessing. I suppose it comes down to what's more important? Her sleep, or the assessment...? In the past on other cases parents have always not wanted me to disturb their child, however we have a job to do.

I assume this is a common issue for 3rd shift nurses. Thoughts?

[caliotter3]

It seems as if you are reading too much into this. You are supposed to keep the two roles separate, so you keep the two roles separate, in your charting. Chart your LPN shift without including info obtained during the other shift, or you could be creating a problem for yourself. If the client is asleep when you start your LPN shift, and you are not to wake the client, then chart that the client is asleep.

[brillohead, ADN, RN]

Might want to ask the moderators to move this to the Private Duty Nursing forum instead of Home Health. You'll get more responses from nurses who do shift work in the home vs home health visits.

[brillohead, ADN, RN]

Also, I spread my assessment out as appropriate throughout the shift, particularly for a relatively stable patient with whom I am already very familiar in general.

For example, I don't flip them all over to check out skin integrity immediately after clocking in -- at some point or another, I'm going to be changing a diaper (several times over) and I can check the condition of the skin on the back and bum and groin at that time. And during the bed bath I can check out the area between the toes, in the armpits, etc. If there's nothing unusual going on with respiration, I don't flip them over to listen from the back.

[NRSKarenRN, BSN, RN]

Moved to Private Duty Nursing forum.