3rd shift nursing assessments

[jab1432, BSN]

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?

[ePerfect]

Unfortunately it is necessary. I have to do this daily and I'm not even in a hospital, I'm in LTC. You want to catch s/sx of infection as soon as possible. You need to know if a wound becomes open again, if they are bleeding, inflamed or puss-filled. These symptoms aren't just going to wait for morning to appear. And, frankly, it's your job. It may not be convenient for the patient or for you but that doesn't really matter. What matters is that your patient is safe and that means making sure their incisions and wounds are safe. Health care doesn't just stop because the sun went down.

[tyvin, BSN, RN]

You need to assess your patient head to toe q shift. It's the hospital, not their home, they expect that someone is going to check on them at night IMO. You don't have to wake them up to look at a drsging. If you don't change the wound on your shift, you should document that you checked the date on the drsging and it was changed as per orders, is it dry, intact, no odor and all that good stuff, etc...? Does your place check vitals q shift?

Now, if there's an order that says not to disturb this patient on your shift specifically and not to assess the wounds on your shift, etc...then don't, but other then that; you're an RN, we are responsible for our patient's well being and safety and that means making sure everything is OK with their condition which includes wounds.

You don't need to buy a trumpet and play revelry to wake them up at night or to even get them to turn...it also has to do with house policy.

Check your house policy/procedure as well; they might have a say about it, but if it were my patient I would be checking.

[amoLucia]

Missed this entry earlier -

To OP - Using your logic, would you NOT look at a PICC site even if you did not do any ABT administration??? After all, the pt is hospitalized because a wound has contributed to overall general decline with a need for therapy (just a pretend scenario).

Wound observation (even if only covered by a clean, dry drsg) is part of the nsg skillset for provision of 'skilled nursing' services for wound care. (Think Medicare charting and reimbursement.) The careplan probably includes interventions for 'q shift observation', so it should be being done.

Another poster here said it that people are in the hosp for services needed (else they would be home). This is true. There is a general common understood expectation that they will have to have things done that may be inconvenient or uncomfortable.

A simple check will suffice. I do try to do them early - I don't want to be surprised later on.

[HouTx, BSN, MSN, EdD]

Make sure you are following your organization's P&P for assessments. Some organizations permit exemptions for walkie-talkie patients that have been stable for a period of time because uninterrupted sleep is very important to the healing process. Neither CMS (Medicare) nor Joint Commission dictate the frequency of nursing assessments based simply on shift schedules. Focused assessments of any invasive lines/devices should include tracing lines & laying eyes on all insertion sites before you use/manipulate them. Dressing inspections can be delayed to coincide with early AM lab work or other reason to wake the patient.

It's important to make clinical decisions based upon fact rather than opinion or habit. Nurses are easily 'imprinted' with the practices of the setting in which are most familiar. If there are no actual reasons for interrupting the patient's sleep, why would you want to?

[jab1432, BSN]

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).

[Baubo516, RN]

I'm an aide on a Rehab/Skilled Unit, and I work nights. Only a few of our patients will sleep through the night without peeing at least once. The RN's I work with will tell me, "Let me know if ____ gets up to pee. I need to look at her incision site." For the most part, they wait until that time or a time when they have to hang another IV bag or give a pill to do the assessments.

I do understand what you are saying, though, about running out of time if you wait until they wake up. I can't believe so many of yours sleep through the night! Why are their bladders so much larger than our patients' bladders? :)

Do you have CNAs/techs who could alert you if they just get up to pee?

[jab1432, BSN]

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...