skilled unit in rehab facility...questions

NotFlo · Feb 17, 2012

It's crazy busy. You will probably have less pts. than on long term floors but it's still too many and will keep you running. What shift are you going to be working? First shift you will be dealing with discharges and admissions, constant family member interruptions, family meetings/discharge planning with social services, pts. going back and forth for lots of appts. and transportation having to be set up for that, and you will be dealing with PT/OT. I TRY to work with my PT/OTs but honestly sometimes they make me crazy. On first shift you will have the longest med passes plus be responsible for most of the treatments.

Depending on how acute the floor is be prepared for extensive dressing changes, lots of bariatric patients, wound vacs, getting people on and off CPM post knee replacement. Be prepared for A LOT of diabetics and a lot of accuchecks and insulin. My floor also has a lot of IV antibiotics and many people coming and going with central lines. We get a lot of traches, I would review trache care and suctioning if you haven't done it in awhile.

This population tends to be demanding, many are on the lights all the time and they expect "service". I find that the facilities admission people usually lead prospective patients to believe they will be at the Hilton and thus the patients expect that we can give them a level of hotel-like hospitality that just isn't possible with the number of staff we have. We try our best...

Second shift can also be crazy, even more family members are coming in, some people sun-down and get wacky, and second shift gets the brunt of the admissions with even less help than you have on first shift.

sbostonRN · Feb 17, 2012

NotFlo said it perfectly! I work day shift on a skilled rehab floor. I use the census sheet my facility prepares and that works for me, it's just a list with the room number, name and a long line across. I like to fit everything on one page so each patient gets a small portion of the page. I use red pen to mark VS or blood sugars for particular patients, and write any PRN's given in green pen. Other info is written in black pen (I'm big on color coding!).

To give you an idea of a typical day...I arrive to work between 6:45 to 7:00, get narcotic count from the night shift and maybe a brief report if I'm lucky. I stock my cart with insulin, any stock meds that are running low, needles, Ensures, applesauce and ice water. We use electronic MAR and TAR, so I look up any patients that are new to me to see if they need Accucheck or other priority in my med pass. I start my med pass by 7:30 and with a full census (20 patients) I'm done by 10:30. In between the meds, I try to get all the Ted stockings and Ace wraps on those patients with edema (or my CNAs help me with that). From 10:30 to 11:45 I do treatments which include dressings, wound vacs, PleurX chest catheters, decub dressings/creams, trach care, and lots of assessments. Some patients are on turning schedules which gets done throughout the shift. From 11:45 to 12:30 I check lunchtime sugars, give out more meds and try to squeeze in a few more treatments. I sit down and eat lunch at 12:30 to 1:00 or so. Then at 1:00 I start my 2:00 med pass. It's usually pretty short (30-45 minutes) and as I go around I finish up any treatments that weren't done in the morning. If I'm lucky and there are no admissions, I start my notes (I have to write daily Medicare notes on all 20 patients), which takes about 2 hours with a full census. The next shift comes on at 3:00 and I pass off the med cart to them. If admissions come in before 2:30 they belong to us, if they come in later then evening shift does the admission assessment. I usually leave work between 4:30 and 5:30, so it's quite a bit of overtime.

I found the job very overwhelming in the first month or two. After that I felt more comfortable and started training for charge nurse duties, which I occasionally still do. I really like being a med nurse though and find that I get to know my patients fairly well. They are there for 1-4 weeks (sometimes longer, as our unit can be a bridge to LTC), so I get to know them, their medical hx, their families and their likes/dislikes. That's one thing that I really love about rehab that I don't think can be found on a med/surg floor.

scrublifenurse10, LPN · Feb 17, 2012

Thanks for the input so far!! VERY helpful!!

catlvr · Feb 17, 2012

One thing that really, really helps: when a pt is admitted, let them know what to expect. Make sure that they and their family understand that it is a rehab facility and the goal (hopefully) is for the pt to go home, so staff will help them, but the pt has to keep moving and progress in rehab *and rehab does not end when they are back in their room! They are still expected to do the most that they safely can*. If they understand that, it makes things much less frustrating for everyone!

Organization and teamwork are the keys to working in this type of setting; if you can develop a good working relationship with your fellow nurses and CNAs, you will be able to give better pt care. We shared responsibility for the confused and fall risk pts sitting at the nurses' station, regardless of what assignment they were on.

If you peek in the LTC section, you'll find lots of helpful threads with tips for organization etc. Rehab/LTC is not a cakewalk, but it is nice to really get to know patients and their families. Good luck with your new position!

TheCommuter, BSN, RN · Feb 17, 2012

I should start off by mentioning that I am a very task-oriented person. After all, skilled rehab in a nursing home involves a massive amount of tasks that must be completed.

I worked on a subacute/rehab unit at a large nursing home/SNF several years ago, and here is how I used to organize for the day. I worked 16 hour weekend double shifts, from 6am to 10pm. Typically, I had about 15 patients to care for. At the beginning of the shift, I would go through the MARs and TARs with a fine tooth comb and, as I go, I would jot down the things that needed to be done in my notebook. My notebook was how I organized my days, and I usually wouldn't forget to do anything. Here is how an old notebook page looked (names have been changed due to HIPAA):

9-23-2007

DIABETICS, FINGER STICKS: Agnes (BID), Agatha (AC & HS), Bill (AC & HS), Wendy (AC & HS), Rex (BID), Jack (BID), Esther (AC & HS), Margie (0600, 1200, 1800, 2400)

NEBULIZERS: Margie, Esther, Bill, Jack, Jane

WOUND TREATMENTS: Jane, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Wendy (Vancomycin), Laura (Flagyl), Rex (ProcAlamine)

COUMADINS: Agnes, Agatha, John, Lucille

INJECTIONS: Agnes (lovenox), Jane (arixtra), Rex (heparin), Bill (70/30 insulin), Esther (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Wendy (wound), Laura (C-diff), Rex (pneumonia), Agatha (MRSA)

1200, 1300, 1400 meds: Margie, June, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Jane's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

scrublifenurse10, LPN · Feb 17, 2012

I should start off by mentioning that I am a very task-oriented person. After all, skilled rehab in a nursing home involves a massive amount of tasks that must be completed.I worked on a subacute/rehab unit at a large nursing home/SNF several years ago, and here is how I used to organize for the day. I worked 16 hour weekend double shifts, from 6am to 10pm. Typically, I had about 15 patients to care for. At the beginning of the shift, I would go through the MARs and TARs with a fine tooth comb and, as I go, I would jot down the things that needed to be done in my notebook. My notebook was how I organized my days, and I usually wouldn't forget to do anything. Here is how an old notebook page looked (names have been changed due to HIPAA):9-23-2007DIABETICS, FINGER STICKS: Agnes (BID), Agatha (AC & HS), Bill (AC & HS), Wendy (AC & HS), Rex (BID), Jack (BID), Esther (AC & HS), Margie (0600, 1200, 1800, 2400)NEBULIZERS: Margie, Esther, Bill, Jack, JaneWOUND TREATMENTS: Jane, Bill, John, Jack, Lillian, Rose, LucilleIV THERAPY: Wendy (Vancomycin), Laura (Flagyl), Rex (ProcAlamine)COUMADINS: Agnes, Agatha, John, LucilleINJECTIONS: Agnes (lovenox), Jane (arixtra), Rex (heparin), Bill (70/30 insulin), Esther (lantus), Mary (vitamin B12 shot)ANTIBIOTICS: Wendy (wound), Laura (C-diff), Rex (pneumonia), Agatha (MRSA)1200, 1300, 1400 meds: Margie, June, Rose, John, Jane, Jack1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, LauraREMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Jane's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

You sound a lot like me! I love to have a list for everything...somehow seeing it wrote down helps me stay focused better. Thanks for the great example and advice!