(I have no pics of my work in rehab, so this image of working with a traumatic brain injury patient is from MSKTC.org )
I don't work in an E.R. or I.C.U. or any critical care conditions. I work in an acute rehab unit. Most nurses I work with yawn when they think about the nursing work in rehab. You only have to chart an assessment once a shift. No one's on a monitor. You don't have very many patient's on I.V.'s. And for the most part, the patients are stable. So when I go home exhausted, feeling like I ran a marathon, my feet ache and I'm pretty sure I didn't document what happened all day very well, I feel a little like breaking down what it is I did all day and saying, "I know it's not critical care, but it's rehabilitative care and that is very labor-intensive and teaching intensive."
Tuesdays and Thursdays are conference days on my unit. Every Tuesday and Thursday the patients individual situations are reviewed in a closed-door meeting of the PPS Coordinator (I still don't know exactly what that means but it's the RN who deals with medicare and justifying patients' needs for acute rehab), the Physiatrist (that's the rehab physician), the OT (occupational therapist), PT (physical therapist), SLP (speech language pathologist), CM (case manager), RN clinical manager, and RN caring for the patient. Depending on how many patients are on the unit this meeting can take anywhere from 5 minutes to 2 hours. Today it took 2 + hours. This occurs while these same therapists and floor nurses are carrying a load of 4-6 patients on the floor that day and bouncing like ping pong balls in and out of the meeting to give their input on the patient, listen to the team's input, and come up with a potential discharge date. Today I had 5 out of the 12 patients to bounce into this meeting to discuss, which meant my morning from 7 am to around 1pm went something like this:
- Get report from two night shift nurses about my 4 patients and the 1 patient a float nurse (a nurse who came to care for patients on our floor but is not a staff member on our floor) has so I can know what's going on with that patient since I will be doing the conference on that patient (float nurses can't do conferences on patients on our floor).
- Sign into the EMR (electronic medical record) and begin documenting that I received report and what the fall risk and mobility score my patients are and what education I will be doing with them that day.
- Review the chart for orders, notes from doctors from the previous day, labs, vital signs, test results and medications that are due.
- It's now 8 am. Conference begins at 10:30.
- Visit each of my patients briefly to introduce myself. Do a general assessment just by talking with them (Are they alert and oriented? Any pain? Any nausea? Are they constipated? Can they urinate? Do they need O2? Do they have any skin concerns/wounds?). Take some patients to the bathroom. Get some of them out of bed. Get some of them water. Get some of their breakfast trays set up. Call a CNA to come help pull someone up in bed.
- It's now 8:30 am. Two hours till conference.
- Go to the Pyxis (the machine that dispenses the medications) and begin pulling 9 am medications for my patients. I pull the meds for 2 patients since they're on the same hall, place them in different bags, label them and set out to look for a WOW (a rolling computer kiosk that I push around all day from room to room to give medications with and document my care of the patients) that works. (It's about a 50% chance that the WOW you pick will loose it's battery life halfway through scanning your patients meds so you hope to find the one you know keeps a charge).
- Answer the phone. It's been ringing the whole time I've been in the Pyxis room getting meds and everyone else is either on the phone already or in a patient's room. It's doctor so-and-so who wants to know who the nurse caring for patient such-and-such is? I put him on hold. Look for the assignment list. Find the patient and their assigned nurse on the list. Use the vocera (a clip-on phone device where anyone can get ahold of you anytime, anywhere as long as you've turned yours on and logged into it) to call the nurse who doesn't have a vocera. I push my WOW to an outlet, plug it in and set out to find the nurse the doctor is holding for. Finding the nurse, I stop to answer 2 call lights (call lights are patients pushing the red "nurse" button on the remote in their bed to get a nurse to come to their room), take an empty breakfast tray out of a room per the patients request and help a patient to the bathroom.
- It's now 9:00 am. I start passing my medications.
- In my first patients room I have a quick, easy assessment looking at wounds that are healing nicely, talking to a patient who's alert and oriented and has no new problems or complaints. But I do make note to follow up with the doctor about a question the patient had. I pull out the meds, scanning the patients armband with a scanning wand exactly like the one in the self-checkout isle at Sam's Club. It beeps. The right screen pops up. The computer confirms that I have the same patient that the patient reports to be by telling me their full name and birthday- I can proceed. I scan each medication telling the patient what it is and what it's for if they don't already know. The patient complains of constipation so I make a note to bring back a medication later to help with that. I ask if there's anything else I can do and since there's nothing I let them know I'll be back to see them throughout the day and hand them their call light so they can reach me. On to the next patient.
- It's now 9:15am. My vocera goes off. Dr. So-and-So is on the phone for me. I push my WOW to an outlet, plug it in. Walk to the nurse's station and answer the phone. I give the Dr. a report on their patient, hang up and return to my WOW. On to patient number 2.
- In patient number 2's room I find a lot more to do. The patient is in bed. The breakfast tray is on a bedside table 10 feet away from the bed, and the room is dark. I introduce myself. Ask if the patient would like to get up and eat breakfast (In rehab we don't leave patients in bed for meals. All patients, if at all possible, get out of bed for all meals). I open the blinds to let some light in. Patient #2 would like to get up. I plug my WOW into the outlet in the patient's room, take the medications with me and set out to find a CNA or willing RN to help me transfer the patient (who requires 2 people to assist with transferring from bed to chair). The nurse's station is empty, a phone is ringing, and 2 call lights are going off. I answer the phone. Patient such-and-such's family member would like to speak to the nurse caring for their loved one. I place the person on hold, vocera the nurse and converse with a doctor who showed up at the nurse's station after exiting my patient's room. We discuss some changes and I get orders for some thing's he'd like nursing to do for his patient. I make a mental note and call for a CNA to help me with my patient. Together we transfer this patient from their bed to the wheelchair. I've performed some of my assessment in talking with the patient and transferring them. I complete the assessment with a listen to their heart, lungs and abdomen and a few orientation questions: What's today's date? Where are you? Why are you here? I go on to ask about pain or any other issues or complaints. The patient shares with me a couple of big concerns. I note them on my "brain" (a piece of paper I scratch notes on all day) and begin scanning the patient's armband and medications. I discuss the plan of care for the day and the changes the doctor wants implemented. I ask if there's anything else I can do before I leave and then exit the room with a promise to return every 2 hours to carry out the new treatment ordered by the doctor.
- It's now 9:50. I head to the Pyxis room to get medications for patients #3 and #4. On my way into patient #3's room I'm flagged down by the WOC,RN (that's the Wound, Ostomy, Continence RN) who would like me to assist her in the assessment of wounds and dressing changes in Patient #2's room. I let her know I'll meet her there in a few minutes. I continue into Patient #3's room and perform my same routine of intro, asking questions, assessing the patients condition and discussing the plan of care for the day. This discussion included plans for discharge today and the patient's concerns and questions about how it was going to happen. While discussing and assessing I was also scanning the patient's armband and medications to give them quickly knowing I was needed in the other room to address wounds. I made quick notes on my "brain" about the patient's requests for PRN meds and asked if there was anything else I could do. I left the room with a promise to return with the requested medications.
- It's now 10:10. Conference begins in 20 minutes and I still have a half a dozen wounds to address, another patient to give medications to and another patient (who wasn't my assigned patient) to assess so I could give some input on that patient in conference.
- I go back to Patient #2's room, assist the wound RN in undressing and redressing wounds. We find more wounds that we were expecting. I leave the patients room to go gather more wound care supplies, return to the room to finish what we started and get called out of the room via my vocera 20 minutes into our care: They are ready to start the conference.
- I leave the wound nurse to finish what she's doing and head to the conference with my notes in hand. It's 10:30.
- 30 minutes later I emerge from the conference on my 1st of 5 patients and call for the next nurse on the list to trade me places. Their turn to discuss their patient. I leave the room with notes in hand about all the requests the doctor made for me to follow up and the concerns brought up by the therapy staff and case manager. I set my notes face-down at the nurse's station and set out to patient #3's room.
Ugh. I'm tired already and it's only 11am on my recall of today's events. What transpired from 11 am to 1 pm was a cacophony of call lights, phone calls, vocera calls, medications scanned and given, following up on things not done yet that were noted on the original visit to patient's rooms, intermingled with 4 more interruptions to go to the conference room and discuss my patient with the team. By 1 pm the conferencing of our patients was over, I was hungry, and way behind on charting.
In nursing there's a saying: If it isn't charted, it didn't happen. Every assessment, every discussion (which is education), every intervention, every phone call to or from a doctor, every order, every vital sign, every medication, every treatment, every meal, every drink, every void, every stool, every transfer, every change in position...every interaction with a patient must be charted in the electronic medical record- or it didn't happen. I estimate it takes about 4 hours of accumulated time to chart throughout the day. Most of it is interrupted charting. Interrupted to care for patients. Which must be charted.
I took a lunch at about 2 pm with only my assessments charted. Half hour later I returned to work on my patient's discharge from the hospital. The case manger is usually the person who takes care of arranging the medical equipment, transportation, follow up appointments and facilities needed for a patient's discharge. But sometimes those things fall on the floor nurse. Today they fell on me. From 2 to 7 pm, when my patient finally discharged from the hospital, I was on the phone with various entities to work out complications in the discharge plans and needs so this patient could leave and go safely. Those 5 hours were interrupted with giving medications, addressing wounds and assisting with my other patients needs along with answering call lights and more phone calls.
At 7pm when the night shift showed up and I said goodbye to my patient who finally got to leave the hospital, I hadn't even begun documenting all that was required for me to chart from the shift. I gave report to the night shift nurses and then sat down to chart. An hour and 15 minutes later I was done. I had completed the required documentation... I think. (Did I mention that in a rehab unit there is an entire additional hour or so of charting that medicare requires from nurses to justify a patient's stay in rehab?)
8:15ish PM I clock out. Walk to my car. Drive home exhausted. And when I've said goodnight to my kids, showered and sat down to unwind before I go to bed, I feel my throbbing feet and recognize the questions still running through my mind, and I think, "What happened today??!"
If you're ever a patient in the hospital you should know your nurse is probably running her tale off. If you see her at the nurse's station on a computer, she's not sitting there doing nothing. She's trying to make sure what she really did today is documented so that if anyone goes looking, it happened. If you have a good nurse she won't mind if you ask her what medications you're taking or question what she's giving you. She'll be glad you are being an advocate for yourself and gladly tell you what you're taking and answer any questions you have. She'll listen to you and talk with you and make sure you're doing ok and then she'll have to go back to her computer and punch keys and scroll through doctor's notes to make sure she's recording what really happened and doing what really needs to be done that day to make sure you get better.
I would really like someone to invent a charting robot.
Quieted,
Sheila
