Assessment

ICURNBSN · Feb 17, 2014

I am a new nurse just started in CICU. But I worked as a tech in the ICU for a year and a half and had my final clinical of 200 hours in the ICU. I do my assessment literally head to toe. Start with pupils, orientation as appropriate, vent placement and settings, assess heart, lungs and bowels. Look at IV sites abd check drips. Peak at the groin as appropriate (art line or Cath lab abd Foley). Thorough check for edema and pulses in extremities. Turn pt. and look and listen to their backside. Pt. Will be in a monitor so take a look at vitals and don't forget temp on those who don't have a temp probe in Foley or something. And check that Foley bag. I like to cluster my care the first time. So when I go in for my first assessment, I just go ahead and bring stuff for oral care, Foley care, I do range of motion if sedated and release restraints. when I turn them I will make sure there is nothing in the bed there shouldn't be like caps, tape, etc. And reposition the pt. Maybe a quick sweep to tidy up the room. That way I know if anything goes down hill I know my other pt. is all tucked in, clean and ready to go. I prefer to do both my assessments and then chart but some nurses prefer to chart right after each assessment so they don't get them mixed up. After I do both assessments and chart them I look at orders. Look at meds and labs as well, core measures and plan if care. As a new grad, I look up my meds right away if I'm not sure what they are and normal dosages. Then I do my 0900 med admin. On both pt. And I go ahead and assess again and reposition because we assess every 2 and 930 or so is close enough for me. The rest of the day is just kind of this cycle unless pt. Are more unstable then of course you assess more and titrate drips as needed. When pt. Are stable but on a vent, I try to titrate drips down during my med pass. I think it is crucial to cluster some care and make sure you think of what you might need before you enter the room so you don't have to make multiple trips. If you are turning them, do you need wipes or new sheet, if you are giving meds, do you have syringes and alcohol, if the pt. is able to drink, go ahead and take fresh ice in with you etc. You will save yourself trips and your patients will appreciate you anticipating their needs. Hope this helps!

ICURNBSN · Feb 17, 2014

Oh, also I do now an hourly list of "to do" on my report sheet.

jpj7 · Apr 3, 2014

Congrats on your new CCU job. I too work on a CCU floor. I have been there for about 2 years. What I like to do is get report in the pts room. This way you have a good idea of what to expect and check your pt and pumps, drips etc. When you are back in the pt's room you will know most often what items you need to take into the room. I think that is a good way to start. Please use your PCA if you have one. Hope this helps.

XelaRN · May 7, 2014

I'm hoping to get a preceptorship on a ccu unit during my next rotation. OP, have you figured out a good method for your assessments? I would also appreciate any tips that nurses, new and experienced, can provide for a nursing student hoping to work in the ccu. Thanks much!