Hi all, I recently started working in a cardiac ICU and I'm wondering if anyone has any tips for time management and keeping on schedule with patient assessments/vitals/daily cares etc. I am visual and have a hard time remembering to follow-up on all the different assessments going on simultaneously unless it's organized and written down. (I haven't come up with my own SBAR/hand-off system just yet.)Our EMR system is wonderful but charting is so extensive, especially when the patient case is complicated (IABP, recent xfer from the cath lab requiring frequent assessment, etc) I feel like I have a hard time keeping up with it without feeling like I'll fall behind or like all I'm doing is charting instead of caring for my patient. Often an emergency transfer/admit comes into our unit and all sense of "on schedule" is lost and my attentions are then refocused on the more critical patient. I'm not alone in patient care yet but I want get head start on time menagement when I can no longer just focus on one patient or when one suddenly begins to quickly circle the drain. I absolutely love the CICU and I will do everything I can to pick up the routines and skills as quickly as possible. Any tips from experienced ICU nurses would be appreciated. If if anyone has any general tips, those are appreciated as well. God bless and thanks
Aug 16, '17
Good news: That feeling is totally normal...and it gets better with experience and time. Two tips:
1) When sh*t hits the fan take a deep breath and then take care of your patient first, the charting can wait. Do what needs to be done to keep your patient alive. Grab a piece of paper towel or use the pt's whiteboard and scratch down some brief notes as you go to stay organized.
2) Once things settle down with the busy patient then make a little "to-do" list on a post-it. For visual people it helps to see your "to-do" list so you can prioritize what needs to happen next/reminders to chart.
Hope this helps!
Aug 16, '17
Thank you for your reply. I'm so excited about learning all there is to learn, my unit is great. Had my first experience with losing a patient Monday, felt a bit strange but it was good to see all that goes into trying to save someone. It's amazing how some people hold on for weeks while others go south right in front of you.
The charting feels endless. But I assume that'll become less cumbersome with time.
Aug 17, '17
*Write things down.*
At the beginning of the shift always have some hustle to not just stay afloat, but to get ahead. Other nurses sit around chatting and drinking coffee until 2000 when they can start giving 2100 meds, but I do my assessments, make sure my meds are here, organize my monitor settings, and so many other things. By 0000 I'm chillin' or am atleast caught up and ready for chit to hit the fan.
Get your linens for morning care at the start of the shift. By early morning, you may not have linens because everyone else took it.
Eat when you can.
Overall, begin organizing your morning while it's still night. I write a quick AM care list to check off: get weight, wash patient, draw labs, give meds, do EKG.
Aug 17, '17
Don't save all documentation until the end of the shift. I see nurses unnecessarily put in 2000, 0000, and 0400 assessments at 0500. Ridiculous.
Keep a list of common phone extensions taped to the back of your badge. i.e. CXR, CT scan, bedboard, nursing supervisor.
Sep 3, '17
Thank you. So far it's the charting that has me the most stressed out. I've been trying to come up with a way to keep on schedule with each assessment.
I do my cardiac strips, check monitor/vent alarms, and do a quick check of my patients IV tubs, bags, dates/labels, etc before my shift starts.
On our unit we do VS/I&Os (PCA's, CRRT, Foley, C-tubes, etc charted on an LDA tab specifically) q1hr, Daily Cares, PCA Pain asmnt, turns q2hr, and complex and IV assessments q4hr. That's for a relatively stable patient.
Obviously giving meds is somewhat constant based on the acuity of the patient. I think once I get used to the routine it'll feel less haphazard to me.
Sep 3, '17
So, i've been handling 1:1 patient care for a few shifts now and my biggest struggle is a combo of time management (mostly remembering which assessments/tasks need to be charted when) and remembering all the little details r/t a specific patient.
Like yesterday, I had a patient w/terminal cancer who'd been brought to our unit after a thoroscopy/VATS procedure, naturally she had 2 chest tubes, a lateral thoracic incision, 3+ pitting edema in LEs, a PCA pump, the whole kit and kaboodle. She was also experiencing what I believe was sun-downers/dilaudid-induced and was actively hallucinating. She was very confused, was not getting relief from pain, pulled out her IV not 20 minutes after I'd given her 5,000 units of SQ heparin so she started bleeding all over the place...I got help, held pressure on her AC all while trying not to step on her right chest tube next to her chair (she wouldn't let me move her to the bed).
I was so distracted with her bleeding that I completely failed to realize she'd pulled out the IV for her dilaudid. Finally I realized (after her daughter who's a nurse on another unit came in) that I needed to hook up her IV to the other arm (the one i'd been avoiding using because it was going bad). As I expected, it finally occluded. The IV team came up but they could not get a line in her. Poor lady. I felt so sorry for her, they even tried to straight stick her basilic vein but nothing. Eventually I had to suggest the PICC team come up.
On top of all of this, throughout the entire shift her blood sugar kept rising to well above her "normal" levels. In the middle of her "IV-extrication" fiasco, pharmacy brought up insulin for an insulin drip. I obviously couldn't hang w/o IV access so I had to improvise and give 20 units IV push.
Another "mistake" I made was not asking myself why her blood sugar was rising so much. I was so focused on treating her that I didn't consider the cause.
I can say I learned a lot from this shift, mostly what NOT to do and what NOT to forget. Did you have those days as well when you first started in the ICU?
Sep 4, '17
Ah yes, that feeling of everything spiraling out of control is totally normal. You will have days like this. I tell all our new hires: "You run the shift, or the shift will run you."
Look at how much you learned in one shift and pat yourself on the back for getting you and your patient to the end of the shift alive and in one piece. Now for the future, the next time you feel a similar shift starting to unravel I would stop, close your eyes for a second and take a deep breath. Count slowly backwards from 10 to 1. With each number as you count backwards think of someone who can help you, eg: "10 - nurse buddy, 9 - charge nurse, 8 - CNA/tech, 7 - that intern walking down the hall, 6 - IV team...etc." This will help you regain control. Then start calling on your friends, remember nursing is a team sport.
Now put your feet up and relax, you survived, next time you'll tackle a day like this even better.
Oct 8, '17
I cannot explain how much I love the CICU. It's hard to believe how much i've learned, the struggles I was having at first seem so much smaller now. I've worked my way up to caring for 2-3 patients at a time and i've been able to see some amazing things. My team is amazing, everyone looks out for each other, it's like a band of brothers, in some ways, more so than I experienced in the Marine Corps.
I truly look forward to going to work and I find myself not very eager to leave in the morning after I give report. That said, giving report is my current challenge. It's hard on the nights where my patient's coded and I've given so many amps of bicarb, epi, titrated all the drips up and down all night. Getting that into an organized story is my biggest challenge. I'm pretty visual and I do try to give report from memory going over the night's events but I find that too difficult in some cases. Other times I get confused about the patient's history, especially when they've been on the unit for some time now and i'm trying to give a synopsis of quite a bit of clinical information. I have a good flowsheet that I use but I still get somewhat sidetracked. The head-to-toe part of report is much easier, it's the other information that throws me sometimes.
I'm told it comes with time and I'll continue working on it. Anyone have those same issues in the beginning?
Oct 8, '17
EVERYONE has those same issues in the beginning... and sometimes after doing it for many years! Some shifts are harder/busier/more complex than others. It sounds like you are doing great! I'm so happy for you that you are loving your unit.
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