ICU Nurses - help with a paper

RNinICU · Mar 19, 2003

Most of these questions I can only answer with my personal opinion, not facts. I don't really feel like typing all of the answers. If you would like to call me, PM me. and I will give you my phone number so I can answer your questions.

ratchit · Mar 19, 2003

1) That the doctors don't always know the answers, either. That no nurse was born knowing how to be a good nurse. I wish I had known how long it would be before I could trust my judgement and my feeling about how a patient was doing. That it is not only OK but important to say "I don't know."

2) Lower patient ratio. I can't keep 4 or 6 or 8 patients straight, but I can remember what my two patients' renal function was like 4 days ago. It's a different thought process- more depth on fewer people. It's also more multi-system thinking than the floors,

I think. Critically ill patients usually have sustained insults to more than one body system; it's important to know when helping one will hurt another. I'm not dissing floor nurses here- they have a tough job that I am not cut out to do. But the balance is harder to maintain in the critically ill. (That is why they are critical. )

3) Burnout is terrible. We work hard for days, getting very involved with patients and families, and then our patients die. The pressure is on to do the right thing the first time and right now, darn it! In many hospitals, the ICU is a general one, so nurses are expected to have a very wide range of expertise- medical, surgical, cardiac, neuro, etc. There are important differences that deserve respect.

4) No certifications are required, just licensure. Most places require med/surg or tele experience before working the ICU's- some take new grads (more common with the shortage) but that is controversial. Orientation ranges from 4 weeks on the job to 12 weeks mixed classroom and clinical depending on hospital and experience. Advanced certification is available in the form of the CCRN exam, but that is not required. In fact, you have to have a certain amount of critical care experience to take the exam.

5) Detail oriented. Able to see both small details, big pictures, and trends. Strong patient advocates. Smart and stubborn. Interestingly, men are more likely to go into critical care. (Something like 5% of nurses are men but something like 10% of critical care nurses- those numbers are approximate, and I am not saying anything bad about male nurses- LOL.)

6) See above. I think tele or med/surg should be required to go into ICU- you need to know what sick people look like as opposed to really sick people and how to manage your time and work with doctors and other health care providers before being thrown into the pressures of the ICU. Some new grads can do it. Most can't and I don't think it's fair to put them in that situation. My opinion, lots of threads where people disagree.

7) Most physical, task related skills aren't ICU specific. Most ICU nurses start their own IVs. Vent and ETT management are important. Knowing how to assist in an emergency central line placement or intubation is important. But most of what makes a good ICU nurse is having certain knowledge that allows you to make good judgement calls, not anything to do with particular tasks.

8) See above. There are some things that are done in critical care areas that aren't done on floors. There will always be exceptions, but in general vents aren't on floors. So suctioning and checking your vent settings is important in critical care. So is managing arterial lines. Some medications are only given in ICU's due to the close monitoring they require for effect and potential side effects: vasopressors, antiarrhythmics, TPA, for example. Neuro ICU's will have ICP monitors and frequent neuro assesments. CVICUs will have open chests or epicardial pacers. PICU and NICU have tiny little patients that are not little adults- I would guess that they have a lot of family dynamics as well, but I have never worked in one. Burn patients have very special needs, physical (tremendous shock and risk of infection) and psychological. Again, I don't work in one, just what I see from the outside. Coronary ICU patients have a lot of denial about how their lifestyle will change. This is NOT an all inclusive list!

9) No idea. You could ask a nurse manager or staffing office. This will depend a lot on how a hospital defines critical care areas. Does PACU count? Step down? Tele? ER? Cath lab? Interventional Radiology? Will vary from place to place.

10) Higher than in non critical areas. Can't be more specific than that, but I think Nursing Spectrum did an article on it a while ago.

11) More patients live now that would have died a few years ago. But, IMHO, our technology has surpassed our compassion. I took care of an 88 year old patient with a major CVA today. Nonverbal, nonpurposeful, seizing on arrival. Coded yesterday. We got a blood pressure back, but is that a technological advancement? Would she want this? We have the technology to do amazing things but we're in denial about death and disability. We don't always know when to stop using all our toys. And we're too afraid of lawyers- we treat the chart instead of the patient far too often.

There are new vents that can do very tricky things. New drugs come out all the time- platelet aggregation inhibitors, clot busters, antibiotics, cardiac meds- amazing! New surgical techniques and vascular interventions like cerebral coiling. There are great beds that can rotate fragile pulmonary or spinal cord injured patients and even do CPT. Lots of great toys out there.

12) Case managers try to get patients out of the hospital ASAP but I have never felt pressure from a case manager to get someone out of the ICU. Insurance doesn't have much to do with my day to day job. In general, there are more long term vent units at nursing homes- those patients used to stay in the ICU forever. Case managers have to arrange for home care like IV antibiotics, vents, and dressing changes that used to be inpatient.

13) Depends on the day. Same surgery: patient done on a Monday will go to the floor. Same patient done on Saturday will go to the ICU because the doctor isn't around as much and wants a lower nurse-patient ratio. Some things that used to go right to ICU (r/o MI, for example) don't automatically come to us any more. I think it varies- can't quantify it further. Interesting point!

Again, not inclusive. Just some idle thoughts.

Whoops! Realized I missed the nursing shortage question. Patient ratios are climbing in some places. CA has limited this by law in response to nurse complaints and studies that showed lower ratios = better patient outcomes. ICUs are hiring new grads because there aren't enough experienced ICU nurses out there. Some ICUs have closed beds that can't be safely staffed. Travel nursing is becoming a huge industry because nurse want more control and higher compensation than they can get as a staff RN.

Jenny P · Mar 19, 2003

What do you know now (regarding ICU work) that you wish you'd known before you started? A.)That I don't have to know the answer to every question a doctor asks; he can look up the lab values also (if we are both at the bedside)! :) B.)And that people are sick and under high stress when they or their family member is in ICU; they won't remember what you told them until you've said it at least 10 times. C.) Keep your stethescope on your body at all times so it won't walk off!

What are the best aspects of working in the ICU? You can concentrate on taking care of 1 or 2 critcally ill patients and following through with their care until they are well enough to leave your unit. You also have the opportunity to help them and their families cope with their disease processes.

Conversely, what are the worst aspects of working in the ICU? The sickest of the sick are in ICU, you have the terrible responsibility of someone's life being in your hands on a day-in; day-out basis. You see a lot of death and it can take a toll on you if you don't learn to deal effectively with it. Our Society seems to believe that death is becoming An Option instead of The Inevitable. The media shows only "good outcomes" and we are seeing people who think that "everything must be done at all cost" to their 96 year old Grandpa. In ICU, you KNOW what that "everything" is and it isn't pretty.

What certifications are required? You need to be licensed as a nurse in my state; and both CPR and BLS are required here. Which are preferred but not required? ACLS and PALS (if dealing with peds patients) may be required by different hospital policies, but I have seen people hired into ICUs straight out of nursing schools without any other experience. The CCRN is a certification that does carry some weight these days. I have been a CCRN off and on (most of the time I have had it, but did let it lapse a couple of times) for the past 25 years, the increasing importance of that certification means that I shall continue to maintain it until I retire from critical care.

What personaltity types are generally drawn to the specialty? I believ there are several different types of personalities that are drawn to critical care. There is the adrenalin junkie; the control freak; and also people who are very detail-oriented. And I agree with the person who said that there are more males in critical care than other areas of nursing, so I think one has to be very assertive to work (or stay) in ICUs.

What is the average experience of an ICU nurse before entering the specialty? It all depends on both the hospital and the nurse. I prefer to see nurses who have worked in med surg or tele units before they come to ICU; but I am not the person hiring other nurses.

What skills set an ICU nurse apart from other specialties? to anticipate what the docs want before they ask; to handle stress in a constructive way; they don't fall apart in a crisies but rather can stay in control whatever hppens.

Vettech; I'l l have to answer this tomorrow. I just can't seem to stay awake to type right now. I promise to do this tomorrow.

JennyP