ICU nursing

mattcastens · May 7, 2002

Well, Jennifer ... it can vary. I would say, in the most general of terms, that the night shift is quieter and slower than the day shift. However, when the night shift gets busy, it gets really busy, because there aren't as many support personnel available.

I work primarily days, with nights every third weekend (give or take). Days are very busy. There are lots of doctors coming and going asking questions and writing orders, not to mention things like P.T. There are road-trips to CT or MRI to deal with, plus an admission or two. Granted, you only really have to deal with your one or two patients, but even that can get you behind if you're not organized. Everybody needs to work as a team.

On the night shift, it's quieter. But as I mentioned, when it hits the fan, it sprays everywhere.

My typical day shift (7a-7p):

Get in at 7 and get report. Organize my day by quickly scanning the chart and orders, both old and new, to see if there's anything I need to be aware of test-wise. Scan the Kardex for cautions or treatments I need to know about. Check the MARS so that I can plan my medication schedule for the entire shift. This all takes me to about 7:30. I get my meds for the first patient and go do my assessment. I do my head-to-toe, and give meds. Then I make sure my room and monitors are set up the way I like them to be. (An organized room makes the day go by much easier.) Then I run off any strips I need and chart my assessment. Now, about 8:15, I get the meds for my second patient (if I have one) and do it all over again. I'm usually done with this first round by 8:45 or 9:00. I go on break. Then it's working with doctors and helping out as much as I can. If my patients need anything, that takes priority. I do my second head-to-toe on both patients from 11:30-12:30 and my third from 15:30 to 16:30. The rest of the time it's doing PRN assessments, meds and therapies, and discussing cases with physicians. It sounds like a really busy day -- and it is -- but there is plenty of time for a few breaks and chewing the fat with my co-workers.

My night shifts (7p-7a) follow pretty much the same pattern. However, since there aren't any doctors around or road-trips to go on (usually) much of the time really is spent watching monitors and giving patients a little more comfort care. Patients need their rest, so I like to let them sleep when I can. During those times I either read or chat.

In terms of what nurses make the best ICU nurses...

Of primary importance is the ability to care for you patient as a person, and make them feel like a person in such a high-tech environment. Remember to care, not just treat. An ICU nurse needs to be a fast and critical thinker. An ICU nurse must not be afraid to ask questions either from other nurses or from the physicians. If you don't understand why a treatment or plan is being followed, you must ask! You might reveal a potential error or suggest a better course of action -- or, you will learn new and valuable information.

Realize, too, that as with any field of nursing (more so in critical care) it will take 12-18 months before you feel comfortable with what you are doing. That's almost two years before you think of yourself as a competent critical care nurse. Hang in there.

fedupnurse · May 7, 2002

I started as a new grad in ICU about 10 years ago. We had a combined CCU/ICU/SICU at that time. High acuity. I worked in the unit while in nursing school so it made my transition much easier. I also had a ton of experienced staff to back me up and learn from. You have to be confident without being arrogant, assertive and compassionate. You have to have excellent time management skills regardless of which shift you work. I've done mostly nights with a couple years of days thrown in. I hated days because the suits are on your back all the time telling you how to do your job (even though they haven't ever done your job!!) There were also far more people around, especially if you will be working in a teaching hospital. I definetly prefer the atmosphere on nights. I usually have time to spend with my patients and get everything done that I need to.

The benefit of starting on days as a new grad would be that if you do miss something on your assessment, someone else will probably pick it up, unless the patient is unfortunate enough to have a doc that does his/her assessment from your flowsheet out at the nurses station-they're out there!!! AT night we rarely see the docs which is fine with me.

Some tips if you go to nights:

Ask the more senior nurses who are recpetive to new staff for pointers on what you have to call for. There are a handful of doctors who I will wake up for a tylenol order at 2 am. Usually I don't have to.

If you do not know something ask, Ask, ASK!!!! It is so important. If a more senior nurse offers advice listen to it. We know short cuts, we can look at a patient and say he'll be gone by morning, we know what works and doesn't and we know the system.

I don't believe you need med surg first. I have said on this site before that I have the utmost respect for Med Surg nurses because I know I couldn't juggle their ridiculous loads! I don't know how they keep their heads above water.

Best of luck to you in your upcoming career! I'm sure you will do fine!

hoolahan, ASN, RN · May 8, 2002

Jennnfier, I did ICU nursing for 17 years before leaving for home health. I can tell you, and I worked nights the majority of that time, I worked most of my hours ON MY FEET!! Like Matt said, it can truly vary, depending on pt acuity.

My typical night in the CT ICU recovering open heart surgery pt's was 7-7:30 report, 7:30 assessment, then vitals, I&O every hour. As son as I assessed the pt, took care of any immediate problems, gave any meds due, and wrote up my initial assessment, I would read my charts. In my initial assessments, I always checked for emergency bedside stock, checked and calculated all drips for accuracy and levels, to see when new bag is needed, if meds are needed from pharm before they close, and to see all alarms are set the way I want them, and all are ON. Then, I read the chart, history, physical, progress notes to see what the plan is for the pt, current labs, what ABG's were on room air, normal filling pressures, what the cath lab report looked like, etc... This took me until about 9:30 10p. I restocked the unit, and tried to give the pt some period of uninterrupted rest. During any time MY pt's were sleeping, I would see if my neighbors needed help. I never sat unless everyone else could also sit. Basically b/c if I sit, I get tired, so I keep moving. About 3 am or so, I got pt bathed for day, weighed in bedside scale sling or standing if possible. CXR's were done at 4, labs at 5, rounds with surgeons at 6, removing CT's, ETT's, whatever needed to be done by MD's. Then clean-up, finish notes, leave fresh bags of IVF if due to run out before 9am (in case day nurse gets busy) give report, and adios! After I left that unit, I went back about a year later, as agency, and they were transferring pt's to the floors before 7:30 am if beds were ready. Well, that was it for me. Nights was already very very busy in that unit, and I decided transferring pt's, for routine reasons and not to triage for an emergency bed, was just not going to work for me, and I never went back!

The only time I ever did experience sitting for any length of time was when I worked nights in CCU. There, they like the pt's to get uninterrupted sleep, so as not to stress them out, after fresh MI. Sometimes I would watch 3 pt's sleep all night. I still read charts, prepped stuff for days, helped neighbors, read journals, etc...

If you start in ICU, I strongly suggest you transfer to nights after orientation. Day shift is sooooo busy with transfers, consultants, pt's going to and fro for CT scans, a major ordeal when on a vent, etc.. I felt like I did tasks all day, and was never able to read the charts, or take in the big picture. It was more like survival from hour to hour. On nights, even though I was busy, I had time to read the chart and think about the responses to the changes in therapies, and titrations of drips I made, b/c I wasn't continuously interrupted by the phone, PT, dietary, pharmacy, etc... I had time to analyze what I was doing, and I really really learned a lot. Now I have worked agency in some hospitals where each nurse had 3 pt's who were all circling the drain at once, and we never stopped to open a chart unless it had orders on it!! Just barely able to suction, give meds, turn, etc... Usually if it's a 3 to one ratio in ICU, it is very hard, 3 to 1 on CCU may be better, but cardiac and fresh MI's can be like little time bombs that will go off when you least expect it, and like Matt said all heck will break loose. 2 to one ratio is good, but as a new grad be SURE you will have a free preceptor who is not counted as staff, you should both be counted as one person for at LEAST 6 weeks. Get them to put you in the ICU cource asap. Take ACLS, and read read read, and ask questions!!

Good luck, and go for it!!!

RNforLongTime · May 9, 2002

I work in an 8 bed ICU. We do primary care for our pt's. We have no Nursing Assistants to help with baths and such. I work night shift and if I have 2 patients I will do my best to see that one of them gets bathed for day shift. If I have a sedated vent patient, I'll wash them up.

Ask lots of questions, I've been an RN for almost 5 years with 4 of them being med-surg and feel like a new grad all over again. ICU nursing is a little of both--watching monitors, suctioning, charting. I do a lot of written charting. No computerized charting in my ICU.

Good Luck!

jfpruitt · May 9, 2002

Thanks for all the wonderful replies. This helps a bunch :)

mattsmom81 · May 9, 2002

Well, Jennifer, I may be the voice of dissention here, but I

don't usually recommend new grads go to ICU until they have spent some time solidifying their medsurg knowledge base, and gaining confidence in the basics. Nursing schools do not offer much of this anymore, IME, and new grads seem to need the OJT. Talk to your instructors and get their input...as they will know what's available in your area for new grads.

I have worked with a FEW successful new grads in ICU, they came through extensive critical care internships on day shift...at least 3 - 6 months in length, in large facilities with very strong, committed program leaders. The program I was affilliated with only rarely accepted new grads; 1 yr minimum medsurg was preferred. Standards for admission were high and required instructor/supervisor recommendation. The unit staff was also committed to the newbies, and we were staffed appropriately so we could spend a LOT of time with these new grads/interns.

Not every facility out there can offer this, and I have seen new grads flounder and truly regret their venture into ICU when the circumstances were NOT as I described above....things can get pretty hairy in critical care, disastrous when you don't have supportive and knowledgable coworkers.

Night shift is frequently understaffed, sometimes quieter but MANY times NOT, and experienced nurses are better choices for night shift, IMO, as we have to really know our stuff. Docs expect an experienced set of eyes on their patients at night.

Some young nurses want to work ICU because they want low patient ratios, but imagine your shift spent in code situations/life and death for 12 plus hours straight...often no docs around to help...you get to wake them up (and they aren't happy) and try to get orders to save lives.....this is what nights in ICU are like many times. This requires a confident, extremely skilled, knowledgable nurse. When a code is called in the hospital, ICU responds....if the patient survives, it becomes YOUR patient; there's nowhere to run....LOL!

Good luck in your venture if you decide this is for you! The nice thing about nursing is all the options! :roll

Goofball · Jul 9, 2002

How busy you are depends a lot on what type of ICU you are working in, and how many beds in the ICU, and who is in charge each shift. Our ICU is 24 beds total, and mixed, varied diagnoses (example: Subarachnoid Hemorrhages with ICP monitors, MI's on Tridil drips, COPD/Pneumonia on ventilator, Suicide Attempt/O.D., GI Bleeder actively bleeding, Septic Shock; these are just a few of our common diagnoses, but you can expect any old thing to come in the door. Our pts average age 70 and have at least 3-4 critical diagnoses going on at the same time, and a history of multiple other problems. I spend nearly the whole shift on my feet running, but I am an i-dotter and a t-crosser. If you are not as obsessive-compulsive, you may be more lax and sit and visit more, or spend more time on your paper than with the patient.

The families eat up a LOT of time on dayshift. They do have needs too, but it can really put you behind; so you have to be very quick/efficient/organized. Our visiting policy is very lax, we are not allowed to keep people out.

So you need to be a people-person too, in a unit like this.