New to ICU? What have you learn so far?

Specialties MICU

Published

I am new to the ICU. I thought we could start with experiences to help us use our critical thinking skills. Any one?

Specializes in CRITICAL CARE.

1) Don't ever leave pt.'s bedside when draining from a ventriculostomy/lumbar drainage.

2) when docs schedule for out of unit tests such as CT scan, try to consolidate all other tests they may want, specially on unstable patients.

3) always get an ekg on a deviation from baseline heart rhythm. you may not know what it means but that's what the docs/cardiologists are for.

4) always consider these factors on all patients: acid-base balance, electrolyte imbalance, and baseline neuro status.

5) consider the amount of labs your collecting on a patient on a daily basis before you report a threading down hgb

6) hgb, inr, and platelets are big ones for post-op patients

7) SvO2, SVR, CI, lactate, bands are big for septic patients

8) assess respiratory status frequently when giving a pt. lots of fluid boluses + transfusions. when it tanks to

9) when a pt. comes in with unknown duration of a-fib, make sure they're anticoagulated before docs attempt to convert rhythm.

10) consult the docs for electrolyte replacement if patient is under-going continuous renal replacement therapy + consult pharmacy drugs your giving are dialised or not

Up Vote Up Vote ×
Specializes in LTC, SICU,RNICU.

Clear your IV pumps at the end of the shift when you write your input and output down.

Check access when you first lay eyes on your patient. This is wonderful to know when your patient crumps 15 minutes after you get there.

If your patient is coherent, make sure you warn him before pushing adenosine.

When you hang a secondary line with your IV fluids, make sure you see it dripping and that it's not clamped.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry/PCU.

I love this ;)

Better to look stupid and have a live pt, than to try and look smart and have a dead one. :)
Up Vote Up Vote ×
Specializes in Cardiac Telemetry/PCU.

Exactly the kind of thing I'm eager to learn; that can only be learned by experience and great mentors. Thanks for sharing :)

Had a pt on Neo, levo, Epi, Vasopressin. We eventually turned off the vent and he died. At one point his pH was 6.9 and blood pressure was in the low 70s. After the bicarb, he came up a bit (high 80s). The charge nurse said "thanks to the bicarb". I am still learning so I asked him to explain. He said the pressors wouldn't work well in the acidic environment. He went on to explain that acidosis also decreases the body's response to catecholamines.

Love learning all this stuff.

Up Vote Up Vote ×
Specializes in ICU.
Had a pt on Neo, levo, Epi, Vasopressin. We eventually turned off the vent and he died. At one point his pH was 6.9 and blood pressure was in the low 70s. After the bicarb, he came up a bit (high 80s). The charge nurse said "thanks to the bicarb". I am still learning so I asked him to explain. He said the pressors wouldn't work well in the acidic environment. He went on to explain that acidosis also decreases the body's response to catecholamines.

Love learning all this stuff.

I learned about this concept while I was still on orientation as a new ICU RN. Had a patient who was an organ harvest and my preceptor explained to me why the bicarb was so important, despite all the pressors the patient had been on prior to our shift.

Some things need to be written down and tucked away for future reference because you might not see them again for a very long time.

Up Vote Up Vote ×
Specializes in Trauma ICU, MICU,Tele. PCU, IMC.

When you are preparing your admit bed, get a bag of 1L LR and 1L NS ready. You never know which you will need, but if your patient has a low BP, it's great to have your bolus on hand and ready to go.

Also when preparing the admit room, write your labels ahead of time. Even if you don't use all of them, as soon as you are spiking the bag of Fentanyl or Insulin, you can label without missing a beat. This way you won't bolus or give the wrong med for the wrong dose by accident.

Have your suction canisters all set up and ready to go. Check the tubing and lines at the beginning of your shift. Make sure the pressure is correct. Especially with trauma admits or stat intubations; having oral suction is critical.

If you are going down to CT, ask the doctors what CTs they want ahead of time. It sucks to take the patient down for a CT head, come back up, and then have to go back down 10 minutes later because the doctor decides to have a CT abdomen as well.

Up Vote Up Vote ×
Specializes in Cardiac Telemetry/PCU.

Great tips, thank you very much! :nurse:

When you are preparing your admit bed, get a bag of 1L LR and 1L NS ready. You never know which you will need, but if your patient has a low BP, it's great to have your bolus on hand and ready to go.

Also when preparing the admit room, write your labels ahead of time. Even if you don't use all of them, as soon as you are spiking the bag of Fentanyl or Insulin, you can label without missing a beat. This way you won't bolus or give the wrong med for the wrong dose by accident.

Have your suction canisters all set up and ready to go. Check the tubing and lines at the beginning of your shift. Make sure the pressure is correct. Especially with trauma admits or stat intubations; having oral suction is critical.

If you are going down to CT, ask the doctors what CTs they want ahead of time. It sucks to take the patient down for a CT head, come back up, and then have to go back down 10 minutes later because the doctor decides to have a CT abdomen as well.

Up Vote Up Vote ×
Specializes in Not too many areas I haven't dipped into.
One thing I have noticed on my unit is that the seasoned critical care nurses are more helpful when I ask for their opinion if I tell them a) what the problem is and b) how I plan to fix it. The more experienced nurses know that we don't know everything, and they expect us to ask questions, but they also expect us to at least have a battle plan ready for them to review. Don't just go ask them "What would you do?", ask instead "This is my problem, this is what I'm thinking will work, what do you think?". You'll get a better answer, and if your solution is the correct one, not only have you gained confidence in yourself, but you gain the confidence of the people you work with as well. Mucho important!

This is soooooo important. I do a fair amount of orientation and I always want every nurse to come to me with what they think they should do so we can work through the thought process. If you always just get fed an answer, then you take that answer at face value and just do it without knowing why. To me, WHY is the most important question of them all..lol.

Always try to keep one line designated at your code line meaning if something happens, this is like your NS line where you know you can push critical meds to keep your patient alive.

Always always label all of your lines and keep them from looking like a tub of worms so you know exactly where everything is when times get tight.

keep your rooms neat and supplied because when the crap hits the fan, you do not want to kill brain cell time by moving stuff around in the room and searching for stuff.

Up Vote Up Vote ×
Specializes in Not too many areas I haven't dipped into.

Your alarms are your friends. Don't ever turn any of them off and set them to how you want them and whatever is specific to the patient. Too often, nurses will just keep the standards and not really use the alarm settings as a way to see changes in their patients.

Never ever take report as the gospel. Sometimes, we repeat what we are told by another and it is like that game where you tell someone something and after it makes it through 12 people it is no longer recognizable.

Always document what you see and hear. Just because the last 5 nurses charted clear lungs and sinus rhythm does not mean that the patient is still like that.

always look at the patient first and the technology second. If lines are not zeroed appropriately, reading can be wrong and you are treating a monitor instead of a patient. Technology is great, but your eyes and ears are your best friend.

always help others around you because it not only gives you a chance to see other patients and how other nurses work but it fosters a rapport with your team mates and they will be more willing to help you out in a pinch.

if something unusual is going on in the unit and it is not your patient, go check it out anyway. Every day is a learning experience.

When the doctors round, be a part of it. You learn their thought processes and build a relationship with them. They are more apt to respect your insight when you are calling them in the middle of the night and you really have nothing to report except you "feel" something is going on with the patient.

don't take what patients say to you to heart. They are not at their best and half the time, it has nothing to do with you at all.

Up Vote Up Vote ×
Specializes in Not too many areas I haven't dipped into.

also, look at lab trends and vital signs trends and not just what happened today.

Look at rhythm strips over the past few days. It is amazing hte subtle changes you can se that might be important.

Up Vote Up Vote ×

I've made a notebook I labeled "ICU Pearls" full of the 'pearls of wisdom' i've collected from the seasoned nurses. Some of the best tips I've gotten are:

1- always make sure that your pump is programmed for the concentration of the drip you are running

2- chart the concentration of the drip bag on your initial assessment

3- always zero your invasive lines at the begining of the shift

4- dont ask for or use dopamine as a pressor if your pt is already tachycardic (you can ask for/use Levo instead)

5- ALWAYS ALWAYS ALWAYS make sure you have IV access, preferably large bore (a 20 is good, but 18 is better). I won't take report on a pt coming to ICU unless they have at LEAST 2 IVs

6- take the initiative, meaning don't wait until an hour before shift change to see what your coworkers need if they are busy and you aren't.

7- right after you take report, check your labs and orders to see if there is anything you need to call the MD about, especially if you are working nights.

8- talk to your patients and their families about what THEY want for end of life care. dont wait until your pt codes, and have the family screaming at you "This isn't what they wanted!".

9- trust YOUR gut... even if it seems silly, that instinct is there for a reason.

thats all i can think of for now, but i'm sure i will think of more

Up Vote Up Vote ×
+ Add a Comment