A question about ICU nursing, taking report, and care in general?

oMerMero · May 3, 2007

Wow, your instructor expects you to know the basics of ICU care after two shifts? That is not a realistic expectation. I had a semester long crtical care class in school, 120 hours of clinical, and then the months long orientation when I started working in the ICU a few years after I graduated from school. And it was still over a year before I felt like I could handle anything that was thrown at me. I would recommend speaking with your instructor and between the two of you, come up with a few realistic goals of what you want to accomplish during your time there. For example, care for a vented patient and perform oral care and ETT suctioning.

JesL2bRN2007 · May 3, 2007

Well, I have to perform in front of her on Saturday...I'm about to graduate so...she wants me to do what I can, I already asked her this. She wants me to give report, pass meds, suction...I do'nt have to take FULL care of the patient. Any tips or hints are really appreciated!

Creamsoda, ASN, RN · May 3, 2007

If youve never been in an ICU before, I feel bad for you...your instructor's expectations are a bit much. Hopefully you get a stable vented patient so there wont be too much to worry about. Ill give you a rundown of my typical routine.

-Get report

-review kardex, meds, and previous shifts orders, organize my day on a timeline.

-assess patient. Do it systematically. CNS, CVS, RESP, GI, GU, misc.

-Check vent setting, alarm limits, if patient is restrained, check restraints

-See what is running...infusions such as insulin, TPN, inotropes/pressors. Make sure all lines are labeled on the pumps and on the ports as to what is in that line. Check compatibility. Try to have 1 line available in an emergency that has something like NS only infusing.

-Reposition patient every 2-3 hrs.

-Mouthcare every 2 hrs.

-vital signs every hr or according to your policy, including urine output.

-Try and do any treatments like drsg changes, line dsg changes ect as soon as you can. Dont leave anything till last minute. Chances are if you do you wont get to do it because sh#t will hit the fan.

-Try and chart as soon as you can, at least your initial assesment. Abolutely do not leave charting till last minute. In ICU there is typically more to chart.

-Dr. rounds will happen sometime during the day so expect new orders.

-Sometimes you have to go on a road trip to CT, MRI, thats always fun but I doubt you will need to do that, or your preceptor will deal with most of that.

Hopefully things go smoothly while you are in ICU.

Last but not least, ALWAYS, ALWAYS ask questions even if you are the least bit unsure. The answer might not be what you are expecting. You want to graduate, so always be sure of what you are doing. The ICU can be an intense experience for new grads and students, but there is alot you will learn while you are there. Have fun! And if you are not too busy, and something interesting is going on in the next room, check it out and see whats going on.

As far as giving report to the doc on rounds or the next nurse, do it like your assesments. Go through the systems systematically. It may be daunting at first, but it becomes pretty routine. In our ICU we have premade report sheets that go through the systems.

Hopefully this will have helped somewhat.

Cher

JesL2bRN2007 · May 4, 2007

Yes it did, thank you SO much. There are so many lines and tubing in the room I'm so confused, is there any websites where I can visualize this? I hope i'm not being too pesky? Anyone? :uhoh3:

oMerMero · May 4, 2007

I am not sure of any websites. But just remember, when looking at lines and tubes, start and one point, and follow the entire line/tube to see where it start/ends. I do this at the beginning of every shift, so I know where my IV lines are going, and what is going with what. If the IV lines are not labeled, I label them after I check to see where everything is going.(either pre-printed labels, or write the drug and on a piece of tape and put it on the tubing) If you don't know what a line/tube is, find one end and follow it to the other end. Multiple IVs can be overwhelming at first.

SICU Queen · May 4, 2007

All the equipment and lines/tubing can be overwhelming if you look at it all at once. Take it one piece at a time.

After you briefly assess your patient then check the:

Vent: check your settings, if you're unsure, ask the therapist or look at their flowsheet. Look at the size of your et tube and where it's taped (cm, and which side of the mouth) For example: #7.5 ETT secure to R lip at 22 cm.

Aline, CVP: check where these are - aline radial right or left and patency of site, the CVP to which port of the central line. Zero them, ask the nurse to assist you if you are unsure as to how to do it.

IVs: Look at each bag hanging, then follow each tubing down to where it's infusing. If the line isn't labeled, label it. Write ALL of this down on a piece of paper so you can chart it. Note the condition of your access site (patent, not red, etc) Also look for "hidden" heplocks in the AC, etc... lol...

Do a complete head to toe assessment, including pain level. Make sure you print an EKG strip for the chart if that's what is done there. Do you have accuchecks? Meds due when?

When I first started I had a report sheet that included a box for every hour of my shift. I used that box to mark my labs due, meds due, accuchecks due. I also jotted occurences down in there as well if I couldn't chart them right away.

I hope I haven't confused you! These are just some things that came to mind. It sounds like your instructor is expecting a lot of you. Do you get access to your patient's info ahead of time? If you do, try to plan the day out ahead of time. It might not go that way but you'll have some sort of framework.

Remember above all to BREATHE. You can do this!

dorimar, BSN, RN · May 9, 2007

Oh my gosh! All those lines are overwhelming and confusing. I have been in ICU for 19 years, and my initial assessment always entails following the tubing from the start to where it ends (and if the lines are not labeled, then i label them) You MUST always know where your going to push stuff in an emergent situation. My initial assessment involves a lot more, buyt you got plenty of that from the others.

MKZ · May 9, 2007

There is some really good advice here. I wanted to emphasize report taking and giving. So far, these are my favorite kinds of days at work. When I get and give report I focus on the following:

I.1) Name age and primary diagnosis.

2) Events leading up to the primary diagnosis

3) Past medical history

II. 1) A brief overview of significant interventions (surgery, medication administration, intubation)

2) Tests performed (eg, EKG, CT scans, X-rays, cultures...)

This takes about three to five minutes

Then review the systems. How is the patient now? Discuss interventions as you go along...kind of like filling up your tool bag)

Neuro:

Alertness and orietation status, if they can move, pupils, grips, pain issues, reflexes, physical activity and limitations, significant psychosocial issues)

Cardiovascular

Temperature Hot or cold?

Heart rythym. Sinus or not so sinus?

Blood pressure conditions

Fluid staus

Skin

Wounds

Dressings and drains

Lines

Medication in the lines

Labs, focus on the basic chem, AKA electrolytes

Respiratory

Mode of breathing, lung sounds, vent settings, plan of care with vent settigs, secretions type and color, cough reflexes, incentive spirometer

Gastoenterology

How they eat, and how the poop. Bowel sounds, abdomens shape, size, tenderness. Tube feeds, residuals, blood sugars,

Urinary

Ins and out via the kidneys. Kidneys not working? then creat levels, dalysis or CVVH schedule, how is this person filtering? Foley in or out? Describe urine (this is where one can be truly creative...describe how it is)

I did not mean to write so much. This is a good review for me. I am sure I forgot something, but I hope this helps..)

nurse4theplanet, RN · May 13, 2007

Excellent posts.

I agree the most important thing you can do as a student in the ICU is to get a good report and perform a really thorough assessment. The learning opportunity for you is substantial, so soak up everything.

When I take/give report I like to start out by finding out why the pt is in ICU. Where did they come from (ER, MRT call, Cath lab, OR, etc.?) What events lead up to their hospitalization/history.

After I have a good idea of why they are in ICU, I go thru my ROS. Neuro...are they alert/sedated/confused. Respiratory...vent/o2/lung sounds. Cardiac...HR/BP/Rhythm. GI/GU...diet/feeding tubes/foley/I&O balance/accuchecks.

Then I ask about IV access, Drips they are on, Incisions/drains/CTs, who their physician's are and what specialties they are, Labs, recent interventions, scheduled tests/diagnostics.

I also like to know about the psycho/emotional needs and the family.

As the report is given, feel free to ask questions. Ex: If they have had a fever ...have they recieved tylenol, have blood cultures been drawn, what abx are they on, do they need to be screened for sepsis, etc.

After report, I like to take a minute to reflect on what my plan for the day is and 'worst case scenario' type situations to help me feel more prepared for the unexpected. Am I going to be weaning any drips? What do I do if my pressure bottoms out? If they are on an insulin gtt, do I have a copy of the hypoglycemia protocol on the chart? Do I need to call the physician about an abnormal lab? What happens if they pull out their ET tube?

Once I feel prepared, I check my Mars for Meds that I need to give that day to make sure I am familiar with all of them and give me an idea of how I need to schedule my time for the day. Do I need to get a morning accucheck and take 8am meds in the room with me. It is important to try and get as much done while your in the room, instead of running back and forth...especially if they are in isolation.

Once in the room, I go through my physical assessment in roughly the same manner that I recieved report...system by system.

I give them the once over (are they in any distress? diaphoretic? possibly in pain? sleeping? etc.) Then I check my vitals and get a wt. Next I check my lines and infusions to make sure everything is connected appropriately and infusing at the correct dosage and rate, especially wt based meds. Then I go thru the systems...Neuro, Resp, Cardiac, etc. I compare my findings to the report I recieved. Are there any changes? If so, why? Maybe something was left out in report...maybe it has changed.

After I get a good assessment on my patient, I then prepare myself for speaking to the physicians and family members. Are there important changes I need to report...which physician does it need to be reported to? Is it something that needs to be called ASAP or can it wait until the physician rounds? What updates need to be communicated to the family? The more you prepare yourself to answer questions, the more the families and physicians will feel confident in your competence.

Finally, I chart. Our system allows you to copy the previous charting...so I always do that to check my charting against the nurse before me. Again, it is just one more way of catching some important info that may have been missed.

Then I start working on my plans for the day. Dressing changes, transporting for tests, weaning drips/vent, giving blood, etc. etc. Whatever the pts needs are.