My First Day at the Neuro ICU

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    I work in a Neuro ICU. It is a brand new facility that has opened only a year ago. It is much more progressive than most other hospitals I've worked in.

    My First Day at the Neuro ICU

    This is not med/surg. This, of course, means that most of our patients are on vents. They usually assign us only 1-2 patients here, but they are quite acute. But, I also think that my med/surg experience helped me out a lot. For example, most of our sickest patients are on a minimum of six(!) drips. I usually keep two TKOs and draw blood from an A-line. Since this is a neuro specialty, many of our patients are on ICP precautions and use drains to allow the CSF to seep out. The monitors are connected to every part of the patient and they are usually on a Foley or dignity tube (which collects feces). Depending on the situation, each patient is hooked up to a vent, an exterior ventricular drain (EVD) for CSF, an A-line which also has a transducer, and an EEG to read brain waves, lumbar drains, and multiple drips. Since I work during the day, I send many of our patients down to CT scan for an angiogram or a surgical coil to plug up their aneurysm, and to surgery so they can get the catheters inserted into the ventricles of their brain.

    My basic responsibilities include hanging lines and drips, maintaining the monitors (except for the vent) & ensuring all waveforms are accurate, supplying emergency airway equipment & maintaining the airway until the RT arrives, administering medications via OG tubes, inserting NG tubes, and drawing labs. Nurses here are more apt to chart by exception so it's not as hard to chart as it was in med/surg. But med/surg helped me to become more comfortable with hanging piggy back lines and mixing antibiotics and other high-risk IV meds.

    What's different about ICU, other than equipment, is that patients look serene because they don't talk to you. But right when you start to go on break, they usually crash and all kinds of monitors are beeping: the Spo2 has gone down to 87% because a patient is desatting, and their b/p is high because they are in pain or are agitated because the family members keep trying to wake them up from their coma, or their labs are off whack simply because they are decompensating. When it comes to physical problems, something is always related to another.

    MY FIRST DAY

    Another thing that I've noticed is that ICU nurses must be more keen to criticize medical interventions. I have a story of my first day here.

    Since many patients would be in too much pain due to their medical condition, they must be sedated and thus are unable to communicate. Every hour, I do my nursing checks to make sure everything is on the up and up. This includes neuro checks.

    The difficulty of neuro brain injuries is that there are few physical tell-tale signs of distress. The brain does not always make profuse amounts of CSF and propofol keeps them from waking so you cannot ask the patient to respond to your commands or inspect the sheets to see if they're bleeding out.

    You can, however, inflict pain. LOTS of pain. You can either pinch them in their traps, or hands or thighs or sternum. It is in the hopes of gaining insight into their basic brainstem functions.

    I had to do this to a poor man who came in due to a spontaneous ruptured aneurysm. His whole family was there. They were quite supportive and talkative, but every time I went into the room to do my checks, I had to inflict pain into him somehow. This caused a hush to come into the room and I would feel ten pairs of eyes watching me pinch, harass, and yell at their loved one.

    Nevertheless, they showed that they had complete confidence in me even though I had introduced myself as a student nurse earlier.

    The nurses warned me that families have little to no neuro experience so they perceive that every little twitch made by the patient is a sign that he/she is going to fully recover.
    Unfortunately, this is rarely true.

    At the tenth hour, I still had no reaction-and things were looking grim. I yelled and screamed and pinched the patient as hard as I could but...nothing. I looked intently to see if he reacted to any of my stimulation. After a minute or so, I retreated to the computer inside the room to document my findings. The EEG readings hadn't changed.

    I could hear the family shuffle slowly past me as an entire group and when I walked back up to the nursing station, they were in a forceful huddle. A few looked intently at me, but went back to consoling their mother (the patient's wife).

    After the shift, I went home. I plopped onto bed, eager to get some sleep. Right then, I sprung up in bed. "Should I have turned off the Propofol before doing my painful neuro checks???"

    When I returned to shift the next day, I walked in and saw that the bed my first patient was in was empty.

    "Hey, what happened to the patient that was in this room?" I asked the charge RN.
    "The family decided to withdraw care."

    At this point, I panicked. Did they make the decision to let their dad go because of me? How did that make his poor wife feel? Could I have changed the outcome of this decision? I felt like my heart fell all the way down to my feet.

    I confessed my worry to my preceptor and the other nurses. But they all swarmed around me and reassured me that it was not my fault. There was no way I should have taken the patient off sedation to do an accurate neuro check because the patient was in too much pain and ventilated with an ET tube that it would be nearly impossible to stabilize him if he decided to buck the vent and crash.

    This made feel a whole lot better about myself, but not so much about the family's situation.
    Weeks later, I find that this is the norm in the ICU. Most days when I return, the patient I had cared for is gone.
    Last edit by Joe V on Jun 14
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  3. by   Okami_CCRN
    Interesting that you bring up doing neuro checks while the patient is sedated, When I work in the Neuro ICU patients are sedated to a RASS score of 0 to -2. We usually pause sedation for a few minutes and do a neuro check and then resume sedation when complete.
  4. by   DaveICURN
    Here in our ICU, albeit more of a stepdown ICU, we use a "Sedation Vacation" once a shift to assess functions. We titrate down on "Rule of 5" and allow the pt to wake, check function, possibly answer questions, and then titrate back up. Our PTs are far more stable than yours, being a neuro unit, so this idea probably not going to be one for your hospital. But its nice to hear a story of a unit that rallies behind a nurse instead of leaving them out to dry.
  5. by   shamrock62
    This describes my day(s) perfectly!!! I also work in a Neuro ICU. I also believe that my medsurg days helped to make me a better Neuro ICU nurse. I can have as many as 9 medications infusing at one time plus the EVD, EEG foley, dignicare, A-line and central lines. Not to mention the large family that watches over your every move. Those days can be extremely hard but in many ways, also rewarding. some of the outcomes are good but just as many are not.....i also feel that it is an honor to be with a patient and their family during the most vulnerable times in their life. I feel that I will always make a difference - no matter the outcome.

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