Intensive Care Nursing Role

meanmaryjean, DNP, RN · May 8, 2017

Have you looked into licensure yet? California is notoriously slow, and if you are educated outside the US- the process can take YEARS.

In the US, nurses are educated as generalists, and if you do not have the required coursework in peds, OB and psych, you cannot sit for the NCLEX.

Have you looked into all of these issues yet?

pjsrav, BSN · May 8, 2017

That was not my question! I already have a license and a ICU job offer in CA. I just wanted to know how's a ICU nurses day in the USA as I never worked there.

Okami_CCRN, BSN, RN · May 10, 2017

You should have received a document with a detailed explanation of your job description, you should read that over carefully as well as the CA Nurse Practice Act to aide you in what is your role as an ICU nurse.

pjsrav, BSN · May 10, 2017

Okami thanks for your input but let's be realistic the detailed explanation of your job description usually is very superficial. You always do more than what it's stated there. Would you be kind enough to let me know how is one of your days at the bedspace?

For example I work in a Cardiothoracic and ECMO Center unit. I start my 12hrs shift with the handover. Then I like to do a patient assessment (ABCDE or head to toe) in order to have a baseline for my shift. I usually have two medical bedside ward rounds (where I get a plan for my day and I can address my concerns) and there's always a doctor around. Apart from the basic nursing care (comfort/pain management, feeding and NG/OG insertion, hygiene, positioning and pressure areas assessment, drug preparation and administration, dressings and drains) I have autonomy to manage inotropic support, to take gases, interpret them and make ventilator changes or replace electrolytes. If the patient is a straightforward case and is not bleeding the nurse would be capable to manage the patient towards extubation and physically extubate the patient.

We help the medical staff with procedures like lines, trache's, decannulations, TOE's among others.

This is an example about the kind of information I would like to have cause someone told me that usually there all your meds come prepared, there's someone responsible for the ventilatory changes, there's someone responsible for positioning the patient. It may sound silly but I just wanted to understand the main differences

Okami_CCRN, BSN, RN · May 10, 2017

That's a little better information about what you want to know. I work on the east coast in a mixed medical/surgical ICU.

We have respiratory therapists who manage ventilators/respiratory treatments for the patient. However we (RN's) are ultimately responsible. Some ICU's also have techs or aides that help, such as getting blood products/equipment, delivering specimens to lab, re-positioning, toileting, etc.

I work primarily at night, so this is what my work flow is like.

I arrive about 15 minutes prior to the start of my shift, figure out what patient's are assigned to me and analyze their strips, see what they were trending like during the day and grab some flowsheets. I then take comprehensive report from the day nurse, once complete we go over to the bedside and conduct a quick bedside report where we greet the patient and go over their drips (make sure they are correct, confirm IV pump settings, etc), we also will look at pertinent issues together; for example if the patient is there for a craniotomy we will do a neuro exam together, if it was a whipple we will look at the dressings and drains together. Once this is done, I go over to the computer and review their latest labs, xrays, see if they have any medications due, etc. Once this is done I go in and do my head to toe assessments (at this point its approx 1930-1945) I will change central line dressings/a line dressings at this time if they are gnarly as well as other dressings. At around 2100-2130 I start giving meds, at 00:00 I will change IV tubing that is due to be changed, at 0200 I will draw labs, at 0400 replace electrolytes and such and bathe intubated patients, last med pass at 0600, get them ready for CXR/CT Scan, and at 0700 give report.

Sprinkled in between obviously there are re-positioning and glucose checks. The residents do a night time round at around 2100, but it is just 2 of them and not the whole team so it is very informal. We use an electrolyte replacement protocol, which works rather nicely. This is a pretty much straight forward night.

pjsrav, BSN · May 10, 2017

That's just the kind of information I was looking for. Thank you so so much.

We also do safety checks on the bedspace, check all the infusions and something that requires our close monitoring (like risk of bleeding points, wounds, blisters) with the nurse giving report.

About the charting you said you grab some flowsheets. Do you use paper charting then? It's a standard across US?

Here we have a very "handy" computer based program called ICIP (don't know if you heard about it) that every hour imports all the data from the monitor, assist devices like haemofilter, ventilator. So you just need to add the other bits. It's very usefull and saves you a lot of time.

Okami_CCRN, BSN, RN · May 10, 2017

It depends on the facility that you will be working for. When I worked in a large teaching hospital everything was computerized, but there was no connectivity between bedside monitors and the software; vitals had to be put in manually.

Where I currently work the ICU's are paper based in regards to vitals and on going assessments, the only thing we document in the computer is education and head to toe assessments because the current electronic health record does not support ICU documentation well. We will be switching to Epic, which is supposed to be much better and user friendly in the next couple of months.

I do have to say, I like my flowsheets.

pjsrav, BSN · May 10, 2017

:) Thanks Okami. It was really helpful and kind. Wish you all the best!

If anyone out there wants to add something else or share their experiences please feel free.

LovingLife123 · May 13, 2017

That's a little better information about what you want to know. I work on the east coast in a mixed medical/surgical ICU.
We have respiratory therapists who manage ventilators/respiratory treatments for the patient. However we (RN's) are ultimately responsible. Some ICU's also have techs or aides that help, such as getting blood products/equipment, delivering specimens to lab, re-positioning, toileting, etc.
I work primarily at night, so this is what my work flow is like.
I arrive about 15 minutes prior to the start of my shift, figure out what patient's are assigned to me and analyze their strips, see what they were trending like during the day and grab some flowsheets. I then take comprehensive report from the day nurse, once complete we go over to the bedside and conduct a quick bedside report where we greet the patient and go over their drips (make sure they are correct, confirm IV pump settings, etc), we also will look at pertinent issues together; for example if the patient is there for a craniotomy we will do a neuro exam together, if it was a whipple we will look at the dressings and drains together. Once this is done, I go over to the computer and review their latest labs, xrays, see if they have any medications due, etc. Once this is done I go in and do my head to toe assessments (at this point its approx 1930-1945) I will change central line dressings/a line dressings at this time if they are gnarly as well as other dressings. At around 2100-2130 I start giving meds, at 00:00 I will change IV tubing that is due to be changed, at 0200 I will draw labs, at 0400 replace electrolytes and such and bathe intubated patients, last med pass at 0600, get them ready for CXR/CT Scan, and at 0700 give report.
Sprinkled in between obviously there are re-positioning and glucose checks. The residents do a night time round at around 2100, but it is just 2 of them and not the whole team so it is very informal. We use an electrolyte replacement protocol, which works rather nicely. This is a pretty much straight forward night.

You manage vents? I'm curious as we have to have a physician order to change any vent setting which is then done by the respiratory therapist. I touch one or two buttons on the vent and only if my patient is having an issue.

pjsrav, BSN · May 13, 2017

Yeah, for example on a straightforward case which the aim is to wake and extubate you start weaning sedation and you can change from a mandatory mode of ventilation to an assisted mode when the patient starts waking and taking spontaneous breaths (enough to clear CO2). If he's on a high support (on assisted mode) you want to decrese it further and obviously check the ABG's to see if he's ready to extubation. When you have a good gas on an asisted mode with minimal support and an appropriate patient obeying simple comands you tell the nurse in charge and the doctor present and if they're happy you can go on towards extubation. Even in long term patients, if you know what you're doing and you feel confident to, you can make changes (which most of the nurses at my unit do). The only times when we tend to check with the medical team prior changes is for example on a very sick patient with acute lung injury when they usually are on ECMO and on a lung protective ventilation mode.

Wolf at the Door, BSN · May 15, 2017

That was not my question! I already have a license and a ICU job offer in CA. I just wanted to know how's a ICU nurses day in the USA as I never worked there.

Well you probably should have stated that in your original post. Plenty of foreign nurses thinking they are just waltzing in the USA.

ICU nurses shift depends on what type of hospital you work at. Private hospital for profit, not for profit, city/state/county, teaching, federal, or military all have different can's and dont's.