New to the ICU Cheat Sheet

[chemshark, BSN, LVN, RN]

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I created an ICU cheat sheet. Though not exhaustive, it helped me when I felt overwhelmed.

Most days when I get up in the morning, I have a routine: I wake up, take a shower, iron my clothes, eat breakfast, brush my teeth, comb my hair, get my things and go. But when you're in the ICU, things are different. You have your IV drips and they are running nice and smoothly, but then something happens. Your patient starts to crash and the resource nurse is busy helping someone else. So hopefully you memorized the orders and parameters and are able to titrate your various drips according to protocol. If you have time to document each and every single dose adjustments, when they were given, what the dose, rate & volume was, and what time, then great. But that's not likely going to happen.

After a few days of the ICU, I felt that it was quite slow. Most of the nursing skills I practice were quite rote. For example, I hung IV bags, gave meds through the OG tube, or turned the patient every two hours. On days when I came in early, I already the patient's H&P down, noted the plan for the day, active orders, lab draws, and MARS. All I had to do was keep up with it and it would be fine. Maybe a family member would come in and fall into tears, but I had learned to expect it. It was better than the alternative, which is when patients' families would scream and yell in the medsurg because they thought it was a restaurant and nurses were the waiters. In the ICU, the nurses were the main source of communication & comfort for the family because they are able to translate what was going on. The family also sees--and are usually thankful for--the hard work that you do because they are in the room right there with you.

Another advantage of being by the bedside constantly is that when patients' status changes often, the nurses are the first person to notify the medical team. One time I had a patient who had her tube feedings turned off and when I received her from the night nurse, her intracranial catheter dressing was undone, she had bitten through her tongue, and there were orders for her to still be on hypothermic precautions even though she was taken off the Arctic Sun machine. I had to discuss these issues with the team during rounds so that they could update the orders for me. But what was really important was that the parameters for the IV drips were updated as well.

Sometimes the doctors preferred to monitor the patient using MAP instead of the SBP, or they would change the parameters if the patient was too sedated or not enough. This would then change my orders for giving 3% hypertonic solution, or Mannitol, or Fentanyl depending on how the patient reacted to those numbers. I had to remember what dosage strength was ordered initially and what the maximum dose was allowed. And since my access was usually limited, I had to choose which lines were compatible, which lines I could temporarily suspend in case I had to draw ABGs or suspend heparin if I was drawing from the PICC for a blue top. It took too long for me to access Micromedex so I relied on my preceptor's experience to know which medications mixed with what. Mainly, nothing mixes with anything filtered, viscous, or high-risk, e.g. propofol or 3% NS, or heparin, FFP, or even diabetisource.

More than once, a seasoned ICU nurse would tell me, "If you no longer have the fear [of making a mistake & killing someone], then you have no business being in the ICU anymore."

I hope I never lose that fear. But then I take a look at my "tree of life" and I find that that's not going to be the case for a long, long time.

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