New to ICU? What have you learn so far?

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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 ICU.

i come from a low-tech country hospital which is one of 15 hospitals in a large system. we ship many patients to our mother ship which is a huge hospital equipped with state of the art medical technology and cutting edge procedures. however, my little hospital does a great job with copders, chfers, pneumonias, etc. we don't do cardiac caths, swans, etc. the most technological monitor i have in my icu is cvps (our motto is "yesterday's technology tomorrow.")

with that being said, my tip is to watch urine output closely. it is often the first sign that the patient is crumping and it is really the only way in my low-tech icu environment that we can directly measure profusion. the kidneys are the most sensitive organs to profusion changes. if they aren't getting properly profused, urine output starts to drop subtly. if the kidneys are getting fed, neither are the rest of the patient's vital organs.

don't get me wrong, i love my monitors, cvps, etc., but a patient's foley can be my best friend. also, with hypotensive patients, the map is more important than the s/d bp numbers.

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the most technological monitor i have in my icu is cvps (our motto is "yesterday's technology tomorrow.") [/size]

:up::up:

your eyes and ears are your best assessment tools! being able to perform a good and comprehensive physical assessment is so important and seems to be lost amongst some nurses and other clinicians. the monitors, the technology, the numbers are all fantastic adjuncts in patient management but always assess your patient. does your assessment data agree with your technological data?

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I've learned to ALWAYS, ALWAYS order more pressors ahead of time before you even get close to running out....lest the Levo runs out and the patient drops their pressure (with no replacement bag to hang). And never, ever stop a pressor when changing the bag- leave the pump running and leave the drip chamber at least half full.

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Specializes in critical care, PACU.

^ yeah I learned that lesson when I saw my patient's bp drop to 60 while my preceptor frantically prepared a new drip his self.

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Specializes in CVICU.

To add to the last few posts: always make sure the pump is programmed to run out of volume before the bag of pressors does and the pump sucks air. You might find yourself like me, fantically digging through lines and tubes to disconnect the line and reprime it with a new bag while your blood pressure is dropping.

Another thing I've noticed, be VERY careful when reprogramming the pumps in any way. You may be trying to add volume into the pump settings but instead change the rate or vice versa. I did this to my insulin gtt and noticed it as soon as a pressed OK and watched 2-3 drops of insulin fall into the chamber in about 4 seconds.. I set it to run in at 100 ml/hr and thank god I saw it right away.

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Specializes in MICU, neuro, orthotrauma.

Another one to echo ordering pressors ahead of time (I message the pharmacy as soon as I hang the gtt) and be sure, even if you think you hit all of the numbers right, make sure you actually hit all of the numbers right by double checking the pump and the gtt. I have made both of these errors, too and the scrambling afterwards was enough to give me a heart attack!

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ask for help from the charge nurse or another nurse whenever you make a big autonomous decision, even if you already know what you want to do.

what are some decisions you've made that you wanted to ask for help even though you knew what you wanted to do? would you always want to check with another nurse or should you just trust your instincts? can you tell i'm a new grad? :o

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Specializes in critical care, PACU.
what are some decisions you've made that you wanted to ask for help even though you knew what you wanted to do? would you always want to check with another nurse or should you just trust your instincts? can you tell i'm a new grad? :o

just like when to call the doc, when to treat bp (esp if you are also treating for pain and anxiety too), whenever you may possibly be choosing to stagger bp drugs or give them all at once, giving insulin when the patient is NPO, IV fluid is cloudy, patient's bp is in the toilet, fever, etc

It helps develop trust with the unit if you ask first and it's always good to have that charge nurse supporting your decision or teaching you to do it a better way. You should try to feel the unit though, because some units arent as big on questions.

it's so funny too because even though I ask about all those things, on my eval, I still was told that I should ask more questions hehehe.

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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!

Also, if your patient has recently had IV dye (like for a PCTA, etc) do NOT give Metformin for at least 48 hours, or you will send your patient into renal failure! (recent experience, didn't give it, but came close)

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Specializes in ICU/PACU.

I'm not SO new anymore, but I'll play...

Check your alarms the beginning of the shift. ALWAYS. Make it one of the first things you do when you go in the room. Never ever turn an alarm OFF. Sats low limit set at 85% by previous nurse, and I don't hear it alarm until it hits 84%? By the time I get to the room the patient is BLUE. Yep.

Always check your drip rates at the beginning of the shift. A SERIOUS thing you MUST do! No matter what! You WILL find them calculated wrong into the pump. These drugs can kill a pt if given at the wrong doses.

Don't be afraid to call a doctor. I started off in a unit where the docs were a-holes and we were all scared of them. Call. Always cover yourself.

Ask your charge nurse or someone with some experience what they would do. Always ask questions. Do your best to look up drugs first, but other questions I ask all the time. I don't care if I'm annoying;) And I've been a nurse almost 5 years.

As a new nurse I remember some of my mess ups:

turn your patient every 2 hours - check for a BM - you don't want to be written up for leaving a pt dirty for the next shift (and of course bad for pt)

clean up your room. some nurses really get ****** off if you leave a dirty/unorganized room for them next shift and I was written up for this my first year as a nurse.

Try not to let mean pts get to you. I had one pt request I not be there nurse while my other pt was telling me what a wonderful nurse I am and asking for my address to send me flowers. You can't always win with your patients...no matter how hard you try.

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Specializes in ICU/PACU.

Some more..

Help your neighbor. Do your best. If your swamped sure you can't help. But when pts are admitted especially or going to / coming back from CT scan you should really go in the room and help. Your coworkers will like you this way. Personality differences happen but if you help your coworkers and play as a team, you will most likely get along with people.

A nurse taught me the 2 A's. Access & airway. Think of that when you go in the room. Always make sure you have good access. And always check on the wall what the o2 is set at. Don't go by verbal report only.

Pay attention to the basics. Tachycardia, low BP, low UOP. Watch these things. I know it's basic, but as a new nurse I remember sadly...not doing anything about my tachycardic pt with a low bp. I just didn't know better. I think she ended up going septic.

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Specializes in MICU, SICU, and transplants.

Wow - these are great tips! I especially like the low-tech ones because a lot of times people are focusing on the more advanced measurements. I am not starting my nursing position in the MICU until October, but for right now (as a tech in same MICU) I am going to start practicing the basics I have learned here.

Thanks to all of you who contribute to this post!

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