Subtle Changes?

[NurseBatzy]

Hi Everyone,

I'm a new grad RN who just accepted a position in a small ICU unit. I've read through many of the posts here, and see a theme of ICU nurses needing to watch for "subtle change." What subtle changes do you most often see, and what do they mean?

Also, does anyone have any advice for starting in the ICU? Other than the obvious "know your meds, know your lab values, know your pressures, etc..."

Thanks in advance for sharing!

NurseBatzy

[ICUenthusiast]

Subtle changes..

Easy example: sign of cushing triad (increasing cranial pressure) is widening pulse pressure. If you do not actually watch the trend, you may not pick up on this sign. This is common in vital signs and labs.. don't just look at most recent, go back and compare the days. If there's a trend (up or down), take note and think of why it might be.

Common example of subtle changes & trends: nurses just keep increase the O2 for someone (or FiO2 if ventilated) little by little. After a week, the patient dies from something breathing related. It could've been prevented if the nurses noticed the trend of increasing the O2 every shift.

Then, if you have had a pt once before, you can pick up on in subtle changes in personality/demeanor and level of consciousness better.. Though they can be hard to if it's a very slow change and you haven't had a patient before. e.g. a pt of mine last night was very alert and awake (ventilated and weak though, couldn't speak). Tonight I came on shift and found her very very lethargic when I just pass by her room. When I get report, I find out they had been doing breathing trials all day.. From knowing the patient (actually had her going on 7 nights whew), I knew these were interrelated, luckily nothing more serious.

[NurseBatzy]

Thanks for the informative reply! I will remember your advice when I start next Monday, although I'm sure no one will leave me alone with patients for some time.

[ICUenthusiast]

Even tho you're a new grad, you'll be expected to start picking up on the trends quickly... it's very important in an ICU area. So even if you aren't going to be alone for some time, act like you will be anyways. You'll get the most out of your orientation that way. (Of course the first couple days on the floor might be shadowing and just learning where things are etc, especially if you did not ever work on the unit as a student.. but I think you understand what I meant.)

[MomRN0913]

Continum of care is the best way to note subtle changes. When you work back to back shifts, you will have the same patients most of the time. You really get to know these patients. Hourly VS are taken for a reason. If you feel somehting is changing, look back back back and notice a trend. You will notate the mentality of you patient, you really get to know them when you have a 2:1 ratio. It comes with time. When you see something once, you will be keenly aware of it the next time you see it.

The ICU where I come from has really good teamwork. If I had a patient for the first time, and if I wanted to know if something was "normal" for them, i would find out which nurse I was on shift with might have taken care of them. Vice Versa.