A Day in ICU
by Jamie Schultz
Amanda arrives in the ICU at 6:55 a.m. to begin her shift. She is looking forward to shift-to-shift rounds to overview all the patients in the unit. Amanda receives her assignment based on continuity of care and acuity of the patients. First patient is a patient she admitted the day before with exacerbation of COPD and on a ventilator. Second patient, an open-heart patient from the other day, is selected for Amanda because of her competence in cardiovascular care. Amanda is also precepting a nursing student today and both patients are great learning experiences.
Once Amanda receives a comprehensive report from the prior shift nurses, audits new orders during the night, and reviews the medication record and recent lab values, she and the nurses round to allow for a quick visual review and introduction to the patients and families.
At 7:30 a.m. Amanda and her student nurse do a complete assessment of both patients, noting potential concerns and evaluating treatments. She is correlating her shift report with the presentation of the patients. At this time she also tries to discuss with patients and families the plan of care for the day until the physicians make their rounds. This also gives the patients and families an opportunity to voice any concerns or questions so Amanda may act as their advocate throughout their hospital stay.
Amanda then begins to discuss the plan of care for the day with her student. She and the student also begin to do their computerized charting.
At 9:00 a.m., Amanda quickly prepares for multidisciplinary rounds, during which she will present her two patients and plan of care for the day. Amanda helped head up a committee that created the rounding format, sharing pertinent details for her patient’s care with the medical director, intensivist, resident, clinical nurse specialist, pharmacist, social worker, chaplain, respiratory therapist, occupational or physical therapist, and dietitian. Amanda proceeds to present her patients and seeks resolution from the team on any issues that could impede her patient’s progress. The rounding process has also become an opportune time for the other disciplines to input their expertise as well as a great opportunity for teaching.
By 9:20, Amanda is satisfied and confident that her patients’ progress is on track. At this point, she begins her medication administration for both patients. She instructs her student on medication safety and two patient identifiers before administering the medications. Amanda also teaches the patients and families what they need to be aware of as they may go home on these new medications. She is able to consult care notes on the computer to give the family printed information on the medications.
As Amanda is finishing up medications, she begins to teach her student about the ventilator on her COPD patient. She also addresses and demonstrates the importance of oral hygiene to prevent ventilator-assisted pneumonia, the importance of a sedation vacation to monitor neurological status, and the importance of turning every two hours to prevent skin breakdown.
Amanda is finishing up her care when the pulmonologist walks in to see the patient. She gives the doctor updates on the patient’s status and addresses any questions the family has. The family is concerned about their loved one not seeming to make any improvements and is becoming confused about all the different information each specialist is giving them. Amanda suggests having the social worker talk with them to set up a family meeting for the next day with the primary caregiver and the specialists that can attend.
After the pulmonologist sees the patient, Amanda, the doctor, and the student nurse sit down to review orders, medications, and labs as they pertain to the patient’s respiratory status. Amanda will repeat this process throughout the day with each consulting physician as they make their rounds. The pulmonologist wants to make changes to the ventilator and then repeat ABG’s one hour after the changes. Amanda notifies the respiratory therapist of these new orders. The orders are then given to the unit secretary to transcribe into the computerized ordering system. Also since the social worker is stationed within the unit, she discusses the concerns of the family and the need for a family meeting.
Another coworker of Amanda’s asks for help in another patient’s room. Amanda is happy to help for she knows how important teamwork is. After assisting her coworker, she sees the nurse practitioner for cardiovascular surgery is here to round on her open-heart patient. Amanda gives a quick overview of the patient’s status, pertinent lab results, and the suggestion that the patient transfer to ICA based on the discussion at rounds today. Amanda reviews with her student the benefits of transferring the patient. After reviewing the new orders and passing the patient’s medications, Amanda calls the ICA unit to give a nurse-to-nurse professional exchange report. As Amanda is giving the report, the ICU clinical leader assists with transferring the patient.
Amanda then proceeds with her care of her COPD patient, keeping up on her patient care, charting, and physician updates. She gives a quick report to her coworker and then takes a break for lunch. As she returns, she checks with her coworker on her patient’s status and takes a report so her coworker can take a break.
While Amanda was at lunch, the ICU clinical leader responded to a rapid medical response. The leader calls Amanda to set up a room for this patient. Since Amanda’s patient is stable and she transferred her other patient she is able to accept this new patient.
The new patient is quite unstable, so Amanda must monitor him/her very closely. Respiratory therapy is also at the bedside to assist with the patient’s oxygenation status. Acute dialysis arrives per the doctor’s orders for stat hemodialysis. Pharmacy is notified of stat vasopressor drugs to be made for Amanda to administer to the patient. As her other coworkers continue to care for the patient, Amanda talks with the family about the plan of care and provides close emotional support. She assures them the doctor will be in shortly to speak with them and if they would like, the hospital chaplain is available to offer support. Soon the patient becomes stable. The vasopressor drugs are maintaining the patient’s blood pressure and the hemodialysis is assisting with the patient’s oxygenation demands.
Throughout the rest of Amanda’s shift she continues her frequent monitoring, assessments, patient care, lab draws and other tests or treatments, medication administration, charting, updating physicians and families and educating patients and families.
As the next shift of RNs arrive, Amanda prepares for her shift- to-shift professional exchange report.