The Intensive Art

07:00–I’m sitting in the staff lounge with my tea in one hand. The day staff is trickling in. Between smiles, you can tell we are all miserable from being up so early and having to work. Everyone watches the large clock on the wall slowly move toward 07:15

07:15–We are given our bed assignment: just the bed number, the rest we will have to wait until we see our patient and hear report.

07:15–I walk to my assigned bed, curious about the acuity. Because I’m just a month of orientation, my patient assignments alternate between ridiculously easy, and slightly challenging (to me) but relatively easy for any other ICU nurse. At this point, a lot of my patients have been completely non-acute. They are walkie-talkies who have been waiting days for a bed on the floor. I’m used to taking care of 6-8 sicker patients than these ones. So, taking care of only one has had the tendency to lead to many head-banging boring moments.

I look at my patient: a moderate number of IV drips, ventilated. This may be one of my more challenging days. A thought crosses my mind: It actually is exactly one month since I finished orientation. That means another batch of newbies will be starting. That means no more easy patients for me. Time to step it up to the next level. I think I’m ready.

07:30–Report is done. My patient is a very tragic case, as most ICU stories are. She broke a hip and had respiratory failure post surgery so was never extubated. She ended up in the ICU paralyzed and sedated. When her respiratory status improved, they weaned the sedation and paralitics. She never woke up. Tests and EEGs showed brain death. A CT scan showed copious fat emboli in the brain stem. She never will wake up.

Family is the true issue. Fights over who will make the long distance trip to see her and “pull the plug.” Add lawyers, social workers, feuding siblings, devastated boyfriends, and a frequently shared family history of severe mental health issues, and you have the makings for a very interested scene.

What it boiled down to is that we were keeping her alive until the appointed family member could make the trip, see him, get all the information that he and his lawyer want, and then “pull the plug.”

07:31–I start my head-to-toe assessment. Spending time in the ICU will hone anyone’s assessment skills quickly. Not out of necessity alone, but out of pure availability of time. I can stop and listen to the lung or heart sounds for several minutes if I desire. I can really take the time to find those pedal pulsed.

Besides my assessment, in no particular order, I do many other things: print of rhythm strips to analyze and add to the chart, check placement of the oral-gastric (OG) tube before testing for residuals and flushing, check blood sugar and adjust insulin drip, suction secretions from her mouth but decide against deep suction as the lungs sound great, change the central line dressing as sweat and phlegm have pulled it away from the neck.

08:00–Crap! It’s already time for my first set of vitals and Ins and outs. No problem, it doesn’t take long.

I check my lines, following the lumens of the central line to their stop cocks to their labels to the pump and to the bag. Dates are checked, labels are checked, concentrations of drugs are checked, the art. line and CVP are zeroed and their wave forms and square waves are checked.

08:15–Respiratory therapy is present to assess and adjust. She putzes around, changing the position of the ETT, fiddles with the ventilator, and does a couple suction passes. She asks if there are any concerns. There are none.

08:30–The dressing to my patient’s incision (remember that hip fracture?) is leaking copiously and has saturated the dressing, the soaker pad, her gown, and much of the bed sheets. I change the dressing, leaving the rest for later.

08:45–The resident-du-jour is present for pre-rounds. He should be assessing the patient, but they never do. He reads the charting since yesterday, asks me for an update, writes down my assessment, mumbles a bit about nothing, and moves on.

09:00–Tip the urine, check the glucose, insulin is running high, adjust insulin rate, enter vital signs, suction mouth, perform mouth care. Tylenol, colace and Antibiotics are due.

09:15–I have to chart everything that has happened so far, including the visits from the RT and residents and every task I performed. Of course, I have to chart my head-to-toe assessment.

10:00–Vitals, urine tipped, glucose checked, insulin adjusted, patient turned, mouth suctioned. It’s also time for a break!

11:00–Vitals, urine tipped, glucose checked, insulin adjusted.

It’s time to start fussing over my patient a little bit! I wash her hair and brush it, I then take my time and clean every nook and cranny of her body. I call for some help and we turn her, wash her back, change every last piece of linen, slather her from top to bottom in moisturizer, turn her on her side, and tuck her in with warm blankets.

11:45–The dietician is at the bedside. Great! I wanted to clarify her tube feed orders.

12:00–Vitals, urine tipped, glucose checked, insulin doesn’t have to be adjusted! YAY! But it’s time to do another head-to-to assessment. It’s always faster the second time, but it still must be charted. OG tube is checked for residuals and flushed.

It’s break time again.

12:30–My break is interrupted by my charge nurse because the “team” is at my bedside wanting report. My adrenaline peaks, I hate presenting at rounds.

I get there and the resident who had done pre-rounds is there and starts giving a brief description of the patient including issues, problems, new stuff that he learned from me in the morning. There’s really not much for him to tell.

I give a complete systems assessment, CNS, CVS, GI, GU, etc., then the respiratory therapist reviews their assessment of the respiratory system, dietician gives recommendations, pharmacist reviews medications, physio shares their imput, charge nurse interjects with his opinions.

The attending physician asks the resident several obscure questions that he has no chance of answering. The attending proves his intelligence by going into a long lecture explaining the answers to these questions.

Goals, plans, new orders are received from all departments. They leave to go the next patient. I go to finish my break.

13:00–Vitals, urine tipped, mouthcare

13:15–I chart that rounds took place and what orders I received. I then complete the orders, which in this case are basic: increase analgesic, decrease fluid intake, change ventilation mode etc.

13:30–The bed across from me is getting a new admission. At the same time, the admitting nurse is trying to help send her other patient to the OR. I help by infusing all the blood products the patient needs before the OR. Then I help with the art. line insertion and lumbar puncture on the other patient.

14:00–Vitals, urine tipped, mouthcare, glucose checked, no adjustment needed in insulin, patient turned.

14:30–I made a mistake with the blood products I helped infuse. I feel horrible despite the very minor nature of the mistake. The doctor is informed but nobody cares. I fill out an incident report despite the fact that the nurse I was helping said there was no need.

15:00–Vitals, urine tipped

15:15–Physiotherapy is at bedside. They don’t to much because there truly isn’t any rehabilitation in this patient’s future. They do a couple deep suction passes after listening to her lungs, and then move on.

15:30–The visitor’s boyfriend arrives with someone pushing him in a wheelchair. He breaks down in sobbing tears and commands his assistant to, “just get me out of here.” That was his version of saying goodbye. It lasted about thirty seconds.

16:00–Vitals, urine tipped, glucose checked, patient turned, mouth care, next head-to-toe assessment completed and charted. OG tube is checked for residuals and flushed.

My educator arrives and decides to go over “head” patients, including: traumas and all types of strokes/bleeds. It was fantastic to have some one-to-one time with this stuff. It’s great to be so supported!

17:00–Vitals, urine tipped, more meds given, time for break.

17:45–I have to mix up some more fentanyl and insulin for the next shift, I change a couple lines as well, I also change the tube feed set-up.

18:00–Vitals, urine tipped, mouth care, glucose checked, patient turned

18:15–I make the mistake of going into another room to help a nurse. This patient is VERY sick and has a 2:1 nurse to patient ratio. I almost have a panic attack! The room is FULL of large machines such as the prismaflex for CRRT and many others (who’s existence I wasn’t even aware of.) I decide that I’m happy with my “easy” patient.

18:30–A smaller version of the “team” is around again: just the attending and resident as well as the overnight attending. They are going bed to bed giving report. They actually skip my patient–such a boring patient for everyone but me!

18:45–I start cleaning up. I make sure the patient is clean, positioned nicely in bed with straightened sheets. Her leaky leg dressing is redressed again. Lines are organized nicely. The side table is cleaned and straightened-up, supplies are replenished and organized nicely. The Foley is emptied. I wipe everything down with sanitizers–not because I have to, but because I like to at the beginning and end of my shift–infection control is everybody’s job!

19:00–You guessed it, Vitals, urine tipped.

I have fifteen minutes with which to sit and relax, reflect on the day, and praise my luck that no bowel movements occurred.

19:15–The same nurse that gave me report is back, which is nice. I can give a “Cole’s Notes” version of report. Of course, she’s of the interrogation-type when it comes to report, “why didn’t you do this?” and “Why did you do that?” or “You totally missed this and forgot that and did this wrong!” and of course, “The doctor shouldn’t have done that! Why didn’t you tell him to do this and that instead?”

My mood can’t be ruined though. I know I did a good job and I am happy with myself. Plus, I have two days off now!

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This entry was posted on Wednesday, May 14th, 2008 at 10:58 and is filed under Musings. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.