Pearls for Critical Care Shift Routine1. Nurse the patient, not the unit culture.
2. Take your time with your head-to-toe assessment.
3. Practice, practice, practice.
A good trick is to use a systematic approach when assessing your patient from head to toe and checking your equipment. The biggest difference now we are all wearing various forms of PPE, based on local protocol. We are faced with an increased need to be aware of maintaining appropriate precautions and ensuring we have the equipment readily available to us to keep ourselves and our patients safe.
Step 1: Equipment Safety Check
Step one of critical care – a safety check. As every shift starts off, have a quick look at your patient. Do they look not so bad? Or do they look terrible? With no apparent threat, we can move on to our full safety check. If you are worried, seek out help right away.
The safety check includes a review of our bedside equipment, such as emergent airway supplies, O2 equipment, clamps for any tubes (i.e. chest tubes), and any other supplies you may need like hygiene items. It is important to have the supplies you may need ready, to prevent coming in and out of the room, breaking seals on negative pressure rooms, or unnecessarily exposing a colleague by bringing you supplies.
Step 2: Cardiac Monitor Alarms
The next stage is a review of monitor alarms adjusted to your preference and patient specific condition follows. This gives the opportunity to review MAP goals, SPO2 goals, and specific BP targets. Typically, vital signs are documented hourly, or more often if the patient is unwell.
Part of patient monitoring is the alarm settings for continuous monitoring. The purpose of an alarm is to catch your attention. Know your patient and set your alarm limits appropriately. If the alarm sounds because your patient is hypotensive, you need to acknowledge it, and do something about this. For example, you could recheck a BP, check equipment, administer medication, give a fluid bolus etc. Make sure your alarms are not going off constantly, because that is stressful for everyone (the team and the patient). If you are working with a buddy, connect to set the alarms together.
|Monitoring||Alarm Limits Example|
|BP arterial line||160-90|
|Non-invasive BP||160-90 every 2 hours|
|Oxygen saturation||100-90 (may go to 88% for COPD)|
Step 3: IV Pump Infusions
It can be daunting to sort out the lines and infusions hanging at the bedside. A systematic approach will break this down into a manageable task. Important tips – verify the medication concentrations (we’ve all been a tired night shift nurse mixing meds!), so check that the bag is labelled with the correct medication, dosage and rate. If it’s not labeled, put it in the bin. You have to be sure of what medication your patient is receiving.
The next step is a compatibility check. You verify that all infusions running together are compatible. Also check that the infusion sites are free of pain and redness.
You will also need to be aware of the IV pump requirements for your patients. In some units, you may need to prioritize which medications need pumps and which can run by gravity. If this is the case, try to reduce the use of pumps as much as you can and to keep them for specific kinds of medication.
Before you exit the room, check your pumps. Is everything ok, will any of the IV bags need to be changed in the next 2 hours? Make sure you or a buddy can always hear the alarm if a pump beeps.
Critical care patients have a lot of tubes/lines in – watch with turning/repositioning the patient and when transport out of unit required (such as taking the patient to radiology). When you are done moving, do a quick check of placement for all the equipment. So we’ve got everything we need, our infusions are running safely and compatibly. Now, we can move on to our detailed head to toe assessment
Step 4: Patient Assessment
Before you start, consideration needs to be given for how dependant these patients are on us for every piece of care, movement, and hygiene they need. Often, patients are sedated to various degrees and have different levels of awareness. It is important to keep this in mind before performing all of the intrusive and potentially invasive interventions we do on a daily basis.
Head-to-toe assessments in ICU are usually done every 4 hours and PRN.
Central Nervous System
- Critical Care utilizes Richmond Agitation-Sedation Scale (RASS) scoring system to assess level of consciousness (see below). Match most appropriate score to patient.
- BPS Behaviour pain scale (see below) is also used. The aim is to have a specific score so that you can reproduce the evaluation.
- Include in your documentation what sedation/analgesic/infusions are running that may be influencing patient responsiveness (ie. Propofol, Precedex, Opiate infusions, Benzodiazepine Infusions etc)
- Check Reflexes: Cough, Gag, Corneal (Indicates proper functioning of different cranial nerves). If there is a loss of reflexes consider, is the patient overly sedated, were paralytics given, is there neurological damage?
- Assess Heart rate/rhythm/sounds (clear S1/S2 on auscultation)
- BP goals usually ordered by Mean Arterial Pressure >65 (or higher, sometimes for cerebral perfusion if the patient has neuro issues)
- Remember to chart all infusions that may be influencing hemodynamics (Inotropes, Vasopressors etc)
- Capillary refill, skin colour/temperature/signs of poor perfusion (mottling, slow cap refill)
- When using an arterial line, check your patient level and do a “zero” patient at every shift
- Lots of variance ventilation techniques, so assess for local protocol
- Ventilated patient – Ventilator settings (explored more in depth later in this guide)
- Non-invasive ventilation – Settings
- Patient may also breath independently, with supplemental oxygen
- All patients: Assess breath sounds, work of breathing, strength of cough
- How do they look? How do they sound? How are they being supported to breath? How are they tolerating that support?
- Presence of cough – spontaneous or stimulated and how strong is that cough
- VAP, ventilated associated pneumonia, is very dangerous, so be sure to implement prevention techniques: https://link.springer.com/article/10.1007%2Fs00134-010-1841-5
- Head of the bed elevated to 30 degrees
- Assess abdominal shape, bowel sounds, pain, BM history, and assessment of gastric tubes (NG vs OG)
- NPO vs being fed – Follow site specific protocols on checking gastric residuals and goal feed rates/increasing feeds. Ensure patient is receiving some type of nutrition unless they need to be NPO for a procedure
- Sedating medications are very constipating, so be vigilant about BM management
- Flush any tubes to maintain patency and give meds with adequate flushes
- Patients are at risk of thrush, so be sure to assess their mouths and give Q4H mouth care
**Special consideration – note internal vs external length of tube with each assessment and confirm tube has not moved from position verified by x-ray, to avoid increased risk of aspiration
- Critical care patients almost always have indwelling catheters
- Check the patency of tube, colour of urine, sediment/cloudy, clots/hematuria
- Hourly amounts typically recorded
- Assess perineum for yeast infection etc.
**Special Considerations: Dialysis may occur
Skin and Lines
- Site specific practices vary
- The basics – thorough documentation and check of skin – wounds/redness/pressure areas
- Note use of special mattresses, pressure relieving devices, (Prevalon boots, positioning) and dressings
- Documentation of lines: Central access (Number of lumens/infusing/capped/site patency and appearance/dressings), peripheral access (usual assessment of site/patency), arterial lines
Remember to talk to your patients, even if they are sedated! It is important to use measures to try and keep people oriented – informing or visible date/time if appropriate. Use of communication boards (pictures or letters) to determine patient needs they are awake enough, or if able to write on a piece of paper. Also try to dim the lights in the evening/night, to give a sense of a normal circadian rhythm.
Families are also an incredibly important part of critical care. This has gotten even more complicated in the times of COVID-19 with visitor restrictions and increased concerns for transmission of illness. Units will be managing this differently, but contacting the family should just be identified as an important daily task to ensure updates are provided to appropriate people. You may wish to designate a family contact person, and refer other family members to them for updates. It is incredibly stressful for families with loved ones in ICU, so be sure to communicate clearly and often.
You also need to assess for legal factors, such as power of attorney, DNR status, etc. There may also be specific cultural practices a family would prefer to observe, if possible. For example, a female Muslim patient may not be able to wear a Hijab, but you could cover her hair with a towel. There will likely be Social Workers, Chaplains, and other supports available- make sure the family connect with these services.