Objectives for Critical Care Rotation

ASSESSMENT 1. Identify assessment behaviors, which indicate actual or impending physiologic instability in the critically ill patient. Assessed a 45 y/o F patient with severe kyphoscoliosis who was admitted because of ARD. S/S observed: hair coarse and sparse, sunken face, pale skin, capillary refill >3 seconds, generalized edema, HR: 96 bpm, RR: 20, weight: 33 kg, urine output low and tea colored with grainy specs throughout. 2. Describe specific attributes of the critical care nurse, which may aid him/her in early detection of patient status changes. The critical care nurse is extremely well organized and on top of every detail of patient care. They have a wealth of knowledge pertaining to physiology as well as lab data, and they use these attributes to aid in their critical thinking skills and patient care. These nurses can tell what is going to happen in their patients condition, as well as what the doctor will most likely do for them, before it actually happens. They have access to instantaneous vital signs and get lab results stat, which aids them in early detection of status changes in their patients. 3. Appreciate the value of instantaneous quantitative data available to the critical care nurse for validating qualitative hunches regarding patient status. When ICU nurses chart assessments, the patients VS are all available to the RN with just the click of the mouse. There are also monitors visibly positioned at the nurses station showing VS and alerting the nurses whenever there is a change in a patients VS. The critical care nurse also has almost instant access to lab work since their labs are done on a stat basis, so they are able to closely monitor their patients statuses.

4. Identify behaviors which indicate effective/ineffective coping in families of patients in the critical care environment. A 52 y/o M patient who had a sudden onset of facial drooping on his L side suffered from a R-sided basal ganglia bleed. The patient had L-sided paralysis, and lost his ability to speak. This patient, up until then, was a practicing Pulmonologist and his wife was a retired ICU RN. It seemed hard on her at times to be the patients wife, and not to be the ICU nurse. She was very involved in every detail of her husbands care, sometimes to the point that the nurses on 5EICU had to step away from the situation. She questioned almost every aspect of care and even questioned and argued with the doctors. She was ineffectively coping by trying to gain control over her husbands care because she felt helpless in the situation. 5. Examine the unique aspects of the environment, which influence delivery of patient care, patient response, and professional and personal communication. The environment of the ICU is set up in such a way that the nurses workstation is directly facing their patients rooms. This allows the families to come straight from the patient room to the closest station and communicate with the nurse instead of having to search for a nurse to talk to like a normal floor. The doors to the rooms are glass so they can see their patients. This set up allows for faster patient care, the nurse can easily look up to see their patient, and can enter the room in no time if needed. The nurses each have their own workspace, so there is no fighting over computers, and there is lots of space, it is very conducive for efficient work. The workstations are individual but within close proximity of the other nurses which makes it easy to communicate with coworkers. 6. Identify own personal characteristics, which may help the nursing student to determine his/her aptitude for practice in the critical care setting. I love how critical care RNs are extremely knowledgeable in every aspect of their patients disease process. I felt like they knew what was going to happen next in their patient before it actually happened. These RNs are very experienced and very organized. Hopefully one day I can be as experienced and knowledgeable as these RNs are! I learned a lot from these RNs about clustering care, taking everything needed into the patients room and getting it done quickly. Also, I like the individual care that as an ICU nurse you provide to two patients as well as their entire family. These nurses truly get to experience total patient care since they have

two patients. That is an aspect that interests me because I feel like being on a medsurg floor you do not always get that experience. I really like the high tech environment of the ICU, the layout of the workstations with the patient rooms right across, and I really like the size of the patient rooms, regular floor rooms are way too small and way too crowded. Maybe someday regular nursing floors will step up and be high-tech and have a layout similar to ICUs and have more space in the rooms! 7. Explore how the critical care nurse copes with the multiple demands of his/her role. The nurses I followed on 5EICU all pretty much rely on each other when they feel overwhelmed from the multiple directions the ICU pulls them. They work with a teamwork oriented mind and do for each other what needs to be done. They also eat a lot of ice cream. DIAGNOSIS: 1. Identify the major problems for which nursing intervention promotes adaptation in patients with primary disruptions of: a. circulation (e.g., cardiac/vascular surgery, CHF) b. oxygenation (e.g., respiratory failure, the mechanically ventilated patient, pulmonary surgery) c. regulation (e.g., endocrine disorders, LAS-GAS, sensory overload/deprivation) d. nutrition (e.g., abdominal surgery, GI bleed, elimination discharge) e. activity/rest (e.g., neurologic disorders, trauma) f. fluid and electrolyte imbalance (e.g., renal disorders, dehydration) The patients I saw on 5EICU had primary problems of oxygenation (respiratory failure -on vent), nutrition (malnourished, GI bleed), and fluid & electrolyte imbalance (dehydration). 2. Establish priority concerns for patients and/or families of patients with the above disorders. Respiratory failure -vented pt: communication, pain/comfort, skin breakdown, clearing secretions (suctioning), possibility of aspirating,

nutrition, fluids, weight loss, adequate oxygenation, weaning off the vent, adequate tissue perfusion Malnourishment: weight loss/weight gain, adequate nutrition, skin breakdown, wound healing, impaired ability to fight infections GI bleed: skin integrity, possible anemia, pride Dehydration: adequate fluid intake/output, renal function, organ function, ability of elderly patient to maintain independence GOAL FORMATION: 1. Set measurable short-term goals for patients experiencing physiologic instability. Respiratory failure -vented pt: (Pt. is bipolar and confused as well as in hand restraints because she is confused and pulling at her tubes) STG 1: Within 5-20 min of administering medication the patient will appear more comfortable AEB decline of restless movements. STG 2: By the end of shift, the patient will be absent from skin breakdown AEB no areas of redness found during skin assessment. 2. Set measurable long and short term goals for families of patients in the critical care setting. (For same patient as above) STG: By the end of the nursing shift, the patients family will understand why the patient needs her hands restrained while intubated AEB the patients daughter verbally communicating the need for restraints to the nurse. LTG: By the end of the week, the patients family will begin to understand the possibility of the patient no longer being able to independently care for herself. 3. Explore the use of evaluative criteria (from precise mandates to general guidelines) which instruct the nurse to maintain critically ill patients within specific physiological limits. Critical care nurses have numerous standing orders which allow them to maintain critically ill patients within very specific physiological limits. Having these numerous standing orders allows them to independently function while giving care to critically ill patients who do not have time to wait for a doctor to call the nurse back, the nurse to write the order, the secretary to enter the order, the

pharmacy to send the medication, etc.,. For example of a general guideline, a doctor came on the floor to see a patient who had been experiencing abnormal episodes of high blood pressure (170s-190s/100s-120s) for the patient. The doctor talked to the RN after seeing the patient and discussed that she would be titrating Nipride for the patient. The doctor did not give a specific dose except which to start at, he left it up to the RN to titrate the dosage just right for the patient. This is one example of how critical care nurses must be comfortable and capable of working independently with only general guidelines to go off of. INTERVENTIONS: 1. In collaboration with the critical care nurse determine appropriate interventions for patients experiencing actual/potential physiologic instability and carry out those interventions (within the scope of knowledge) with minimal assistance. Regarding the patient who is bipolar, confused, intubated, and restrained, I collaborated with the RN to talk with the doctor to get her an anti-anxiety medication. When talking in report to the RN the night before, she informed me that at home the patient regularly took pain medications, and anti-anxiety medication. I did not think anything of it that night because the patient appeared like she was resting peacefully. When I arrived the next afternoon however, the patient was completely different than the night before, she was restless, moving her legs constantly, turning her head side to side and just looked genuinely uncomfortable. Concerned, I discussed with this new RN the information I had discovered the night before and wondered if the patient was experiencing withdrawals. The RN and I performed an assessment on her and her HR and BP were a little higher than last night, she was restlessness, sweating a little, and irritable. We decided we should call her doctor and discuss with her our findings, the doctor agreed to let us give her Ativan IVP. I drew up the prescribed dose and following the 6 Rights, administered the drug. The patient was considerably calmer only 5-7min after administering and she was sleeping by 20min. 2. Determine complex interventions (family and patient) performed by the critical care nurse and analyze the rationale for those interventions.

RN had to explain to daughter that her mother was most likely having withdrawals from not taking her medications at the times when the patient took them at home.

3. Explore the use of advanced technologies and medical therapeutics as a physiologic support for critically ill patients. A ventilator is a machine that supports breathing. Ventilators get oxygen into the lungs, remove carbon dioxide, helps patients breathe easier, and breathes for those who are unable to breathe on their own. Ventilators basically do the work of the lungs for a patient who is unable to. Ventilators can be used during treatment for a serious lung disease or other condition which affects normal breathing. A ventilator is not a cure or used to treat a disease, it is used as a life support. Retrieved from: www.nhlbi.nih.gov/health/health-topics/topics/vent/ A nasogastric tube is a flexible plastic tube that goes through the nose and into their stomach. The NG tube allows the ICU staff to empty the stomach and prevent built up fluids from entering the lungs if the patient vomited. The NG tube also provides a means to give medication or nutrition for a patient who is unable to swallow. The NG tube may be connected to a pump, drainage bag, a suction device, or closed. An NG tube is necessary until the patient is capable of swallowing or until the gastrointestinal tract is functioning. Retreived from: www.intensivecare.hsnet.nsw.gov.au/nasogastric-tubes-ng-tube 4. Facilitate expression of feelings/need for patients with limited means of communication. Patient who had the basal ganglia bleed and lost the ability to speak communicated through his wife, but I could tell he was frustrated with the way she was communicating for him. That what she was saying, was not what he wanted to say. They had tried to get him to write, but he could not communicate well that way either. 5. Utilize documentation processes unique to the critical care setting. Documented patients VS every hour using the monitor button in the assessment, automatically documents VS according to the patients continuous monitoring system.

EVALUATION: 1. Determine patient/family response to interventions performed and modify or assist in the modification of the plan of care as needed. Regarding the interventions previously discussed, the daughter of the bipolar patient who was intubated was relieved to see that her mother was not restless anymore. No modification of plan needed. For the patient with the basal ganglia bleed, the RN needed to come up with a communication system, so they came up with grunting for no and blinking for yes, this helped communication somewhat. 2. Examine the value of documentation processes unique to the critical care setting as a record of patient status change. The documentation process that is unique to the critical care setting is a continuous monitoring system that is connected to the patient giving BP, HR, Pulse Ox, and feeding the patients VS back to a monitor in the nurses workstation. This vital information is available in real time and the nurse can also go back and look at previous times as well.

PROFESSIONALISM: 1. Describe at least one major ethical issue common to the practice of critical care nursing (e.g., starting/stopping life-sustaining measures). Should a patient who is bipolar, ventilated, confused, and restless be restrained for her own good? I believe the answer is yes, but I struggled with these facts when first coming into the patients room. I do not like to see patients restrained, but I can understand that it was for her own safety. She just seemed

very child-like and afraid, unsure of what was going on around her and why she was tied to a bed. 2. Evaluate the impact of crisis on inter-professional communication. One of the nurses working in the ICU said she often floated to different ICUs, she was a very competent and caring nurse. I asked her how she dealt with such a high level of chaos and critically ill patients all the time, she said she loved being an ICU nurse and that floating gave her the opportunity to experience all different types of illnesses, some not as critical as others, but that she loved the high level of acuity she works in. 3. Identify areas of weakness/strength in professionalism, which may be unique to critical care nursing. Weaknesses: Not all, but a couple of the ICU nurses I had experiences with seemed a little hardened to their jobs at times. A few of the nurses tended to gossip about patient families and did not try to be secretive about it. Strengths: Critical care nurses have an extensive knowledge of pathophysiology and lab values, excellent critical thinking skills as well. 4. Examine the role of the critical care nurse in the coordination of care/specific interventions given by other members of the health care team. The Respiratory Therapist wanted the nurse to talk to the doctor about weaning the patient off of the vent, the nurse agreed that the patient was well beyond stable enough and did discuss with the doctor. Critical care nurses coordinate well with members of the health care team, when it is in the best interest of the patient. 5. Discuss the scope of responsibility for decision making and the accountability for actions based on those directions. The critical care nurse has the responsibility to act and make decisions based on knowledge and empirical evidence, always acting in the best interest of the patient. These nurses must follow the standard orders set by doctors and practice within their scope of knowledge.

6. Describe the symbiosis of caring and technology unique to the critical care setting. Technology is evident everywhere in the ICU. The technology is unique to this setting and even though it is a computer monitor telling the nurse the status of her patients, there is a level of connectedness with the technology. When an alarm sounds, nurses often look at the monitor and ask Is that my patient? 7. Appreciate the need for continued learning to maintain competence in an advancing nursing specialty. The critical care nurses I worked with had extensive and impressive knowledge of their patients illnesses; these nurses are highly motivated to maintain competence in their nursing specialty. Being a critical care nurse means staying up to date on current research and best practices. I have the utmost respect for these nurses, and hope that one day I can be even half as competent.