Peer reviewed by Rachael Johnstone and Steven Musca
Setting the scene
I am caring for a patient admitted with pneumonia. They have been in ICU for two days and yesterday they had to be sedated and intubated as they were tiring with their breathing despite maximal non-invasive therapies. They have a few comorbidities with type 2 diabetes and hypertension to note.
The handover from the night shift informs me they have had to increase sedation to assist with maintaining ventilation, the noradrenaline requirements remain stable to achieve a MAP >65 and their temperature is starting to rise.
Safety check
Once the handover is complete, I do a quick check of the patient from the end of the bed. I make sure their breathing tube is secured, they are ventilating, they are haemodynamically stable and what continuous infusions are running. Next I check the safety of the bed area to ensure the machines are running correctly, I have my alarms set appropriately, and there is equipment ready should I need it in case of an emergency.
Nitty gritty
With this out of the way, I can do a full head to toe assessment of my patient. This is an in-depth look at how the patient is and tell me what issues are present. Things I note for this particular patient include:
- Responding to central and peripheral stimulus despite being heavily sedated.
- Requiring noradrenaline to maintain a MAP >65 but their hands and feet are a little cool.
- Ventilated in a mandatory mode with a PEEP of 10 and appropriate settings to maintain adequate ventilation and oxygenation.
- Some vibrations felt through the chest wall during palpation and some crackles present on auscultation.
- Temperature is continuing to rise and is now at 38⁰C.
With this information I can prioritise the issues, identify anything I need to alert the medical team to, and any interventions required. I know the patient needs to be suctioned down the breathing tube because of the crackles and vibrations in the chest. I am concerned that their temperature is increasing. This is something I will watch over the shift and alert the medical team to. I will also discuss with them if the patient should have more fluids. Their hands and feet are cool suggesting they may not have enough circulating volume and while their blood pressure is stable at present, they do require noradrenaline to achieve this.
Moving forward
After the ICU team do their round and assess the patient, we discuss the plan for the day.
- Wean sedation to get the patient to the point where they can spontaneously breathe on the ventilator but remain comfortable with the breathing tube in.
- Give a fluid bolus and reassess noradrenaline requirements and fluid balance post.
- Continue to monitor their temperature. If it goes above 38.5⁰C, collect blood, sputum, and urine specimens for cultures.
- Have physiotherapy come to assist with clearing sputum.
- Monitor blood sugar levels considering their history of T2DM and the use of steroids.
As the day continues, I am able to wean the sedation so the patient is able to breathe spontaneously on the ventilator. They are requiring hourly suctioning to remove the sputum in their lungs. This is made easier after the physio team have been to do some chest physio and with regular turning to mobilise the secretions.
Setbacks are part of the game
After coming back from a break, I notice the patients oxygen saturations are dropping with no improvement after suctioning. Their tidal volumes are also smaller and I am needing to increase the amount of support needed on the ventilator, again without much success. I notify the medical team to come and review. They assess the patient as well and I suction the breathing tube again. On this occasion a large, thick amount of sputum is removed and the patient improves. I give the patient some time to recover before weaning the ventilator settings again.
As the shift continues, the patient’s temperature increases to 38.8⁰C and their noradrenaline is on the rise because of it. As per the ICU plan I take a full septic screen including blood, urine and sputum specimens. These will take a few days to test and get results but are important in ensuring we are using the most appropriate antibiotics.
But wait there’s more?
While these are the big things that happen during the shift, many smaller things occupy our time in between. These include but are not limited to:
- Frequent blood gases to assess pH balance, ventilation, oxygenation, electrolytes and blood sugars.
- Managing blood sugar levels from the results of the gases with insulin infusions that need to be closely monitored.
- Turning the patient regularly to prevent pressure areas and help clear chest secretions.
- Hourly documenting of observations, sometimes more frequently if needed.
- Attending to hygiene needs such as brushing teeth, washes and eye care.
- Administering medications from sedation to antibiotics.
- Aspirating the nasogastric tube to ensure the feeds are being tolerated.
Communication is key
A big part of our day is spent communicating with different people. Many people are involved with providing the best care for the patient and as the nurse is always present at the bedside, we are often the first point of contact.
- Updating the ICU medical staff on changes and effectiveness of the treatments we are giving.
- Discussing with my nursing team leader and nurse in charge about what is happening with the patient.
- Talking to the visiting medical teams involved with the patient’s care who visit at least once a day.
- Discussing the feeding regime with the dietician to ensure the patient is getting the optimal nutrition.
- Talking with our SSAs who help with regular turns and taking blood tests to the lab.
- Talking with Pastoral care to ensure the family and patient are provided with support if needed.
- Coordinating with radiology for imaging that may be required.
- Talking with family both over the phone and at the bedside. This is important so they are involved with the process and so we can coordinate our care around visiting times and phone calls.
Summary and handover
Coming to the end of the shift it is time to sit down and write my notes of what has happened and how the patient is progressing. This document is important to provide a concise summary of what happened for the shift from a nursing point of view. It complements the notes provided by all the teams involved.
I finish by double checking my documentation, ensuring all medications needed are given, the patient remains stable, and the bedspace is clean and tidy. It is now time for the cycle to continue for the next nurse with my handover…