This is my "Average Day" in the Neuro Critical Care Unit.
1) Face to face report on 1 to 3 patients (depends on your assignment)- Usually takes 5 to 30 minutes total.
2) Complete assessment of all patients - Temp? VS? ICP/CPP (if applicable)? Pupils PERL? MAE/SAE? A/Ox3? Lung sounds? Pain rating (1-10 or FLACC scale), Vent settings (if applicable)? Bowel sounds? NG/OG (if present) placement and residual? UO color and quantity? PAWP if SG in place; oral care per Sage Protocol for all vented patients.
3) Go put the confused craniotomy patient back to bed and reorient - place in a posey PRN.
4) Verify all IVFs - figure needed constants for titrated drips (based on the weight your tech has just done - if you have one).
5) Level, zero and flush all invasive monitoring lines - art line, CVP/Swan, ICP (can't flush this one), make sure art line is compatible with NIBP and make sure you have the appropriate wave form on each. Make sure NIBP is set to appropriate time interval if no art line present.
6) Take your ACOM CVA patient for a stat CT as they have had a significant change in neuro status.
7) Call the trauma doctor on call (Trauma Doctor = 5th year resident) concerning the combative drunk with a subdural bleed and in a Miami J collar who has just pulled out his CVL, art line and foley. Place in bilateral wrist restraints.
8) Explain at length multiple times to input-overloaded family members that their loved one will not be fully recovered by next weeks’ family reunion. Also explain 6 different times in 6 different ways the necessity and function of the various monitoring tubes/lines and what the numbers on the monitor mean and why the vent alarms and why they are receiving this med and why they aren’t opening their eyes or squeezing their hands and why family aren’t allowed into the unit any time they wish or able to stay in the patient’s room overnight.
9) Deliver appropriate meds at appropriate times and by appropriate route, changing IV tubing q12, 24, or 96 hours as prescribed by policy. Call blood bank for PRBC or FFP as needed. Make sure all future labs are in the computer at the correct times.
10) Assist techs with bathing and turning patients - if you have a tech, otherwise you're on your own (with whatever help you can trade with another nurse). :-)
11) Place a twirled up sheet across the chest and under the arms and tie to mattress frame of patient described in #3 as they keep trying to slide out the end of the bed despite the posey.
12) Hourly (or more frequently) required tasks = documentation of VS - includes current IVF/TF rates, piggyback med amounts, UO, vent settings, invasive monitoring read-outs and ICP/CPP and CVP if applicable. Hourly accuchecks as ordered with insulin drip adjustments
(if applicable). Adjustments of vasopressors/dilators as indicated by patient.
13) Sedate, paralyze and intubate patient described in #7 since unable to curb the combativeness. Set up for 2nd replacement all pulled lines.
14) If designated to take first admit, admit new patient with a subarachnoid hemorrhage due to a right MCA aneurysm; take to vascular for stat cerebral vessel arteriogram. Patient has constant titration of vasodilators (usually Nitroprusside) to keep SBP < 140.
15) Every 4 hours repeat #2.
16) Take patient described in #7 for MRI to rule out cervical spine injury not apparent on flat films. Since patient is paralyzed, this shouldn’t take more than an hour. If not paralyzed, than up to 3 hours as patient can’t comprehend the need to lie very, very still.
17) Take exactly 2 minutes to sit down, eat lunch and do a quick check of email.
18) Every 8 hours complete trach care as appropriate; perform CO if SG in place.
19) Go check the patient describe in #3 as the monitor tech insists the patient is either tapping on the white lead or is in v-tach.
20) Call a code on the patient describe in #3.
21) After the code is called, go check on your other patients to make sure they are still alive. Notify family members and primary physician of the coded patient if not already done so. Complete required code-related paperwork and notify Midwest Transplant Network of death to determine eligibility of donorship if family agrees.
22) Open charts (finally) to get caught up on charting of all patients while continuing to answer call lights, vent alarms, replace IVF bags, draw blood from CVLs for the lab personal, check and verify the next days MARs.
23) Replace potassium and magnesium as per replacement protocols as indicated by the morning lab results. Call all other abnormals to the appropriate physician.
24) Continue to chart as you are only to “midnight” on patient #2.
25) Take a phone call from a family member inquiring about how the night went. You answer, “they slept quietly” and continue to be very vague unless they provide the prearranged password.
26) Breathe a sigh of relief when you see the on-coming shift arrive on the floor. Give face to face report – continue to finish charting.
27) An hour and a half after your shift ended, run from the building screaming, vowing not to return the next night.
28) All bets are off when the neurosurgeon comes in at 0655 to place a ventriculostomy and didn't bother to call and tell you he was coming.
Honestly, I'm not exaggerating all that much. There are nights when it feels just like this. Last week was as close to this as it's been :-)
