Slight and subtle changes matter in ICU – Q&A with ICU nurse Sophie

Introduction

My name is Sophie, I am 3rd year ICU nurse currently halfway through completing the Post Graduate Certificate in Intensive Care.  I chose to nurse because I wanted to work in an area where I can help others out in their time of need. I realised nursing would be a great career path for me when I used to volunteer at my local aged care facility during high school. I was told that my nature and personality seemed to make nursing a great fit and went from there.

I completed my bachelor of nursing at Deakin University as soon as I finished high school, then commenced my grad year at a large Melbourne hospital. Before ICU I worked in a general medical ward which I loved, and a urology GIT surgical ward which was very fast-paced. I had never stepped foot in ICU before the day I started, and I had no idea what I was getting into. I applied for the 6-month introduction to ICU course and started my journey from there.

It was off the recommendations of my ANUMs that I should try it out, and I realised that all my nursing role models that I aspired to be like one day, had one distinct thing in common. One thing that led them all to be confident, knowledgeable, kind-hearted and have a strong attention to detail when it mattered most, was that they had all worked in intensive care throughout their careers. So, I thought it would be a good idea for me to pursue the same.

Important Traits for ICU

I think the important traits for an ICU nurse are the same qualities I admired in my ANUMs and experienced nurses I look up to.  You need a lot of patience and understanding, not only for the person you’re caring for, but the families as well. ICU can be very overwhelming, especially when the patient has multiple infusions or machines that are involved in their care. For them, and their families, it can be scary or too much to deal with. Supporting the patient’s emotional needs and their families through their difficult time by the nurse can really make the difference for patients who are acutely unwell.
An enjoyment for learning.

Every day in ICU you will learn something new. A new illness or condition, a new way to assess your patient, a new aspect of pathophysiology that you can apply to your patient, it never stops. I always get excited when I have a new experience and even after so many years, I’m still experiencing many “firsts” and it’s just the nature of the ward.

On top of that, I think you really have to have strong attention to detail. I am one of those who loves to have an order to most things in life, colour coded if I can, and “dot your I’s and cross your T’s”. So that comes in handy in ICU because the SMALL details matter. It could be a subtle trend of the respiratory rate, it could be a slight rise in the ST segment on the ECG, it could be an increase in the lactate on your ABG or it could be a slight difference in the patient’s behaviour. Picking up the small things before they become big and obvious signs of patient deterioration will not only make you an attentive ICU nurse, but I’ve seen many times where it’s saved the patients life.

What kind of patients does your unit care for?

In my unit we specialise in Cardiothoracic surgery, so we see a lot of open-heart surgeries! This can vary from CABG, valve repairs/replacements, to complex procedures such as the Bentall’s or Ross procedure. We also see a lot of neurological surgeries such as craniotomies and laminectomies, unstable or major orthopaedic surgeries, major GIT surgeries such as the Whipples procedure, and operations on the lungs. We see a lot of medical conditions such as Anaphylaxis, Sepsis, DKA, severe pneumonia, acute kidney failures, and patients at risk of airway obstruction. We also get Code Blue admissions from the ward, complications from theatre and admissions from ED. That’s not everything, but as you can see there’s a big variety! You never really know what type of patient you’ll look after that day.

A day in the life of an ICU nurse

One thing that you immediately notice for ICU nursing is the handover. Our ratios are usually 1:1, sometimes 1:2, and after spending 12 hours with your patient you learn a lot about them, which makes our handovers pretty long! They can vary from 20 to 30 minutes after you go through each past history, their reason for admission, notable events occurring in hospital, tests and procedures they’ve had done, a full head to toe handover, review of the latest ECG, review of all their pathology results and trends, medications they’re on, infusions that are running, inspecting the wounds and drains they have, and the list goes on.

You then do your safety check and patient assessment. That’s checking every machine that’s running for them, checking all your alarms, ensuring no medication is going to run out soon, make sure you have enough oxygen, your suction is working, there is battery left on the temporary pacemaker, and you essentially check and assess everything on and attached to the patient, also anything you might need in an emergency. The last thing you need when you’re on your way to the theatre is for your oxygen tank to run out or something simple that should have already been checked.

After completing that, checking an ABG if needed, giving your medications you prepare for your ward round. The intensive care team (which consists of the Intensivist or consultant, the ICU registrars, your nursing team leader and yourself) will review and discuss the patient’s condition, and plan for the day whether that is the management of the illness or potential discharge to the ward. The doctors are very approachable and always want to hear the nurses input and any concerns we have for our patients that we have noticed on our assessment.

Then your day continues as per the plan discussed on the ward round! You might have to transfer your patient to have a scan in the radiology department, may require new medications, a central line or Artline inserted, follow up with a specialist, or involvement from allied health. Your focus is always on patient care and safety, using your knowledge to optimise the current condition and improve it.

Sometimes. Things don’t go as planned. You might have a fantastic schedule, you might have everything organised, everything prepared, and then out of the blue your patient, or your neighbours’ patient rapidly deteriorates. Maybe there was an issue with their temporary pacing, maybe they suddenly aren’t ventilating on the ventilator anymore, maybe they rapidly become hypotensive and it’s hemodynamically compromising the patient to the point of an arrest.

But that’s why it’s so interesting to be a nurse in an ICU. I love how the nurse is constantly monitoring and assessing for the potential decline, and their prompt intervention with an actively deteriorating patient. Always on your toes but just in a different way.

Tell us about an interesting ICU machine/item?

When I first started in intensive care, I had at least heard about a ventilator, a pacemaker, and I had looked up some of the emergency medications I saw whenever I checked the crash cart on my previous ward. One thing I had never heard of before was the Swan Gantz Catheter which is a Pulmonary Artery Catheter (PAC). Majority of patients who returned from theatre after open-heart surgery seemed to have this massive yellow line coming out of their neck! It looked a lot longer than a PICC line and had so many lumens coming off it, it was fascinating. It’s nicknamed “the yellow snake” and from the picture, you can see why!

The PAC as its name entails is usually inserted via the right internal jugular vein which flows down to your superior vena cava. The PAC follows through the right atrium, the right ventricle and sits just in the pulmonary artery. This is about roughly 50cm internal length (give or take) and approximately 50cm of external length too.

We use a PAC in intensive care for continuous cardiac output monitoring, central temperature monitoring, measurement of pulmonary artery pressure, measurement of mixed venous saturations and administration of many medications – often including a variety of vasoactive or inotropic medications to improve the patient’s cardiac function.

An ICU nurse monitors and uses this line frequently. We are the ones who complete regular cardiac outputs, obtain the mixed venous gas, watches the pulmonary artery pressures preventing hypertension, and we constantly observe the waveform. This is important because sometimes – it moves. If the PAC moves forward, it can occlude the pulmonary artery and can cause ischemia, trauma or worse case – a perforation. If it moves backwards, it can irritate and tickle the right ventricle. The ventricles don’t like being touched, so ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation can occur leading to an Advanced Life Support situation.

The Swan Gantz or PAC is just one useful tool we use for our patients, and requires a high level of nursing attention, monitoring and care. The haemodynamic values it provides is extremely useful when managing a cardiac patient, but you can’t just look solely at the numbers, it’s a holistic patient consideration and assessment that’s going to help your patient improve.

The positives and challenges about working in ICU

I am so grateful to have the opportunity to come to work every day and work in Intensive Care. I remember one of the older nurses who had been working for a few decades on the ward telling me as a grad, “find a job that you love and you’ll never work a day in your life”. And she was right! My alarm goes off each day and I bounce out of bed excited for my shift. ICU is that area where I care for some of the most vulnerable and critically ill patients in the hospital. I’m able to anticipate changes in my patients’ condition, rapidly respond with attention and compassion, so I can provide advanced and therapeutic nursing care when my patients need it most.

When patients are really unwell or they have a complex presentation, that makes their management a bit more challenging. Whether it’s a difficult social situation they’ve presented from or they are acutely hemodynamically unstable, it can make a shift exhausting or intimidating when you start. However, that feeling of uncertainty fades quickly, as I have many people in the unit who are always available and happy to help. My educators, team leaders, ANUMS, doctors and fellow co-workers are all incredibly supportive, and even though the ratio might be 1 nurse for 1 patient, there is always a large group of people ready to assist you no matter how big or small the nursing issue is, and that makes such a big difference.

Where Do you See Yourself in 10 years?

In 10 years’, time I hope to be an ICU ANUM or liaison nurse for the hospital. Both are roles I admire as they both require a lot of knowledge, experience, confidence and leadership skills to support the team. I always want to get involved in the unit, participate in educational workshops, assist with developing patient care initiatives, and make a difference for improving myself and support my team for the better. I just hope that in 10 years’ time I have developed my nursing skills so I can provide the high level of care as a proficient and compassionate intensive care nurse, and always keep learning and training to become the best nurse I can be.

Nursing Tips!

Night shift tips: A warm bed with an extra blanket, eye mask, earplugs and lip balm before you sleep does wonder. I’m always out like a light!

Destressing after a shift: I love talking with my family about my day and unwinding chatting with them, they’re so supportive and even after a hard shift, I find that getting it “off your chest” makes it easier. Truthfully, I’m hooked on Law and Order so I just happen to be watching an episode of that when I finish a shift as something completely non-medical related to unwind to. ????

Tips for anyone thinking about post-grad: If the time is right and you have support then go for it! It has been such a fantastic opportunity and experience working through the degree. In 6 months, I feel I’ve had so much exposure and challenges compared to my previous 2 years in ICU. I took an extra year to consolidate my learning and I didn’t rush into starting the post-grad course.

I also made sure that people involved in my other commitments such as my volunteering, travelling, and large hobbies all knew I was doing the course in 2020 and were understanding. My priorities in the course came first for one year. Staying on top of the course work, and my preparation have led to a stress-free experience and these were all decisions I don’t regret, and I’m grateful I took this advice on for myself!

Can you think of a really funny situation you’ve had while working?

During the handover of this elderly gentlemen, the patient interrupted the nurse’s handover to ask if we wanted to hear a funny joke! Myself and my team looked at each other and figured ‘why not! Let’s hear it!’ and to this day it’s the funniest medical joke I’ve heard. It’s a bit naughty though…

3
A student nurse receives a patient from the theatre. He has his oxygen mask on, fluids running via his IV and blankets tucked up under his neck. The student nurse starts checking his vitals when the patient asks “nurse, are my testicles black?”
Clarifying what she had just heard she says “oh I’m sorry, I think I didn’t hear you correctly, what was your question?”
“Are my testicles black?”
“Oh…uhm…uhh-“
“Are. My. Testicles. BLACK?”
“I DON’T KNOW BUT I’LL CHECK!”
And so, the nurse pulls back the sheets, lifts up and thoroughly inspects the area.
“Sir I have looked and can reassure you, your testicles are not black”
The elderly man looks at the nurse, takes off his Hudson mask and says “nurse, I must tell you, that did feel lovely, but I was asking you, Are My Test Results Back?”
Hehehehehehe

Thanks for reading! Hope you enjoyed and learnt something new about Intensive Care nursing. ????