ICU

Starting Shift Safely

Getting report

• During handoff, get the complete clinical picture

During handoff, get the complete clinical picture:

• ID patient, Rm #, code status, precautions, allergies & team

• PMH and story:

  • Why the patient is admitted and significant events (was the shift eventful or uneventful)

• Go through body systems:

  • Neuro/msk, cardiac respiratory (supp.O2 or ventilator settings), renal, GI/GU, skin

• Current drips

• Access sites

• Chest tubes and drains

• Recent abnormal labs & what labs need to be collected

If restraints are being used, verify:

• There is a current order according to policy

• The restraint is correctly applied

  • Quick release knot

  • Secured to a section that moves with the patient when repositioned

• Two fingers fit underneath it

• Circulation and skin are intact = Q2 neruovascular checks

• Tubes and lines remain protected

• Required assessments and documentation are being completed

• The patient still needs the restraints

IV drips

Check:

• Correct medication

• Correct concentration

• Correct dose and pump rate

• Compatibility with anything sharing the lumen

• Verify volume (VTBI) on the pump matches the bag

Also check:

• Whether unused ports have disinfecting green caps

  • This is especially important for pressors, sedation, insulin, heparin, and other high-risk infusions.

Monitor Alarms

• “Alarm parameters” are on, such as limits for HR, BP, O2 sat, RR, as well as other monitored values.

• “NIBP freq.” is the frequency of noninvasive BP measurements. Confirm the cuff is cycling at an appropriate interval, especially the patient does not have an A-line.

• “Level/zero transducers”

  • A-line: zero & leveled Q4

    • Check that the transducer is at the phlebostatic axis (4th intercostal space)

      • If too low may read falsely high.

      • If too high may read falsely low.

    • Waveform is appropriate

  • CVP: zeroed Q4

  • PA: zeroed Q4

Emergency equipment

• Verify that emergency respiratory equipment is present and working:

Verify that emergency respiratory equipment is present and working:

• Suction is patent, connection checked and functioning

• Yankauer is always in the room

• Ambu bag is always in the room and is ready to be connected to oxygen when required

• Oxygen regulator or “Christmas tree” adapter is in the room

• If the patient has a trach = make sure a trach emergency bag is at bedside (same trach size + one size smaller & an obturator)

  • Fresh trach <5 days self decannualiton = code blue, call charge to notify team, RT, and gather supplies.

    • CMAC

    • Intubation box

    • RSI meds (otomadate + succs or roc)

      • Add Phenylephrine/Neo if BP is low (phenylephrine works on A1 receptors)

    • ET-tube holder

    • Inline suction

  • Older trach >5 days self decannuaiton = stay with patient, call for help & reinsert

What lines would you avoid pushing meds through?

Can’t:

• A-line

• PA port

• HD lines w/o an infusion port

• Lumen that is infusing TPN

• Cordis with TVP

Understand the anatomy of veins, especially major veins, of the upper extremities

• Most veins lie 2-10mm under the skin

• So the deepest veins are no greater than 1/2” deep

• This means at a 45 degree a ¾ needle is long enough to hit the deepest veins for a PIV

  • 1-1/4” to 2-1/2” catheters are preferred

    • 1-1/4” = easier to thread

    • 2-1/2” = slightly more difficult to thread

Cannot draw blood cultures from what lines specifically at SLUH?

Central lines (call phlebotomy)

Continuous IV tubing can remain in place for _____ before it must be changed. Tubing that is disconnected between intermittent infusions must be changed every _____.

• Continuously running & connected = change every week

• Disconnected 2 or more time or end was touched or not capped upon setup = 24 hours