Tuesday 21 August 2018

Early in my career as an ICU nurse, I was lucky enough to have a preceptor who helped me develop a solid morning routine I have carried ever since. Because my experience is primarily Cardiac ICU, this routine mirrors what I do in that area of practice, however, it can be tailored to meet the needs of any ICU patient.

Nurse Career, Nursing Responsibilities, Nursing Certification

While the following list may look like a lot, pending any instabilities or interruptions with the patient, it can be completed within 30-90 minutes (depending on experience level) for each patient after a few months of experience.

Of note, this routine is completed simultaneously with a thorough head to toe assessment. The steps for a head to toe assessment are not included in this post. The purpose of this is to incorporate parts of a morning routine that are often missed, but when completed, can make your day much smoother.

This is how I do it but, make sure to follow your hospital's protocol or previous training.

The following comprises the 20 integral steps that have worked for my personal routine as an ICU nurse.

1) Upon arrival to the unit and after receiving your assignment, breeze past both patient’s rooms and glance at the patients and monitors. Make sure nothing needs your immediate attention, and if the patients are restrained, make sure the restraints are tied properly.

2) Take bedside report – it is evidence-based practice to receive report at the bedside. Encourage your peers to partake in bedside report as well.

3) Do a quick check of orders, medications, and the morning chest X-ray. Also, trend pertinent labs. Looking at the trend of labs is very important. For instance, you can note if a hemoglobin is dropping or a white blood cell count is trending up. Whereas, if you just look at the morning set of labs, you will not know if your patient’s condition is worsening or improving.

4) Go into the room of the most critical patient first.

5) Check drip concentrations, confirm the weight programmed into the IV pump matches the patient. Confirm infusion rates, and patient name on IV bags.

6) Check monitor alarm parameters. Alarm parameters should be patient specific. For example, if your patient lives with a heart rate of 50, you will want to set the high alarm around 70 and low alarm around 45. But if your patient has a heart rate of 70, the parameters might be set 50-100.

7) Check the IV access on patient. Flush all peripheral IVs and central access with a normal saline flush to ensure proper functioning. I always make a note of the functionality of my access and think, “if my patient were to code, where could I push code drugs?”

8) Check for an accessible ambu bag in case of emergency, trach supplies and obturator if warranted, and ensure one suction apparatus is set up and functioning.

9) Check ET tube size, length, and vent settings, including peak pressure.

10) Check settings on any device and insertion sites: CRRT, IABP, LVAD, ECMO, PA cath etc. Level, zero, and flush all tranducers, note waveforms.

11) Note the feeding tube length and securement, check residuals and placement if applicable (tube dependent and per hospital policy.)

12) Note the date on central line dressing and all dressings. Change per hospital protocol.

13) Complete urinary catheter care and make sure there are no dependent loops or kinks in tubing.

14) Make sure all chest tubes, cords, IV tubing, drains are operating properly (either hooked to suction or not per order, canisters aren’t full, tubing isn’t under patient, etc.)

15) Note the patient’s skin, particularly the bottoms of heels and behind the ears. Prop heels on pillows, change draw sheet and chucks pad, note sacral region for breakdown, turn patient.

16) TALK to the patient and develop a plan for the day, also let them know what you are doing during your morning routine and why. The ICU strips so much control away from patients. By giving them the opportunity to develop a plan, you are providing better patient-centered care.

17) Make sure the patient’s call light is in place and the TV is on their chosen channel. You can also put on music for your vented patients.

18) Complete the CAM-ICU delirium scale or delirium scale per your hospital protocol. 

19) Throw away old supplies, Cavi wipe surfaces, move any chairs or tables out of the way that might be blocking a path to the patient or cluttering room.

20) Repeat with next patient. 

What is your morning routine for your specialty? As an ICU nurse would you add anything to the above list?


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