I spent a year and a half on a telemetry floor before beginning my career as a critical care nurse.
I have been working "on my own" in the surgical-trauma ICU for a little over a year now, which is long enough to not be terrified for the drive in to work each morning, but not long enough for my nerves to completely quiet down.
I watch the work of the expert nurses on my unit and try to remember what I see them do in critical situations and the pearls of wisdom they give me when they have time to lend a hand.
So far, what I can say for sure is that each of them has something different to teach me. One expert nurse may be a pro at Swan-Ganz catheters but communicates poorly with grieving families, or vice versa. But despite their differences, I have honed in on two categories in which all expert nurses excel: preparedness and observation.
As my seasoned and very conscientious preceptor taught me, I am always trying to think of how I can be better prepared. What if my surgical patient begins to vomit blood? Do I have suction at the bedside?
What if an arterial line is kinked and splashes blood when I remove it? Am I wearing my goggles? What if my bradycardic patient's heart rate slows even further and my patient loses consciousness? Do I have atropine at the bedside?
You cannot be prepared for everything as a nurse in the ICU, but it certainly helps to try. And this aspect of critical care nursing comes just a little easier than the observation part.
I can be prepared for anything as long as I am able to anticipate it. And so as a novice, I listen. I look. I try to be aware of nuances in my patient even if I can't catch them all.
I recently had a patient whose stay on our unit reminded me how important it is to assess, and keep assessing. We'll call my patient Mr. Clark.
Mr. Clark was on our unit recovering from an abdominal surgery performed by the trauma team. He was an older gentleman with dementia. When I did my morning assessment, I noted his distended abdomen, his very edematous extremities and some other things mostly expected of our postop patients, like hypoactive bowel sounds and slightly coarse lungs.
His vital signs were stable and his labs that morning were unremarkable. At his advanced age and with dementia, it would be very important to mobilize Mr. Clark and to be aggressive with his pulmonary toilet.
PT stopped by that morning, and with my assistance, moved Mr. Clark to the edge of the bed. Mr. Clark yelled out in pain with each movement of his legs. We knew at that point that we would not be able to stand him at the bedside, and we repositioned him in his bed. I thought to myself that Mr. Clark might not receive regular physical therapy in his nursing facility, and the edema in his legs might have made them very tender.
Shortly after PT left, I began to notice slight decreases in Mr. Clark's blood pressure. He had dropped from a systolic BP of 140s to low 100s, and then into the 90s. I reported this finding to the trauma team, and they asked me to draw a complete blood count.
The CBC results showed Mr. Clark's hemoglobin had dropped from 9 to 6. Immediately, the trauma team came to the bedside to examine Mr. Clark. The fellow asked me, "Any signs of bleeding?" And, I said, "Other than the fact that his abdomen has been distended, no." And so I was ordered to give Mr. Clark a bolus and travel to CT.
When we arrived in CT, we were preparing to move Mr. Clark to the table when I brushed his leg with my hand, moving the Foley or some other thing that we had in the bed. It was rock hard.
I lifted up the sheet, and saw nothing out of the ordinary. Then I ran my hand along Mr. Clark's leg, and felt the dramatic hardening on his left lateral thigh. It was more than edema. It felt like a massive hematoma. I called the trauma physician and he ordered me to have Mr. Clark's thighs scanned. I went around to the tech area during the scan and heard the radiology technician say, "Whoa, he's got a lot of blood there."
We hurried Mr. Clark back up to his room and the trauma residents and attending came by to assess the leg. They decided hurriedly to take Mr. Clark back to the OR for evacuation of the hematoma and to assess the origin of the bleed. Mr. Clark was taken to the OR within the hour, and he returned just as fast, hematoma evacuated and bleeding stopped.
I had felt bad reporting to the doctor that I had missed the hardened leg before heading down to CT. I had even had a clue earlier, when PT and I had tried to move Mr. Clark and he was unable to express his pain in words but had yelled with each movement of his leg.
Earlier, when I had done my assessment, I lifted the sheets and felt Mr. Clark's ankles, thinking only, "Wow, he's really swollen," but not using my assessment skills to do any more investigation. The doctors were happy I had discovered the location of the bleed when I did, but I knew I could do better.
Mr. Clark taught me yet another lesson in the school of observation and assessment. Don't assume the most obvious explanation is the answer.
Now, when my patient looks edematous, palpation is a must. In a few years, when I am teaching a new nurse like me about observation and preparedness, I'll be sure to pass on that pearl.
Anna Reda is an RN at Tampa General Hospital, Tampa, FL.