Being an ICU nurse sounds like a pretty cool job, doesn’t it? Really, any job with the word “intense” in the title sounds… well, intensely awesome. I’m here to dispel any doubt and inform you that yes, ICU nursing is pretty legit.
While it sounds cool, many are not aware of what ICU nurses actually do during a typical 12-hour shift.
From 2012-2016 I worked in a neurocritical care unit, and floated to the intensive care unit (ICU), cardiac intensive care, and step-down/intermediate care unit. I obtained my national critical care certification, and loved working there. Let’s go over how a typical shift in the critical care environment typically flows.
What do ICU Nurses Do?
Before you can take care of your patients, you have to learn about them, meet them and their families, and review their chart. Nurses share this information in a fast-paced discussion called “nursing report”. Let’s dive in!
Starting your shift – report
Report in the ICU takes 30 minutes, however you’re discussing only 2 patients during that time rather than 5-7 like you would in the med surg environment. (Interested in what a med surg nurse does? Check out my previous post on med surg nurses.)
Generally speaking, the information discussed report in an ICU consists of the following:
- Name / attending and consulting physicians / Code status / allergies
- Precautions like fall, seizure, infection prevention, bleeding, etc.
- Chief complain / why they’re in the hospital
- Past medical history and current status
- For example, “the patient has a history of PAD, CAD, HTN, OSA, DM, hyperlipidemia, GERD, gout. They were admitting on 12/2 after being found down at home unresponsive. They were intubated in the field, started on Levophed, and a head CT showed a large ICH.”
- Important events that have happened during the admission with corresponding diagnostics
- For example, if they had a decreasing level of consciousness and the CT showed the left paraychamal ischemic stroke has increased in size from 5 cm to 7 cm, or a change in lung sounds and increase in WBC was noted so a chest xray was completed and showed pneumonia in the left lower lobe.
- Assessment findings by body system
- Neuro: LOC, cranial nerves, if they follow commands, movement and strength of extremities, sedation/pain medications that may impact assessment
- Cardiovascular: cardiac rhythm and any changes, blood pressure and/or heart rate limits, drips/PRN meds needed, intravenous access
- Pulmonary: breath sounds, O2 sats/respiratory rate, oxygen requirements, ventilator settings/ETT size and location if the patient is intubated, secretion from the oral cavity and via ETT suction catheter noting the color/thickness/frequency of suctioning
- Gastrointestinal: how the patient is getting nutrition (oral vs. enteral vs. parenteral), size and location of any feeding tubes and corresponding flushes, type and rate of any tube feedings, or oral diet orders
- Integumentary: any skin issues, wounds, or incisions
- Genitourinary: how the patient voids, if an internal or external urinary catheter is being used, last bowel movement or if a rectal pouch or tube is required, if output it inadequate, adequate, or excessive
- Activity order: strict bed rest vs. up to the chair vs. ambulation, and if therapy (physical/occupational/speech) is ordered
- Pertinent and abnormal labs like the latest CMP/BMP, CBC, blood gases and trends
- Questions to ask the medical or any other member of the health care team
- Any psychosocial / family and support system concerns that may not be reflected in the chart
- Important medication considerations
- Weaning off vasoactive drips, transitioning to oral medications, electrolyte replacements, blood product administration, PRN meds needed and so forth
- Pain management and goals
- What are our goals this shift?
- For example, getting an MRI, weaning off of a drip, transferring out of the ICU, family care conference, sedation holiday and hopefully an extubation
Another thing I do during this time is verify orders and corresponding alarms. I love my colleagues, but I trust no one when it comes to this! If the previous nurse said the goal is to keep the systolic blood pressure less than 160, but I look in the chart and it says less than 140 – we need to make sure we’re on the same page. Then, I check to make sure the bedside monitor has its alarms set to match the orders. That way, if I’m in my other patient’s room for an hour doing an extensive dressing change, bath, assessment, meds, and tubing changes, I will know if my other patient’s blood pressure is too high or too low because I’ve set my alarms appropriately.
During report, I’m checking to make sure my drips have enough volume in them for a few hours and aren’t going to run dry mid-med pass. I also check when tubing needs to be changed, and if my patients need to be changed.
As the oncoming nurse, you will be receiving all of this information and need to be aware of it throughout your shift. At the end of the day, you will provide it to the night shift.
Here is an example of me giving report to a day shift nurse in a fictional neuro ICU patient:
The beginning of the shift – right after report
Once I obtain report on all of my patients, I take a second to analyze which patient is the most unstable this moment. Does someone need a drip titrated? Are vitals within parameters? Is there a time-sensitive medication? Is their arterial line leveled and zeroed appropriately so I know their blood pressure on the bedside monitor is accurate? Does someone need an intervention right now?
ICU patients are not always going to be stable and things change so incredibly quickly; sometimes, it’s moment-to-moment… literally second-to-second. And occasionally, you are receiving report in the midst of a soon-to-be code, or urgent situation. Yes, shift change codes happen. You truly have to be ready to pivot any second.
Now, let’s say my patients are both relatively stable. Once I get report, I sit at a computer to fill in any questions left from report, collect my thoughts, and get my to-do list finalized.
This list includes:
- A full assessment at least every 4 hours
- A more focused assessment more frequently may be required. For example, most neuro patients require a full neuro assessment every 2, if not more frequently or a patient who just received a femoral-popileal graft may require more frequent peripheral vascular checks
- My documentation requirements
- Telemetry strip, education, care plan
- Are all meds appropriate?
- For example, if a patient is on a drip to RAISE their blood pressure, I need to see if they have any scheduled home medications intended to lower blood pressure,hold those, and clarify with the physician if they should be discontinued
- If oral meds are due, can they be given orally?
- Are the medications safe and necessary given the latest labs and diagnostics?
- Are all meds appropriate?
- Vital signs
- What are the trends?
- Blood sugars
- Is the patient on a drip?
- Frequency of blood sugar checks, sliding scale insulin, and/or scheduled
- Any time-sensitive tasks
Usually, by this time it’s approximately 0800. I am permitted to administered my 0900 medications at 0800 so I’ll grab all meds and supplies for my first patient. I then grab all of my gear (stethoscope, alcohol swabs, saline flushes, brains, Sharpie, pens) and head into my first patient’s room
PS – if you want to see all of my recommended nurse gear from scrubs, to bags, to socks, to water bottles, check out what nurses need.
Assessing my patients
After I get everything I need, I head into my first patient’s room. I say hello to the patient and anyone else in the room and then complete a detailed nursing assessment. I’m looking over every inch of skin, at every piece of equipment (ventilator, enteral feeding pump, IV pumps, arterial line, central venous pressure monitoring, bedside monitor) as well as every tube coming out of the patient (endotracheal, urinary catheter, extraventricular drain, pacing wires, chest tubes, rectal tube, JP drain, arterial line, central venous catheters, IV catheters).
I complete the assessment, check out the equipment, lines, drains, airway, and monitoring, and then give meds. Many ICU patients receive meds through a feeding tube, so it can take some additional time to crush these, mix them appropriately, and flush them down, in additional to any IV push or an IV piggyback medications. Of course, throughout this process I’m watching their vitals and drips closely, to see if they are tolerating their medications.
(Need some time management tips? Check out my book, Anatomy of a Super Nurse for an even more detailed description.)
Throughout this time, I’m talking to the patient and whomever is with them about what I’m doing, why I’m doing it, and what else to expect for the day. Providing any amount of predictiability for intensive care patients and loved ones is very valuable because they have lost all control over everything with their loved ones hospitalized, being taken care of by strangers.
Once I see this patient, I head in to see my other patient and follow the same process. In the med surg world of nursing, I would spend approximately 10 minutes with each patient between the assessment, conversation, medications, education, and documentation. In the ICU, you’re looking at more like 30-45 minutes each.
Constant monitoring and evaluation
ICU patients can change in a matter of moments, therefore it is the ICU nurse’s responsibility to keep a vigilant eye on them. One must know their vital sign and assessment trends to know when they’ve deviated.
Like I said before, instead of assessing a patient once per shift, an ICU nurse must complete a head to toe assessment on the patient typically at least every 4 hours. If changes occur, another one must be completed. If a procedure was performed or the patient went for surgery and came back, then assessments occur more frequently.
The ICU nurse must know their patient backwards and forwards. I’m talking vitals, labs, assessments, meds, history, lines, airway, equipment… everything. It’s crucial to know these things because when things go downhill, you don’t have time to put the clinical picture together in that moment.
You’re constantly asking yourself questions about the patient, whether the goal is to get them more stabilized and figure out what’s going on, or to progress them out of the ICU.
You will find yourself asking…
- Can we wean this drip?
- Is this patient suffering from ICU delirium, or is this a neuro change?
- Should we switch this drip to a different one?
- Do we need another CT scan, set of labs, MRI?
- Is this medication even working?
- Is this patient working harder to breathe?
- Should we get another ABG?
- Where’s respiratory? [spoiler alert: if you’re an ICU nurse, you’re going to become BFF’s with respiratory therapy]
- What are our goals here? Is what we are doing in line with the patient’s advance directives?
- Who is the next of kin?
- Do we need an arterial line?
- Do we need to get a central line?
- Do we need to start dialysis?
- Can you call respiratory again? I know they were just here 3 minutes ago… but, I need them again 🙂
Physicians round once per day and many times the ICU physicians are housed within the unit for constantly changing needs. However, it is still up to the bedside nurse who is constantly monitoring the patient to update the physician as needs change.
It’s no surprise that codes happen more frequently in the ICU. ICU nurses quickly become acclimated to those adrenaline-filled scenarios. ICU nurses know when a patient starts to not look so hot that things are about to go down. You become familiar with a code cart, the various roles within the code (chest compressions, meds, considerations, ACLS algorithms, and the person running the code). ICU nurses also know that some people will help with the code, while others have to continue to care for the rest of the unit who is not actively dying.
These happen unexpectedly, so ICU nurses must always try to stay caught up on their tasks because you never know when you, or your coworker, will be dealing with a coding patient for 2 hours. And, should the patient pass, once they have been taken to the funeral home or downstairs to the morgue, you’ll be open for the next admission… which, consequently, could be another code from a nursing floor or the emergency department.
That brings me to my next point: ICU nurses have to be ready to receive any patients who may code out in nursing units or stepdowns. (A patient who codes on a regular med surg floor has to be emergently transferred to an ICU bed once they are ready to move.) Because of this, a bed in the ICU must be ready for this… and it’s typically called “the code bed” because it’s reserved for that unexpected patient.
As you can imagine, documentation for an ICU nurse is incredibly detailed. In addition to all that the med surg nurse must document, you’ve got to document even more in the ICU. Some patients get vitals every 15 minutes (or even more frequently), you’ve got more detailed assessments which occur more often. Some patients change frequently, and these changes must be reflected within the documentation. Also, patients typically have many invasive lines and it is paramount to prevent infection. Therefore, you’ve got to meticulously document what you’ve done to clean and prevent infection, as well as that you’ve reviewed its necessity.
After working on both med surg and the ICU side, I can confidently say that the amount of time it took for me to document on one of my ICU patients is equivalent to 2.5-3 med surg patients.
Furthering the care plan – working towards transfer
While the med surg nurse’s goal is discharge, the ICU nurse’s goal is transferring the patient out of ICU. We’ve got to note the medical diagnoses, consider our nursing diagnoses (yes, you actually use these whether you realize it or not!), and progress them to a point in which they don’t need constant monitoring.
Do we need to increase their cardiac output? Do we need to transition them from drips to oral medications? Do they need some fluids, or do they need a beta blocker to increase the efficiency of their cardiac contractions? Is there an electrolyte imbalance that needs correction? Will that help with our cardiac output? [Spoiler alert: yes.] Do we need to increase gas exchange? Does that mean we’ve got to do some pulmonary toileting and increase activity to attempt to wean the oxygen down?
There is a lot to consider, all at once, in a very fast-paced, constantly-changing environment. Being a new grad nurse in an ICU can kind of feel like…
But it’s okay, it gets better! (Overwhelmed? Check out tips for a New Grad Nurse, it might help.)
It’s also important to get them out of the ICU as fast as possible because of something called ICU Delirium. Basically, when a patient is critically ill, in a different environment, receiving many different treatments, medications, and interventions, hearing many different alarms, buzzes, and sounds while being cared for by strangers, it is terrifying and people become delirious. People who seem totally fine neurologically can suffer from this, and it may impact individuals years later and result in long-term cognitive impairment and PTSD. This is another reason why it is crucial to transfer patients out of the ICU as soon as it is medically appropriate.
Physicians and their support staff round on their patients once a day, but it’s a little different in the ICU. Because things change so quickly, ICU nurses are chatting with the providers more frequently than on the floor. In addition to rounds, you’re updating the physician whenever the patient declines or new needs arise.
In the ICU environment, it’s a bit more realistic to be present for when physicians and their APP round because you’re balancing 1-2 patients rather than 4 or more. It’s also really helpful to do this because you hear what the physician is telling the family, so you can reinforce this information throughout the shift.
Like med surg units, this rounding is done during day shift, which means routine order changes, transfers, and scheduled post-op patients arrive during day shift. New orders will typically only come through on night shift when acute changes occur.
Interdisciplinary rounds occur daily as well in many facilities. The attending physician, the nursing staff, therapy services (PT/OT/ST), chaplain, dietician, pharmacy, case management, social work, and nursing leadership typically go through each patient and their needs.
While discharges are a big focus for med surg nurses, admissions are more of a focal point for the ICU nurse. An ICU admission is typically an unstable patient who needs the typical tasks completed like (good IV access, admission documentation, med administration), a very solid baseline assessment, labs/diagnostics, and so forth. But they also need to be stabilized FIRST! Stabilization is the key!
In the med surg world, a patient coming to that unit must be stable enough for the nurse to patient ratio, only having 1 assessment per shift, and vitals that are [typically] only done every 4 hours. This is not the case in the ICU. Your next admission could be an actively coding patient, one who was just coded, or someone on the brink of a instability. The patient could have very little going on, or they could be hooked up to 8 IV pumps, a ventilator, CRRT (continuous renal replacement therapy) machine, an arterial line, and more. For the level of unpredictability you may have in med surg nursing, it’s significantly increased in the ICU.
In addition to transfers when patients are ready, there’s another piece to the puzzle. Sometimes, the ICU is full and there is no room to admit another patient. However, you get a call that there is a patient who needs to come who is incredibly unstable and must be in the ICU.
What do you do?
Well, what happens is one patient must be transferred to another ICU with open beds, or the nursing staff (or medical staff if it’s a closed unit) must analyze which patient is most appropriate to transfer out to either stepdown or the floor to make room for this new patient. You may be in the situation in which you have to urgently give report to another unit to get one patient out, only to get a much sicker patient back.
Dealing with death
Patient die in all areas of the hospital, but it’s a bit different for ICU nurses. It’s more frequent than many other units (with the exception of possibly oncology and hospice, respectively), and can be pretty… well, ugly and traumatic. Patients die after long and brutal codes, after sudden injuries, at any age, both expectedly and completely out of the blue.
In nursing school, we learned a lot about advanced directives. I remember thinking to myself that the likelihood I’d ever need to pull one out for a patient to actually follow it was slim to nothing. When I started working in neurocritical care, I realized how often this is actually done. You may find yourself, as an ICU nurse, pulling up a patient’s advanced directive to have a difficult conversation.
Dealing with trauma and death on a routine basis does take an emotional toll on an individual. Therefore, if you’re considering ICU nursing, I highly recommend getting set up with a counselor to emotionally process work in a healthy way. I know many ICU nurses, myself included, who see a professional to work through all of the tragedy with someone objective and also to develop healthy coping and processing techniques.
After 12 hours of assessing, monitoring, pivoting, stabilizing, tweaking, educating, and documenting, it’s time to give report to the next shift. Sometimes, you feel like you’ve run 20 miles all around the unit, and you get to report and feel like it looks like you’ve done nothing all shift. It can be a little defeating. But, what’s important is that the tasks that needed to get done for the patient are completed. Documentation is important, but it’s not more important than providing the in-the-moment, time sensitive care to the patient. So, if someone tries to make you feel bad for not getting that admit navigator done when you’ve been running around drawing labs, hanging fluids, starting IVs, and getting CT scans, don’t trip. Rest in the reassurance that you’ve done the tasks that needed to be done for the patient in that moment and you are only 1 person who cannot do 50 tasks at once.
Like a workout, it’s helpful to have a post-work cool down routine.
Nurses typically get off work at 7:30 pm at the earliest and may have to be up again at 5:00 am for the next shift. The sooner you can relax and calm down post-shift, the better you will sleep, and the more mentally prepared you will be for your next shift.
More resources for new ICU nurses
Learn both hard and soft skills about ICU nursing care. From vasopressors to emotional support, this comprehensive ICU skills workshop covers topics applicable to every nurse working in critical care, as well as those sending patients to, or receiving patients from, intensive care.
Use code ICUskills for $20 off!
YouTube has tons of great free videos (Khan Academy, for one), or check out your speciality nursing organization. The American Association of Critical Care Nurses has tons of great resources for critical care – I HIGHLY recommend becoming a member, or you can check out the NRSNG Academy.
NRSNG Academy is primarily an NCLEX resource, but there is a ton of information applicable for the new ICU nurse. The EKG, Lab Course and MedMaster Course are particularly applicable to this group. They go in depth on mechanism of action, nursing considerations, contraindications, and more within MedMaster. The EKG Course dives deep into each rhythm, nursing considerations, pathophysiologically and electrically what’s occurring, and more. The Lab Course does a deep dive into specifically what each lab is measuring, why it’s important, and more.
- Tips for New Grads in the ICU: Showing Initiative
- Tips for New Grads in the ICU: Nurse Characteristics
- Tips for New Grads in the ICU: Be Your Own Advocate
- How to survive in the ICU
- What Do Med Surg Nurses Do? – FreshRN Blog
- What Does ICU Stand For? – The Nerdy Nurse
- The FreshRN Podcast
- ICU Time Management Tips
- Managing Your Time in Critical Care, Part I
- Managing Your Time in Critical Care, Part II
- The Ultimate Guide to Creating an ICU Report Sheet (for new critical care nurses and nursing students)
- 3 Code Blue Tips for New Nurses (how to survive your first code)
Anatomy of a Super Nurse: The Ultimate Guide to Becoming NurseyNRSNG AcademyCritical Care: A New Nurse Faces Death, Life, and Everything in BetweenWomens Intensive Care Unit ICU Nurse T-Shirt Small Black