ICU Prioritization: How to Prioritize your day and Examination

When you are working in the ICU, it is important to be able to perform a comprehensive exam on each patient. This will help you to identify any potential problems early on, and ensure that the patient receives the best possible care.

We will discuss how to organize your day and how to perform an ICU assessment. We will go over each step in the process so that you can be sure to get the most out of your shift with less stress.

Table of Contents

patient records

Receive report and look up your patients

Many nurses, especially those new to the ICU, tend to look up their patient’s information prior to receiving the report while others will wait until after they receive report. Your report style will come with time.

I prefer to look up my patient’s information before I receive the report as you will be able to get a more accurate mental picture of your patients from the data gathered. This will help to guide the conversation during the report.

For each patient, you will want to know:

  • Patient’s name and preferred name – While you will need to provide the patient’s legal name for charting, obtaining medications, or blood products, the patient may have a preferred name such as the legal name Matthew but prefers to be called Matt.
  • Medical record number (MRN) – Good information to have when you are needing to order medications or other products not within your department
  • Age
  • Gender Identification – Not everyone identifies with the sex they were born with or with any gender at all. It is important to be cognizant of someone’s personal beliefs and identity.
  • Code Status – DNR/DNI status patients have a specific set of guidelines that they want to follow in case of cardiac arrest or respiratory distress. These are important to know so you are following the patient’s wishes.
  • Isolation and Other Precautions – Are these patients on standard, contact, or airborne precautions? Are they on C-Diff precautions? Does this patient have COVID-19? Are there any neuroblockades on board?
  • Admitting diagnosis – What was the reason they are admitted to the hospital?
  • Current working diagnosis – What is the current diagnosis we are working on now?
  • Allergies
  • Medications (including drips and pumps) – never let your drips run dry!! Always check your drips during report.
  • Vitals Trends
  • Labs Trends
  • Recent diagnostics including x-rays or CT scans (if any)
  • History and Physical
  • Specialty consults (if any) – read the most recent consults and don’t try to read notes from when the patient was admitted as these notes are no longer relevant based on the current presentation of the patient
  • Double-check your orders – make sure that you understand all of the physician’s orders and that they are within your scope of practice and make sense based on the patient’s presentation.

Armed with this information, you will be able to provide better care for your patients. You will also be able to ask more informed questions during the report. It is important to have this information at your fingertips so you can answer questions on the fly during multidisciplinary rounds.

notebook plan

Plan your day and prioritize your patients

After receiving report, you will want to sit down and develop a plan of care for the day. This is when you will prioritize your patients based on their current status.

Some factors you may want to consider when prioritizing your patients:

  • Are they hemodynamically unstable?
  • Do they have high ventilator settings or are they intubated?
  • Do they have a new diagnosis?
  • Do they have an infectious disease?
  • Do they have a new procedure or diagnostic test scheduled?
  • Do they have a family member or friend at the bedside?
  • Do they require frequent monitoring?

Once you have prioritized your patients, you will want to develop a plan of care. This plan should be fluid and change as the patient’s condition changes. Remember in healthcare that no everything you planned will go as planned.

Your plan of care will include:

Assessment – This is a continuous process as the patient’s condition can change at any moment.

Medications – As stated before, never let your drips run dry!! You do not want to be that nurse on hold waiting for the pharmacy to make your medication while others are trying to stabilize your patient. Always have an extra bag at the bedside if you know the patient will be maintaining this drip for a while.

Tasks – These are the interventions you will be performing for your patient. These can include turning, bathing, ambulating, providing range of motion exercises, or anything else that needs to be done for the patient.

Treatments – These will be given at specific times and you need to ensure that you have the supplies on-hand before you start the patient’s shift.

Procedures – If your patient is scheduled to go down for a procedure during your shift, it is important to start planning the coordination between the procedural area, respiratory team, and any other disciplines to get your patient down safely.

Documentation – This will be done throughout the shift and you need to ensure that you have the time to do this properly.

Check the Patient's Chart

You will also want to check the patient’s chart before you start your shift to make sure the correct information is located inside such as a copy of the Do Not Resuscitate, patient labels, and anything else you may need during your shift. Many times there are documents within the chart that may need to be signed or may be missing that you will need to follow up with.

Patient Assessments and Rounds

ICU nurses are responsible for performing frequent patient assessments and rounds. These are important to ensure that the patient is remaining stable and to catch any changes in their condition.

The frequency of these will be determined by the patient’s current status. For example, a patient who is hemodynamically unstable will require more frequent monitoring than a patient who is stable.

Some things you will assess for during your rounds:

  • Review of Systems
  • Mental status
  • Vital Signs and Pain Level
  • Check the monitor against the orders – does the monitor parameters match the orders?
  • Drips – are the bags getting close to empty? Do you have another bag?
  • Turn and Positioning
  • Check the skin for any indentations from devices, under dressings, wounds, reddening, etc.
  • Perform oral care if indicated
  • Laboratory Results
  • Intake and Output
  • Laboratory Results
  • Print and interpret your EKG strips

This exam is going to be more comprehensive and thorough compared to lower acuity assessments.

After completing your assessment, you will want to make sure you have all the supplies and medications you will need in your room. This includes:

  • IV fluids and tubing
  • IV medications
  • Syringes and flushes
  • Resuscitation equipment – make sure you have a crash cart in your room at all times!
  • Oxygen – portable and wall mounted
  • Nasogastric (NG) tube supplies, if indicated
  • Parenteral nutrition (PN), if indicated
  • Blood products, if ordered
  • Linen

And finally, always wash your hands and don your PPE before entering the room! This includes gloves, gown, mask, and eye protection. Hand hygiene is the most important thing you can do to prevent the spread of infection!

Patient Documentation and Charting Your Assessment

After completing your assessment, it is important to document your findings in the patient’s chart. This will help communicate your patient’s condition to the rest of the healthcare team, as well as provide a record of the care you have provided.

When documenting in the chart, always use objective language. This means that you should avoid using terms like “looks” or “seems.” For example, instead of saying “the patient looks agitated,” you should say “the patient is yelling and thrashing about in bed.”

It is also important to document the patient’s response to interventions. For example, if the patient is on oxygen, you should document their oxygen saturation levels before and after starting the oxygen. This will help to ensure that the patient is receiving the appropriate level of care.

And finally, always remember to date and time stamp your entries! This will help to ensure that the patient is receiving timely care and protect yourself in case you are questioned regarding your documentation in the future. Remember, if it isn’t documented it didn’t happen!

Start Performing Tasks for the Shift

Once you have completed your assessment and gathered all your supplies, you can start performing tasks for the shift. These tasks will be determined by the patient’s current condition, orders that are in place, and the plan of care you created prior to your assessment.

It is important to cluster care as much as you can to minimize the time you leave the room for either tasks or missing supplies. This will save you an immense amount of time during patient care activities. For example, if you need to turn the patient, bathe them, and check their dressings, try to do all of these activities while you are in the room. This will minimize the number of times you need to enter and exit the room, as well as protect you from exposure to any potential pathogens.

Some of the tasks you may need to perform during your shift:

  • Turn and position the patient every two hours to prevent skin breakdown
  • Proning may have an independent schedule based on facility guidelines
  • Assess the patient’s vital signs, mental status, and pain level
  • Provide the patient with oral care
  • Assess and document the patient’s intake and output
  • Check the patient’s IV fluids, drips, and medications
  • Change the patient’s dressings
  • Provide the patient with wound care
  • Assess and document the patient’s laboratory results
  • Interpret and document the patient’s EKG strips
  • Provide the patient with parenteral nutrition, if indicated
  • Administer blood products, if ordered

And finally, always remember to reassess the patient throughout your shift to ensure that their condition is not deteriorating!

Attend Multidisciplinary Rounds

Multidisciplinary rounds are an important part of the ICU. They provide a time for the entire healthcare team to meet and discuss each patient’s plan of care. During rounds, the patient’s nurse or provider will present the patient’s case to the team and update them on the patient’s condition. The team will then make any necessary changes to the plan of care and discuss any next steps.

It is important to attend rounds, as they provide you with an opportunity to ask questions and voice any concerns you may have about the care of your patient. Additionally, rounds are a great time to learn from your colleagues and gain new insights into the management of critically ill patients.

Always be prepared to advocate for your patient and actively participate in these rounds. Remember, you are the expert on your patient and you know them best!

And that’s it! These are the basics of working in an ICU. Of course, there is much more to learn, but this should give you a good foundation on which to build.

Final Thoughts

Working in an ICU can be both challenging and rewarding. It is a fast-paced environment where you will be constantly learning new things. But it is also a place where you can make a real difference in the lives of your patients.

If you are thinking about working in an ICU, or are already working in one, always remember to:

  • Assess your patient thoroughly and frequently
  • Document everything meticulously
  • Communicate with your team openly and honestly
  • Be prepared to advocate for your patient
  • And most importantly, never stop learning!

Do you have any tips for working in an ICU? Share them in the comments below!