When providing critical care, effective time management is of the utmost importance (why else would we still be talking about it?). And yet, the very nature of the job makes thoughtful planning and the development of a stable, consistent routine that much more difficult for even the most organized nurse.
Sounds a lot like being between a rock and a hard place, doesn’t it?
Luckily, where there’s a will, there’s a way, especially when that will is supplemented with even more advice from the queen of critical care strategy, Kati Kleber.
One of the most important things to master in critical care is prioritization…what do you do first? It’s kind of like prioritization on the floor, except the stakes are higher. Instead of doctors rounding, patients being hypertensive, patients in pain, families wanting you to discharge them 10 minutes ago or having to facilitate a transfer to a nursing home, you have patients with subarachnoid hemorrhages who are suddenly developing hydrocephalus; septic patients on four different drips to increase their blood pressure, active GI bleeds profusely bleeding from their rectum; patients with Impellas who cannot move a muscle; and very emotional family surrounding everyone all the time. Oh, and the guy next door has basically been coding for the last two hours.
All right, so how do I figure out who needs me most?
A lot of intensive-care time management has to do with the “who needs me the most right now” mentality. Yes, all of them always need you…however, who needs you MOST?
If you don’t know which task to do next, ask yourself: Which patient is the least stable right now? That can help you quickly prioritize when there are many tasks that need to be completed.
Once you’re more familiar with the urgency of certain situations and disease processes, you’ll figure it out. And also, once you’ve screwed it up a few times, you’ll never forget!
Here are three examples of typical critical care situations. Both patients need you now, but who needs you right now? (Sorry for all the neuro, I love it so much!)
1. One patient has had a hemoglobin drop from 7.9 gm/dL yesterday to 6.9 gm/dL today and has two units of PRBCs due now. He’s asymptomatic. Your other patient has a stable subarachnoid bleed (not in vasospasms) and his blood pressure limit is to keep his systolic pressure less than 160. His last three pressures were 159, 168 and 174 over the last 45 minutes. He’s also asymptomatic. How do you handle this?
2. One of your patients had a devastating stroke in her brainstem yesterday. The family has all arrived and is at the bedside, and wants to allow the patient to pass naturally. She was made a DNR last night and the MD ordered comfort care measures once everyone has arrived. Respiratory therapy just pulled out the endotracheal tube and her oxygen saturation is 71 percent and her heart rate is 39. Your other patient was admitted from the floor with septic shock. Antibiotics were initiated, cultures have been sent and up until this point, his vitals were stable. Now his pressure is 69/42 with a MAP of 51. You can only do one thing right now—what do you do?
3. One of your patients has an intercerebral hemorrhage and is on Cardene to keep her systolic pressure less than 160. Her pressure is now 185/90 and climbing. Your other patient is in respiratory distress. He’s been on 4L NC all day and has an O2 saturation of 95 percent, but all of a sudden he’s 84 percent on that 4L NC and clearly in distress. How do you handle this?
All right, here’s how I would handle all of these situations.
1. Which patient is the least stable? Typically asymptomatic anemia is only treated if it’s less than 7.0 gm/dL and you’re barely below that. He hasn’t had a major drop, only 1 gm/dL overnight, so he’s not acutely bleeding. That guy can wait a second for you to start that blood; you need to deal with your hypertensive subarachnoid. Check your PRN medications to see what you have; if you don’t have anything, you need page the MD immediately, get a STAT order and administer it NOW.
2. Which patient is the least stable that you’re going to treat? The family of your patient receiving comfort care may need you more emotionally, but your septic patient is not perfusing blood to his organs with a MAP of 51. You need to get him on some Levophed and Vasopressin (or whatever is ordered) STAT. Do that first, then go emotionally support the family of your dying patient. It would be ideal if you could delegate starting your drips to someone else and stay with the dying patient, but realistically that’s not always an option.
3. Which patient is the least stable? The guy in respiratory distress! Yes, that’s a scary high blood pressure for someone with a bleed in their brain, but Mr. Respiratory Distress needs you, like, NOW! Get a non-re-breather on them and crank it up all the way and see if that works. If not, they may need to be emergently intubated. If possible, delegate to someone to titrate your Cardene up. Again, that’ s not always going to be an option. In the case that it’s not, you need to get Mr. Respiratory Distress stabilized and then titrate your Cardene.
These are a little neuro-y—does anyone who works in cardiac or SICU/MICU have a good scenario they’ve experienced? One where both need you right now, but you had to figure out who needed you more? The newbies to critical care will greatly appreciate it!
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