Karen Higgins has been nursing for 28 years, she is past President of the Massachusetts Nurses Association, and writes here of what it takes to be an effective nurse on an Intensive Care Unit.
Why nursing is different now
I have been a critical care nurse working in intensive care units for almost 28 years. I graduated from nursing school when I was 21. At first I worked on a regular hospital floor. Three years later I came to the ICU and never left. I was attracted to critical care nursing because of the challenges and rewards of taking care of very sick patients in a fast paced environment. Here in the ICU my nursing skills are pivotal to the patient's survival and my role continues to evolve.
People ask me what is the biggest change in nursing over the years, and my answer is advancements in both technology and medications and also the patients themselves. Many of the patients I care for in the ICU would not be alive 10 or 20 years ago. New technology and medications are wonderful in that they give more patients a chance to survive and live longer but the problem is that when they come to me, patients are now more acutely ill than ever before. The bottom line is that patients now need more care and attention from the nurse. The assumption is that with the developments in technology and medications there is less need for the care by a nurse. But the opposite is true.
Let me give some examples.
Recently on a shift I was responsible for two patients, both of them elderly women in their 70s.
A Juggling Game
Of these two patients, one had severe lung disease and pneumonia, as well as being diabetic. The other had sepsis, a blood infection that can be deadly and affect nearly every system in the body. Both patients were hooked up to ventilators to assist their breathing, had feeding tubes and catheters in their bladders so we could monitor their kidney function. They also both had a myriad intravenous lines to administer complex medications, and they were hooked up to monitors to measure their heart rate and the oxygen in their blood. We're talking about millions of dollars of technology and equipment being used on the patient. But all of it is worthless without a nurse like me to be there to monitor manipulate the technology based on how I access the patient.
My morning started with the patient with pneumonia, and my order from the physician was to wean her off the ventilator so she could breathe on her own. But this was easier said then done. When I tried to take her off the ventilator her heart rate began to increase, and her blood oxygenation level began to drop. She became agitated. At that point I knew there was no way she was getting off the ventilator that day, at least not until I could get her other symptoms under control. First, I needed to lower her blood pressure and calm her anxiety. To accomplish this, I needed to sedate her and then I could more closely monitor her oxygen levels and blood pressure until she was once again stable. She was also a diabetic and I was required to monitor her insulin level every four hours to make sure her diabetes was also under control.
When I was finally able to stabilize this patient, I was then able to move to my second patient, the woman with the severe blood infection. Upon making my initial assessment, I noticed that she had spiked a fever, which is a sign of a new infection. I immediately took samples of her urine, blood and sputum to be sent to lab for a culture to determine what might be going on. I then called her physician to update him on what was happening. This patient was on a number of medications, each being delivered by an intravenous line, including a sedation drip and insulin drip that I was monitoring. I had to evaluate her reactions to the medications and to titrate them, which means to adjust the flow of medication based on what I saw. I soon noticed that her oxygenation level was border line and that her blood pressure was dropping. I immediately lowered the head of her bed and I started giving her fluids (saline) through an IV line which is something we do to help increase blood pressure, I also noticed that her urine output was starting to drop. I again notified the physician of the changes. The patient was not responding to the fluids I was administering so I started giving her IV medications to bring her blood pressure back up.
My entire day was spent moving between these two patients, making assessments and adjustments to their treatment with the goal of keeping them as stable as possible and with the hope of moving them closer to recovery.
The problem is that the whole time I'm with one patient, I'm worrying about the other patient, hoping that nothing significant has changed that I might miss while I'm out of the room. Granted, there are alarms connected to the technology that go off when things really go bad, but the true value of a nurse is having her in the room to spot trouble BEFORE it happens. At this stage in my career, I can walk into a room and just by looking at a patient, I can sense how the day is going to go and if there is going to be trouble.
When technology meets intuition in patient care
These assessment skills are second nature for an experienced nurse like myself. I need them in the ICU where a patient's health status can suddenly change. I remember one patient I cared for, a young man in his thirties. He had been sent to my unit with a pericardial effusion, which means he had fluid built up around his heart. He was also suffering from kidney disease, and was on dialysis to cleanse his blood of toxins. The night before the patient had a pericadial cap this means a tube was inserted into his chest to draw out the excess fluid around his heart. When I got the patient—the tube had been removed and my job was to monitor the patient in the ICU making sure his heart function was stabilized so we could get him ready to go out to a floor later that day and possibly home the next day .
In cases like this it is very important to monitor the patient's heart rate and blood pressure carefully for discrepancies. You need to listen through a stethoscope for certain irregular sounds which can signal a problem. This is not something that can be done by a machine, it takes a trained ear of a nurse who knows what to listen for.
While this patient's heart rate was fine, his blood pressure was a little low, but not in a range that typically signaled a problem. He was eating on his own and he seemed to be doing well. The physicians were pleased with his progress. But I soon began to sense that something was not quite right. While he was on the dialysis machine removing the toxins from his blood –every time the dialysis nurse attempted to adjust the machine to draw fluid from the patient his blood pressure would drop.
Still, this was not abnormal during dialysis and the call from his physician was that everything looked fine and that the patient could be transferred. But something just didn't sit right with me. I knew that this patient usually put out a lot more fluid during dialysis and that his blood pressure normally ran high. I had a feeling something was still wrong. I couldn't point at just one thing that signaled a problem. So I went to the attending cardiologist overseeing his care, someone I had worked with for years and I told him, "Something is just not right with this patient.” I went over my concerns and asked if we could repeat his echocardiogram, just to make sure before transferring him out. This physician knew that I was a skilled nurse with good instincts, so he agreed to do it.
Once they did the echocardiogram they found out that in fact the patient's condition had deteriorated. Fluid was re-accumulating around his heart. And he was rushed to surgery within a few hours. There is a good chance that had I not intervened, this patient would have been sent out to the floor with plans to possibly discharge in the morning. He could have died.
Why I stay
For me this experience is a prime example of what nursing is all about. Like air traffic controllers, we watch over our patients making sure they remain safe and don't crash. We are the surveillance system for our patients. But as a nurse I not only monitor my patient's condition—but I am also pilot who delivers complex technological care on a minute by minute basis. As the nurse I am the one person who is responsible for the patient's survival from the moment he or she comes into my care and making that care is continuously tailored to meet the patient's needs.
I love being a nurse and love using my years of experience and skill to care for patients and their families at perhaps the most difficult time of their lives. But the expectations of nurses have become unrealistic. I cannot be in two places at once—and as patient's medical needs become more complex, I worry that I will not be there at a critical moment to access a patient in need. For the last twenty-eight years I have been my patient's last line of defense and will continue to be there until I can no longer provide safe care.