#AskOurNurses is an initiative where we invite nurses from various hospital departments to share more about the department, and what it is like to be a nurse in their respective departments.
We have APN Mei Siew from National University Hospital Intensive Care Unit to share about ICU Nursing, and address some of the questions you have posted on our IG story. The following are the questions that our guest speaker have answered.
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APN Mei Siew: Hi, my name is Mei Siew, currently I’m (working) as an advanced practice nurse in ICU. I’ve been working in the ICU for the past 20 years. My daily job includes taking care of patients, formulating a care plan and discussing the care plans with the consultants, and once it is agreeable, we execute the plan. We provide education to the nurses, and work collaboratively to initiate some of the good quality work to improve patient care.
Question: Describe Critical Care Nursing in 1 word
APN Mei Siew: Excitement
Question: What made you choose to be in critical care nursing?
APN Mei Siew: Strong patient advocate and holistic care
Question: What qualities are needed in critical care nursing?
APN Mei Siew: Good planning. As a good planner, you can anticipate the problem before the problem arises. Secondly, sensitivity to patients’ non-verbal cues, most of the time [patients] are not able to verbalise what they want and what they need. Third, i believe [it] would be patience. You have to be patient, to stand there quietly, trying to understand from patients, what they are trying to tell you, what they need at that point in time.
Question: Do you think ICU nurses are OCD?
Question: What are the common skills performed as an ICU nurse?
APN Mei Siew: Most of the time [would be] assisting in airway intubation, [central] line insertions, managing patients with ventilators, sending intubated patients to out of unit procedures, managing patients with multiple lines and tubes, and drugs (medications).
Question: How do you juggle so many things at once?
APN Mei Siew: I think the keyword [here] is PRIORITIZING. As an ICU nurse, we prioritise our work based on (i) Emergency - ‘die die must do’, (ii) Urgency - ‘can wait, but cannot wait too long’, (iii) Need to do [Work that needs to be done before shift ends] (iv) Can be skipped.
So you prioritize the work according to [the emergency status of the task] like life threatening situations [first].
Question: Is it true that ICU nurses must know every single detail about their patient(s)?
APN Mei Siew: We used to know every single detail at a single tip [at our fingertips], because in the past it was all manual [and hardcopy]. And as of current, all information are digitalised and with a single click the answer would appear. However, we are very meticulous, as our patients are intubated, they are not able to tell us what they feel, if they are feeling pain anywhere or having any aches. There are a lot of times whereby we need to closely observe patients' facial expressions, their vital signs to tell us how they would be feeling. So these are the details and cue we pick up along the way in our daily work that can tell us what the patient’s needs are.
Question: How do ICU nurses and General ward nurses differ in terms of having to know details about their patients?
APN Mei Siew: Let’s talk about ICU. As an experienced ICU nurse, we have garnered the knowledge and skill sets on what is important on a particular shift. For example, a patient with a central line, all the [ICU] nurses would be interested in the duration of the central line in the patient’s body. Each central line is a foreign body, which equates to the risk of infection, which is why it is vital for ICU nurses to know the duration of each central line in a patient.
Other things we [ICU nurses] are quite particular about would be drug (medications) calculation, drugs (medications) dilution and when was the drugs (medications) changed, because each drug has their own duration that is allowed to be kept in a syringe pump. So these are some of the details that ICU nurses would need to know.
In comparison to nurses in general ward, yes [it differs]. Mainly because central lines are not frequent in general ward, and the drugs used in ICU are pretty infrequent in general ward.
Question: What is the most challenging task as an ICU nurse?
APN Mei Siew: This often comes towards end-of-life care, when patients are not truly doing well. We would then explore the patient's end-of-life wishes. So the challenge comes when the patient’s are ready to let nature take its own course, but the family would decide on the total opposite. I would say the challenge [as an ICU nurse] is not the technical skills per se, it is the [communication skills] that is the most challenging task. At one end as a nurse, we would want to fulfill the patient's [last] wishes. But on the other end, we need the family to come together to support the patient's last journey. That conversation is challenging.
Question: How do ICU nurses stay calm seeing multiple pumps and machines?
APN Mei Siew: Don’t panic. Do one thing at a time, [know] what is the focus. The general approach as an ICU nurse is using the head-to-toe approach. So when we enter the patient’s room, we screen through the room, taking note of how many pumps, how many drugs (medications) [are running] and the machines being used on the patient. That would be the first step and would probably take about 15 seconds. Subsequently, we run through systematically from head to toe.
‘Are there any drains in the head?’ ‘What is the tube used?’
Moving on the neck, what are the lines insitu, what medications are being infused?
Essentially, it is going through the flow step by step, and to ensure no to skip steps.
Question: Are ICU patients categorised according to certain departments or in general ICU? (i.e cardiothoracic ICU, neuro ICU or general ICU?)
APN Mei Siew: Now is department-based, or patient population-based. Let’s say you are a cardiac [patient], came in because of heart attack, you would go to coronary care unit. Let’s say you would require surgery due to the heart attack, you would go to cardiothoracic ICU.
Question: How would you describe the work culture in ICU?
APN Mei Siew: Generally in ICU, we depend on each other a lot. I do not think ICU nurses can do a lot of thing by themselves, one person. Be it physical [sponging or turning], resuscitation and sending patients out of the unit for procedures, we need people. That is where teamwork [comes in], and it is something we cultivated [amongst our nurses]. Open communication is also something we encourage. When we feel there is a need to talk about an issue, we communicate the issue, and the approach is that all these open communication is targeted for learning. So that our colleagues and friends would not repeat the same mistakes.
Question: Do you have any tips for student nurses who are interested in joining ICU?
APN Mei Siew: First thing, students have to ask themselves if they feel excited and adventurous to find out about ICU nursing. In terms of not knowing what is going to happen for the particular shift, what kind of patient is coming in. Generally, ICU nursing is very unpredictable. We will not know what conditions we will be caring for. This is where attentiveness and alertness have to be there at all times.
Question: What is the most memorable case you had in ICU?
APN Mei Siew: One of my patients, a young lady. [This happened] when I was a young junior as an APN. So she was pretty young, [in her] 30s to 40s. She came in for status epilepticus [first onset], previously healthy with no past medical history. Out of the blue, she came in because of status epilepticus.
For those who know about status epilepticus, patients who are admitted to ICU for status epilepticus, the standard care of management would be securing the patient's airway. So she was intubated. Next, we would want to control the seizures, and that’s when she needs to be sedated. Central line was inserted and sedations are being infused. [We would hook up the EEG (electroencephalogram)] and show seizure activity, we realised this medication is not enough to control the seizure. So we had to add on multiple agents to control the seizure.
On top of that, we still have to administer antiepileptic medications. That’s where we would have 5 to 6 pumps running and we have to perpetually come back and replace the infusion medications. This management lasted for about 10 days, trying to figure out what happened to the patient, and why she is having status epilepticus out of the blue.
She underwent plasma exchange and IVIG therapy. 10 days later, the seizure eventually stopped. I thought that was the time we could cut down on our sedation. The moment we withdrew the sedation, the patient went into a seizure episode again. That’s the ups and down as an ICU nurse. So we basically went back to day 0 and restarted the investigations. This process lasted for another 3 weeks. We adjusted the medications and eventually we managed to wean the patient off the sedation totally. She started to open her eyes and has no recollection of what has happened. This is common in ICU, and it is important for ICU nurses together with the family members, to tell the patient what happened, what she went through and explain what all these lines and pumps are used for. Their attention is very short because they are lethargic. You realise you will have to repeat the whole story again, for about the next week.
She started to retain more information, and started to improve on her power limbs. Imagine being sedated and not moving, the power limbs are weakened, and as simple as lifting up her hands or lifting up a pencil can be challenging for her. That is one of the issues for ICU patients for too long. As part of the rehabilitation process, we sat her out on the chair. Unfortunately, one afternoon, while sitting on the chair, she started to seize again.
All of us were shocked, thinking about what could have gone wrong. After struggling for the past 3 to 4 weeks to get to where she was, able to rehabilitate, we went back to day 0. The whole process went on for another 6 more weeks, before she became seizure-free. Due to the prolonged ventilator use, she had a tracheostomy which we managed to wean her off the ventilator before we sent her up to the general ward.
Within 3 weeks, she went to community hospital for about 4 weeks for further rehabilitation. She came back to the ICU, walking and she was able to recall the nurses’ name that cared for her. That was a huge joy, satisfaction and fulfilment, knowing that all the hard work done for the patient was worthwhile. That was the most memorable experience I had. This is what ICU nurses would want to achieve. We would want to bring them back to where they were before, and continue with their lives (as mothers, daughters, wives etc).
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