My Night Shift Work Routine at the Medical ICU - Part 1

Welcome back! In my last post, I wrote about working with various types of providers and what I learned from them. You can check out that post and others here!

Multnomah Falls

As I’ve mentioned before, I was at a level 1, trauma and academic hospital in Portland, Oregon. My last hospital was more akin to a rural hospital, so the routines were slightly different compared to an academic hospital. For starters, prior to starting the shift, we would have a pre-shift huddle. If you aren’t familiar with what a huddle is, huddles are usually brief meetings that are held before the start of a shift.

Pre-Shift Huddle

By 7 PM each bedside nurse coming in would pick up an assignment sheet that would list all of the patients admitted, their diagnoses, and pertinent issues to be addressed. The charge nurse would lead the huddle and start by addressing unit-specific announcements, equipment and safety points, staffing issues, and eventually patient assignments. My unit, and all of the other ICUs, promoted independence and nurse autonomy so we were free to advocate for ourselves about which patient assignments we would like to take.

I actually enjoyed having pre-shift huddles because we would be able to share awareness of what was going on in the unit. This served to promote unit cohesiveness and teamwork since everyone would be informed about some of the sickest patients and which assignments would be heaviest. I found that whenever I picked up a heavy assignment, I was never without help and I never felt that I was drowning in an assignment!

Report, Hand-off, Endorsement

After the huddle, we would head into the unit to our chosen patient assignments and get a report (sometimes called hand-off or endorsement) from the previous shift’s nurse. If you aren’t familiar with endorsement, the process of endorsing a patient helps to ensure that the oncoming nurse has all the necessary information to provide high-quality, safe, and effective care to their patients. During the report, the outgoing nurse informs the oncoming nurse about the patient’s condition, past medical history, the history of their present illness, current treatments, medications, labs, diagnostics, and a review of their body systems.

Some nurses, depending on their experience level or preference, will use report sheet templates or a blank piece of paper. Personally, I like to use a structured report sheet because it keeps me organized, especially during hand-off. If you’ve seen any memes about what it’s like to give hand-off after a long shift you’ll know that end-of-shift fog is a shared experience among us nurses! However, I will say that I’ve impressed myself whenever I’ve made it through a shift with a regular blank piece of paper as my report sheet and given report without having to read it!

Before report was finished, we would do a bedside check on the patient to verify any active drips that are ongoing. This helped to give me a chance to see the patient before reviewing their chart. I would use this opportunity to address any discrepancies or concerns about the patient before the outgoing nurse would leave.

Chart Reviews, Assessments & Meds

Once I’ve finished getting report, I would sign into my patient’s charts. This hospital used Epic and this is by far my favorite electronic medical record system. From the patient dashboard, I’ll verify any information that was given to me during report, trend any pertinent labs, write down the timeline for medications and other orders to be carried out and anything else that stands out to me.

Next, I would grab all of my equipment (temperature probe, stethoscope, glucometer - this would depend on the patient) and head into the room. I would use the acronym AIDET, to structure my first encounters with my patient and their family. If you aren’t familiar with AIDET, it stands for - Acknowledge, Introduce, Duration, Explanation, and Thank you. As I make my way into each patient’s room, I’ll acknowledge them and their family, introduce myself, and explain what I’ll be doing in that moment and any future interventions as well as their respective durations. I would usually end each encounter with a thank you.

Regarding my assessments, I usually take a head-to-toe and systems-based approach. I’ll ask for my patients to tell me their name, date of birth, where they are, what the current date is, and why they were admitted. At the same time, I would physically perform a neurologic assessment. After that, I would move onto listening to their heart, lung, and bowel sounds while also feeling for their upper extremity pulses and skin temperature. If there are any tubes or lines in place, I would take those into consideration and verify their placements (this would of course affect other parts of my assessments, especially if the patient was intubated).

After a thorough assessment of the patient, I would do an environmental assessment. This would include inspecting any machines in the room, such as the ventilator, non-invasive ventilation machines, IV pumps, bed, monitor, and any other devices pertinent to the care of the patient.

Finally, if I managed to get through my assessments early enough, I would head to the medication room to grab any medications that were due or soon to be given. Ideally, I would start grabbing my meds by 8 PM. However, if my patient’s were sick and needed more attention or interventions, I might push back routine medications and prioritize anything I needed to do to keep them stable.

Remember what I said about unit awareness and teamwork earlier? Well, these situations are when nurses nearby, including the charge nurse or resource nurse, would help. When I say I never felt like I was drowning, I meant it!

Check back again later to read about the rest of my night shift routine. Thanks for reading and until next time! Salamat and si yu’us ma’ase!