ICU clinicals can be intimidating, especially if you’ve never been in a critical care environment before. In this article, you’ll learn what to expect in the ICU so you can approach your clinical rotations with excitement instead of fear.

How is ICU different from Med Surg?

Patients in the ICU are sicker, require advanced interventions and more frequent (even continuous) monitoring. Some common examples are:

  1. A patient on a ventilator
  2. A patient who requires powerful medication (vasopressors) to keep blood pressure up
  3. A patient who has received TPA and requires frequent neuro assessments
  4. A patient in diabetic ketoacidosis who requires hourly blood glucose monitoring and an insulin infusion
  5. A patient recovering from open heart surgery
  6. A patient in septic shock
  7. A patient with an active GI bleed who is receiving frequent blood transfusions
  8. A patient with an EVD who requires careful fluid replacement and frequent neuro assessments.

Patients in the ICU have their heart rhythm, heart rate, RR, and SpO2 monitored continuously and blood pressure measured as often as every five minutes. In addition, some patients have advanced hemodynamic monitoring in place so we can see things like blood pressure and cardiac output in real time.

Another key difference between ICU and Med Surg is the nurse to patient ratio. While California is currently the only state to mandate ratios, most ICUs are a 1:1 or 1:2 ratio, though with staffing shortages, a 1:3 ratio in some locations is not uncommon (doesn’t mean it’s safe, though!). In contrast, nurses on a Med Surg floor can have 5 to 7 patients.

ICU first impressions

When you walk into a critical care environment the first thing you’ll likely notice is the amount of high-tech equipment. Each patient will have their own monitor displaying HR, RR, SpO2, and Blood Pressure at a minimum. Other displays may show things like ICP, CVP or PAWP. In addition to the monitoring equipment you’ll see ventilators, bedside dialysis machines, feeding tube pumps, a lot of IV pumps, and possibly even ECMO.

Typically each patient has their own room, which instead of a traditional door, has a glass wall so the patient can be seen from the hallway. Intensive care ALSO means intensive monitoring. 

The next thing you’ll probably notice is how much noise there is. All this high-tech monitoring equipment and therapeutic equipment raise alarms on a regular basis. There are alarms for heart rate and rhythm, alarms for respiratory rate, SpO2, and blood pressure. There are high pressure alarms on the ventilator, low pressure alarms on the ventilator, BiPAP alarms, IV pump alarms, feeding tube alarms, and so much more. It’s a pretty stimulating environment and an ICU nurse must be able to differentiate what’s happening with the patient based off a wide variety of sounds. 

ICU Clinical Safety Tips for Students

The ICU is a great opportunity to get in there and get your hands on patients and equipment. You’ll likely get a lot of practice with hands-on skills, but don’t discount the really golden opportunity in the ICU which is the opportunity to practice assessing patients with significantly altered physiology. This is where you’ll hear lung sounds so coarse it sounds like a washing machine, feel subcutaneous emphysema, get a lot of practice with the doppler, get great at grading edema, get exposure to recognizing signs of shock, understand what a GCS of 3 actually looks like, and get a feel for recognizing patients in respiratory distress. 

You’ll also get opportunities to get your hands on a lot of different equipment…feeding tubes, IV pumps, indwelling catheters, tracheostomy tubes, ventilators, Pupillometers, hemovacs, chest tubes, central lines, extraventricular drains, pacemakers, hemodynamic monitoring devices, arterial lines, LVADs and more. 

While I encourage you to get your hands on as much of this equipment as possible, never do so without your preceptor’s supervision. Equipment can, and will, malfunction, and there are times when this could be a critical situation such as with an EVD, pacemaker, tracheostomy tube, ventilator, arterial line or chest tube (just to name a few). 

In addition to always manipulating equipment with supervision, a few other ICU safety tips include: 

  • Make sure BP cuffs are the appropriate size and positioned optimally so you can be assured of the most reliable reading. 
  • Take all alarms seriously until proven to be non-serious. Get in the room and put eyes on the patient. If anything is unexpected, call for help or get your preceptor STAT.
  • Know where the code blue button is in all your rooms.
  • Never reposition a patient on a ventilator or with a lot of lines/tubes yourself. This requires a team approach for patient safety.
  • Before stepping away from the bedside, look down to ensure no tubes or lines are in danger of being pulled out. Things can, and do, find their way to wrap around your legs, stethoscope and hemostats that are hanging off your scrub top. The last thing you want to do is step away and pull out a central line in the process.
  • If your patient is restrained to prevent pulling of tubes and lines, make it a habit to always assess the restraints are applied correctly before stepping away from the bedside. I precepted a new nurse who failed to do this, and the confused patient pulled out their NG tube. The nurse had to replace the NG tube, but didn’t watch the patient’s hands. As soon as the NG tube was inserted, the patient pulled it out again. The tube had to be reinserted again…and this wasn’t fun for the nurse OR the patient.
  • Notify the nurse you’re working with if you notice anything unexpected in your patient. I once had a student who recognized a loss of pedal pulses and because of her, the patient got prompt treatment that likely saved her leg.
  • Tripe check all medications and check them a fourth time with your preceptor. Only give IVPB medications or hang fluids with your preceptor’s supervision.
  • Never turn off a pump alarm. If a pump is alarming, let your preceptor know immediately, especially if the mediation is life sustaining such as a vasopressor. 
  • Never silence ventilator alarms. Let your preceptor know, especially if the ventilator has a low-pressure or high-pressure alarm. A low pressure alarm means something has gotten disconnected, and a high pressure alarm is often due to an occlusion and the ETT may need to be suctioned.
  • Lastly, never do anything you’re not checked off to do and always check with your preceptor about anything you are unsure of. 

Scenarios you’ll see in your ICU Clinical

Let’s talk briefly through three common scenarios you’ll see in critical care so that when they happen, you don’t feel like you’re seeing them for the first time.

Your patient has a drop in blood pressure

When the patient becomes hypotensive, the nurse you are working with will likely do the following: 

  • Verify the measurement by assessing the BP cuff placement and assessing BP on the opposite arm. If the patient has an arterial line, the nurse will check that the arterial line is at the appropriate level and that the waveform is as it should be. 
  • The nurse will notify the MD using SBAR.
  • Orders can include crystalloids, colloids, or vasopressors such as norepinephrine.
  • If IV fluids are ordered, these will be administered as a bolus, meaning they must be infused quickly. The nurse may use a rapid infuser, a pressure bag, or manually squeeze the fluids in using special IV tubing that has a bulb.
  • If vasopressors are ordered, the nurse will want to get this powerful medication initiated quickly. The patient may need additional IV access, which could involve the nurse starting another IV or advocating for a central line. 
  • Patients who receive vasoactive medications will require more frequent monitoring, with blood pressure measurements taken every few minutes until the goal is reached, and then at least every 15 minutes thereafter.

What if your patient goes into respiratory failure and requires emergent intubation? What happens?

  • Someone will grab the intubation equipment, this could be a tray in the crash cart, or a dedicated intubation tray.
  • Someone needs to remove the headboard from the head of the bed. This is so the MD can get into position to intubate.
  • The MD will order specific medications for what is called a rapid-sequence intubation. Common medications include rocuronium, succinylcholine, etomidate and propofol. Though you, as a student precepting in the ICU, will not be pushing these medications, be aware that succinylcholine causes K levels to rise temporarily so it is avoided in patients with hyperkalemia. It can also trigger malignant hyperthermia in susceptible patients. 
  • Medications are pushed by the RN or MD (depending on facility policy and scope of practice).
  • The MD intubates the patient with assistance from a respiratory therapist. 
  • The RN monitors the patient throughout for dropping O2 saturation, tachycardia and hypotension and communicates concerning changes to the MD.
  • Note that hypotension occurs for a few different reasons. 
    • The switch to positive pressure ventilation decreases venous return, preload AND cardiac output. 
    • Circulating catecholamines that normally would help maintain vascular tone and cardiac output are made less effective in an acidic environment (respiratory acidosis)
    • The effects of RSI medications
  • The MD may order a fluid bolus or vasopressors to address hypotension, and a nurse will be responsible for administering these medications.
  • Endotracheal tube placement is initially confirmed by the MD by listening for bilateral breath sounds and with ETCO2. Some facilities utilize a colorimetric CO2 detector which turns color from purple to gold when it detects exhaled CO2. The MD will then order a chest x-ray to confirm placement as well as any medications needed for hemodynamic support and sedation. 
  • Prior to the x-ray technician arriving at the bedside, the nurse will likely insert an OG tube for parenteral nutrition and medication administration. The OG tube placement can be confirmed at the same time as the ETT. 
  • The ETT  is secured by RT. 
  • The ventilator settings typically start at 100% FiO2. An ABG is drawn, and ventilator adjustments are made.

Another scenario that’s unfortunately somewhat common in the critical care setting is a code blue.

As a student, the best role for you is to perform high quality chest compressions. Don’t be afraid to get in line to perform compressions. Remember the training you received in BLS and remember to push hard and fast at a rate of 100 to 120 compressions per minute. 

If you’re the one to witness the code. You know what to do. Check for responsiveness, check for breathing and a pulse. Push the code button and immediately start compressions. That’s all you have to do and if you do it well, it can be absolutely life saving.

I hope this brief overview of what it might be like to have a clinical rotation in the ICU helps alleviate any anxiety you might have so you can be excited about this wonderful opportunity. 

Take this topic on the go by tuning in to episode 311 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.