Posted in Tips and Advice

There I was, standing in the room of a vented patient with my new-to-the-ICU orientee. Suddenly, it started to rain and tiny balls of hail pelted the windows making an unexpected sound in our otherwise tranquil room. Note that we don’t get hail that often where I live, so the level of “unusualness” for this sound was pretty high. My orientee whipped his head around and looked straight at the patient. Why? Because of hypervigilance…and it is one of the most useful and desirable traits in a nurse. I tell you, I could not have been more proud of him in that moment….he didn’t ignore the new, strange and unexpected sound…he didn’t look at the monitor or a piece of equipment. He looked at the patient. And that, my friends, is how it is done. Hypervigilance is key to providing safe nursing care.

Before someone comments that hypervigilance isn’t always a good thing (as in the case of PTSD), let me start off by saying that I am not referring to a level of vigilance that causes you emotional or psychological distress. I am speaking of a level of vigilance that makes you acutely aware of any changes in patient condition or potential threats to your patient’s condition. Now that we’ve cleared that up…

What does it mean to be hypervigilant as a nurse?

One of the most exhausting things about being a nurse isn’t necessarily the physical toll that it takes on your body (we can talk about that another time!). It is the weight of being “on” for 12 straight hours. And when I say that you are “on” I am talking about your level of attention, focus and vigilance that you give to your patients, whether you are in ICU, cath lab, the ER or Med/Surg.

Hypervigilance means being acutely aware of what is going on around you at all times and, especially, what is going on with your patient. Did the HR go up by twenty beats? Did you notice that temp climb up above 101? Did you notice that your BP has been trending down over the past few hours? Are you responsive to the monitor alarms? Did you recognize that change from normal sinus rhythm when it happened? Have you noticed any fluctuations in neuro status, urine output, VS, heart sounds, lung sounds, cap refill? Did you send off a lab test and also remember to check the result? Does your patient have all the orders, meds, labs, fluids, diagnostics, interventions, supplies and resources they need? And on and on it goes.

Being a nurse means tracking hundreds of data points and bits of information for each patient, every single shift. The good nurse is able to prioritize this information, notice changes in patient condition and then…and here’s the next most important part…intervene appropriately.

Tips for staying hypervigilant

Being new to any environment can be absolutely overwhelming, whether you’re a brand-new nurse or simply changing from one unit to another. I know that when I am in a new environment, I am easily overwhelmed by all the new stimuli….the sights, sounds, layout, people, processes…they’re all new and force my brain to assimilate a lot of new information all at once. This can be especially stressful when you are also tasked with actually taking care of sick folks…so here are some tips for staying hypervigilant even when your brain is already on overdrive.

Stay in the moment. It sounds so zen, right? But it’s actually extremely important and relevant for nursing. When you are pulling your meds, pull your meds and do nothing else. Don’t chat with a coworker or kvetch about the lack of garlic fries in the cafeteria. Pull your meds.

When you’re assessing your patient, focus entirely on that assessment. Same with giving meds (extremely important!)…family members (and patients themselves) will also offer opportunities for enormous distraction. It is okay to say, “I am happy to address your questions and concerns once I am finished giving medications so that I can ensure it is done safely.” NO reasonable person wants to jeopardize their own (or their family member’s safety), so you shouldn’t expect much grief from this. Of course, you want to make sure you provide education on the meds, but beyond this it is absolutely fine to delay more discussion until after you titrate your dopamine…got it? Ok…what else?

Identify your high-risk factors. At the beginning of your shift, identify what data points are going to set off alarm bells in your head…is your patient intubated? Then you’ll know that any vent alarms or O2 alarms are going to get your attention STAT. Are you worried about hypotension? Ensure your monitor alarms are set appropriately and that you watch those numbers like a hawk. Is your patient heading toward acute renal failure? Then you’re going to be acutely aware of urine output and/or electrolyte abnormalities.

Identify the main things your patient is at risk for and tune your brain, eyes, ears into those particular data points. You want these things to be top of mind so that they don’t get lost in the chaos and complexity of a typical shift.

Expect the unexpected. Now, just because your patient has PROBLEM A does not mean that they can’t unexpectedly develop PROBLEM B, C and D! This is especially important in critical care areas such as the ICU and ED. For example, I had a patient that came in for elevated blood sugar and I started the shift dealing with all the things related to diabetic ketoacidosis. By the middle of the shift, I was dealing with all the things related to subarachnoid hemorrhage.  Completely unexpected, but hypervigilence is what tuned me into the fact that the patient had a secondary issue (and a pretty awful one to have). The key to expecting the unexpected is being OPEN to receiving new data points and IMMEDIATELY RECOGNIZING data that doesn’t “fit”.

For example…your patient in DKA may definitely come into the ED with decreased level of consciousness. But once their pH is balanced, their anion gap is heading toward closed and their blood sugar is nearing goal range…you’d expect them to wake up and ask for a turkey sandwich. But when they don’t…you are seeing data that doesn’t “fit.” You have now entered the UNEXPECTED territory. Your assessment should then dive deeper into this new area.

You’ve heard that phrase, “see something, say something?” Well, it doesn’t just apply to suspicious activities on mass transit. It also applies in nursing. You see something, you report it AND you do something about it. Never ever ever ever ever let an abnormal data finding go unexplored. If something seems “off” about your patient, you will not just let it ride. You will investigate, assess, discuss. Got it? Of course you do…you’re awesome!

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What tips do you have for staying hypervigilant? Share them in the comments below!