Starting the Day with Critical Patients

The walk-by before report, what to look for in the room, bedside handoff, what to do after report, and the head-to-toe on an intubated patient.

If I know I'm assigned to critical patients, before even getting report, I'll do a quick walk-by of their rooms. I glance at: • Whether the patient is intubated • If sedation appears appropriate • Vital signs at a glance • How many IV medications are running • Visual cues about the patient's condition (Are they guarding? Pale? Showing signs of respiratory distress? Completely sedated?) I also scan the room for clues: • Crash cart nearby? Likely a recent resuscitation • Blood tubing visible? They've probably been transfused • Any equipment or setup tells a story about what's been happening

Bedside Report for Critical Patients

For high-acuity patients, bedside report is safest and most effective. It ensures you: • Get a comprehensive handoff • Can ask questions on the spot • Have a visual reference for the patient's condition Especially for neuro patients, doing a joint neuro assessment during report is critical. This helps you identify any baseline deficits, so if a change happens later, you'll catch it — rather than mistaking it for something that was already there. What Happens After Report? It depends on the situation: If the patient is stable, I may: • Review key parts of the chart: o Chief complaint / Admitting diagnosis o Labs and imaging o Medical history and allergies o MAR (Medication Administration Record) o Provider plan and pending tasks (CTs, labs, meds) Then I plan my shift: • When will I do what's pending? • What needs to be prioritized? If the patient is unstable, I immediately address: • Hypotension • Cardiac rhythm changes • Desaturation • Seizures • Inadequate sedation • Urgent transport to CT or OR

Entering the Room: What to Focus On

Once you're in the room, here's what I do:

Initial Review

• Check vitals • Confirm and interpret ECG rhythm • Review all infusions: o Is the pump programmed correctly? o Are meds running as ordered?

Airway and Ventilation

• Confirm ET tube size and depth • Review ventilator settings • Assess if the patient is synchronous with the vent • Check sedation meds and rates

Lines and Tubes

• Inspect IVs, central lines, arterial lines, chest tubes • Assess the OG tube (placement, length, security) • Confirm urinary catheter position and output • Check for soft restraints (if intubated), ensuring: o There's an order o They're not too tight o Extremities show no signs of compromise

Assessment Tips

• Do your head-to-toe assessment simultaneously as you check everything else • Pay extra attention to the primary reason they're admitted o CHF? -> Check lungs, heart sounds, edema, work of breathing, ECG, SpO2, BP o Neuro? -> Do a thorough neuro exam and document clearly o GI bleed? -> Always lift the gown and visualize the abdomen and assess for bleeding And remember: intubated patients can't speak for themselves, so you must be thorough. Your first assessment sets your baseline for the shift, which is crucial for identifying changes. Always protect patient privacy, but never skip assessments — especially of invasive lines or known areas of concern like a femoral central line or post-procedure site.

Starting the Day with Critical Patients