10/09/25 ICU-Junior Support/Leadership/Conflict

Two things to reflect on today.

I was doing ACCESS role today, and one of the nurse I supervised is a transition phase 3 nurse.

The patient has encephalitis and was intubated til this morning, the Dr assess him and the patient obey all commands, so they want to give a go to extubate him. 

After the extubation, the patient was initially coping ok with HFNP 50L and 50%, but by the afternoon, I noticed the patient is quite tachypnea up to 40-50, SaO2 hasn't changed much, ABG hasn't changed much, but something is just not feeling quite right, so I flag with the doctor. 

The doctor said to encourage Triflow and sit the patient right up, we did but it's not very effective, anyway we just keep monitoring the patient as the Dr suggested. 

By 6.30pm, the ABG was getting worse with PO2 trending down and PCO2 trending up, so we flagged with the Dr again. 

Just when we were discussing with the Dr, the patient suddenly dropped SaO2 to 88% and looks purple, we quickly called the Dr to r/v and put HFNP up to 100%, 60L. 

The patient's symptoms resolved but he also stated he is feeling hard to breathe, the Dr r/v him and believe there's some upper airway secretion that the patient can't clear it off. So I suggested to called the on-call physio as patient has very ineffective cough. After the physio treatment the patient gets slightly better.

I think I should have be more vigilant with the patient situation as the transition nurse may not have enough experience to pick up early signs of respiratory distress.

Second thing is that when I was helping the other nurse doing tubey round, the patient was not ventilated very well, I gave some propofol bolus, and let the nurse know the patient is not ventilated too well. 

The nurse acknowledged it but I feel that she didn't take it serious enough, she was spending too much time to turn the patient and making laugh with the patient's loose bowel situation. 

I felt it was not appropriate and so I became a bit firm and let the nurse know that the patient is not stable, we need to finish the turn quickly. 

I believe the nurse and the wardies can acknowledge my voice tone change and realise the seriousness, so we were able to finish the turn without causing further issues.

I believe I did the right thing by having a more firm/authority leadership style at the time to ensure the patient safety is maintained.

Overall it was a good learning day.

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28/08/25 ICU-Long-Term Patients/Proning

Today I looked after a long term ventilated patient that has been with us for more than 3 months.

She was really agitated/frustrated at times cuz it's hard to communicate with her. I'm glad I only did an 8hrs shift cuz Ill be running out of patience very soon.

I did all the basic care, and took her out to the balcony, and plays her favourite music. I think the biggest lesson I learnt today is how to said no nice/firmly to the patient. She wants to be repositioned every half hour, we just don't have the resources to facilitate that unfortunately.

And she constantly changing her mind/moody all day, so it's hard to keep her happy all the time.

But I've been trying my best to help her and also not to overworked myself, and I did learn a lovely thank you from her, that's enough to make my day I think.

In the afternoon I also helped deproning the same patient from yesterday. The only major difference is that we don't need to put 3 pillows on, the rest are quite similar.

Overall I'm glad it's only an 8hrs day cuz I'm tired.

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27/08/25 ICU-Bronchoscopy/Proning/Tracheostomy

Wow I learnt so much today from being an access nurse.

Today I learnt how to set up Tracheostomy and Bronchoscopy.

First I grabbed the airway trolley, central line trolley, Tracheostomy pack and procedures pack, Glide scope and Bronchoscopy.

I also need Betadine and lignocaine with Adrenaline in it.

Then I set up the bronchoscopy, put high suction unit on the wall, and connect suction tube to the white side of the canister, and attached another suction tube to the canister for the bronch itself. We used the one that didn't need sample today, if they want a sample, we will change bronch to the one that needs sample container. There's also tip syrnge and water for flushing if we need it. Also make sure PIP alarm is set to the very top limit, and put oxygen to 100%. Also we need to put bodai on the ETT, and get rid of the in-line suction.

Oh and also get the drugs ready as well, and asked the doctor what size/type trachea do they want, and always grab one size down trachea as well.

The rest is just assist doctor to complete the tracheostomy.

After the trachea, we cleaned and restock the equipment, and get the XRAY done. That's pretty much it.

Today I also helped proning as well. Before proning, we put Meplox border on joint and nipples to prevent PI, and take ECG dots off. Then we have slide sheets underneath the sheet, and put 3 pillows (with pillowcases) one on the chest, one on the abdo and one on the lower side.

After that we put a clean sheets on top of the pillow, and we have doctor do the airway, 3 nurses on each side, then we start rolling the sheets towards the patient. After that we PULL the patient away to the side we are turning, then we half turn the patient, and nurses on the opposite side will switch hands (top hands to bottoms, bottoms hands to the top), then we finished the other half turn.

After the turn, the patient's head facing the side we turned to, and the arm that the face is facing is put to 90 degrees elbow, the other arm can be left down (swimmer's position). After this we make sure all the lines are ok, and tidy up the patient, and put ECG dots on the back (RA to RA, LA to LA etc). 

Oh we also need to make sure the patient is on Nimbus mattress, and deflate the cell around the ankle area.

It was a really busy day but we all work as a really good team, I enjoyed it.

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20/08/25 ICU-Decisionmaking

My patient is ok last night, but I just want to talk about my decision making process.

So my patient has a non citrate filter, and her TMP has been around 100mmHg pretty much all night, but just after the last morning turn, her TMP creeping up to 250mmHg, which seems a bit high.

It's high but it's not that high yet, it's still in the green zone, but I wasn't sure if I should just keep an eye on it or if I should change the filter now so it doesn't clotted. 

I think this difficult decision making is due to my lack of experience with the filter. Anyway, I decided to ring the access to get her opinion as she has way more experience than me. She said 250 is probably still ok but just make sure it's still in the green zone, if it swing to the yellow zone then we should change it to prevent clotting. So I keep observing till I went home, and luckily the TMP didn't go any higher than 250mmHg by the time I left.

So yeah, it's a good decent making experience.

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15/08/25 ICU-Conflict/Febrile/Neuro

Ah

Where do I start?

I think I could have done better last night, but I was so tired of night shift. 😔

So my neuro patient has been off sedation for more than 48hrs, best GCS is M5 with me, and she can get quite strong and restless every now and then.

Anyway, the first incident is that I found his chooks was detached from the CVL, cuz I found my sheet is a bit wet. Because of this, we are not sure how much morning Panadol and KCL actually gone into the patient. After I realised the line was detached, I quickly cleaned the CVL, aspirate and flush, and put new chooks and IV line on.

Second thing is his high temperature, I was told we are not worried till it's 38.5, and it comes up to 38.5 around 4am, so we did a full septice screen, and I noticed the urine was a bit cloudy in the beginning of the shift, which I should probably raised earlier and maybe changed it earlier. Anyway I found the temp cable was a bit loose, so I tightened it, then temperature jump straight to 40 degrees....😭

But because we don't want to sedate him, so we can't really use the active cooking machine, so my access helped me to put multiple ice packs and cold towel around the patient, also around that time, I notice the CVL center is a bit red, which I didn't notice earlier, and I felt bad about it.

Anyway we decided to change the IDC as well, and weirdly, the IDC went in ok, but very little urine come out, or it became bypassing afterwards. We ended up had the SR to do it, he also didn't get much urine out, but he aspirate and flush the IDC with saline, and apparently fixed it. Something I could probably try to use to troubleshoot next time.

The SR was pretty rude at the time, after he put the IDC in, he asked in a demanding way "Who's changing catheter in the middle of the night?" Well I don't back off neither, I said " because the patient has high temperature and the urine looks cloudy, so it's a very good reasons to change the catheter in case it's the source of infection. I thought we would want to eliminate the source of infection as soon as possible." Then he went silent and didn't argue back, I was proud of myself at the time.

Overall it was a messy morning, just little pieces I wish I have found or escalated earlier, not until temperature is super high.

Good thing is his B/C came back negative, and WBC actually coming down, so the high temp could also be neurogenic related.

What a night and I will definitely be more vigilant next time!! 

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14/08/25 ICU-Admission

Today I helped settled an admission from ED.

The patient had an OOHCA and was tubed and on some infusions.

When the patient arrived, we first moved the portable ventilator closer to our own bed.

Then we gave some sedative bolus and took the infusion off the pump temperoly. Apparently if there's inoteopes on the infusion, you can either transfer them to the ICU pump quickly, or have someone holding the pump while transferring the patient.

Next I took the brain off the central monitor, and removed the defib machine.

After all this we then put the beds together and pat slides the patient across to our bed.

Once patient is in the bed, we then attached to our ventilator and put infusion into our pump.

Then we hook the patient onto our monitor, take bloods/gas, do ECG, reposition A-Line/CVL, and someone documenting the lines/Obs.

Then usually we have CXR and just following order to prepare whatever is needed for the patient.

Also don't forget to put PT's details into our central monitor.

Overall I think it was pretty smooth and efficient.

A rare and good night shift last night!

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10/08/25 ICU-Jordanframe/Spinal

Today I was doing an access role for my night shift.

We had a ped vs car multi trauma patient coming at 1am.

When I tried to transfer the NORAD line to our IV pump, the pump keeps showing pt occlusion, we tried to aspirate and flush the CVL and it was very easy. We ended up disconnect the line and free priming it and that's the only way to solve the problem. Very weird.

Also I get to practise how to put Jordan frame on a full spine precaution patient.

Just need to make sure the strap first go around and under the bar and facing outward. That way we can easily feed the strap to the other side. Also do the head and foot bars/straps first so it's secure.

And when we lift the patient, the traction will need to come up too, so 2 people will need to help with the traction.

Overall it was a very busy night.

Oh and I had a spooky experience for my night shift yesterday. My next door patient's phone rang at 3am, I pick it up and the reception said the patient's Dad is on the line, I told them to ring back as the main nurse is on the break.

Later then the next door nurse came back I told her that the patient's Dad rang, and she said it's impossible because the patient's Dad has passed away.... And the phone never rang again.

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