Tips for a new nurse going into ICU - page 2
Hi all! I am a new nurse with about a month of home health experience. Most of my clients have vents, trachs, gtubes, electrolyte imbalances, and other complicated medical problems that make my... Read More
Jun 26, '13 by AwesomemissOmg I thought the same thing! I've escorted pts off to ct or whatever, and never thought about the fact that I would be handling that code and pushing the meds.... My god. AND I HAVE MY ACLS! Lol but to give me some credit, I have never oriented to the icu, I was taking a "room raider" pt load, like tele pt that is just taking up room in the icu till we have a bed on tele. AND I'VE NEVER HAD A CODE, AND NEVER HAVE REALLY USED MY ACLS SINCE THE CLASS! But I should be ready for it, I am supposedly ready for it. Lol
BTW LOVE THIS THREAD, LOVE YHE NEAR MISS STORIES!Last edit by Awesomemiss on Jun 26, '13 : Reason: Grammar
Aug 23, '13 by smarine123This may still help you. I precept people in ICU. I was on my way to work a few years back and I was dealing with a new grad, which BTW, I think can be some of the BEST people to work with because you have a brand new slate to write on (so to speak) and you absorb what someone is telling you if they are good at what they do. In addition, it gives us the opportunity to give you the RIGHT information (if you have a good preceptor). So, with that said... I was driving to work one morning and I thought to myself "what would I have taught myself when I was a new grad, with my current 23 years of experience?" So, I started writing a list. Here is what I came up with. Now, keep in mind, this is not book knowledge- that would take forever for me to write. Make sure you read the very last one at minimal.
1.) ALWAYS give and receive a head to toe report (I do mine in this order: Name (pt), Code status, Allergies, Dx (diagnosis), Hx (history), then here is your head to toe... Neuro, Pulmo, CV, GI, GU, Integ/Ortho, then throw in labs). I put my IV's/IVF's under the CV section since it goes through the circulatory system. If you do it this way, then you will not miss anything in report. Label a piece of paper every day when you come in or type one up like I did and then make copies. Trust me, when you give report to someone, they LOVE this format!
2.) Get parameters in report or look them up in the orders after report (if the nurse does not know them). For instance, if someone is on Dopamine/Neosynephrine/Epi, Cardizem/Cardene or NTG/Nipride (any titratable gtts) know what the Dr. is expecting your pressure or HR to be. You are the one accountable ultimately in the court of law to ensure that you followed the orders.
3.) Labs: call Dr. for critical labs or labs that have drastically changed, i.e. BUN/Cr call nephrologist, newly elevated Troponin call CV doc, ABG's call pulmonologist. Now, to a seasoned nurse, this seems like it is common sense, but when you are a new nurse, you just really are not sure who to call. At minimum, call the primary care doc and tell him you wanted to update him with the new labs. You should be trying to figure out why they are abnormal. This is what a good nurse does. For example if the BUN and Cr are beginning to raise, is it because the person has chronic renal failure? is this something new? could it be rhabomyolysis? is it medication induced? is the person dehydrated? etc...
4.) Set your alarms in your room as soon as you go in. The defaults on the computer are sometimes too high or too low (HR may be set at 50 and should be set at 60 if their regular all of the time. If they normally run on the low side, then keeping it at their normal is acceptable). I have seen where someone set the alarms at HR of 40 and the person brady'd down to the 40's quickly and the nurse was unaware because they had not set their alarms. So, I make all of my orientees set that first thing in the AM. Same for the B/P. You want to know early on when something is changing and you need to take care of it.
5.) Call any abnormal V/S or assessment findings within 15 min. This is just enough time to reassess whatever is abnormal or recheck a pressure. You need to report abnormals quickly. This will keep you from dealing with something far worse- like a code.
6.) Document- many will say do not duplicate something from the assessment or you don't have to document every 2 hours. You document as much as it takes for you to be comfortable. Anyone who tells you not to, I assure you, will not be there when you are placed on a bench in court because you did not. You will be covered if you document more than if you did not. Anyway, who can remember 5-7 years ago (statutes for law suites).
7.) Anticipate (this is ongoing) what changes might take place with this person's diagnosis or treatment. For example, if they are actively having an MI, expect that they might begin to have heart blocks, they may code, they may have arrythmias. So, are you ready for that? Do you have ACLS (most ICU nurses do!) and if so what meds are you going to be giving to them? Do you know where the crash cart is (I hope so)? Do you know who the cardiologist is for this case? Do you know who you will call on to buddy with you if something happens? Do you have an ambu bag and suction set up in the room if they code (this is for all patients)?
8.) Call a Dr within 15-30 minutes of abnormality or prn tmt that is not working (you have a small window of opportunity to fix some abnormalities before you are dealing with a much more serious situation). by recognizing this, you will have less codes and/or poor outcomes.
9.) Draw scheduled labs on time or early- not late- and follow up on results.
10.) Complete ALL orders during your shift unless impossible. Justify when it is not possible. This is etiquette. Leave the oncoming nurse with plenty of IVF's (especially vasoconstrictors). GO to CT or MRI on your shift if the order is written during your shift. Do not pawn things off to make it easier. You will be respected much more for doing what you are supposed to do.
11.) Leave the patient better than you received them and your room too.
12.) When relieving another RN- YOU are responsible for their patients just as though you are the actual nurse. Make sure you peek in at least once during the nurses 30 min break.
13.) Appoint 1 spokesperson for the patient. This will prevent multiple phone calls during the day for updates and less stress for you. That person will be the one who calls and updates all other family/friends.
14.) With each new diagnosis- educate yourself. Go home and read about it if you are unable to fit that in at work right away.
15.) Write down things that you want from the Dr before you call him/her or what you want them to know or want them to address. (i.e. SBP 160 anti-HTN?_________ Keep SBP/MAP<?___________). I write it just like this when I am calling even now.
16.) During report, know why each Dr. is on the case. If any consults were ordered by one of the consulting physicians' out of courtesy, call the primary care physician and tell them. The PCP (primary care physician) has the right to decide if they want that particular consult or if they want another one. Remember the PCP is the one accountable for this pt from head to toe also and they have certain Dr that they trust and know will treat their patient the best.
17.) Update the PCP with any drastic changes or when consults are going to be performing a procedure or interventions. They will respect you for this.
18.) Prioritize and reprioritize constantly. You will be constantly doing this.
19.) Chart defensively. As I discussed earlier, you chart so that the court knows that you did, basically, all of the things above that I mentioned. If a lab was abnormal, chart that you notified the Dr and that no new orders were given to you, etc... Chart as though each and every patient you have will end up in court.
20.) Follow policy- EVEN over a Dr's orders. (i.e., Dr. says you can use the triple lumen cath and CXR confirmation has not been completed to verify placement. This is a NO NO! The facility policy TRUMPS a Dr order- every time).
21.) Know frequency of when you should do V/S. Dilators and pressers usually every 15 min. Again, what is the policy?
22.) Always have nurse that you are comfortable consulting for things once you are off orientation. I gave my number to every nurse that I precepted and told them to call me if they had anything that they were questioning. Dr's do this all the time, even those with experience.
23.) When things are hectic and you are being pulled in all directions (Dr's are calling, patients are calling, family wants you, the phones are ringing, call lights are on, bells are alarming) ALWAYS think ABC (just like you do with ACLS)!!! ABC then stat orders is the order that you should prioritize in these situations. A- is the pt's airway intact? or do they need to be intubated? B- is their breathing okay? or are they in distress? C- is their cardiac status okay right now (B/P, rhythm, HR, chest pain)? THEN whatever stat orders that are to be done comes next. This will help you to figure out which thing you need to be dealing with.
I personally used Swearingen's Critical Care Manuel (Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management, 6e (Baird, Manual of Critical Care Nursing): Marianne Saunorus Baird RN MN, Susan Bethel RN MS CNRN: 9780323063760: Amazon.com: Books. You can get them for pretty cheap online. I learned so much from them. They way the present critical care information is so easy to understand and the book is not really thick. I brought it to work and looked up everything in that book! The book gives pathophys, what to expect, the definition of the diagnosis and what the nurse should monitor for. Hope this helps! Good luck to you!
Last edit by Esme12 on Aug 23, '13 : Reason: TOS/links removed
Jan 29 by NatureLoverx3smarine123, Thank you so much for this plethora of information!! I am starting ICU capstone and I'm sure anyone would be lucky to have you as a preceptorLast edit by NatureLoverx3 on Jan 29 : Reason: Wanted to reply to commentor