[RNNPICU]

HI

I just finished my first few shifts (3 to be exact) as a brand new grad in the PICU. I realize that the learning curve is steep, just as for any new grad, and I realize that things will come to me each day and that I will be precepted for 6 months. I know it seems silly, but I feel accomplished over only knowing how to fill out the flow sheet. How long has it taken others to feel that they know what to do when they get an abnormal lab value, or when to bolus a patient, or when to send labs. Sometimes I have been told, it is just something we do, and other times it is a standing order. I feel the magnitude of the PICU (which I should) and I wonder how long before it will take before my learning curve doesn't feel like Mount Everest and more like the foot hills to the Rockies.

I actually like the PICU and the nurses are very smart and really know what they are talking about. It is hard because I am so new and everyone tells me wow for day three you are ahead of the game, but it doesn't feel that way. It is hard not to compare myself to the others that were on the night shift who have 5,10 years of experience in the PICU. I am starting off on nights (7p-7am) which is good because it is not as crazy as days with all the other disciplines present, I can just focus on the nursing aspect.

[janfrn]

When I first started in PICU nine years ago, I wasn't a new grad, but I too felt like the range of knowledge and skills I had didn't even make a dent in what I needed to know. When after five years I moved to another PICU with a higher acuity and cardiac patients I was terribly afraid I'd made a huge mistake. I was totally out of my depth at first and I didn't feel totally comfortable with cardiac admissions for almost two years. There are things that you will just develop an understanding of over time, like when to report an abnormal lab value. Your preceptor should be helping you get a feel for what is usual in your unit. For example, in our unit, we run KCL 10 mmol in NS 10 ml on our cardiacs for serum K+ <3. I feel quite confident getting the syringe from the PYXIS, priming the tubing and attaching it to a stopcock before I have an order, because I know that's what they're going to do. Then all I have to do once I have the order is turn on the pump. By the same token, after monitoring the serum K+ for several hours, I see that it's now 4.2, I'll just turn off the infusion then let the doctor know. Another example is with our fresh post-ops. Our SOP is to give 5 mL/kg of 5% albumin for pressure problems before starting pressors. They often will experience a phenomenon we like to call "post-pump slump" about 3-4 hours after they arrive; this is when their BP just tanks. After I've notified the charge nurse, I'll have the albumin ready to go by the time the doctor has come to the bedside. Sometimes I'll just go ahead and give it if I know that's the chosen remedy; keeps the kid from crumping while I'm waiting. But I've been looking after these kids four years now and I've got a feel for what will be next on the list.

No one can know everything and no one can learn it all in six months. View this as a life-long learning opportunity. Every day you will learn or understand something new and every day your confidence level will increase, even if only a smidge. Use your resources. Your preceptor, your charge nurse, the respiratory therapists, the pharmacist, the nurses at the bedsides around you all have something to contribute to your education. Don't be afraid to ask questions. My philosophy is that the only stupid question is the one you don't ask. Hey, you have the flow sheet figured out... that's a great start. Now just keep going.

[Gompers]

It generally takes new nurses about a year just to feel comfortable in the ICU. After two years, you start to REALLY get it! You're doing fine.

[RNNPICU]

Thanks to both Janfrn and Gompers, I am working tomorrow night and Thursday night. Hopefully I might learn another task, if not, I have my Hazinski book (Manual of Pediatric Intesive Care) to read and learn. That book is such as great resource and it really helps explain labs, diagnosis, etc in a clear way.

[Humbled_Nurse]

rnnnpicu:

Congrats. on completing your first week. janfrn wrote some good advice as usual . Be sure to read anything that janfrn posts because she has a lot of knowledge of the PICU and is very smart.

It will take at least a year or two to feel somewhat comfortable in the PICU. I work NICU and it took me years to feel comfortable, but it is a gradual process so as each month goes by it gets a little better. The PICU can be a scary place. I think it would be too intense for me to work PICU. Although I work NICU not every baby in the unit is critical, but if you are in the PICU you are likely to be critical.

Just know that you have a long road ahead of you and to take one day at a time. It will likely get worse before it gets better. I remember a few months into the NICU as a new grad I was seriously considering leaving and working in newborn because it was just so stressful at times and it didn't seem I would ever get it all, but as time went by it got much better and I am very glad I didn't give up.

Enjoy your days off and do fun relaxing things on your days off to regroup and get refreshed.

Keep us updated on your progress and when things get tough come to allnurses and vent. We have ALL been there!

[heelgal]

Hang in there. Were you not humbled, I would be worried. The new grads that are dangerous are the ones who come in acting like they know everything. They can be unteachable. I love precepting new grads who simply want to learn and care. They might appear naive in the eyes of an experienced nurse, and this is not to be mistaken for stupidity. No one knows how to do anything without being taught. If you have questions, it is not because you are incapable of learning. You simply haven't been given the information necessary.
Of course, nothing can replace the value of simple experience. If your peers seem to make decisions that are quick and rational, it is because they have made those decisions hundreds of times. I remember one time early in my PICU career when I was calling low potassiums on my patients- levels at 2.8, 2.9 etc. I was always mystified that the docs never did anything, just grunted a "thanks" and hung up. It was a few months later when I heard one of my attendings say to another new nurse, "You know, patients usually don't die of low potassiums." I got the message. They really didn't care about a low potassium, unless it was crazy out of range. I don't call with low K's anymore. This was something I had to learn that was particular to the unit I was working in that I was not taught in school.
You will get in the groove. Just think of every day as an oppoutunity to learn. If you don't know something, take the time to Google it when you get home. You will build a base of knowledge that you can grow from. If you make a mistake, don't take it personally. Learn from it and go on from there. Be patient with yourself. Be kind to yourself. And remember that at the center of all this skill you are obtaining, there is a kid who needs to be cared for- body, mind and spirit.

Godspeed

[sammyrnlv]

Hey, kiddo, I have 13 years in PICU and I always report a low K; every kid is different and they will shoot arrhythmias at all different measures; some kids do it as little as 3.3; others will let you go to 2.9. When out of the range of what your hospital uses, report it and smile if the intensivists say "Thanks"; then, document it. Consider if they are on Lasix, but still report.