New to PICU - discouraged advice please

Specialties PICU

Published

Hi everyone. I am a new grad who started in the PICU a few months ago. I am just a month away from being totally off of orientation and I am terrified. At my last meeting with my preceptors I was told that I am still lacking some critical thinking skills which is true. My biggest problem is that I am a very linear thinker so it's harder for me to learn pathway thinking. Example: my patient is hypotensive. But for one patient I may do one intervention and another patient I may do a different intervention because it's two different scenarios. That kind of thing confuses me. If my patient is on sedation drips would I first give them volume or would I go down on the sedation? I've seen it done two different ways for patients on sedation drips and don't understand how each nurse came to their conclusion.

Do you guys have advice or resources I could turn to to help develop these critical thinking skills? I think I am screwed in general and may have to quit before I am fired...

Also if anyone can throw out general tips on what to do/what not to do in certain situations in a PICU setting (really anything you can think of that might be helpful), that would be appreciated. Thanks everyone.

Specializes in PICU, Sedation/Radiology, PACU.

I think that knowing what interventions to perform is something that comes with experience.

I started in the PICU about 8 months ago, as a new grad as well. I had a great preceptor and work with an excellent team. Of course, there is no way I could learn as much as the experienced nurses and gain all their experience in just a few months. Even know, five months of orientation, I still ask a lot of questions and not one of my co-workers faults me for that.

I think that at this point it's much more important for you to be able to recognize the changes in patient condition and report it quickly. At our PICU, there is always a resident or an attending on the floor, or they are quickly available by phone. So if your patient's BP is decreasing, the most important thing is that you recognize it and report it to the doctor. You can't give a fluid bolus or change the rate of sedation without an order from a doctor, so they are the ones making the official decision.

If you ever have a questions about a patient or worry that their condition isn't normal, don't hesitate to ask a co-worker. I frequently ask the other nurses to double check an abnormal finding with me and I run my thoughts by them before I speak to the doctor. I've found that in 8 months I am learning so much that I can now point out to the residents when something doesn't appear right or the patient needs some sort of intervention. You'll get this too, with time and experience.

Have you taken PALS yet? PALS will be really helpful in teaching your how to respond in emergency situations.

Right off orientation, you shouldn't be getting the sickest kids by yourself. You'll probably start off with the stable patients and work your way up. Remember that even if you're off orientation you're never alone on the floor. If you need help or have a question, then ask. Even if you're afraid that someone will think you don't have good critical thinking skills. The well-being of your patients is the most important thing.

BelgianRN

190 Posts

Specializes in GICU, PICU, CSICU, SICU.

Ok it's been a while since my unit was "the" designated PICU but I remember the days well :)

First of all I think it is important to realize that being scared isn't a bad thing. When I'm precepting any of my newer nurses, the ones that feel they can do it all and don't need guidance scare me much more than the ones that realize they have a long way to go. As long as you are not terrified to the point where you freeze up don't think of it as something bad.

If all you were told is that you are missing some critical thinking skills that doesn't sound too bad to me. You can't know everything not even after years of experience so certainly not right after you are "set free". I hope and trust the nurses at your department are honest and caring enough to make the right call on setting you free. If they felt you were a huge risk to the patients you wouldn't be let out of sight. And hopefully they would have more to say than missing some critical thinking skills.

What I really appreciate is, when our newer nurses come to me to ask for advice on "patient Y" or "situation X" that they include me in their critical thinking process. In a very black and white sense: I couldn't care less if you decided to do "Z" but I want to know why you are thinking "Z" is a good idea. That shows me some insight in what your thought process is and where I need to provide additional insight to you. And at the same time it prevents me from just coming over and fix your issue because that would teach you nothing. I'd be creating a "monkey that can do a trick" and not an independent and critical critical care nurse. And thirdly when my newer nurses do this with me I feel I can trust them because they think on their own, aren't reckless and aren't clueless and I'm much more likely to let them explore the (P)ICU by themselves instead of having them be my "tailnurse".

I would advise doing the same thing when a more experienced nurse did "XYZ" ask them to motivate why they chose for this approach over something else. As long as you make sure to ask when the situation is relaxed and don't come across as "questioning them" I've rarely seen anyone react poorly to this method.

A lineair brain is great in the ICU but can be a curse as well. I've learned to create "action sets" in my head when I encounter an issue. I'll explain a bit. When my patient desats I'll have a checklist in my head that automatically starts running. I'll check clinical assessment, other vital signs and if the monitoring is adequate, vent settings and make adjustments, mechanical obstruction and other ETT issues, auscultate the chest and the list goes on (I find it hard recalling all the steps that form in my head and the exact order). But I find this helps organize and control adverse situations. Some problems are much easier to form into an "action set" than others. But these "action sets" grow as your experience grows and pick up some tricks from others. And in the beginning one of the first things will probably be "seek a more experienced nurse" (much like APLS: "seek expert help") and you'll notice you'll grow to control these things and get better at thinking quick on your feet.

Something that I really found helpful when taking care of the sick kids back in our PICU days was stick to your ABC's rigorously. Getting your APLS will certainly help you in this way of thinking. But it helps you in any acute situation to start out and you will be sure you won't miss something else because you were too focused on the actual problem and not seeing the bigger picture. And the more trained you get in doing these ABC - checks (and the rest of the letters ofcourse) the faster it goes.

Hope this helps and good luck!

JKNewRN

4 Posts

Thank you for your encouragement and advice. Yes I have taken PALS and it was helpful so I hope I can respond appropriately in a real emergency. Next week we have a mock code too which I think will help me feel even more prepared.

JKNewRN

4 Posts

Thanks! I think you hit the nail on the head of what worries me the most...focusing too much on a specific problem and missing the bigger picture. I guess it will get better with more experience!

Sloan RN

33 Posts

There's really good advice here.

My main advice for you would be to not put too much pressure on yourself to know everything. All new nurses do this; I did it too. You're not expected to know everything, to understand everything, or to know what to do in every situation. People who think they can do any of that are dangerous. Your job, like someone else already said, is to recognize changes in your patient and tell someone about it. You don't necessarily need to know what to do about it...that will come with time, and there's not a whole lot you should be doing without a doctor's order anyway.

Just remember you're not alone. You have the nurses next to you, your charge nurse, and doctors on hand 24/7 for a reason. They're there to help you and be your resources, so use them!

I've been working in the PICU for about 2.5 years now...it took me at least a year to feel comfortable, and another year after that to feel truly confident. Don't expect to feel confident right away...you will constantly see things that you've never seen before, no matter how much experience you have. That's what makes our job so interesting!

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