Can I pull it all together quickly?

Ruby Vee, BSN · Mar 18, 2018

I'm at 16 weeks orientation and just had my first sick patient assignment at week 14. My orientation went well till then. I was told that I am not functioning at the level that I should and I need to re-evaluate my fitness for ICU. I have worked on Med-surg for 6 years and I loved my job.
After some soul searching, I found out that here are my problems.
1. I don't have a system or a routine, my first 6 weeks didn't go well (preceptor prob.) My mistakes (missed urine OP for 3 hours, clamped EVD) are prob. related to my lack of a routine.
2. to compensate for the lack of a system, I focused on tasks instead of the big picture (which will help me with my priority setting)
3. I have a lot of other responsibilities, so I didn't set time to process and think.
I know I am capable and am usually good at critical thinking. I want to clear my mind and try to make this work. but my mind and emotions are like riding roller coasters. I am not sure whether realizing my problems is too late to correct them. Any seasoned nurses here can shed some light? thanks.

Your emotions aren't helping you here, so control them or tune them out. Easier said than done, I know. But seriously, we get so many posts from new nurses who think their emotions are a good reason to "report someone" or "give them a piece of my mind" or "ask for a new preceptor." Your emotions are YOURS -- no one but you can control them. They may be causing problems for you where there don't need to be problems. It's not about YOU at all, it's about the best care for our patients. Your emotions may be getting in your way. So control them.

You need a system -- maybe not a routine, but a system. I usually do the I & O first thing on the hour. We have electronic charting, so the vital signs will be there when I click them down (and I always look at the monitor on my way into the room so I'll know ahead of time if the vital signs are out of whack) but the I & O can get away from you if you don't do it right away. If you're charting on paper, maybe you do the VS first and then the I & O. Get into the habit of checking the monitor on the way into the room and the way out of the room -- rhythm OK? VS within range? Waveforms appropriate? OK!

Some people do head to toe assessments, some do systems, some do a focused assessment on the problem system first and then follow up with head to toe or systems -- figure out what works for you and with your patient population. It really doesn't matter what system you use as long as you don't miss anything. How are your preceptors doing it? Maybe try their way first.

The tasks need to get done, but you also need to know why you're doing them. Empty the urimeter, but if that urine output is high or low, why do we care? (Put out 1200cc the last hour? Check a K+. No urine output the last hour? Why not? Balloon pump migrated? Clots in the tubing? Foley partially pulled out? Kinked?) So if you've got the critical thinking down, the tasks will come. If not, make sure you carry a "brain sheet" and list the tasks that need to be done and the times you need to do them and cross them out as you go.

You DO have time to process and think, but you probably do not have time to stand like a statue and stare into space while you do so. Process and think while you're doing tasky things. It doesn't require a whole lot of your brain power to clean up a code brown or empty a Foley bag or replace someone's SCDs. If all else fails, excuse yourself to use the restroom and take a breather to THINK.

If you absolutely cannot think while you're moving, maybe ICU isn't for you. But most of us can think while we're moving.

Usually as the end of orientation arrives, there are two meetings that occur -- one between preceptors or preceptors and management and one with the orientee. The preceptors tell the manager that "She's doing well overall, but needs more experience with admissions" or "She's really smart, but she's over-confident" or "We like her and we like working with her but she needs more time on orientation."

If they like you and they think you're catching on overall, they might recommend a couple more weeks of orientation. Take that as the gift that it is and make the most of it. Work on your system, your critical thinking, etc. Make sure you're studying at home (you have been all along, haven't you?) and do some of your processing and thinking at home or during your commute.

Hopefully, you can pull it all together in the remaining orientation and shine!

Wuzzie · Mar 18, 2018

Are you using a "brain"?

Ruby Vee, BSN · Mar 19, 2018

Are you using a "brain"?

A "brain sheet". I knew what you meant, but I wouldn't want anyone to think you were accusing them of not using their heads.

A brain sheet is a pretty important part of getting it all together and of keeping it all together. The one you used for Med/Surg won't be as useful in the ICU, you'll need a new and improved version. I've seen threads on brain sheets on this forum, so perhaps if you do a search for "brain sheets" you might find something that will work for you.

Kareegasee · May 5, 2018

I think you can make it but you definitely need a system, like Ruby says.

I think a good way of staying on top of your priorities is constantly cycling your mind around them. Picture a clock with each issue in the place of a number. The clock can have as many things in it as you need, but ideally, keeping the main ones in there will help you focus on them. Once you've mentally noted each issue or completed a task, move to the next. When you've finished your mental "rounding," start over. This can go on while you are completing other tasks. Here's an example of good mental rounding.

TBI patient

Report and (1) assessment right away (focused assessments are great when things get tasky. Do it in pieces if you have to. Start with the neuro in a TBI. Cardiovascular in a CHF).

(2) Note your ICP, BP, CPP (with appropriate interventions if needed)

(3) Check your EVD (make it a habit to visualize it every single time you leave the room).

(4) I/Os

and repeat.

To start, circle your main priorities in report (ex. MAP goal >65, I/O qhour). Don't circle things that aren't subject to change such as "cervical spine precautions/logrolling/HOB