New To Peds

Pediatric Critical Care Columnist · Aug 1, 2007

There will be a lot of familiarity I think. The same sorts of issues you'd see in ER will be seen in PICU... lots of really sick patients, not always an optimal staff mix, short-staffing and hectically busy shifts, a bottleneck at the door... they can get in but not back out!

From a purely peds perspective, if you like to interact with your patients, you won't get much chance to do that in PICU. They're usually heavily sedated to prevent them from delining and extubating themselves and from climbing out of bed. (Happens anyway, but we have to try!!) By the time they're with it enough to interact, they're usually on their way out the door. You'll do far more chatting with the parents than with the patient... and the parents are often there ALL the time. Some people have a particularly hard time making that transition, especialy if coming from an adult area.

There will be a lot of drugs given on your shift, most shifts. Many of your post-op cardiacs will have more than a dozen infusions going. When your only access is a triple lumen central line, you have to know who plays well with others and who doesn't. Then there are the antibiotics and other intermittent meds. What do I do with them? Where can I give or run them? Get used to fluid restrictions that seem physiologically impossible. Neos will have a TFI of maybe 6 mL an hour and it has to include the fluid keeping your pressure lines open, perhaps 3.5 mL by themselves. At the same time, know that you will be pushing what seems like gallons of fluid into tiny bodies irrespective of their TFIs. Get used to the idea of running concentrated potassium. Learn to love the sump chest tube... it really is your friend, hateful as it is. Plan to ignore the fact that you have to nurse your patients sitting up on a huge roll of soakers. The VAP police will get you if you don't! Plan to ignore too the CV surgical fellows who think they can give you verbal orders and you'll just hop to. All your orders will have to come form the PICU intensivist, fellow or resident.

The learning curve will be very steep. Don't be afraid to ask questions, even if you think they're stupid and you should already know the answers. The life you preserve might be your own. Seek out opportunities to learn new skills, new concepts, new tricks to make your life easier. Ask to be allowed to observe procedures in the unit; in ours we routinely close sternums at the bedside. We also cannulate patients for ECMO in the unit (they'd die if we had to take them to the OR), do flexible bronchs, tons of echoes, head ultrasounds, and other bedside exams. We nurses place nasojejeunal tubes in the unit and assist with all sorts of interesting and scary things. When your orientation is over, you won't be assigned to the really sick kids for quite some time. (They are reserved for the war horses like me.) You'll start off with stable single system patients, often the ones who are nearly ready for transfer. Be thankful, it will give you time to develop a routine and a system for keeping on track with tasks, to get to know the people you work with and who you can go to with those stupid questions and who you'd rather just leave alone, to know your own limits. When you start feeling underwhelmed by your assignment, ask for more of a challenge. But be prepared for the challenges to come out of the blue... if you transfer your patient out, you might find yourself admitting a trauma...

Welcome to PICU. I hope you enjoy your career here and that someday you're the one offering advice to the new kid on the block!

MA Nurse · Aug 1, 2007

There will be a lot of familiarity I think. The same sorts of issues you'd see in ER will be seen in PICU... lots of really sick patients, not always an optimal staff mix, short-staffing and hectically busy shifts, a bottleneck at the door... they can get in but not back out!
From a purely peds perspective, if you like to interact with your patients, you won't get much chance to do that in PICU. They're usually heavily sedated to prevent them from delining and extubating themselves and from climbing out of bed. (Happens anyway, but we have to try!!) By the time they're with it enough to interact, they're usually on their way out the door. You'll do far more chatting with the parents than with the patient... and the parents are often there ALL the time. Some people have a particularly hard time making that transition, especialy if coming from an adult area.
There will be a lot of drugs given on your shift, most shifts. Many of your post-op cardiacs will have more than a dozen infusions going. When your only access is a triple lumen central line, you have to know who plays well with others and who doesn't. Then there are the antibiotics and other intermittent meds. What do I do with them? Where can I give or run them? Get used to fluid restrictions that seem physiologically impossible. Neos will have a TFI of maybe 6 mL an hour and it has to include the fluid keeping your pressure lines open, perhaps 3.5 mL by themselves. At the same time, know that you will be pushing what seems like gallons of fluid into tiny bodies irrespective of their TFIs. Get used to the idea of running concentrated potassium. Learn to love the sump chest tube... it really is your friend, hateful as it is. Plan to ignore the fact that you have to nurse your patients sitting up on a huge roll of soakers. The VAP police will get you if you don't! Plan to ignore too the CV surgical fellows who think they can give you verbal orders and you'll just hop to. All your orders will have to come form the PICU intensivist, fellow or resident.
The learning curve will be very steep. Don't be afraid to ask questions, even if you think they're stupid and you should already know the answers. The life you preserve might be your own. Seek out opportunities to learn new skills, new concepts, new tricks to make your life easier. Ask to be allowed to observe procedures in the unit; in ours we routinely close sternums at the bedside. We also cannulate patients for ECMO in the unit (they'd die if we had to take them to the OR), do flexible bronchs, tons of echoes, head ultrasounds, and other bedside exams. We nurses place nasojejeunal tubes in the unit and assist with all sorts of interesting and scary things. When your orientation is over, you won't be assigned to the really sick kids for quite some time. (They are reserved for the war horses like me.) You'll start off with stable single system patients, often the ones who are nearly ready for transfer. Be thankful, it will give you time to develop a routine and a system for keeping on track with tasks, to get to know the people you work with and who you can go to with those stupid questions and who you'd rather just leave alone, to know your own limits. When you start feeling underwhelmed by your assignment, ask for more of a challenge. But be prepared for the challenges to come out of the blue... if you transfer your patient out, you might find yourself admitting a trauma...
Welcome to PICU. I hope you enjoy your career here and that someday you're the one offering advice to the new kid on the block!

Do you take care of neuro pts.? That's the assignment I had the other night. Our hospital does a lot of neuro surgery. What are your experiences, likes and dislikes about it? I thought it was sad...the 8 mo old I had couldn't have a BM so had to be on meds for that. She was in a little body cast too and it was hard to move her.

canadian_girl75 · Aug 1, 2007

Janfrn...thanks for the reply. Your information was quite helpful. I have been reading alot of the posts in this forum and it seems you have a wealth of to share. I know that the transition and learning curve is going to be quite steep. I feel I now ready to take that next step though. I wanted to wait until I was comfortable with my basic skills before I made the switch to peds and now that I am I am ready for the challenge. One thing about me is I don't care who I frusterate I ALWAYS ask questions even they are stupid ones I think I should know...the bottom line for me is someonemay get upset with me but at least my patient will live and thats all that counts. In any case gotta leave for work...would love to stay and write a whole bunch but I look forward to reading more replies later on. Take Care and Thanks again.

MA Nurse · Aug 1, 2007

Good luck to you! I'm going to be working in PICU, too because our NICU is slow and I will have no problem asking any question...better safe than sorry!

Pediatric Critical Care Columnist · Aug 2, 2007

Kimbalou, I do take care of neuro patients. We get quite a few of them, as we're a full-service PICU, so to speak. We have two world-class pediatric neurosurgeons who are pioneers in several procedures. On my last night shift out of 11 kids, 2 were neurosurgical: one a cranial vault remodeling and the other a posterior fossa tumor removal. The first, my patient, was ready for transfer, the other still in the unit and not doing well. I've cared for kids with brain tumors, with traumatic brain injuries, with stroke, with spinal cord injuries... all sick, all sad stories. Some recover and some don't. They are challenging kids to look after because subtle changes can have a huge impact on their outcome, they're often hectically busy because of the need to keep their ICPs under control and their BPs high enough to ensure cerebral perfusion. I don't like the sudden drastic change that signals impending herniation. I do like when a child we'd pretty much lost hope on comes back walking, talking and laughing. One girl I'll remember forever was in a rollover and had both a thoracic spinal cord injury and a traumatic brain injury complicated by an intracranial bleed some days after the initial injury. She came so close to celestial discharge several times; we all expected her to be one of those "failures" we sometimes see. A few months ago, I took my son to the rehabilitation hospital here for Botox treatments for his spastic leg; we were coming out of the underground parking lot to take the elevator to the main floor when this girl in a power chair whizzed by, nearly running us over. She turned to grin at us, and it was the same girl. She is able to control the chair very well, as she demonstrated for me later; she's come so far and is home now.

Canadiangirl_75, I like your attitude. It will be helpful that you've developed your basic nursing skills and that you won't hesitate to ask questions. Nobody can know everything, although some will try to tell you that they do. I learn as much here at allnurses as I contribute. Sometimes when I read a question someone has posed, I'll know the answer, but not how to explain it to someone else, so I make myself understand the concept or problem better so I can help the other person understand it, and I learn SO much. My daughter says that new, more important information pushes out the old and less important in our brains, but so far I haven't found my file drawers to be that full.

Both of you, best of everything in your new worlds!

canadian_girl75 · Aug 2, 2007

Thanks, all I can hardly wait until Spetember when my new PICU job starts. I'm so excited an nervous all in one. I'm really looking forward to the concept of "family centered care" I am looking forward to being able to work with not just my patients but also thier families. One of my greatest strengths is being able to communicate effectivly with my patients and thier families. I hope that I cam really make a difference. Once the technical skills are mastered the real nursing begins. Mind, body and soul. And it is touching the hearts and souls of people that make my job worthwhile. So I almost feel like this area will gove me the chance to develop into both the clinical expert while incorporating some of the best parts of nursing theorist such as Watson and Porifice into my practice.