NICU nurse making the jump to PICU!

Pediatric Critical Care Columnist · Apr 17, 2011

There will be a bit of a learning curve, but not too steep! You have the basic critical care skills so the main part of your orientation will be getting used to the huge variety of conditions and sizes you'll be exposed to. PICU is so much more interesting and challenging than NICU. Oh, and the culture is a little different. We're not quite as ... umm... particular as NICU nurses. We round our meds to the nearest single decimal point, for example. And with sedation, always round UP. I hope you enjoy it!

preemieRNkate, RN · Apr 17, 2011

Haha....I know exactly what you mean about NICU nurses being particular. Mostly because, well, I am! Thank you for your reply!

Pediatric Critical Care Columnist · Apr 17, 2011

And you'll see why once you really get in there. There simply isn't time to do a 3 minute scrub when your 4 year old patient is trying to climb out of bed, or your teenaged head injured supposedly comatose jock is grabbing his foley with one hand and his ETT with the other.

I work in a unit very similar to the one you're going to. We keep track of our fluid balance hourly and can tweak it as needed so that we meet our fluid balance goal at the end of 24 hours. We calculate our 'ins' a bit differently, 100 mL/kg for the first 10 kg, 50 mL/kg for the second 10 and 20 mL/kg for any additional kg. So a neonate who weighs 3 kg will have a TFI of 300 mL. Then we ruthlessly fluid-restrict the cardiacs to 50% from admission until several days post-op. For example, our post-op hearts tend to be very fluid overloaded in the first 24 hours or so due to hemodynamic instability post-op. So over the next several days the goal will be to remove all that extra fluid. So we might shoot for negative 250 mL for a neonate. We concentrate our infusions so as to give the minimum of fluid with them and use diuretics to pull off excess fluid. It isn't always possible on the tiniest babies to maintain that 50% TFI when they're on multiple infusions. Pressure lines (art, CVP and LAP) will take up 3.5 mL/hr of the 6.25 mL/hr that 3 kg baby is allowed. Not much room for epi, norepi, milrinone, nitro, sedation gtts or nutrition! So we'll be careful but not too anal about the 'ins', concentrating more on the 'outs'. Surprisingly enough, it works out well in most kids.

Does your new unit do transplants too? That's a whole other ball o' wax!

umcRN, BSN, RN · Apr 18, 2011

Glad you started this thread, I am also thinking of making the move, from NICU to CICU, units within the same hospital. Thinking of making the switch for a variety of reasons but am very nervous/excited/apprehensive about it all at once. I haven't applied yet and don't know if I'll get it, but i'm interested. Babies are all I know, the big kids opens up a whole new world of things to learn!

TinyHineyRN · Apr 21, 2011

Welcome! A few months ago I made the switch from general Peds to PICU and I LOOOOVE it! I am so happy I made my career change. I was in Peds for almost 3 years and in that time, we would float to PICU and NICU, so I already had some exposure to PICU. However, in the few months I have been full time in PICU, I have already learned so much, especially about patho and pharm. Its amazing!

I hope you have a successful transition! Good luck!

littleneoRN · Apr 22, 2011

And you'll see why once you really get in there. There simply isn't time to do a 3 minute scrub when your 4 year old patient is trying to climb out of bed, or your teenaged head injured supposedly comatose jock is grabbing his foley with one hand and his ETT with the other.

And your newborn patients never grab their ETTs? :) We don't always have time for the three minute scrub either, but we make time if at all possible. Ideally, the offgoing nurse doesn't leave til you're scrubbed. HAIs cost patients a lot more than a lot of money.

I have some experience with PICU, and there is definitely more variety. I don't know that I'd blanket say that it's more challenging. That depends on your unit and population. You can get kids who are sick as can be in either unit. Have fun learning lots of new things!

nickel38 · Sep 10, 2011

I too am making the jump from NICU to PICU. I spent 4 years in a level three NICU then moved and the only day position available was in PICU. I kind of always wanted to do PICU. I love kids and wanted a change. My question is how do you know you got it, that you can handle it? I've done 9 shifts so far, having to get used to paper charting, not to mention all these differen disease. I had my first critically ill patient with my preceptor that day and I thought it went well. I thought with more time, that I could be confident in what I do, prior to this day I was having my doubts about PICU, I love the kids but felt like I was paper pushing a lot. Well after I thought things went well, my preceptor tells me that I didn't seem like a NICU nurse(she said most nicu nurses are detail oriented), she felt like I was task oriented and I missed the big picture. Then it really made me question my whole decision again. I am an ICU nurse and I don't want to work on the floors, should I just go back to NICU?

Pediatric Critical Care Columnist · Sep 10, 2011

NO! Don't make such a drastic decision based on a throw-away comment from your preceptor. Are you familiar with Patricia Benner's novice-to-expert stages of clinical competence? It's a nursing-based adaptation of Dreyfus' Staged Models of Skills Acquisition. Benner's work has been used by educators around the world to help people understand why they function the way they do in different situations and environments. (You can read a good summary here: http://www.umdnj.edu/idsweb/idst5340/models_skills_acquisition.htm) Well, this applies here. When you left your NICU job, you were one of the experts. You knew your job, you knew your patients and you knew yourself in that world. Now you're one of the novices, or perhaps an advanced beginner. You're more concerned with mastering "the rules"; you won't be able to move into applying them until you're got a grasp of them. This is NORMAL. As someone with some critical care experience, you may move through the first three stages more quickly than someone without that background, but you'll go through the stages nonetheless. I've said many times that the learning curve in PICU is not a curve at all, it's a ladder! Don't judge yourself so harshly, and don't sell yourself short. Give yourself a chance. Orientation isn't an event, it's a process. Processes take time.

As for the paperwork, well... If you're accustomed to computer charting with a lot of tick-boxes, putting that same info on paper may seem onerous. It does get easier as you become more familiar with what goes where. Some facilities require a lot of duplication (or triplication!) of information, even in their computer charting. Legal experts will tell you that the more places you're required to document a single piece of data, the more likely there are to be small discrepancies that can be magnified into huge issues by a savvy personal-injury lawyer. It could be something as simple as charting a routine med on the MAR at 0910 and making a narrative comment that states it was given at 0915... who hasn't done that? And who is going to remember one dose of Zantac 10 years later? The lawyer will pounce on something seemingly so insignificant and turn it into an inquisition into every single thing you've documented. "The MAR says 0910, but your nurses' note says 0915. Which is it? What time did you actually give this med? How can we trust any of your charting if you've made this kind of documentation error??" If you find that your new employer is expecting the same piece of data in several spots on the chart, perhaps you could ask them if they've thought of this little snag. Maybe you'll be the catalyst for reducing the paperwork!

picurn1972, RN · Sep 13, 2011

Get ready for resuscitaton on a whole new level, when your 16 yo is bleeding out from GI bleed!

TinyHineyRN · Sep 13, 2011

The sheer fluid volumes alone will be a huge change! Yes, you can really give that whole liter bag AND 500ml of albumin AND a unit of PRBCs AND FFP!!!

HazelLPN, LPN · Sep 14, 2011

I did the opposite actually. I did adult ICU for years before I did PICU....huge learning curve for me...and I was pushing 60 at the time. (oh to be 60 again!). Later, I stared moonlighting in the NICU. Looking back over my career (I'm retired now) I would say PICU was the most satisfying place to work in all my years of nursing. NICU was a nice change of pace, but I don't think I could have spent my entire career there. If you love variety and learning something new everyday.... and seeing many of your patients get better (which I didn't get with adults)....you will love being an PICU nurse.

Best to you,

Mrs H.