Picu Nurses Please Help Me !!!!

Pediatric Critical Care Columnist · Sep 8, 2005

The answer to your question depends on a few variables. The biggest is related to the type of patients your PICU handles. For example, some PICUs are mostly respiratory units, some are primarily neuro units, some are cardiac units and some are a little bit of everything. Is the hospital a teaching facility or not?

The unit where I work is a mixed unit in a teaching hospital; most of our patients are post-op cardiacs, but we also see trauma, neuro-oncology, respiratory, septic shock, burns and transplant patients and everything in between. We are also one of three PICUs in Canada that provides extra-corporeal life support. In addition to basic nursing care, on a given day I will give a number of drugs from a variety of categories: diuretics, antimicrobials, vasoactives, sedative-analgesic-hypnotic-anaesthetics, cytotoxics and the list goes on. We use a lot of blood products in our unit. I will be continually assessing my patient for changes in vital signs and LOC, respiratory status and fluid balance. I will be monitoring and troubleshooting a number of parameters and equipment (cardiorespiratory monitoring, mechanical ventilation, chest tubes, Foleys, nasogastric tubes, external ventricular drains, Jackson-Pratt drains, etc) and adjusting my care accordingly. I will provide pulmonary toilet with or without the aid of an RT. I will send off multiple lab specimens (blood mostly, but anything goes) and analyze results, communicating important information to the physician. I may place IVs, nasogastric or nasojejunal tubes, Foleys, assist with insertion or discontinuation of central venous catheters, arterial lines, external ventricular drains, epidural catheters, endotracheal tubes, and so on. My patient could require a road trip to CT or MRI, or go to the OR. I will provide support in whatever form required to the family of my patient, and to the patient as well if they're awake. I will interact with a dozen or more health care professionals from as many different disciplines. And I will do a ton of documentation. Other days I may be the resource nurse, helping with anything that needs doing, providing break relief and coordinating the code team. There really isn't a typical day for a PICU nurse, each day is different and it's rarely boring; the things I've listed are things that happen on most shifts, regardless of why the patient is there. Assessment and time management skills, sound nursing judgment, organization and attention to detail are all required to function well in PICU. A solid understanding of physiology also doesn't hurt. Neither does a good understanding of one's own limitations. The only stupid question is the one you don't ask.

I'm going into my ninth year of PICU nursing and I love my job. I love that every shift is different, that today I could have a 2.5 kg infant with congenital heart disease and tomorrow I could have a 70 kg teenager who was in a car crash. PICU is about the broadest scope of practice there is. We see it all. If you choose PICU, I wish you all the best. It's a great place to be.

rach_nc_03 · Sep 19, 2005

hi,

i'm a new grad working in a PICU, and after almost 3 months, I can tell you that janfrn's description is right on the money, as far as my unit is concerned. we also have a large number of cardiac patients, and the capacity for 2 ECMO patients at any given time. we recently split our unit- cardiac PICU and general PICU- and i'm personally looking forward to having more non-cardiac patients. outside of multiple heart patients, some of the more memorable cases i've dealt with so far:

1- two week old with shaken baby syndrome in state custody- the child had irreversible brain damage, and the hospital social services people were working to find a way to get the state to consider a DNR order for him. very sad, and a lot of working with interdisciplinary team members

2- MVA with a group of young teenagers thrown from a truck bed. One had multiple open fractures, one needed a halo for a spinal fracture. The parents were driving, and i spent a lot of time with them, which involved comforting them, getting pastoral care and social services resources, and supressing any judgmental thoughts i had about their actions

3- 10 month old with hemolytic uremic syndrome; receiving daily plasmaphoresis and CVVHD...that involved careful monitoring of her electrolyte and respiratory status, since she had to be taken off CVVHD in preparation for surgery (which was 5 hours late), and working with a mom who spoke only spanish

4- 3 year old in respiratory failure after 2 failed bone marrow transplants. she'd been in the PICU for months, and coded and died on my first night shift. her parents were present for the code, and most of the staff in the code were crying by the time the parents gave consent to cease interventions. seeing this patient dying was hard enough, but it was even harder to see the reaction of the staff members who had worked with her for so long

mind you, i had a very experienced preceptor in each of these situations, so i never felt alone. anytime i needed anything at all, there were plenty of experienced nurses who jumped in to help me. in nursing school, several of our clinical sites were much less collaborative, so this level of team work was something new- and very reassuring- for me.

some of the great things i've noticed in my unit:

1- everyone- and i mean EVERYONE- is intelligent, articulate, and dedicated to what they're doing. our respiratory therapists are top-notch...i've learned so much from them, especially with our ECMO babies and kids on non-conventional ventilators. in fact, everyone in the unit is willing to turn pretty much any situation into a learning opportunity (except codes, obviously). nobody has ever been dismissive when i've asked a question, and i can get a mini-lecture on a topic from someone knowledgable pretty much anytime i need it.

2- the MD's and NP's treat the nursing staff with respect- even the newbies like me. few and far between are the docs who give orders without taking input from the nurses, and when i have a question for them, they answer me without belittling or patronizing. some are obviously more receptive than others, but overall, even the attendings are 100% approachable.

ok, on the minus side:

1- this is a million times harder than anything i've ever done, both in and out of nursing. i had no idea it would be this difficult. one of the biggest issues i have is fear of killing my patient by making a mistake. the good thing is that there's always someone i can ask, but when you're in the room alone and your baby desats to the 60's all of a sudden, it's a real challenge to keep from panicking.

2- as jan said, this is an incredibly broad field. there's NO WAY to become proficient in everything quickly, and even the nurses with 20 years on the unit say they frequently come across something they've never dealt with. as one of my preceptors said last week, 'you don't have to know a little about everything- you have to know a LOT about everything.' i spend a lot of time reading outside of work, and when i have a few moments to spare on the unit, i'm usually researching something. just when i feel comfortable with something, i discover something else that's completely foreign and seemingly insurmountable.

3- it's tough to keep going in, day after day. for some people, the whole aspect of dealing with critically ill babies and children is the hardest part, and some people find dealing with the families difficult. for me, i'm still struggling with knowing what i'm doing, and feeling confident that i'm providing safe care. I've always been a high achiever in everything i've ever done (this is my third career), and I always learn and master things very quickly. that's simply not possible in a PICU. it's just not. i think accepting that fact is the single most difficult aspect of my job. it's humbling to know how steep the learning curve is, and that i'm not going to be good at this for quite some time. On many, many days, I hate it. I've also been told by everyone i work with that most people hate it for at least six months- sometimes for a year or more. Our manager encourages us to stick it out for a year before deciding if we want to be there or not. I'm willing to make that commitment, and i think that's crucial for anyone to know going into it.

4- nobody really understands what it's like except other PICU nurses. Even my friends who are nurses can't really identify with the experience if they haven't worked there. It's important to talk to people who *do* understand...we're required to have a mentor on my unit, someone who's not your preceptor- someone you can just sit with and vent.

5- there's no such thing as autopilot. as i'm sure you've heard, PICU kids can crap out on a dime, since they compensate so well for so long. I worked as a student in an adult neuro icu, and those patients usually show signs of deterioration quite a while before something bad happens. with kids, they can seem fine, then five minutes later, they're cold and blue. even a slight change in any system has to be followed closely. you not only have to draw labs frequently, you have to check the results, look at the trends, and make sure you alert the appropriate team members when you see changes. i've made the mistake of assuming the residents have seen my kid's labs, and thought about interventions- big mistake. not only must you be aware of the changes, you need to think about what *you* think an appropriate intervention might be, based both on the lab results, but also your own clinical observations, as the doctors are relying on *your* input. you're at the bedside, and they're not.

all in all, even though my stomach is in knots most days when i leave for work, i'm happy with my decision to go straight to the PICU as a new nurse. yes, it's incredibly difficult- but it's also very gratifying, while terrifying at the same time. I'm not trying to scare you- just wanted to share the perspective of a brand-new grad in a PICU. I hope you take the opportunity to shadow on the unit before your preceptorship- that's what convinced me to go for it.

Good luck in whatever you decide!

Pediatric Critical Care Columnist · Sep 19, 2005

Good job, Rachel!!! You've really covered a lot of ground in your post and very much captured PICU. You'll be a great PICU nurse!

rach_nc_03 · Sep 20, 2005

Good job, Rachel!!! You've really covered a lot of ground in your post and very much captured PICU. You'll be a great PICU nurse!

thanks- I certainly hope you're right!! Keep your fingers crossed for me. :rolleyes:

brina · Sep 29, 2005

Hey guys!! Well, I am 5 weeks into my PICU preceptorship and I love it! I have had a couple of patients where on the 1st day of having them I was totally overwhelmed and intimidated. Both were CP children, one had a peritoneal shunt that was not working and his pupils were changing every 30 minutes! One was a 4mm or 5mm and the other would go from 2mm to 3mm! It was neat to see that on a real person and not just in a text book. Well on the 2nd day of having him, I felt comfortable with his peg tube, as well as giving him his meds. I did have a little problem getting the hang of the syringe pump because I had never used them before, but I am glad to say that I now have the hang of it!!

Now my 3rd patient had me questioning if i was cut out for this or not. She was an 8 yr old CP pt that was in for sepsis and septic shock. She was totally not there; not aware of anything or anyone, just literally drooling,.... very sad quality of life. AND she had trach. My first pt with a trach!! (Screaaammmmm) Then she was on a NTG drip, a Dopamine drip and she had a femoral AC line!! You guys I was terrified. Because I had never had this type of pt, even during my critical care rotation! So....

After being intimidated at first by all the lines and drips, and by how she looked. I got the hang of it. On my second day I did trach care, suctioned her. Titrated down her dopamine and NTG drips ( we were trying to wean her off), gave her her meds through her peg tube, and fed her by TPN through her line. This was very good practice, and I am sooo glad that I have been exposed to this type of patient. And I am proud of myself if I do say so myself! :)

Now, I am thinking about this: Should I start out in the NICU intsead of PICU? Everyday, I could literally have a new type of patient even after years and years of working in the PICU. I think that the NICU would offer more stability and more of a chance to get better at my skills and assessing versus the PICU where I could have a trauma pt or a CP pt or a septic pt, or a snake bite, or a seizing pt or a pt with a colostomy that's not working, or a surgical pt etc to infinity! This is just some of the patients that I have seen in the PICU during my 4 weeks there, lol. My preceptor told me that she did NICU for a little while but got kind of bored with it because it was usually just one of 5 things wrong with the neonate. Well that's what I think I need as a new grad. I want to get used to and comfortable with working with just a few types of patients, and then I can see moving on to PICU where at least I will be confident in my skills while learning all of these new disease processess.

Ok. Sorry so long, but I had so much to say, lol. So if anyone actually reads this all the way through, what do u think about my taking the NICU position instead of the PICU? Thanks!

BatsonPICURN · Oct 3, 2005

I m a recent grad and i have been in the PICU as an RN for now 4 months or so. I have a thought to your NICU vs PICU question you posed in your last response. I only respond because in our orientation class we have an experienced (8 years) NICU nurse. I work at a teaching hospital and from what i have been told through my time here. (nursing school and working as a student) it's one of the biggest in the nation. She comes to the PICU for the transition you spoke about. But she was overwhelmed with the difference in the patients and esp. in the medication adminsitration. In our nicu the pharmancy gives all the meds, so medication calcs and administration was a very real problem. I know there is (well at our hosp anyways) some nicu nurses that would defend and say they take more pt (sometimes 8) and can take care of them when the picu nurse (at our hosp) only has two max. But coming from the former NICU nurse of 8 years it is nothing like the nicu and she feels very overwhelmed even more than us who are just starting. I worked in the picu as a student 1.5 years before graduation so i knew how things worked, the staff, and what to expect. But even for my classmates that had never been in the picu except as a student were better suited maybe because they didn't know what to expect and for the experienced nurse she knew what to expect from her NICU time but found it to be much more time consuming than having even 8 NICU pt.'s Time management is a huge issue in the picu. You have two very sick children, where just like the others have said "they can crap out on you in a sec". So i understand your reasoning and would have almost agreed before my orientation experience. But i'm sure that any picu would have an extensive orientation process for a new grad. We have had 4 months of precepted training. Modules on every disease process imaginable, caridac classes, invasive lines, cont cariac infusions, etc etc etc. and yes even test i thought i was done with tests when i was done with nursing school but o was i wrong. so your skills will be excellent by the time you take your first pt on your own. My first pt out of orientation was Saturday night. 6 yo ped vs car...i came into a disaster. Two traumas 30 min apart both TBI's the attending is at my BS trying for a line and neurosurg at the other kids putting in a EVD. if it were not for 4 mo of on the job experience and excellent training for situations just like this provided by the education staff it would have be crazy even for an experienced nurse but as said earlier you will never be alone. as others have stated it is a team environment like i have never seen and are privledged and excited to now be apart of it. the picu is a wonderful place because kids are miracles and they will amaze you when you least expect it. Sure it is sad somedays and sometimes you win and sometimes you lose but the kids and families make each day very special. SO i would say pick PICU but of course i m biased. SO i wish you the best of luck in you decision and upcoming future.

mlr4 · Oct 3, 2005

hi,
i'm a new grad working in a PICU, and after almost 3 months, I can tell you that janfrn's description is right on the money, as far as my unit is concerned. we also have a large number of cardiac patients, and the capacity for 2 ECMO patients at any given time. we recently split our unit- cardiac PICU and general PICU- and i'm personally looking forward to having more non-cardiac patients. outside of multiple heart patients, some of the more memorable cases i've dealt with so far:
1- two week old with shaken baby syndrome in state custody- the child had irreversible brain damage, and the hospital social services people were working to find a way to get the state to consider a DNR order for him. very sad, and a lot of working with interdisciplinary team members
2- MVA with a group of young teenagers thrown from a truck bed. One had multiple open fractures, one needed a halo for a spinal fracture. The parents were driving, and i spent a lot of time with them, which involved comforting them, getting pastoral care and social services resources, and supressing any judgmental thoughts i had about their actions
3- 10 month old with hemolytic uremic syndrome; receiving daily plasmaphoresis and CVVHD...that involved careful monitoring of her electrolyte and respiratory status, since she had to be taken off CVVHD in preparation for surgery (which was 5 hours late), and working with a mom who spoke only spanish
4- 3 year old in respiratory failure after 2 failed bone marrow transplants. she'd been in the PICU for months, and coded and died on my first night shift. her parents were present for the code, and most of the staff in the code were crying by the time the parents gave consent to cease interventions. seeing this patient dying was hard enough, but it was even harder to see the reaction of the staff members who had worked with her for so long
mind you, i had a very experienced preceptor in each of these situations, so i never felt alone. anytime i needed anything at all, there were plenty of experienced nurses who jumped in to help me. in nursing school, several of our clinical sites were much less collaborative, so this level of team work was something new- and very reassuring- for me.
some of the great things i've noticed in my unit:
1- everyone- and i mean EVERYONE- is intelligent, articulate, and dedicated to what they're doing. our respiratory therapists are top-notch...i've learned so much from them, especially with our ECMO babies and kids on non-conventional ventilators. in fact, everyone in the unit is willing to turn pretty much any situation into a learning opportunity (except codes, obviously). nobody has ever been dismissive when i've asked a question, and i can get a mini-lecture on a topic from someone knowledgable pretty much anytime i need it.
2- the MD's and NP's treat the nursing staff with respect- even the newbies like me. few and far between are the docs who give orders without taking input from the nurses, and when i have a question for them, they answer me without belittling or patronizing. some are obviously more receptive than others, but overall, even the attendings are 100% approachable.
ok, on the minus side:
1- this is a million times harder than anything i've ever done, both in and out of nursing. i had no idea it would be this difficult. one of the biggest issues i have is fear of killing my patient by making a mistake. the good thing is that there's always someone i can ask, but when you're in the room alone and your baby desats to the 60's all of a sudden, it's a real challenge to keep from panicking.
2- as jan said, this is an incredibly broad field. there's NO WAY to become proficient in everything quickly, and even the nurses with 20 years on the unit say they frequently come across something they've never dealt with. as one of my preceptors said last week, 'you don't have to know a little about everything- you have to know a LOT about everything.' i spend a lot of time reading outside of work, and when i have a few moments to spare on the unit, i'm usually researching something. just when i feel comfortable with something, i discover something else that's completely foreign and seemingly insurmountable.
3- it's tough to keep going in, day after day. for some people, the whole aspect of dealing with critically ill babies and children is the hardest part, and some people find dealing with the families difficult. for me, i'm still struggling with knowing what i'm doing, and feeling confident that i'm providing safe care. I've always been a high achiever in everything i've ever done (this is my third career), and I always learn and master things very quickly. that's simply not possible in a PICU. it's just not. i think accepting that fact is the single most difficult aspect of my job. it's humbling to know how steep the learning curve is, and that i'm not going to be good at this for quite some time. On many, many days, I hate it. I've also been told by everyone i work with that most people hate it for at least six months- sometimes for a year or more. Our manager encourages us to stick it out for a year before deciding if we want to be there or not. I'm willing to make that commitment, and i think that's crucial for anyone to know going into it.
4- nobody really understands what it's like except other PICU nurses. Even my friends who are nurses can't really identify with the experience if they haven't worked there. It's important to talk to people who *do* understand...we're required to have a mentor on my unit, someone who's not your preceptor- someone you can just sit with and vent.
5- there's no such thing as autopilot. as i'm sure you've heard, PICU kids can crap out on a dime, since they compensate so well for so long. I worked as a student in an adult neuro icu, and those patients usually show signs of deterioration quite a while before something bad happens. with kids, they can seem fine, then five minutes later, they're cold and blue. even a slight change in any system has to be followed closely. you not only have to draw labs frequently, you have to check the results, look at the trends, and make sure you alert the appropriate team members when you see changes. i've made the mistake of assuming the residents have seen my kid's labs, and thought about interventions- big mistake. not only must you be aware of the changes, you need to think about what *you* think an appropriate intervention might be, based both on the lab results, but also your own clinical observations, as the doctors are relying on *your* input. you're at the bedside, and they're not.
all in all, even though my stomach is in knots most days when i leave for work, i'm happy with my decision to go straight to the PICU as a new nurse. yes, it's incredibly difficult- but it's also very gratifying, while terrifying at the same time. I'm not trying to scare you- just wanted to share the perspective of a brand-new grad in a PICU. I hope you take the opportunity to shadow on the unit before your preceptorship- that's what convinced me to go for it.
Good luck in whatever you decide!

Wow, your unit sounds so great! Which hospital are you in? I'm starting my PICU preceptorship in two weeks and really looking forward to it!

tomahawk · Jan 10, 2006

If you decide to work in the PICU you will not be bored for many years. The other nurses that have replied have it right. Some PICU are low accuity and some are high. The one I work in caters to ER and OR in a moments notice. The beds change over quickly. Another thought is to look how the nurses work together as a team, what kind of education is offered to the new grad, what kind of ongoing education is available? Do the doctors get along with the nurses? What is their turn over rate? What are some examples of evidence based education? Is there an educator? Talk to some of the nurses away from the management.