PICU or NICU

Pediatric Critical Care Columnist · Feb 19, 2014

It can definitely be a bit intimidating to start in NICU/PICU with no critical care experience, but don't discount your OR/procedures experience. That's a big part of what we do in PICU - assisting with central line placement, chest tube placement, intubations, extubations, complex dressing changes, endoscopy, bronchoscopy and many other procedures. Of course, there's a huge knowledge base but no one expects a new-to-PICU nurse to have it.

In NICU there are about maybe 10 typical diagnoses and it can be very routine nursing. Some people love it, but I found it didn't challenge me much after a couple of years. In PICU the patients range from neonates to young adults. They present with a wide variety of problems, with a wide variety of underlying conditions. No two days are the same. One day you could be caring for a toddler with seizures, the next it could be a 15 year old with a traumatic brain injury and the day after that it could be an 8 year old in DKA. After 16 1/2 years of PICU nursing I'm still learning something new and facing challenges every day. My bias is obviously showing but it sounds like you're already leaning that way anyway, so let me give you a little nudge...

Humbled_Nurse · Feb 19, 2014

Well it depends on what you are passionate about. Are you drawn to 1 particular area more than the other? Is this an area you have wanted to go into before? When I was in nursing school I was only interested in kids or babies. I pretty much had no interest in adult care. I was lucky enough to be able to go straight into the NICU and have had no regrets.

There are some similarities between these areas but there are several differences as well. Here is a breakdown. Remember I have only worked NICU. I have no experience in the PICU.

1) The PICU has a very wide range of ages. Anywhere from newborn to age 18 and it isn't uncommon for some PICU's to have patients older than 18. Usually the "adults" in the PICU have a defect/disease common to children such as cystic fibrosis, congenital heart disease, etc... These kids are living much longer now and adult doctors really don't know what to do with them.

2) The PICU has a wider range of diagnoses. Depending on the type of PICU you are in you may see trauma patients, post surgery patients, and of course a wide variety of medical issues. In the PICU you will see a lot of kids with chronic illnesses that get admitted often. In the NICU you generally see the same type of diagnosis. LOTS of respiratory issues, but if you work in a large, high acuity NICU that does surgery you will see more variety.

3) The level of acuity varies between these units as well. Generally if a kid is in the PICU they are very sick and need the higher level of care. In the NICU not every baby is critically ill. Some babies are in the NICU just for a 48 hour rule out of sepsis and may just need antibiotics for 48 hours. A lot of babies are just a little premature and just need some time to grow and learn to feed. They really aren't "sick." Does that make sense? On the other hand you can have some very sick babies in the NICU. You could be taking care of a 1 pound baby on the oscillator with multiple drips. Also, those babies that don't seem "sick" can turn on you in an instant and become the sickest baby in the unit. Generally speaking though most of the babies in the NICU do pretty well.

4) There is tons of teaching in the NICU. Remember these babies haven't gone home yet so everything is new to mom and dad. Especially if they are 1st time parents. Throw in the fact that their baby is sick or premature and there is much more teaching that goes along with that. It may be as basic as teaching them how to change a diaper or it may be more complicated like teaching about the ventilator, trach care, etc.. In the PICU there will be a lot of teaching as well, but if the child has a chronic illness/disease the parents may be teaching you instead of the other way around. They know there child better than anyone else. Regardless, you will be dealing with the parents A LOT whether you are in NICU or PICU.

I would suggest that you request to shadow in both of these units so you can get a feel for what may be a better fit for you. Regardless of which unit you picked you want to make sure you get an extensive orientation. Everything will be new and different. You will probably feel like a new grad again.

You also need to consider what you can handle emotionally. I am a mom of 3 small kids so at this point in my life I don't think I could handle working in the PICU. Don't get me wrong the NICU can be very sad and heartbreaking, but I just don't think I could handle taking care of a 2 year old that was severely injured in a car accident or had a near drowning. I just think it would be too much for me.

Also you have to put your judgments aside which can be hard. Think of the child in the PICU that was abused and is now neurologically devastated or the mother that just gave birth to her 8th child at 24 weeks and has a positive drug screen and she doesn't have custody of any of her children. There can be some very heartbreaking situations in both units.

Also in the PICU you would likely encounter a lot of former NICU patients.

If you are in a Children's hospital that has a NICU and a PICU you usually are required to float between the 2 units so that would give you experience in both.

Hope that helps

Good luck!

babyNP., APRN · Feb 23, 2014

I'll jump in as a NICU RN who has floated to PICU...it depends on what type of units you will be going to. I work at a large academic center and we have a large variety of diagnoses, from every specialty. In a smaller level NICU, Jan is right, however, that there will be less diagnoses.

I would agree that a large portion of our preemies are not sick in the traditional sense (although many are), but they are certainly extraordinarily fragile and it takes a lot of careful attention to pick up on signs that they are getting sick. I've had on more than a couple occasions that my infant was on full feeds or near it and by the end of my shift, ventilated, pushing products, and running down to the OR for nec.

And to show my complete bias for NICU vs PICU, we float down to PICU sometimes. It's fairly miserable to take care of these CP kids who just lie in the bed and are not cognitively aware of what's around them. Or when your toddler is roaming around his crib and pulls out his tracheostomy. That's just not for me...I completely respect those that do it, but I can't do it.

NicuGal, MSN, RN · Feb 24, 2014

It depends on what you are looking for...a heart or trauma center has a lot of action...we see some unusual things but mainly center around respiratory.

I decided I couldn't be a PICU nurse when I floated up and they have me a former patient of mine who was trached and 13 years old, who met me as he came out of the bathroom wearing only his trach collar and a big smile lol Lordy lol

HazelLPN, LPN · Apr 5, 2014

I worked in a large teaching hospital with a 45 bed NICU (including step down) and a 27 bed PICU. I worked contingent for both units for 18 years after working most of my career in adult ICU.

You get everything and anything in the PICU from hearts to hem/onc to ID to burns...you name it we got it. I learned something new everyday and to me, it was the most challenging and fulfilling place that I worked.

Even though I regularly worked in the NICU and enjoyed it, I never considered myself a real neonatal nurse....more of a versatile and adventurous PICU nurse who was competent with most of the NICU population. Compared to the PICU, there is much less diversity. 90% of our patients were premie/RDS but there were meconium aspirations and the various congenital problems and birth defects. This is not saying that NICU isn't challenging. On the contrary, its highly specialized. I could take care of anything in the PICU and I always felt that I could handle it with good people around me. In the NICU, I felt much more isolate when I worked over there. I was great with the routine stuff....two stable vents or three feeder growers were the assignments that I liked to have. My comfort level dropped significantly caring for complex chronics and the tiny micropremies under 26 weeks. I could do it, but I felt there were much better people for the job.

As far as intimidation is concerned, I started PICU when I was pushing 60 after doing adult ICU for most of my career. If I can do it...so can you. You just have to love want you are doing and be willing to put the time in to read and learn on your own outside of work.

Best to you,

Mrs. H.