TIPS for New Grads entering ICU

ICURN3020 · Sep 30, 2014

Have an effective, reliable method of coping with stress in place before starting your new position. That was the biggest aspect that I struggled with as a new grad in the ICU....the overwhelming stress! I don't think you can prepare for it, so having strategies in place to handle it will keep you from snapping under the pressure. Good luck to you!

Go-GetterRN · Sep 30, 2014

When you start your shift, do a good assessment on your pt, make sure all IVF are running at the rate that the previous nurse told you, check to see when these fluids need to be replaced (esp pressors and sedatives-its not good to let them run dry before reordering,) make sure everything in the environment is safe and appropriate for the pt, and see when your next scheduled labs are. Look through your scheduled orders, meds, and labs to see what is appropriate for the pt and what additional things you may need. Make a list of everything you need and call the doc if you are missing something urgent. After a while, you will be able to come up with a plan for your patient for your whole shift in the first 5 minutes.

I usually stay busy the first couple hours of my shift getting everything in line for all my pts in hopes of a smooth night..then cross your fingers nothing too crazy happens.

planetleah · Sep 30, 2014

Hello all! I've also recently accepted a new grad ICU position and I start next week. I'm grateful for the advice given above, and can't wait to hear any other tips from seasoned ICU nurses!

MrsICURN14 · Sep 30, 2014

I'm a new grad in the ICU. Been there 4 months.

For me, the hardest part has been the feeling that I'm expected to know everything right off the bat. I left work feeling like an idiot most times during orientation. The critical thinking aspect is huge in the ICU.

To make my day easier, I get to work at least 30 minutes early and write down all recent labs/orders etc on my pts and I make a check list of everything I need to chart, as well as a to do list. I make a chart for all my meds for the whole day and what time they're due, so I don't have to worry about looking all

That up after report. Once I receive report I immediately assess my patients and I organize and pick up my room and make sure I have all the necessary supplies if the night nurse didn't leave me well equipped.

As far as what I do to make it easier on the night nurse, I make sure all IV bags are at least 1/2 full and if it's due to run out in an hour or two after shift change I put another bag in there for them. I make sure I leave my patients "fluffed and buffed" and my room clean and organized. Some days this works out better than others. IF I have extra time I try and change out lines/TF tubing if it'll be due the next day. Some days you do well just to get your meds passed by shift change. Things can turn on a dime with ICU patients.

Also, make sure you're ready for report on time if not 5-10 mins early. By the end of your shift you're ready to give report and get the crap out of there, have the same courtesy for the off going nurses. Make report short and to the point, but address everything important. Don't use report to chit chat, the off going nurse wants to go home.

Make sure you have a sense of urgency if you're going to work in the ICU. If your fellow nurse's IV pump is beeping and they're busy, go check it for them because it could be a pressor and if it runs out the pt could crash. Some patients are very sensitive to pressors/inotropes etc.

Just be flexible, and a good manager of your time. That's the most important aspect.

PGH_BSN · Sep 30, 2014

I started in a level 1 trauma ICU right out of school..I'm approaching 10 months there soon.

- Most difficult aspect for me was earning the respect from the other nurses that have been there for a while. Being a new grad, you're kind of a different breed going into the ICU right off the bat. They expect you to know certain things and look at you weird if you ask an off the wall question. The other things I struggled with is ensuring everything got done in a timely manner and have the sense of urgency. On my orientation, I was getting TBI head protocol in one room with a proned patient in the other room. It's just how our floor operates with the acuity. There were times I wanted to cry because my preceptor would let me drown before helping me. It worked out in the end because I am now a confident nurse that looks at challenges as problems and I want that every day.

- The best piece of advice I can give you is to be a sponge on orientation. Do not walk in there thinking you know things, because that is how people on orientation get fired from our unit. Take everything in, and always listen before speaking because even if you've learned a skill 1000x before, you could possibly learn something new. Also, don't be afraid to solve things for yourself. You're going to need to when you're off orientation and by yourself. They'll tell you if you're messing up. Good luck to you, ask anything and maybe I can help.

What kind of ICU are you starting in?

NurseJoy101 · Sep 30, 2014

Have an effective, reliable method of coping with stress in place before starting your new position. That was the biggest aspect that I struggled with as a new grad in the ICU....the overwhelming stress! I don't think you can prepare for it, so having strategies in place to handle it will keep you from snapping under the pressure. Good luck to you!

Thanks for your response! Hopefully my support system, time management, and my eagerness to balance life and work will help with the stress I'll experience while working in the ICU.

NurseJoy101 · Sep 30, 2014

Hello all! I've also recently accepted a new grad ICU position and I start next week. I'm grateful for the advice given above, and can't wait to hear any other tips from seasoned ICU nurses!

Hey! I'm so happy you've landed a position in the ICU as a new grad too! Another resource that I found to be helpful was icufaqs.org. Specifically the 'Starting out new in the icu' document. Gives a bit of insight of what to expect on the floor and offers some tips as well. Good luck to you!

NurseJoy101 · Sep 30, 2014

I'm a new grad in the ICU. Been there 4 months.
For me, the hardest part has been the feeling that I'm expected to know everything right off the bat. I left work feeling like an idiot most times during orientation. The critical thinking aspect is huge in the ICU.
To make my day easier, I get to work at least 30 minutes early and write down all recent labs/orders etc on my pts and I make a check list of everything I need to chart, as well as a to do list. I make a chart for all my meds for the whole day and what time they're due, so I don't have to worry about looking all
That up after report. Once I receive report I immediately assess my patients and I organize and pick up my room and make sure I have all the necessary supplies if the night nurse didn't leave me well equipped.
As far as what I do to make it easier on the night nurse, I make sure all IV bags are at least 1/2 full and if it's due to run out in an hour or two after shift change I put another bag in there for them. I make sure I leave my patients "fluffed and buffed" and my room clean and organized. Some days this works out better than others. IF I have extra time I try and change out lines/TF tubing if it'll be due the next day. Some days you do well just to get your meds passed by shift change. Things can turn on a dime with ICU patients.
Also, make sure you're ready for report on time if not 5-10 mins early. By the end of your shift you're ready to give report and get the crap out of there, have the same courtesy for the off going nurses. Make report short and to the point, but address everything important. Don't use report to chit chat, the off going nurse wants to go home.
Make sure you have a sense of urgency if you're going to work in the ICU. If your fellow nurse's IV pump is beeping and they're busy, go check it for them because it could be a pressor and if it runs out the pt could crash. Some patients are very sensitive to pressors/inotropes etc.
Just be flexible, and a good manager of your time. That's the most important aspect.

Thanks for the advice! I was a bit worried about how to begin/prepare for my shift & glad to know preparation, prioritization, and organization will aid in a successful shift. Great tips!!!

NurseJoy101 · Sep 30, 2014

I started in a level 1 trauma ICU right out of school..I'm approaching 10 months there soon.
- Most difficult aspect for me was earning the respect from the other nurses that have been there for a while. Being a new grad, you're kind of a different breed going into the ICU right off the bat. They expect you to know certain things and look at you weird if you ask an off the wall question. The other things I struggled with is ensuring everything got done in a timely manner and have the sense of urgency. On my orientation, I was getting TBI head protocol in one room with a proned patient in the other room. It's just how our floor operates with the acuity. There were times I wanted to cry because my preceptor would let me drown before helping me. It worked out in the end because I am now a confident nurse that looks at challenges as problems and I want that every day.
- The best piece of advice I can give you is to be a sponge on orientation. Do not walk in there thinking you know things, because that is how people on orientation get fired from our unit. Take everything in, and always listen before speaking because even if you've learned a skill 1000x before, you could possibly learn something new. Also, don't be afraid to solve things for yourself. You're going to need to when you're off orientation and by yourself. They'll tell you if you're messing up. Good luck to you, ask anything and maybe I can help.
What kind of ICU are you starting in?

Glad to know hard work pays off in the end. I will definitely not feel too horrible when times get tough as I see it is common amongst lots of new grads who go straight into the ICU (and even most other floors).

Please do expect oncoming messages from me! I'm a very curious person & I'm not afraid to seek help. Thanks so much for your comments and willingness to help.. It's greatly appreciated!

Also, I believe I'll be starting in the MICU(?). I'm unsure if our facility has specialty ICU units.. I haven't been to the hospital orientation just yet.

Here.I.Stand, BSN, RN · Oct 1, 2014

Great tips so far! I wasn't a new grad, but newish when I started my first ICU position. It was in the SICU/CVICU (two adjacent units that shared staff) of a big teaching hospital, and I'd been an RN 18 months.

When I come on, I like to look up their most recent labs, when they have labs due, look at their MAR--for scheduled meds and available PRN's--and if they have any tests scheduled during my shift. As an ICU RN you will be accompanying your pt if they need to go off the unit for tests; it's not like on the floor where you can just send your pt with the CNA or transport staff, so you'll need to plan. I like to read the admit note and the most recent primary team progress note for a quick idea of what brought the pt in and where we are now. For our multiple traumas I write down their injuries on my brain sheet. Towards the end of a crazy shift, I don't want to have to ask myself "The pulmonary contusion is on which side?" etc.

I always do a safety check first thing when in the room. I make sure there's an ambu bag that's out of the packaging and ready to use, make sure my drips are programmed into the pumps correctly, make sure I either have another bag of my drips in the med room or another bag ordered. I check to make sure my alarms are on and appropriate. For example, is your pt on a pressor and you want their MAP >65? You want to make sure the MAP will alarm when low, not necessarily the systolic. (I'm thinking of one pt I had whose systolics were fine, but diastolics in the 20s-30s. Therefore, her MAPs were low and an alarm set to go off when her SBP was 160? That would drive a lot of people nuts very quickly. :madface: Customize those alarms.

I like to have pts looking neat and comfortable ("fluffed and buffed") before I leave. I like to leave IV/TF bags with at least two hours worth of volume in them, or at least a new bag in the room. If that tubing is set to expire, I will string up and label that new bag so all the next RN has to do is give it. Some days this works better than others!!

When giving report, I like to go by system. I give a brief history, and then give their neuro status, HEENT status, CV and respiratory... just head to toe. If one system is normal I don't spend a lot of time on it, e.g. "she's neuro intact," but I do address it. If I just skip the normals, the oncoming RN will ask about them anyway. I don't go over every single lab, but if there's any we're watching for trends or abnormals that the MD is already aware of and being addressed, I'll give the oncoming RN a heads up.

Take good care of yourself! You have a huge learning curve ahead. Congrats on the position! :up:

delphine22 · Oct 1, 2014

-- I prefer bedside report, but it isn't always feasible. If you give report outside the room, make sure it's at a computer so you can look up labs together. "I see the K+ was 2.9 this morning, how much did you replace?" You're not being mean, the previous nurse has had a long shift and may not remember everything to tell you. Then when report is done, go into the room together. Might be a good time to turn the pt, make sure their skin is OK and that they're clean. Yes, nurses want to go home, but they want to do this too, and make sure you leave time to do this also at the end of your shift. You don't want to leave someone poopy in report.

-- If you have a choice, go to nights, even if just for a little while. The pace is much better for learning without all the family and craziness around.

-- Be careful about coming in too early. It's nice to look up stuff but don't get into the habit of working for free. (And of course you can't punch in too early.) I look up stuff immediately after report. I check labs, next meds due, progress notes, scans. Again, nights makes this easier bc I'm not trying to set people up for breakfast.

-- Do not ever EVER walk past an alarming pump, even if it's not your room, even if it's an isolation room. You are all a team and you need to help each other.

-- Get good at IVs. Practice on the sedated people. Seriously! That's something you miss when you skip the floor.

-- Make sure your preceptor is OK with it, then tag along with the code nurse, especially if you haven't seen many. If it's your first or second, jump in with compressions. Ask for relief when you get tired, then jump back on after you've rested. Then watch and listen. If you've been to a few, record. (I hate recording!! But it makes you really pay attention.) Use your watch with a second hand. Make sure to call out 2 minutes and always know when the last epi was.

-- I work MICU and we get lots of renal failure. Really understand the patho behind this. What are the different causes? How are they treated differently? Who gets flushed with fluid, who gets fluid restricted, who gets dialyzed, who gets bicarb? Read the DKA protocol backwards and forwards, because they can get complicated and you don't want to be trying to decipher it when the pt rolls in.

-- Make friends with respiratory. They will save your butt lots of times. Ask them respectful questions: "Does this pt need suctioning? Why would you/wouldn't you suction in this case?" etc. Talk to them during SBTs about how the pt is doing, review vent settings with them. They are your best friend when your vented pt has to go to CT.

-- When your pt travels, YOU ARE THE BOSS, not the people in the receiving department. Be helpful but your main job is to monitor the pt and their safety/comfort. Don't enter the CT control room until you're sure you can see the pt's monitor from where you're sitting. Don't be afraid to ask people to wait a minute so you can get everything straight for your pt. No matter how backed up they are, your pt is the sickest one and therefore gets extra time and attention.