What did I do wrong?

meandragonbrett · Jan 6, 2010

First I assess my environment....>Do I have an ambu bag, O2 source, working suction x2, Bed low and locked? Assess your airway...ETT, trach (do you have spare supplies at bedside?) vent settings. Any drainage from the ETT or trach? What color sputum is coming out. Assess vent settings/high flo cpap/etc. Is it appropriate for this patient? Are their respirations even or unlabored? What is the character of their respiratory drive? Trachea midline? Chest rise equal? What do their lungs sound like? Do they need an albuterol tx? What's their SPO2? Are the thoracic catheters draining or clogged? Do you have air leaks? Crepitus? What color is the drainage?

Do they have appropriate pupillary responses? Is their gaze conjugate? Are their EOM's intact? What do the slcera look like?

What is their GCS? Do they respond appropriately to verbal stimuli? Noxious stimuli? Are they alert and oriented? Do they localize, extend, flex, or withdraw? etc. Do they move all extremities? Will they grasp your hands (you sticking your hand in theirs and telling them to squeeze does not tell you if they are following commands).

Is their rate regular and audible? Is it distant or muffled--->Are they a thoracic surgery or trauma? Are the aortic, mitral, triscupsid, and pulmonic valves appropriate upon auscultation. Any murmurs, clicks, rubs, etc? Is their skin warm and dry or cold and clammy? What color is their skin? Radial, bracial, DP and PT pulses. Capillary refill. Do they have an AV graft--Is there a bruit and thrill present? What is their blood pressure on the cuff and A-line. Does your a-line have an accurate square wave? Does your PAP and CVP have accurate squarewave. How far in is your swan ganz? Appropriate PA and CVP waveforms? Do your numbers reflect your clinical picture? What's their SVO2? Does it make sense?

Abdomen...Soft, round, flat, compressible, distended? Do they have bowel sounds? Surgical incisions-->Draining? How are they closed, How do they look. Is that dead bowel that you see peaking through your abd cassette or are they pink and moist. Is that NGT in place and hooked to LWS or is it clamped? What color is the drainage and how much?

Foley in place? What color is the urine? Is it concentrated, cloudy, sediment, etc. Where are your lines? Are those central line dressings CDI with biopatch (or w/e device your hospital uses). Do you have blood return and do the lumens flush easily? Are your transducers at the phlebostatic axis? Restraints intact? Does your patient need to be suctioned-->What is the PIP? Do you have a IABP attached to your patient-->What are your settings, are they working, etc. Is your patient on CRRT? Is the UF Rate appropriate for your patients hemodynamics?

Check your gtts. Is your Levophed, Vasopressin, Fentanyl, Versed, propofol, diltiazem, etc. all programed into the pump with the correct concentration? Are your lines labeled so you know where you can push drugs in an emergency. Is your patient a bit too sedated and hypotensive?

Then get busy charting and move to the next room and do it all over again =)

MSRN70 · Jan 6, 2010

Did they know they were interviewing a new grad? I wouldn't expect anything but a basic (albeit textbook) head to toe from you. Did you ask them to clarify where you went wrong?

TemperStripe · Jan 6, 2010

I graduated in December, 2008 and started working in an ICU right away (although I had been interning there for 6 months already.) I can't imagine working for an employer who expects you to have perfect, spot-on assessment skills right out of school. Nursing school only teaches you the basics! I have been spoiled by a truly supportive employer (as well as amazing co-workers) and I think that is the only way to go! You are an infant ICU nurse. Gotta run before you crawl...wait, switch that. What I'm saying is, you might be better off somewhere else that has a better understanding and expectation of what a new ICU nurse will bring to the table. Make sure you go somewhere with a STRONG orientation program! Otherwise, you can expect to sink very quickly. These places DO exist, you just might have to do some searching. My hospital has a lesser-known ICU orientation program and a smaller ICU, but from hearing about other people in the city, I think it's one of the BEST. Keep on truckin...

carolina4 · Jan 6, 2010

ok, meandragonbrett, thats nice of you to take "walk me through an assessment" to the max, but honestly i can not believe that however interviewed you had the nerve to make you do that!!! i would have FREAKED.

fiveofpeep · Jan 6, 2010

maybe they were looking for an initial focused ABC assessment. I remember that during my first ICU interview I forgot to mention that I would do a quick overview of ABCs before doing actual head to toe. I gave them an assessment Id do for a jolly pregnant lady (thats what I was up to that semester) instead of a critical patient with more pressing issues than top to bottom

carebearsRN · Jan 6, 2010

thanks for replying everyone. meandragonbrett, thanks for the walk through!

I asked the interviewer what she meant by too basic... and then she just said "you're just not fitting for ICU yet, advise you to start in Med/Surg first" sigh.

When she asked me to start head to toe assessment, she said "ok that means include neuro when you start at the head" ...which I did mentioned =T

highlandlass1592, BSN, RN · Jan 6, 2010

thanks for replying everyone. meandragonbrett, thanks for the walk through!
I asked the interviewer what she meant by too basic... and then she just said "you're just not fitting for ICU yet, advise you to start in Med/Surg first" sigh.
When she asked me to start head to toe assessment, she said "ok that means include neuro when you start at the head" ...which I did mentioned =T

Oh good grief!!!! I hate that mantra that " you need to start in Med Surg first". It's garbage. I was a new grad to the ICU and 12 years later, I'm just fine. I'd look at other ICU's and focus on how excited you are to join the unit, how much you look at expanding what nursing school taught you...stuff like that. NO new nurse is going to be able to verbalize an accurate ICU assessment and you shouldn't be able to. And to be honest, Med Surg is a specialty all unto it's own..why should you be expected to spend time in a practice you have no desire to work in??? Unfortunately, the person who interviewed you seemed to be pretty closed minded..I'm sorry for that. Keep plugging away at other units..and don't give up your dream.

carebearsRN · Jan 7, 2010

and I was interviewing for a new grad critical care training prog. I told the interviewer ...isnt this the purpose to have this prog so new grads can learn from it? it just doesnt make sense that she said I was not advanced enough =T

but thanks a lot everyone for listening!

VegetasGRL03RN · Jan 7, 2010

CarebearsRN,

I'm GOING to be a new grad in 4 months (trying to speak it into existence :)) and I want to start in the ICU, too. So would you mind providing a detailed walkthrough of what you did for your assessment in the interview? Just seems like a chance for a good learning/sharing experience, if it's okay.

shoegalRN, RN · Jan 11, 2010

thanks for replying everyone. meandragonbrett, thanks for the walk through!
I asked the interviewer what she meant by too basic... and then she just said "you're just not fitting for ICU yet, advise you to start in Med/Surg first" sigh.
When she asked me to start head to toe assessment, she said "ok that means include neuro when you start at the head" ...which I did mentioned =T

When you did your neuro assessment, did you check for GCS? Meaning did you state you would ask the pt their name to see if they are oriented to self, where they are to see if they are oriented to place, and do they know what month it is to see if they are oriented to time? Of course this is considering your pt is awake and not intubated and sedated. Did you mention they open eyes spontenously or to voice? Did you mention the pupils are round, equal, reactive, brisk, and 3 mm? Did you mention they follow all commands, moves all extremities, and have equal strength bilaterally in upper and lower extremities? If your pt is sedated and intubated, you need to mention if pt is on propofol, versed, or fentanyl gtt's and the rates those gtt's are going.

This is all part of neuro assessment.

Neuro assessment is extremely important in the ICU, because any change in neuro status could mean something is going on in the brain that is not right, and off to CT the pt goes.

Now, this is what some consider "basic" assessment for the ICU. Of course, you wouldnt get this detailed in a med-surg setting. I don't think a new grad coming out of nursing school would know this without having spent some time doing a preceptorship in an ICU during nursing school. I didnt know how important neuro assessment was until I became a RN and started working in the ICU.

Maybe the interviewer wanted to see if you took the initiative to study upon these things prior to the interview, I don't know, but I think it was not a fair question to someone who is a new grad without any prior experience in an ICU.

LeLeeFNP · Jan 13, 2010

Have you spent any time in the ICU at all? I mean as a tech? An intern? Have you even shadowed? I would definately say learn from this experience and try to at least get a shadowing experience in the ICU. That way you will at least be able to speak upon what you have seen other nurses do and you can know if it is a fit for you or not. An ICU assessment is very different than a floor assessment, an ER assessment, or any other area of nursing. I believe it is the most detailed. Yes as a new grad you won't be able to speak about everything but if you are applying as a new grad in the ICU you should have done a bit more research to see what it is that ICU nurses are doing everyday. How else will you know it is a fit? Obviously they gave you an interview to give you a shot and you were not prepared. If that weren't the case they wouldn't have even bothered to interview a new grad. I am not trying to be mean but you have to look at it from the employer's standpoint. Why would they waiste their time, money, and effort on a new grad that didn't even take the time to research the department they want to work in? Most people don't even think about how much money these facilities spend on bringing newbies up to speed. If you never spent any time in the ICU and didn't bother to do research what makes them think you will even make it?

If I were you I would absolutely get some shadowing done, do as much research as possible, get your portfolio together (reference letters, awards, etc) and bring your "A" game to the next interview if you are so fortunate to get one. Lets not forget that positions are hard to come by these days and employers are fortunate to be able to only except the cream of the crop. I am giving you this advice because I too started as a new grad in the ICU, but I wouldn't have had the audacity to come to an interview without blowing them out of the water with my skills and background (I had one year of LPN experience at a Vent hospital, a prior internship in ICU, and already had my ACLS, and EKG certification as well as numerous recommendation letters from instructors and former employers). None of the other new grads could compare with what i brought to the table which is why I was told i got the position.

If you really want to fulfill your dream YOU will make it happen.

Good luck.