Words of wisdom for a new grad starting in the ICU?

Biffbradford · Sep 15, 2013

Hello! I'm a new grad (Aug '13) and have just passed boards at the beginning of the month. I've accepted a position in an ICU internship beginning in October in a 70-bed ICU at a L1 trauma center and am curious if any of you wonderful nurses have pearls of wisdom-- not necessarily what to expect etc as programs vary, more so things you know now that you'd wish you'd known as a new grad? Any advice for a newby is welcome. Thanks! :)

Be a sponge and don't be in a hurry. It seems to me that the newbies who couldn't get into CVVH and IABP fast enough, were the first one's to burn out. Sounds like a huge unit and probably has plenty of patients who are 'sicker than snot'. Just pace yourself. Good luck!

FlorenceNtheMachine · Sep 16, 2013

Be a sponge and don't be in a hurry. It seems to me that the newbies who couldn't get into CVVH and IABP fast enough, were the first one's to burn out. Sounds like a huge unit and probably has plenty of patients who are 'sicker than snot'. Just pace yourself. Good luck!

I can't like this enough. I agree wholeheartedly. I feel my edges getting a little burned out from taking the 1:1 sickies. I love to take care of them, but I see the nurses who were raised this way and see how much they dislike their job. I've gotten a break lately, and feel slightly more energized.

FlorenceNtheMachine · Sep 16, 2013

Some tips: don't hurry ANYTHING. Even the scariest moments, you can take a second to breathe, and check what you are doing.

A nice quote:

"Listen or your tongue will make you deaf."

KenH · Sep 18, 2013

Be positive.

Pace yourself

Ask Questions, be teachable.

If your asked a question and don't know it, admit it, ask them to teach you, tell them you will find the answer, then ask them if there is anything you missed.

Read up on the patients you are seeing.

Try to work harder than anyone else there,impressions matter.

Its a competition.

Be Positive.

Be on time.

goodgrief · Sep 18, 2013

ALWAYS put your KVO pump (for antibiotics and other IVPB drugs) on one side of the bed, and put all other IV drips (vasoactive drugs, insulin, sedation, anticoagulation, etc) on the other side of the bed, or at least somehow separate the KVO pump from all your other pumps.

One time I took over care of a patient that had the KVO pump and a Bivalirudin pump on the same IV pole (these weren't smart pumps, they were the kind where you have a plus/minus below each digit on the screen and you adjust/bolus the drips that way). Vancomycin was due, so I hung it piggyback on the KVO pump and set it to infuse 200mL over an hour. I came back an hour later and noticed that the vancomycin bag was still full and the Bivalirudin bag was almost completely empty. My heart sank into my stomach when I realized I had just made my first med error, and it was a huge one. Instead of programming the KVO pump, I accidentally programmed the Bivalirudin pump to bolus 200mL in an hour when the normal rate was like 3mL/hr. I thought the pt was going to die.....long story short, I was the happiest RN on the unit the day I saw that pt discharged well & alive.

Advice: separate the KVO from other infusions, slow down, take your time when giving meds and double-check your work.

bmendi · Sep 19, 2013

Thank you all so much! It means the world and I hope to put your advice to good use soon :)

Bringonthenight · Sep 19, 2013

Take time to organize your patient and room at the start of every shift after report.

LABEL YOUR LINES!

Check everything for yourself:

- pump settings and what they are infusing.

- drains/wounds

-alarm settings

-etc

NEVER ASSUME ANYTHING (a general nursing rule) just because the nurse who handed over to you has 20years+ experience doesn't mean she didn't accidentally set the PCA up with the wrong opioid.

Tidy your room.

Check your labs.

Check vent settings.

Realize your an advocate and that this might make you unpopular on a Drs list from time to time- they'll get over it.

Realize it's about the whole patient, not the tasks you need to complete.

Build your assessment skills and trust them.

Ask questions and write answers down.

Know when to call for help and don't feel bad about doing it.

Realize your not going to be fast super nurse from day one- pace yourself, no one expects you to "get it" straight away. Don't compare yourself to other nurses.

You'll never get out right on 7 o'clock.

That's all I can think of right now! Good luck.

ak2190 · Sep 19, 2013

Cannot stress enough about being OCD with your lines. Label, label, label.

And check everything that goes in or comes out of your patient any time other people have been in there without your supervision. (Which should be almost never.)

johnwaynehair, BSN, RN · Sep 19, 2013

1) Eat when you can, pee when you can, sleep when you can.

2) Keep your eyes and ears open, and take whatever lessons you can where you find them.

3) Don't let a senior nurse bully you into doing something you are unqualified to do (I cardioverted a patient with a doctor on the phone, but not in the hospital once in my first year because an older nurse said "we do this all the time"; luckily it turned out OK).

4) Forgive yourself for the mistakes you will make, and resolve never to make them again.

5) Check and re-check.

6) Realize that patients will die on you no matter if you do everything right.

Good Luck in your practice, and Welcome to Critical Care.

greyL · Sep 20, 2013

I'm not an experienced nurse. I'm a new grad and I've only been in ICU for 4 weeks now, but here are the things I've learned:

1) Assess your patient right away. It doesn't have to be a complete assessment. Check the IV lines to make sure they look good. Double check what's running through the lines. And check your alarms!! I learned that the hard way. My patient started to desat and the night nurse had turned all the alarms off!

2) Don't be afraid to tell people that you're new. Sometimes doctors will start asking me a whole bunch of questions, and sometimes you just won't know the answer. Go get your preceptor, and then remember what the doctor wanted to know, so you can look it up next time!

3) Make a list of the doctors and their specialty. The first couple of weeks, I spent so much time being confused over who was the kidney doctor, and the pulmonologist, and the cardiologist, etc.

4) Know your labs. We all know whether a lab value is abnormal or not, but piecing it together with the patient's condition is harder.

5) Most importantly, always ask yourself, "why?" Why are you doing what you're doing? Why are you giving a certain med. Why is radiology coming up to take a chest x-ray? This seems like common sense, but there have been times when I've had to give a report and the nurse has asked me why I did a certain thing, and I didn't know what to say!

For example, I had a patient yesterday whose entire lower left leg was necrotic. It was awful. It smelled like death. The family decided to switch him to hospice, so we were going to transfer him to med-surg, and I was giving report to the nurse, and the nurse asked me why we weren't just amputating the leg. Well, it was obvious to me just from looking at the patient that he was dying, and that he probably couldn't survive a surgery like that, but why? I felt like an idiot.

jalyc RN · Sep 21, 2013

Congratulations on the start of an amazing career.

Johnwaynehair has some wonderful suggestions, especially numbers 3 and 6.

1. Learn all that you can.

Read up on each condition that your patient has and correlate what you learn to that person. Easier to remember 'Mr. Smith's problems' that just text. Lab results mean more when you understand the bruising from DIC. Xrays are easier to read when you see the hairline fracture because you looked harder due to the swelling at that site.

2. Volunteer for any and every opportunity to participate in something new.

You can learn a lot from side comments during tests, ect. and ask more about reading Xrays, interpreting labs, observing symptoms while they are happening. Techs can be a wealth of knowledge to new nurses.

3. Take that extra minute to breathe, to think, to calm down, so you can respond appropriately.

Don't be like me replying to bystanders that my friend who was passed out on the median after an auto accident "... is fine because she is a nurse." She WAS fine, but us being nurses had nothing do with that. lol (Immediately after that comment, I checked her pulse, etc. duh!)

4. NEVER be afraid to ask questions or to admit you don't know something.

Everyone has to learn things. As a new LPN in CCU 40 years ago I once asked one of the founding doctors of our hospital why we would do q4h V/S on a fresh cardiac through the night if they needed so much rest. The head nurse and all others were freaking out behind his back. "NO!!!! He is DR. D!!! You don't ask him questions like that!!!!!" He took off his glasses, looked at me for a minute or two, then started explaining how the heart works and how low B/P affects the kidneys,in turn how kidney function affects the B/P, etc. etc. etc. Thirty minutes later I had an encyclopedia of knowledge that I did not have before.

5. Don't let negative people or experiences get you down.

Move on and above them. As a new grad, I worked the county hospital in L&D and we did our own C-sections. The first one I did the doctor exploded to my head nurse after to NEVER put me in with him again. I worked hard to learn the instruments, how to assist, what to do and QUICKLY. A month later we had an abruption come in. Baby was out in 10 minutes from getting to the ER and she was closed in 30. The same doctor, when now praising my work to the head nurse was told, "But you said you never wanted to work with her again." in front of everyone. Things do get better with time and experience. You WILL get there.

Best wishes for your future.