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This is a guest post.

The purpose of this episode is to offer tips and advice to new graduate RNs starting in an ICU.

All opinions in this post are that of the guest author and not those of their employer.

As a new grad in the ICU there is a learning curve. Learning to be your own advocate will help you learn things the way that is best for you.

 

This is part three in a 3 part series. Be sure to check out part one, New Grads in the ICU, Nurse Characteristics, and part 2, Tips for an ICU Nurse, Showing Initiative.

Melissa Stafford, BSN RN CCRN SCRN is the author, and will also be our featured guest nurse in Season 2 of the FreshRN Podcasts.

 Advice #4: Know yourself and be your own advocate

  • Learning style vs. teaching style: If I’m going to teach you how to knit me a scarf, how do you learn best? Can I just talk you through it? Do you want me to give you an article to read? Do you want to watch me do it? Or, do you need to hold the needles and do the stitches? Or… do you learn best with a combination of those things? Your learning style and my teaching style may be very different, so we should talk about that at the beginning. Or, best way you learn knitting may not be the best way to learn figure skating. Talk to your preceptor about things that are or are not working, that’s how you’ll learn to adapt to each other.
    • Know your limitations. Recognize what you don’t know. Nothing will kill your credibility quite like being the ‘know-it-all’. As a new grad, it will make you look dangerous. I would recommend you have regular conversations with your preceptor.
      • Example: Your post-op patient is becoming increasingly tachycardic.
        You: “My pt is tachycardic. I’m concerned they might have internal bleeding”.
        Preceptor: “Why do you think that? The patient has a fever.”
    • This would be your opportunity to show your critical thinking skills by reviewing the patient’s other vital signs (say a low BP), or your preceptor may direct you to check the patient’s lab work, or most recent dose of pain medication.
    • It takes time for your preceptor to validate your knowledge and technical skills. By allowing this natural progression, you will only improve your credibility among your peers, which will help demonstrate your independence.
  • Ask for help. This coincides with knowing your limitations. Asking for help is not always a weakness. Sometimes it can be a key strength in safe patient care. If you aren’t sure how to titrate your vasoactive drips on the new IV pump, or, if you need a refresher on how to perform trach care, ask. Your preceptor may want you to demonstrate what you do know, but this will help identify learning opportunities.
  • Find a mentor. This will likely NOT be your preceptor during orientation (but they will often become one after you are on your own). This person does not have to be the most experienced person. But, it should be someone who has experience in the unit who can offer a sounding board after a rough day, suggestions for your performance, or how to interact with your preceptor. This would be someone who is not grading your knowledge/technical skills, but someone focused more on personal and interpersonal development.
  • Own your orientation. Orientation is an extension of nursing school, without the formal grading. Use resources like textbooks, professional nursing organization references, or reputable internet sites to look up unfamiliar things (like disease processes) on your own time. Your preceptor and manager will appreciate your self-motivation to learn! Bonus: These notes will give you something to go back to when it comes back up again in the distant future.

Advice #5: Keep your orientation organized

There will be a lot of paperwork during orientation. You will be (or should be) exposed to many types of patients during orientation. The same goes for types of equipment (IVs, vents, monitors, pressure lines, etc.) You should keep notes on what you’ve experienced, what you’ve done well, and what you need help with. I hope you’ve got a preceptor helping with this one!

Advice #6: Organized routine is key

Whether it pertains to organizing orientation paperwork (as above) or to how you run your day, having an organized routine will help things run smoother. Below are some of my thoughts for starting out.

  • Assessments: Head to toe. Getting in a routing on what/how to assess your patients will help you master the patient assessment. Furthermore, good assessments are the foundation to success in critical care. This is how you will learn to recognize changes early. Technical skills are important, but your assessment skills are more so.
  • Report: Needs to be organized/streamlined whether giving or receiving. You should have a tool (whether self-developed or a borrowed) for report. It’ll help you organize your thoughts, ask questions, and plan your day. CAUTION: Do not regurgitate the report you received as the report you are giving someone else.
    • Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
    • Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
    • Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
    • Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump. Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
    • Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.
    • Practical application: I start my day like this:
      • Receive report. I need to know why my patient is here and the most pressing issues. (WARNING: you will likely not receive every piece of information you need during report. For this reason, do not rely on word of mouth for your orders. Review the chart for active orders and current MD notes)
      • Assess the patient: Your eyes should go to the patient first, NOT the monitor. Seeing your patient is dusky and short of breath will tell you way more than an SpO2 of 94%. Same goes for an awake, chatty, pink healthy patient whose SpO2 is reading 52%.
      • Assess the monitor: Are the vitals normal? Anything I need to address urgently. (WARNING: check to be sure your alarms are set appropriately, both numeric values as well as sounds)
      • Assess IV meds: Look at what is actually hanging vs. what is programmed into the pump (my IV insulin story). Also, you should have enough fluids to get through the first couple of hours. If not, address promptly. The last thing you want to do is run out of Levophed while in the midst of starting your day.
      • Go from there. You decide when charting assessments, scheduled med administrations and the dozens of other nurse tasks will get done over the next 8-12hr shift.

Advice #7. Learn your alarms and use them to your advantage

There is a reason for every alarm. All alarms have to be answered promptly. Still, in an ICU there are often many alarms occurring simultaneously. It’s important that you learn to prioritize. For example, a V-fib alarm needs to be addressed before an occluded IV. Each alarm has a different sound, and therefore it is imperative that you to recognize the sounds.

Even better, use these alarms to your advantage. My favorite 2 alarms to utilize in this way are IV pump alarms and tube feeding pump alarms. On an IV pump, you can program the VTBI so that you know when one antibiotic is done and it’s time to hang another one. Or, use it to remind yourself half way through to make sure you have another bag of Levophed with plenty of time before it’s empty. Titrating your tube feeding rate to goal? Use the volume to trigger an alarm on the pump as a reminder when to turn up the rate.

Advice #8: You need downtime

Becoming a nurse is an exciting, but stressful time. Becoming a critical care nurse right out of school adds another layer to that stress. Learn to separate from the physical, mental, and emotional stress of work. You will have good days and bad days, both to varying extremes. Sometimes things don’t go your way, and sometimes is very hard to accept that. But, you cannot (and should not) be in orientation 24/7. Identify stress relievers, whether that’s exercising, bowling, painting, hanging out with friends, or shooting targets at a range. Do something fun! Home-work balance is important to your long-term success.

Bottom line: you will likely have some (or many) days where you think, “I can’t do this.. or what have I gotten myself into?” But rest assured that you can. It takes time, trial and error, and confidence in yourself to become a safe and competent ICU nurse.

Welcome to Critical Care Nursing!

  • Tips for New Grads in the ICUMelissa Stafford, BSN RN CCRN SCRN graduated from nursing school in 2000, and after a short time on a medical surgical floor transitioned to neuro critical care. During her career, she has precepted multiple nurses, taught classes ranging from neurological/neurosurgical specific subjects to general critical care medicine, been involved in shared governance and resides as chair for nursing peer review. She has received various recognition’s, including the Great 100 Nurses of North Carolina and DAISY Award. Melissa enjoys spending time with family, painting, watching sports, visiting the beach whenever possible, and vacationing at Disney World

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