Quote from hbshearer, rn
So, I just got my transfer request accepted to go to CVICU from med/surg -oncology, which is all I know. I am a fast learner and very dedicated....just wondering if the seasoned professionals have any recommendations to prepare myself for this transition! Taking ACLS next week and they will be sending me to the CCU classes along with additional CV classes. I didn't know if there was anything else I should brush up on, like meds, procedures, etc?? I just want to set myself up for success....thanks!!
ACLS is a great place to start!
+Do you know what types of patients you'll be receiving? In my CVICU, we see:
-CABGs, pre and post-op
-Congenital repairs in adults
-Surgically/medically managed aortic aneurysms/dissections sometimes with lumbar drains/ICP monitoring
-Pre/post-op and chronic device patients coming in with complications (Heartmate II/Heartware LVAD, Jarvik Heart, Impella, Tandem Heart, IABP, Centrimag, ECMO)
-Cardiogenic shock requiring device management
-Heart and lung transplants
-Miscellaneous thoracic and vascular surgeries (pneumonectomy, transhiatal esophagectomy, lung reductions, fenestration and stents, open femoral vein/artery exposure)
+Things that almost all of your patients will have that you should be/or get comfortable managing/knowing when there are problems:
-Chest tubes, both pleural and mediastinal
-Pulmonary artery catheters/Large bore jugular central lines and their care/management/calculations, such as cardiac outputs and cardiac indices (CO/CI), central venous pressures (CVP), pulmonary artery pressures (PAP).
-Bowel management systems
-Permanent/transvenous/epicardial pacemakers/ICDs and their management
+Ventilators. Ask your respiratory therapists many questions; Most of them love it when nurses do.
-Get comfortable with the most common ventilator settings and what it means for your patient
-Learn what terms like 'PEEP,' 'Pressure Support,' 'Bi-level,' 'Volume Control' mean; don't be afraid to ask an RT to explain a more "exotic" ventilator setting to you, such as HFOV (high frequency oscillation ventilation)
-Learn why you would use nitric oxide (a.k.a "nitric" as it's commonly referred to)
-Arterial blood gases (ABGs) and venous blood gasses (VBGs)... learn the norms, learn what they mean...understand what an ionized calcium is (iCal) and why it's important
-Learn your facility's policy for managing endotracheal tubes
-Don't be afraid to suction those buggers out either...it'll make your patients cough, but that's the idea
..just make sure their hands are far away from them...having someone self-extubate will ruin your day, but it happens to even the most experienced and attentive of nurses, so don't sweat it too much if it happens...just make sure you get back-up ASAP
Know dosages/pharmacology for ALL infusion medications below:
-Milrinone (this one is special in that it is both an inotrope as well as an afterload reducer)
+Afterload reducers/blood pressure reducers,
+Paralyzing agents (less commonly seen, but still seen):
-Cisatricurium is the most popular one we see in our CVICU as an infusion... always make sure there is some sedative to go with this! Also, get comfortable with the term "train of four" in relation to intentional paralysis
+Telemetry, telemetry, telemetry! ACLS will take you a long way, however, become more intimately familiar with some more obscure things such as reading a 12-lead ECG, identifying ST-elevations/depressions, bundle branch blocks, electrical alternans, etc... it will pay off, can save your patient's life and will impress those around you
+Common surgical complications, identification/management:
-Clotted chest tubes
-Conversely, too much chest tube output
-Things other than blood/serous fluid coming out of chest tubes (stool, pus, chyle)
-Cardiac tamponade (Look at your chest tubes, your ECG, your arterial/pulmonary artery waveforms/values as well as assessment findings)
+Get comfortable with blood product administration (PRBCs, FFP, PLTs, cryoprecipitate, albumin) and coagulation labs and monitoring
+Be prepared to give pain meds, and lots of them...PCAs, fentanyl infusions and epidurals will be your friends
+End-of-life/comfort care.. who runs your codes? Do you hit the "Code Blue" button or a "Staff Assist" button? We run our own codes, so we hit "Staff Assist." Utilize appropriate resources like bedside music, chaplains, social work, palliative care, etc... also be familiar with your state's organ donor policy
+ Know your hospital's restraint policy...and don't be afraid to use them if needed...some things are definitely worth the paperwork
+A sense of humor! You will see some wacky shizz working in the ICU...laugh about it with your co-workers...it helps blow off some of the stress!
The above was a hitting on the more common things you'll experience. Some of the more advanced devices, if your hospital uses them (like CRRT, ECMO, Centrimags) will come with time as will taking sicker and sicker patients. Anyway, most important, find your resource people! Ask your charge! ALWAYS, ALWAYS ask if you have a feeling something isn't right or you're not sure of. The one thing the ICU builds is confidence; speaking as an extreme introvert, it took a while for me to be brave enough to question the doctors and/or go up the chain of command if necessary. There is a steep
learning curve coming from the floor going to the ICU, especially a place like a CVICU. Ask questions, listen, ask to see/help in procedures you've never experienced before.
If you have any questions in particular, feel free to grill me; I'd love to pass on my experience while it's fresh since I'm leaving the big city very soon for the boondocks and camp nursing
icufaqs.org is a great on-line reference that I still peek at now and then too