What's your favorite thing about working in CVICU?

  1. This fall I start my IP in a CVICU at a large, level I trauma hospital that also has a cardiac research institute. After getting over some initial disappointment that I did not receive my first choice for IP, I'm REALLY excited to spend a whole year in CVICU and think it's going to be a great fit for me. I was wondering...

    What's your favorite thing about working in CVICU?
    What do you find most challenging?
    What do you dislike about the CVICU?
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  2. 6 Comments

  3. by   sjalv
    What's your favorite thing about working in CVICU?

    This is probably applicable to all kinds of nursing, but you never know what you're going to walk into when you get to work. You might be walking into a fresh code where the critical care doctor is still in the process of placing lines, the nurse is mixing vasoactive drips to save his pressure, the RT is trying to make the image of an emergently intubated patient look presentable, and you're looking at the board hoping that you don't have a 2nd patient. It is either feast or famine. You might have a patient that's been there for a few days and you are just keeping an eye on them to ensure they don't go from stable to crashing, or you may be the one stabilizing the crashing patient coming from ER/OR.

    What do you find most challenging?
    Patients in the ICU, regardless of subspecialty, are at their sickest. The choices you make as a nurse can literally make or break a patient's recovery. Again this is is present in most types of nursing but the reality of it is amplified in critical care nursing because of how sick these patients are. You have to know the mechanism of action of the drugs you are giving, not just what they do in layman's terms. You have to know why calcium channel blockers are detrimental to patients with low EF's, you have to know why beta blockers shouldn't be given when patients are on some inotropes. You can't just know that "lopressor lowers blood pressure and heart rate" and be a safe practitioner. You need to know how it does it and what else the patient has going on that will affect their physiology. A tremendous knowledge set is required to be a safe and competent ICU nurse and as someone who is nearing the 2 year mark, I know I'm not even close to the tip of the iceberg.

    What do you dislike about the CVICU?
    I hate it when we get overflow from less acute floors just because we have the most beds in our heart hospital. This doesn't happen too often, mainly when there are no beds on the cardiac intervention unit and we have to take a stented [N]STEMI. I don't mind these patients. They're typically easy to take care of and it's not like we're tripled with them. However you get more demanding patients just due to their lesser acuity and it can really irk you. When you have one patient who has been on the vent for 6 days with no promise of being extubated, worsening renal failure new to this admission, can't keep a blood pressure for more than a minute of the levophed being put on hold, then you have a 2nd walky talky patient who really does not need to be in the ICU complaining that you don't have ice cream readily available on your unit (hello, it's an ICU; most patients can't eat), it really can be trying. For the most part, if you can use your call light to complain about your dietary options, you probably shouldn't be in the ICU.
  4. by   shan_elle
    Thank you for the detailed response sjalv! This sounds like it's right up my alley! Not to mention the cardiovascular system has been my favorite since A&P. I'm really excited for the steep learning curve and gaining a much deeper understanding of pharm & patho. I can really relate to what you're saying about having a walky talky. I work on an intermediate unit as a CNA and there have definitely been days when a really sick patient needs a lot of my time, meanwhile there is another patient near d/c who is constantly on their call light wanting me to change the tv channel or bring them ice cream. I guess there is no escaping that!

    I was researching the CVICU I'll be placed on and it says they also take care of renal, plastics, orthopedics, OB, and ENT. I was surprised to see these other specialties on the cardiac unit. I'm sure it changes from hospital to hospital, but I was wondering if you get these type of patients on your unit or if this is pretty standard?
  5. by   sjalv
    Quote from shan_elle
    I was researching the CVICU I'll be placed on and it says they also take care of renal, plastics, orthopedics, OB, and ENT. I was surprised to see these other specialties on the cardiac unit. I'm sure it changes from hospital to hospital, but I was wondering if you get these type of patients on your unit or if this is pretty standard?
    We take care of a lot of renal patients, particularly when their hemodynamic system becomes unstable and they require pressors to maintain their blood pressure and therefore cannot tolerate their typical dialysis treatments. We often start CRRT which is a type of continuous dialysis that allows for lower volumes of fluid to be taken off per hour since it is a continuous treatment as opposed to just a few hours like HD is.

    I have never taken care of a patient being seen by a plastic surgeon so it's either our hospital or my unit, but regardless I don't see them.

    We see ortho patients pretty often. It's usually a case of an elderly person undergoing something like a total knee replacement and just crashing during surgery. We also often get patients who have recently had knee replacements or other such ortho procedures and then developed sepsis and just get worse from there.

    We see OB patients occasionally, usually due to massive blood loss during delivery or fatal hypertension during pregnancy. I've never had such a patient but I'm a 22 year old male so that's probably a factor in those assignment choices. When we have patients like these, an OB nurse usually comes up to assist us with our OB assessment since for most of us, we've either never had to palpate a fundus or it's been years. Also, if the patient is pregnant and fetal heart monitoring is being done, an L&D nurse has to be at bedside to monitor the fetal heart rate since they cannot see the FHR remotely while the pt is outside of L&D for whatever reason.

    When you mentioned ENT I just think of patients who have trachs. We frequently have patients who require prolonged mechanical ventilation and cannot be safely extubated, so they have to be trach'd. This is usually a joint effort between the pulmonologist and the general surgeon.

    Remember that the ICU is just a higher level of care. We see many of the patients that other units see, except the sicker ones come to us. So a dialysis patient can easily be on the floor, except when they require more intense therapy and need blood pressure support. Post-op ortho patients typically go to the floor and go home after a day or two, except when they crump intra/post-op. Pregnant patients typically deliver and go home, except when their delivery goes south. So, I think what you discovered about this unit is pretty typical, but it isn't like you're going to be getting the healthy patients of this type. They'll still go to the appropriate unit, unless they require the higher level of care that they can get in the ICU.
  6. by   shan_elle
    Quote from sjalv
    We take care of a lot of renal patients, particularly when their hemodynamic system becomes unstable and they require pressors to maintain their blood pressure and therefore cannot tolerate their typical dialysis treatments. We often start CRRT which is a type of continuous dialysis that allows for lower volumes of fluid to be taken off per hour since it is a continuous treatment as opposed to just a few hours like HD is.

    I have never taken care of a patient being seen by a plastic surgeon so it's either our hospital or my unit, but regardless I don't see them.

    We see ortho patients pretty often. It's usually a case of an elderly person undergoing something like a total knee replacement and just crashing during surgery. We also often get patients who have recently had knee replacements or other such ortho procedures and then developed sepsis and just get worse from there.

    We see OB patients occasionally, usually due to massive blood loss during delivery or fatal hypertension during pregnancy. I've never had such a patient but I'm a 22 year old male so that's probably a factor in those assignment choices. When we have patients like these, an OB nurse usually comes up to assist us with our OB assessment since for most of us, we've either never had to palpate a fundus or it's been years. Also, if the patient is pregnant and fetal heart monitoring is being done, an L&D nurse has to be at bedside to monitor the fetal heart rate since they cannot see the FHR remotely while the pt is outside of L&D for whatever reason.

    When you mentioned ENT I just think of patients who have trachs. We frequently have patients who require prolonged mechanical ventilation and cannot be safely extubated, so they have to be trach'd. This is usually a joint effort between the pulmonologist and the general surgeon.

    Remember that the ICU is just a higher level of care. We see many of the patients that other units see, except the sicker ones come to us. So a dialysis patient can easily be on the floor, except when they require more intense therapy and need blood pressure support. Post-op ortho patients typically go to the floor and go home after a day or two, except when they crump intra/post-op. Pregnant patients typically deliver and go home, except when their delivery goes south. So, I think what you discovered about this unit is pretty typical, but it isn't like you're going to be getting the healthy patients of this type. They'll still go to the appropriate unit, unless they require the higher level of care that they can get in the ICU.
    Thank you sjalv! This gives me a great picture of the unit and what to expect!
  7. by   CCU BSN RN
    to add to above:
    1. Plastics patients when a postop heart gets osteo in their sternum and ends up getting their sternum removed and a muscle flap. Again, rare, and typically still not attended by plastics, but did technically have plastic surgery.
    2. OB patients, what you said above, and add post C section septic shock. You'd think sepsis could go to MICU but they take one look at the prolonged (hours at a time sometimes) SVT with rates in the 180's-200's and turf them right to us.


    In answer to your original questions:

    What's your favorite thing about working in CVICU?
    The autonomy. Protocols to titrate 5 pressors, sedation, pain meds. Draw labs and replete electrolytes, order blood, pace the patient. Also having the providers (residents and PA/NP staff) right on the floor 24/7. No waiting for people to page me back while I pray my patient doesn't crump in the hour it takes for a Hospitalist to call back.

    What do you find most challenging?

    Most of these patients are in this very fragile state where we have them sort of stable on lots of drips and therapies, but the tiniest misstep can be catastrophic. I honestly am not that bothered when patients die. I am cripplingly afraid, however, that it's going to turn out that one of my actions (of lack thereof) killed them. I know I'm not alone in saying that I go home after my patient codes or dies and run through the scenario a million times in my head, trying to pinpoint something that I could have done differently, kicking myself for not knowing some piece of patho or pharm that would've guided me in a different direction. Mind you, other RNs and doctors are at bedside in these situations and typically the patient's outcome is not directly the result of anything that I did. Letting go of that personal responsibility JUST the right amount is what's really hard for me. You can't let ruminating about work run your life, interfere with your sleep or relationships. You also can't NOT think about these incidents at all. Because that piece of patho I was missing that would've helped, you bet your butt I looked it up and I'll never forget it again. You need to be like, 4-6/10 scared of making the wrong choice, not having necessary info, because that moderate fear is what keeps you improving, it's what makes you a good nurse. Crippling fear, however, will just make you kill MORE people, so find some meditation tapes or a Xanax prescription.

    What do you dislike about the CVICU?

    I dislike that we are not nearly as ready to talk about futility of care, DNR/DNI/CMO, the risk/benefit of surgery and various procedures. Sure, we tell the family there's a 5% chance of death from surgery or a 10% chance of stroke or surgical site infection (I'm making these figures up, they're calculated per patient). We don't tell them that their loved one is 93 years old, and even if they beat the above odds, they're looking at months and months of rehab, pain. We don't tell them their loved one might be unable to wean from the vent, have to get trached. That they might aspirate or fail to thrive and require an NGT and then eventually a PEG tube to feed them. That they will most definitely be delirious after surgery, and should they survive, could even have PTSD about their prolonged ICU stay. We take this awesome patient, who is 'very good for 93', ambulatory, independent, oriented, but getting winded on long walks due to aortic stenosis, and we rob them of a decent quality of life and replace it with the above.

    In short, just because we CAN do surgeries, procedures, therapies, etc. doesn't mean that we SHOULD. And the American public reads at a 5th grade level, so even when I am allowed to broach these topics with patients and families, getting them to truly understand what I'm saying can feel like gouging my eyeballs out with a rusty spoon.
  8. by   shan_elle
    Thanks for your in-depth post and words of advice CCU BSN! It was very insightful. I was recently talking to an RN who also mentioned the futility of care, especially in a research/teaching hospital where patients' family members expect all the newest medical technology be used, despite what that means for quality of life.

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