A day in a CCU RN's life

LifesAJourney · Jul 7, 2013

This is from a user Fox_RuN that I'll just copy and place here.

+Do you know what types of patients you'll be receiving? In my CVICU, we see:

-CABGs, pre and post-op

-Valve replacements/repairs

-Myomectomies

-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

-CRRT/CVVHD patients

-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

-JP drains

-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).

-Arterial lines

-Foley catheters

-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

-Tracheostomies

Know dosages/pharmacology for ALL infusion medications below:

+Vasopressors/inotropic agents:

-Norepinephrine

-Epinephrine

-Phenylephrine

-Vasopressin

-Dopamine

-Dobutamine

-Milrinone (this one is special in that it is both an inotrope as well as an afterload reducer)

+Afterload reducers/blood pressure reducers,

-Nitroglycerin

-Nipride

-Esmolol

-Fenoldopam

+Sedatives/analgesia:

-Propofol

-Dexmedetomidine

-Midazolam

-Fentanyl

+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

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+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)

-Various pneumothoraxes

+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!

WHEW! 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.

dreamalwyz · Jul 17, 2013

@LifesAjourney- THANK YOU:)

LifesAJourney · Jul 17, 2013

Lol, don't thank me! Thank user Fox_RuN! The user summed it up nicely. Also, I posted a little something about how we handle fresh hearts on another thread. Just review my post history and you will find it :)