CVICU Stepdown

i worked on a cardiac stepdown for about 2 years. i absolutely loved it, and miss it alot actually. at my hospital, we had 4 pts each...every once in a while someone would get 5 pts if we were really busy. but trust me 4 is plenty. our pts were mainly ppl that had just had openheart surgery and were like 1-2 days post op. they are very easy pts. they are up and moving. should be walking the halls atleast 3 times daily. and keep them up in the chair all day! dont let them lay in bed all day or they can develop pneumonia. most have a midsternal incision thats easy to care for. the other type of pts we had were alot from the ER that come in with chest pain. most ppl are fine. you will have codes on that floor, more so than regular med surge floors. but dont panic. there are a ton of ppl around that jump in when something goes wrong. start studying up on telemetry now. and i would get to know your cardiac meds really well. also learn the cardiac drips. we almost always had patients on either an amiodarone or cardizem drip. the floors itself is usually a clean floor, no mrsa, no cdiff. its nice. it is very repetitive, so while you may feel overwhlemed at first, after a short time u will get it. if u have any other questions let me know :)

I work in the CVICU but am occassionally floated over to the CCU (coronary care unit). Typical patient load is 3 patients to one nurse in the CCU. Typical population consists of patients waiting to have open heart (and needed to be hospitalized for one reason or another prior to surgery), patients going to or coming from the cath lab, rule out MI, pre or post thoracotomy patients and occassionally overflow from other units, i.e. altered mentation, pneumonia etc.

As mentioned in another post, know your rhythms, common cardiac medications, anticoagulant medications (fragmin, coumadin etc), diabetic medications etc. Be able to educate your patient on catheterizations, CABG (on pump vs off pump), valve replacements, different types of valves (mechanical vs tissue). Most of the open heart education is covered in a specific class or by educators that come around to specifically see the patient; still good info to know since families will still ask and seek clarification, support and just general ease of anxiety.

Also, the nurses in the CCU can pull sheaths. Read your institutions policies on who can do this and what the procedure consists of i.e. two nurses in the room, medications/fluids at the bedside, holding manual compression vs fem-stop, how long the pt needs to remain flat etc. Make sure you know potential complications associated with caths and pulling sheaths (patient c/o back pain, bradycardia, hypotention; must investigate and alert MD!!) Sometimes the patients have PICC lines or the cordis still in. Know how to manage these (pretty simple but still need to mention).

In my hospital, post open heart and thoracotomy patients have chest tubes, sometimes for several days depending on how much they are draining. Know how they work and what complications can arise. The open heart patients also have epicardial pacer wires; usually just ventricular but sometimes atrial as well (depends on if the patient had a valve or CABG). Know how to use the pacer i.e. setting rate, milliamps, sensitivity, checking underlying rhythm if paced 100% etc.

We do not make our post op patients sit up all day! They had a big surgery and are typically low for H/H; less blood circulating, less oxygen circulating. It requires a lot of energy to just sit in the chair! The goal on our unit is to keep the patient in the bedside chair for one hour (we get them up for every meal). Some patients tolerate this well and some do not. For those who do, if they want, we let them sit up longer. For those who do not, we try to keep them up for the hour and let them get back to bed after their hour is up. Sometimes, they can't even make it the full hour. As they get better moving around, we keep them up longer and have them start walking. We continuously emphasize sternal precautions.

Whew!!! It seems like a lot at first, but once you are doing it for a little while, it will all fall into line and the information will come to you quickly. I have been in critical care for over 4 years and still look up everything I can and ask, ask, ask! Its fun; you'll love it!!

Working in a Cardiothoracic Stepdown right out of school was the best decision I could have made. It forced me to learn (quickly) and become comfortable when things go wrong; hopefully you will have the same experience I did.

As far as nurse to patient ratios we are 1:3 or 1:2 if we have a pediatric lung transplant. Our types of patient's include pre and post op heart's (bypass, valves, aneurism repairs), post op thoracic cases (wedge resection, lobectomy, esophagogastrectomy, etc.), adult heart and lung transplants (heart/lung or heart/lung/liver is becoming common) as well as pediatric lung transplants and VAD's. On occasion we will have medicine patient's but more often than not they are cardiology or EP.

If you don't already have it, I would recommend getting ACLS certified if it isn't a requirement.

As far as workload is concerned, it is tough. Once you get comfortable with the patient's you will gain a better idea of how to prioritize your day. Ambulation and pulmonary toileting are key to a successful recovery and there can sometimes be resistance with patient's who don't want to ambulate.

Familiarize yourself with the hospital policy's regarding A.Fib, Aspiration Prevention and Swallowing, Blood Product Administration, Chest Pain, Chest Tubes, Enteral Tube Feedings, Groin Bleed Management, IV Drips, Pacemakers, Pain Management (including PCA's and Epidurals), D10, Skin Care/Pressure Ulcer Prevention and Tracheostomy's.

Review Hemodynamics, Fluid/Electrolytes, Dysrhythmia's, ABG's and if you have transplants you should be familiar with what medications NOT to give in a code.

Finklemeyers Cardiothoracic Surgical Nursing is a book that has been very helpful in expanding my knowledge of patient populations.

As far as medications to know make sure that you ask that when you start orientation. Every facility is different in what medications they take out on stepdown unit's. Definitely read up on pressors and inotropes.

Hope that helps and may you love your job as much as I love mine!!

^^ I too started at Duke CT stepdown right out of nursing school... best decision I made. I work in the ICU now, and it makes a world of difference getting your feet wet first, understanding the pt population and knowing what to expect. Also you establish rapport with the docs and midlevel providers. If you ever decide to transition to ICU you'll have a big advantage. Not saying that new grads can't do it right out of school, but I felt like I understood the "bigger picture" right away, as it may take more time for new grads to get it.

I enjoyed working on stepdown... start familiarizing yourself with the types of surgeries and procedures your pt's will be going through, and learn about the typical pt stay, post-op complications and common meds. Even after all that, there's nothing that will replace the hands on experience when you start. Be prepared to move fast, work hard, and have fun!

That book Finklemeyers Cardiothoracic Surgical Nursing is the bible... and many of our protocols, and other hospital's CT protocols are based off that book. Ditto to that! :)

Good luck!