Graduate Nurse on Cardiovascular PCU: Advice/Brain Sheet

RaeRiddle · May 20, 2015

Congratulations, and good luck! I started in a PCU as a GN a little over two years ago, so believe me, I know the struggle. :)

Just to be clear: do you really have vasopressors (such as levophed, vasopressin, generally only allowed in ICUs), or do you mean drips like dobutamine, dopamine, amiodarone, and diltiazem (I don't know the blanket term--I think vasoactive is too broad)? If the latter, it sounds like a similar floor to mine.

My biggest pieces of advice that I have tried to drill into the heads of every student I have ever had:

1. Know your normals, but more importantly, know what is abnormal enough that you need to do something about it. I'm talking lab values, vital signs, urine output, pulse ox, chest tube outputs, and overall assessments. I recently transferred to our CVICU, so I am constantly asking my preceptors to put things in scale for me. Ask your preceptor specific questions, like what chest tube output is moderately concerning? At what point do I need to call the PA (we have a nurse practitioner or physician assistant on the floor 24/7 as a go-between for the surgeons)? When do I need to call the surgeon? What pH on the ABG is going to send me screaming to the med room for some bicarb? What blood pressure do I need to hold a metoprolol and notify the PA about, and what blood pressure do I need to urgently notify the PA and probably give a fluid bolus or start an inotrope drip? What telemetry rhythms do I need to notify for? When do I need to yell for the crash cart? You need to have a good understanding of what is BAD for an "average" patient, while keeping in mind that sometimes the acceptable limits change based on the individual patient. Which brings me to my second soap box:

2. Understand the big picture. This will become easier with experience, but generally you want to sort of keep your mind wrapped around everything going on with the patient. If your patient has COPD, respiratory will be a bigger deal, but (as you have been taught many times throughout nursing school) your SpO2 can usually range a little lower than "normal." If your patient has known carotid artery blockage that they for some reason decided not to disturb, often you will want to keep a higher blood pressure to ensure perfusion of the brain. Similarly, patients with renal failure generally like a higher blood pressure to keep the kidneys perfused. And so on.

I don't use a pre-printed brain. Some nurses on our PCU have very elaborate organization sheets that even include assessment. Ain't nobody got time for 'dat! I find that a little overwhelming. Really, what I do is take a blank sheet of paper and draw lines dividing it into 6 boxes (because you may start with 4 patients, but if you're working days you will normally discharge 1-2 and admit 1-2). Our nurse to patient ratio is 1:4, so I start with the top four boxes. I put the room number in the top left corner of each box and a grid on the right side of each patient's box to list med admin times and important meds. On the bottom left I jot down my rhythm measurements (SR 72, PR 0.19, QRS 0.15, etc. so they are handy when I'm charting). I don't bother with writing down meds like colace, sennakot, pepcid, and vitamins on my grid--the PA is never going to come up to me and ask, "Now how much vitamin D did you give that patient?" I put the things that are useful to me--BP meds with a dose, amio with a dose and schedule (because when they go into a. fib, someone is always going to ask you how much amio they are on, and how much beta blocker did they get this morning), aspirin with a dose, antibiotics, insulin, and anything unusual. And then the rest of the box I use as a to-do list. It's simple, it keeps me halfway organized, and it works well as a cover-sheet for my SBARs (report sheets) to preserve confidentiality.

I hope this is helpful. Again, good luck!