mar354

I've worked as a MICU nurse since I graduated 3 years ago with a little travel experience peppered in, but want a change, and hope to apply to CRNA school. I just got hired at a great academic CVICU and am so excited! Any advice from ICU RN's who have transitioned to CV, or known those who have? I've taken super critical MICU patients & done a bit of SICU, but the land of ECMO, VADs, (occasionally) cracking chests at the bedside, etc seems wild. What are your unique priorities and what do you wish you'd known? I'm solid on walking people w/ multiple chest tubes, but the immediate postop period's all new. Thanks in advance :)

I'm relatively new to working as an RN in the Medical ICU, and have had several patients transition to DNRCC (called "AND" in some areas) during my shift. Our hospital has a standard DNRCC order set which our MICU docs use when those patients are ready to transition, w/ individual modifications if necessary. The order set includes vitals every 24hrs, dc'ing all continuous monitoring including tele, pulse ox, hemodynamics, etc, and dc'ing all meds except those given for comfort. O2 is rarely ordered, usually only if it's used at home. Even if used, we don't typically titrate off sats--just titrate in a small range based on comfort, w/ PRN meds for SOB available too. So, when I transition a patient to DNRCC, I detach their telemetry leads, pulse ox, and any extraneous equipment that can only impede comfort, turning off the monitor. If pt and/or family has a strong desire to keep the monitor on, I put it in "comfort care" mode, which displays vitals without warning alarms. However, CC mode still alarms for a lethal rhythm, which is another reason I prefer to take my folks off entirely--the order is dc'd, after all. I've been surprised to find that most nurses I give these CC patients to in report seem surprised and displeased that I took the pt off the monitor. No one has really told me why that is, however. I understand that we may have a better picture of how close the pt is to passing w/ monitors on, but the purpose of comfort care is comfort--I'm personally fine w knowing we can get an extra full set of VS if desired. Our hospital doesn't require a tele strip of asystole as part of death declaration when the patient is a CC, and docs are happy to declare by physical exam. So, long story short, am I missing anything here? Are there benefits to tele in these CC patients i'm unaware of? What does your unit do in these situations? Thanks!

Caring for VIP patients can be a nightmare, and your stories of demanding, unforgiving VIPs are beyond frustrating! On the other side of the coin though, I think sometimes hospital administrators, unit leaders, etc. put those "VIP treatment" standards on themselves. I've been lucky and this often isn't the case, but I've found that several of my "VIP" patients simply wanted to be left alone and treated on a person-to-person level, so they could build the casual, "nurse lets their guard down" rapport that ordinary folks enjoy. Some VIPs have the same fears, insecurities, and feelings of powerlessness that most inpatients do. Yet management/leadership orchestrates clearly over the top measures in an attempt to impress that patient, assuming that's what they want. It can come off as so superficial and fake--as if we care about the patient's "name status" and how they might perceive us more than we care about their illness, or connecting with them personally. Granted, I haven't taken care of anyone beyond a "local celebrity". But I've heard that from a few folks, including a retired attending I took care of, and a local gov member--definitely stuck. Something to think about!

My general medicine unit carries "activity aprons", which each patient can keep throughout their stay and at discharge, so long as they don't become soiled. However, success with those has depended on the patient. One of my nonverbal dementia patients gave me quite the glare when I showed her an apron, and another played with it for a good 3 minutes before going back to pulling pads off her siderails. I checked on her to discover a bloody arm and asked if she removed her IV, to hear "yeah, so now I can finally go to sleep." Fun times. Also, asking dementia patients to "help me" fold towels has worked better for the more alert ones. You just have to keep up with them and learn what clicks with the individual!