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I've used Cammy House-Fancher's online video seminar for CMC (I also have her previous CCRN audio cd's). It's a great course and includes sample questions. Plus you can get reimbursed and get CE credit. The PASS CCRN test bank is pretty helpful as well (just set it to cardiac only questions).

Haha yep. Been there, done that. Inexperienced doc or RT tubes them and "fixes" the CO2.

If you go the KCC route and plan to work while getting your BSN, you should realize that your job prospects are much more limited with only an ADN. Queens already does not hire ADN's and HPH is moving that way as well. If you're planning on working in a non-acute area, it won't matter though.

Where are you coming from? If the job market in your current area is better, it's definitely better to stay and get a couple years experience before moving. Also, be aware the the major hospitals are moving towards only hiring BSN prepared nurses. Queens already does not hire ADN/ASN - even for an aide/tech position. The reasoning is that they would rather hire a BSN new-grad into an aide/tech position so that they can eventually advance them into an RN position. I believe HPH (straub, kapiolani, pali momi, wilcox) is also moving towards BSN only.

You don't keep them snowed. There's tons of research showing the long term neurological deficits associated with prolonged sedation in the ICU. A lof of us were trained with the mentality that we're helping our patients by letting them sleep through their critical illness. In a lot of cases, it's quite the opposite. Over sedation leads to more vent days, longer hospital stays, and more complications. We also don't see the neurological damage we cause because the memory and cognitive problems don't become evident until long after we've extubated and downgraded our patients. The goal should always be to get the patient off all sedation/analgesia as long as it's safe to do so. That means spontaneous awakening trials every shift at a minimum. It can be really difficult to change your unit's culture, but all the evidence shows that we need to change. If your unit isn't already a part of the SCCM ICU Liberation Collaborative, I'd encourage you to explore the work being done and consider adopting some of the bundles/guidelines. ICU Liberation | About

It doesn't matter what you put. You'll get paid exactly the same as every other nurse with the same amount of experience. Most hospitals don't pay you job rate until you hit 2 years though.

I think you got some of your variables switched around. Ohms law is actually V=IR. Voltage = current x resistance. The analogue to this in terms of fluid dynamics is: deltaP=QR Or the pressure difference from point A to point B is equal flow times resistance. In terms of hemodynamics of the human body we kinda simplify this to BP = CO x SVR. Or (MAP-CVP) = HR x SV x SVR

index

Took mine in 2015. I thought it was a bit more challenging than the CCRN. One of the biggest challenges was the lack of information and test prep materials at the time. I used Cammy House-Francher's test prep, which I thought was very helpful (much like her CCRN courses). Her course included a lot of practice questions in addition to around 10 hours of lectures. I'm renewing my CCRN this year (by exam) so I just went to one of Cammy's in-person CCRN review courses last month. I chatted with her a bit and she mentioned that the CMC changed a bit last year. She retested recently and said they took out a lot of the Swan number interpretation type questions (since almost no one uses swans anymore).

Doesn't really matter. If you get accepted into a new grad program, you'll be paid exactly the same as every other new grad. Most of the hospitals in Hawaii are unionized and have very fixed payscales. Those "desired salary" fields are for other salaried positions where pay is negotiable.

index amazing resource for anyone new to the ICU

Changing the pressure bag depends on your facility's IV policy. If fluid bags get changed every 24 hours, you change that just like any other drip. Deflate the bag and spike a new one. Repressurize. Changing the whole CVP setup is the same as your initial setup. Spike and prime. Swap it with the old set. Just clamp the lumen while you switch, obviously. Arterial transducer setups are a bit more challenging if the setup connects directly to the catheter with no extension or stopcock in between. You'll basically be trying to controlling a squirting artery with one hand while you swap the set with the other. You'll probably make a big mess. Put a chux down. There will be a lot of blood. haha

That is absolutely a patient safety issue. Your patient could have died and it would be your preceptor's and your fault. Maybe it was wrong of your preceptor to leave you unattended, but you were at nearly 2 months into orientation at that point? It sounds like this is a pretty toxic unit, but regardless of the circumstances - there is something wrong if an orientee that does not understand the danger of a vasoactive drip running dry. That is day-one critical care basics. Make sure your vent is working, make sure your gtts are infusing, make sure your alarms are set. If these things are not done, your patient may die and it will be your fault. No ifs ands or buts. Nurses do eat their young and this problem is only magnified in critical care settings. However there is a very good reason critical care nurses are so protective of their patients. Physicians, residents, nurses, and family members all have the potential to KILL our patients with very minor mistakes. It doesn't sound like you understand the gravity of your mistake and how close you came to killing a patient. Yes it would ultimately be your preceptors fault for not properly "supervising" you, but your preceptor must have had a certain degree of trust in you if they felt comfortable leaving the unit. If you did not feel comfortable caring for those patients without your preceptor, it was your responsibility to say so.

If your ultimate goal is to work as an RN in acute care, you should be looking for an aide/tech job on the inpatient side. Competition for new-grad positions is still very tight and many new grads still spend about a year working as aides/techs before being accepted. Do you have any acute care experience? The role of LPN's in the acute setting has been rapidly disappearing over the years. Most employers will not count non-acute RN/LPN work experience so you're still in the same boat as new-grad RN's when it comes to applying for acute care positions.

I urge you to read the current literature and some of the links users have posted. Many of our ICU's are involved in the SCCM's ABCDEF Bundle Collaborative. The "twilight state" you're describing IS delirium. The research shows that a lot of the sedatives/analgesia's we use to "help" our patients are actually causing acute ICU delirium and long-term neurological deficits. Avoiding or minimizing analgesia and sedation is a major component, but other things like promoting proper sleep cycles (e.g. no 2am baths) are important as well. You mention sedation vacations, but does your unit routinely assess for delirium using the CAM-ICU tool? What is your target for sedation? Do you use a reliable tool like the RASS? It's normal to resist change, but just because we've always done things a certain way or we were taught a certain way does not mean it is right. There was definitely a lot of resistance in my unit initially as well (especially from the more "seasoned" nurses) but we've definitely seen a reduction in vent-days and shorter ICU stays. It's now quite common to most of our vented patients awake/alert. Some of them even ambulate around the unit. And yes, there are exceptions. Some patients simply cannot be safely weaned off sedation/analgesia. Patient safety still takes priority. However, you'll find that when your unit is more aggressive with weaning sedation/analgesia and assessing for delirium a lot of your patients were being more heavily medicated than necessary.

That's really old school thinking. Have you read any of the research on long term neurological deficits secondary to ICU delirium? Minimizing sedative and analgesia use for the prevention of delirium is one of the major goals for improving patient outcomes. ICU Liberation | Guidelines One of the great things about medicine is that it's always changing. Stay up to date, and get your unit on board with current practice guidelines! Snowing our patients may make our shift go way more smoothly, but our patients ultimately pay the price.

I think the pay is definitely a big factor. Especially when you've got a mountain of school loans to pay off. Working in non-acute care is a pretty big pay cut.. Probably around 50% or so. It might just also be what people are familiar with. Most nursing schools have clinicals heavily focused on acute care so you don't get a lot of exposure to nursing roles outside of the hospital. Another factor is that while you can go from acute to non-acute later in your career, the other direction is not really possible. It's quite difficult for nurses that have been working in a non-acute setting to make the transition. They typically have to go through a new-grad training program, regardless of how long they've been working outpatient. Taking the non-acute route post-graduation definitely limits your career options. That is not necessarily a bad thing if you know what you want to do long-term.

Very difficult. It's also very difficult to get an aide/tech position as new grad RN. And you basically need to get an aide/tech job and work about a year before you have a chance at getting into a new grad program. This only applies to acute care though. There's more opportunities in outpatient/SNF but there's quite a big pay cut.

Umm you do realize that Hawaii is part of the United States, right? We're not a foreign country.

Are you saying there's literature that supports the need for a transducer to be ZEROED at the phlebostatic axis? Would be interested in seeing a source and explanation.

You're right. Doesn't matter where the transducer is when you zero it. Atmospheric pressure doesn't vary much with such small changes in height. It's one of those things people do just because that's the way they were taught without actually understanding the mechanics behind the equipment.

index Amazing resource. Written in an easy to read format, much like the way a preceptor would talk to a new ICU orientee. You can order it in book format as well but all the resources are free on the website. Helped me out a lot when I started as a new grad.

Just to clarify, the position of the patient and transducer don't matter when you zero. You're referencing the transducer to atmospheric pressure - which doesn't vary significantly with a couple inches in height. When we measure pressure we're actually measuring the difference in pressure between the catheter tip inside the patient and atmospheric pressure outside the patient. When taking a measurement of the patient, position of the transducer matters because the pressure exerted by the weight of the fluid column in the line makes a relatively large difference in relation to the small pressures being measured.

The new grad situation hasn't improved much. If anything it's gotten worse. It still takes new grads at least a year or so of CNA/Tech work before getting an RN position and the interview process is still highly competitive. We also now have a FOURTH nursing school churning out new grads. That equates to a couple HUNDRED new grads hitting the job market annually and all competing for the couple DOZEN new grad positions offered between all the hospitals on the island. Nursing schools are a great business as long as your customers don't realize what the job prospects are really like. =p

Nursing co-op (internship) is basically an inexpensive nursing orientation/interview for the hospital. It mutually benefits the university and the hospital. If a student does well, the hospital isn't risking much on paying for the rest of their new-grad training. So yes, priority is given to students who have already proven their merit through an internship. If other nursing program are able to build that same relationship with hospitals it would be great, but as things stand - all nursing schools are not created equal. Especially in this highly competitive new-grad job market. There's a reason UHM is so difficult to get in to.