ChelleChelle

depends totally on the hospital that you are inquiring at: i've worked at many different hospitals and they all called their open heart surgery unit something different. inquire at the hospitals in your area. find out who does a large number of cardio-thoracic procedures. call up the nurse manager and ask what they look for in new staff when they interview. if you have what they are looking for.........great! if not..........work towards it. units i have worked in that included ohs patients: cru - cardiac recovery unit - post ohs unit ccu - coronary care unit - several did not include ohs patients, a couple were "combo" units that had medicine as well as surgical cardiac patients cicu - cardiac intensive care unit - mostly mi patients; a couple units were combo medical & surgical units cccu- cardiac comprehensive care unit - combo medical and surgical cardiac patients cvicu - cardiovascular intensive care unit - mostly surgical, but did work in one unit that called itself cvicu that was both medical and surgical patients ctsu - i haven't personally worked in unit with this designation hope this helps.

Hi All, I haven't read any of the posts on this thread for 3 weeks or so...........so was very happy to read all of the notes from those who recently achieved their CCRN. Congratulations! :balloons: As for signing or not signing CCRN after your name............it's a personal choice, but as others have noted when you do share with others that you have passed, it does help to promote a culture of certification on the unit. Others who might not have sought out the certification on their own start to get curious about it. You can now act as inspiration and a confidence booster to others. CCRN is not about being a better nurse than others..........but the process of discovery and study that you go through to get it really does make you a better nurse...........and that leads to better patient outcomes...........which is a great thing for everyone. DeeDawnTee............thanks for all that you are doing to assist others in achieving their goals. As for me.............I'm deciding between studying up for my CMC and CSC. Anyone have any experience or suggestions for studying for either exam?

Hi All, I haven't read any of the posts on this thread for 3 weeks or so...........so was very happy to read all of the notes from those who recently achieved their CCRN. Congratulations! :balloons: As for signing or not signing CCRN after your name............it's a personal choice, but as others have noted when you do share with others that you have passed, it does help to promote a culture of certification on the unit. Others who might not have sought out the certification on their own start to get curious about it. You can now act as inspiration and a confidence booster to others. CCRN is not about being a better nurse than others..........but the process of discovery and study that you go through to get it really does make you a better nurse...........and that leads to better patient outcomes...........which is a great thing for everyone. DeeDawnTee............thanks for all that you are doing to assist others in achieving their goals. As for me.............I'm deciding between studying up for my CMC and CSC. Anyone have any experience or suggestions for studying for either exam?

MarySunshine, It sounds to me like you are describing the difference between "pole-mount" transducers mounted on an IV pole in a transducer holder with the transducer stop-cock at the level of the phlebostatic axis and "patient-mount"............where the transducer is attached to the patient usually via a garter belt type system or taped either to the patient or to a small towel roll. In EITHER case...........you are correct in that the transducer stop-cock is supposed to be leveled to the phlebostatic axis when you are recording readings. (We rezero every 4 hours.......or whenever the readings are "iffy". I haven't noticed a great difference in the patients that I care for between pole-mount and patient mount, but personally I prefer patient mount............as "extra tubing" could tend to increase or amplify catheter whip, spike or overshoot and error. However amongst the 4 ICU's in my hospital, there is GREAT debate whether pole mount or patient mount is better..........and folks who are convinced that one or the other is ABSOLUTELY the only way to go. Currently our cardiac unit is the only unit that insists on pole mount, the other 3 all go with patient mounts. If the transducer is high the reading could be FALSELY low; if the transducer is low, the reading could be FALSELY high........why bother with numbers you can't trust??? I make sure I can trust the numbers by keeping the transducers at the phlebostatic axis and by determining the following the trend between cuff and art line. We handle arterial lines the same as PA lines in the following expected practices: See attached PA practice alert. Meaning the expected practice is: 1. The RN does a square wave test at the beginning of each shift and whenever the art line appears dampened or distorted 2. The transducer stop-cock is level with the phlebostatic axis and the patient is supine with the HOB up no greater than 60 degrees when readings are recorded. 3. I also correlate the arterial line with a manual pressure in both arms at the beginning of my shift; manual pressure in the arm without the art line in it; occlusion pressure in the arm in which the art line is placed. Or manual pressure in both arms if the art line is somewhere other than a brachial or radial artery. I'll try to look it up in the AACN procedure manual and get back to you tomorrow................ about whether it mentions anything about pole mount versus patient mount, but I doubt it does. PA Catheter Practice Alerts.pdf

I agree about the methemoglobinemia................but there is also a component with the vasodilators that increases perfusion to non-ventilated alveoli which contributes to the increased shunt or VQ mismatch.

Hello mdinelle, Yes! Absolutely it will get easier with time. It sounds to me that you are comparing yourself..............a new grad with 4 weeks experience to a preceptor with at least 2 years (probably more) of experience. That is just not a fair thing to do to yourself. Actually if you told me that you weren't somewhat overwhelmed............it would be much more concerning to me than hearing you feel overwhelmed. Your orientation period is about YOU............so make sure you are getting what you need out of it. Talk with your preceptor about how you learn best, and things he or she can do that you would find helpful. Even at the end of your orientation you are only expected to function at the level of a competent, safe, NOVICE critical care nurse, expected to know who and what your resources are and how to access them, as well as to continue to ask plenty, plenty questions and to seek out new learning opportunites as they are available. In my experience..............it takes about 9 months to a year for a new grad in critical care to start really feeling like they have the hang of it............and about 2 years is considered to be the "advanced beginner" stage. Things you can do to help yourself: 1. Develop a peripheral brain.........a notebook or place that you write down important information, resources, phone numbers, unit routines, etc. 2. Ask your preceptor and other RN's in the unit for tips and trick of how to organize your day.............maybe develop your own report sheet or time management tool.......something that works for you. 3. Ask PLENTY questions, get in the "learner" mode and seek out opportunities........nothing scares experienced RN's more than someone who is new and does not ask questions. 4. If you make a mistake..............like forgetting to print out a new med reconciliation. Accept that you are not perfect, and don't beat yourself up too badly. Choose one thing that you would do differently next time and figure out a plan for yourself so that you won't do it again. (Everyone makes mistakes...............the real problem is if you keep making the same one and not learning from them). 5. Pay attention to mistakes that others make..............not so you can feel superior to them.................but so that you can NOT make the same mistakes. Thank goodness, we can all learn from each other. 6. Learn the unit routines........get them down pat!!! Try to set yourself a timeline of when (by what time) you will have your initial assessment done and charted, by what time you will have AM care down, by what time you will have meds given, etc., etc. Challenge yourself to meet your timeline and keep trying to get faster! 7. If your unit has adult emergency protocols, or hypoglycemia protocols, or standing orders get a copy of them and commit them to memory..............know what you can and cannot do while calling a MD to see the patient. 8. Focus on EXCELLENT patient and family care. You can prove yourself to the other nurses in your unit by taking excellent care of your patients 9. At the beginning of your shift...........ask yourself what you think are the top 3 nursing priorities for each patient that you care for that you need to accomplish during your shift. Bounce your thoughts off of your preceptor and see if your ideas match up with theirs. 10. Make sure that you ALWAYS know the plan of care for each patient that you care for. If you don't get this information in report from the previous shift...........ASK!!! Because the next shift that you report off to, is going to hold you responsible for giving them the information. 11. Introduce yourself by first and last name to ALL of the staff who come through your unit. Housekeepers, RTs, PTs, OTs, residents, attendings, chaplains, social workers, nursing assistants...........EVERYBODY! Treat everyone with the same respect and insist that they treat you with respect. Over time you build rapport that makes your work life easier. 12. If you need a call a MD.............get all your info lined up, anticipate what questions they might ask you...........bounce ideas off of the charge nurse or your preceptor before you call............and then make the call. Use some type of succinct, concise communication method such as SBAR. (situation, background, assessment, recommendations) to get what you need. However, you should pretty much KNOW WHAT YOU WANT from the doc before you make the call. 13. If you take care of a patient with a disease process or pathology that you are not familiar with............go home and look it up. It really helps to tie learning in with a real patient. Helps it stick in your brain better. Final note: The things that you are feeling and experiencing are NORMAL. Are you part of a New Grad class or Critical Care Course? Talk to some of your classmates............and if they are honest, they'll tell you the same thing. If not.........seek out some of your nursing classmates and see if they are going through the same thing. Hang in there...........it does get better........... however it probably won't happen as fast as you would like it to. Nurses that are attracted to critical care are usually the type that want to know EVERYTHING!!!! and they want to know it YESTERDAY!!!! I've been a critical care nurse for 22 years and I know plenty.........but I definitely do not know everything. And I'm not ashamed to ask questions or admit that I do not know something.............and the truth is I still learn new things almost everyday and I enjoy what I do.

One of the complications of nipride as well as nitrates is pulmonary shunting. Some patients are more sensitive than others. I can even remember a patient that we used hurricaine (benzocaine) spray (back in the dark ages) to numb up the back of an intubated patients throat. That's when I learned that benzocaine spray can increase intrapulmonary shunting in some patients! Turns out that the patients family thought that if a little benzocaine spray was good........ALOT was better. Every time the staff left the room, they squirted a little more in!!!!! If you notice the QS/QT is increasing on any of your patients.......or the 02 sat is dropping.........always good to figure out why. Was the patient receiving NTG IV? Large or small amounts? Here is an excerpt from "Circulation" "We conclude that the decrease in arterial PO2 following sublingual nitroglycerin is caused by redistribution of pulmonary blood flow with imbalance in ventilation-perfusion relationships or shunting." The complete reference may be found at: http://www.circ.ahajournals.org/cgi/content/abstract/57/1/106 It's kind of an old article............but do a google search or a medical library search and I'm sure you can access more information. Here's another excerpt from another source. "The intravenous nitrodilators nitroglycerine (TNG) and sodium nitroprusside (SNP), may cause hypoxemia by increasing the blood flow to alveoli with a low V/Q ratio" Complete reference may be found at: http://users.otenet.gr/~fkanak/shunt.html http://www.springerlink.com/content/v62167562l27205p/ Hope that helps

Hello Windward Oahu RN, Thanks for your response and I appreciate the honest answer. The hospital that I work at offers a one-time specialty certification bonus. In your mind is that enough? Or would an hourly differential be more attractive? I'm still looking for ways to promote certification...........and not just in terms of "looking good" for magnet status application. Anybody have any ideas?? Also, BTW..............if you are looking for a less expensive way to maintain CE contact hours necessary to maintain your CCRN or other specialty certification, as of July 2007, AACN is offering FREE UNLIMITED on-line CE credits to any AACN member. Check it out at: www.aacn.org/ce.htm Non-members are still charged the customary fees.

Has anyone out there set up a in-house program to promote specialty certification? What creative or innovative strategies did you employ in order to create a culture of certification in your facility?

I originally learned them as: CHEAP MD Cardiac Tamponade Hypoxia, Hypovolemia, Hydrogen Ions, Hyper (Hypo) glycemia, Hyper (hypo) kalemia Embolus PE and Embolus MI Acidose Pneumothorax Myocardial Infarction Drug Overdose Now that it's the 6 H's and 6 T's..............I just remember them individually..........and remember they are not just the differential diagnosis for PEA anymore...........but also apply to bradycardias, tachycardias, as well as PEA. Hypovolemia Hypoxia Hydrogen ions Hyper & Hypokalemia Hyper & Hypoglycemia Hypothermia Trauma Tension Pneumothorax Thrombus MI Thrombus PE Trauma Toxins or Tablets

Hi CVICU RN, A little pre-test jitters are normal. Everybody gets them. Do you have the 88 page application packet? Go through the packet and do all the test questions in there (even the PCCN, CMC, CMS, Pediatric CCRN, CCNS........all of them!) It will help you get an idea of what types and format of questions you may get. Another way to calm your nerves is to buy the $50.00 SAE (self assessement exam) on-line from AACN. It will help you practice, but you also get contact hours for it. http://www.aacn.org/certcorp/certcorp.nsf/vwdoc/SAEEXAM Don't reschedule your exam; trust me...........it will just prolong your agony!!! Review the books you have and keep taking the practice quizzes. Make sure you are focusing on the things that are on the test blueprint. http://www.certcorp.org/certcorp/certcorp.nsf/e2adc54ac4b1fc078825692f006d1826/9fbcc3eace387e5288256671007795f8?OpenDocument Focus on cardiovascular and pulmonary. Know ABG interpretation, ACS and anatomical localization of acute MI on a 12 lead EKG, ie know which leads are inferior, septal, lateral, etc and what the possible complications are. Review the other categories following the test blueprint. Also make sure that you know normal lab values. As you are currently taking the practice exams in the resources you have purchased keep track of why you miss each question that you miss. Did you miss it because you read the question or the answers incorrectly. If so, make yourself slow down and read more thoroughly. Did you miss it because you are totally unfamiliar with that particular content. If so, review some more in that area. Did you miss it because you "read too much" into the question. If so, stop doing that............take the question at face value. All of the necessary information to answer the question is supplied. Focus on key words such as best, initial, priority, post-op etc to give yourself clues about the question. Also, the priority in answering critical care questions is always Airway, Breathing, Circulation, Disability. Actual problems are always higher priority than potential problems. And pain and patient safety are also important. After that.............most of the test is mental. Tell yourself going in that you are an excellent test taker, that you are a competent critical care nurse and that you will do well on the exam. Go down and check out where the exam location is about a week ahead. Plan where to park. Plan to arrive a little early the day of the exam. The proctor will orient you to the computer and will give you some practice questions. Your test "time" doesn't begin until after you finish the practice questions. If you feel yourself freaking out during the exam.........take a few deep breaths and remind yourself again that you are an excellent test taker, that you are a competent critical care nurse and that you will do well on the exam. You can mark questions that you are unsure of and go back to answer them at the end. If you really don't know the answer at the end.........narrow it down and take an educated guess. Have faith in yourself. The CCRN exam is difficult enough that you will feel challenged...........and you will truly feel that you have accomplished a goal when you are done................but it is not so difficult that it is impossible.

Hi CVICU RN, A little pre-test jitters are normal. Everybody gets them. Do you have the 88 page application packet? Go through the packet and do all the test questions in there (even the PCCN, CMC, CMS, Pediatric CCRN, CCNS........all of them!) It will help you get an idea of what types and format of questions you may get. Another way to calm your nerves is to buy the $50.00 SAE (self assessement exam) on-line from AACN. It will help you practice, but you also get contact hours for it. http://www.aacn.org/certcorp/certcorp.nsf/vwdoc/SAEEXAM Don't reschedule your exam; trust me...........it will just prolong your agony!!! Review the books you have and keep taking the practice quizzes. Make sure you are focusing on the things that are on the test blueprint. http://www.certcorp.org/certcorp/certcorp.nsf/e2adc54ac4b1fc078825692f006d1826/9fbcc3eace387e5288256671007795f8?OpenDocument Focus on cardiovascular and pulmonary. Know ABG interpretation, ACS and anatomical localization of acute MI on a 12 lead EKG, ie know which leads are inferior, septal, lateral, etc and what the possible complications are. Review the other categories following the test blueprint. Also make sure that you know normal lab values. As you are currently taking the practice exams in the resources you have purchased keep track of why you miss each question that you miss. Did you miss it because you read the question or the answers incorrectly. If so, make yourself slow down and read more thoroughly. Did you miss it because you are totally unfamiliar with that particular content. If so, review some more in that area. Did you miss it because you "read too much" into the question. If so, stop doing that............take the question at face value. All of the necessary information to answer the question is supplied. Focus on key words such as best, initial, priority, post-op etc to give yourself clues about the question. Also, the priority in answering critical care questions is always Airway, Breathing, Circulation, Disability. Actual problems are always higher priority than potential problems. And pain and patient safety are also important. After that.............most of the test is mental. Tell yourself going in that you are an excellent test taker, that you are a competent critical care nurse and that you will do well on the exam. Go down and check out where the exam location is about a week ahead. Plan where to park. Plan to arrive a little early the day of the exam. The proctor will orient you to the computer and will give you some practice questions. Your test "time" doesn't begin until after you finish the practice questions. If you feel yourself freaking out during the exam.........take a few deep breaths and remind yourself again that you are an excellent test taker, that you are a competent critical care nurse and that you will do well on the exam. You can mark questions that you are unsure of and go back to answer them at the end. If you really don't know the answer at the end.........narrow it down and take an educated guess. Have faith in yourself. The CCRN exam is difficult enough that you will feel challenged...........and you will truly feel that you have accomplished a goal when you are done................but it is not so difficult that it is impossible.

Check with your hospital pharmacy to see if your institution has a specific policy. Because it it is a glass bottle, I put it in the biohazard trash (all glass items go in there) or in a needle box.

As at other institutions we use the IHI Ventilator Bundle 1. HOB up 30 to 45 degrees unless medically contraindicated 2. Sedation Vacation or Daily Awakening 3. Peptic Ulcer Prophylaxis 5. DVT Prophylaxis Other initiatives * Use of a CASS (continuous airway sub-glottal suction) tube to intubate on any patient going to the ICU or any re-intubation * No break in the ventilator circuit during transportation (or any other time for that matter) *Squirting NS down the tube it is a "no-no"!!! * Vent tubing is no longer changed frequently (remember when we used to change it every 24 hours??) * Religious oral care or "interventional" hygiene as we like to call it * Pushing patients to early extubation. Our theory is, if we don't have to reintubate a few of them............then we are not getting them off the vent soon enough *Handwashing, handwashing, handwashing! *Changing the Yankauer every 24 hours and keeping it covered *Maintaining separate suction canisters (the CASS tube separate from oral suction separate from CT suction separate from rectal tube suction, etc.) * We also use an acronym......"WHAP the VAP" Wean Early Hand Hygiene Aspiration Precautions Prevent Cross Contamination I'm sure there are a few more that I have forgotten. We are by no means perfect and the VAP rate varies between our cardiac ICU, medical ICU, surgical ICU, and neuro ICU............but many of the units have sustained a zero VAP rate for quite some time.

Hi Italian RN, Do you have a specific reason for asking this question?? The reasons for a patient going into DIC are many, and the outcomes are varied. DIC is never the primary problem...........it is always the result or complication of another issue. DIC is BOTH a bleeding and a clotting problem; often referred to as a consumptive coagulopathy Patients I have seen in DIC. * A pregnant patient who delivered but had retained remnants of placenta that then went into DIC * Trauma patients especially those who received massive blood tranfustions or with significant burns who then went into DIC * Lots of septic (usually those with gram negative sepsis) patients who went into DIC * The one that was most memorable to me personally was a 30 something-ish man with a remote history of hepatitis C who went into fulminant liver failure and developed DIC. In less than a 24 hour period, he went from not feeling too well..........thinking he might have the flu, to coding three times, bleeding out of every orifice of his body and dying. * Most recent patient was a gentleman with a peanut allergy who was exposed to another type of nut oil, had an anaphylactic shock reaction and then went into DIC...........he eventually made a full recovery. The end outcome in most but not all of the above patient scenarios was death. The true way to combat DIC is BEFORE the patient goes into it. Hope this helps.