guest239592

Worked in a high-risk 30 bed CVICU as a new grad for 3 years and am in anesthesia school now. I work with PACU nurses on a daily basis and I have never met a PACU RN who was not required to be an ICU nurse first (jobs I've generally seen posted require at least 5 years ICU experience). Would PACU help you transition to ICU, absolutely. If you do happen to get the job PM me because you will be the first nurse I know getting hired in that area without ICU experience.

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My first patient death was the summer after my junior year in nursing school when I was a Summer III intern at Mayo Clinic in one of their ICUs. The pt was in septic shock admitted from the floor, fairly young, and within 2 hours of being admitted into the ICU went into V-Tach and died. It was my first time ever doing CPR on a real person and the emotions were heightened as her children (about my age at the time) were outside the room screaming to save their mother. This all happened at the start of our 12 hour shift, and after the family had their time with their loved one, and we did her final bath and sent her to the morgue, we had to pick up another assignment. I had the next few days off, and the following day after I had slept (it was a night shift) I got up and just stared at the TV (which wasn't even on) for hours and couldn't move. Later that summer I had several more deaths occur on my shift, some comfort care, some codes. Fast-Forward a few years when I got my first job as an RN in a high risk cardiovascular intensive care unit, and I can't even tell you how many times I've done CPR on people or been involved in comfort care, too much to count. Saying that, as someone posted earlier, it does get easier over time and there will be some that will stick with you for whatever reason (extraordinary circumstances, connections with the patient and or family etc). I personally believe codes are much more traumatic for all involved than comfort care. In fact, providing comfort care was one of my favorite parts of my job in the ICU not because I wanted to see people die, but because I was given the honor and privilege of being involved during a very intimate moment in a family's life. Many families probably don't remember my name or even what I look like, but I can promise they will remember my actions, whether good or not. It's an amazing responsibility to guide a patient and family through the process of dying, something I very much miss in my new role in anesthesia school. My advise, find a hobby outside of work (I'm a runner and that was a great way to release some energy). If you have co-workers that you're friends with outside of work, they can be a great source of support because your own non-medical family and friends will try to empathize, but they can never really know what you're going through. Finally, most hospitals have free counseling services you can use and if not, every hospital has chaplains who can be a great source of support whether you are religious or not. I almost utilized them one week when I had 3 days in a row of patient deaths (4th day was a cake assignment though which I needed!) Best of luck in your new career. Nursing is the hardest job I've ever had, but we're able to do things in our work that make a true difference in people's lives, if even in a small way, every day.

Where do I start?? Too Many... This one though has stuck with me for awhile (wasn't my pt thank God) Transferred a pt to our unit at 2300 from small outlier hosp with initial unstable angina, suspect non-ST MI which was relieved by a nitro drip (the hosp had a 24/7 cath lab). Cardiologist wanted to wait to cath the pt till morning because the pt was a diabetic with renal failure (on outpatient dialysis) and had allergies to contrast dye. Plan was to do bicarb drip overnight and load pt with Benadryl before the procedure. The pt was hemodynamically stable with no active symptoms at the time of admission, and we started a heparin gtt upon admission. Through the night the pt became progressively more symptomatic (all the classic signs including now ST elevation in multiple anterior and lateral leads), called the doc 4 times insisting the pt was unstable and needed to be cathed, still didn't want to cath and by change of shift (when docs started rounding) pt was being prepped for emergent cath (duh!!) Well, during shift report the pt of course coded, I responded to the code and initiated compressions, the first compression I did I could feel the pt's entire sternum fracture which spread to the pt's ribcage bilaterally. After we got the pt intubated, copious amounts of blood were coming out of the ET tube (didn't help he was on Heparin overnight) and literally the way we ventilated was RT would give 1 breath and 1 of the nurses would suction. So breath, suction, breath, suction. This went on for over 45 minutes before we finally called it (and the room looked like a murder scene by this point, though not nearly as bad as some of the ruptured aneurysms mentioned above, so are the worst!) The sadest part of the story was about 10-15 min before the code, the pt called their spouse to let them know everything was ok and to not rush in (about an hour drive for the spouse from where they lived). We couldn't get a hold of them during the code after multiple attempts, by the time the spouse got there the pt had expired (needless to say we had a Chaplin there when we broke the news, heartbreaking...)

Believe me you have more than enough experience to take the exam. A lot of it is integration of clinical picture (pt signs and symptoms, swan numbers, drips) to intervention. I worked in a CVICU as a new grad for 1.5 years when I took my CSC (2 months after passing CCRN) and passed just fine with no problems (granted this was a high-risk, high-volume center 5-9 cases/day every day which helped me compensate in this area for my lack of many years of experience). In addition to my experience I read the book Cardiac Surgery Essentials for Critical Care Nurses. Very well written, learned a lot, case studies at the end with ?s geared toward CSC and an overall easy read (read the whole thing casually in about 3 weeks). Just think the ? through and you'll do fine. I see your original post was on Aug 27 so sorry if you've already taken the test...

Cardiac Surgery Essentials for Critical Care Nursing (search on Amazon). It LITERALLY takes you step by step through the entire postoperative process for CV surgical patients, addresses multiple patient populations (CABG, OFCABG, Valve patients, Transplant, VAD etc.) and also has specific chapters on common problems in the CV population and interventions (postop bleeding, respiratory, neuro, rhythm, hemodynamics etc etc). I read this book in preparation for the CSC exam (passed first time no problem after reading the book), I had been a nurse for 2 years (started in CVICU as a new grad) at a high-risk heart center doing hearts all day every day and I learned a TON after reading this book (my only regret after reading it was that I didn't find it as a new grad). It's very readable (read it casually cover to cover in 3 weeks, although if you're new it may take you a little longer to get through the chapters) but the chapters aren't overly long, font size is reasonable, written very well, paperback. I'm sure all of the above books mentioned are great (I actually also had Manual of Perioperative Care in Adult Cardiac Surgery by Robert M. Bojar at the time which is like a bible for CV surgery) but this book is written specifically by nurses for bedside nurses in no-nonsense way. Whatever book you decide on will be better than no book at all and I commend you for wanting to further your education being new to the ICU to take better care of your patients. Good luck in your new career, it's hard as a new grad but worth it 100% :)

I feel like I had a somewhat similar experience to you (2 yrs CVICU experience when I took the CSC, (started in CV as a new grad so only experience I had), passed CCRN 2 months prior to taking CSC, and also wanted practice ?s/exam) so here's my advise. Other than the test plan on the AACN website which lays out for you very simply what you should know, objectives and I believe a few practice ?s, there were not any practice tests I knew of at least when I took the exam (Jan 2011). I bought and read cover to cover Cardiac Surgery Essentials for Critical Care Nursing by Sonya Hardin and Roberta Kaplow (very reasonable price on amazon for a textbook). This book should honestly be REQUIRED reading for anyone starting in CVICU. Even with 2 years of solid experience doing high-risk hearts all day every day, I learned SO much in this book, and it is not difficult reading at all (font size reasonable, paperback, pages not huge, finished it in 3 weeks doing just casual reading hear and there). At the end of each chapter is a case study with practice ?s geared to prepare you for the CSC exam (Which they state in the book). I did all of those, read the chapters and took the test first time, no problems. I know you're in school now and have a ton of reading to do (believe me I know, I'm in CRNA school now!) but if you just get the book for the practice ?s and to skim it's well worth it. Sorry this got long but that's my advise! :) [h=1][/h]

In this situation, the physician is not acting appropriately or in the best interest of his patient. As others have posted, check your hospital's policy because most are taking a hardline stance against this kind of behavior as it does lead to more medication errors. With EMRs now rapidly being employed in hospitals this is a lot easier for administrators to track. I do want to mention and I'll probably get a lot of disagreement on this (this doesn't apply in this case) that there are times when taking a verbal in non-emergency situations is ok to help the doc out. Let me give an example I worked in a high-risk CVICU for nearly 3 years, got to know the surgeons very well, and worked well with most of them. Many of them would come by early before their morning surgeries started and do a quick round through the unit (to see how the night went) before they more fully rounded with their NPs later in the day. When we had paper charts, it was easy for them to pull the chart out and write a few orders quickly. Most of these orders technically could have waited until their NPs initially rounded in the next few hours, but it was nice get started on some of them to get the patient transfer ready for example "40mg IV Lasix, then D/C foley" "D/C CTs" "D/C Swan" etc etc. Some were a little more urgent such as "Give 1 unit PRBC" or "Consult EP" Now I know EMR is the future, and I think it's a good thing (I was a superuser for 2 major transitions), but if the surgeon had to log into each patient's chart, put the orders in, log out, see the next pt, etc. that would delay surgery start time for the day which is definitely NOT a good thing esp since their pts were in the OR being getting prepped by anesthesia. Now I know, I know, you could argue "It's not my job to do that" or "Well then they should round earlier" but honestly there's also something called teamwork, and if this can help them get started with surgery on-time and get a little more sleep (since they really do get a lot of calls in the middle of the night and then are expected to perform a highly complex surgery) then I'm happy to help. I'm just glad they're taking the time to come at least a little early to see their patients. Helping them out honestly helped me develop a better rapport with them rather than always being at odds, which in the end having a good rapport I think leads to better patient care. To summarize, in most situations (and certainly yours) the physician should put in their own orders because it is their job and it does lead to safer outcomes. But there times in non-emergency situations where I think it's ok and appropriate for us to help them out. Just my :twocents:

Here's my take, as many of the posters have previously said, depends on your facility, Docs, and diagnosis. I work at the largest hospital in the state with the largest CVICU in the state taking the most critically sick patients. Since we put a Swan in every CV-Surgical pt, the nurses are experts at managing the system, and interpreting the numbers IN CONJUNCTION to other signs and clinical symptoms. Our Docs are good about not just treating numbers and if they think it's inaccurate they'll have us pull them. We pull swans out of pt's as soon as we can. We also have overflow on our floor if surgical census is down, which I would say about 98% of those pt's don't have Swans and don't need them. CV pt's esp the sick ones in my opinion need them. As a previous poster stated, if interpreted correctly you can start treatment immediately for the correct problem and not just guess. For ex: A fluid challenge for low BPs, then let's try a vasopressor when the real problem all along is a weak pump needing inotropes. Now you just volume overload the pt more who already has a weak heart. The new PICCO and FloTracs are a nice alternative, BUT you have to have a great arterial waveform with an obvious dicrotic notch for it to be accurate (Which as you know isn't always the case). Bottom line, the reasons most studies don't show a difference in M/M is because too many docs without extensive experience with swans will overtreat pt's based on numbers alone. If you look at the whole picture they can be very useful.

I'm in as well!!! Congrats to those who got in, as well as those on the waiting list. From Minneapolis originally (in Milwaukee now) Can't wait to get back home!

Fent gtt with bolus orders on all patients, generally weaned off by morning if extubated, taking PO etc. Dilaudid while intubated Morphine 2-4mg IV q1hr Vicodin 1-2 tabs q4hr Oxycontin 5-10mg q2hr Torodol generally if pt is young, creat normal, has to be approved by surgeon though, all others listed above are all protocol. With the exception of younger male patients, and those with chronic pain or drug addicts, we can get pretty decent pain control with what's listed above.

I work in a high-risk CVICU (we do VAD, Transplant, IABP, CVVH, ECHMO etc. etc.). Machines with the exception of long-term VADs are always 1:1, though recently they've been starting to pair more fresh VADs (2-3 days out of surgery) with another patient which is just plain unsafe. I don't know how you can pair CVVH, IABP. Those are some of the sickest patients on the unit, there's a reason why they're on a specialty machine! Our sickest are 1:1 but that doesn't always happen, very rare though to go beyond 1:2. Some of these 1:2 pairings though are just insane as well Generally if out fresh hearts are "stable" 4 hours out of surgery they're paired, sometimes with other fresh hearts 4 hrs out of surgery, and my definition of stable is a lot different than management's. That of course doesn't always happen either, i've been paired fresh heart 2.5hrs out of surgery before. Hospitals only care about money, they're becoming like what they were in the early 1900s, except instead of ppl dying of infection, they're getting unsafe care that could lead to increased mortality with under-staffing when we have countless new grads looking for jobs. I can't wait until I leave the ICU one day, it's broken me...

I've been a nurse now for almost 2 years, like you I started out as a new grad in the highest risk cardiovascular intensive care unit in the state (What was I thinking!?!? :) I did have a summer internship at Mayo Clinic the previous summer in an ICU so I did have a little experience, but it was pretty overwhelming starting out as a new grad. A great resource I used when I was starting out was a textbook called "critical care nursing a holistic approach" I used this book in my ICU nursing class and really liked it. It explains things really well, has great pictures and is pretty all-encompasing. It will be a great resource for you to learn more about topics that you first learn at work. Ok so I'll put some basics down also. EKG normal/abnormal vital signs Labs: Na, K, Glucose, Mg, Ca, ionize Ca, CK-MB, Myoglobin, Troponin-I, PT/INR, PTT, H/H, WBC, Platelet count, Fibrinogen, ABGs (also agree with above, this takes time) Note Labs: These are a lot, but in my opinion you learn so many in nrsg school and these are the ones I see all the time in my every day practice. Those are the basics, things to start really getting down once you start and get experience would be for sure hemodynamics, vents, ABG analysis, common invasive gtts (vasodilators, vasopressors, inotropes) and antiarrhythmics. Please know this stuff will come with TIME and EXPERIENCE You will face frustrating days ahead, learning how to be a nurse and then an ICU nurse at that is very tough. However you seem like someone who has a drive to learn. Just be patient with yourself and know that it takes TIME to get good at this stuff. I can say from experience both for myself and many on my unit who started as new grads that you can totally do it, and not only do it but be very successful at it. Just take one day at a time! Good luck!!

A lot of nurses on our unit had no idea we had it as a system-wide policy standing order. Unfortunately now they took it off our policy orders because apparently someone thought a pt could become lidocaine toxic if say for ex they were getting it from other sources like IV etc. etc. What a joke, it's only like 2% and barley anything...

Some facilities have standing orders for this, others will require a physician order, but definitely use Urojet which is lidocaine jelly. Basically it comes prepared as a prefilled syringe that screws into the deployment device. You put the tip into the urethra and inject and let it dwell for a few minutes before catheter insertion to let it take effect. You can also use it to lubricate the catheter. Again check with your facility to see if you already have standing orders to use it, else if you happen to be talking to a physician, get an order for this, it's a lot more comfortable for patients.

Thanks, your screen name is pretty clever too!

I work in a large high risk CVICU. I haven't had this issue before with MD visitors, but have definitely had this issue MANY times with family members/friends of family who are nurses, physical therapists etc. etc. Like your situation, these family members work in clinics, nursing home, rehab etc. etc ie: Basically have no clue what's going on. What makes me laugh the most is when they'll just stare at the monitor when the pt has a Swan Ganz Catheter (basically every pt of ours initially) It makes me chuckle because you can look at the dang thing all you want, your still not going to have a clue what it means. They'll say things like, "Oh his blood pressure is high/low" or "oh his heart rate is kinda fast" It's like, uh ya, he just had his chest ripped and sawed open, those numbers are going to be a little off for a bit from what "our normal" is. I just wish these people would say, "I'm a nurse, but not an ICU nurse so I really don't know what's going on, is he/she doing ok?" I guess for these people thinking they know something/suggesting something maybe gives them back some sense of control they may feel they have lost with their loved one being in this situation. These are some of the reasons I switched to straight nights a few months ago (not that we don't have annoying family at all hours of the night, we have a 24/7 visitation policy, argh...) Rapid Response, I feel your frustration.

I work in a 30 bed CVICU, largest CV unit in Wisconsin that takes the highest risk patients in the state. We see IABP A LOT (I'll be trained in March, can't wait!) Our training is 1 8 hr class. When ppl are newer at machines (CVVH, IABP, LVAD) or are new transplant nurses, our charge nurses try to get us in those assignments right away to get us used to those pts/machines (the charge nurses have a list in their binder of who is new to what machines etc.) This helped me a lot when I became a CVVH nurse, I had almost 3 weeks straight of CVVH and now I feel like very comfortable with it just from repetition. Our pt's on IABP are ALWAYS 1:1 (and honestly other than our pre-vad pt's that we put a balloon in the night before surgery, all of our balloons are VERY sick) Like others have said, adequate staffing is pretty key.

In my unit (30 bed CVICU, largest in the state, and takes the highest risk pt's of the state) we use CVVH A LOT. We use the NxStage Machine (Which I hate by the way, had way less issues when we used Prisma in the past) ICU nurses control all aspects of the machine from initiating orders, to set-up, troubleshooting, changing filters, and discontinuing therapy (we do have a very good clinical engineer program at our facility and an engineer is always on call 24/7). Our staffing ratio is always 1:1, for us it pretty much has to be, I can't remember the last CVVH pt we had that wasn't on multiple inotropes, pressors, antiarrhythmics, EF 10% etc. etc. We use citrate and CaCal on pretty much all of our systems, but if our pt is real septic we're lucky to have it last 12-24hrs.

I work in a Cardiovascular Intensive Care Unit. We use vasopressin ALL THE TIME. Our surgeons hate levo and phenylephrine (and there's research that suggests pt's having low endogenous vasopressin levels after bypass) Our max dose range is 0.1 units/min. However I've seen the docs write orders to titrate up to 0.2units/min, and just yesterday had a pt where we could go up to 0.3units/min (we ended up doing that AND had to add levo, she was on CVVH I might add at zero net loss of course!) A few months ago our pharmacists told us they are working to put a hard stop in our smart pumps to not allow us to go up to this range because there's evidence that beyond 0.1units/min there's the effectiveness of the drug drops way off, and the risks outweigh the benefits. Obviously, treating a septic pt vs. a CV pt is like comparing apples to oranges, just thought I'd throw my 2 cents in as to what I've seen in my practice. Oh and btw, as far as your co-worker I would have done the same thing and written an incident report. Wether the doc wants to go beyond the recommended range is up to them, but you can't just do "maverick" nursing like that, it's dangerous and illegal if you don't have prescriptive authority. I think you did the right thing (plus if you weren't meeting BP goals at 0.04 and needed to go up to 0.2, I would think you would probably want to LET THE DOC KNOW!!!!)

My second code I was part of at my summer internship in the med/surg ICU. It was the last day of my internship, i happened to stay late that day for a 16 hour shift to help out due to short staffing (working more as a nursing assistant, stocking rooms etc.) We had two sides to the unit, the side we were on usually only had a few pts on it, so there had to be at least 2 RNs at all times in case someone coded. I remember like it was yesterday, 2 nurses were in the room doing some routine care w/ the pt, when one nurse screamed to get the crash cart and get the MDs there (teaching hosp so residents on all night). Pt dumped a liter of blood from a deep abd drain he had hooked to LIS. Eyes rolled back, V-Tach, V-Fib. Pt was in hemorrhagic shock. We were doing compressions on our way down to the OR, I was pressure bagging blood in. Ended up pt blew his iliac artery. Surgeon was barely able to do a cut down in time and did save him. I swear it looked like something from TV. This code was told to me by my critical care nursing instructor. She has been and ICU nurse since the early days of ICUs coming into existence in the US. This code was in TX, very hot day. Their hosp pharm somehow ran out of lidocaine (before the days of amio) Pharmacist ran outside a few blocks to a competing hospital to get Lido, brought it back and was pouring in sweat. He was leaning a little too close to the metal side rail and sure enough got shocked w/ the pt and he went into V-Fib, so the team had two codes to manage now. Thankfully both the pt and the pharmacist lived.

I'm an RN in a very large CVICU and we D/C IJ Cordis all the time. I agree with everyone else that you should always have pt lying flat as tolerated for just about any central line removal, esp an IJ. You'll likely be protected if your policy says you can remove while up in the chair. Also of note, to those saying they get clots in their cordis sheaths, I'm surprised your facility doesn't have you running TKO fluids all the time through the cordis to prevent that.

Sounds like you did a great job. I work in CVICU so we use nipride all the time for the immediate post-op period. Nipride is a great drug but can be tricky to find the right amount the pt needs. When we're titrating all the time for it we call it "playing the nipride game" Anyway... starting low with this drug is always a good idea (which you obviously know now, it is pretty amazing how fast it works) Some pt's respond to just a few drops of it. I had a pt just last night how required a pretty high dose of nipride and as others have said at high doses you can get pulmonary shunting (as well as cyanide toxicity, but our bags have sodium thiosulphate to help prevent this). If shunting occurs you're going to want to get another drug on-board so you can come down on your nipride. Also to be on the safe side you'll probably want to check a methemoglobin level. If that's elevated you can give methylene blue to reverse it and that may fix your problem. Nipride in my opinion is a drug like any other vasoactive drug you just have to have respect for

I have an ipod touch and LOVE it as a PDA. There are a bunch of free programs out there are decent if you look in the app store under the health/medical category. The ones i have are epocrates, medical calc (awesome) and Eponyms (basically a medical dictionary) Skyscape has some free stuff which is nice, but if you want the really good apps I would consider looking at some of their apps on their website for what you want/need. I personally wanted a better drug book, so i bought the mosby drug book (you can preview all of the programs on the skyscape website) I got the program for like 45 bucks for a yr, WELL WORTH IT.

Those pumps can support two channels. They look pretty flashy w/ a good-looking user interface, colorful, touchscreen etc. HOWEVER... I have had a lot of horror stories. I was a student nurse intern last summer on a highly acute med/surg/transplant ICU when our facility went w/ these pumps. First, the tubing diameter you have to use is really small, so it's super easy to get small air bubbles (nothing i was concerned about), which leads to endless alarms. This also means it's hard to bolus fluid fast. Another annoying thing is the touch screen. You have to be so precise when touching it else it won't take you to the screen you want, or do the function you want. A lot of times I like touch screens (like the Phillips monitor screens) but this one is glitchy. That's not really the worst though, more the annoying. The worst stories i've had is pumps shutting off for no reason, (and yes it was plugged into the wall, so it wasn't a battery issue). You can imagine how bad this is when you have multiple vasopressors running in, or other critical drips. To make matters worse, we would try to get the line out of the channel holder (there's a way to force it open w/o having the machine on) and this wouldn't work from time-to-time. I read online that Hospira recalled about 11,000 of their pumps not too long ago. Maybe the problems will get fixed. Personally for smart pumps I've used, the new Alaris ones are nice for having additional attachment capabilities (esp the PCA, that's pretty sweet I think so you don't have to get a whole new pump to add to all the clutter). They're pretty slick and I personally like them. I would have to say though my favorites are the Baxtor colleague w/ guardian drug index. These pumps are so easy to use, are very small, can have up to three lines running per pump, and hardly give you problems. They may not look that flashy, but from my experience w/ the hospira pumps, as long as the equipment works, who cares if it's old/not flashy.